Mr.JamesHendersonMA,MB,BChir,MRCS,MD,FHEA,EurDipHandSurg,FRCS(Plast)ConsultantPlastic,Reconstructive&HandSurgeonHonorarySeniorLecturer,UniversityofBristolPersonalAssistantSarahGamlinsarah@jameshenderson.net07913610304Moles&SkinCancerTherearevariouswaysthatlesionsontheskincanberemoved,andIwilldiscussthesewithyouduringyourconsultationandrecommendthebestoption(s)foryou.Moleremovalisusuallycarriedoutusinglocalanaesthetic,wheretheskinisnumbedwithinjections.Ialwayscleantheskinandsurroundingareathoroughlytominimisethechancesofinfection,andcarryouttheseproceduresusingproperasepticsurgicaltechnique.IwearmagnifyingglassescalledloupestoensurethatIcanclearlyseethelesionsandperformthesurgeryaccurately.ShaveExcisionThisiswhenamoleisslicedoffatthebase.Thisisthesimplestandquickestwaytoremoveamolethatisraisedupfromtheskin.Itmaywellbethebestoptionwherethereislittlespareskintoenableawoundtobeclosedwithoutdistortion(forexampleonthenose).Ofcourse,thistechniqueleavesascarthatisthesamesizeandshapeasthefootprintofthemole;thismightnotbeaproblem,andcaneasilybecoveredwithmakeup.Because thebase isnot removed, there is a chanceof themole re-growinginthefuture.FormalExcisionI remove themajority ofmoles in thisway. Themole, and the skin beneath it, iscompletelyremoved,usuallywithaverynarrowmarginaroundtheedge,withtheaimofpreventingitevercomingback.Theresultingwoundisusuallyellipticalinshape,andisclosedwithstitches.Thisgivesastraight-linescar,whichIpositioninthebestpossibleorientationtoensurethatitisashardtonoticeaspossibleonceithashealed.SkinCancerRemovalSkincancersareusuallyremovedwithamarginofnormalskinaroundthem:thisistailoredtothediagnosis,takingintoaccountthesiteonthebodyandthepatient’swishes. Once the tumour is removed, a reconstruction may be required. Optionsinclude skin grafting and ‘flap’ reconstruction. I will discuss what is required, andrecommendappropriateoptionsforyou.Althoughthismaysoundverydaunting,theresultscanbeextremelypleasing,evenoncomplexareaslikeears,nosesandeyelids.Pleaseseephotographshereforexamples.

CurettageandCauterySomesuperficialskinlesions(e.g.seborrheickeratoses)areremovedinthisway;theyarecarefully‘scraped’fromthesurfacewithaspecialinstrument,andtheresultingwoundiscauterisedtopreventbleeding.Thewoundisthentreatedwithantisepticointmentandhealswellinaweekortwo.

WhattoexpectEvenasmallprocedurecanstillbeasourceofgreatanxiety.Wehaveanexcellentteam,andeveryonewilldotheirbesttomaketheexperienceaseasyaspossibleforyou.BeforehandForalocalanaestheticprocedure,youcaneatanddrinknormally.Thereisnoneedtofastunlessyouarehavingregionalorgeneralanaesthesia.Pleasewearclothesthatmakeiteasytogettothelesionthatyouarehavingremovedandthatarenottoodelicate.Wecanprovideagowntowear,butyoumayprefertokeepyourownclotheson.Pleasetrytoarriveinplentyoftime–thetrafficcanbeaprobleminBristol,andyoudon’t want to be stressed about running late.We allow plenty of time for everyproceduresothatweareoftenrunningaheadoftime(themostcommonreasonforusover-runningisthatthepatientaheadofyouwaslatearriving).Itisoftenbetterifyouhaveacompanionorfriendthatcanaccompanyyou.ConsentWewillsitdowntogetheragainbeforeyourproceduretoconfirmexactlywhatweareplanningtodo.Imaydrawonyouwithapen,andIwillaskyoutosignaformtosaythatyouwishtogoaheadwiththesurgery.Iwillremindyouoftherisksofsurgery,whichwewillusuallyhavediscussedalreadyatyourconsultation.Afterthis,wewillgototheprocedureroom.Therewillbeanursewhowillassistwiththeprocedure.Therearecoathooksandasparechairthatyoucanputyourthingson.

