Q: Am I put to sleep for my Mohs surgery?
A: In Canada, patients are not put to sleep under general anesthesia for their Mohs surgery. The main reason is that there are many long waiting periods for Mohs surgery, during which time the pathology portion of the care is occurring. If a patient is under general anesthesia for these long periods, where no active surgery is occurring, this can often be very bad for the typically elderly patient with skin cancer. Reports of irreversible changes in cognition have been reported.
Light oral sedation may be used for nervous patients undergoing local anesthetic procedures, but they must arrange for alternate transportation from the centre as a patient is not able to drive a vehicle after receiving sedating drugs. Patients failing to heed these instructions will be required to sign a disclaimer releasing Dr. Cowan and the Skin Care Centre from any responsibility if a patient is driving after surgery.
Q: How long will the surgery be?
A: Even at the start of your surgery it will be difficult for Dr. Cowan to predict the exact length of your surgery. Cancers can spread quite a distance from the visible cancer on the skin surface. Every cancer case is different and may require a different number of surgical levels to remove the cancer. The entire procedure of cancer removal and reconstruction is done on the same day but will take most of the day (6-10+ hours). Be prepared to stay with us for the entire day and have food and entertainment materials with you.
Q: What is a surgical level?
A: Dr. Cowan will remove all of the visible cancer on your skin during the first step, however there are also cancer roots that cannot be seen on the surface. The removed tissue is then processed onto microscope slides for Dr. Cowan to analyze. The removal of tissue takes about 10-15 minutes each time and is followed in every case by the processing of tissue into slides (approximately 45-90 minutes depending on the amount of tissue and number of tissue pieces required). Each removal and processing is called a “Mohs’ level”. There are typically two or more levels to each case.
A: In Canada, patients are not put to sleep under general anesthesia for their Mohs surgery. The main reason is that there are many long waiting periods for Mohs surgery, during which time the pathology portion of the care is occurring. If a patient is under general anesthesia for these long periods, where no active surgery is occurring, this can often be very bad for the typically elderly patient with skin cancer. Reports of irreversible changes in cognition have been reported.
Light oral sedation may be used for nervous patients undergoing local anesthetic procedures, but they must arrange for alternate transportation from the centre as a patient is not able to drive a vehicle after receiving sedating drugs. Patients failing to heed these instructions will be required to sign a disclaimer releasing Dr. Cowan and the Skin Care Centre from any responsibility if a patient is driving after surgery.
Q: How long will the surgery be?
A: Even at the start of your surgery it will be difficult for Dr. Cowan to predict the exact length of your surgery. Cancers can spread quite a distance from the visible cancer on the skin surface. Every cancer case is different and may require a different number of surgical levels to remove the cancer. The entire procedure of cancer removal and reconstruction is done on the same day but will take most of the day (6-10+ hours). Be prepared to stay with us for the entire day and have food and entertainment materials with you.
Q: What is a surgical level?
A: Dr. Cowan will remove all of the visible cancer on your skin during the first step, however there are also cancer roots that cannot be seen on the surface. The removed tissue is then processed onto microscope slides for Dr. Cowan to analyze. The removal of tissue takes about 10-15 minutes each time and is followed in every case by the processing of tissue into slides (approximately 45-90 minutes depending on the amount of tissue and number of tissue pieces required). Each removal and processing is called a “Mohs’ level”. There are typically two or more levels to each case.
Q: Why does the day take so long?
A: Mohs surgery is a step-by-step tumor removal. It is labor intensive, and highly precision dependent, but this is how we achieve such a high accuracy for removal of the tumor.
Each step requires approximately 15 minutes for tissue removal followed by 45-60+ minutes of tissue and slide processing. As 95% of Mohs cases require two or more tumor removal levels, it may take most of the morning to remove your cancer before Dr. Cowan starts any reconstructions. Also, as other patients are also having the same procedure on your surgical day, your reconstruction will be triaged by Dr. Cowan, with the simpler reconstruction occurring first for time efficiency. Be prepared to spend the day.
Q: Why do I have to bring reading material and a lunch?
