Cosmetic Surgeon New Jersey, Dr. Parker - Skin Cancer Patients
At the Parker Center in Paramus, New Jersey
Introduction
Skin cancer rates continue to rise dramatically in the United States. Currently, one in six Americans develops skin cancer at some point. Skin cancer accounts for one third of all cancers in the United States. Most of these are non-melanoma cancers such as basal cell carcinoma and squamous cell carcinoma. Mortality associated with these skin cancers is unusual. Melanoma, the eighth most common malignancy in the United States, accounts for 75 percent of all deaths associated with skin cancer.
The rising incidence of skin cancer is thought to be due to increased sun exposure associated with changing lifestyles and the depletion of the protective ozone layer.
Prevention
Since sun exposure is a major cause of skin cancer, prevention is possible through avoidance. Preventative measures are as follows: sunscreens, clothing and education.
Sunscreens
The efficacy of sun protection is measured by its sun protection factor (SPF). The SPF is the ratio of the least amount of UVB radiation required to produce erythema on protected skin compared to the amount of UVB required to produce the same amount of redness on unprotected skin.
Sunscreens function either chemically or physically. Chemical sunscreens absorb UV radiation and therefore reduce skin penetrance by UV radiation. Physical sunscreens reflect UV radiation by providing a physical barrier. Common physical sunscreens are opaque agents such as titanium dioxide, zinc oxide, etc.
Useful sunscreens should have an SPF of at least 15. Sunscreens only provide a mechanism to reduce sun damage - they are not a license to go out under the sun for prolonged periods of time.
Clothing
Regular clothing provides little protection against the sun. A cotton T-shirt has an SPF of less than 10 - this decreases rapidly when the clothing is wet.
Education
Patients should remember: Sunscreen should be applied 30 minutes before sun exposure and re-applied every 2 hours. Re-apply more frequently after swimming or heavy perspiration.
- Avoid outdoor activity during peak tanning hours.
- Wear additional sun protective clothing.
- DO NOT USE TANNING BEDS.
- Have regular dermatologic evaluations.
Diagnosis
The ABCD checklist (A=asymmetry, B=border irregularity, C=color variation, D=diameter > 6mm) has been reported to have a high likelihood of detecting melanoma. The threshold for biopsy may be lowered when a patient is worried that a nevus may be cancerous or reports recent changes in the nevus such as increased size, alteration of shape or color, itching, burning, bleeding or pain.
Clinical studies have shown that even the most experienced physicians can accurately diagnose 71% of malignant lesions and 94% of benign lesions. This strongly suggests that biopsies are indicated since even experienced physicians are unable to predict malignancy.
Tumor types
Benign lesions - the most common pigmented lesions are benign nevi: junctional, compound and intradermal. They can mimic melanoma along with other benign lesions such as seborrheic keratoses and solar lentigines.
Pre-cancerous - atypical, dysplastic or Clark's nevi may all lead to melanoma. Actinic keratosis may transform to either basal or squamous cell cancer. Trichoepithelioma may mimic basal cell cancer. Keratoacanthoma may closely mimic squamous cell cancer.
Malignant lesions - basal cell, squamous cell and malignant melanomas comprise the vast majority of the skin cancers seen in our practice.
Treatment
Benign lesions
These lesions can be treated in a variety of ways depending on the discussions between the treating physician and patient. Because these lesions are benign and are very unlikely to become cancerous, watching or observing them over time is a very logical course of action.
Patients who wish to have them removed for cosmetic or other reasons may elect to do so by one of two ways. A dermatologist will often remove these lesions by shaving or scraping them down to the second level of the skin, called the dermis. Plastic surgeons will often remove these lesions by excising, or cutting them out, and carefully repairing the wound with stitches.
The ultimate appearance after one of these procedures varies based on the size and location of the lesion, type of skin, age of the patient and skill of the practitioner. The patient should understand that some type of scar will almost always be present. It is very important for patient and doctor to discuss how conspicuous this scar will likely be in order for the patient to make an appropriate informed decision.
Precancerous lesions
These lesions should usually be biopsied to obtain a tissue diagnosis. Actinic keratoses can be treated topically but atypical, dysplastic, Clark's nevi, trichepiteliomas, and keratoacanthomas are almost always removed. Dermatologists can remove some of these lesions if they are deemed small enough. Larger lesions are usually referred to a plastic surgeon for excision.
The ultimate appearance after one of these procedures varies based on the size and location of the lesion, type of skin, age of the patient and skill of the practitioner. The patient should understand that some type of scar will almost always be present. It is very important for patient and doctor to discuss how conspicuous this scar will likely be. Because these lesions will often transform into skin cancers, removal is usually recommended, however.
Malignant lesions
These lesions are always biopsied with a definitive tissue diagnosis prior to removal. This is important because the biopsy will tell not only what type of skin cancer is present, but also its level of aggressiveness. Options for removal are based on the type of cancer, level of aggressiveness, size and location of the lesion, and overall medical health of the patient.
