Treatments for Skin Cancer

If skin cancer is suspected, a biopsy must be taken and examined microscopically. If the diagnosis is confirmed, there are many different treatments available. The treatment of skin cancers has four goals:

Completely remove the cancer,
Preserve normal skin,
Preserve function, and
Provide an optimal cosmetic result.

Dr. Tse and the SkinCare Physicians & Surgeons team can best advise you about the most appropriate type of treatment for your specific diagnosis.

Mohs Micrographic Surgery

Moh’s surgery is a highly specialized treatment for the removal of skin cancers. The technique, originally termed chemosurgery, was developed by Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin in the early 1940s. The procedure has since been refined.

Dr. Tse has a particular interest in the diagnosis and treatment of skin cancer. As a fellow of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, she has trained extensively in Mohs surgery, the most precise and effective method of treating skin cancer. Dr. Tse will remove the tumor and then remove very thin layers of the remaining surrounding skin, one layer at a time. Each layer is checked under the microscope during surgery, and the procedure is repeated until the last layer viewed is cancer-free. This technique saves the greatest amount of healthy tissue and may reduce the rate of local recurrence. It is often used for tumors that have recurred or are in hard-to-treat places such as the head, neck, hands, and feet. By tracing skin cancer microscopically, the Mohs technique is highly effective, often resulting in scars that are barely noticeable.

The Mohs procedure, generally completed in one day, is performed as follows:

The skin suspicious for cancer cells is treated with a local anesthetic so that there is no feeling of pain in the area.
The visible skin cancer is scraped with a sharp instrument to determine the initial tumor borders.
A thin piece of skin around the scraped skin is removed surgically.
The physician examines the tissue under the microscope and draws a careful map of where skin cancer cells remain.
If the cancer is still present, another layer of tissue is then surgically removed and the procedure is repeated until the physician is satisfied that the entire base and sides of the wound have no cancer cells remaining.

Mohs surgery results in the careful, accurate, and complete removal of the skin cancer with minimal removal of normal surrounding skin. By microscopically pinpointing areas involved with cancer and selectively removing only these areas, normal tissue is preserved to the greatest extent possible. This procedure results in the smallest possible tissue defect and therefore the smallest possible scar. In addition, the cure rates for skin cancers treated with Mohs are very high, often 97-99%, even if other forms of treatment have failed.

Patient 1 with a basal cell carcinoma		Patient 1 defect from basal cell carcinoma

Patient 1 after skin flap to repair defect from basal cell carcinoma		Patient 1 (1 month) after Mohs surgery and skin flap

75 year old man with a basal cell carcinoma after Mohs surgery.
See More Before & After Photos

Preparing for Surgery

The evening before your surgery, we recommend a thorough bath or shower, including washing your hair to ensure that the wounds can be kept dry after the surgery. A good night’s rest following by a light breakfast is the best way to prepare. Take medications as usual unless we direct otherwise and bring a complete list of medications with you on the day of surgery. Please stop taking any aspirin or aspirin-containing compounds (like Anacin, Bufferin, and Ascripton) at least a week prior to surgery, as they may interfere with normal blood clotting mechanism and could cause excessive bleeding during surgery.

You should expect to be in treatment most of the day so it is wise to bring some reading materials. Please do not make other plans or appointments for that day. Also, because the day may prove to be quite tiring, it is advisable to have someone accompany you on the day of surgery and drive you home.

What Happens on The Day of Surgery?

Appointments for surgery are usually scheduled early in the day to allow us to complete the treatment by the end of the day. Once you are checked in, medical history taken and informed consent signed, you are ready for treatment. The area around your skin cancer will be anesthetized (numbed) with a local anesthetic. This step may be uncomfortable for a few seconds, but usually is the only discomfort you will experience during the entire procedure. Once the area is numbed, a layer of tissue is removed and the bleeding controlled. The tissue will be carefully handled by the surgeon, mapped and color coded, and sent to the technician to be processed for viewing under the microscope. After a pressure dressing is placed over your wound, you will be escorted back to the waiting room while the tissue is processed and examined by the surgeon. On average, it takes an hour for tissue to be prepared and studied. Most Mohs surgery cases are completed in two or three stages. Once we are sure that your skin cancer has been completely removed, we will discuss with you the recommendations for dealing with your surgical wound.

What Happens After Surgery?

In the days following Mohs surgery, you may experience the following:

Pain – while you will likely experience little discomfort, you may take Tylenol if needed. We request that you not take aspirin.
Bleeding – rarely does bleeding occur after surgery. If it should happen, it can usually be controlled by the use of pressure. Apply a gauze pad with constant pressure over the bleeding point for 20 minutes while lying down. Do not lift up or relieve the pressure at all during this time. If bleeding persists after continued pressure for 20 minutes, call our office or go to the nearest emergency room.
Swelling & bruising – these are very common following Mohs surgery, especially when performed around the eyes. These conditions usually subside within four to five days and can be decreased by sleeping with your head slightly elevated and by using ice for short periods during the first 24 hours.
Redness – A small red area may develop surrounding your wound and itching, especially in areas where adhesive tape has been applied, is normal. If redness does not subside in two days or if the wound begins to drain pus, notify our office immediately.
Scarring – scars always result from surgery of the skin. The scar is minimized if the defect after cancer removal is small – one of the major advantages of Mohs Surgery.
Restrictions – Depending upon the size of the wound and the location of the lesion, we may recommend restricted physical activity for several days.
Numbness – At times, the operative site will be numb to the touch. This area of numbness will persist for several months until tiny nerve fibers grow back into the area, at which time the skin sensation gradually returns to normal.

After the wound heals, it may feel tight but will relax within a few months. Occasional itching or twinges of pain may also occur. Itching may be because the new skin on the wound does not have as many oil glands. Plain petrolatum jelly will relieve the itching.

A pink, raised scar may remain for many months, but should become flat and pale in a year or so. Ocassionally scars become thick, raised and red. These, if persistent, should be treated immediately.

Reconstructive Surgery

After the skin cancer has been removed by Mohs surgery, the resulting surgical defect must be repaired to restore the area that the skin cancer has destroyed. Typically, this would entail the placement of stitches and may also involve either a skin graft or a skin flap. A skin flap or graft may be performed on the day of surgery or may be delayed by a day or so. Delayed reconstruction does not significantly increase the risk of infection or poor healing.

A skin graft is a procedure whereby skin from another part of the body (typically either behind the ear or in front of the ear for the best match of skin) is transplanted onto the area where the skin cancer was removed. A skin graft heals in one week. Often skin grafts heal beautifully, but occasionally, they will require fine tuning with a laser procedure several months later.

A skin flap is a procedure where an additional incision is made in the tissue adjacent to the area where the skin cancer was and the adjacent tissue is then moved into the “defect”. Both skin grafts and skin flaps are stitched into place. Skin flaps can help to restore/maintain the natural contours of the face and they too usually heal very nicely. However, sometimes fine tuning is also needed for these procedures as well with a laser.

Other Treatments for Skin Cancer

There are several other treatment options for skin cancer. The method chosen depends on several factors, such as location of the cancer, its size, and previous therapies.

Cryotherapy – Freezing of skin cancer.
Curettage and Electrodessication – The procedure of scraping off the growth is done several times to help assure that all cancer cells are eliminated.
Excisional Surgery –The entire growth is removed along with a surrounding border of apparently normal skin as a safety margin. The incision is closed and the growth is sent to the lab to verify that all cancerous cells have been removed.
Radiation – X-ray beams are directed at the tumor several times a week for a few weeks. This is ideal for tumors that are hard to manage surgically or for patients in poor health.