Sydney

Skin Cancer Surgery

Cancer cells often reach further than what you can see on the surface. Taking a measured border of normal-looking skin with the lesion makes it more likely the whole thing is cleared in one operation. How wide that border needs to be comes down to the type of skin cancer and, with melanoma, how thick it is.

Australian guidance puts numbers on this. With uncomplicated basal cell and squamous cell carcinomas, Cancer Council Australia’s keratinocyte cancer guidance describes elliptical excision with a 3 to 4 mm margin. For melanoma, the Cancer Council Australia working party recommends 5 to 10 mm for melanoma in situ, 1 cm for invasive melanoma up to 1 mm thick, 1 to 2 cm for melanoma between 1.01 and 4 mm, and 2 cm for melanoma thicker than 4 mm. A wider margin leaves a larger wound and a longer scar. That is why margins are matched to the diagnosis instead of being made as large as possible.

This is standard practice, not a sign that something went wrong. The first procedure is a narrow excision biopsy to confirm the diagnosis and measure how deep the melanoma goes. The margin for the definitive wide excision cannot be chosen until that depth is known.

Australian melanoma guidelines recommend an initial excision biopsy with roughly a 2 mm margin wherever possible. Partial samples, such as punch, incision or shave biopsies, can be unrepresentative and may lead to misdiagnosis. The pathologist reports the Breslow thickness. That measurement is what sets the margin for the second operation. For melanomas 1 mm thick or more, or 0.8 mm with other high-risk features, the guidelines say sentinel lymph node biopsy should be discussed, and lymphoscintigraphy needs to be performed before the wider excision. If the order of it all is confusing, ask your surgeon to go through the sequence with you.

It goes to a pathologist. They examine it under the microscope and report whether the cancer appears to have been completely removed and how close it came to the edges of the specimen. Results usually take several days, and you will be contacted once the report is back.

If the report shows cancer cells at or very close to a margin, further surgery may be recommended to clear what is left. It is also one reason reconstruction is sometimes staged on purpose. Closing a large defect before the margins are confirmed can make a second excision harder. Australian melanoma guidance states plainly that positive or close histological margins are unacceptable and that further excision should be considered. Ask for a copy of your pathology report and hang on to it. It is useful background for any future skin checks.

That depends on the size and site of the wound. Plenty of excisions are closed directly with sutures. Larger defects may need a skin graft or a local flap instead, and so may wounds on the face, where the skin is tight and a free edge such as an eyelid or nostril can be pulled out of shape.

A graft is skin taken from another area and laid over the wound, where it has to pick up a new blood supply. A flap is different. It is nearby skin moved into the defect while it stays attached to its own blood supply, so the colour and texture usually match more closely. Under the Medicare Benefits Schedule, a flap counts as clinically appropriate where the defect cannot be closed directly, where the scar needs to follow a skin crease or landmark, where contour on the face or neck has to be maintained, or where direct closure would distort a nearby structure. Where reconstruction looks likely, it is normally discussed and planned before the day of surgery, not decided on the spot.

Yes. Some scarring is unavoidable. Incisions are planned to follow natural skin creases where the anatomy allows. Clearing the cancer still comes first, though, and that sometimes means a longer incision or one in a spot you would not choose.

An excision is usually designed as an ellipse so the wound closes neatly. The scar therefore ends up longer than the lesion was wide. That catches people out when they were expecting a mark the size of the spot. Scars tend to look their worst in the first few weeks. They then flatten and pale over the following months, and most keep changing for around 12 to 18 months. Keep a healing scar out of the sun while that happens, since sun on new scar tissue can leave lasting discolouration.

Complications are uncommon, but they do happen. Reported risks include bleeding, infection, persistent pain and swelling, incomplete removal of the cancerous area, changes in skin sensation or colour, damage to nerves and blood vessels, reactions to anaesthesia, and poor scarring. The risks that apply to you are discussed with you before you consent.