A: The entire Mohs process takes a full day. All patients are brought into the facility to allow surgery to commence at 7:30 AM. If you are not called into a room at precisely 7:30, don’t be worried as you still may be the first of Dr. Cowan’s patients to leave, depending on the complexity of your reconstruction. Patients are able to sit in a special waiting room with a water cooler, television, coffee, and a bar fridge to keep food cold.
Q: Can I bring a caregiver or loved-one to the procedure?
A: Yes! Dr. Cowan insists on an escort to drive patients home from the surgery centre, but there is room to have one friend or loved one with you on the day of surgery. If you bring more than one companion, they will be asked to wait in the external waiting room with little contact with you for the entire day. Unfortunately, the specialized Mohs waiting room was originally designed for smaller caseloads than the numbers requiring care today and cannot accommodate large numbers. The office staff and nurses strictly enforce this policy.
Q: How big a defect will you make?
A: As cancers grow underneath what may appear to be normal skin, the extent of cancer growth is very hard to predict. The defect made in the removal of the cancer is often bigger that the portion of the cancer you see on the surface of your skin. In general, the bigger the visible cancer, the bigger the final defect.
Q: What type of reconstruction will I need?
A: The type of reconstruction required after removal of your cancer is impossible to predict before Mohs surgery. By the nature of the surgery and its tissue preservation aim, your post-cancer defect will be as small as possible, limited only by the extent of your cancer. It is important to realize that cancers can often spread much wider and deeper than we can predict initially, and that you may have a much larger defect than you might have predicted once the cancer has been removed. Reconstructions required vary from simple wound closure to local tissue flap, skin grafts and complex, multi-staged reconstructions.
Q: What will I look like after the surgery?
A: As a Plastic and Reconstructive surgeon trained by Canada’s Royal College of Physicians and Surgeons, Dr. Cowan will always offer you the best reconstruction in every specific case. In many cases, this involves additional cuts on adjacent skin to intricately move local skin to close the cancer defect in a cosmetically sensitive way. In plastic surgery the best closures are often achieved with similar skin to the skin being removed, and the best place to get this is beside the cancer defect. In some cases, due to tissue quality, location or large size of the wound, a skin graft or distant “multi-staged” flap may be required to close your wound.
Initially, wounds appear raised and red. Local tissue can be tight and stretched. It takes many months of healing before the tissues settle. Scar improving agents are available at an additional cost through the office. We can also make recommendations for early sunscreens and concealing agents that you may find valuable. Unfortunately, cancers do not always grow in concealed spots and you often have to wait approximately 12 months before you can truly assess the cosmetic success of the reconstruction.
Q: Will I need further surgery?
A: In Mohs surgery, the pathologic clearance of the cancer is simultaneously performed with the removal. In this way, at the end of your surgical day you will be informed that the cancer has been completely removed BEFORE any reconstruction is performed. This is unlike surgical excision of cancer by non-Mohs surgeons, where the clearance of the cancer, or presence of residual cancer, is often reported 10-12 days after surgical closure. In many cases of non-Mohs excision, the best tissue for repair has been used for the first closure, before tumor clearance is known. If residual disease is found, this additional healthy tissue often must be sacrificed in the cancer removal, leaving less adequate tissue for closure and ultimately a poorer cosmetic outcome. In 5% of all cases, additional surgery is required for cosmetic revision.
Q: Are other treatments more appropriate?
A: Mohs micrographic surgery is the “gold-standard” for non-melanoma skin cancer excision, with the highest cure rates available for treatment of the majority of tumors. Certain patient and tumor conditions may result in Dr. Cowan arranging alternative treatment. A few examples are clinical well-defined cancers of the head and neck; extensive neglected cancers in the very elderly; patients that are not able to mobilize from the operative to waiting room multiple times during the day; or individuals with unique medical conditions best suited to surgical treatment in the main hospital.
Q: Who will be performing my Mohs surgery?
