Skin Cancer

At Alexander Cosmetic Surgery, taking care of skin cancers is one the procedures we perform on a daily basis.

Skin cancers usually develop on areas of the body that have been exposed to the sun. They often present as an irritated area that is flaky, red, ulcerated, or doesn’t seem to heal. It can be difficult to tell if a patient has a skin cancer just with the naked eye or magnification because pre-cancerous lesions and even benign growths can imitate cancers. The only way to tell for sure is to remove the growth and have it examined by a trained pathologist.

Most skin cancer procedures are very quick and simple and can usually be done with a local anesthetic in just a few minutes.

Many of our patients are referred for treatment by dermatologists. Others are referred by friends or family members after being told by their dermatologists that they need Mohs surgery.

What is Mohs surgery?
Mohs surgery is a technique performed by dermatologists which, in theory, is supposed to remove the skin cancer with the smallest possible defect, or hole.

First, the lesion is biopsied, usually with a punch, which creates a small divot that may take several weeks to heal in. If the diagnosis comes back positive for skin cancer, the Mohs procedure is scheduled. Mohs is done by removing a small piece of skin under local anesthesia, then the patient waits while the tissue is prepared and looked at under the microscope by the dermatologist who determines which edges of the specimen are positive for cancer. Then, another small piece is taken and looked at and this process continues until the dermatologist is certain that there are no more malignant cells. This procedure can require being numbed up by injection several times and can often take several hours to perform. Because Mohs surgery is done piece by piece, it stands to reason that the defect, or hole, will be small, because the doctor stops when he gets to normal tissue. It also decreases the chance of the skin cancer coming back, because the tissues are checked so thoroughly.

Mohs was originally developed to treat skin cancers on areas of the face that would be difficult to reconstruct if too large a defect was made, like the nostril or eyelid. It was also designed to treat large, aggressive, or recurrent skin cancers. However, even though Mohs was designed to be used occasionally in difficult situations, it is now generally recommended by Dermatologists for almost all skin cancers, even when the suspected cancer is tiny or occurs on an area of the body or face that is extremely easy to treat!

How is the Mohs defect closed?
If the defect is small, then the dermatologist will close it himself. However, if the defect is large, then the patient is referred to a plastic surgeon who performs a more complex procedure to close the defect. This might require moving skin around, a flap, or a skin graft taken from another part of the body. Some reconstructive procedures require more than one procedure.

Why is Mohs surgery supposed to be better?
Mohs is promoted as having two main advantages:

1. That the defect will be smaller, and
2. That the recurrence rate is smaller than simple excision.

Why is recurrence an issue? It is obvious that no one wants a cancer to come back. But many dermatologists regard skin cancer to be extremely dangerous, even though most skin cancers do not spread to other parts of the body. It is common for us to consult with patients who have been told by their dermatologists that if they don’t have Mohs right away that the skin cancer might erode into deeper structures of the body, face or skull. While this is possible in extreme instances where skin cancers have gone untreated for decades, it would be unheard of for the typical skin cancer routinely treated by dermatologists and plastic surgeons.

Is Mohs the best way to go?
In our experience, most patients choose not to have Mohs surgery after a frank conversation regarding the pros and cons of the surgical options. We have dozens of patients who have first experienced Mohs surgery, then had a simple procedure with us. Without exception, patients find a simple excision to be much quicker and easier, with the most obvious differences being the simplicity, decreased time for the procedure and healing, and decreased scarring.

Without exception, patients find a simple excision to be much quicker and easier, with the most obvious differences being the simplicity, decreased time for the procedure and healing, and decreased scarring.

This table will help you understand the differences in treatment options so you can make an informed decision.

