If you’re facing skin cancer treatment, you likely have questions about what lies ahead. In this patient-focused video guide, Dr. Winchester shares his extensive expertise as a micrographic surgeon at Ada West Dermatology to help answer your most pressing concerns about Mohs surgery. With over 14,000 successful cases performed, Dr. Winchester offers clear, practical insights into this sophisticated surgical technique.
Drawing from his experience since joining Ada West Dermatology in 2017, Dr. Winchester walks you through every step of the Mohs surgery journey—from what to bring on surgery day to what you can expect during recovery. You’ll discover why this precise procedure has become the preferred treatment for basal cell and squamous cell carcinomas, offering both outstanding cure rates and the best possible cosmetic outcomes.
This comprehensive guide addresses the questions patients ask most often, including concerns about scarring, recovery time, and preparation steps. Whether you’re scheduled for surgery or still exploring your treatment options, Dr. Winchester’s straightforward, caring explanation will help you feel more confident and prepared for your procedure.
Watch Time: 12:00 minutes
Transcript:
What is micrographic Mohs surgery?
Hello, I’m Dr. Winchester. I’ve been here since 2017. I’m a micrographic surgeon here at ADO West Dermatology, so I prefer Micrographic surgery. Also called MOH surgery after the inventor of MOH surgery, Frederick Mohs. It’s a procedure that was developed in order to treat skin cancers like basal cell carcinoma, squamous cell carcinoma, and now it’s used to treat almost any skin cancer you can think of. It’s a procedure where we numb the skin excise around the original biopsy site and evaluate the skin under the microscope using what we call horizontal sections. The top layer of the skin is called the epidermis. The epidermis is a defined skin margin, so that means that if we have the epidermis on every slide, we know where that margin is. We’re able to evaluate that and assure that we have a clear margin while the patient’s still here. And if we see cancer, we have a way of mapping that out.
That’s where the graphic part of micrographic surgery comes from. That allows us to be very precise about where we remove more skin. That gives us a better curate. It also allows us to be more precise and have a smaller defect or smaller amount of skin removed, which as you could imagine means we can reconstruct that skin in a way that has the least amount of damage to you. The traditional conventional way of removing skin when it wasn’t done with MOH surgery is to take the skin out and cut it with what we call bread loaf slices or permanent vertical sectioning. And that is a very good way to look at the skin when you’re looking for skin architecture, which the pathologists need to make a good diagnosis. We don’t use that method here, which sacrifices a little bit of the skin architecture on our views.
That’s okay. We know the diagnosis when we’re working on you. We just need to know if said diagnosis is at the margin, and that’s why we use our horizontal micrographic surgery or mos sectioning to give you that precise clear margin with the least amount of damage to you so that way when you leave here, you know that your cancer’s been removed and that it has the best cure rate that it could possibly have. And that also means that when you walk out of here, we’ve done the least amount of skin removal on you that we could do. So to be able to have the best curate and the least invasiveness, that’s a very unique thing. That’s why most surgery stands as the gold standard and is yet to be replaced for most patients.
What happens on surgery day?
What happens is this is an outpatient procedure, so you arrive at our clinic, you’re treated in a surgical suite just like this.(see video) It might even be this very same one here. You check in at the front, we bring you back, we do some vital signs on you and go over history with you to make sure we’ve looked over anything that might be related to our surgery and can address that. And then your experience here is that you’re awake during your procedure while we’re working on you. We’re very, very aware of that. And so we assure that after we’ve marked everything out and kind of described this procedure to you, we numb your skin and we have a little distraction technique we use for that where we vibrate your skin and then inject it as it’s being vibrated to distract you. And once it’s numb, it’s numb and we keep numbing it every time we come back if we have to take more skin or do the repair. But usually you don’t feel much of that.
So your experience here is you come and you sit down and go through all that process with us, and we take great pride in being able to get you distracted. In fact, it’s one of my favorite parts of the job is to get your mind off of your surgery swept away into something else while we focus intently on getting your cancer removed and then getting you fixed up. So generally you come, you get the removal done, it takes us a mere a few minutes, and then you spend some time waiting while my lab is processing it or Dr. Thorpe or Dr. Busman’s labs. It’s all the same type of procedure. And then if we need to take more skin, we bring it back, we remove some more. We do it till it’s all gone over 90% of the time. We get it in the first two attempts.
So we’re generally not trying to keep you here all day. It’s the benefit of you and us to get this removed efficiently. And then we repair it, and that can take a few minutes. So you’re here usually for a few hours, sometimes very short, sometimes a little longer than that, and a lot of the time you’re waiting and whether that’s in the room here or in the waiting room, and then we leave you with a bandage, a set of instructions that includes a video that you can watch that goes over wound care and bandaging. You have my phone number available to you or Dr. Boothman or Dr. Thorpe’s phone number if you’re treated by them. That way we don’t cast you off into the wilderness alone. We’re here for you at any time of the day if you need any help afterwards. But between our instructions and everything, most of our patients go home very comfortable knowing how to manage it over the next few days and then we’ll check in with you and oftentimes remove sutures and if needs be, follow you up in consecutive visits afterwards.Oftentimes that’s not necessary. So that’ll all be determined your day of your surgery.
How large will my scar be?
A lot of patients ask how large will their scar be? That very much is determined by how large the cancer is and the location of where it is. We are very interested in getting your cancer removed and reconstructed with the least amount of invasiveness possible. That’s one of the things that most surgery does that makes it so unique. So we can’t really determine that. Like I said, if you were to grow a skin cancer right at the tip of your nose versus right in the middle of your cheek, those are going to both require different types of repairs. Your nose is, for example, a very dynamically convex surface. It’s got a lot of unique anatomy. Doing a real simple side-to-side closure oftentimes isn’t available as an option without distorting your nose, so that might require a little bit of finesse work by us to move the skin around in a way that’s going to maintain the shape and form of your nose.
