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Skin Lesions (Moles etc.)
What are Skin Lesions: A skin lesion is something that develops in or on (and I have included "under" although that is not strictly correct) the skin that is not normal or is undesirable. Something like a mole is undesirable because it looks ugly, or a lump under the skin like a cyst which would not normally be there. Most are benign, but some are malignant skin cancers and need to be removed!
Reasons why people want skin lesions removed:
Patients come into see me because they have a mole or some other skin growth that has been gradually enlarging until it reaches a size that is no longer acceptable. They want rid of it! Other patients have a skin growth that has changed suddenly or developed symptoms such as itching or has bled and quite reasonably are worried it might be something nasty and want something done about it. Most of this type of lesion is sent to the pathologist for analysis after removal to find out what it is. The final group of patients have already seen their GP or a dermatologist who have recommended I see the patient to deal with the skin lesion.
Where I Operate:
Although I can do this type of surgery at any of the Hospitals I work at, The Circle Clinic (The Hand Clinic) at Windsor is a purpose built Local Anaesthetic facility.
It has the advantage of free, ample parking, staff who are familiar with all the local anaesthetic procedures and it allows me to do See and Treat clinics on Thursday mornings. This is a very time effective way patients can get treatment. I would see you for a consultation and then if you wish to proceed we go into the theatre and carry out your surgery. Essentially, the whole process of consultation and surgery are rolled into one visit. After contacting Janet, my PA (01483 764100), she will arrange a mutually convenient time when you come to the clinic for a consultation and surgery. How is it done?
I am often sent patients with lesions on the face or body, the reason being that as Plastic and Reconstructive surgeons we are trained to remove lesions and have the skills to reconstruct the defects with minimal scarring or disruption to the natural anatomy of an area. We have the options of closing the wound directly or using a skin graft or a flap. A skin graft is skin from a different part of the body while a flap is skin moved from an adjacent area to the wound. Where possible I prefer to use a flap as the skin colour and texture will be very similar to the tissue removed. The result is cosmetically much more acceptable.
Once you have signed consent we go into the operating theatre. I do the procedures in theatre because the lighting is good and it is a very clean environment which reduces the risk of infection. Once your skin has been cleaned I will use a felt pen to mark what I am going to do. I will then administer the local anaesthetic. This involves an injection into the skin where the surgery is going to be carried out. The injection is uncomfortable but the discomfort only lasts a few seconds and once in it is very effective. I then do the surgery. You will feel me working, pulling moving etc, but NO pain. I usually close the wound with dissolving sutures which are placed under the skin so you will not see them. Then paper strips are placed over the wound. These act as a splint to keep the skin from moving and allow the wound to heal in the best way possible during the first critical five days. These strips are shower proof and therefore the dressing causes the least inconvenience. Occasionally I have to use external sutures. These are very fine, and are also covered, but have to be removed at between five and seven days.
Pathology If there is anything in the history or examination that makes me feel even slightly suspicious of the lesion being removed I will recommend it be sent for histological examination. It is important to know the true nature of what is being removed. Certain types of lesion might need further surgery or other treatment depending on what they turn out to be. In addition if the clinical diagnosis is of a skin cancer it is important to know it has been completely removed - only a pathologist examining the specimen can assure us with any degree of certainty of that. If it turns out not to have been completely removed, further surgery may be advised to be certain of complete removal.
After Care
The dressing we put on is shower proof which means you can shower and it won't come to any harm if it gets a little wet. Occasionally the wound will start to bleed. If this happens, get a tissue and apply firm pressure to the whole dressing for at least FIVE minutes. Remain in an upright sitting position if the wound is above the waist, if it is on your leg, put the leg up and get someone to help with the pressure. If it keeps bleeding in spite of trying the pressure a few times, you will need to get in contact for advice. If the dressing we put on is still firmly in place leave it alone and add some of your own on top of ours to hide the stains from the bleeding. Infection usually does not happen until a few days post operation. The signs are:
The stitches I use to close the wound in the majority of cases are placed under the skin, "buried" in the wound. Occasionally the end of the suture works its way out and can be seen or felt in the edge of the wound. It is often associated with a little redness at the site. Once the thread is sticking out it will not dissolve and needs to be removed or it can be a focus of infection. You can get a pair of tweezers and try to pull it out or at least pull on it and cut it flush with the skin so what remains ends up under the surface, or come into one of my clinics and we will do it for you.