	Dermatology: Mohs Surgery	Plastic Surgery: Simple Excision
Initial biopsy required	Yes	No
Worry level created by Dr.	High	Low
Time to perform procedure	0.5-several hours	5-15 minutes
Multi stage procedure	Usually	Occasionally
Anesthesia	Local	Local
Size of the defect	Usually large	Usually small
Outcome after first day	Wound may be closed or left open	Wound always closed
Second day	Major reconstruction may be required	N/A
Healing time	May require months	Usually normal appearance within a week.
Disfigurement	Often notable scarring	Usually no notable scarring
Cost	$1000-5000	$100-500
Pathology	Read by dermatologist	Read by pathologist
Waiting time for result	None	1 week
Recurrence rate	1%	5%
Treatment for Recurrence	Mohs surgery	Another 5-15 minute procedure

Plastic Surgery vs. Dermatology
If the advantages of simple excision are so great, why is Mohs surgery done at all? This is a good question. Doctors acquire their knowledge, foundation, and training for their future medical practices in their residency programs. Residencies can be a little like religion. An individual brought up with a certain set of beliefs is likely to come to very different conclusions than another individual brought up with a completely different set of beliefs and values.

Plastic Surgeons usually undergo 3-5 years of General Surgery training followed by 2-3 years of Plastic Surgery training, making their total surgical training 5-8 years. During this time extremely complex, difficult surgical fundamentals and procedures are learned. A plastic surgeon views skin cancer surgery as one of the most simple and straightforward procedures they do. They view the procedure in a simple, straightforward way and tend to treat it the same way. Thus, they will tend to convey to the patient that skin cancer is “no big deal” and encourage the patient not to worry about it.

Dermatologists usually undergo 4 years of Dermatology training, the majority of which is non-surgical. The surgical exposure they do receive is related to treating skin cancers. Despite having a relatively small amount of surgical training, many Dermatologists refer to themselves as Dermatologic Surgeons, which can be confusing to a public who is not aware of the different requirements of various training programs. Because skin cancer procedures are some of the biggest procedures a Dermatologist does, they tend to view this procedure as fairly complex in relation to other aspects of Dermatology practice.

What about the cost?
Both types of procedures are covered by insurance, but Mohs surgery usually costs 10-20 times as much as a simple excision because it is so much more involved. This is especially true when reconstruction is required.

The Bottom Line
In our experience, patients who undergo Mohs surgery usually experience procedures that take a long time to perform and end up with very large defects that often require complex reconstruction and months to heal. Patients who undergo simple excision usually experience an extremely quick procedure, have a very small defect, and look close to normal in less than a week.

Several important factors should be considered when choosing a surgeon, including the doctor’s personality, recommendations from friends, physician training and board certification, and experience.

Personality: It is important to develop a good relationship with your surgeon so that communication is easy and trust can be developed. You should feel that you are in good hands. Bedside manner is important.

Referral from Friends: Many prospective patients find confidence if they have a close friend or other trusted individual who has already undergone a successful procedure by a certain doctor. This is often a good first step in making a decision. In fact, most of our patients are referred to us by friends who were very satisfied with their results. However, not all patients know someone who has had surgery.

Training and Certification: In years past, only plastic surgeons performed skin cancer surgery. However, in recent years doctors from many different specialties are more commonly performing these procedures. Only a surgeon who has been certified by the American Board of Plastic Surgery has received the most extensive training in plastic and reconstructive surgery. There are many Boards, and it is easy for patients to become confused or assume that when a doctor says they are “Board Certified,” it all means the same thing. BE CAREFUL! Learn more about the significance of Board Certification here.

Experience: Finally, consider the physician's experience—the most important factor in making a decision. As with all professions, expertise is directly proportional to experience, meaning the total number of procedures performed. Medical literature illustrates that biggest predictor of success in surgery is volume, in other words, the number of times that a doctor has performed a procedure.

If the doctor is recommending a specific procedure, how many has he performed? Also, how often does he do this procedure? While board certifications and training are important, a surgeon's experience with the procedure itself is more important. Don't hesitate to ask pointed questions about recommended procedures.

Candidates for skin cancer surgery:

• Have a spot on the skin, usually a sun-exposed area, that is crusty, scaly, ulcerated or intermittently tender or open.
• Have had a biopsy positive for skin cancer.
• Have had a cancer removed by another doctor and need reconstruction of the defect.

Because every case is unique, the only way to determine which procedure is best for you is to consult with Dr. Alexander. Our goal is to treat your condition with the best procedure available.

