Reconstructive Skin Surgery
Plastic surgery is a fascinating specialty - it addresses clinical problems from head to toe and has been a wellspring of surgical creativity and innovations for centuries. Its fundamental principles – wise planning of reconstruction, creative thinking and delicate operating – represent a rock upon which a plastic surgeon's mindset is set, a solid foundation upon which all other, additional subspecialist expertise is built on later.
Basal Cell Carcinoma (BCC) is the most common and least dangerous form of skin cancers. Over 50,000 new cases of BCCs are reported each year in the UK. Fortunately, it is a very slow growing type of cancer and extremely rarely spreads to other areas or organs in the body. If left untreated however, it can be locally invasive and very destructive to the nearby tissues leading to disfigurement, especially if present on the face. Sun exposed facial skin is commonly involved . Early recognition and treatment is important.
BCCs are caused by long-term, intermittent exposure to sunlight. This is why it frequently occurs on sun exposed areas of the body – face, scalp, ears, hands, shoulders and back. BCCs are frequently seen in persons aged over 50 years, but increasing number of younger adult report this problem over the last decade.
At particular risk of developing BCCs are the white adult population, those with a history of sunburn, recreational sun exposure, outdoor occupations and fair skin.
Examine your skin every 6-12 months for early warning signs. Systematically look and feel for any changes in your skin, ask someone you feel comfortable with to examine your back, neck, ears or scalp or seek advice from your GP.
- Aim to cover up and wear wide-brimmed hats when outdoors to protect the area’s most at risk
- High factor sunscreens (minimum SPF 15+) are vital. Apply them before going out in the sun and re-apply every 2-3 hours, or more frequently if perspiring or swimming
- Wear 100% U.V protective sunglasses as the skin surrounding the eyes is vulnerable to sun damage
- Seek shade between 11:00am and 3.00pm
- Make sure you do not burn and take extra care if with children
- Avoid using artificial sun tanning beds
Remember – early recognition is important as it may reduce the necessity for more invasive treatment. PREVENTION IS BETTER THAN CURE !
Most lesions on the skin are benign, temporary and clinically not worrisome. Gallery below illustates few clinical examples and subtypes of these cancers to give you an idea what to look for. If you notice a skin lesion or sore that fails to heal within 4-6 weeks and has two or more of the following features, you should have the lesion checked:
- an open sore or ulcer; a smooth raised growth can appear with an ulcer in the centre
- a red patch on the skin, which may be itchy, painful or crusty; sometimes no symptoms are felt but the lesion does not heal or fade
- a firm nodule in the skin; these, too, can appear flesh coloured, pink, shiny, red or pigmented, or sometimes, just like a mole
- a flat, scar-like area in the skin, this area appears pale or white compared to surrounding skin and may have an ulcer or indentation in the centre; the affected skin look taut and shiny
The diagnosis is often clinical, but ultimate confirmation is obtained by histopathological (under the microscope) examination. This can be done by sending only a small portion (biopsy) or the whole tumour (excision) away. In my practice, most specimens are eaxmined really quickly and reslts can be expected within the first 72 hours. More complicated resections and/or rare lesions might take up to two weeks to report on, especially if additional specimen processing is required in laboratory or second opinion deem appropriate.
All treatments modalities aim to cure the lesion permanently. The superficial skin cancers can be treated in a number of ways whereas skin cancers which extend into the deeper layers are more likely tackled by surgery.
The most appropriate form of treatment depends on exact type, size, site and history of the particular lesion. You should hear expert opinion on the possible option for your treatment, but do not be surprised if various specialists give you different opinions. Clinician’s preferences often vary, especially across different specialties (dermatology/plastic surgery). This is because most lesions can be address differently and still in line with recognised skin cancer treatment Guidelines.
The commonest non-operative methods of treatment are:
- Topical treatment – cream and/or ointments (for example Efudix and Aldara) which cause skin inflammation and in that way attracts body’s own immune cells to fight and eradicate tumour cells. Treatment is normally applied for 3-6 weeks and takes up to 3 months to settle down
- Cryotherapy (Freezing) – eradicating the tumour and superficial layer of skin by freezing (liquid nitrogen is applied to the area via special spray pump). This procedure is carried out in outpatients and incurs minimal localised discomfort
- Photodynamic therapy (PDT) – treatment with light after ‘sensitisation’ of skin with a special cream (this is usually a single outpatient procedure)
- Radiotherapy – usually used for any remaining tiny tumour cells around the surgical area; for large ones which affect a big area making surgical reconstruction difficult, too complex or impossible; radiotherapy can have unfavourable effect on the surrounding tissues; it requires several visits over the short period of time in order to complete the treatment
It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:
- Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
- Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery
- Plan your time off school / work / sports
- Allow at least few weeks after surgery before considering travel
Treatment is usually carried out under local anaesthesia, on an outpatient basis, with minimal disruption to your daily routine.
Curretage – simple scraping away of the damaged cells in the superficial, top layers of the skin leaving the wound to heal on its own over the next few days (this is possible as these wounds are very superficial)
Excision – Surgery aims to remove the abnormal lesion and a narrow rim of normal tissue around it in order to adequately clear the area of the cancer. One of the major advantages of surgery is an opportunity to obtain a specimen for histological assessment and reliable confirmation as to weather tumour has been removed completely.
Certain wounds are small and/or superficial enough that can heal on their own (even without suturing) with regular change of dressings. In most cases however, once the cancer has been removed, the edges of the wound are stitched together (the simplest mode of surgical reconstruction). If the defect is larger or at a specific anatomical sites (especially on the face), sometimes it might be necessary to close the wound with a skin graft or flap. Skin grafts are harvested from certain areas of the body as a thin or thick piece of skin and placed over the wound. Grafts will have to acquire a new blood supply at the site of reconstruction. Skin flaps on the other hand, have their own blood supply and are raised from the area around the wound or even further away and transposed into the defect. Flaps provide very good colour and contour match and usually lead to a very favourable aesthetic outcome.
Regardless of reconstructive option used, I prefer to use the stitch which is hidden under the skin surface and needs to be pulled out in 7-14 days (see picture). In my experience, such stitches are least irritating, produce the fine line scar and leave no stitch marks. I always use magnifying surgical loops during surgery to ensure accurate and neat operating.
Once the BCC is completely removed, you should consider yourself ‘cured’ and can be discharged. No follow ups are required. If the margin of safety is too narrow or tumour has not been completely excised, additional surgery and/or radiotherapy might be required as well as a longer follow up.
- Bleeding and haematoma formation (rarely requiring return to theatre)
- Scarring (including hypertrophic scarring)
- Graft loss or flap necrosis
- Painful scar
- Incomplete excision
- Secondary procedures
Urgent concern after your surgery ?
Please ring the hospital where you have been operated on or my secretary and they will get in touch with me