Surgical Dermatology

Whether you have a benign growth to remove or a large skin cancer that requires surgery, Miller Family Dermatology should be your first stop. We will help find the best treatment option for you and provide you with excellent care in our state-of-the-art procedure center.

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Actinic Keratoses

Actinic Keratoses are an incredibly common precancerous condition. They are very much related to sun exposure and tend to show up on the head, forearms, and the back of the hands. Left untreated, they eventually can develop into squamous cell carcinoma, which may require surgery to remove. Since it is difficult to determine which ones are going to turn into cancer, we recommend getting rid of all of them so that they never have the chance.

Squamous Cell Carcinoma

Squamous (rhymes with famous) cell carcinoma is the second most common type of skin cancer. There are about 700,000 cases of squamous cell carcinoma each year in the United States. They can grow anywhere on the body, but are far more common on sun-exposed areas like the rim of the ear, lower lip, face, bald scalp, forearms and backs of the hands. They often look like red or skin-colored patches or bumps and are often scaly. Many times, they look like warts or even just a patch of dry skin.

Basal Cell Carcinoma

Basal Cell Carcinomas, or BCCs, are the most common type of skin cancer. They grow from the bottom, or basal layer of the epidermis (the outermost layer of the skin). They can look like open sores, red patches, pink growths, shiny bumps, or scars. A sore that looks like it should heal, but never does, is a classic presentation. Basal Cell Carcinomas almost never spread (metastasize), but they can become highly disfiguring if ignored. Most of the time they develop on parts of the body that have seen excessive sunlight, such as the face, ears, neck, scalp, shoulders and back.

Melanoma

Melanomas often resemble moles, but typically are darker in color, have several shades of brown, have irregular edges, and are larger than a pencil eraser. Another way to think of them is that normal or benign moles often look well put together, or orderly in some way. Melanomas often look like they were made by a slob. However, there are many exceptions to this general guide, which is why new or changing moles or moles that just don't look right should be examined by a dermatologist.

Skin Cancer Screening

Skin cancer is by far the most common skin cancer in the United States, but with early detection it is usually curable. Skin cancer screening is quick, painless, and saves lives.

Skin Cancer Treatment

There are many options for treating skin cancer, including simple office procedures, topical medicines, and advanced surgical removal by Mohs Surgery. We can provide any of these and will recommend the best treatment for you.

Surgery FAQ

We provide a wide range of skin surgery on all body surfaces, including destruction of benign and malignant growths, excisional surgery, Mohs Micrographic Surgery, skin biopsy, and scar revision.

It is very important that we have adequate time to discuss the risks, benefits and alternatives of a given surgical approach with you before we schedule your procedure. Careful review of your existing pathology, medical history and care goals will determine the most appropriate treatment. Infrequently, additional biopsies must be performed prior to making a treatment recommendation.

Your pre-operative clinic visit ensures that we have all of the information needed regarding your skin cancer, your medical history and your treatment goals to schedule the appropriate surgical procedure. It will also give you a chance to ask questions you might have about your condition and your treatment plan.

Surgical complications do occur, but we are there for you 24/7. You will receive your surgeon’s cellphone number at the time of surgery. We will ensure that your post-operative course is as smooth as possible.

About Mohs Surgery

Mohs micrographic surgery is a technique that allows dermatologists to selectively remove areas involved with the skin cancer, while at the same time preserving the greatest amount of normal tissue possible. If surgical repair of the defect is necessary, it can be done with the knowledge that there is no tumor remaining. As a result, Mohs micrographic surgery is very useful for large tumors, tumors with indistinct borders, tumors near vital functional or cosmetic structures, and tumors for which other forms of therapy have failed.

Over 60 years ago, Frederick Mohs, MD, of Madison, WI developed a unique form of treatment for skin cancer called chemosurgery. Dr. Mohs applied a caustic chemical to “fix” (harden) the area involving the tumor so that it could be removed and traced to all of its edges. This often took several days.

