Common Procedures Performed in Dermatology
This section describes the most common procedures performed by dermatologists to treat skin cancer and noncancerous and precancerous growths. Various treatment options are available and, depending on your diagnosis, your dermatologist will recommend the most appropriate treatment plan for you.
Following is an introduction that outlines the order of the information presented in this section. Review the introduction, then scroll down to read any topics of interest or select the topics recommended by your dermatologist.
There are many factors influencing the choice of treatment:
- Type of skin cancer or noncancerous or precancerous growth
- Location, size, number, and aggressiveness of the tumor
- Patient’s general health
- Side effects, possible complications, benefits, and cure rate of a procedure
- Dermatologist’s experience and familiarity with a particular procedure
Each case is different. Your dermatologist will decide the most appropriate treatment plan for you.
During the office visit, your dermatologist will discuss with you your medical history, examine and diagnose your skin growth, explain what could happen if left untreated, and then describe treatment options and follow-up care. In most cases, your dermatologist will determine the most appropriate procedure and perform it during this visit. However, if the examination indicates the possibility of skin cancer, your dermatologist may take a biopsy and schedule you for surgery at a later date.
Following are some questions you may want to ask your dermatologist before treatment begins:
- What type of skin cancer do I have?
- What is the stage of my skin cancer?
- What are my treatment options and which one do you recommend for me?
- What are the benefits and side effects of each type of treatment?
- Will I have pain after surgery?
- Will I have a scar?
- Will treatment affect my normal activities or my work? If so, for how long?
- What is the follow-up care?
Common procedures performed in dermatology to diagnose and treat skin cancer and noncancerous and precancerous growths
A skin biopsy is a simple procedure performed by your dermatologist under local anesthesia. Your dermatologist will first inject a small amount of anesthesia into the designated area. After the area is numb, your dermatologist will remove either part of the growth or the entire growth. The growth will then be sent to a pathology lab for microscopic examination by a dermatopathologist (a pathologist or dermatologist specialized in the microscopic examination of skin disease). After the biopsy is performed, a bandage will be placed over the wound area, and your doctor will explain to you the postoperative wound care instructions. The biopsy results, which will take a few days, will indicate whether or not you have skin cancer and, if so, what type of skin cancer you have. There are different techniques to perform a skin biopsy. Your dermatologist will select one of the techniques listed below, depending on the location of the treated area and the type of skin growth to be analyzed:
- Shave biopsy: a surgical blade is used to cut a superficial slice of either part of the growth or the entire growth. There is usually no stitching involved with this biopsy technique, and the wound heals by itself over a period of 1 to 3 weeks, thus the resulting scar is minimal. If the shave biopsy goes deeper into the skin, the resulting scar will be more visible and the shape of the scar will be the shape of the skin biopsy.
- Punch biopsy: a small cylindrical instrument is used to cut either part of the growth or the entire growth. The resulting wound is usually stitched side by side. The punch biopsy technique allows for a deeper sampling of the growth. Because the wound is usually stitched, the resulting scar is linear. If nondissolvable stitches are used, they will be removed within 1 to 2 weeks after the biopsy, depending on the location of the treated area.
- Excisional biopsy: a surgical blade is used to completely remove the growth. The resulting wound is usually stitched side by side. As with the punch biopsy, the resulting scar is linear. If nondissolvable stitches are used, they will be removed within 1 to 2 weeks after the biopsy, depending on the location of the treated area.
Shave removal is similar to the shave biopsy, except that the intent is to cosmetically remove a noncancerous growth with the appropriate depth so that the wound heals flat. In shave removal, a surgical blade is used to cut a superficial slice of the entire growth. There is no stitching involved and the wound heals by itself over a period of 1 to 3 weeks, depending on the location of the treated area. Because the wound is usually superficial, the resulting scar is invisible or minimal. If the procedure goes deeper into the skin, the resulting scar will be more visible and the shape of the scar will be the shape of the shave removal.
In cryosurgery, liquid nitrogen is usually used to freeze and destroy single or multiple growths. A special canister is often used to spray the liquid nitrogen directly onto the growth; however, sometimes the liquid nitrogen is directly applied with a cotton tip applicator. The procedure does not involve any numbing of the skin, involves minimal discomfort, and is performed within a few minutes in the office. After the growth is frozen, it forms a scab that will fall off after 1 to 3 weeks. A few days after the procedure, you may notice a black blister at the treatment site. This is normal; the blister is usually left alone and dries out or ruptures in a few days. When the freezing is superficial, the resulting scar is minimal to undetectable. When the freezing is deeper, the resulting scar may be more visible and appear as a white blemish. After the procedure, your dermatologist will explain to you the postoperative wound care instructions and will schedule a follow-up visit to assess your treatment results.
