Justin Piasecki, MD is a uniquely trained member of the Mohs College, who is also board-certified in plastic surgery and in facial plastic surgery. His combination of skills offers the high cure rate of Mohs surgery with the optimum cosmetic result of facial plastic surgery and general plastic surgery, for the most convenient, cost-effective skin cancer treatment available.
Plastic micrographic surgery, or Mohs surgery with cosmetic reconstruction, begins with a surgical evaluation. The surgeon and patient decide together which treatment method is the best approach for the patient’s particular skin cancer. Although plastic micrographic surgery and Mohs surgery offer the highest cure rate with the most tissue preservation, surgery is not always the best approach for every patient. One of the benefits of plastic micrographic surgery is that the plastic surgeon who will repair the defect evaluates the patient prior to any tissue removal; only patients who are candidates for reconstruction will undergo Mohs surgery.
Other possible treatments for skin cancer include: ED & C (scraping and burning), liquid nitrogen, radiation or simple excision with wide margins. Dr. Piasecki personally performs all treatment options based on indications and patient needs; patients needing radiation are referred to other providers.
Mohs surgery is a unique procedure for skin tumor removal developed more than 50 years ago by Frederic Mohs, MD, a general surgeon at the University of Wisconsin. The Mohs technique has been refined and advanced since then, and now offers the highest cure rate (over 99%) for certain types of cancers while reducing the amount of tissue removed in the process.
During Mohs surgery, pieces of tissue are removed until the cancer is gone and the margins are clear. Following Mohs, Dr. Piasecki uses plastic surgery techniques in his own ambulatory surgery center, to reconstruct the defect rather than referring the patient to another plastic surgeon for the reconstruction.
Plastic micrographic surgery is a more convenient process for the patient and lowers costs for the patient and the insurance company, while providing the same high cure rate and tissue preservation associated with traditional Mohs surgery.
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Under local anesthesia, the Mohs surgeon removes skin tumors one layer at a time, and the entire edge – or margin – of that removed layer of tissue is immediately examined under a microscope. The surgeon then removes additional tissue only in the area(s) where the margins are positive. Those tissue sections are examined under a microscope and the process is repeated until all margins are clear of cancer. These tumors often grow like roots of a tree, extending farther under normal-looking skin than what can be seen with the naked eye. While most cases are cleared in one to three stages, larger or recurrent tumors often require multiple stages. Defects that can be closed without reconstructive surgery are closed immediately in our clinic. If reconstructive surgery is necessary, it will be performed in our ambulatory surgery center. This facility was built to the strictest AAAHC and Medicare standards and provides the safest environment for reconstructive surgery. Some reconstructions are performed at the end of the surgery day, others are performed at a scheduled time the following day.
Dr. Piasecki has extensive training in reconstructive and cosmetic procedures. He closes wounds with stitches, grafts or flaps and presents all the reconstructive options to patients before deciding together which course to take. Careful consideration of the functional as well as aesthetic requirements of the face are essential, and Dr. Piasecki helps patients weigh the desired cosmetic result with the recovery process. Mohs surgery preserves the maximum amount of normal skin compared to other techniques, resulting in smaller defects and optimizing long-term appearance.
Patients may continue taking their usual medications, even on the day of surgery, unless otherwise directed by a physician. Patients are asked to inform Dr. Piasecki if they are taking any blood-thinning medications such as warfarin, Plavix, aspirin, ibuprofen, vitamin E or others. Blood thinners can lead to increased bleeding, swelling and bruising following surgery.
Patients are instructed to get a good night's rest and can eat normally prior to surgery. We provide coffee, tea, juice, water and granola bars in our Mohs waiting area. If you would like additional snacks, there is a refrigerator and microwave. We also are attached to St. Anthony's hospital which has an excellent cafeteria. Wearing comfortable clothing and an extra layer for warmth is also important. A buttoned or zippered shirt that can be removed without going over the head is helpful. Books, magazines or a laptop computer can help pass the time during the waiting periods of the day. Patients can drive themselves home if necessary on the Mohs excision day, but should arrange for transportation for their reconstructive surgery day.