Today, this surgery is performed using a “fresh tissue” technique that avoids the use of this caustic chemical and allows dermatologists to remove all of the tumor in one day.

If you have a primary basal cell carcinoma, there is about a 99 percent chance that you will be cured. If you have a primary squamous cell skin cancer, you can be about 95 percent certain you will be cured with Mohs micrographic surgery. However, follow-up visits to detect the rare recurrence are very important. You should be seen at least once each year to rule out the possibility of recurrence and/or new cancer development.

Mohs micrographic surgery is performed in a procedure room under sterile conditions with a long-acting local anesthesia. Once anesthesia is complete, the visible portion of the tumor may be removed by scraping with a sharp instrument called a curette. Following the removal of most of the tumor, a thin layer encompassing the complete undersurface of the tumor is excised. That layer is then cut into small pieces and a map is drawn to identify the location of each piece. The edges of each piece are marked with colored dye to aid in orientation on a map. Each piece is then frozen and cut, stained, and examined under the microscope by Dr. Miller. Any areas in which the tumor is found are marked on the map and Dr. Miller returns to remove these areas. This procedure is repeated until no more tumor is found and the cancer is entirely removed. After each layer of tissue is obtained, oozing or bleeding vessels are cauterized or ligated with suture. A pressure dressing is applied. You may then rest in our waiting area with your family member or friend.

Mohs is a unique way of treating skin cancer.  What makes it special is that it is the only method of examining the entire margin of the removed tissue to ensure that no cancer remains.  Because of this, the cure rate is exceptionally high.

Normally, when a surgeon removes tissue and sends it to a pathologist, it is cut into sections like a loaf of bread.  The pathologist examines a few representative slices of tissue from the excised tumor to determine if the margins appear clear.  However, some tumors, like basal cell and squamous cell carcinoma of the skin, are capable of spreading by sending out small microscopic extensions.  In order to not miss these extensions, there needs to be a comfortable safety margin when using this standard approach.

Dermatologists who perform Mohs surgery are trained to obtain and process the tissue in a completely different way.  Instead of looking at the margins in 3 slices of bread out of a loaf of 200 like a pathologist does, the specimen is processed so that the entire margin is examined.  This is done by processing the tissue like a saucer and then cutting it into sections where each sections represents a thin layer of the entire margin. While doing this, the dermatologist makes a map on the patient and of the tumor that makes it possible to keep track of where any remaining tumor is located.  If cancer is still seen, another thin layer of skin is removed from that location.  When the surgery is complete, we can have a much higher degree of certainty that the entire tumor has been completely removed.

In most cases, the amount of tissue removed is less than with a standard excision.  It must be remembered though, Mohs Surgery is not performed for cosmetic reasons, it is performed to ensure complete removal of tumors and provide oncologic cure.  There are times when the amount of tissue removed using Mohs Surgery is greater than a standard excision, BUT because of the nature of Mohs Surgery, this only occurs when the skin cancer had extensions or “roots” extending far beyond the tumor.  If these roots are not removed, the tumor will recur and the surgery was a failure.  So, if the defect left by Mohs is large, it is because that tissue had to be removed in order to obtain cure.

Dermatologists with specialized training in Mohs surgery are the only ones capable of removing the tumor and performing a complete pathologic analysis of the margin. For this reason, the highest rate of cure is obtained if the tumor is removed by a Mohs surgeon.
Once the tumor has been cured, a defect is left that must be repaired.  Having a plastic surgeon repair this is definitely an option, and for some patients this is  best.  When Dr. Miller feels that the defect left by the removal of the tumor is likely to be large, he often refers you to a plastic surgeon prior to your Mohs surgery to discuss this as an option.  Sometimes you can get the best of both worlds- the highest possible cure rate via Mohs and the best possible repair via plastic surgery.  We are happy to facilitate this.

Preparing for Surgery

How should I prepare for surgery?

Eat your usual breakfast and/or lunch. If you normally skip breakfast, please have a morning snack on the day of surgery.