A: Dr. Cowan or his surgical fellow (under Dr. Cowan’s supervision) will be performing your surgery. Surgical fellows are internationally certified dermatologists or surgeons who have been assigned to the Vancouver training centre by the American College of Mohs Surgery to train in Mohs surgery. Unfortunately, due to the high demand for Mohs surgery in Canada, and in an effort to increase the number of surgeons performing this critical care, surgical fellows must be involved in the care. In addition, as Assistant Clinical Professor at UBC, Dr. Cowan will often have senior dermatology, plastic surgery or ENT residents with him that may participate in your care. Be assured that medical students do not perform this intricate work, but also that a team approach is the only way to accommodate the current caseload.
Q: Can I fly right after my surgery?
A: Dr. Cowan recommends that you use ground transportation for at least the first 7 days after surgery. Flying before that time may result in you being in a compromised position should your wounds start to bleed or you experience other post-operative difficulties that could be aggravated by cabin pressurization, and you would not have access to timely, appropriate medical care in-flight. Although problems in flight after 7 days are rarer, they can occur, and the decision to fly and the associated risks are yours to assume should you do so.
Q: What drugs do I have to stop before the operation?
A: Please stay on all of your normal medications and take them on the day of surgery, with the exception of (Aspirin) ASA and all non-steroidal anti-inflammatory drugs. These should all be stopped 10 days prior to surgery. Dr Cowan recommends that you put this on your calendar when you get your surgical date to ensure that you remember to do this. If you have medications provided in blister packs and do not know which tablets are the blood thinners, speak to your pharmacist so that these specific drugs can be taken out of the packs prior to your surgery.
Q: What are the common blood thinners that a patient can be on?
A: Coumadin (Warfarin), Plavix (Clopidogrel), ASA (Aspirin, Acetylsalicylic Acid) ticlodipine, dipyridamole, Pradaxa (dabigatran), apixaban and heparin. Ask your family doctor or pharmacist if you are not sure.
Q: How far ahead do I have to stop my blood thinners?
A: Completely avoid aspirin, or other anti-inflammatory medications ideally for 10 days before your surgery. These medications interfere with blood clotting and may cause excess bleeding or the development of a hematoma that can significantly reduce the success of your surgical repair. Anti-inflammatory drugs are also often included in many over-the-counter drug products such as Alka Seltzer, Anacin, Bufferin, Bayer Cold Tablets, Excedrin, or Talwin. Tylenol (acetaminophen) does not affect the blood clotting system and can be used safely up until surgery.
If you are on Coumadin (Warfarin), Plavix, Eliquis, or any other stronger prescription blood thinner, consult your family doctor or prescribing physician to determine if it is safe to stop this medication prior to your surgery. In some cases these medications may only require 3- 5 days termination, prior to surgery, to normalize clotting and in many cases will improve the success of your surgery, reduce bleeding risks, and make available reconstruction procedures that are not performed on anticoagulated patients. In some cases, your family doctor can arrange “bridging anticoagulation”.
Q: Do I take my regular medications other than blood thinners?
A: Yes! Over the years this has often been a point of confusion for our most elderly patients. Your routine medications are valuable in maintaining balance of your blood pressure, sugar levels, lipid levels, anxiety and other medical conditions. As you can eat the night before and throughout the day of your Mohs surgery, these medications will maintain you normal body function during that time and make surgery easier. Failure to remain on your other normal medications may result in elevated blood pressure or sugar levels that can result in the cancellation of your surgery.
Q: Do any other aspects of my diet affect bleeding?
A: Alcohol can affect your bleeding time. Avoid alcohol for three days before and after your surgery. Garlic, hawthorn, Vitamin E, omega-3 fatty acids like fish oil, flaxseed oil and mesoglycan, selenium, vitamin C, folic acid, vitamins B6 and B12, betaine, policosanol and coenzyme Q10 supplements, Bilberry, ginger and ginkgo can also affect bleeding.
Q: I am a smoker. I have heard that this may negatively affect my surgery. Is that true?
A: Yes! It has been well proven that cigarette smokers have a much higher rate of post-operative infections and death (necrosis) of tissues moved in the process of reconstruction. Due to this fact, all smokers are instructed to stop smoking or dramatically reduce their smoking prior to and after cancer surgery. Failure to reduce smoking may be very detrimental to your surgical outcome.
Q: Could my surgery get cancelled on the day?
