Frequently Asked Questions About Skin Treatment

This information supplements, but does not replace, the consultation between you and your physician. REMEMBER – There is no such thing as an unimportant or silly question.

A biopsy is the removal of a small sample of a growth of skin. The sample is sent to a pathologist, a doctor who examines this sample under a microscope, and renders a diagnosis regarding the type of growth and disease present.

Your dermatologist reviews the pathologist’s findings and combines that knowledge with their observations of your condition. Knowing the type of growth or disease helps your doctor determine the best possible treatment for a successful outcome.

Skin Cancer is not one problem but a collection of separate diseases. There are three common forms of skin cancer:

  1. Basal Cell Carcinoma
  2. Squamous Cell Carcinoma
  3. Malignant Melanoma

Basal Cell Carcinoma in not only the most common forms of skin cancer, but is also the most frequently occurring of all cancers of the body. The name is derived from the skin cell that is growing in an uncontrolled fashion – the basal cell. This is the cell type located at the base or the bottom of the upper skin layer – the epidermis. Although basal cell carcinomas can damage the skin where it appears, it rarely spreads to other parts of the body unless its size becomes enormous. It does not spread throughout the bloodstream and almost never involves the lymph nodes (glands). One might think of a basal cell carcinoma as a colony of termites. If left untreated, it will destroy any tissue or structure in its path of growth. This is a particular concern when basal cell carcinoma is located near the eye, ear or nose. One cannot predict how quickly basal cell carcinomas will grow. Although they are usually slow-growing tumors, basal cell carcinomas can grow rapidly and spread. Basal cell carcinomas initially may have the appearance of a small pimple, a non-healing or bleeding sore, a shiny papule, a cyst or a larger growth. Discomfort and itching can occur but are rare. The diagnosis of a basal cell carcinoma cannot be confirmed without a biopsy or sample being sent to a pathology laboratory for microscopic examination.

Squamous Cell Carcinoma can be a more serious disease than basal cell carcinoma. The squamous cells are located above the basal cell layer in the epidermis. This tumor may spread to the nearby glands or lymph nodes or travel through the bloodstream to distant areas of the body. Squamous cell carcinoma usually appears as a rough, scaly plaque or larger growth.

Malignant Melanoma, which often looks like a brown or black patch, or an unusual mole, is potentially the most serious form of skin cancer. Microscopically controlled surgery is used with special stains for the very earliest form of this cancer.

Unfortunately, we do not know most of the factors that cause skin cancer. However, skin cancer does occur more frequently in people with fair complexions (blond hair, blue eyes), individuals of Celtic descent and those who tend to get more than average exposure to the sun. Accumulated exposure to the damaging ultra-violet radiation of the sun over many years may change normal skin cells to cancerous cells. This is why areas of the body exposed constantly to the sun (head, face hands) tend to be more prone to skin cancer than the sun-protected areas. However, this is not the entire answer. Dark-skinned individuals who hide from the sun can still develop skin cancer. Other factors such as heredity and environmental agents may also play some role.

The only factor you can control is exposure to the sun. Proper use of sunscreen with a Sun Protective Factor (SPF) of 30 or greater is the most important preventative measure. You can also wear broad-brimmed hats or protective clothing. Avoid sun exposure between 10:00 AM – 2:00 PM and stay in the shade if possible. You do not have to change your lifestyle – only use caution.

Skin cancer can be treated effectively by a variety of methods, including traditional surgery, curettage and desiccation (scraping and burning), freezing (cryo-surgery), X-Ray (radiation therapy) and Mohs, or microscopically controlled surgery. The treatment of skin cancer must be individualized, taking into consideration such factors as the patient’s age, location of the cancer, type of cancer and whether or not the cancer has been treated previously. In some instances, more than one type of treatment may be appropriate, but this is unusual in most cases.

Microscopically controlled surgery was developed by Dr. F. Mohs in the 1930’s as a precise method of treating certain skin cancers. The technique has been refined in subsequent years. It combines surgical removal of the cancer with immediate microscopic examination of the removed tissue to identify cancerous areas.

There are many indications for selecting Mohs surgery, a few are listed below:

  1. When the tumor occurs in an area of the body where it is not effectively curable by other methods.
  2. When the tumor is located on a structure that is so important that one wishes to remove only the diseased tissue and spare as much of the normal skin as possible (e.g., the nose).
  3. When the cancer has been previously treated and has come back.
  4. When the margin or extent of the tumor cannot be easily defined.
  5. When the cancer has an aggressive growth pattern.
  6. When the cancer is of considerable size.

Mohs surgery not only has the highest cure rate of all treatment methods, but it creates the smallest possible surgical defect, allowing for the best cosmetic results (less scarring). Unlike other methods of treatment, Mohs surgery does not rely on surface inspection to judge the extent of the skin cancer. What one sees on the surface may only be the ‘tip of the iceberg’. If the tumor is not well defined, if it blends into normal skin, or if it is mixed with scar tissue from a previous operation, a surgeon might either remove too little tissue and leave tumor cells behind, or over-compensate and remove too much. Mohs surgery, using the microscope control, allows the surgeon to trace out the extent of the tumor and remove only diseased tissue.

Mohs surgery is a minor surgical procedure normally performed on an outpatient basis in the office.  Please be prepared to spend the whole day at our office. Eat a full breakfast and bring snacks and some reading material. It is also important to bring a friend or family member along.  The surgery is performed in steps or stages.  Each stage involves about 15 to 20 minutes of surgery to remove cancerous tissue plus about 1 to 1.5 hours to check if any skin cancer remains. During this wait time, you may leave the office, but we ask that you return after an hour. The number of steps or stages required depends upon the size and depth of the cancer. Please take into consideration additional time to repair the defect once your skin cancer has been removed.

The actual procedure is as follows:

  1. A local anesthetic will be injected into the area of surgery.  This is the only part of surgery that will cause any discomfort – the sensation of stinging or burning.
    • The pain of injection can be eased with the use of a topical numbing cream.  If you are interested in applying this cream 1 hour prior to your surgery, please let us know so that we can give you a prescription. Please be aware that some patients respond minimally to the topical numbing cream.
    • Patients may also request a medication (Valium) for treatment of symptomatic anxiety related to the procedure up arrival into the clinical area.  This medication helps to promote relaxation and may also produce light drowsiness.
  2. Once the area is numb, a small layer of tissue will be removed. Unless the cancer is quite small, more surgery is almost always required. Remember, it is always better to initially remove too little tissue and perform the second step or stage than to remove more normal tissue than necessary.
  3. The small amount of bleeding will be stopped with a machine that coagulates the blood vessels, a dressing will be applied and you will wait in the operating room.
  4. The tissue will be brought back to the laboratory, where it will be examined for the presence of skin cancer. The tissue is processed, and microscope slides are prepared and examined.
  5. If microscope examination reveals remaining tumor, a map is drawn indicating the precise location.
  6. Additional anesthetic is injected to reinforce the first injection. In most cases, the initial anesthetic has not worn off and you feel little or no discomfort.
  7. The second stage now involves the removal of another layer of tissue- but only where the map indicates residual cancer. The healthy tissue is left alone; only the diseased tissue is excised.
  8. The tissue is brought back to the laboratory and the process is repeated until all evident cancer is removed.
  9. Once your skin cancer has been removed, the physicians will discuss the best option to repair your wound. Unfortunately we do not know the best option until the final size and depth of the wound is established. With that being said, there are some cases where we decide to delay the repair.
  10. Occasionally it is necessary to delay a repair to optimize the wound bed for the best surgical outcome or to appropriate ample time to optimize the conditions for a complex reconstruction.

The average tumor requires two to four stages for removal, so do not be discouraged if your cancer is not removed in one step.  We are tracing the extent of the tumor very carefully and trying hard not to remove any uninvolved normal tissue.  This must be done in small layers.

Dayton Skin Care commits to the highest quality of care, state of the art equipment and facilities and continuing education includes the training of a very select group of board certified dermatologists in advanced surgical technique.  In partnership with the American College of Graduate Medical Education, Micrographic Surgery and Dermatologic Oncology Fellowship Training Program, Dayton Skin Care is one of a small group of independent practices certified to provide training in Mohs Micrographic Cancer Surgery to board certified Dermatologists who choose to dedicate additional time increasing their knowledge of skin cancer treatments. Physician participation in this program requires a rigorous application process and selection from a talented pool of candidates based on a variety of considerations, including exceptional academic ability, excellent recommendations from their peers and extraordinary achievements during their medical education process.

As a patient of Dayton Skin Care, your attending surgeon will discuss care alternatives, introduce the Fellow and seek consent for their participation in your care. Please be assured that the attending physician will provide continuous oversight and instruction during your care. It is crucial to the quality of future healthcare that these doctors are afforded a broad exposure and hope that, by providing an understanding of the Fellowship process, you will be comfortable in allowing their participation in your medical care.  Please feel free to inquire to either your attending surgeon or the staff about any questions or concerns you may have.

Discomfort, if it should occur with this procedure, is usually mild and can be managed with Extra-Strength Tylenol.  Do not take aspirin or aspirin-containing products (Excedrin, Anacin, etc.) unless prescribed by your primary care physician for a cardiac or stroke history as these can promote bleeding.  A pressure dressing applied to the wound should be left on 1-3 days to minimize swelling and bleeding.  Although some minimal bleeding is typical, brisk bleeding after surgery is infrequent.  If brisk bleeding occurs, lie down, take some gauze or a dry washcloth and apply firm pressure for twenty minutes (by the clock) on the wound.  Do not remove the pressure prior to this.  If the bleeding persists, contact the on-call physician at the emergency contact numbers shown on your post-operative instructions.

Other problems that may occur include black and blue marks, swelling, and redness for approximately 2 months and a bumpy suture line for approximately 4 months.  Rarely, if the skin cancer involves nerves of the skin, surgical removal can lead to numbness or muscle weakness in the area.  Numbness usually resolves in 12-24 months, but may occasionally be permanent.

Remember, every surgical procedure produces scarring of some type.  Although every attempt will be made to minimize and hide the scar, the extent of scarring depends on the size and depth of the cancer.

On very rare occasions, a patient may experience sadness and emotional lability after the procedure.  These symptoms generally resolve after 2 weeks.  Please notify the office if you are experiencing these feelings, so that we may refer you to a specialist.

The main goal of Mohs surgery is to remove skin cancer as completely as possible and prevent recurrence.  Although the cure rate is not 100%, it offers the highest cure rate of any available procedure.  Most patients never require further treatment.

Please remember, this information provides a general guide to skin cancer and Mohs surgery.  Please consult your physician if any questions arise.

OFFICE POLICY FOR TIME OFF AFTER SURGERY

At Dayton Skin Care we would like for you to have the time off that you need for a full recovery from your surgery. One of our nurses will be happy to fill out any forms that you may have for medical leave. Once the form is complete, your physician will sign the form.

A work excuse will be given for the time period from the day of surgery until your pressure bandage or tie over dressing is removed. Your return to work date will be the day immediately following the pressure bandage or tie over dressing removal from a successful surgery. The form will indicate your return appointment (day and time) for suture removal. Any activity restrictions will also be noted.

If you have any questions or concerns regarding this policy, please make an appointment to speak with our clinical director.