SKIN CANCER
DIAGNOSIS, TREATMENT
& PREVENTION

SKIN CANCER SURGERY AND THE MOHS MICROGRAPHIC SURGERY UNIT

Mohs surgery is a specialized technique for the removal of skin cancer and is recognized as the most effective method of skin cancer treatment available. Rapid processing and microscopic examination of the tissue results in high cure rates and maximal sparing of normal tissue, particularly on the face. Reconstructive surgery (skin grafts, flaps, or suture closure) can usually be done on the same day as Mohs surgery. Since not all skin cancers require Mohs surgery, Dr. Rayhan or his associates will discuss the various treatment options available and recommend the most suitable on for you.

Our office-based laboratory allows for the immediate processing and microscopic examination of tissues removed during skin cancer surgery. Using the Mohs technique or standard frozen sections provides for the most accurate and complete removal of previously diagnosed skin cancers. Patients are spared the inconvenience and high costs of receiving such services in a hospital or surgery center.

The Mohs Micrographic Surgery unit meets or exceeds all current state and federal requirements for a high complexity laboratory facility. Only qualified personnel are used in the processing and preparation of tissue. Additionally, our lab is subject to quality control standards established by the American Society for Mohs surgery.

Dr. Rayhan and his associates have been performing Mohs surgery for many years and have completed many cases of Mohs’ Micrographic surgery, most being located on the face, head, and neck. Dr. Rayhan in an affiliate member of the American Society for Mohs Micrographic surgery. He is board certified in dermatology and dermapathology. Dr. Rayhan also has a teaching position at UCI as an associate clinical professor at in dermatology.

TYPES OF SKIN CANCER

Fortunately, most skin cancers can be easily treated if they are detected early. Any growth on the skin, particularly on sun exposed areas, that changes should be examined by a dermatologist. Signs of possible skin cancer include bleeding, ulceration, crusting, redness, pain, or discoloration.

Basal Cell Carcinoma (BCC) is the most common type of skin cancer. Although BCC rarely spreads to other parts of the body (metastasis), it can be locally destructive - invading nerves, muscle, or bones.

Squamous Cell Carcinoma (SCC) is the second most common form of skin cancer and is responsible for about 15 percent of new cases. This form of skin cancer may occasionally spread beyond the original area of the tumor. Complete removal, therefore, is very important.

Malignant Melanoma is the least common but most dangerous form of skin cancer. Malignant melanoma usually begins as a darkly pigmented or irregular mole. Malignant melanoma often spreads to other parts of the body in its later stages of development. Early detection and treatment of malignant melanoma is important in managing this life-threatening form of skin cancer.

BIOPSY: ESTABLISHING THE DIAGNOSIS

After the clinical examination, the next step in the treatment of skin cancer is to establish the diagnosis by performing a biopsy. A small fragment of skin from the suspected cancer is removed and examined under the microscope. Once the biopsy results have been obtained, the best method of treatment can be decided upon.

TREATMENT METHODS

Several techniques can be used to surgically remove skin cancer. Most methods use local anesthesia so that the patient does not experience discomfort during the treatment. Very small cancers can be treated cauterizing the skin and then scraping away the dead tissue. Another traditional methods of treating skin cancer is surgical excision. In this method of treatment, a circular or "football-shaped" incision is made around the cancer. By removing a wide border of normal tissue, the doctor is trying to include any roots of extensions of the cancer that cannot be seen with the naked eye. The skin removed during surgical excision is then examined under the microscope to assure that all the cancer has been removed.

MOHS MICROSCOPICALLY CONTROLLED SKIN CANCER SURGERY

Mohs microscopically controlled skin cancer surgery is a specialized technique for removal of skin cancer. During the procedure, tissue is carefully removed layer by layer - examining each layer under the microscope - until no cancer remains. Because the tissue is thoroughly examined, Mohs surgery is recognized as the most effective method available for the treatment of skin cancer and offers the highest cure rate. Although this procedure was developed by Dr. Frederic Mohs approximately 40 years ago, only recently has it become more widely available to patients for the treatment of skin cancer. Because Dr. Mohs' method was found to be so effective in removing skin cancer, many refinements have been added over the years. By using what has become known as the "fresh tissue technique," skin samples removed during surgery are immediately processed and examined under the microscope for cancer. Within minutes the surgeon knows if any cancer remains or whether additional treatment is needed.