Treatment begins with a consultation with Dr. Piasecki. Dr. Piasecki reviews the patient's medical history and discusses all viable options for skin cancer treatment. He then works with the patient to decide which option is best. The informed consent form is then completed to ensure that Dr. Piasecki and the patient have a mutual understanding of the surgical process and treatment is scheduled.
Click here for a copy of the Mohs surgery consent form to read and sign prior to surgery.
Local anesthesia is administered to the affected area. Once the anesthesia has taken effect, the first level of tissue is removed. The patient is then taken to the waiting room to relax while the tissue is frozen and processed. This frozen tissue section processing and microscopic examination of the lesion requires 45 minutes to an hour. During this time, the patient sits in the Mohs waiting room with friends or family, and can read, watch tv, use their computer or enjoy a snack. We provide beverages such as coffee, tea and water in this quiet, peaceful environment.
If any of the cancer remains, the patient goes back to the operating room and another layer of tissue is removed in the area where the margin was positive. The patient then returns again to the waiting room to relax while the tissue is examined. This process continues until the margins are clear of cancer.
If the wound can be closed without reconstructive surgery, Dr. Piasecki will close it in the clinic. If reconstructive surgery is required, the patient will receive a surgery time for the following day. Dr. Piasecki will perform reconstructive surgery in the ambulatory surgery center using the plastic surgery technique that he and the patient have agreed will satisfy the patient’s needs and provide the best aesthetic result.
The tumor removal process typically takes 2-4 hours. Unless patients request medication for nerves for this procedure, patients may drive themselves home and even return to work after this surgery. If reconstructive surgery is required, it generally lasts 30 – 90 minutes. We ask that all patients have a driver for this procedure. Reconstructive surgery times are usually assigned following the mohs excision, however, if a patient would like their time in advance, we can certainly accommodate. Occasionally, complex cases require more time, many stages and/or delayed reconstructive repairs. In such cases, Dr. Piasecki will discuss these issues in advance, answering any questions or concerns and working with the patient to determine the best overall approach to treatment
In nearly all cases, the skin cancer excision and reconstruction occur on the same day. Most patients describe the pain following surgery as “throbbing” or “like a deep bruise”, but it is not typically sharp in nature. Surgery on the forehead or scalp may trigger headaches on the first night or for a few days of recovery. Patients should take it easy for a week to ten days following surgery, with no heavy lifting (greater than a gallon of milk) or strenuous exercise.
Depending on the size of the wound, “oozing” of fluid from the wound will occur for the first week or so following surgery. Bruising, drainage of fluid and swelling will be at their peak at 72 hours following surgery, and occasionally this bleeding becomes heavier; if this happens, patients are asked to apply continuous pressure for 20 minutes. If the bleeding persists, call Dr. Piasecki immediately to come into the clinic or a local emergency room.
Mohs surgery is a minimally invasive procedure and complications are rare, but they can happen. Dr. Piasecki will discuss these with you the morning of surgery.
If you have any concerns following surgery, we ask that you call Dr. Piasecki during business hours at 253-858-5040 or after hours at 253-509-4438.
A patient may be given antibiotics on the day of surgery and for a short period post-operatively. In addition, a mild sedative (lorazepam) may be given if the patient feels anxious or the tumor is complex and requires prolonged removal and reconstruction time.
Over-the-counter and/or prescription pain medications may also be prescribed to minimize discomfort.
Combining Plastic Micrographic Surgery with Cosmetic Surgery
A board-certified plastic surgeon, Dr. Piasecki can combine plastic micrographic surgery and cosmetic surgery. Patients often appreciate the convenience of combining minimally invasive procedures with plastic micrographic surgery; because you are already in our operating room, the rate for the cosmetic procedure is discounted.
Please contact our office to schedule a consult if you are interested in combining procedures. Cosmetic procedure add-ons will not be performed if they might jeopardize your skin cancer treatment recovery. Dr. Piasecki reserves the right to cancel the cosmetic portion of your surgery if the skin cancer turns out to be more invasive than expected.
Procedures that may be combined include: