The primary goal of treatment for skin cancers is the complete removal of the tumor, which is usually done via surgical excision performed by a dermatologic surgeon, plastic surgeon, general surgeon, or GP, depending on the location and size of the tumor. The aim is to remove (or excise) the tumor in its entirety, so as to reduce the risk of recurrence while preserving as much tissue as possible.
Moh’s Micrographic Surgery is considered to be the gold standard for surgical excision of skin cancers and involves removing thin layers of skin that contain skin cancer progressively until the only tissue that remains is that without cancer. The defect is therefore as big as it needs to be – no smaller (with the risk of leaving skin cancer behind) and no bigger (sacrificing normal tissue). This is a lengthier technique than standard excision and there are few surgeons trained in Moh’s surgery in South Africa. It’s a privilege to be part of a Moh’s and Reconstructive Surgery team at Summerhill Surgical Centre led by Dermatologist, Dr Johann de Wet. I’m extremely grateful to work in this team because I know our patients benefit enormously from Dr de Wet’s skill and this technique.
Reconstruction after excision of even small skin cancers on the face, can be complex, due to the proximity to sensitive and critical facial structures, such as the eyes, nose, lips, and ears. It often involves some rearranging of tissue surrounding the resection so that scars are hidden in the natural contours of the face, while critical structures are reconstructed to minimise any disfigurement or functional deficit.
Surgery may be performed under local anesthesia, sedation, or with general anesthetic, depending on the size and location of the tissue deficit, as well as the condition and the age of the patient. This is usually a day case surgery, but in cases where more extensive reconstruction is required, patients may need to stay in hospital overnight.
A fair amount of downtime can be expected, with bruising taking roughly 10 – 14 days to settle, while swelling may take longer, finally subsiding after approximately 3 – 4 weeks. Procedures performed around the eyes and on the forehead result in more significant swelling around the eyes, but this usually settles quickly.
Wounds on the face are usually fully-healed within 2 – 3 weeks, while wounds on the body may take a little longer (roughly 3 – 4 weeks), with skin grafts on the lower leg sometimes taking longer to heal, depending on how good the blood supply is. Scars can sometimes be red and raised while healing, and can take around 9 – 12 months to mature fully. Fortunately, scars in elderly patients usually heal very well and are hardly noticeable with time.
Once you have been diagnosed with skin cancer, you’re at a high risk of developing a second skin cancer. Studies have shown that there is a 30% risk of having a second primary Squamous Cell Carcinoma within 5 years after therapy for the first malignancy (Cutaneous Squamous Cell Carcinoma. N Engl J Med. 344: 2001; 975 – 983), so lifelong follow-ups and skin checks are essential.
When it comes to prevention, it’s estimated that regular application of a sunscreen with SPF15 or higher for the first 18 years of life could reduce the lifetime incidence of Non Melanoma skin cancers by 78%, so it’s vital that you ensure that you children are protected from the sun’s damaging UV rays at all times. Once a person has had more than 5 sunburns the risk for melanoma doubles, whereas regular daily use of a sunscreen with an SPF15 or higher can reduce the risk of developing Melanoma by roughly 50% (and the risk of developing Squamous Cell Carcinoma by approximately 40%). When it comes down to it, there really is no reason not to apply sunscreen on a daily basis – it could greatly reduce your chances of developing both Melanoma and Non Melanoma skin cancers, and could end up saving your life.
The Most Common Types of Skin Cancer
The three most common types of skin cancer are Basal Cell Carcinoma, Squamous Cell Carcinoma, and –the most dangerous of the three – Melanoma. Melanoma is certainly the most feared skin cancer, and it also has the highest mortality rate. Fortunately, Melanoma is still relatively uncommon compared to Basal Cell Carcinoma and Squamous Cell Carcinoma, but incidence is rising at a rate of approximately 33% for men and 23% for women from 2002 to 2006.
Melanomas typically present in the form of unusual moles or a suspicious, pigmented lesion. Initial diagnosis is done via a biopsy, where all or part of the suspicious lesion is removed for analysis. Surgery remains the primary treatment for Melanoma. Your doctor may discuss and/or advise that you undergo Sentinel Lymph Node Biopsy (SLNB), depending on how deep the melanoma is.
There are currently many exciting developments underway when it comes to drugs used to treat Melanoma, including drugs that stimulate the body’s own defenses in order to destroy cancer cells (called immunotherapy) and drugs that target specific pathways the cancer cell uses to grow and replicate (known as targeted therapy).
Non Melanoma Skin Cancers
There are several cancers that fall under the broader category of Non-Melanoma skin cancers, but Basal Cell Carcinoma and Squamous Cell Carcinoma are the two most common types, with Basal Cell Carcinomas (BCC) being roughly 4 – 5 times more common than Squamous Cell Carcinomas (SCC). BCC usually presents in the form of a small, pearly or waxy bump on your skin, often resembling a pimple or a small pinkish (or flesh-toned) mole, while SCC usually appears as a red, scaly patch or wart that may ulcerate or bleed if scratched.
Although Non-Melanoma skin cancers are considered less dangerous than Melanoma in that they are less likely to result in fatality, they are locally destructive and can result in disfigurement and damage to critical facial structures, such as the eyes and ears. And especially in the case of Squamous Cell Carcinomas, can spread to distant lymph nodes. They can also be more challenging to remove, since they are often large in size and occur more frequently on the face than Melanomas.