Surgery for skin cancer

The main purpose of an excision biopsy is to diagnose a skin cancer. This is usually done under local anaesthetic. There is more about excision biopsy in the section on diagnosing skin cancer.  

For most basal cell and squamous cell skin cancers an excision biopsy may be the only treatment needed. The British Association of Dermatologists recommend a border of healthy tissue should be removed as well. This is to make sure that the edges of the tumour are inside the portion taken away. The healthy tissue border will be examined under the microscope to make sure it doesn't contain any cancer cells. If it does, you may need further surgery.

These include

• Curettage and electrocautery
• Cryosurgery
• Mohs micrographic surgery (MMS)
• Wide local excision
• Skin grafting
• Lymph node surgery (lymphadenectomy)

Curettage and electrocautery

This is also called curettage and cautery or C and C. It is only suitable for small skin cancers and you have it under local anaesthetic. Curettage means scraping away. A small spoon shaped tool or round blade, called a curette, is used to remove the cancer and the tissue around it. In case there are any cancer cells left behind, an electric needle is then used to kill the cells immediately around the wound. The electric current also helps to control any bleeding. C and C is often repeated 2 or 3 times to try to make sure all the cancer is gone. If you have a very small cancer it may only be done once.

Cryosurgery

This means using extreme cold to remove the cancer. You have it under local anaesthetic. This type of treatment is sometimes used for solar keratosis. Or for small skin cancers that have not grown too far into the skin. Cryosurgery is not used on skin near organs such as the eye. The doctor sprays liquid nitrogen is sprayed onto the area to freeze the cancer. This will feel very cold. Over the next month, a scab forms. The scab then drops off, taking the cancer cells with it.

Mohs micrographic surgery (MMS)

This technique is named after the doctor who invented it – Dr Frederick Mohs. It is sometimes called margin controlled excision. It is a specialist technique and you may have to be referred to another hospital to have this treatment. MMS is most useful for

• Basal cell cancers that have come back
• Basal cell cancers that are growing into the surrounding skin tissue
• Large skin cancers
• Cancers in areas where it is important to remove as little tissue as possible (near the eyes and nose, for example)
• Some rare skin cancers

MMS is a slow process because a little cancer tissue is removed at a time. But you will keep as much healthy skin as possible. The surgery is done under local anaesthetic. The tissue is then examined under a microscope immediately. If the tissue contains cancer cells, more tissue is removed and examined. The surgeon continues in this way until they have removed all the cancer.

Wide local excision

Sometimes your biopsy results show that your skin cancer has not been completely removed. Or it was removed with a safety margin that is too small. If this is the case you may be asked to go into hospital for an operation called wide local excision. This means taking away the remains of the skin cancer plus a safety margin of normal skin.

Wide local excision may be done under local or general anaesthetic. How much tissue is taken away depends on the size of the cancer. You may have stitches in the area where the cancer has been removed. This may feel a little tight at first. But as it heals, the surrounding skin will stretch and the tightness should ease.

Sometimes, the doctor has to remove a large area of skin has to be removed. If this is the case you may need a skin graft to repair the area.

Skin grafting and skin flaps

If you have had a large area of skin removed, you will need to have the area replaced (repaired). This can be done with skin grafting or with a skin flap.

Skin graft

A skin graft is a piece of skin taken from another part of your body. This is done during the operation to remove your cancer. It is done by a plastic surgeon under local or general anaesthetic.

A thin sheet of skin is removed from the donor site and placed over the area that needs to be covered. The donor site is usually somewhere where it will not be too obvious, such as your inner thigh. The donor site will look like a large graze. The skin will grow back quite quickly, usually over a couple of weeks. Sometimes the skin for the graft is cut out and the donor site repaired by stitching it back together.

The area where the skin graft is put will be very delicate while it heals. It is very important that the graft is not damaged while it is healing. You must be very careful not to knock it. Your doctor and nurses will be very careful that your wound does not become infected. You may have antibiotics to help prevent this. Most people having a wide local excision do not need a skin graft. The area heals up well enough without one.

A disadvantage of skin grafting is that sometimes the skin looks different from the surrounding area. It may be a different colour and appear as a dent compared to the surrounding skin.

Skin Flap

Another way of repairing a large wound is a skin flap. To do this, doctors use a flap of skin and the tissue underneath it (the subcutaneous tissue). The flap is taken from very close to your wound. It is cut away more deeply than for a skin graft, but is left partly connected to its original site. This means the skin flap is still connected up to your blood supply. The flap is then positioned over your wound and stitched in place. Then the area it has been removed from is stitched closed. The skin flap has its own blood supply, so is likely to heal well.

Skin flaps are a very type of specialist surgery and are  more complicated than doing a skin graft. The advantages are that this type of repair often looks better than a skin graft.  So it tends to be used where the appearance of the skin is most important, such as on your face. As this is complicated surgery, it is done by a specially trained dermatologist or by a plastic surgeon.

After both skin grafting and skin flap repair, your nurses and doctors will keep a close eye on your wound site. This is to make sure the site is getting a good supply of blood, which brings oxygen and food to the healing tissues.

Lymph node removal

If any of your lymph nodes are found to have cancer cells, you will have an operation to have the nodes removed. This is rarely necessary. But this type of operation is sometimes done for squamous cell cancers. It should be carried out by a plastic surgeon who specialises in skin cancer. The type of surgery you have will depend on where the skin cancer was. There are large groups of lymph nodes in the neck, armpit and groin. 

So if you have a skin cancer on your scalp or face, the lymph nodes on the same side of your neck may be removed.

There are some side effects from this type of surgery. Healing may take several weeks.You are likely to be in some discomfort after the operation.  A few people have long lasting problems with pain after lymph node surgery. 

Shoulder stiffness and pain are the most common problems after the lymph nodes under the arm have been taken out. This should get better as the area heals. You may find that you are unable to move your arm as freely as you could before the surgery. 

With lymph node dissection in the groin, swelling of the leg on the same side is the most common problem after surgery. This is called lymphoedema. It can usually be controlled with a combination of exercise, massage and wearing an elastic stocking on the affected arm or leg. Your doctor or clinical nurse specialist will be able to help you with any problems you may have.

This means treatment after surgery to try to lower the risk of a cancer coming back. If your doctor is worried that some cancer cells may have been left behind, you may be offered radiotherapy after your surgery.