Skin Cancer SurgeryBasal cell carcinoma, squamous cell carcinoma, and malignant melanoma are the common forms of skin cancer requiring surgical treatment. The cancer type, size, location, and histopathological features determine the treatment type advised by your dermatologist.
Simple excisionSimple excision is the cutting out of the tumor, with a scalpel or scissor, with a margin of healthy surrounding tissue. In preparing for skin cancer surgery, your dermatologist will first usually have performed a biopsy of the lesion and will know exactly what kind of skin cancer is present. During a pre-op meeting, your dermatological surgeon will review a complete medical history, including any need for antibiotics prior to surgery, medications taken, especially anticoagulants, and the presence of any implanted medical devices such as a pacemaker. Skin cancer surgery is an outpatient procedure performed under local anesthesia. On the day of your skin cancer surgery, you will be taken to a procedure room. After completing the informed consent, you will change into a gown and be positioned for the procedure. Your dermatological surgeon will mark the area and confirm the location by comparing with photographs taken previously. After that, the area will be numbed with injections of local anesthetic. Your dermatological surgeon will then prep the area with antiseptic, drape it, and start the surgery. Most skin cancers will be excised as an ellipse around the lesion, resulting in a linear scar approximately 2.5-3.0 times as long as the original lesion. This is necessary to close the wound without leaving unsightly bunching of skin (called "dog ears"). After cutting out the skin cancer and a margin of healthy tissue, your dermatological surgeon will consider how best to repair the defect. This can include closure with subdermal and superficial sutures, flaps, grafts, or allowing to heal by "second intent", meaning without further closure. Most excisions are closed with buried resorbable sutures, such as Vicryl, and a superficial layer of Nylon sutures, which must be removed 1-2 weeks after the procedure. After repairing the defect, a dressing and antibacterial ointment will be applied to the wound and wound care instructions provided.
Mohs Micrographic SurgeryMohs micrographic surgery is a procedure in which skin cancers are excised and immediately processed for review by light microscopy. The Mohs surgeon evaluates the tissue to confirm that all of the tumor has been removed. During this time the patient is bandaged and waits for the results. If the margins of the excised tissue is negative for tumor, then the resulting wound is repaired. If the margins contain residual tumor cells then an additional piece of tissue is excised (termed a "stage"). This process continues until the margins are negative for tumor. The key to Mohs surgery is that it achieves complete "histological control" of the margins, due to the method in which the specimen is excised and processed. Mohs surgery achieves the lowest recurrence rate and simultaneously spares the maximum amount of healthy tissue. This is especially important in cosmetically sensitive areas like the face.
Who should undergo Mohs surgery?The decision as to which tumors should undergo Mohs surgery depends on the the nature of the tumor and the site. Established indications include:
- Recurrent basal cell carcinoma (BCC) or squamous cell carcinoma (SCC)
- BCC or SCC with clinically indistinct borders
- Lesions in "high-risk" areas of the face
- Cosmetically sensitive areas and areas with limited adjacent skin for repair, such as genitals, anal and peri-anal, hands, feet, and nail units
- Rapidly growing tumors
- Tumors >2cm in diameter
- Tumors with certain aggressive histological subtypes
- Tumors arising in sites of previous radiation treatment
- Tumors in immunosuppressed patients
- Patients with basal cell nevus syndrome.