The Scar
With regard to the scar, time is your greatest ally. Initially when the dressing is removed you will see a slightly bumpy line and possibly a little surrounding bruising. The scar then will become a red line as blood vessels grow into it to aid the healing process. The scar will thicken a little as scar tissue is formed to hold the wound together. Then gradually, sometimes over many months, the colour will fade and the scar will soften and flatten. The more time goes by the less evident the scar will become. The face generally heals very well with fine scars. Some scars do not heal as well as might be expected and some parts of the body are more prone to unfavourable scarring. I will discuss this with you at consultation depending on what part of the body we are operating on. A scar may stretch. This is as though there was not enough scar tissue to hold it together. Sometimes it is the opposite and it is as if the body keeps making scar tissue which builds up into a raised chord of tissue which is known as hypertrophic scar tissue. If the scar tissue continues to enlarge and extends beyond the site of the original wound, this is keloid scarring. It is quite rare but a major problem to deal with. If your scar does not seem to be settling into a relatively fine line it is best if you arrange to see me again. If there is anything to be done to improve a scar that is not settling well it is best to do it sooner rather than later.
Lesions I commonly treat
Benign moles are slow growing lumps on the skin. They may be quite dark or flesh coloured and occasionally have a tuft of hairs growing out of them - the typical lump drawn on a witch's chin. It is precisely this ugly appearance that drives people to have them removed. Most are clinically benign but if there is any doubt I will recommend a histological examination. Sebaceous cysts are firm nodules that develop under the skin and feel like a subcutaneous grape. Sometimes quite smelly white material can be squeezed out of it. They are best removed because not only are they unsightly but they do have the potential to get infected and form a nasty abscess. I am able to remove these through a tiny incision leaving a tiny scar. Lipomas are benign fatty tumours that grow slowly under the skin. Patients usually decide to get these removed once they become noticeable. Skin tags are the tiny lumps of skin that hang on stalks, usually in clusters in areas where the skin gets rubbed. Quite large numbers of these can be removed at one sitting. Seborrheic keratoses are the crusty slightly raised lesions that are common in older skin. They are very superficial lesions so can be removed by the technique of shaving which leaves an almost imperceptible scar. Basal Cell Carcinoma is the commonest malignant skin tumour. Fortunately this tumour very, very rarely spreads to other parts of the body. When I remove this tumour I design the operation so that the tumour is removed completely and surrounded on all sides and underneath with normal tissue. I always send it for histological examination. The pathologist will confirm the diagnosis and tell me if the tumour is completely excised. If it is for all practical purposes you are cured. Squamous Cell Carcinomas are less common and more aggressive- they can spread in the body. The sooner they are removed the less likely they are to have had a chance to spread. Wide excision and a comprehensive histological assessment are important in making decisions about what further treatment might be necessary. Your management will depend on a number of factors which I will discuss with you. Malignant Melanomas are very dangerous tumours. Any skin lesion that has been enlarging rapidly, changing colour, spreading across the skin or forming a nodule, particularly if it is black or dark needs to be looked at by a specialist. If you have noticed change from week to week or month to month, get it seen! If you come to see me with a history of a lesion that has been changing suddenly and rapidly which looks even slightly suspicious to me, I am likely to recommend immediate excision biopsy that same day. Scar Revision. Clearly these are not skin growths but sometimes a revision can improve the cosmetic appearance. It is never possible to make a scar disappear but sometimes features of the scar can be modified to make the scar less noticeable. Torn earlobes are an unsightly and inconvenient problem that I can easily deal with a short local anaesthetic procedure. Come in and see me and we will get your ears sorted out ready for a nice new set of earrings!
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