Hundreds of thousands of people are diagnosed with skin cancer each year in the United States. While this is an alarming number, the vast majority of those diagnosed are easily treated. Skin cancer surgery is focused on removing all cancerous cells while sparing as much healthy tissue as possible. This should be followed by a careful and cosmetic wound closure.
Most skin cancers are detected while they are very small and can be easily treated by simple surgery, under local anesthetic. In these cases, the scar is usually minimal requiring less complicated surgical closure.
In more advanced cases of skin cancer, the surgery can result in a larger defect that can be located on crucial structures such as the lips, eyelids or nose. This subsequent cancer defect can result in significant disfigurement that must be repaired by a plastic surgeon with extensive experience in facial reconstructive surgery.
All facial reconstructive surgery should be performed by a plastic surgeon who is board-certified by the American Board of Plastic Surgery—the only plastics board recognized by the American Board of Medical Specialties. This certifies the full spectrum of the specialty of plastic surgery, including procedures of the head, neck, trunk, and extremities.
Select a Facial Specialist for Skin Cancer Repair
Dr. Joshua Lampert is one of the most highly respected facial cosmetic and reconstructive plastic surgeons in the Miami area. He is constantly sought for repair after cancer surgery due to his technical skill as well as his artistic sense. He meets each challenge with enthusiasm and confidence. Dr. Lampert believes that a meticulous and detailed effort is necessary in order to optimize his patients' peace of mind and ensure that they will be able to resume their normal lives without feeling self conscious.
Common Types of Skin Cancer
Skin cancer is typically caused by over exposure to the sun. UV (ultraviolet) rays from the sun have been shown to damage the genetic makeup (or DNA) of cells in laboratory studies. Experts agree this is the reason that sun exposure causes skin cells to genetically mutate into cancer cells. The three main types of skin cancer are:
- Basal Cell Carcinoma
- Squamous Cell Carcinoma
Basal cell carcinoma is the most common and least deadly form of skin cancer. It can, however, be dangerous and grow quickly in its immediate vicinity. It was once commonly referred to as a “Rodent Ulcer” or “Rat Bite Ulcer” due to its ability to eat or gnaw away at nearby tissues as it grows. This can create an expanding sore or ulcer that can be a significant concern, especially on the face when encroaching on important nearby structures such as eyelids, nose, lips, ears, etc. As this cancer mutates, it may become more and more aggressive, grow faster and cause greater and deeper destruction. With time, this growth may require a much larger surgery to excise it if left untreated. This cancer usually starts to grow slowly on the head, neck, tops of the ears or anywhere on the upper body. This type of cancer appears in an estimated 75% of skin cancer cases.
Squamous cell carcinoma is responsible for about 20% of skin cancers. It isn’t typically as dangerous as melanoma, but if undiagnosed and left untreated, this type of skin cancer can spread to other parts of the body and become deadly. In general, squamous cell carcinoma is much more dangerous when it appears near any mucous membranes, such as the eyelids, mouth, ear canal, genitals, anus, etc.
Melanoma is considered to be the most dangerous skin cancer. It can become metastatic and spread to other parts of the body such as the brain, liver, lymph nodes, and lung. Although melanoma is responsible for only about 5% of skin cancers, it is responsible for the majority (approximately 75%) of all skin cancer deaths. Melanoma typically presents as a pigmented lesion, or darkly colored spot that changes or varies in color. Staging of melanoma is typically based on the pathology specimen, how deep the tumor has invaded into the skin, if there is any ulceration, or if the cancer has already spread.
Pigmented skin lesions, birthmarks or moles that meet the following “ABCDE” criteria should be evaluated for biopsy to rule out a possible melanoma.
A: Asymmetry or asymmetric shape
B: Border that is irregular, scalloped, or that has uneven edges
C: Colors with multiple variations (brown, blue, black, and tan) all within the same skin lesion
D: Diameter growing in size or exceeding 1/4 inch or 6 mm
E: Evolving in shape or size. Any change in color, crusting, ulceration, scabs, or overall change in appearance.
Since melanoma is staged based on the depth of invasion, excisional biopsy (or cutting the lesion entirely out) should be performed. For this same reason, a shave biopsy (or partial excision) should usually NOT be performed whenever there is a real concern for melanoma. Furthermore, the roles of frozen section and MOHS surgery for the excision of melanoma is extremely controversial for fear of missed margins and the potential to leave more melanoma cells behind which may ultimately propagate, spread, and metastasize. For melanoma, surgical excision with adequate margins still remains the gold standard for treatment.
Before & Afters
All plastic surgeons should be judged on the aesthetic merits of their work. Review Dr. Lampert’s before and after gallery to see what he has accomplished.
Skin Cancer Surgery – Excision with Frozen Sections or Mohs Surgery
The most important factor in successfully treating skin cancer is early detection. Skin cancer may appear as a small spot on the surface but underneath can be quite widespread.
