Dermatological surgery at Exeter Hospital

What is dermatological surgery?

Dermatological surgery is the surgical treatment of skin, hair and nail conditions, ranging from medically necessary procedures to cosmetic ones. It's carried out by dermatologists and other trained specialists, most often using a local anaesthetic in an outpatient setting.

What conditions does it treat?

Dermatological surgery is essential for removing skin cancers and suspected skin cancers, including melanoma, squamous cell carcinoma, many basal cell carcinomas, and rarer skin tumours. It's also used to remove benign growths that are a nuisance or unsightly, such as large moles and seborrhoeic keratoses, and to treat conditions including warts and actinic keratosis.

What are the benefits of dermatological surgery?

Surgery is often the most effective way to fully remove a skin cancer and check it's been completely taken away, since the tissue is sent for laboratory analysis. Techniques have advanced significantly in recent years, meaning many procedures are now minimally invasive, safer, and allow quicker healing than in the past.

Are there different types of surgical approaches?

• Simple excision: the lesion is cut out, usually as an ellipse shape, and the wound closed with stitches
• Mohs micrographic surgery: used especially for skin cancers on the face where the edges aren't clear or the cancer has come back before; tissue is removed and examined layer by layer under a microscope until no cancer cells remain, so as little healthy skin as possible is taken
• Curettage and cautery: the lesion is scraped away with a small instrument, then the area is sealed to stop bleeding; this heals without stitches
• Shave excision: a raised, benign lesion is shaved off level with the surrounding skin
• Cryotherapy: lesions such as warts, seborrhoeic keratoses and actinic keratosis are frozen off using liquid nitrogen.

If a wound is too large to close directly, your surgeon may use a skin flap (skin moved from next to the wound) or a skin graft (skin taken from elsewhere on your body) instead. Dermatological surgeons also carry out cosmetic procedures, such as dermabrasion, scar treatments, laser resurfacing and soft-tissue fillers.

What happens before the operation?

Melanoma and squamous cell carcinoma must be referred urgently, usually within 2 weeks, while some lower-risk basal cell carcinomas and pre-cancerous conditions can be managed by suitably trained professionals in the community.

Before your procedure, your surgeon will discuss the type of surgery, the risks, and the fact that any tissue removed will be sent for laboratory testing (histology). You may also be photographed beforehand.

It's worth avoiding scheduling surgery on a visible area shortly before an important occasion, since some visible healing, swelling or bruising is normal afterwards.

What happens during the procedure?

1. The area is marked out, usually in an ellipse shape around the lesion, following the natural lines of your skin where possible.
2. A local anaesthetic is injected into the surrounding skin, so you shouldn't feel pain, though you may feel some pressure or pulling.
3. The skin is cleaned and covered with sterile cloths, then your surgeon uses a scalpel to cut along the marked lines and remove the lesion.
4. The sample is placed into a pot of preserving fluid and sent to a laboratory for analysis.
5. Any bleeding is stopped, usually using heat (cautery), and the wound is closed with 1 or more layers of stitches.
6. A dressing is applied, and you're given instructions on caring for the wound and when your stitches will be removed.

Most dermatological surgery is done under local anaesthetic in an outpatient clinic, so you're awake throughout and can go home the same day.

What does recovery look like?

How long your stitches stay in depends on where they are: around 5 to 7 days on the face, about 10 days elsewhere on the trunk, and up to 14 days on the hands, back or over a joint, though your surgeon will confirm timing based on your healing.

Keep the wound clean and gently washed daily, and your surgeon may recommend a moisturiser to help it heal. Scars can take up to 18 months to fully mature, and scars on the back or scalp tend to widen slightly over time.

What are the risks and complications?

Immediate risks include:

• bleeding
• damage to nearby nerves, which can cause altered sensation near the scar; this is fairly common and is sometimes permanent
• a reaction to the local anaesthetic or other medicines used.

Delayed risks include:

• wound infectionthe wound coming open
• the lesion not being fully removed, needing further treatment; this is more likely for tumours with unclear edges, or those on the nose or inner corner of the eye
• a raised, thickened (hypertrophic or keloid) scar, which is more likely on the chest, upper back, shoulders and upper arms, in people with a previous keloid scar, and in younger people, women, and people of Afro-Caribbean heritage.

With a shave excision specifically, up to 1 in 4 lesions can come back, and if the lesion was pigmented, around 1 in 4 people develop a flat pigmented mark where it was.