These options include the following. Removal by a dermatologist with cryotherapy or electrodessication and curettage for superficial cancers on the trunk or extremities; more recently topical treatment has been used by some dermatologists for superficial cancers. Surgical removal by a plastic surgeon or specially trained dermatologists, known as a Moh's surgeon. Finally, radiation therapy may be employed by a radiation oncologist in certain circumstances.
Our Approach at the Parker Center
Initial Consultation
A careful history and physical examination are performed by Dr. Parker on all patients presenting with skin lesions.
Benign lesions
If the lesion clearly appears to be benign, based on this evaluation, observation is usually recommended. If the patient and/ or family are bothered by the appearance of the lesion, Dr. Parker provides a detailed discussion about removal options. Consideration may be given to shave removal by a dermatologist, and if elected, an appropriate referral made.
Surgical excision by Dr. Parker and careful soft tissue repair are discussed as well. An anatomic diagram is drawn for the patient, demonstrating how the lesion is to be completely removed. In addition, diagrams are used to demonstrate the use of cosmetic surgical techniques employed by Dr. Parker in his cosmetic surgeries to try to make the resultant scarring as inconspicuous as possible.
Precancerous lesions
Lesions suspicious for being pre-cancerous or cancerous are treated with a full-thickness skin biopsy, either incisional or excisional, as discussed by Dr. Parker with the patient.
Precancerous lesions are referred to a dermatologist if topical treatment is appropriate. If not, surgical excision by Dr. Parker and careful soft tissue repair are discussed. An anatomic diagram is drawn for the patient demonstrating a more aggressive surgical removal than for benign lesions. In addition, diagrams are used to demonstrate the use of cosmetic surgical techniques employed by Dr. Parker in his cosmetic surgeries to try to make the resultant scarring as inconspicuous as possible.
All of these lesions are reviewed by a pathologist to verify the histology of the lesion and for the completeness of removal.
Malignant lesions
Lesions suspicious for being cancerous are treated with a full-thickness skin biopsy, either incisional or excisional, as discussed by Dr. Parker with the patient. Once the diagnosis is known, options for treatment are discussed with the patient.
Moh's surgery
Moh's micrographic surgery is performed by a specially trained dermatologist under local anesthesia. The treatment involves the progressive excision of the cancer using serial frozen section analysis and precise mapping of the excised tissue until no evidence of remaining tumor exists. Moh's surgery is recommended by Dr. Parker in the following circumstances: for difficult and high-risk basal and squamous cell carcinomas including tumors greater than 2 cm in diameter, located in areas where deep invasion is more likely, rapidly-growing, recurrent or ill-defined tumors, and those located in an area of previous radiation or where perineural invasion is likely.
Coordinated reconstruction of the patient undergoing Moh's surgery is performed by Dr. Parker later that same day or the following day. The resultant size and extent of the soft tissue defect determines the type of reconstruction to be done. Some defects are best repaired with a skin graft (skin removed and transferred from a distant area); others are better suited for a skin flap (the sliding of adjacent skin into the defect). In either case, Dr. Parker utilizes techniques borrowed from his cosmetic surgeries to make the resultant scarring as inconspicuous as possible.
Surgical excision with frozen section margin control (non-melanomas)
Patients who do not need Moh's surgery for their basal or squamous cell skin cancers are treated entirely by Dr. Parker. He surgically excises the skin cancer with an appropriate margin of skin. With the patient still on the operating table, a pathologist microscopically evaluates the removed tissue to be sure all peripheral and deep margins are free of tumor. In the great majority of patients, the margins are negative for residual tumor. Occasionally, the pathologist asks Dr. Parker to remove more tissue from a certain area. Once the tumor has been completely excised, the soft tissue defect is repaired.
The resultant size and extent of the soft tissue defect determines the type of reconstruction to be done. Some defects are best repaired with a skin graft (skin removed and transferred from a distant area); others are better suited for a skin flap (the sliding of adjacent skin into the defect). In either case, Dr. Parker utilizes techniques borrowed from his cosmetic surgeries to make the resultant scarring as inconspicuous as possible.
Surgical excision of malignant melanomas
Based on the Breslow thickness (in mm) of the biopsied melanoma, the appropriate surgical excision will be performed. The following peripheral surgical margins are obtained: in situ: 0.5 cm margin, less than 1 mm: 1 cm margin, 1-4mm: 2 cm margin, greater than 4 mm: 2-3 cm margin. The depth of excision extends completely through the skin and subcutaneous layer to the underlying fascia. For tumors greater than 1 mm thick and with non-palpable lymph nodes, sentinel lymph node biopsies are discussed.
The resultant size and extent of the soft tissue defect determines the type of reconstruction to be done. Some defects are best repaired with a skin graft (skin removed and transferred from a distant area); others are better suited for a skin flap (the sliding of adjacent skin into the defect). In either case, Dr. Parker utilizes techniques borrowed from his cosmetic surgeries to make the resultant scarring as inconspicuous as possible.