A surgical procedure is usually necessary to excise the cancer growth and a very thin border of healthy tissue. This tissue is microscopically examined to see if there are any cancer cells present in the healthy border tissue.
Most skin cancer excision is typically done by a plastic surgeon, dermatologist, or surgical oncologist. For basal cell and squamous cell carcinoma, frozen section or Mohs techniques may be utilized. Using the frozen section technique, a surgeon excises the lesion and a separate expert pathologist (who specializes only in microscopic tissue examination) looks at the slides immediately during the procedure. These two physicians work together as a team while the patient is still undergoing surgery.
Alternatively, skin cancer is also frequently excised by a dermatologist through Mohs procedure. With a Mohs procedure, the dermatologist both excises and also reads their own pathology prepared slides. With either surgery, the tissue is examined under a microscope to ensure that no cancer cells remain in the healthy tissue. If so, another very thin layer of tissue is removed and checked for cancer cells. This process is continued until the tissue sample is clear of cancer cells. Reconstruction can then be done with confidence that the cancer is gone. No technique is 100% accurate at removing only the cancerous cells, but these techniques are the current gold standard for most basal and squamous cell cancer treatment scenarios.
Whatever technique is used, skin cancer excision can leave a large defect of tissue or a complete absence of an important facial structure.
Patients who are planning to undergo skin cancer excision should arrange to see a board certified plastic surgeon immediately after their cancer excision procedure with their dermatologist. If a large defect is created with cancer excision, patients typically want to have their reconstructive surgery done immediately. Sometimes, it is very difficult to determine the actual size and depth of the subsequent facial defect after cancer removal.
Seeing a fully capable and experienced board certified plastic surgeon with further specialty training in reconstruction of the nose and face is very important for skin cancer patients. This will allow the highest chance for a successful surgery to restore a normal appearance to the nose and face in general. Dr. Lampert coordinates his surgical plan with the patient’s cancer surgeon in order to afford patients the least amount of stress and healing time. This also allows patients a faster return toward a normal appearance and their regular daily lives.
Methods of Repairing Skin Cancer Wounds
This is where the plastic surgeon’s experience with cosmetic and reconstructive procedures is put to the test. There are several methods of reconstruction that can be used, depending on the size and shape of the affected area. Dr. Lampert will work in coordination with the patient’s medical team to begin the reconstruction process as soon as possible. Dr. Lampert feels that immediate reconstruction, when possible, can often optimize successful outcomes and minimize patient down time. There are many surgical benefits to close a wound that is fresh and without contamination. Still, sometimes due to a very severe case, a large defect or a patient’s other medical problems, reconstruction may need to be delayed or performed in the operating room after hospital admission.
The general principles of plastic surgery are actually quite vast and currently require at least 6 years (usually longer) of dedicated residency surgical training in order to achieve board certification by the American Board of Plastic Surgery. There are many methods that a plastic surgeon carries within their “bag of tricks” when it comes to a cosmetically acceptable cancer defect reconstruction. For smaller defects, a very meticulous layered wound closure may be all that is needed for an aesthetically excellent result. For larger defects, tissue may need to be arranged and rotated or advanced into the defect in order to minimize deformity. More significant defects may require more distant flaps, cartilage or fat grafts, skin grafts, or a staged multiple procedure approach.
The plastic surgeon is the tissue sculptor who spends the most time training to handle the delicate soft tissue and skin. The plastic surgeon’s specialty, by definition, is to conceptualize the least conspicuous and best matching donor sites for this tissue trade, often aesthetically “borrowing from Peter to pay Paul.”
After 6 years of intense plastic and cosmetic surgery training in Manhattan, Dr. Lampert spent extra time training in cosmetic and reconstructive surgery of the face. During this time, he trained even more extensively to learn the wide variety of flaps, skin grafts, and tissue expansion techniques that can be used to reconstruct the broad diversity of facial defects that can be seen.
For the largest and most complicated defects, a method called microvascular free tissue transfer, or a “free flap,” may be required. In this procedure, skin, soft tissue and sometimes bone tissue is harvested along with supporting blood supply. The blood supply to this tissue includes a feeding artery and a draining vein. The tissue is harvested from a donor area that can be more easily and aesthetically closed. This free flap is then transplanted into the cancer defect and the artery and vein are connected to recipient vessels under the microscope with microsurgery. This procedure is quite complex but may be necessary when large areas of tissue have been removed by the surgical oncologist. Some flap procedures require more than one surgery to ensure blood supply is established.
Most surgical removal of skin cancer and subsequent reconstruction is done on an outpatient basis under local anesthetic. The recovery process is mainly concerned with the care of the wound site during healing. This is to ensure that the fresh suture line is not subjected to mechanical stresses such as motion, force or swelling. Following Dr. Lampert’s specific instructions can help reduce tension and wound disruption and ultimately optimize scar formation. Following directions helps produce the best and finest surgical scars.
After surgery, extensive instructions are provided concerning wound care, bathing, resuming normal activities, returning to work and when to follow up with Dr. Lampert.