On skin cancer and its scars

Disease won’t always kill, but plastic surgery is often vital

WHO’S MOST AT RISK

More than 2 million Americans annually are diagnosed with some kind of skin cancer, which is the most common cancer in the U.S. and around the world. “Skin cancer is a malignant tumor of the skin,” says Dr. Joshua Rosenberg, assistant professor of otolaryngology at Mount Sinai. “It’s very common, but can be as deadly as any other cancer. However, skin cancer is also a very treatable and often curable cancer, especially when caught early.”

Many skin cancers are related to sun exposure, though other individual factors such as overall health, immune system function or a genetic predisposition to the disease can play a role in their development. “The majority of skin cancer occurs on the head and neck, because those are the areas that get the most sun exposure and resulting skin damage,” says Rosenberg. “Considering that almost half of Americans will have a skin cancer in their lifetime, a question many people will have to consider is: What do you do when you finally do get that skin cancer?”

The answer will depend on what type of skin cancer you develop. “The three most common types are basal cell carcinoma, squamous cell carcinoma and melanoma — they develop differently and often require different treatments,” says Rosenberg. “Basal cell carcinoma rarely metastasizes, but can become big locally and be destructive to the area. Squamous cell carcinoma grows locally, but it can be more aggressive and can be fatal, while melanoma is the least common, but has the highest rate of mortality — it can spread very quickly from even a small lesion and metastasize.”

Why does one person develop a potentially life-threatening melanoma when someone else develops a less threatening basal cell carcinoma? “Researchers are asking questions like, ‘are there certain immune aspects, innate to individual patients, that make some people more prone than others?’ Right now, we just don’t know.”

SIGNS AND SYMPTOMS

“Get checked out any bump, lesion or spot that has changed or grown, especially anything on your face that you are uncomfortable with that has persisted for a few weeks,” says Rosenberg. “See a dermatologist so they can evaluate this unexplained bump.”

TRADITIONAL TREATMENT

If the dermatologist does determine that the suspicious bump is skin cancer, the next step is to remove it. “For both basal and squamous cell carcinomas on the face, the gold standard is the Mohs technique, an approach that allows a specially trained dermatologist to take out the skin cancer with only a very narrow margin of skin around it by using a microscope to map out areas where the cancer is.” Squamous cell carcinoma may require radiation after surgery.

Mohs surgery removes the smallest amount of healthy tissue possible, but still leaves a small hole or defect that needs to be fixed. If it is on the face, “our two main options are to use a skin graft from somewhere else on the body, which can be different color tone than the rest of the face, or we can use a local skin flap that pulls skin from the surrounding areas to cover up the hole.”

“Every surgery cut leaves a scar, but the trick is to leave the scar in a pattern that is not easily recognizable to the human eye,” says Rosenberg. “We can place the incision in the boundaries of anatomical features, so human perception doesn’t pick up on it.”

Depending on the size and placement of the skin cancer lesion, some patients will have reconstructive surgery after Mohs. “In most cases, you can have Mohs in the morning and reconstructive surgery in the afternoon,” says Rosenberg. “Almost always, both of these procedures can be done in the office setting, as opposed to the hospital.”

“Anyone who is concerned about the results post-Mohs — and especially anyone with larger lesions on the face — should take the time to meet with a reconstructive surgeon pre-surgery,” says Rosenberg.

Recovery can take a while, but doesn’t require patients to do much. “For the first one to two weeks, we usually recommend lowered activity to reduce swelling, but other than that, all you need to do is basic wound care: applying petroleum- or silicone-based jelly is the only thing that has been shown to help scarring,” says Rosenberg. “The scar itself takes many months to mature ... six months to two years.”

RESEARCH BREAKTHROUGHS

Researchers are always on the hunt for new skin cancer drugs and for new techniques to improve healing. “There are a number of new drugs, including one for basal cell carcinoma, though only a small number of patients are currently considered candidates,” due to questions about how much to take and side effects, says Rosenberg. “There are also many promising studies in wound healing, including a research project we’re doing that uses honey to help healing, which is an ancient technique that we’re testing out for modern use.

QUESTIONS FOR YOUR DOCTOR

If you receive the diagnosis of skin cancer, ask, “What kind of cancer do I have?” Also ask, “What are my treatment options?” And don’t hesitate to ask upfront, “What do you recommend?” If you do meet with a reconstructive surgeon, be proactive about asking, “What are your credentials?” And, “Can I see before and after pictures?”

“Skin cancer is something that we all need to be on the lookout for, but it’s also something we can prevent, catch early, and treat extremely effectively,” says Rosenberg. “If you have a skin cancer on the face and you’re concerned about what you’ll look like after having it removed, make an appointment with a reconstructive surgeon so you can learn about and discuss your options.”