Skin Cancer Washington DC/McLean/Tyson’s Corner

Introduction

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 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.

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Basal cell carcinoma may come in many forms. It often begins as a small, pearly nodule.

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Squamous cell carcinoma may begin as a red, scaly patch, a group of crusted nodules, or a sore that doesn’t heal.

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Malignant melanoma is often asymmetrical, with blurred or ragged edges and mottled colors.

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Small skin cancers can often be excised quickly and easily in the physician’s office.

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Simple excision usually leaves a thin barely visible scar.

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A bone/soft tissue flap is used to reconstruct the nose following skin cancer excision.

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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 are 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 is located near the eye).

Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. 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 is 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 are 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 bumps; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that is rough, dry, or scaly…a firm, red lump that may form a crust…a crusted group of nodules…a sore that bleeds or does not 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 are 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, Dr. Baker can refer you to the appropriate specialist.

Diagnosis and Treatment

Skin cancer is diagnosed by removing all or part of the growth and examining its cells under a microscope. It can be treated by a number of methods, depending on the type of cancer, its stage of growth, and its location on your body.

Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician’s office, using local anesthesia. The procedure may be a simple excision, which usually leaves a thin, barely visible scar. Or curettage and desiccation may be performed. In this procedure the cancer is scraped out with an electric current to control bleeding and kill any remaining cancer cells. This leaves a slightly larger, white scar. In either case, the risks of the surgery are few.

If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, major surgery may be required. Other possible treatments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time. (Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as follow-up.)

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 is 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.

Mohs Surgery

What is Mohs Surgery? Mohs surgery is a technique in which a dermatologist reviews the pathology of a skin lesion as it is being excised to determine whether the lesion has been entirely removed or if some of the skin cancer remains. If the Mohs surgeon sees that some skin cancer remains, he/she will make subsequent small re-excisions until the cancer is completely excised. This technique was originally designed for excisions of basal and squamous cell carcinomas in anatomic areas where it is important to minimize the amount of normal tissue removed such as the nose, ears, or eyelid.

What is the role of the Mohs surgeon? Mohs surgery is the subspecialty of dermatology that has expertise in reading the pathology of the skin specimens as they are excised. Although the term surgery is used in the term Mohs surgery, Mohs surgery is not a surgical specialty recognized by the American College of Surgeons.

Is every skin cancer best treated with Mohs surgery? Mohs is not the best option from a cosmetic point in many cases of skin cancer because by definition, Mohs surgery removes all the cancer on one stage. In many cases, especially on the face, a staged excision performed in the plastic surgeon’s office results in a much smaller scar. Since it is extremely rare for cutaneous basal cell or squamous carcinoma to metastasize, there is no rush to remove the lesion in one stage. For example, Dr. Baker sees many children with large birthmarks on their face and body. In many of these cases he could remove the entire birthmark in one stage (similar to Mohs surgery), but he elects to remove the lesion in a series of smaller steps to keep the scar as small as possible. By using several smaller steps the final scar is much less than that of a flap that is required to close a Mohs defect. Remember, Mohs surgery was developed to minimize removal of normal tissue when removing skin cancer not as a technique to remove the entire lesion in one step.

How do I get a Plastic Surgery closure if I want to use a Mohs surgeon to remove the cancer? If a patient desires a plastic surgeon to close the wound left after Mohs surgery, he/she can arrange both procedures so the Plastic Surgery closure is done the same day or the day after the Mohs surgeon removes the lesion. For a patient with skin cancer in the eyelid, nose, or ear this combined approach optimizes the patient’s outcome by combing the expertise of a Mohs surgeon who removes the cancer with minimal damage to normal tissue and a plastic surgeon whose surgical expertise achieves an excellent aesthetic outcome.

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 have been treated for skin cancer, your doctor should schedule regular follow-up visits to make sure the cancer has not recurred.

Your physician, however, cannot prevent a recurrence. It is 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 have 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.

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