Skin Cancer Excisions

Skin cancers are very common, particularly in fair skinned people. They are also linked to the amount of sun exposure we have. There are three main types of skin cancer; basal cell carcinoma, squamous cell carcinoma and melanoma.

If you have a new lump or ulcer that will not heal or go away on your skin, it should be checked for any signs of skin cancer. Likewise if an existing skin lesion such as a mole changes in size, shape, colour or becomes itchy or bleeds, it too should be checked.

If a skin cancer is suspected, it is usually recommended that the skin lesion is removed.  Some early skin cancers may be treated by other means such as prescription ointments or cryotherapy.

Procedure Details:

Usually this surgery is carried out under local anaesthesia (while you are awake after the skin has been numbed).   Sometimes, if more extensive or in a very tricky location, the surgery is done under general anaesthesia (while you are asleep). The procedure usually takes between 10 and 60 minutes depending on the extent of surgery. More than one lesion can be removed at the same time.

The skin lesion is removed and usually the area is stitched together carefully. If a skin cancer is suspected, a small rim or margin of normal appearing skin is removed with the lesion to ensure that it is fully removed. The size of this margin is usually in the region of 3 to 4 mm but for some skin cancers can be up to 2 cm. This will depend on the exact type and size of the skin cancer. The lesion will be sent away for histological analysis.

If after removing the lesion, the skin is unsuitable to stitch together directly (i.e. the tissue would be too stretched or the edges would not meet) then Ms Nugent will perform a local flap or a skin graft to the area. A local flap involves moving skin from the surrounding area in a carefully planned way so that the wound can close nicely. The borrowed skin is then stitched in place. A skin graft involves transferring skin from one area to another to heal the wound. The skin graft is then stitched or glued into its new position. Where it is taken from (the donor site) is either stitched together or allowed to heal from the remaining bottom layer of skin depending which type of skin graft is used.   

Postoperative Course:

Usually the area is dressed with brown surgical tapes. These will withstand a quick splash of water or a quick shower but not a prolonged shower or a bath.   You can shower the day after surgery and gently dab the tapes dry. You may use a hairdryer on a cool setting to speed up drying of the tapes before dressing. In the face, stitches will need to be removed between 5 and 7 days following surgery. When possible elsewhere on the body, Ms Nugent uses absorbable sutures, which do not need to be removed. If she has to use non-absorbable sutures, they will need to be removed between 10 and 14 days following surgery. It is usual to have some swelling and bruising in the area in the early stages.  

A skin graft will usually be left undisturbed for 5 to 7 days and will have a dressing on it that will need to be kept clean and dry until then. If you had a split thickness skin graft, a well-padded dressing will be placed on the donor site as this may ooze for a few days. Unless problematic, this dressing should be left undisturbed until your follow up appointment.

Recovery:

It is usually possible to return to light activities the next day but strenuous activities will need to be avoided for about 2 weeks. If the procedure was on your head and neck area, it is best to avoid bending and stooping as much as possible for the first few days and to sleep on an extra pillow at night.   If the skin lesion was on your arm or leg, it is best to try to elevate the limb as much as possible for the first few days. These measures help to minimise bleeding and swelling after surgery.   The area is usually healed in 2 to 3 weeks but the scar will continue to strengthen and then to soften and fade for 12 to 18 months afterwards. Most of the changes in the scar occur in the first 6 weeks but it continues to slowly change after that.

Scar Management

Once healed, Ms Nugent usually advises moisturisation and massage of the scar with a Vitamin E or a plain moisturiser 2 to 3 times daily. This helps to soften the scar. If your scar shows any signs of being raised or lumpy or slow to settle, she may advise use of silicone ointment or sheets on the scar or further scar treatments. It is also important to protect your scar from the sun.

Complications:

• Poor scar. Most scars heal quickly and gradually fade to a thin white line. Sometimes they may be more red or raised or lumpy or stretched than expected and further treatments will be recommended.
• If inflamed or ulcerated, Ms Nugent will prescribe antibiotics. Otherwise they are not routinely needed for skin surgery. If an infection develops, it will be treated with dressings and/or antibiotics as needed.
• It is common to have a small amount of bleeding over the day following your procedure. Holding firm pressure for 10 to 15 minutes with a clean towel or tissue is usually sufficient to stop this. If this is more than expected, please contact the hospital or clinic so that you can be advised or assessed.
• Slow healing or wound separation. Occasionally wounds can be slow to heal or open after stitches are removed. If this happens, you may need further stitches or dressings on the wound until it heals.
• Suture spitting. Sometimes dissolvable stitches take longer to dissolve than expected and they can poke through the surface of the wound. If this happens, the suture can be removed in the clinic and the wound should heal normally after that.
• Loss of part or all of a skin graft or skin flap. While usually skin grafts and flaps heal very well, sometimes part or all of the flap or graft struggles with its blood supply in its new site. If part or all of the transferred tissue is lost, it may mean a longer time with dressings on the wound or occasionally further surgery to remedy the problem and heal the wound quicker.
• Incomplete excision. Although every effort is made to remove a skin cancer completely, sometimes microscopically there are cancer cells right at the edge of the sample removed. Ms Nugent will normally recommend a further procedure in this instance to completely treat the skin cancer and reduce the risk of it recurring.
• If fully removed, most skin lesions do not recur. However in some situations, they may recur and require further treatment in the future. This is most relevant for skin cancers and some types require regular checks for up to 5 years to check for this. Ms Nugent will advise you on your individual situation.

Need For Further Treatment

Sometimes, depending on the diagnosis, further investigations such as CT scans or further treatments such as radiotherapy or more surgery are required. If this is necessary, Ms Nugent will explain this to you and will arrange for you to see the relevant specialist or to have the investigations or surgery indicated.

Need For Follow Up Appointments

Ms Nugent will always offer you an appointment in the weeks following your procedure to check on your healing and if needed, to explain your histology results to you. Often this is the only appointment required but some conditions require further follow appointments e.g. some skin cancers. If this is needed, Ms Nugent will recommend follow up with your GP, a dermatologist or with her as required.

Discussion at Specialist Skin Meeting

It is recommended that certain types of skin cancer (squamous cell carcinoma and melanoma) are discussed at the regional specialist skin meeting. This is a meeting of plastic surgeons, dermatologists, radiologists, pathologists, oncologists and specialist nurses who are all involved in the treatment of skin cancer. They will review your case and may make recommendations regarding further treatment.   If this is required, Ms Nugent will arrange for this to happen at the Queen Victoria Hospital in East Grinstead and will explain any recommendations that they may have for treatment to you.

Most skin cancers can be treated with surgical removal. The skin cancer is removed with a small rim of normal skin to ensure complete removal of the cancerous area. The removed area can then be analysed to confirm the diagnosis and to check for complete removal or “clear margins”. For small skin cancers, the skin is simply stitched together after removal. If the area involved is larger or in an area where the skin is very tight, it may be necessary to have a skin graft or skin flap procedure to close the wound.

Other techniques used to treat skin cancers include topical ointments, cryotherapy, photodynamic (light) therapy and radiotherapy.

“I was very impressed with the friendliness and professionalism of all those involved. I would certainly recommend or use them again.” excision of a skin cancer at Purity Bridge 2016

“Whole procedure process undertaken in a competent professional manner which sets one at ease” MD, excision of a skin lesion at Purity Bridge 2016

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