Skin cancer is one of the most common forms of cancer in this country. There are three major types, including basal cell carcinoma, squamous cell carcinoma, and melanoma.
Dermatologists trained in Mohs surgery can excise skin cancer with both precision and accuracy. Plastic surgeons usually take a standard margin for each type of skin cancer and check the margins with a “frozen section” where a pathologist looks at the excised skin cancer under the microscope to check for clear margins at the time of the surgery.
Both Mohs surgery and the plastic surgeons’ excision techniques using standard margins have excellent cure rates for skin cancer. In cases where the Mohs surgeon performs the cancer excision, reconstruction is performed on the same day at a surgery center by a plastic surgeon. There are various techniques for reconstruction, including primary closure, skin graft, and local flaps.
What is skin cancer reconstruction?
While many early or pre-cancerous lesions can be treated effectively by dermatologists with topical or non-surgical treatments, that’s not the case with more advanced skin cancers. They require surgical removal. Since many of these cancers appear on the face, these excisions can leave unappealing scarring.
That’s why Mohs micrographic surgical methods have been gaining more and more acceptance, especially for removing facial basal cell and squamous cell carcinomas. Mohs only takes the minimum amount of healthy tissue around the cancerous tissue, minimizing the excision area. But there still is an excision area, and this will leave a scar.
That’s where skin cancer reconstruction with Dr. Lee comes in. He uses his board-certified plastic surgery training, expertise, and experience to reconstruct the area of your face after your Mohs surgery. The goal of skin cancer reconstruction surgery is, of course, to minimize the appearance of the scarring. But on areas such as the nose or mouth, it may also involve maintaining function.
Who is a candidate for skin cancer reconstruction?
Anyone who is having skin cancer removed from his or her face is a candidate for reconstruction. Of course, this doesn’t apply to a small lesion being removed with a curette. If that leaves a scar, it will be minimal. Reconstruction is needed after Mohs procedures remove a larger area of tissue. These excisions often create problems both aesthetically and with the function of that area of the face. Dr. Lee follows the Mohs surgeon. His goal is to minimize any remaining scarring.
What are the different types of skin cancer?
Skin cancer begins in the epidermis, the skin’s top layer. The epidermis contains three main types of cells: squamous cells that lie just below the outer surface, basal cells beneath the squamous cells, and melanocytes in the lower part of the epidermis. The common forms of skin cancer get their names from the cell types. Here are their descriptions and what they look like.
Basal cell carcinoma
Eighty percent of skin cancers are basal cell carcinomas. These cancers usually develop in sun-exposed areas, especially the head and neck. They tend to grow slowly and rarely spread to other parts of the body. Diagnosing and removing basal cell skin cancer is not usually difficult. But if left untreated, basal cell carcinomas can grow into nearby areas and invade bone or other tissues beneath the skin, making removal potentially disfiguring.
Basal cell carcinomas look like a flesh-colored, pearl-like bump or a pinkish patch of skin.
Squamous cell carcinoma
Squamous cell carcinoma accounts for roughly one-fifth of all skin cancers. Squamous cell cancers appear on sun-exposed areas of the body such as the face, ears, neck, lips, and backs of the hands. They are more likely to spread to other parts of the body than basal cell cancers, but this is still rare.
Squamous cell carcinomas will look like a red firm bump, scaly patch, or a sore that heals and then re-opens.
This deadliest form of skin cancer is also, fortunately, the rarest. But, unlike basal and squamous cell cancers, melanomas are far more likely to grow and spread if left untreated. When melanomas grow downward, they can begin to deposit cancerous cells into the bloodstream, which can then spread cancer anywhere in the body.
A melanoma will suddenly appear as a new dark spot on the skin. They will also show as a change in the size, shape, color, or elevation of an existing mole. This is more typical in people with over 50 miles.
What is Mohs surgery?
Named for Dr. Frederic Mohs, who first started this method of skin cancer removal in 1953, Mohs surgery is now the gold standard method for effectively removing skin cancer lesions.
Mohs surgery is the most effective technique for removing many basal cell carcinomas and squamous cell carcinomas, particularly on the face. Mohs surgery eliminates virtually all of the guesswork involved in traditional excision surgery, where there is always a question if the surgery has removed all of the skin cancer.
