MEDICATION PRECAUTIONS

FOR SKIN SURGERY PATIENTS

Many medications (both prescription and non-prescription) can inhibit the blood's ability to clot and may increase the tendency to bleed during surgery and the post-operative period. Many of these medications are anti-arthritic, anti-rheumatoid, anticoagulant or circulation medications. Most of these medications contain aspirin or ibuprofen. If you are currently taking any of these medications, please contact our office at 874-3444 to speak with a nurse about your medications.

Please contact your primary physician prior to discontinuing any PRESCRIPTION or OVER-THE-COUNTER DOCTOR ORDERED medication (i.e. coumadin, aspirin). Inform your doctor of your scheduled surgery and ask if and when to stop your medication. He/she may also inform you when to resume the medication post-op.

If you are taking any non-prescription medications that were not ordered by a doctor (i.e. aspirin, or other-over the-counter anti-inflammatory medications) that may increase your tendency to bleed, we would like you to discontinue them 2 weeks prior to your surgery.

A list of common medications that contain aspirin or can increase your tendency to bleed may be found on the next page.

Note: If you need minor pain medication, please take Tylenol (acetaminophen). If you are allergic to acetaminophen or are unable to take it for other reasons, please notify us to arrange for a suitable substitute.

The following is a list of common medications that increase your tendency to bleed:

Advil (Ibuprofen)
Alcohol
Aleve (naproxen)
Alka Seltzer
Anacin
Anaprox (naproxen)
Ascriptin
Aspirin
B.A.C. (butalbital / aspirin / caffeine)
Buffer Cataflam (diclofenac / potassium)
Children's Aspirin
Clinoril (sulindac)
Cogesprin
Coumadin (warfarin)
Daypro (oxaprozin)
Diorinal (butalbital / aspirin / caffeine)
Disalcid (salsalate)
Doan's Pills
Dolene (propoxyphene / aspirin / caffeine)
Dolobid (diflunisal)
Doraphen Compound (propoxyphene / aspirin / caffeine)
Doxaphene Compound (propoxyphene / aspirin / caffeine)
Dristan
Easprin
Ecotrin
Empirin
Excedrin
Feldene (piroxicam)
Fiorinal (butalbital / aspirin / caffeine)
Fiortal Caps (butalbital / aspirin / caffeine)
Four-Way Cold Tabs
Halfprin (aspirin)
Ibuprofen
Indocin (indomethacin)
Iodine (etodolac)
Isollyl Improved (butalbital / aspirin / caffeine)
Lortab ASA (hydrocodone / aspirin)
Marnal (butalbital / aspirin / caffeine)
Meclome (meclofenamate)

Medipren (ibuprofen)
Midol
Mono-Gesic (salsalate)
Motrin (ibuprofen)
Nalfon (fenoprofen)
Naprelan (naproxen)
Naprosyn (naproxen)
Naprosyn (naproxen)
Norgesic (orphenadrine / aspirin / caffeine)
Nuprin (ibuprofen)
Ordis (ketoprofen)
Oruvail (ketoprofen)
Pamprin IB (ibuprofen)
Panwarfin (warfarin)
Percodan (oxycodone / aspirin)
Percodan-Demi (oxycodone / aspirin)
Persantine (dipyridamole)
Plavix Tabs (clopidogrel bisulfate)
Ponstel (mefenamic acid)
Relafen (nabumetone)
Robaxisal (aspirin / methocarbamol)
Roxiprin (oxycodone / aspirin)
Salflex (salsalate)
Sine Aid
Sine Off
Soma Compound (aspirin / carisoprodol)
Talwin Compound (aspirin / pentazocine)
Tegretol (carbamazepine)
Ticlid (ticlopidine)
Tolectin (tolmetin)
Toradol (ketorolac)
Trental (pentoxifylline)
Trigesic (acetaminophen / aspirin / caffeine)
Trilisate (choline / magnesium / trisalicylate)
Vanquish (butalbital / aspirin / caffeine)
Vitamin E Supplements
Voltaren (diclofenac)
Warfarin
Zorprin (aspirin)

PATIENT EDUCATION

The following information is provided to our patients and their families who are considering Mohs Skin Cancer Surgery, Mohs Surgery was named after the originator, Dr. Frederic E. Mohs. Please feel free to contact our staff for any additional questions or concerns. 

SKIN CANCER 

WHAT IS SKIN CANCER?

Skin cancer is a common tumor seen with a greater frequency as our life span increases and we receive more sun exposure. There are several types of skin cancer: basal cell carcinoma and squamous cell carcinoma (composing the non-melanoma types of skin cancers), and melanoma. Basal cell carcinoma is by far the most common of the three. A variety of methods, including excisional surgery, radiation therapy, curettage combined with electrical burning, and freezing (cryosurgery) techniques are used to treat skin cancer. Mohs is a special type of excision surgery that is explained below. 

WHAT ARE THE CAUSES OF SKIN CANCER? 

The causes of skin cancer, like other forms of cancer, are not completely known. Excessive exposure to sunlight is the single most important factor associated with the development of skin cancers on the face and arms. Fair skinned people develop skin cancers more frequently than dark skinned people. Skin cancers also tend to be hereditary and occur very frequently in certain ethnic groups, especially those with fair complexions, such as Northern Italians and people from Northern Europe. Other possible factors contributing to the development of skin cancer include x-ray, trauma, and certain chemicals. 

HOW DOES SKIN CANCER BEGIN? 

Skin cancer begins in the uppermost layers of the skin and grows downward, sometimes spreading horizontally along the surface of the skin. Unfortunately, these extensions cannot be directly seen. Therefore, what is apparent to the naked eye on the surface of the skin may be only the "tip of the iceberg". 