Consultations for skin cancer are relatively quick. A simple examination of the skin under magnification can determine the need for surgery. Areas that have already been biopsied are easily identified.

Be prepared to discuss:

• Your type of skin cancer
• Medical conditions, drug allergies and medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
• Previous surgeries
• The likely outcomes of your treatment and any risks or potential complications

We may also:

• Evaluate your general health status and any other pre-existing health conditions or risk factors
• Examine your skin
• Take photographs for your medical record
• Discuss your options and recommend a course of treatment

• Are you certified by the American Board of Plastic Surgery?
• Were you specially trained in the field of plastic surgery?
• Do you have hospital privileges to perform this procedure? If so, at which hospitals?
• Is the office-based surgical facility accredited by a nationally or state recognized accrediting agency?
• How many procedures of this type have you performed?
• Am I a good candidate for this procedure?
• What will be expected of me to get the best results?
• Where and how will you perform my procedure?
• What shape, size, and incision site are recommended for me?
• How long of a recovery period can I expect?
• What are the risks and complications associated with my procedure?
• What happens if the biopsy shows that not all the skin cancer has been removed?
• How are complications handled?
• What are my options if I am dissatisfied with the outcome of my skin cancer surgery?
• Do you have before-and-after photos I can look at for each procedure and what results are reasonable for me?

Anesthesia—General: The patient is asleep, requiring that the airway be protected either by a standard breathing tube or by a laryngeal mask (LMA), an inflatable mask that is placed in the back of the throat but not down the trachea. An anesthesiologist releases gases through the airway that put the patient asleep. Drugs may also be given through the IV.

Anesthesia—Local: The surgical area is numbed up with an injection, but the patient is awake. Sometimes a patient will be given an oral medication, like Valium, to help with relaxation.

Anesthesia— Sedation (Twilight): The patient is made sleepy with medications given through an IV. The level of sedation can be adjusted, from barely sleepy to very sleepy. Occasionally sedation is given by the surgeon, but most of the time it is administered by an M.D. Anesthesiologist.

Basal cell carcinoma: The most common form of skin cancer. Occurs in the epidermis. These growths are often round and pearly or darkly pigmented.

Cancer: The uncontrolled growth of abnormal cells in the body. Cancerous cells are also called malignant cells.

Dermis: The deeper portion of the skin.

Epidermis: The uppermost portion of skin.

Excision: A simple surgical process to cut the lesion from the skin.

Frozen section: A surgical procedure in which the cancerous lesion is removed and microscopically examined by a pathologist prior to wound closure to ensure all cancerous cells have been removed.

Local flap: A surgical procedure used for skin cancer in which healthy, adjacent tissue is repositioned over the wound.

Melanoma: A skin cancer that is most often distinguished by its pigmented blackish or brownish coloration and irregular and ill-defined borders is the most serious form of skin cancer. It occurs in the deepest portion of the epidermis, and for this reason, melanoma is the most likely form of skin cancer to spread quickly in the skin and to other parts of the body.

Mohs surgery: A surgical procedure that’s used when skin cancer is like an iceberg. Beneath the skin, the cancerous cells cover a much larger region and there are no defined borders.

Nevus: A mole.

Squamous cell carcinoma: The second most common form of skin cancer, usually found on sun-exposed areas of the body.

Skin graft: A surgical procedure used for skin cancer. Healthy skin is removed from one area of the body and relocated to the wound site. A suture line is positioned to follow the natural creases and curves of the face if possible, to minimize the appearance of the resulting scar.

Skin resurfacing: Treatment to improve the texture, clarity, and overall appearance of your skin, usually with a chemical or laser peel.

Cost is always a consideration in elective surgery, but most skin cancer procedures are covered by insurance. A quote will be provided to you after your consultation with Dr. Alexander.

Cost may include:

• Surgeon’s fee
• Operating Room and Supplies
• Prescriptions for medication
• Anesthesia fees (if not done under local anesthesia)

Your health insurance plans should cover skin cancer surgery. Pre-certification is often required for reimbursement or coverage. Be sure to consult with your insurance company in advance of any surgery.

