Mohs Surgery Informed Consent

Please read this form fully before signing.

Name  ___________________________________  DOB  _______________  Date  _______________

Planned surgical procedure: “Mohs” Micrographic Surgery for Skin Cancer

Reason for surgery:

Diagnosis  ___________________  Location  ______________________________________________

Skin cancer is the most common form of malignancy in the United States. The major cause of skin cancer is ultraviolet light exposure, both from the sun and from artificial sources. Over 1.5 million Americans develop skin cancer each year. Basal cell carcinoma is the most common type of skin cancer and accounts for 75 to 80 percent of skin cancers. Squamous cell carcinoma is the next most common and comprises 15 to 20 percent of skin cancer.

Mohs surgery is a precise surgical method combined with microscopic mapping for a targeted removal of skin cancer. This procedure was developed by Dr. Frederic Mohs of the University of Wisconsin.

Mohs surgery provides the greatest assurance of cancer removal along with the most conservative margins of removal. It has the highest cure rates for skin cancers, 97 to 99 percent for the first time skin cancers and 95 to 96 percent for cancers that recur.

Mohs micrographic surgery is a time consuming and technically demanding method which requires special equipment and laboratory in order to microscopically examine the cancer tissue and map out and target its removal. This method allows the Mohs surgeon to track out and eliminate the extensions and the roots of the cancer.


Patient Information on Potential Complications or Side-effects of Skin Surgery

  1. Scar Formation: Scars form whenever there is injury to the skin. Some scars are more noticeable than others. Some individuals are more prone to thickened or keloid scars. Scars in areas of high sebaceous gland concentration and activity such as the nose and forehead are more likely to widen and become depressed.
  2. Pain: Post-operative pain will depend on the extent of surgery and also on the particular individual. Pain medications are prescribed which may be taken after surgery if needed. With pain medications, do not drive, operate machinery or make important decisions. Alcohol can amplify the effects of pain medications. It is best to eat something solid before pain medications since they may irritate the stomach and cause nausea.
  3. Bleeding: Bleeding after surgery can usually be controlled with pressure applied to the wound for fifteen to twenty minutes and with ice compresses. Some oozing is to be expected. For severe or persistent bleeding, please call 913-722-5551 or 816-454-0666.
  4. Swelling: Various degrees of swelling will occur. Cold compresses on 20 minutes and off for 10 minutes for the first 24-48 hours will lessen swelling. Elevation of the head at 15-20 degrees while lying down or sleeping will help to reduce edema. A reclining chair usually provides a good angle of head elevation.
  5. Bruising: Bruising around the surgery site will resolve. With surgery of the anterior scalp, forehead or around the eyes, a black eye may develop within 12-72 hours after surgery. Sometimes the eye will swell shut.
  6. Hematoma: This is a lump that forms under the skin from bleeding after the surgery. It represents a collection of blood.
  7. Infection: With any injury to the skin or surgery, infection is possible. An antibiotic ointment will be prescribed at the time of surgery and sometimes antibiotic tablets. Wound infections usually occur four days after the surgery. If you suspect an infection, please call 913-722-5551 or 816-454-0666.
  8. Numbness: It is common to have numbness in the area of surgery because there are always sensory nerves running through the skin. Usually this numbness will go away in six to twelve months. But in some instances, it may be permanent.
  9. Paralysis of Nerve: If a cancer extends into the area of a nerve that controls the movement of muscles, temporary or permanent paralysis may occur. The greatest areas of risk on the face are in the temple area where the nerve to the eyebrow and eyelid runs and on the lower cheek where the nerve to the lip runs.
  10. Wound Dehiscence: In straightforward terms, this means the wound separates or pulls apart. This can happen anywhere but it is most prone to occur when the wound overlies an area of muscle mass such as on the back or extremities. If a body movement seems to tug on the wound, stop the movement and relax.
  11. Wound Healing: Not all skin wounds heal ideally. At times a skin repair, graft or flap may fail to heal well or the wound may seem to lift up or protrude. This may affect part of the wound or the whole wound. Most often the wound will still heal adequately with treatment. Sometimes additional surgery is required.

I voluntarily and without compensation authorize Dr. Frank C. Koranda, Dr. Colleen M. Reisz and/or Dr. Joseph B. Schneider to take photographs and video images of me and to publish, print and show pictures and video images.

By signing this form, I acknowledge that I have read or had this form read and/or explained to me, that I fully understand its contents, that I have been given ample opportunity to ask questions and that any questions have been satisfactorily answered.


I hereby request and authorize Dr. ________________________  aided by any assistants he may require, to perform the “Mohs” surgery procedure.


_______________________________________         _________________
Authorized Signature (Patient or Legal Guardian)         Date


_______________________________________
Witness

 

Please print this page, sign and date it and bring it with you to your next appointment

Creekwood
5330 North Oak Trfwy.
Suite 201
Kansas City MO 64118
P 816-454-0666
F 816-454-1694

Liberty-Seaport Complex
124 Westwoods Drive
Liberty MO 64068
P 816-883-2965
F 816-454-1694

Georgetown
8901 W. 74th Street
Suite 145
Merriam KS 66204
P 913-722-0020
F 913-362-0583

College Boulevard
8490 College Boulevard
Overland Park KS 66210
P 913-722-5551
F 913-362-0583

Scheduling
816-454-2655

Skin Renewal Scheduling
(Creekwood and College)
913-831-4880