This is possible because Mohs is performed in stages. The first excision is made, and the sample is immediately sent to the lab. The entire sample is tested to see if any cancer cells can still be found. If so, the doctor removes another ring of tissue, and the process is repeated. This is repeated until no cancer cells are found. The incision is then permanently closed, and the procedure is complete.
When traditional methods are used, the doctor removes a larger area to ensure the skin cancer has been removed. The problem with this is that there’s no way to know all of the outer cells have been removed. To help reduce the possibility of remaining cells, a larger area is removed, which often removes more healthy tissue than necessary.
That contributes to Mohs having a 99 percent cure rate for skin cancers not previously treated.
What are the primary techniques used for skin cancer reconstruction?
Dr. Lee performs skin cancer reconstruction on the same day as the Mohs surgery is done. He can employ various techniques for making the excised area as inconspicuous as possible. Here are descriptions of various methods:
- Primary closure — This is the most straightforward approach to repairing a skin cancer defect. This method simply brings the edges together, making a circular opening into a linear scar. In most cases, Dr. Lee needs to make the wound longer so that he can bring the edges together evenly. The final scar created is typically two to three times the length of the original wound. Primary closure can be used in cases where the excision of skin cancer is relatively small.
- Local flap closure — Local flap reconstruction is the most common type of technique used for facial skin cancer reconstruction. This involves using a skin that is adjacent to the site of cancer to repair the defect. There are many different types of flaps employed for this type of reconstruction. Essentially all local flaps involve extending incisions from the original cancer defect to allow for elevation of a flap of skin that can be rotated or advanced to cover the removed area. The final shape of the scar created can be very irregular and much longer than the original defect. The goal is to re-drape the skin in a smooth manner and to hide the scars created as much as possible in existing facial lines or shadows.
- Skin grafting — Skin grafting involves taking skin from an area of the body where there is sufficient laxity and using it to repair the defect at the location of cancer. Because the donor site skin had laxity, the skin is deemed expendable and can be used for the graft. These grafts can be partial thickness, where the top layer of skin is shaved without making a deep incision. Or they can be full thickness, where the skin is surgically removed and the wound sutured closed. On the face, it’s rare for Dr. Lee to use a partial graft, as they tend to heal with significant contraction, and they may appear lighter in color and shinier when compared to the surrounding skin.
- Structural grafting — When skin cancer is removed from the ear or nose, it often is deep enough in the tissue to involve removing the cartilage below the skin along with the skin. Cartilage is the stiff, supporting structure that gives the ear or loses its shape. When a piece of that structural cartilage is removed it needs to be replaced with a structural graft. For an ear repair, Dr. Lee often takes the cartilage from behind the ear. For the nose, the graft will most likely come from the nasal septum that divides the nostrils. Small pieces of cartilage are taken from the donor site and custom shaped to recreate the structure that was removed with the cancerous cells. The grafts are strategically placed and secured like a framework beneath the skin until the desired support structure is achieved. Then the overlying skin is re-draped.
What is recovery like after skin cancer reconstruction?
Healing of these lengthy incisions will take up to a full year. Throughout the healing process, Dr. Lee may be involved again to make adjustments to help even further minimize the scar. These interventions could be topical wound care therapy, injections of steroids, possible laser treatment, or even surgical revision of the scar.
What scarring should I expect after skin cancer reconstruction?
You’ll be amazed at how minimal your scarring can become with these different reconstruction methods used by Dr. Lee. There will be scarring — any time the skin is cut scar forms — but it won’t be something you’ll feel the need to hide. At first, your scarring will be quite angry, but with time, and possible scar revision treatments, it will continue to improve. Dr. Lee’s goal with skin cancer reconstruction is to have the patient be able to return to their normal daily life without having to worry about how others view their face, and without any limitation in function.
Schedule a Consultation Today
If you have suffered from skin cancer and are interested in learning more about reconstruction, Dr. Richard H. Lee can help. Schedule a consultation at his Newport Beach practice today by calling 949-548-9312.