INDICATIONS FOR MOHS SURGERY:
WHEN IS IT USED?

In the past, Mohs surgery was reserved for skin cancers that were large and sent out deep roots or those tumors that had recurred after routine therapy. Experience has shown, however, that even very small skin cancers around the nose, mouth, eyes and ears have a tendency to send out extensions that may not be removed by conventional methods of treatments. Unfortunately, if these skin cancers are not completely removed they may recur years later and may have grown to a much greater size before their detection. When used to remove a small or previously untreated skin cancer – especially on the face – Mohs surgery yields an exceptionally high cure rate, greatly reducing the danger that a cancer will return years later.

MOHS SKIN CANCER SURGERY:
THE PROCEDURE

Mohs Surgery is an outpatient procedure using local anesthesia. Although the patient is awake, discomfort is minimal and no greater than in routine methods. The area to be treated is cleansed, marked and injected with a local anesthetic. The first step is to remove all of the visible skin cancer. The removed tissue is carefully marked on a map of the treatment area. A thin layer of tissue is then removed and again coded and marked on a map (see diagram). These sections of tissue are then processed and immediately examined under the microscope for the presence of cancer. Areas still positive for cancer are marked on a map and another thin layer of skin is removed only from these areas. The tissue is marked, processed and examined under the microscope just as before. This series of steps is repeated until all the cancer has been removed. This means that the greatest amount of normal, non-cancerous tissue is preserved. This is of critical functional and cosmetic importance when working around the nose, eyes, ears, mouth, and hairline or on the hands, feet and genitals.

IMMEDIATELY AFTER SURGERY
WHAT CAN I EXPECT?

Before beginning surgery, there is no way to precisely predict how much skin will have to be removed. The final surgical wound may be only slightly larger than the initial skin cancer. Occasionally, however, removing the deep roots of a skin cancer may result in a sizable defect. Keep in mind, though, that only cancerous tissue is removed during surgery and normal tissue is spared. After surgery, there may be an open wound that requires simple daily care. The body is able to heal itself quite rapidly, even after extensive surgery. If there is a wound to be cared for, you will be given detailed instructions after your surgery.

RECONSTRUCTION AFTER SKIN CANCER SURGERY:
CLOSURE, SKIN GRAFTS AND FLAPS

If the surgical area is small enough after skin cancer surgery, then direct closure by sewing the sided of the wound together may be possible. In certain areas on the body, there is very little tissue that can be stretched to cover a wound. Therefore, a skin graft or skin flap must be used. In closing wounds with a skin flap, the skin next to the surgical defect is partially cut free and then rotated or moved forward to cover the surgical area. Stitches are then placed to hold the "flap" in its new position. This provides immediate coverage for the wound. Other areas may require a skin graft to provide coverage. Skin from the side of the neck, behind the ear or over the collarbone may be cut free, placed over the wound, and then sewn into place. The original site of the graft is then closed with stitches or allowed to heal on its own.

After skin cancer is removed and the surgical area has completely healed, there will be a scar. Frequently the final results, even after extensive surgery, are quite acceptable. Scars do remodel and improve to appearance for 6-12 months through the body’s natural healing process. Wounds which are allowed to heal on their own often result in barely noticeable scars. Most scars, of course, can be revised or improved at a later time by further reconstructive surgery. Scars which become depressed or indented may be elevated with an implant such a Zyderm Collagen. Likewise, a raised or rough scar may be smoothed out using Laser Resurfacing or Chemical Peeling. Skin flaps and skin grafts may also require a second tough-up procedure to further improve their appearance. Therefore, many techniques are available to the patient for enhancement or improvement of the surgical area after undergoing skin cancer surgery.

