Procedures
Skin Cancer
Individual results may vary.
Not all skin lesions deserve a trip to the doctor. If a lesion is growing, if it is clearly unusual to you, if it results in bleeding or skin breakdown, if it is darker in color than one’s normal skin, if it is raised above the skin level, it probably deserves a physician’s examination. Of course, if a lesion such as a mole is disturbing to a patient by its appearance, any dermatologist or plastic surgeon can be consulted for its elective removal, typically as an office procedure. If there is an obvious or biopsy proven skin cancer, I prefer a surgical removal over a treatment with liquid nitrogen (a freezing agent) so that the confirmation of clear margins is achieved. Yes, freezing is quicker but it may also result in a recurrence deep in the skin. I also do not advocate treatment of skin cancers by Radiation.
Early Diagnosis & Treatment — Why Surgery Is Often Preferred
The vast majority of skin cancers are diagnosed early enough so that Surgery to remove them is usually a minor procedure and can be easily done under local anesthesia as an outpatient. Many of these patients are first seen by their family physician or dermatologist. Dermatologists are excellent diagnostic sources, but they are not trained surgeons. The patient who has an undiagnosed skin lesion that is growing or symptomatic might prefer to seek out a Board Certified Plastic Surgeon to both make a correct diagnosis and perform the surgical procedure to remove it. Often this can be done in a one step procedure, where the surgical specimen can be immediately examined by a Board Certified Pathologist, and the surgeon can finish the reconstruction of the wound with any of a variety of techniques known to plastic surgeons.
When I see a new patient in the office with a skin lesion which is suspicious for cancer, we discuss the surgical excision and whether it should be performed in the office or hospital. Many lesions, especially those not on the face, can be cared for by an in-office procedure with local anesthesia. The specimen is marked and sent to the pathologist for confirmation of clear (no tumor) margins. These patients usually return only for suture removal and wound check . For more complex cancers of the face, scalp, neck and ear, the hospital provides all of the surgical necessities, as well as the presence of a Board Certified Pathologist who can give an immediate interpretation of the type of lesion, and whether the borders of the lesion are fully removed. This allows me to simultaneously complete a one stage reconstruction by whatever surgical means is best to achieve the desired result. This also allows the patient to normally return home the same day with the confidence that additional surgery will not be necessary. Follow up for suture removal and wound check takes place usually within seven days at the office.
Dermatology vs Plastic Surgery — Differences in Approach
By contrast, patients who visit a Dermatologist may frequently experience a separate procedure for biopsy , another procedure for additional biopsies, and one or more additional procedures for a dermatologic attempt at removal of the lesion. Even then, the patient may still require referral to a plastic surgeon for closure of a complex wound. Patients with skin malignancy often ask about the need for MOHS surgery. The long established technique of MOHS chemosurgery (or so-called micrographic surgery) was started by Dr. Frederic Mohs, a general surgeon from Wisconsin. Some dermatologists have adopted this procedure, in large part because it can be performed in an office. (Most dermatologists do not have surgical privileges in hospitals or in certified outpatient surgical centers) MOHS surgery for cancer lesions can be as highly accurate as Plastic surgery in experienced hands and with Board Certified Pathologists.
Concerns With MOHS in Dermatology Offices
Unfortunately ,however, most Dermatologists do not employ experienced Pathologists to work in their offices as was originally promoted by DR. MOHS.This situation means that patients can incur more office visits, biopsies and surgeries for tumor removal than absolutely necessary. My principle goals are: to inform the patient of the correct diagnosis and nature of their problem, its prognosis, the best solution surgically for them, and deliver care efficiently and safely. Patients would be wise to ask questions regarding how many procedures are necessary, where they should be performed (office or hospital), where and by whom the pathology will be examined , and what complexity of wound will there be before making a final decision about their procedure and who is most capable of performing all of their care. Patients should understand that if a surgery requires complex methods of closure or reconstruction, a Board Certified Plastic Surgeon is most capable of providing this expertise.
Complex Lesions & Advanced Surgical Reconstruction
Patients with more complex skin lesions such as melanoma or large squamous or basal cell carcinomas of the head and neck will inevitably have need of plastic surgical consultation, preferably before any resection is done. These patients should also inquire of the plastic surgeon’s experience with resection and reconstruction of such lesions and feel free to see examples of their work and seek other opinions if desired. Finally, surgeons who treat complex skin cancers and their reconstruction have the awareness of and familiarity with other hospital specialists, medical and surgical, who may need to be involved in comprehensive patient care.