A: Yes! In some specific cases, the physician that has referred you for Mohs surgery may not have provided Dr. Cowan with critical information about either your health or your specific cancer (it’s size, duration or prior treatments). If your surgery requires stabilization of your current medical condition, if your cancer is too advanced to be treated under local anesthesia, or if additional surgeons need to be arranged to assist in your care, your case may be cancelled and rescheduled. Understand that in the 1000-1200 cases that occur each year, this happens to less than 25 cases. Dr. Cowan has created a specialized referral form for Mohs cases, but this has not been adopted, or complied with, by all referring doctors.
Q: Why do I have to wait until the morning of surgery to meet Dr. Cowan?
A: There are currently only 17+ Mohs trained surgeons in Canada, making this surgical procedure the one of the most highly demanded surgical procedures in the country. To efficiently treat as many patients as possible, Dr. Cowan relies on comprehensive referrals from your referring physicians. In addition, Dr. Cowan’s practice area encompasses all of British Columbia, the Yukon and North West Territories, and extends to the underserviced areas of the prairies. Even though referrals for Mohs have been essentially restricted to within BC for the last 5 years, the high demand for ongoing surgery makes pre-consultation essentially impossible unless the specific nature of the case demands it.
Q: Can I receive Mohs care by Dr. Cowan if I am not a Canadian?
A: Dr. Cowan does offer Mohs surgery to non-residents of Canada. Given the long waiting list for Mohs surgery in the province of BC, this is only done on a specific case-by-case basis. Non-citizens of Canada must sign a specific legal waiver, a standard for performing surgery on any non-Canadian in this country, stating that any legal issues relating to surgery or interactions with the surgeon or the centre must be conducted through Canadian courts and by Canadian legal system.
Q: Why does the day take so long?
A: Mohs surgery is a step-by-step tumor removal. It is labor intensive, and highly precision dependent, but this is how we achieve such a high accuracy for removal of the tumor.
Each step requires approximately 15 minutes for tissue removal followed by 45-60+ minutes of tissue and slide processing. As 95% of Mohs cases require two or more tumor removal levels, it may take most of the morning to remove your cancer before Dr. Cowan starts any reconstructions. Also, as other patients are also having the same procedure on your surgical day, your reconstruction will be triaged by Dr. Cowan, with the simpler reconstruction occurring first for time efficiency. Be prepared to spend the day.
Q: Why do I have to bring reading material and a lunch?
A: The entire Mohs process takes a full day. All patients are brought into the facility to allow surgery to commence at 7:30 AM. If you are not called into a room at precisely 7:30, don’t be worried as you still may be the first of Dr. Cowan’s patients to leave, depending on the complexity of your reconstruction. Patients are able to sit in a special waiting room with a water cooler, television, coffee, and a bar fridge to keep food cold.
Q: Can I bring a caregiver or loved-one to the procedure?
A: Yes! Dr. Cowan insists on an escort to drive patients home from the surgery centre, but there is room to have one friend or loved one with you on the day of surgery. If you bring more than one companion, they will be asked to wait in the external waiting room with little contact with you for the entire day. Unfortunately, the specialized Mohs waiting room was originally designed for smaller caseloads than the numbers requiring care today and cannot accommodate large numbers. The office staff and nurses strictly enforce this policy.
Q: How big a defect will you make?
A: As cancers grow underneath what may appear to be normal skin, the extent of cancer growth is very hard to predict. The defect made in the removal of the cancer is often bigger that the portion of the cancer you see on the surface of your skin. In general, the bigger the visible cancer, the bigger the final defect.
Q: What type of reconstruction will I need?
A: The type of reconstruction required after removal of your cancer is impossible to predict before Mohs surgery. By the nature of the surgery and its tissue preservation aim, your post-cancer defect will be as small as possible, limited only by the extent of your cancer. It is important to realize that cancers can often spread much wider and deeper than we can predict initially, and that you may have a much larger defect than you might have predicted once the cancer has been removed. Reconstructions required vary from simple wound closure to local tissue flap, skin grafts and complex, multi-staged reconstructions.
Q: What will I look like after the surgery?