Take all of your regular medications unless directed otherwise by your surgeon or your regular physician. If you take medicine with aspirin, salicylates, other pain medicine, anti-inflammatory medicine, or arthritis medicine, please discuss this with Dr. Miller prior to your visit. DO NOT STOP ASPIRIN THAT WAS PRESCRIBED BY YOUR DOCTOR WITHOUT YOUR DOCTOR’S PERMISSION. DO NOT STOP COUMADIN IF YOU ARE TAKING IT.

Do not take any herbs, Vitamin E, niacin, fish oil tablets (omega 3) or non-steroidal anti-inflammatory medicines like Motrin, Nuprin or Advil the WEEK before surgery.  These all increase bleeding complications.

Wear comfortable, loose-fitting clothing that you can get into and out of easily. Avoid any pull-over clothing. You may also bring a blanket and/or sweater with zipper or buttons in case the room is cool.

Please leave your whole day available for surgery. Doing so will allow enough time for you to rest and recover from the procedure. On the day of your surgery, we encourage you to bring one close friend or relative with you who will drive you home. They may also keep you company between each stage of the procedure if you wish.

Wear comfortable clothes and avoid “pullover” clothing. If we are operating on the face please do not wear make-up or lotions on or around the area the day of the procedure.

We suggest that you eat a normal breakfast unless you have made a same day reconstruction appointment with another doctor. In this case you should follow the pre-op instructions that they give you.

Yes. Continue any medications prescribed by your doctor. However, aspirin is a drug that may prolong bleeding. We ask that you avoid aspirin unless you have had a history of heart problems or this is prescribed to take by your doctor (including Anacin, Bufferin, Excedrin, Alka Selzer, Percodan, Motrin, Advil and Naprosyn) for one week prior to surgery. If you are taking any blood thinners (Coumadin) please call our office before your scheduled surgery. In addition, alcohol will also promote bleeding, so avoid alcoholic beverages 24 hours before surgery.

Healing Process and Followup

Most patients do not complain of pain. If there is discomfort, Tylenol or Acetominophen is all that is usually necessary for relief. Avoid taking medications containing aspirin (unless prescribed) as they may cause bleeding. You may have some bruising around the wound especially if the surgery is close to the eye. We advise you to rest after your procedure and ice the area to reduce swelling. We would like you to keep your physical activity to a minimum for one week after surgery, this includes no heaving lifting, bending or strenuous exercise.

Yes. We recommend that the patient take it easy for the week after surgery which includes no exertion, heavy lifting, bending or straining.

This depends on several factors:

Consult

Surgery

Suture removal

 

How will my wound heal?

The human body healed itself naturally for thousands of years before the advent of modern medicine. It has great recuperative ability. After the complete removal of the tumor, several options may be considered for managing the wound.

Healing by spontaneous granulation

Letting the wound heal by itself is rarely done, but does decrease the chance of a recurrent cancer being invisible or hidden and in selected body locations offers an excellent cosmetic outcome. If at any time during the course of healing, the scar is deemed to be unacceptable, a cosmetic surgical procedure can be performed

Closing the wound or part of the wound with stitches

This procedure often speeds healing and can offer good cosmetic results, especially when the scar can be hidden in a line of facial expression or wrinkling. Sutures generally remain in place for 5 to 7 days and occasionally up to two weeks, depending on the location. Do not bathe the area until the dressings are removed. You must avoid swimming for 25 days.

Closing the wound with skin grafts, flap repairs or other reconstructive procedures


For wounds that are too large for primary closure, Dr. Miller may repair the wound with a flap or skin graft. Occasionally, a further tune-up of the repair may be needed, such as laser abrasion or scar revision. Sometimes delayed closures of wounds may be required. Dr. Miller will re-discuss these options with you after the cancer has been totally removed. PATIENTS REFERRED FOR MOHS SURGERY BY ANOTHER SURGEON WILL HAVE THEIR REPAIR DONE BY THAT SURGEON ON THE DAY OF MOHS SURGERY OR THE NEXT DAY.