Topical chemotherapy involves the application, onto the affected area, of a chemotherapeutic agent that destroys precancerous and cancerous growths. Chemotherapeutic agents include 5-fluorouracil, diclofenac, and imiquimod. Each agent works differently and is applied by the patient at home. Treatment course varies from a few weeks to several months, depending on the agent being used, the condition being treated, and the choice of treatment option. Your dermatologist will give you careful instruction about how to apply the agent and for how long. Usually, during the course of the treatment, the treated area becomes irritated and tends to crust. Your dermatologist will monitor the treated area to make sure that there is not too much or not enough reaction to the agent. Some agents are more irritating than others, and some agents are more effective than others. Your dermatologist will discuss with you the chemotherapeutic agents that are most appropriate for your condition.
In photodynamic therapy, a chemical (aminolevulinic acid or methyl aminolevulinate) is applied to the precancerous or cancerous growth. After a few hours, the treated area is exposed to a light source that photoactivates the chemical, thus destroying the precancerous or cancerous cells. A different light source is used for different photosensitizing agents. The chemical is applied either by you at home or by your doctor at his office, depending on the chemical being used. A few hours after the chemical application, your doctor performs the photoactivation with the light source. There is usually minimal pain during exposure to the light source. After the treatment is completed, your doctor will explain to you the postoperative wound care instructions. Crusting of the treated area appears the day after treatment, and careful sun protection and sun avoidance is necessary. A follow-up visit will be scheduled to ensure that the precancerous or cancerous growth is completely treated and that the healing process is taking a normal course; however, sometimes the procedure has to be repeated to ensure that the growth is completely treated.
Electrodessication and curettage
Electrodessication and curettage (ED&C) is a simple procedure performed by your dermatologist under local anesthesia. ED&C involves scraping away the growth with a sharp surgical instrument called a curette. An electrosurgical unit may then be used to stop the bleeding and remove a small surrounding area of normal skin. A few cycles of burning with the unit and scraping are used to remove some types of cancerous growths, such as basal cell carcinoma and squamous cell carcinoma. After the procedure is completed, a bandage will be placed over the wound area and you will receive postoperative wound care instructions. There is no stitching involved, and the resulting wound heals by itself over 1 to 3 weeks, depending on the location of the area being treated and the depth of the ED&C. Scars resulting from ED&C are usually round shaped and slightly bigger than the treated growth. After the wound has healed, the resulting scar may appear pink and raised and usually improves in appearance over several months to a year.
A conservative excision involves the removal of the growth and a small amount of normal skin surrounding the growth. It is a simple procedure performed by your dermatologist under local anesthesia. Your dermatologist will first inject a small amount of anesthesia into the affected area. After the area is numb, your dermatologist will cut the skin and remove the growth with a surgical knife. The resulting wound is usually stitched side by side. After the procedure is performed, a bandage will be placed over the wound area and you will receive postoperative wound care instructions. Usually, the growth will then be sent to a pathology lab for microscopic examination by a dermatopathologist (a pathologist or dermatologist specialized in the microscopic examination of skin disease). The stitched wound heals by itself over 1 to 2 weeks, depending on the location of the treated area. If nondissolvable stitches are used, they will be removed after 1 to 2 weeks. Because the wound is usually stitched, the resulting scar is linear.
Mohs micrographic surgery
Mohs micrographic surgery is a precise surgical technique used to remove skin cancer. It is usually performed by a dermatologist who has extended his training in the required surgical and laboratory techniques. This procedure enables your surgeon to remove the skin cancer completely, while preserving as much normal skin as possible and achieving the highest cure rate. In Mohs micrographic surgery, the skin cancer is removed in layers. Each layer of tissue is examined under the microscope to determine the location and extent of the skin cancer before more tissue is removed. While the procedure is time consuming, it produces a very high cure rate without an excessive loss of normal tissue. Mohs micrographic surgery is recommended for the treatment of skin cancer, such as basal cell carcinoma and squamous cell carcinoma. It is not routinely used for the treatment of malignant melanoma. This procedure offers many advantages, including the most precise and complete removal of the skin cancer, the highest cure rate for skin cancer treatment, maximum conservation of normal skin, and preservation of important structures.