A: As a Plastic and Reconstructive surgeon trained by Canada’s Royal College of Physicians and Surgeons, Dr. Cowan will always offer you the best reconstruction in every specific case. In many cases, this involves additional cuts on adjacent skin to intricately move local skin to close the cancer defect in a cosmetically sensitive way. In plastic surgery the best closures are often achieved with similar skin to the skin being removed, and the best place to get this is beside the cancer defect. In some cases, due to tissue quality, location or large size of the wound, a skin graft or distant “multi-staged” flap may be required to close your wound.
Initially, wounds appear raised and red. Local tissue can be tight and stretched. It takes many months of healing before the tissues settle. Scar improving agents are available at an additional cost through the office. We can also make recommendations for early sunscreens and concealing agents that you may find valuable. Unfortunately, cancers do not always grow in concealed spots and you often have to wait approximately 12 months before you can truly assess the cosmetic success of the reconstruction.
Q: Will I need further surgery?
A: In Mohs surgery, the pathologic clearance of the cancer is simultaneously performed with the removal. In this way, at the end of your surgical day you will be informed that the cancer has been completely removed BEFORE any reconstruction is performed. This is unlike surgical excision of cancer by non-Mohs surgeons, where the clearance of the cancer, or presence of residual cancer, is often reported 10-12 days after surgical closure. In many cases of non-Mohs excision, the best tissue for repair has been used for the first closure, before tumor clearance is known. If residual disease is found, this additional healthy tissue often must be sacrificed in the cancer removal, leaving less adequate tissue for closure and ultimately a poorer cosmetic outcome. In 5% of all cases, additional surgery is required for cosmetic revision.
Q: Are other treatments more appropriate?
A: Mohs micrographic surgery is the “gold-standard” for non-melanoma skin cancer excision, with the highest cure rates available for treatment of the majority of tumors. Certain patient and tumor conditions may result in Dr. Cowan arranging alternative treatment. A few examples are clinical well-defined cancers of the head and neck; extensive neglected cancers in the very elderly; patients that are not able to mobilize from the operative to waiting room multiple times during the day; or individuals with unique medical conditions best suited to surgical treatment in the main hospital.
Q: Who will be performing my Mohs surgery?
A: Dr. Cowan or his surgical fellow (under Dr. Cowan’s supervision) will be performing your surgery. Surgical fellows are internationally certified dermatologists or surgeons who have been assigned to the Vancouver training centre by the American College of Mohs Surgery to train in Mohs surgery. Unfortunately, due to the high demand for Mohs surgery in Canada, and in an effort to increase the number of surgeons performing this critical care, surgical fellows must be involved in the care. In addition, as Assistant Clinical Professor at UBC, Dr. Cowan will often have senior dermatology, plastic surgery or ENT residents with him that may participate in your care. Be assured that medical students do not perform this intricate work, but also that a team approach is the only way to accommodate the current caseload.
Q: Can I fly right after my surgery?
A: Dr. Cowan recommends that you use ground transportation for at least the first 7 days after surgery. Flying before that time may result in you being in a compromised position should your wounds start to bleed or you experience other post-operative difficulties that could be aggravated by cabin pressurization, and you would not have access to timely, appropriate medical care in-flight. Although problems in flight after 7 days are rarer, they can occur, and the decision to fly and the associated risks are yours to assume should you do so.
Q: What drugs do I have to stop before the operation?
A: Please stay on all of your normal medications and take them on the day of surgery, with the exception of (Aspirin) ASA and all non-steroidal anti-inflammatory drugs. These should all be stopped 10 days prior to surgery. Dr Cowan recommends that you put this on your calendar when you get your surgical date to ensure that you remember to do this. If you have medications provided in blister packs and do not know which tablets are the blood thinners, speak to your pharmacist so that these specific drugs can be taken out of the packs prior to your surgery.
Q: What are the common blood thinners that a patient can be on?
A: Coumadin (Warfarin), Plavix (Clopidogrel), ASA (Aspirin, Acetylsalicylic Acid) ticlodipine, dipyridamole, Pradaxa (dabigatran), apixaban and heparin. Ask your family doctor or pharmacist if you are not sure.
