My Working Day in Mohs Surgery Quiz

Answer: Start cleaning the surgical bays and trolleys

We clean the surgical bays and trolleys with a mixture called 'Chlor Clean'. This is to ensure that everything is cleaned properly and effectively, ready to start setting up for the day.

Answer: To cut near the eye

The patient is going to the eye hospital to be repaired by the ophthalmologist. As the eye is delicate, these scissors will see some use as their shape allow easy access in that area.

Answer: Yes

If a patient is taking any medication that thins their blood such as warfarin or aspirin, they should immediately let the nurse know as they are prone to bleeding. The nurse should then immediately let the consultant know so he is aware of this. It is sometimes acceptable for patients to still take their medication, but are told beforehand.

This also means that if they need to stop their medication, they can be notified of when they need to stop taking it prior to surgery. This is because some anaesthetics also thin the blood.

Answer: Wash her hands

As I am opening the gloves up ready for her she will wash her hands. Once her hands are dry she will put her apron on then wash her hands again then put the gloves on, making sure not to touch the palms or fingers as she will be touching the patient with those.

The nurse will be following the ANTT procedure (Aseptic Non Touch Technique) which is a practice that ensures safety for both patients and clinical staff in relation to infection control.

Answer: A curette

He will curette the lesion first before cutting around the tumour. Once he has finished, he will cauterise the area with the bipolar to stop any bleeding. A curette is a spoon-shaped instrument that cuts away at the lesion. A scalpel is a blade that is used to slice around the area. Monopolars and bipolars are different types of forceps used for cauterisation. We use bipolars in Mohs surgery.

Answer: Cryostat

The cryostat will freeze the sample so it can be cut into thin slices (If the layer is very fatty, the cryostat will freeze the skin at -30 degrees Celsius). Once thin enough, the technician will gently place it onto a slide then dye it (This is so the consultant will be able to see any visible tumour under the microscope).

Answer: Manipulating the skin so that it 'jumps' into the wound and can be stitched

The way the consultant taught me about different repair flaps was through chess. He described an advancement flap (The sliding skin) as a rook/castle as it will only move in a straight line. He described a rotation flap (simply rotating without jumping into a new area) as a bishop as it moves diagonally, and a transposition flap (the answer) as a knight as it can jump over other pieces.

The answers which involved cutting off skin and placing it on the wound were types of grafts.

Answer: Frederic

Frederic E Mohs created the Mohs technique back in 1938. It is a highly accurate procedure with a 97-99% success rate. There are only a dozen Mohs departments in the UK, and the busiest is in the North West England. Mohs surgery is only performed on the face and other sensitive areas; if a tumour is found anywhere else on the body a wide margin of skin can be taken and repaired but this is not the case with the face.

The most common skin cancer we deal with in Mohs surgery is basal cell carcinoma which are also known as 'rodent ulcers'. Though these very rarely kill you like other cancers can, it is best that they are removed as they can destroy local tissues.

Answer: 1mm a month

As he explains to the concerned patient, when he cut the tumour out, he had to cut some nerves as well. The tingling sensation he is currently feeling is the nerves reforming under the skin.

Answer: Yes

This means that the borrowed skin is getting plenty of blood supply so it can attach nicely to the rest of the skin. Skin grafts require specific care instructions as they are more sensitive compared to the other repairs we see.
A skin graft works by cutting another piece of skin from a 'donor site' which matches the texture and colour of its new site. It will then be stitched on and secured with a dressing which is also stitched.
Another skin graft we see is a Burow's Graft, which involves the wound being cut open more and the skin that is left will be preserved in saline. The pieces of skin will then be reattached, closing the wound up as well. This type of graft is usually done in a diamond shape, as two triangular pieces of skin are removed and replaced.