POTENTIAL COMPLICATIONS FROM SURGERY

All surgical procedures carry the potential for complications and skin cancer surgery is no exception. During surgery, tiny nerve endings are cut. This may produce a temporary or permanent numbness in and around the surgical area. If a large tumor is removed or extensive surgery is required, occasionally a nerve to muscles may be cut which may result in temporary or permanent weakness in a part of the face. This is, however, an unusual complication. The surgical area may remain tender for weeks or months after surgery, especially if large amounts of tissue were removed. Rarely, some patients experience intermittent itching or shooting pains. Skin grafts and flaps used to cover surgical areas may not fully survive, requiring additional repair. No surgeon can fully guarantee that a procedure will be totally free of complications or adverse reactions. This is true for all surgical procedures and should be understood by the patient.

FOLLOW-UP VISITS AFTER SURGERY

After surgery it is very important that the patient be seen on a regular basis until the surgical wound is completely healed. Despite the fact that skin cancer surgery ensures a high cure rate, no method is 100% effective and your follow-up visits are very important. Of the cancer is going to come back, it often does so in the first year; nevertheless, the area of surgery should be watched for at least five years. Skin cancer patients are encouraged to have yearly exams by a dermatologist throughout their lifetime.

HOW TO PROTECT AGAINST SKIN CANCER

For the best protection against developing skin cancer, patients should avoid constant over-exposure to the sun from infancy through adulthood. By selecting appropriate clothing and applying proper sunscreens, it is possible to enjoy outdoor activities while maintaining healthy skin. Whether individuals bum or tan depends on a number of factors, including their skin type, the time of year and the amount of sun exposure they have received. The skin's susceptibility to burning has been classified on a 5-point scale as follows:

SUN TANNING

Tanning is not encouraged, but some individuals will seek a tan regardless of warnings. The safest way to tan is to do it gradually and to use an appropriate sunscreen. Gradual exposure permits optimal production of the browning pigment melanin to take affect. Melanin protects somewhat against sunburn and migrates to the skin surface where it is visible as a tan. Gradual exposure also helps to thicken the outer layer of the skin. This in turn serves to protect the easily damaged inner skin layers from harmful sunrays. By adopting a common sense, gradual approach to tanning, sunbathers are able to promote their melanin production and to thicken their outer skin, which provides protection. Getting out of the sun before your skin becomes red helps prevent major bums.

HOW TO PREVENT BURNING

The three best ways to prevent sun bums are: 1) avoid the sun during the peak hours of solar radiation, 2) use sun screen or sun block preparations and 3) wear loose clothing. Because 70% of the sun's ultraviolet rays can penetrate clouds and overcast conditions, it is quite possible to become burned on a cloudy day. Staying underwater does not afford protection since the sun’s rays can reach up to three feet below water. In the mountains, where there is less atmosphere to filter out UV rays, hikers and skiers can become sunburned easily. Snow reflects up to 85% of the sun’s rays. Protective clothing, such as long sleeved shirts made of closely woven cotton fabric, can protect the forearms. Hats with a brim will deflect light from the ears and upper cheeks. Wearing hair just over the top of the ears is also helpful. Sunscreens come in the form of ointments, creams, gels and lotions. They are rated according to their effectiveness in blocking out the sun’s rays, with the higher numbers indicating more blocking action.

USE OF SUNSCREENS

Individuals should select a sunscreen to provide protection according to their particular skin type, the time of year, their location and the activities they plan to do. The sunscreens that are currently available are only partially effective in preventing premature aging of the skin and skin cancer. However, they can provide substantial protection against the damaging effects of sun exposure. People with fair skin who bum easily and tan poorly (Type 1 and Type 2) should use a product with a Sun Protection Factor (SPF) of 15 or greater. Individuals with less sensitivity can use sunscreens with lower numbers when exposed to the sun. Persons with Type 3 and 4 skin will usually tan when they use sunscreens with SPF values of ~ and under. Newer sunscreens are more resistant to loss due to perspiration and water, however, sunscreen should be reapplied frequently during peak sun hours or after swimming. Individuals with jobs outdoors or extreme sun sensitivity should apply an opaque sunblock such as zinc oxide the nose, lips and tops of the ears. Dr. Rayhan will make specific recommendations for the type of sunscreen that is best for you. To be effective, however, the sunscreen must be used regularly and according to instructions.