Q: How far ahead do I have to stop my blood thinners?
A: Completely avoid aspirin, or other anti-inflammatory medications ideally for 10 days before your surgery. These medications interfere with blood clotting and may cause excess bleeding or the development of a hematoma that can significantly reduce the success of your surgical repair. Anti-inflammatory drugs are also often included in many over-the-counter drug products such as Alka Seltzer, Anacin, Bufferin, Bayer Cold Tablets, Excedrin, or Talwin. Tylenol (acetaminophen) does not affect the blood clotting system and can be used safely up until surgery.
If you are on Coumadin (Warfarin), Plavix, Eliquis, or any other stronger prescription blood thinner, consult your family doctor or prescribing physician to determine if it is safe to stop this medication prior to your surgery. In some cases these medications may only require 3- 5 days termination, prior to surgery, to normalize clotting and in many cases will improve the success of your surgery, reduce bleeding risks, and make available reconstruction procedures that are not performed on anticoagulated patients. In some cases, your family doctor can arrange “bridging anticoagulation”.
Q: Do I take my regular medications other than blood thinners?
A: Yes! Over the years this has often been a point of confusion for our most elderly patients. Your routine medications are valuable in maintaining balance of your blood pressure, sugar levels, lipid levels, anxiety and other medical conditions. As you can eat the night before and throughout the day of your Mohs surgery, these medications will maintain you normal body function during that time and make surgery easier. Failure to remain on your other normal medications may result in elevated blood pressure or sugar levels that can result in the cancellation of your surgery.
Q: Do any other aspects of my diet affect bleeding?
A: Alcohol can affect your bleeding time. Avoid alcohol for three days before and after your surgery. Garlic, hawthorn, Vitamin E, omega-3 fatty acids like fish oil, flaxseed oil and mesoglycan, selenium, vitamin C, folic acid, vitamins B6 and B12, betaine, policosanol and coenzyme Q10 supplements, Bilberry, ginger and ginkgo can also affect bleeding.
Q: I am a smoker. I have heard that this may negatively affect my surgery. Is that true?
A: Yes! It has been well proven that cigarette smokers have a much higher rate of post-operative infections and death (necrosis) of tissues moved in the process of reconstruction. Due to this fact, all smokers are instructed to stop smoking or dramatically reduce their smoking prior to and after cancer surgery. Failure to reduce smoking may be very detrimental to your surgical outcome.
Q: Could my surgery get cancelled on the day?
A: Yes! In some specific cases, the physician that has referred you for Mohs surgery may not have provided Dr. Cowan with critical information about either your health or your specific cancer (it’s size, duration or prior treatments). If your surgery requires stabilization of your current medical condition, if your cancer is too advanced to be treated under local anesthesia, or if additional surgeons need to be arranged to assist in your care, your case may be cancelled and rescheduled. Understand that in the 1000-1200 cases that occur each year, this happens to less than 25 cases. Dr. Cowan has created a specialized referral form for Mohs cases, but this has not been adopted, or complied with, by all referring doctors.
Q: Why do I have to wait until the morning of surgery to meet Dr. Cowan?
A: There are currently only 17+ Mohs trained surgeons in Canada, making this surgical procedure the one of the most highly demanded surgical procedures in the country. To efficiently treat as many patients as possible, Dr. Cowan relies on comprehensive referrals from your referring physicians. In addition, Dr. Cowan’s practice area encompasses all of British Columbia, the Yukon and North West Territories, and extends to the underserviced areas of the prairies. Even though referrals for Mohs have been essentially restricted to within BC for the last 5 years, the high demand for ongoing surgery makes pre-consultation essentially impossible unless the specific nature of the case demands it.
Q: Can I receive Mohs care by Dr. Cowan if I am not a Canadian?
A: Dr. Cowan does offer Mohs surgery to non-residents of Canada. Given the long waiting list for Mohs surgery in the province of BC, this is only done on a specific case-by-case basis. Non-citizens of Canada must sign a specific legal waiver, a standard for performing surgery on any non-Canadian in this country, stating that any legal issues relating to surgery or interactions with the surgeon or the centre must be conducted through Canadian courts and by Canadian legal system.