Before Your Surgery

Prescription blood-thinning medications are taken by many people to prevent dangerous clots, heart attacks, and strokes. Common blood thinners include aspirin, warfarin (brand name Coumadin), clopidogrel (Plavix), apixaban (Eliquis), rivaroxaban (Xarelto), and dabigatran (Pradaxa). These medications increase bleeding during surgery. However, stopping them without medical guidance can be far more dangerous than the extra bleeding they cause. Your Mohs surgeon is trained and experienced in operating on patients who take blood thinners, and the procedure can almost always be safely completed even if you continue these medications.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), naproxen (Aleve), and similar over-the-counter pain relievers. Thin the blood by affecting platelet function (platelets are the tiny blood cells that help form clots). If you take NSAIDs regularly for pain or inflammation, discuss this with your surgical team. In general, it is best to avoid these medications in the 7 days before surgery unless they are medically necessary. If you need pain relief before your procedure, plain acetaminophen (Tylenol) does not affect bleeding and is a safe alternative.

Many vitamins, herbal supplements, and natural remedies also affect bleeding and should be stopped before surgery. Vitamin E supplements (not dietary vitamin E from food) can significantly impair platelet function. Omega-3 fatty acids (fish oil, flaxseed oil) in supplement form have a blood-thinning effect. Several herbal supplements, including garlic capsules, ginkgo biloba, ginseng, and St. John's Wort. Also increase bleeding risk. These should generally be stopped 7 to 14 days before surgery. Dietary sources of these nutrients (eating fish, for example) do not need to be changed.

Shower or bathe the evening before or the morning of your surgery. Wash the surgical area with mild soap and water. Do not apply any lotions, moisturizers, sunscreens, or makeup to the surgical area on the day of surgery, as these can interfere with skin preparation and the accuracy of surgical markings. If your surgery is on or near your scalp, wash your hair the night before. It may be difficult to wash comfortably for a few days after surgery.

Choose clothing that is comfortable and easy to put on and take off without pulling over your head, especially if the surgical area is on your face, scalp, or neck. Button-front shirts, zip-up tops, or loose cardigans are ideal. Wearing dark or patterned clothing is helpful, as small amounts of antiseptic solution (used to clean the skin before surgery) can occasionally stain light-colored fabric. Wear comfortable, flat shoes since you may be sitting or lying down for extended periods.

You will not be able to drive yourself home after surgery, even though you will not receive general anesthesia (medication that makes you fully unconscious). Local anesthesia does not impair your ability to drive, but bandages in certain locations, particularly near the eyes. May temporarily limit your vision. Additionally, the emotional experience of surgery, combined with medications you may have taken for anxiety, can affect your ability to drive safely. Arrange for a friend or family member to drive you home, or arrange a taxi or ride-sharing service before the day of surgery.

After your surgery, you will need to care for the wound at home. Gathering supplies the day before means you will not need to make a trip to the pharmacy while you are bandaged. Your doctor's office will give you specific instructions, but standard wound care supplies commonly include: plain petroleum jelly (Vaseline or equivalent) to keep the wound moist, non-stick gauze pads or sterile telfa pads, paper or hypoallergenic surgical tape (avoid rough adhesives near the face), and cotton-tipped applicators (Q-tips) for applying ointment carefully. Ask your surgical team exactly what supplies to purchase for your specific procedure.

Unlike surgeries that require general anesthesia, Mohs surgery does not require you to fast (avoid eating or drinking) beforehand. Eat a normal breakfast before you come. Having food in your stomach helps keep your blood sugar stable and reduces the chance of feeling lightheaded during or after the procedure. Take all of your regular daily medications with a small amount of water as you normally would, unless your surgical team has specifically instructed you otherwise. If you take medications at specific times of day, bring them with you in case your visit runs long.

Mohs surgery involves multiple rounds of tissue removal and lab processing, and the waiting periods between stages are a real and significant part of the day. Most patients spend 45–90 minutes waiting between each stage while tissue is processed and examined. Bringing something to keep yourself occupied will make the time pass much more comfortably. A book, magazine, e-reader, tablet, laptop, or smartphone with downloaded content (do not count on having reliable WiFi) are all good choices. Bring earbuds if you plan to listen to music or watch something. Bring any reading glasses you need. Comfortable clothing and layers (waiting rooms can be cool) are also a good idea.

Having a family member or friend accompany you on the day of surgery is strongly encouraged. A companion provides emotional support, can drive you home, and can help you remember any post-operative instructions given by the surgical team. They can keep you company during waiting periods and can help communicate with the surgical team if you feel anxious or are not fully tracking information after surgery. Most Mohs clinics welcome one companion in the waiting area. If your companion cannot stay the full day, arrange for them to be reachable by phone and available to pick you up when you call.

Do not apply makeup, foundation, concealer, or other cosmetics to the surgical area or the surrounding skin on the day of surgery. Makeup must be removed before surgery can begin, which adds time and creates extra work for the team. If your surgery is on the face, it is simplest to arrive without any facial makeup. Do not wear perfume, cologne, or strongly scented products. Some surgical team members may have sensitivities, and strong scents can be uncomfortable in a small clinical space. Remove any jewelry from the face or scalp if surgery is in those areas.

Plan to spend between 3 and 5 hours at the clinic, and understand that it may occasionally take longer. Up to a full day for complex cases or tumors requiring many stages. Studies show that about 50% of Mohs cases are cleared in a single stage, about 80% are cleared within two stages, and about 95% within three stages. Each stage involves surgical removal, tissue processing, microscope examination, and a discussion of results. A cycle that typically takes 45 minutes to 2 hours depending on the number of tissue sections. You cannot predict in advance exactly how many stages will be needed.

You will spend most of your time in the waiting room between stages. You will be comfortably bandaged and can move around, eat, use the restroom, and use your phone or other devices. The surgical team will call you in when results are ready for each stage. Do not feel anxious if the waiting seems long. Extended processing time does not necessarily mean the news is bad. The lab process simply takes time regardless of the result.

Once your surgeon confirms that all cancer has been removed, the wound is closed. Usually on the same day. Depending on the size, location, and depth of the wound, closure options may include direct stitched closure (pulling the wound edges together), a skin flap (repositioning nearby skin to fill the defect), a skin graft (moving skin from another area of the body), or allowing the wound to heal on its own (second intention healing). Your surgeon will discuss the best reconstruction plan for your specific wound. If your reconstruction is complex, a separate specialist may be involved.