LocalAnaestheticAfterplanningtheprocedureanddrawingonyouwithapen,Iwillcleanyourskinandthenperformtheanaestheticinjections.Thesetakeafewseconds,andthisisthepartoftheprocedurethatmost(butnotall)patientsfindunpleasant.Dependingonthesiteofthelesion,youmayfindthat,forexample,yourlipgoestemporarilynumbaswellasyourcheek,orthatyoucannotraiseyoureyebrowforalesiononyourtemple.Theanaestheticwearsoffafterabouttwohours.PreparationIwillcleanyourskinagainwithanantisepticsolution,thistimecleaningalargearea.IwillthenplaceadrapeovertheareatoensurethatIhaveasterileoperatingfieldtominimisetheriskofwoundinfection.ProcedureIwillcheckthatyoudon’thaveanysensationatthesitebeforestarting,althoughyouwill feel a small amount of ‘pushing and pulling’. Most patients do not find thisunpleasantatall,andpeopleareusuallysurprisedthatthispartofthetreatmentisrelativelyquick.SuturesIwillselectsutures(stitches)togiveyoutheleastvisiblescar.IfappropriateIwilluseabsorbable(‘dissolving’)sutures,althoughtheseprobablydon’tresultinquitesuchagoodscarasthesyntheticonesthatneedtoberemoved.Mostsuturesareremovedaftersevendays,althoughthisdoesvarywithbodysite.Ontheface,Iuseveryfinesutures, and on the back, Imay use very strong sutures buried under the skin topreventthewoundfromcomingopen(dehiscing)beforeitisfullyhealedandtostopthescarfromstretchingovertime.DressingsIalwaysprovideadressingforthewound,anddependingonthesiteofthewoundandyourpreference,thismaybe‘steristrips’ (stickypaperdressingstrips),glue,orantiseptic ointment, as well as conventional sticky dressings and bandages. Thedressingisanimportantpartofthesurgery,andIselectdressingstooptimisethefinalscarappearanceaswellastomakeyourlifeaseasyaspossibleafterwards.ImmediatelyafterPatientsmayfeela little lightheadedimmediatelyaftersurgery,andsoevenifyoufeelfine,welikeyoutositdownfor10minutesafterwardsandhaveadrink.Youcanusuallyresumenormalactivitiesafterthis,dependingonyouroccupationandplans.Iwill advise you about specific restrictions, sports and return to work at yourconsultation.Follow-upWewillarrangeanappointmentforremovalofsutureswithyou,andiffurtherfollow-up is needed, my secretary will contact you to offer an appointment at yourconvenience.Ifsampleshavebeensentawayforanalysis,Iwillcontactyouwiththeresults(usuallybypost).ScarmaturationScarstakeuptotwoyearstofullysettle(mature).Initially,yourwoundisthesame

colourasyourskin,butas itheals,thescarbecomesthickerandred,Scarrednessusuallypeaksbetweenfourandeightweeks.Thescarwillthensettlegradually.Afterayear,thescarisusuallypalerthanthesurroundingskin.Theprocessofscarmaturationcanbespeededupby‘scarmassage’.Oncethewoundhashealed,youshouldusealittlemoisturiserandmassagethescar.Thisreallymeansapplyingpressuretothescar,andthisgradually leadstoarealignmentofcollagenfibrestosoftenandsettlethescar.Iwillshowyouhowtodothis.SunprotectionScarsaresensitivetothesun,andcanbecomehyperpigmented,wheretheydevelopatan,whichisdarkerthanthesurroundingskin,ordoesn’tfadeinwinter.Forthisreason,youshouldusestrongfactorsuncreamonanyexposedscars.RisksofminorsurgeryAllsurgerycarriessomerisks,althoughwetakeeverycaretominimisethese.Youwillbeprovidedwithcontacttelephonenumberssothatyouhave24-houraccesstohelpifyouhaveanyconcernsafteryoursurgery.Thereisnoadditionalcosttoyouforanyfurthertreatmentthatyoumightrequire.Infection–Aninfectedwoundbecomesred,hot,swollenandpainful,andtherecouldbedischarge.Ihaveapersonalwoundinfectionrateoflessthan1in200cases(0.5%,with only one case in 2015-16). Usually, an infection can be treated simply withantibiotics, especially if detected early. Occasionally an infected wound will needcleaningupormoresurgery.Bleeding–Occasionallypatientswillhaveproblemswithbleedingafterminorsurgery.Mostbleedingstopswithpressureappliedfor10minutes.Bleedinginsideawoundcanleadtoahaematomathatmightneedtoberemoved.Againmypersonalrateislessthan1in200cases(0.5%).Dehiscence–Ifyouaretooroughwithyouwound(orifyouareunlucky),thenthewoundcanburstopen.Veryoccasionallythishappens(lessthan1in200),inwhichcase I can resuture thewound.Wounds on the back or the back of the neck areparticularlyatrisk,soIclosethesewoundswithlayersofsuturesforextrastrength.Scarproblems–Asabove,scarsonthebackareundertensionwhenyoubendover,sothescarcanstretchovertime.TopreventthisIuseabsorbable(dissolving)suturesthatkeeptheirstrengthforalongperiodoftime.Theseareburiedunderyourskinsoyoudon’tneedtoworryaboutthematall.Somepatientsmaydevelopunsightlyorlumpyscars.Idesignallmyscarstominimisethechancesofthis.Akeloidscarisonewherethescargrowstobelargerthantheoriginalwound.Thisismoreduetothegeneticsofthepatientthananythingthatthesurgeoncancontrol.Keloidscarstendtoariseinwoundsonthecentreofthechest,theshoulder/upperarmarea,andtheear.Theyruninfamilies,particularlythosewithdarkerskin.Goodtreatmentsarenowavailableforkeloidscars,buttheyremainadifficultproblem.©JamesHenderson2016