Mohs micrographic surgery is also recommended for the following: (1) cancer of the face, nose, and eyelids or in cosmetically important areas; (2) cancer with indistinct borders; (4) cancer that has recurred after other treatments; (5) cancer with a high likelihood of recurrence; and (6) cancer that is larger than 1 inch in diameter. Before your surgery, you may have a preoperative visit. This visit gives you the opportunity to meet your dermatologist and the medical staff and to learn more about your surgery. Your dermatologist will examine the skin cancer, obtain your medical history, and discuss with you the reconstructive options that may be appropriate for you. Because it can be difficult to fully estimate the size and extent of the skin cancer, often, the best reconstructive option can only be determined at the actual time of your surgery, as the skin is removed and analyzed under the microscope.
In preparation of the surgery, the area surrounding the skin cancer will be cleansed and positioned with sterile drapes. A sticky pad will be placed on your arm or leg, or you will be given a grounding plate to hold, which “grounds” the electrosurgical machine used to stop any bleeding. The area containing the skin cancer will be numbed with a small local injection of anesthetic. Once the area is numb, the surgeon will cut a layer of skin and microscopic sections will be prepared in the pathology lab next to the operating room. You will remain in the office while the sections are processed and examined under a microscope. Depending upon the amount of skin removed, processing usually takes 30 to 45 minutes. If microscopic examination reveals the presence of additional skin cancer, additional layers of skin will be removed. Most skin cancer is removed in one to three surgical stages. After removal and the extent of the final skin defect is known, your dermatologist will discuss with you the most appropriate reconstructive option. The reconstruction is usually performed the same day. On occasion, other surgical specialists may perform the procedure because the skin cancer may be larger than anticipated. When the reconstruction is completed by other surgical specialists, it may take place on the same day or a subsequent day. There is no harm in delaying the reconstruction. Extensive reconstruction may require hospitalization. It is likely your surgical wound will require care during the weeks after surgery. Your dermatologist will provide you with detailed written instructions. You should also plan on wearing a bandage and avoid strenuous physical activity for 1 to 2 weeks after surgery. If the wound has been stitched, then nondissolvable stitches will be removed 1 to 2 weeks after surgery. Complete healing and maturation of the scar takes place over 12 to 18 months. The site may feel swollen or lumpy, especially during the first few months. Some redness may occur. Gently massaging of the area and keeping it lubricated with lotion, starting about 1 month after surgery, will speed the healing process. You may have minimal pain after surgery, which you can alleviate with over-the-counter pain medication. As your wound heals, you may also experience temporary tightness and itching across the surgical area. Significant blood loss is rare, but bleeding may occur after surgery. A follow-up visit will be scheduled after the surgery to ensure that the skin cancer is not recurring and that the healing process and maturation of the scar is taking a normal course.
Common procedures performed for the treatment of malignant melanoma
Wide local excision
A wide local excision is a simple procedure performed by your dermatologist under local anesthesia. Your dermatologist will first inject a local anesthetic around the growth to be surgically removed. After the area is numb, your dermatologist will cut the growth and a margin of normal skin around the growth. The width of normal skin that needs to be removed depends on the thickness of the skin cancer and how deeply it has invaded the skin. Most of the time the resulting wound will be stitched side by side. After the procedure is performed, a bandage will be placed over the wound area and you will receive postoperative wound care instructions. The growth will then be sent to a pathology lab for microscopic examination by a dermatopathologist (a pathologist or dermatologist specialized in the microscopic examination of skin disease). Stitched wounds are usually allowed to heal for 1 to 2 weeks, depending on the location of the treated area. If nondissolvable stitches are used, they will be removed 1 to 2 weeks after surgery. Because the wound is usually stitched, the resulting scar is linear. If the area of skin removed is large and cannot be stitched side by side, then a skin graft may be used to repair the area. For this procedure, your dermatologist uses skin from another part of the body to replace the skin that was removed. A follow-up visit will be scheduled after the surgery to ensure that the cancerous growth is not recurring and that the healing process and maturation of the scar is taking a normal course.
