Skin cancer is the most common form of cancer in the United States. More than 500,000 new cases are reported each year and the incidence is rising faster than any other type of cancer. While skin cancers can be found on any part of the body, about 80 percent appear on the face, head, or neck, where they can be disfiguring as well as dangerous.
The purpose of this web page is to educate you about the different types of skin cancer, their causes, and preventive measures you can take; to help you know when to consult a doctor; and to explain the role of the plastic surgeon in the diagnosis and treatment of skin cancer and other skin growths.
Basal cell carcinoma may come in many forms. It often begins as a small, pearly nodule.
Squamous cell carcinoma may begin as a red, scaly patch, a group of crusted nodules, or a sore that doesn't heal.
Malignant melanoma is often asymmetrical, with blurred or ragged edges and mottled colors.
Small skin cancers can often be excised quickly and easily in the physician's office.
Simple excision usually leaves a thin barely visible scar.
A bone/soft tissue flap is used to reconstruct the nose following skin cancer excision.
The incision lines of the flap are hidden within the natural creases of the nose and face.
Who Gets Skin Cancer...and Why?
The primary cause of skin cancer is ultraviolet radiation, most often from the sun, but also from artificial sources like sunlamps and tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and perhaps the thinning of the earth's protective ozone layer are behind the alarming rise we're now seeing in skin cancers.
Anyone can get skin cancer, no matter what your skin type, race or age, no matter where you live or what you do. But your risk is greater if...
- Your skin is fair and freckles easily.
- You have light-colored hair and eyes.
- You have a large number of moles, or moles of unusual size or shape.
- You have a family history of skin cancer or a personal history of blistering sunburn.
- You spend a lot of time working or playing outdoors.
- You live closer to the equator, at a higher altitude, or in any place that gets intense, year-round sunshine.
- You received therapeutic radiation treatments for adolescent acne.
Types of Skin Cancer
By far the most common type of skin cancer is basal cell carcinoma. Fortunately, it's also the least dangerous kind; it tends to grow slowly and rarely spreads beyond its original site. Though basal cell carcinoma is seldom life-threatening, if left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage (particularly if it's located near the eye).
Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it's not treated.
A third form of skin cancer, malignant melanoma, is the least common, but its incidence is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it's not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly.
Other Skin Growths You Should Know About
Two other common types of skin growths are moles and keratoses.
Moles are clusters of heavily pigmented skin cells, either flat or raised above the skin surface. While most pose no danger, some-particularly large moles present at birth, or those with mottled colors and poorly defined borders-may develop into malignant melanoma. Moles are frequently removed for cosmetic reasons, or because they're constantly irritated by clothing or jewelry (which can sometimes cause pre-cancerous changes).
Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and sometimes develop into squamous cell cancer.
Recognizing Skin Cancer
Basal and squamous cell carcinomas can vary widely in appearance. The cancer may begin as small, white or pink nodule or bump; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that's rough, dry, or scaly...a firm, red lump that may form a crust...a crusted group of nodules...a sore that bleeds or doesn't heal after two to four weeks...or a white patch that looks like scar tissue.
Malignant melanoma is usually signaled by a change in the size, shape, or color of an existing mole, or as a new growth on normal skin. Watch for the "ABCD" warning signs of melanoma: Asymmetry-a growth with unmatched halves; Border irregularity-ragged or blurred edges; Color-a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; and Diameter- a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size.
If all these variables sound confusing, the most important thing to remember is this: Get to know your skin and examine it regularly, from the top of your head to the soles of your feet. (Don't forget your back.) If you notice any unusual changes on any part of your body, have a doctor check it out.
Choosing a Doctor
If you're concerned about skin cancer, your family physician is a good place to start. He or she should examine your skin at your annual physical, and can refer you to a specialist if necessary.
If you notice an unusual growth yourself, consult a plastic surgeon or a dermatologist. Both are skilled at diagnosing and treating skin cancer and other skin growths. A plastic surgeon can surgically remove the growth in a manner that maintains function and offers the most pleasing final appearance, a consideration that may be especially important if the cancer is in a highly visible area. If a treatment other than surgical excision is called for, the plastic surgeon can refer you to the appropriate specialist.
What Happens During Skin Cancer Surgery?
Depending on the size, type and location of the lesion, there are many ways to remove skin cancer and reconstruct your appearance if necessary.
