Skin Cancer Surgery

Surgical excision is the primary treatment for most skin cancers. The procedure involves the complete removal of a malignant lesion along with a surrounding margin of clinically normal tissue to ensure all cancer cells are eliminated. Excision provides both a definitive diagnosis through histopathological examination and therapeutic removal of the tumour. It remains the gold standard for the management of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma.

Types of Skin Cancer Treated by Excision

Basal cell carcinoma is the most common form of skin cancer. It is typically slow-growing and rarely metastasizes, but if left untreated it can invade surrounding structures and cause significant local tissue destruction. Surgical excision with adequate margins achieves cure rates exceeding 95 percent for primary BCC.

Squamous cell carcinoma is the second most common skin cancer. Unlike BCC, SCC carries a risk of metastasis, particularly when arising in high-risk locations or exhibiting aggressive histological features. Complete excision with histologically confirmed clear margins is critical for reducing the risk of local recurrence and metastatic spread.

Melanoma is the most serious form of skin cancer due to its propensity for early metastasis. Wide excision with margins determined by tumour thickness (Breslow depth) is the standard surgical treatment. Early detection and prompt excision are essential for achieving favourable outcomes.

Surgical Margin Guidelines

The width of the surgical margin depends on the tumour type, size, location, and histological subtype. For well-defined primary BCC, margins of 3 to 4 millimetres are generally recommended. SCC typically requires margins of 4 to 6 millimetres, depending on tumour size and degree of differentiation. For melanoma, margins are determined by Breslow thickness: 5 millimetres for melanoma in situ, 1 centimetre for tumours up to 1 millimetre thick, and 1 to 2 centimetres for thicker tumours.

In cosmetically or functionally sensitive areas such as the face, ears, or eyelids, narrower margins may be considered, and referral for Mohs micrographic surgery may be appropriate to maximize tissue preservation while ensuring complete tumour clearance.

Pre-Operative Assessment

Prior to definitive excision, a thorough clinical assessment is performed, including dermatoscopic examination of the lesion and evaluation of its extent. A diagnostic biopsy is typically obtained to confirm the type and subtype of skin cancer before surgery is planned. All current medications are reviewed, with particular attention to blood-thinning agents that may increase bleeding risk. Any allergies, chronic conditions, or implanted medical devices are documented. A detailed consent process ensures the rationale, steps, and expected outcomes of the procedure are understood.

The Excision Procedure

The treatment area is marked with a surgical pen, delineating the tumour boundaries and the planned excision margins. Local anaesthesia is administered to ensure comfort throughout the procedure. An elliptical incision is made around the lesion, and the tumour is excised along with the predetermined margin of normal tissue. The specimen is oriented and placed in formalin for submission to a pathology laboratory.

Electrocautery may be used during the procedure to achieve haemostasis. The wound is then closed with sutures, typically in two layers: absorbable deep sutures to reduce tension and surface sutures that are removed after four to fourteen days depending on the anatomical site.

Histopathological Margin Assessment

The excised specimen is examined microscopically by a pathologist to confirm the diagnosis and assess the adequacy of the surgical margins. If the margins are reported as clear, the excision is considered complete. If tumour cells are found at or near the margin, re-excision may be recommended to ensure all cancer has been removed. This histopathological evaluation is a critical advantage of excision over destructive techniques such as curettage and cautery or cryosurgery, which do not provide tissue for margin evaluation.

Post-Operative Care and Follow-Up

Following the procedure, a sterile dressing is applied and aftercare instructions are provided. The wound should remain dry for 48 hours, after which gentle cleansing is permitted. Signs of infection such as increasing redness, swelling, or drainage should be reported promptly.

Regular follow-up is essential after skin cancer excision. The frequency and duration of surveillance depend on the type and stage of cancer treated. Patients with a history of BCC or SCC are at increased risk of developing additional skin cancers and benefit from ongoing periodic skin examinations. For melanoma, follow-up protocols are more intensive and may include clinical examination, dermatoscopy, and imaging as indicated.

At the Centre for Medical and Surgical Dermatology, skin cancer excisions are performed by Dr. Maksym Breslavets with meticulous attention to oncological margins, tissue preservation, and cosmetic outcome.