Double board-certified Facial Plastic Surgeon Dr. Sang W. Kim of the Natural Face™ Clinics offer surgical dermatology for patients residing in the Syracuse metropolitan area and Central New York cities including, Ithaca, and Rochester.
Over the past few decades, there has been an increase in the incidence of skin cancer in the United States. However, while there are more skin cancers being diagnosed, the survival rate has improved significantly. This is due to an increase in awareness with screening and early diagnosis followed by timely and appropriate treatment of the disease.
We offer surgical dermatology services to our medical patients. Many are referred by their primary care providers while others find us through their family and friends. We treat patients who present with concerning skin lesions. Often, we can provide same day examination and/or biopsy of the lesion. The confirmatory diagnosis of the excised skin lesions is made by the pathologists who examine the tissue specimen under the microscope with the assistance of special stain studies if necessary.
Routinely our practice has encountered patients who self-referred to our office for evaluation and treatment of skin lesions involving the face, head, and neck. Over the past several years, we have streamlined our practice to accommodate an effective, convenient, and prompt care for patients with skin lesions.
Screening for Skin Lesions
Skin lesions are typically categorized into pigmented or non-pigmented lesions. If a pigmented lesion is determined to be malignant, it is most likely a melanoma. If non-pigmented lesions are determined to be malignant, the two most common types of non-melanoma skin cancer are basal cell carcinoma and squamous cell carcinoma.
While routine screening for skin cancer of the general population may not be practical, it may be prudent for careful assessment during an annual physical exam in patients with high risk for skin cancer. These risk factors include current immunosuppressive therapy (example, organ transplant patients), personal history of skin cancer, first-degree relatives with melanoma, dysplastic nevus syndrome (100+ benign nevi or 5+ atypical nevi on exam), or history of radiation. Symptoms including itchiness and tenderness have been associated with the non-pigmented lesions with skin cancers. Patients frequently describe a non-healing lesion with intermittent bleeding.
Melanoma is classically described as a pigmented mole with ABCDE signs: asymmetric margins, uneven or irregular borders, several shades of colors, diameter > 6mm, and evolving or changing over time.
Diagnosis
Skin biopsies are categorized into two types: incisional and excisional biopsy. During an incisional biopsy, only a part of the lesion is removed for evaluation. Examples include shave biopsy for raised lesions and partial punch biopsy for flat lesions and pigmented lesions. An excisional biopsy involves the removal of the entire lesion for evaluation, and examples include large punch biopsy, saucerization, and fusiform excision.
Pigmented lesions should have a full-thickness punch biopsy. This is because, in addition to determining whether the lesion is melanoma, additional features such as the depth of penetration, plays a key role in subsequent work-up and treatment planning. If the initial biopsy of melanoma was performed as a shave or superficial biopsy, it will distort the assessment of the actual depth of penetration. While most literature indicates the type of biopsy does not negatively impact the melanoma survival rate, one should perform a full-thickness biopsy which will help with accurate tumor staging, prognosis, and subsequent treatment planning.
Treatments
There are several treatment options for basal cell carcinoma and squamous carcinoma of the skin. For areas of low risk of recurrence, superficial ablative treatments may be adequate. These include electrodesiccation and curettage, and cryotherapy. While these techniques are the simplest and least involved, the downside is that, without the actual removal of the tissue specimen, we cannot have the histologic confirmation of margin clearance.
For most, basal cell carcinoma and squamous carcinoma of the skin, full thickness ablation with histologic confirmation of the margin clearance allows for the highest cure rate. This type of wide local excision involves en bloc removal of the lesion along with a margin of adjacent clean tissue all around the lesion including the deep surface. While various guidelines for an ideal margin of clearance exist, most literature supports 3 mm of clear margin for basal cell carcinoma and at least 5mm for squamous cell carcinoma of the skin.
Through coordination with our partnering pathologists, we are able to provide a same-day frozen section evaluation in the office setting to ensure a complete excision of the entire lesion as well as an adequate clear margin surrounding it.
Repair of the Skin Defect
After the skin lesion or cancer has been removed, there will be a skin defect, or a “hole in the skin”. Depending on the size and the location of the skin defect, there are several options for repair. In the face, head, and neck area, careful planning is particularly important because so much of cosmesis and function depend within these areas.
For a small skin defect, careful and meticulous closure can lead to an excellent cosmetic and functional outcome. Small skin defects in some areas with concaved surfaces such as the inner corner of the eye or the temple often heal nicely without any repair.
Other areas of the face, such as the rim of nose, around the eyelid, or the lip should be approached with a low threshold for surgical repair. Surgical repair will involve recruiting skin tissues from surrounding areas to fill the defect from the excision. The specialists recommend this method because the closure of the defect is not the only goal of the repair. One must consider subsequent functional problems that may arise in these areas following healing and contracture of the tissue. These problems may not be evident until there have been enough time lapses for wound contracture to occur.
For example, if the skin defect is adjacent to the eyelids, the nose, or the lips, suboptimal repair may still look acceptable immediately following simple closure with stitches. But months or sometimes years later, as the wound heals, the skin tissue at the repaired site will begin to contract and deform the adjacent structures. This is the process that can lead to retracted eyelid with dry eye or scarring of the cornea, retraction of the nasal rim or collapsing of nose with compromised nasal airway, or the retraction of the corner of the lips resulting in drooling and slurred speech. Carefully planned repair procedure at the time of excision (sometimes by recruiting surrounding healthy tissue to cover the defect) will help prevent such complications and also lead to optimal cosmetic outcome in the long run.
Follow-up/Screening
For patients with a history of skin cancer, there is almost a 10-fold increase in incidence of another skin cancer at a different location compared to the general population. Therefore, routine screening is important for patients who had skin cancer.
For basal cell carcinoma, which is known to be locally destructive but without the tendency for regional or distal spreading, one must monitor the excised area to ensure that the cancer does not return. For cutaneous squamous cell carcinoma, almost a 95% recurrence from the initial cancer will be detected within the first five years. Therefore, consistently follow-up for the first 5 years after the treatment of squamous cell carcinoma is appropriate with palpation of regional lymph nodes during the annual visits and sometimes with aid of CT imaging.
For the melanoma, depending on the initial staging of the disease, the patient may be closely followed by more than one specialist, especially if it was treated in a multidisciplinary fashion. Most importantly, the patient and his/her family should be actively engaged in routine self-examination. As described above, if there are any lesions that show suspicious features, one should promptly notify their health care provider.
Double board-certified Facial Plastic Surgeon Dr. Sang W. Kim at Natural Face Clinics specialize in aesthetic enhancement of the face, head, and neck, exclusively. Patients come to see us from the Syracuse metropolitan area and Central New York area including Ithaca, and Rochester. At Natural Face Clinics, we specialize in restoring the youthful neck contour, tired appearance of the brows and eyes, and skin laxity. We offer customized treatment, both surgical and non-surgical, including facelift, eyelid surgery (blepharoplasty), nose surgery (rhinoplasty), brow lift, neck lift, and skin resurfacing. Find out more by scheduling your personal consultation today.