Sentinel lymph node biopsy and lymphadenectomy
Skin cancer can spread through the blood vessels anywhere in the body or through the lymphatic channel in the lymph nodes. The lymphatic channel and lymph nodes collect the fluid around the cells in the tissue. The sentinel lymph node biopsy is a surgical procedure used to find, biopsy, and analyze the first lymph node collecting the fluid in the area around the skin cancer. This technique is used to see if the skin cancer has spread to the lymph node. Lymph node metastasis is an important prognostic factor. Sentinel lymph node biopsy is performed by a surgical oncologist (a surgeon specialized in the treatment of cancer) in the operating room of a hospital or in an outpatient surgical facility under general sedation. The sentinel lymph node biopsy is performed after the malignant melanoma biopsy but before the wide local excision of the skin cancer. Your surgeon will first inject a combination of dyes, one radioactive dye and one blue dye, around the skin cancer. The injection causes minor stinging and burning; however, gentle massaging at the injection site helps ease the pain and helps spread the dyes into the lymphatic channels. This is usually performed several hours before the actual biopsy. The surgeon follows the movement of the radioactive dye on a computer screen using a radioactive counter. The first lymph node containing the substance is called the sentinel lymph node. The visualization of the lymph nodes, along with a radioactive tracer, is called a lymphoscintigraphy. Then, during the biopsy, the surgeon uses a radioactive counter and looks for the lymph nodes that are stained with the blue dye. One or several nodes may have absorbed the blue dye and radioactive dye, and these nodes are designated the sentinel lymph nodes. The surgeon then removes these lymph nodes and sends them to the pathology lab for microscopic examination by a pathologist. If skin cancer is detected in the lymph node then all of the lymph nodes are removed in that area. The surgical removal of the lymph node in an area is also called lymphadenectomy. The advantages of sentinel lymph node biopsy include (1) decreasing the unnecessary procedure of a lymphadenectomy and its associated complications, and (2) increasing the attention on the nodes identified to most likely contain cancerous cells. The main use of this procedure is for the treatment of malignant melanoma; however, it is still controversial that the complete removal of the lymph nodes in the area of the cancerous growth (lymphadenectomy) increases the survival rate of patients with malignant melanoma. If skin cancer cells are identified in the lymph nodes, other procedures may be performed after surgery to treat any cancer cells that remain in the body. The individual may receive radiation therapy, chemotherapy, biological therapy, or a combination of these therapies.
Picture frame excision for the treatment of lentigo maligna melanoma
Picture frame excision is used to treat lentigo maligna melanoma of the face. Lentigo maligna melanoma is a slow-growing type of melanoma that usually appears as a slowly enlarging freckle. Picture frame extension is not routinely used to treat other types of malignant melanoma. Lentigo maligna melanoma is usually large, up to 1 inch, and appears on the face near or adjacent to the ear, nose, or eyelid, where the preservation of the normal skin and structure is important. It is difficult to determine clinically the extent of lentigo maligna melanoma because this type of skin cancer has individual cells that extend away from the tumor. For this procedure, a thin rim of normal-appearing skin similar to the frame of a picture is surgically removed under local anesthesia and divided into several segments. These segments are then sent to a pathology lab for histopathologic examination by a dermatopathologist (a dermatologist or pathologist specialized in the microscopic examination of skin disease). Only the outside edge of the rim of each segment is analyzed on its entire surface. If the rim does not have cancerous cells, then the remaining lentigo maligna melanoma is removed and the final skin defect is repaired by your dermatologist or a facial plastic surgeon, depending on the extent of the defect. If microscopic examination of the rim appears to have cancerous cells, then a second rim is removed only in the affected area, examined microscopically by a dermatopathologist, and the same process is repeated until the lentigo maligna melanoma is completely removed. Permanent section is used instead of fresh frozen section (like in Mohs micrographic surgery) because a single cell in lentigo maligna melanoma can travel away from the tumor, and permanent section allows for a more precise microscopic examination than fresh frozen section. The repair usually involves stitching. If nondissolvable stitches are used, they will be removed after 1 to 2 weeks, depending on the location of the treated area. Because the wound is usually stitched, the resulting scar is linear. If the area of skin removed is large and cannot be stitched side by side, then a skin graft may be used to repair the area. For this procedure, your dermatologist uses skin from another part of the body to replace the skin that was removed. After the surgery is completed, a bandage will be placed over the wound area and you will receive postoperative wound care instructions. A follow-up visit will be scheduled after the surgery to ensure that the cancerous melanoma is not recurring and that the healing process and maturation of the scar is taking a normal course.
