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.
Squamous cell carcinoma (SCC) is the second most common skin cancer. It starts in the outer layer of the skin. Fortunately, SCCs are very slow growing, but if left untreated, they can disfigure the skin and may spread to other organs of the body (metastasise).
There is strong evidence to suggest that ultraviolet (UV) rays from the sun can do long-term damage to the skin, which may contribute to the development of squamous cell carcinoma.
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 (punch or incision biopsy) or the whole tumour (excision) away. The results of tissue sample analysis are normally available within 3-5 days of your surgery, in urgent cases after 24-48 hours.
Sometimes it might be sensible that biopsy is taken after non-surgical treatments (creams, shaveing, liquid nitrogen, light therapy) to check if the lesion has been fully cleared.
Examine your skin every 6-12 months for early warning signs. If you have had one SCC, it is possible that others will develop over the years. 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 G.P.
- 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% UV 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 with children
- Avoid using artificial sun tanning beds
- Advise others to protect themselves and carry out annual whole body skin checks
Remember – early recognition is important as it may reduce the necessity for more invasive treatment. PREVENTION IS BETTER THAN CURE !
Surgery is the commonest treatment option, but some types of SCC can be treated by radiotherapy, chemotherapy and topical ointments/creams. Surgery 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 – aims to remove the abnormal lesion and a narrow rim of normal tissue around it in order to completely clear the area of the cancer. If tumour is small, the removal of the tissue for diagnosis will also act as the cure. 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.
Cryotherapy – 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
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
Follow ups vary from 6 months to 2-3 years. It is important to rule out any recurrence in the vicinity of the operated area and lack of cancer spread into the nearby lymph glands. Enlarged lymph glands need to be tested, but might not necessarily be related to skin cancer.
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