Whereas in the middle of your cheek, they can get quite large and we can still repair ’em by just pulling ’em together in a nice thin line. And another thing to keep in mind is when Dr. Thorpe or myself or Dr. Boothman work on you, our number one priority of course is to get the cancer out. But after that, it’s to reconstruct your face, to put your symmetry back. And so when we look at each other, we don’t notice people’s lines. You might think that they notice your lines. They really don’t. They notice whether your face is symmetric or not. So if we reconstruct anything, we want your facial symmetry back. So we don’t want divots dents or bumps. So we’re going to make that line in a way that’s going to assure that your cheek or your nose or wherever we work has got its contour and shape back without any asymmetries because that’s the most important thing for when somebody looks at you.
Taking care of your skin after Mohs surgery
Once we’re done repairing, you will usually have a scar. It’s hard to remove skin and not have scar tissue form. Of course, we do everything we can to optimize that. So you have the least amount of scarring you could possibly have. And then after that, it’ll take some time to heal. We cut through the skin and suture it up. It’s a relatively deep injury. It’s going to take some time. It’s going to take a few weeks at least to get sealed over. Then there’s often a course, depending on how far we went, where it might be a bit discolored, and we’ll give you lots of instructions that talk about protecting your skin from the sun. The sun can make your scar more prominent. So using sunscreen and covering, it’s going to be important. We want to keep the scar moist and we have some products available that can help put that scar line in the most optimal position available, such as ciy, sometimes Vaseline alone and certain people’s scars is going to be sufficient for that.So we will help you find the most optimal way to keep your scar as minimally noticeable as it could possibly be.
When can I resume normal activites after mohs surgery?
Patients will often ask us how long it takes to go back to normal activities. That very much also depends on your unique skin cancer, the location and the repair. Sometimes within a few days you’re back to most of your normal activities, sometimes even the next day. But there will often be restrictions on how much you can lift and how high you can get your blood pressure up. Because once we remove these skin cancers, frequently they require some suturing and those blood vessels, once they’re sutured down, there’s still a bit fragile. And if you get your blood pressure up, or especially if you put tension or torque on that scar line, that could really compromise it. So we get into specific details during your surgical day, but in some cases that might be a couple of weeks before you do anything really strenuous.
But for most patients within a day or two, they can start moving around the house, going up and down stairs, attending their daily activities, even usually the same day for those. But we’ll get into specific detail your day of your surgery.
Do I need someone to drive me?
Some patients will ask, does somebody need to drive me? For most cases, patient, we would want someone to drive you. There are rare exceptions, but it’s often nice to have someone here who can take you back home, especially if we’re working in the middle of your face, even though the spot might not look like it’s by your eye, by the time we put a pressure dressing on there, which is really a requirement to keep you from bleeding, the bulky bandage might limit some of your visual fields, so having someone who can drive you is helpful. Like I said, there are occasionally exceptions and our schedulers can discuss that with you.
How do I prepare for Mohs surgery?
Patients will often ask how they prepare for their surgery. It’s important to know that if we are just doing the surgery in the reconstruction for you, which is the case, 97% of the time you can come. You can eat and drink, you can take your pills like normal. We would ask you just to come ready to wait for a while. So I would try to get good night’s sleep. If you like breakfast, eat a good breakfast, come prepared to wait here for a few hours, bring a book or something to entertain yourself and bring some snacks. We have a few snacks here. They might not be the ones that you would want though, so I’d be prepared with things like that.
Dr. Winchester’s training and experience
I was lucky enough to train at the Mayo Clinic if you’ve ever gone to the Mayo Clinic or heard much about it. They do have a mission statement that guides everything they do, which is that the needs of the patient come first and foremost.
And I’ve tried to reflect that in my practice since then. Also during there, I was able to experience some cases from a broad spectrum of difficulty levels from patients really all over the world. Since then, I’ve come out here to Idaho and realized that we have quite an enormous catchment area, Dr. Thorpe, Dr. Boothman and I in a way kind of act like an academic practice here in that we get referrals from the entire region, including very rural areas where patients don’t have very good access, and these cancers can be very, very large and aggressive. And so that’s been a wonderful experience for me and for my two partners. And it’s also meant that we’ve done a very large volume of cases at this point. Even at my relatively young age, I’ve done nearly 14,000 cases. I think I was once telling someone, I don’t think there’s a square millimeter on the human body skin that I have not done surgery on multiple times.
So that vast experience in such a short amount of time due to the narrow practice scope that I have has been a wonderful thing for me. It’s provided a lot of confidence to myself for our patients in our practice here, and it’s really given me the ability to feel like I always can provide the very best thing for my patients since they’ve got such a broad experience. I know if there’s some other thing out there, patients will often ask me to, because I’m a dermatologist, to treat their veins or something like that. And they’ll often tell ’em, I want the person to treat this for you that does it the most and has the best experience, and that means that it might be somebody else.
Hope for patients needing Mohs surgery
I can feel confident that myself and Dr. Thorpe and Dr. Boothman, when we treat your skin cancer on your face, we treat it more than anyone else does, and we have the broadest experience. And I can feel confident looking at people in people’s eyes and telling you that I can give you the very best treatment that there is for this problem. And I love providing that kind hope to people and that confidence.
We love getting involved in answering your questions, and I don’t think there’s anything that makes me feel better than having someone show up anxious here, and then just seeing that anxiety just go away during the visit knowing that they can sense that they’re in the right hands and that their problem is getting addressed. I think that’s probably provided the most satisfaction of anything I’ve ever done in my job, is just knowing that I can give people the very best treatment they can get, and also give them that sense of relief and just watch that anxiety just flow away.
