Skin Cancer and Melanoma

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Skin cancer treatment depends on an accurate diagnosis.  At KM Surgical and Dermatology Associates we have specialist expertise and training to ensure that the correct diagnosis is made.

Melanoma, basal cell carcinoma and squamous cell carcinoma are the most common types of skin cancer but in fact there are also hundreds of other different and less common skin cancers which are equally important.  ALL SKIN CANCER should be taken seriously.
Because there are so many types and sub-types of skin cancer a biopsy might be required before definite treatment is undertaken.  Sometimes, however, this is not required when the exact diagnosis is clear clinically. 

Skin cancer precursor conditions such as solar (actinic) keratoses are often present in fair skinned and sun affected patients.  These conditions can be managed with treatments such as liquid nitrogen or with 5 fluorouracil (Efudix®) cream or photodynamic therapy (PDT).  Other modalities such as the immune response modifier imiquimod or laser resurfacing with the CO2 laser may sometimes by indicated and for individual lesions surgical shave excision or curettage and electrosurgery may be preferred.

Melanoma can be a fatal condition if not recognised early and treated with curative surgery.  Other cancers such as merkel cell and angiosarcoma may be equally lethal if not recognised early.  A thorough skin and mole check with an experienced dermatologist will help to make sense of things.

The majority of skin cancers are well defined and can be adequately visualised and identified for surgical excision (see further).  When cancers are more complex, ill defined, recurrent or of a potentially aggressive subtype in high risk areas, Mohs surgery may be indicated (see further)

For skin cancer treatments, the primary objective is to fully excise the skin cancer but at KM Surgical we also have an emphasis on achieving good aesthetic outcomes which are so important for any skin sites. 

Effective skin surgery includes many techniques to achieve the best possible outcomes.

Mohs Micrographic Surgery (Mohs)

Mohs micrographic surgery is a specialised procedure for the microscopically controlled excision of skin cancer.  Mohs gives the highest cure rate for non-melanoma skin cancer (approximately 97%) and is the most advanced and effective treatment procedure for invasive basal and squamous cell skin cancer available today.  Mohs surgery is performed by specially trained dermatologists (Mohs surgeons.)

http://www.dermnetnz.org/topics/mohs-micrographic-surgery

 

Mohs micrographic surgery – information for patients

 

What is Mohs micrographic surgery?

Mohs micrographic surgery, or Mohs surgery, is a precise surgical technique in which the complete excision of skin cancer is checked by microscopic margin control.  It offers the highest cure rates while maximizing preservation of healthy tissue.  The principles behind it were developed by Dr Frederic Mohs in the 1930’s.

Mohs surgery is recognised as the treatment of choice for high risk basal cell carcinoma and squamous cell carcinoma.  The skin cancer is progressively removed in stages.  After each stage, the excision margins are microscopically examined for remaining cancer cells and this process is repeated until all cancer has been removed. 
 
 
Preparations for your Mohs procedure
 
It is best to wear comfortable clothing, preferably with a front zipper so that upper body      clothing does not have to go over your head when you take it off.
Remove any jewellery before you attend the surgery.
Do not wear make-up.
It is advised to bring some form of entertainment for yourself, such as a book, phone or music.
Make sure a support person takes you home safely after the procedure as you may not be allowed to drive yourself.
When you are on blood thinners, please continue to take them as usual, unless instructed otherwise.
If you are on warfarin, please have your INR checked within three days before your procedure. The INR level should not exceed 3.5 on the day of the procedure.
It is advised not to smoke the week before and after the procedure to minimise wound infection and promote wound healing.
Please bring with you a list of all current medications you are taking.
Expect the procedure to take up the whole day. Even though the surgical procedure itself may not take very long, there will be significant time where you will be waiting for results.
Make sure you have a supply of paracetamol at home for after the procedure.
Please note that you do NOT need to be fasting so you can have breakfast as usual on the day of the procedure. 
 