How much risk you carry varies with the size and site of the lesion, your general health, whether you smoke, and any medication that affects bleeding or healing. Tell your surgeon about blood thinners and about any previous trouble with wound healing or anaesthetic. Increasing pain, spreading redness, fever or bleeding after your operation are all reasons to contact the practice or seek medical help rather than wait for your next appointment. A/Prof Bish Soliman’s website has a dedicated risks and complications page that covers surgical risk in more detail.

Keep the wound clean and dry. Follow the dressing instructions you are given, apply any topical medication as directed, and stay away from activities that put tension on the healing skin. Keep the site out of the sun, since exposure while the wound is healing can cause lasting discolouration.

Some pain and swelling as the incision heals is normal. Pain relief can be prescribed. Keeping stretch off the wound matters more than people expect on the back, shoulders and legs, where ordinary movement tugs at the closure. Not smoking helps as well, since smoking cuts the blood supply that healing tissue depends on. You will be given written instructions specific to your procedure. Ask at the time when your sutures come out and when you can get back to work and exercise. Those answers change with the site of the surgery.

Mohs surgery takes a skin cancer off in thin layers. Each layer is mapped and examined under the microscope during the same appointment, and that continues until the margins are clear. In Australia, Medicare rebates for Mohs apply only where the specialist is recognised by the Australasian College of Dermatologists as an approved Mohs surgeon.

That restriction has applied since 1 November 2018. In practice, Mohs is performed by accredited dermatologists, not by every doctor who treats skin cancer. The MBS items cover tumours on the head, neck, genitalia, hands, digits and lower leg. Mohs is generally kept for lesions with poorly defined borders, or ones that have come back after earlier treatment. Repair of the defect left behind is sometimes done by the Mohs surgeon and sometimes referred on for reconstruction, depending on how complex the closure is. Most skin cancers in Australia are treated with standard surgical excision rather than Mohs.

Generally yes. Excision of a malignant skin lesion is medically necessary treatment and attracts a Medicare rebate where it meets the criteria of a Medicare Benefits Schedule item. A rebate rarely covers the full fee, so an out-of-pocket amount is common. Ask for a written estimate.

The MBS lists excision of malignant skin lesions across the 31356 to 31383 range. Separate items cover skin flap repair and skin grafting where reconstruction is needed. Benefits for flaps are payable only where the flap is clinically appropriate. For a procedure performed in hospital, Medicare pays 75 per cent of the schedule fee and, where your policy covers the procedure, your health fund generally pays at least the remaining 25 per cent. Your out-of-pocket cost is whatever is charged above the schedule fee, plus separate anaesthetist and hospital accounts where those apply.

Yes. A GP referral is essential to see A/Prof Bish Soliman for any type of surgery. You also need a current referral to claim a Medicare rebate on your specialist consultation. A referral from a GP is valid for 12 months. A specialist-to-specialist referral is valid for three months.

Bring your pathology or biopsy report if you have one. Photographs of the lesion taken before the biopsy are worth bringing too, because both help with planning. A GP referral form is available on A/Prof Soliman’s website, and consultations are booked by paying the consultation fee in advance at the time you make the appointment. If a lesion is changing quickly, bleeding or not healing, say so when you book instead of waiting for the next routine appointment.

Usually yes. Having had one skin cancer increases the chance of developing another, so regular skin checks still matter after a lesion has been completely removed. Who carries out those checks, and how often, depends on what was found and where it was.

Published guidance suggests no additional specialist follow-up is needed after complete excision of a low-risk basal cell or squamous cell carcinoma, while a basal cell carcinoma with high-risk features warrants review every six months for the first year and annually after that. Melanoma follow-up is planned separately according to stage. Cancer Council Australia reports that about two in three Australians will be diagnosed with some form of skin cancer in their lifetime, and that caught early, skin cancer is highly treatable. Keep checking your own skin between appointments, and see your GP promptly about anything new, changing or not healing.