Prior to surgery, we will have you:

• Take certain medications or adjust your current medications
• Avoid taking aspirin, anti-inflammatory drugs, and herbal supplements as they can increase bleeding
• Stop smoking in advance of surgery

Medications are administered for your comfort during the surgical procedure. The choices include local anesthesia, intravenous sedation and general anesthesia. We will recommend the best choice for you based on your personality, your desires, and the complexity of your procedure. Most skin cancers are removed with simple local anesthesia.

The procedure typically takes about 5-15 minutes depending on the individual face and certain surgical variables.

There are three basic steps to Skin Cancer surgery.

Step 1 – Marking
It is important to mark the lesion carefully under magnification.

Step 2 – The Incision
The incision lines for the procedure are designed so that scars will be well concealed within the natural grain of the skin.

Step 3 – Closure
Most defects can be closed directly, or primarily. A large defect can be reconstructed with a local flap. A flap may also be necessary where excision may result in a disfiguring appearance. A local flap repositions healthy, adjacent tissue over the wound. A suture line is positioned to follow the natural creases and curves of the face if possible, to minimize the appearance of the resulting scar.

If a skin graft is needed, healthy skin is removed from one area of the body and relocated to the wound site.

Pathology
The specimen is marked appropriately and sent to the pathologist, who makes a diagnosis and comments on the margins, whether or not all the cancer has been removed. In our experience all margins are clear approximately 90% of the time. If a margin is positive, the scar will usually be re-excised in the next 1-3 months

When the cancer is particularly large or recurrent, Dr. Alexander may order a frozen section. In this procedure, the cancerous lesion is removed and microscopically examined immediately by a pathologist prior to wound closure to ensure all cancerous cells have been removed.

The goal is to look for a clear margin — an area where the skin cancer has not spread. If clear margins are found, the resulting wound is reconstructed. If clear margins are not present, Dr. Alexander will remove more tissue until the entire region has a clear margin. This process is similar to Mohs surgery, and is rarely required.

Pain
Pain from skin cancer surgery is usually minimal. Pain pills are usually not required but can be provided if necessary. Significant pain is extremely rare.

We will explain in detail the risks associated with surgery. You will be asked to sign consent forms to ensure that you fully understand the procedure you will undergo and any risks and potential complications.

Possible risks include:

• Bleeding (hematoma)
• Infection
• Unfavorable scarring
• Frozen-section inaccuracy
• Recurrence of skin cancer
• Possibility of revisional surgery

After your skin cancer has been removed and primary reconstruction is completed, a dressing or bandages will be applied. It is important to follow all wound care instructions such as cleansing and applying topical medications exactly as directed. Most patients can go about their normal activities and get the incision site wet. Patients should try to limit movement that may stress the wound and the sutures.

Be careful
Following your doctor's instructions regarding medications and other post-operative measures is key to a quick recovery. It is important that the surgical incisions are not subjected to excessive force, abrasion, or motion during the time of healing. We will give you specific instructions on how to care for yourself.

You will be given specific instructions that include:

• How to care for the surgical site
• Medications to apply or take orally to aid healing and reduce the potential for infection
• Specific concerns to look for at the surgical site or in overall health
• When to return to the office

Sutures are usually removed after 4-7 days. Pathology reports usually return in about one week. We will call you with the result. If you do not receive word from us after two weeks, please call the office so that we can make sure that your report has been received.

Healing will continue for many weeks or months as incision lines continue to improve. It may take a year or more following a given procedure for incision lines to refine and fade to some degree. In some cases, secondary procedures may be required to complete or refine your reconstruction.

Continuing a Skin Care program can help maintain your result and help keep your skin young and healthy. We offer a complimentary facial after your procedure to introduce you to our Aesthetician, Leanne, and our Physician Assistant, Joanna, in our excellent Skin Care Clinic.

Life-long sun protection will help to maintain your rejuvenated appearance by minimizing photo-aging or sun damage. In addition, a healthy lifestyle will also help maintain a rejuvenated, more youthful appearance.