The initial Mohs procedure steps
 
You will be welcomed at the reception and asked to fill out a form with some basic questions on your current health status.
Next, you will be taken to a separate waiting room, which is the area where you will be spending most time during the day of your procedure.
You will be asked to wear a surgical hat and shoe covers. You can also leave your belongings which will be kept in a safe place. 
After this you will be taken to the procedures room. 
During the day, lots of photos will be taken of the area that needs operating on. These will be stored in a safe way to protect your privacy.
The treatment area will be cleaned with a disinfectant first and drapes will be used to create a sterile field. Please keep your hands away from the sterile field at all times.
You will be given a dose of oral antibiotic.
The area that is going to be excised will be marked with a skin marker.
Next fast-acting local anaesthetic will be injected to numb the area, so you do not feel pain after that.
The affected area will be excised which normally takes between 15 and 45 minutes, after which a second, longer lasting anaesthetic is used to keep the area numb for several hours after.
The wound will be dressed with a temporary dressing and you can go back to the waiting area together with the other patients that are treated on the same day.
While you are waiting the excised skin will be frozen and cut into microscopic slides by a technician. These slides are then examined under a microscope by your Mohs surgeon to check for any remaining cancer cells in the excision margin.
The process takes a few hours on average. You can eat and drink while you wait, read a book or chat with the other patients if you wish.
Please make sure you bring your own lunch and snacks as these will not be provided. Water, tea and coffee will be provided for you.
 
Next steps of the Mohs procedure
 
You will be informed on the outcome of your excision when this has been examined under the microscope.
You may need additional stages in the procedure room if not all tumour has been excised in the first round. On average 2 or 3 stages are needed for complete tumour clearance but occasionally multiple stages are required.
When all cancer cells have been removed the wound can be closed. This may be performed by your Mohs surgeon on the same day or by other surgeons.
If your wound is closed on the same day you may sometimes need to wait for other patients’ results to come back before your wound can be closed.
Wound closure often involves a skin flap or graft. When adjacent skin is moved into the wound and blood supply is left intact, this is referred to as a flap. A skin graft means taking a thin piece of skin from elsewhere, which is patched onto the wound.
Different options of wound closure will have been discussed with your Mohs surgeon or referring doctor in most instances. However, tumours may sometimes prove to be larger or more extensive than they appear from the outside and wounds can therefore be larger than expected. The type of wound closure will depend on the ultimate wound site and cannot always be predicted beforehand. 
 
After your procedure
 
You will go home the same day. Usually the pain after the procedure is mild, but you may require paracetamol 1 gram up to a maximum of 4 times in 24 hours.
It is advised not to take other painkillers as they can have a blood thinning effect and increase risk for bleeding (particularly non-steroidal anti-inflammatory drugs).
It is normal for the area around the wound to get swollen or bruised in the next few days after your procedure. Surgery near the eye may cause a black or puffy eye which is normally not a reason for concern.
The dressing normally needs to stay in place during the whole week after your procedure. Usually you will have an additional pressure dressing on top which can be removed after 48-72 hours.  If there are any specific requirements you will receive instructions for this.
It is important to keep the dressing on and the wound dry until you return for follow up and removal of stitches after one week.
Make sure to avoid exercise and bending over during the week after your procedure. This is very important to prevent postoperative bleeding and infection.
 
Possible complications
 
All procedures involve risks. Fortunately, serious adverse events after Mohs are extremely rare. The following complications might occur:
 
Bleeding. If the wound bleeds apply firm pressure to the area using a clean tea towel for at least 20 minutes. If this does not control the bleeding you should seek medical advice from KM Surgical or your nearest 24-hour emergency service. If the wound becomes red, swollen and painful and you feel unwell or have a fever you may require antibiotics. You should seek medical advice from KM Surgical.
Scarring. All operations will lead to a scar which is not a complication but a normal reaction. The scar may extend quite a bit beyond the initial tumour however, especially when a flap is required. Note that a larger scar often leads to a better functional and cosmetic result.
 
Dr Middelburg carries out Mohs surgery at this practice.  You will require a consultation. 
 
 

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