Step 1 – Anesthesia
Medications are administered for your comfort during the surgical procedures. The choices include local, intravenous sedation and general anesthesia. Your doctor will recommend the best choice for you.
Step 2 – Removal
A small or contained lesion may be removed with excision – a simple surgical process to remove the lesion from the skin. Closure is most often performed in conjunction with excision.
Skin cancer can be like an iceberg. What is visible on the skin surface sometimes is only a small portion of the growth. Beneath the skin, the cancerous cells cover a much larger region and there are no defined borders. In these cases, a specialized technique called Mohs surgery may be recommended.
Your plastic surgeon may order a frozen section. In this procedure, the cancerous lesion is removed and microscopically examined by a pathologist prior to wound closure to ensure all cancerous cells have been removed.
The goal is to look for a clear margin – an area where the skin cancer has not spread. If clear margins are found, the resulting wound would be reconstructed. If clear margins are not present, your plastic surgeon will remove more tissues until the entire region has a clear margin.
Step 3 – Reconstruction
A large lesion or one that has been removed with frozen sections can be reconstructed with a local flap. A flap may also be necessary where excision may result in a disfiguring appearance. A local flap repositions healthy, adjacent tissue over the wound. A suture line is positioned to follow the natural creases and curves of the face if possible, to minimize the appearance of the resulting scar.
A skin graft, healthy skin removed from one area of the body and relocated to the wound site, may also be applied.
Step 4 – See the results
After your skin cancer has been removed and any primary reconstruction is completed, a dressing or bandages will be applied to your incisions.
Skin Cancer Surgery Recovery
Following your skin cancer surgery, incision sites may be sore, red or drain small amounts of fluid.
- It is important to follow all wound care instructions such as cleansing and applying topical medications exactly as directed
- You may be able to return to light activity the day of your surgery
- Make certain to keep your incision sites clean and well protected from potential injury
- Try to limit movement that may stress your wound and your sutures
Be sure to ask your plastic surgeon specific questions about what you can expect during your individual recovery period.
- Where will I be taken after my surgery is complete?
- What medication will I be given or prescribed after surgery?
- Will I have dressings/bandages after surgery? When will they be removed?
- Are stitches removed? When?
- When can I resume normal activity and exercise?
- When do I return for follow-up care?
Healing will continue for many weeks or months as incision lines continue to improve. It may take a year or more following a given procedure for incision lines to refine and fade to some degree. In some cases, secondary procedures may be required to complete or refine your reconstruction.
Practice diligent sun protection every day of your life and quit smoking to insure continued healing and good health. Sun exposure on healing wounds may result in irregular pigmentation and scars that can become raised, red or dark. Sun exposure may result in a recurrence of your skin cancer, or the development of skin cancer in another region of your body.
Discussing Your Options and Concerns
All of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal cell and squamous cell cancers, and even for malignant melanoma if it's caught early enough.
You should discuss these choices thoroughly with your doctor before beginning treatment. Find out which options are available to you, how effective they're likely to be for your particular cancer, the possible risks and side effects, who can best perform them, and the cosmetic and functional results you can expect. If you have any doubts about the outcome, get a second opinion from a plastic surgeon before you begin treatment.
A Word About Reconstruction
The different techniques used in treating skin cancers can be life saving, but they may leave a patient with less than pleasing cosmetic or functional results. Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as your nose, ear, or lip.
In such cases, no matter who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques, ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body, can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function.
Preventing a Recurrence
After you've been treated for skin cancer, your doctor should schedule regular follow-up visits to make sure the cancer hasn't recurred.
Your physician, however, can't prevent a recurrence. It's up to you to reduce your risks by changing old habits and developing new ones. (These preventive measures apply to people who have not had skin cancer as well.)
- Avoid prolonged exposure to the sun, especially between 10 a.m. and 2 p.m. and during the summer months. Remember, ultraviolet rays pass right through water and clouds, and reflect off sand and snow.
- When you do go out for an extended period of time, wear protective clothing such as wide brimmed hats and long sleeves.
- On any exposed skin, use a sunscreen with an SPF (sun protection factor) of at least 15. Reapply it frequently, especially after you've been swimming or sweating.
- Finally, examine your skin regularly. If you find anything suspicious, consult a plastic surgeon or a dermatologist as soon as possible.