Skin Cancer Reconstruction
Skin Cancer Reconstruction in Sydney
Are you considering skin cancer reconstruction in Sydney?
Australians have the highest rate of skin cancer in the world. The combination of our sun blessed country and a high proportion of Caucasian/white skin is a perfect storm for the development of skin cancer, especially on sun exposed skin. Most of us will develop a skin cancer during our lives due to the effect of sunlight on our skin. This can lead to the need for skin cancer removal and then skin cancer reconstruction in Sydney. In fact, the best skin care that you can provide is just using sunscreen consistently!
This page is written with reference to skin cancer development in Caucasian skin (the most common scenario).
What are the types of skin cancer?
In terms of managing skin cancers, it is useful to categorise them as follows:-
1. Melanoma and subtypes
Melanoma is a cancer that arises from melanocytes, the cells that provide pigment (or a tan). With sun exposure, these cells are stimulated to produce pigment to protect the deeper layers of skin. There is a correlation between the amount of childhood exposure to the sun and the risk of developing melanoma. Due to the developmental origin of this cell, when it develops into a cancer, it has a much greater chance of spreading than most other types of skin cancer. There may be concerns that go beyond skin cancer reconstruction in Sydney; an oncologist may need to treat with chemotherapy and/or radiation.
The Sydney Melanoma Unit is at the international forefront of management of melanoma. Most Specialist Plastic Surgeons are able to manage most patients with melanoma, advanced cases should be reviewed and managed by this multi-disciplinary team.
2. Basal Cell Carcinoma
Basal Cell Carcinoma (BCC) is a very common type of cancer that arises from the cells in the deeper layers of skin. The risk of developing this cancer is related to cumulative sun exposure. It tends to develop in the upper face. This type of skin cancer rarely spreads to distant sites (metastasises) but spreads in the local area, leading to the need for removal and then skin cancer reconstruction in Sydney. Some sub types of this cancer can spread quickly and with indistinct edges.
3. Squamous Cell Carcinoma
Squamous Cell Carcinoma (SCC) of the skin is also a very common type of cancer. It tends to be found on the lower face (especially lower lip), and is the most common type of skin cancer for all areas of the body other than the face. The risk of developing SCC seems to be linked to the number of sun burns suffered. This type of skin cancer can metastasise to other organs, but the risk is small if the cancer is removed whilst it is small.
Other cells within the skin can develop into cancers of many different types; however these types of skin cancers probably amount to only a couple of percent of skin cancers in total.
What is involved in skin cancer reconstruction in Sydney?
Depending on your type and size of skin cancer, a margin is required to be excised with it to ensure that it is completely removed. This establishes the area, shape and depth of the reconstruction required. Depending on the position and orientation of the defect, differing reconstruction options may be suggested. Specialist Plastic Surgeons have been trained to analyse these problems and provide the best functional and cosmetic outcome from your skin cancer reconstruction.
There are a few common options for skin cancer reconstruction in Sydney.
1. Direct closure
Skin lesions that are small enough, orientated well, and in areas where there is enough laxity in the skin, can usually be removed and closed with a straight line scar.
A flap is a segment of tissue (skin) with an intact blood supply. The can be twisted and manipulated through various geometric patterns to cover up a segment of missing skin. Depending on the site and size of the defect, these can be simple or very complicated.
A graft is a segment of tissue (skin) that is separated from its blood supply and used to cover a defect. It relies on a good bed for new blood vessels to grow into it – much like laying turf. There are varying thicknesses of graft that can be used in skin cancer reconstruction in Sydney, each with advantages and disadvantages.
What is margin control?
All cancers need to be removed with a margin of ‘apparently normal’ tissue to ensure that microscopic extensions of the tumour are removed. If parts of the cancer are seen at the edge of the removed tissue, that is termed an ‘incomplete excision’ and the treating doctor should remove more tissue (if possible) until they have a ‘clear margin’.
This has direct implications for immediate skin cancer reconstruction in Sydney. If the margins are not clear, then the tissue used to reconstruct the defect needs to be, in the very least, re-elevated whilst further tissue is removed. This may mean that the reconstruction is not as good as it could have been, as the area of the excision may no longer match the area of the reconstruction. In more serious cancers, the initial reconstruction may need to be considered contaminated, necessitating the removal of the first reconstruction and beginning a second reconstruction from scratch.
In practice, there are three methods of ensuring clear margins for immediate skin cancer reconstruction in Sydney.
1. NHMRC guidelines
The Australian National Health and Medical Research Council publish guidelines for the recommended clinical margins to be removed when removing a BCC, SCC and Melanoma. These margins vary according to the size and thickness of the tumour. Following these recommendations, a doctor can expect to have clear margins 98% of the time. Other skin cancers do not have nationally published guidelines for clinical margins.
2. Frozen section
Frozen section refers to a special method of viewing tissue by pathologists. The usual method is that removed tissue is embedded in paraffin and stained to allow pathologists to see different cells. This process usually takes about 24 hours until the treating doctor receives a report if everything runs smoothly.
Frozen section allows the tissue to be analysed within 10-20 minutes. Frozen section is not quite as accurate as paraffin slides, but the greatest limitation on accuracy is the tissue that the doctor provides the pathologist. By taking a donut of tissue around the cancer and a specimen of the deep surface, a complete three dimensional analysis of the tumour margins can be obtained. The central area is processed later with paraffin technique to confirm the frozen section report. With a good team of surgeon and pathologist, clear margins at the end of a skin cancer reconstruction can be expected > 99% of the time.
3. Moh’s micrographic surgery
Moh’s surgery refers to a technique of excising the lesion and mapping it. It is analysed under the microscope using frozen section techniques. This is performed by a small number of dermatology practices in Sydney. It is reported to have clearance rates of over 99%. By taking very fine slices and analysing them before removing more tissue, the advantage is that a skilled practitioner may be able to minimise the amount of tissue requiring later skin cancer reconstruction.
Melanoma is poorly identified by frozen section (and therefore Moh’s technique), so neither technique is very accurate in determining margins for immediate skin cancer reconstruction in Sydney.
Some of the rarer skin cancers are very difficult to obtain clear margins on. These may be better suited for a delayed reconstruction. This means that the cancer is removed and then analysed (paraffin method), and the skin cancer reconstruction is not performed until a formal report from the pathologist is obtained that confirms clear margins. This may require several episodes of excision, and having a dressing on your surgical site for up to a few days during the process.
Please discuss the advantages and disadvantages of the varying methods of margin control, and how they apply to your skin cancer, with Dr Sandercoe during your consultation.
Are there any options other than surgery for treating my skin cancer?
Yes. Very thin cancers of some types can be treated with creams that stimulate the immune system. Other skin cancers can be treated with radiotherapy. There are several other less common methods of treating skin cancers. The advantage of these treatment modalities is the absence of a surgical scar.
The inherent limitation of non surgical management of skin cancers is that you never know if you have treated enough of the cancer. With a surgical excision, the pathologist can inform you if the cancer is completely removed. Non surgical treatment of skin cancers requires ongoing surveillance to watch for signs of cancer recurrence.