Other procedures performed
Radiation therapy can also be used to destroy cancerous cells and is useful in certain types of skin cancer, as well as in selected individuals for whom surgery is not possible. If radiation therapy is indicated, your dermatologist will refer you to a specialized center, usually a hospital or a clinic. You will then have a consultation with a radiation oncologist (a doctor specialized in the use of radiation treatment) who will explain to you the side effects and benefits of the treatment. Usually, radiation therapy involves multiple visits over several weeks. Not all types of skin cancer are suitable for radiation treatment. Some cancerous cells are more easily treated by radiation than others. Radiation can also affect the adjacent normal structure, resulting in nerve damage and cartilage damage (such as deformation of the nose and ear). Radiation can also cause damage to the skin, resulting in an increased risk of skin cancer many years after the treatment.
Chemotherapy is a type of treatment that uses chemical agents to stop cancer cells from growing. Chemotherapy is sometimes used to treat skin cancer that has spread beyond the skin. The chemical agents are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually an individual has chemotherapy as an outpatient (at the hospital or at the doctor’s office); however, depending on the type of agents given and the individual’s general health, a short hospital stay may be needed. Individuals with skin cancer may receive chemotherapy either by mouth or injection, allowing the agent to enter the bloodstream and travel throughout the body.
Biological therapy (also called immunotherapy) is a type of treatment that uses the body’s immune system, either directly or indirectly, to fight cancer. Biological therapy for malignant melanoma uses substances called cytokines, which are proteins secreted by cells of the immune system. Using modern laboratory techniques, cytokines can produce in large amounts. In some cases, these cytokines are given after the surgery in an attempt to prevent malignant melanoma from recurring. For individuals with metastatic malignant melanoma or a high risk of recurrence, interferon-alpha and interleukin-2 may be recommended after surgery.
General risks with skin surgery
Listed below are some general risks associated with skin surgery. Your dermatologist will discuss these risks and any additional potential problems associated with your case.
- Complete removal of the skin cancer may create a blemish larger than anticipated. Tumors may be larger than surface appearance indicates. Scarring will occur at the site of removal. Although every effort is made to obtain optimal cosmetic appearance, the primary goal is to remove the entire tumor
- At times, healing is slow or the wound may reopen because of bleeding, poor overall physical condition, diabetes, smoking, or other disease states. Grafts and other repairs to the wound may fail to heal
- You may experience loss of movement or feeling because of impaired nerve function. Many types of skin cancer are near or on important structures, such as the eyes, nose, or lips. Portions of these structures may be removed with resulting cosmetic or functional deformities. Your dermatologist will let you know if this is a possibility
- The wound may become infected. A small number of surgical wounds (less than 5%) may become infected and require antibiotic treatment. If you are at higher risk for infection, you may by given an antibiotic before surgery
- You may experience side effects to medications. Your dermatologist will carefully screen you for any history of problems with medications, but you may develop new reactions
- In some cases, the tumor may regrow after surgery. Previously treated tumors and large, longstanding tumors have the greatest chance for recurrence
- You may experience possible numbness or loss of feeling. Skin cancer frequently involves nerves, so there may be a loss of movement or feeling. Frequently, skin cancer invades nerve fibers that must be removed during the surgery. Also, nerves adjacent to the skin cancer may be severed or injured during the reconstruction of the skin defect. If you experience numbness, sensation will usually, but not always, return. In most circumstances, nerve function will return over a prolonged period of time, up to 24 months. In some cases, numbness may be permanent. If a motor nerve is involved, you may be unable to move the muscle. For example, you may be unable to wrinkle your forehead. Prior to your surgery, your dermatologist will discuss any major nerves that may be near the skin cancer
Every technique that results in the destruction of skin cancer can result in the formation of a scar. Scarring is part of the process of healing. Scarring evolves and matures over 6 months to 2 years, depending on the location of the treated area. Some locations scar better than others. The face heals better than the back, chest, or shoulder. In addition, different biopsies, surgical techniques, and treatment options will result in different shapes of scarring.
Sometimes scarring can be improved. Raised scars can be surgically leveled with dermabrasion or the use of a laser, or they can be flattened with corticosteroid injections. Any surgery will result in some scar formation; however, your dermatologist will place the cut so that the resulting scar will be within the skin line. During the healing and maturation process of the scar, it is important to protect the area from the sun since sun exposure can result in a brownish discoloration of the scar, making it difficult to treat and fade over several years. Rarely, soft tissue augmentation in the form of injectable collagen is used to improve depressed scars. A laser is also sometimes used to treat broken blood vessels and redness associated with the scar. Use of multiple over-the-counter products, including silicone patches and gels, as well as daily massage can help improve and speed the maturation process. Your dermatologist will discuss with you what are the most appropriate products to treat your scar.