Skin Cancer Surgery: Know Your Treatment Options
Reviewed by Heidi A. Waldorf, MD
Skin cancer treatment involves more than just the surgical removal of the visible lesion. Your surgeon must be sure to remove all the cancerous tissue under and adjacent to the surface tumor to ensure that all the cancer cells are gone. This can be especially challenging when skin cancer develops on your face.
In 2009, skin cancer tumor removal accounted for 70 percent of all tumor removals reported to the American Society of Plastic Surgeons (ASPS), making it one of the most common types of reconstructive plastic surgery in the United States.
Treatment options depend on the type and stage of cancer, the size and location of the tumor, whether it has spread and your general health. Several types of surgical procedures are available to remove skin cancers; your doctor will advise you on which one(s) is right for your individual case.
- Mohs micrographic surgery is a specialized procedure for skin cancers that grow in a continuous fashion. The dermatologic surgeon maps out the entire edge of the tumor by cutting it out in thin layers and immediately processing and reviewing each under a microscope. If there are cancer cells at any margin, the surgeon removes more in that area. The process is repeated until all the margins are clear of cancer cells. Mohs micrographic surgery allows the doctor to maximize the removal of the cancer while minimizing the removal of normal skin, and it has the highest cure rate of all procedures used for basal cell carcinoma and squamous cell carcinoma. It is the treatment of choice when these cancers are in cosmetically sensitive areas like the central face or for particularly aggressive forms of these cancers. By minimizing the removal of healthy skin, the defect remaining tends to be smaller and can be closed with sutures.
- Shave excision involves using a scalpel to shave off the tumor and some surrounding normal skin. The wound is allowed to heal with topical care and dressings, and the excised tissue is examined under a microscope to make sure all the malignant cells have been removed.
- Surgical excision is the procedure most often used for melanomas, but it can also be used for other skin cancers. The cancer is cut out along with a border of apparently normal skin. The size of that border is standardized based on the type of the cancer, its size and depth. The defect remaining is closed with sutures. The tissue specimen is sent to the laboratory to be processed and reviewed by a pathologist. For particularly deep malignant melanomas, the surgeon may also check lymph nodes at the time of the excision.
- Electrodesiccation and curettage is performed by first scraping off the tumor and a peripheral border using a sharp, ring-shaped tool called a curette. Then a needle-shaped electrode with a high-frequency electric current is used to stop the bleeding and destroy any cancer cells that remain. The cycle is generally repeated immediately two or three times for a complete treatment. This treatment is most frequently used on the trunk and extremities, on less-aggressive basal cell carcinomas and squamous cell carcinomas, and in older patients and those on anti-coagulant therapy.
- Cryotherapy, or cryosurgery, uses liquid nitrogen to freeze and destroy the skin cancer tissue. The growth crusts over and a scab develops that usually falls off within weeks. The results are similar to electrodessication and curettage.
- Laser surgery uses a narrow beam of intense light to cut out or vaporize the outer layer and variable amounts of deeper skin. Carbon dioxide or erbium YAG lasers give the doctor good control over the depth of tissue removed. It is sometimes used a secondary therapy when other techniques are unsuccessful.
- Topical chemotherapy or immunotherapy agents (5 fluorouracil cream and Imiquimod cream) use prescription topical creams that are applied to target the cancer cells. 5-FU is a chemotherapy agent that seeks out and destroys the 'bad' cells, causing them to scab, crust and heal. Imiquimod cream is an immunotherapy that stimulates the patient's immune system to react against the cancer cells. The area becomes inflamed, red and scaly until clear.
- Photodynamic therapy is used for non-melanoma skin cancers. A chemical is applied to the affected area which makes the cancer cells susceptible to specific light waves. The area is exposed to those wavelengths to destroy the tumor.
Facial Skin Cancer: Special Issues
Reconstructive surgery after facial skin cancer treatment can be especially challenging. One of the primary issues is the limited availability of well-matched donor tissue. Facial skin grafts, which are very thin layers of skin, are usually harvested from a donor site near the face, such as behind the ear or the neck, where the texture and color matches are best. If a large percentage of facial tissue has been removed, a slightly thicker skin flap may be created from adjacent tissue. Both of these highly-specialized surgical procedures are best performed by a board-certified dermatologic surgeon, facial plastic surgeon, or plastic surgeon.
Skin Cancer Surgery: Insurance Coverage
Skin cancer surgery and any necessary reconstructive surgery may be covered at least in part by health insurance. Prior to treatment confirm coverage with your insurer and make sure your surgeon accepts your insurance. Costs vary considerably and are based on the procedures involved.
About the Reviewer of this Article
Heidi A. Waldorf, MD, is the director of Laser and Cosmetic Dermatology at The Mount Sinai Medical Center in New York, NY, and an Associate Clinical Professor in the Department of Dermatology at The Mount Sinai School of Medicine. She graduated magna cum laude from Harvard University and received her medical degree from the University of Pennsylvania School of Medicine in Philadelphia. After completing her internship training at the Hospital of the University of Pennsylvania and her residency in the Department of Dermatology at Harvard University School of Medicine, Dr. Waldorf completed a fellowship program in Mohs Micrographic Surgery, Laser Surgery and Cosmetic Dermatologic Surgery. She is a diplomate of the American Board of Dermatology, a fellow of the American Society of Dermatologic Surgery, a fellow of the American Society for Laser Medicine and Surgery, a member of the American Academy of Cosmetic Surgery, and a fellow of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. Dr. Waldorf sees patients at her offices in New York, NY, and Nanuet, NY.