IS SKIN CANCER DANGEROUS? 

The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. Basal cell carcinoma enlarges locally from the point of origin and usually does not spread (metastasize) to distant parts of the body. Squamous cell carcinoma does have the potential to metastasize to regional lymph nodes and beyond and should be evaluated and treated appropriately. These types of skin cancers are generally recognized in the early stages and are more easily cured. However, if not completely removed, both types will frequently invade and destroy structures in their path. 

Malignant melanoma may be life threatening if not treated early. It usually appears as a brownish-black spot or bump on the skin, which enlarges and sometimes bleeds. Occasionally melanomas originate in moles which have been present for many years. 

MOHS SURGERY 

WHAT IS MOHS SURGERY? 

Mohs Surgery is a highly specialized procedure for the total removal of skin cancer. There are three surgical steps to Mohs Surgery: 

1. The surgical removal of the visible portion of the skin cancer with excision or curettage. 
2. The surgical removal of a thin layer of tissue at the bed and complete outer margin of the cancer. 
3. The examination of the excised tissue under the microscope. 

By examining the bottom portion (i.e. entire outer margin: lateral, base, etc.) of the tissue, the surgeon is able to trace out and exactly locate any additional areas of cancer remaining. Before the tissue is examined, it is marked with colored dyes to distinguish top from bottom and right from left. By doing this, we are able to pinpoint the exact location of any remaining tumor during the microscopic examination. If more cancer is present, the procedure is repeated. Only the area of remaining cancer is removed. 

ADVANTAGES OF MOHS SURGERY 

Using microscopic examination, the surgeon pinpoints areas involved with cancer and selectively removes only those areas. In this way, skin cancer is traced out to its roots. This results in preserving as much normal tissue as possible with the highest chance for cure. 

THE HIGHEST CHANCE OF CURE - MOHS SURGERY 

Because Mohs surgery uses complete systematic microscopic control to search out the roots of the cancer, it cures almost all patients (97-99%) - even those in whom skin cancer has persisted in spite of several other treatments. 

PREPARING FOR MOHS SURGERY 

GETTING READY FOR MOHS SURGERY 

• Try to get a good night's rest. 
• In most cases, we allow our patients to eat a light breakfast unless informed otherwise by your physician. 
• If you are taking any medications, take them as usual unless directed otherwise (see Medication Precautions handout). 
• We request that you do not take any aspirin or aspirin containing products for two weeks prior to the surgery (again, see Medication Precautions above). There are other medications that thin your blood and cause more bleeding, such as coumadin, etc. If you are on any of these medications, please consult the physician who is prescribing the medication to see if we can remove this medication for a few days. In any case, we will follow your physician's recommendation(s). 
• Please do not drink any alcoholic beverages for 12 hours prior to your surgery. Alcohol causes blood vessels to dilate and could aggravate bleeding problems. It is a good idea to bring a laptop, book or magazine with you on the day of surgery. The procedure may take a full day, much of which you will spend in the waiting room. During this time your removed tissue will be processed in our laboratory and examined by your physician/ surgeon under the microscope in our Mohs laboratory. 

THE DAY OF THE SURGERY 

Please note that you might need to have someone drive you home from the procedure, depending on the location of the lesion (i.e, near the eye) and / or medications that might be required. 

When you arrive for surgery, the surgical assistant will take you to the surgery suite and prepare the involved area of the skin for surgery. If you have any additional questions, feel free to ask them. The physician surgeon will also see you at this time and review your case. 

The area of skin (tissue) containing cancer will then be anesthetized with a local anesthetic. It usually takes a few minutes to anesthetize the involved area. The surgeon will then remove the cancerous area. After the tissue has been removed, the bleeding will be stopped with a cauterizing machine, which generates heat. Before you leave the surgical suite, the surgical assistant will cover your wound with a bandage. The tissue will be sent to the laboratory for examination. 

It will then take approximately two to three hours to prepare the tissue for microscopic examination. If examination of the tissue removed reveals that your tissue still contains cancer cells, the procedure will be repeated. Several excisions and microscopic exams may be done in one day. It is seldom necessary for you to return the following day for additional surgery. The average number of surgical sessions for most skin cancers is two to three. 

THE SURGICAL WOUND 

When the skin cancer has been completely removed, a decision is made on the best method for treating the wound created by the surgery. The methods include: 

1. Closing the wound directly with stitches (sutures); 
2. Letting the wound heal by itself (granulation); 
3. Closing the wound with a skin graft or flap. 

We will recommend which of these methods will be best for your individual case. Repairs may be completed by us or by other surgical specialists. Each patient is unique and we must individualize your treatment to achieve the best results. 

You may experience a sensation of tightness (or drawing) as the wound heals, and this is normal. As time progresses, you will feel this less and less. On occasion, skin cancers involve nerves and it may be one or two years before your sensation returns to normal. In some cases, the numbness may be permanent. Any form of surgery will leave a scar. The Mohs procedure tends to minimize this as much as possible. Mohs surgeons try to remove only those tissues involved with cancer and preserve as much normal tissue as possible. We make every effort to obtain the optimal cosmetic results for you and work in conjunction with other surgical specialists in the field of cosmetic and cutaneous surgery. 

The new skin that grows over the wound may contain many more blood vessels than the skin that was removed. This results in a red scar and the area may be sensitive to temperature changes. This sensitivity improves with time and the redness gradually fades. If you are having a lot of discomfort, avoid extreme temperatures. You may experience itching after your wound is healed because the new skin does not contain as many oil glands. Petroleum jelly will help relieve the itching.