Procedures - SKIN CANCER

Skin cancer is the most common cancer in South Africa with about 20 000 reported cases every year and 700 deaths. South Africa has the second highest incidence of skin cancer in the world after Australia.

The World Health Organisation (WHO) reports that between 2 to 3 million non-melanoma skin cancers and approximately 132 000 malignant melanoma occur globally each year. Skin cancer is the most common form of cancer in the United States. More than 500,000 new cases are reported each year-and the incidence is rising faster than any other type of cancer.

While skin cancers can be found on any part of the body, about 80 percent appear on the face, head, or neck, where they can be disfiguring as well as dangerous. The purpose of this brochure is to educate you about the different types of skin cancer, their causes, and preventive measures you can take; to help you know when to consult a doctor; and to explain the role of the plastic surgeon in the diagnosis and treatment of skin cancer and other skin growths.

Who Gets Skin Cancer ...And Why:
The primary cause of skin cancer is ultraviolet radiation -most often from the sun, but also from artificial sources like sunlamps and tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and perhaps the thinning of the earth's protective ozone layer are behind the alarming rise we're now seeing in skin cancers.At least 80% of sun-induced skin damage occurs before the age of 18 and only manifests later in life.

Anyone can get skin cancer-no matter what your skin type, race or age, no matter where you live or what you do. But your risk is greater if:

  • Your skin is fair and freckles easily
  • You have light-colored hair and eyes
  • You have a large number of moles, or moles of unusual size or shape.
  • You have a family history of skin cancer or a personal history of blistering sunburn.
  • You spend a lot of time working or playing outdoors
  • You live closer to the equator, at a higher altitude, or in any place that gets intense, year-round sunshine.
  • You received therapeutic radiation treatments for adolescent acne.

Types Of Skin Cancer:
The three most common types of skin cancers are basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM).

By far the most common type of skin cancer is basal cell carcinoma. Fortunately, it's also the least dangerous kind--it tends to grow slowly, and rarely spreads beyond its original site. Though basal cell carcinoma is seldom life-threatening, if left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage (particularly if it's located near the eye).

Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it's not treated.

A third form of skin cancer, malignant melanoma, is the least common, but its incidence is increasing rapidly, especially in the South Africa. Malignant melanoma is also the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it's not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly.

Other Skin Growths You Should Know About:
Two other common types of skin growths are moles and keratoses.

Moles are clusters of heavily pigmented skin cells, either flat or raised above the skin surface. While most pose no danger, some-particularly large moles present at birth, or those with mottled colors and poorly defined borders-may develop into malignant melanoma. Moles are frequently removed for cosmetic reasons, or because they're constantly irritated by clothing or jewelry (which can sometimes cause pre-cancerous changes).

Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and sometimes develop into squamous cell cancer. These can be effectively treated by cryotherapy (freezing) or using certain topical creams.

Recognizing Skin Cancer:
Basal and squamous cell carcinomas can vary widely in appearance. The cancer may begin as small, white or pink nodule or bumps; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that's rough, dry, or scaly...a firm, red lump that may form a crust...a crusted group of nodules...a sore that bleeds or doesn't heal after two to four weeks...or a white patch that looks like scar tissue.

Malignant melanomamay be seen as a small, brown or black, or larger multi-coloured patch with an irregular outline, which may crust and bleed.Malignant melanoma may occur in pre-existing moles or skin spots. They can also appear like freckles from previously normal skin. Melanoma is usually signaled by a change in the size, shape, or color of an existing mole, or as a new growth on normal skin.

Watch for the "ABCDE" or the Glasgow 7-point checklist warning signs of melanoma: Asymmetry-a growth with unmatched halves; Border irregularity-ragged or blurred edges; Color-a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; Diameter- a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size. E – evolving (enlarging or changing)

Glasgow 7-point checklist
Major features:
  • Change in size
  • Irregular shape
  • Irregular colour

Minor features:
  • Diameter >7mm
  • Inflammation
  • Oozing or bleeding
  • Change in sensation

If all these variables sound confusing, the most important thing to remember is this: Get to know your skin and examine it regularly, from the top of your head to the soles of your feet (Don't forget your back). If you notice any unusual changes on any part of your body, have a doctor check it out.

Choosing A Doctor:
If you're concerned about skin cancer or notice an unusual growth yourself, consult a plastic surgeon or a dermatologist. Both are skilled at diagnosing and treating skin cancer and other skin growths. A plastic surgeon can surgically remove the growth in a manner that maintains function and offers the most pleasing final appearance- a consideration that may be especially important if the cancer is in a highly visible area. If a treatment other than surgical excision is called for, the plastic surgeon can refer you to the appropriate specialist.

Skin cancer is diagnosed by removing all or part of the growth and examining its cells under a microscope. Removal of a small sample of tissue is called an incision biopsy and is easily performed in the consulting rooms under local anaesthesia. This enables a complete tissue diagnosis. If the growth is small enough, it may be possible to remove this in its entirety (excision biopsy).

In some cases, you may require digital mapping of the skin lesions (“Molemax mapping or scan).

Mole mapping is particularly useful for individuals who have:
  • Very many moles (more than 50 to 100)
  • Dysplastic or atypical naevi – moles that are large, unusual colour(s) or shapes
  • Moles on the back, which may be difficult to keep an eye on
  • Previous history of melanoma
  • Strong family history of melanoma
  • Moles and fair skin that has been severely sunburned
Concerns about individual moles or freckles, e.g. because of their appearance or recent change

Treatment of skin cancer:
It can be treated by a number of methods, depending on the type of cancer, its stage of growth, and its location on your body.

Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician's office, using local anesthesia. The procedure may be a simple excision, which usually leaves a thin, barely visible scar.

If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, major surgery may be required. Other possible treatments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time (Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as follow-up). Mohs surgery may be substituted by a “frozen section” procedure in which a pathologist, present during the surgical excision procedure, guides the extent of the excision, based on tissue margins that are free from cancer. The plastic surgeon closes the defect as deemed necessary.

Discussing Your Options And Concerns:
All of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal cell and squamous cell cancers -and even for malignant melanoma, if it's caught very early, before it's had a chance to spread. You should discuss these choices thoroughly with your doctor before beginning treatment. Find out which options are available to you...how effective they're likely to be for your particular cancer...the possible risks and side effects...who can best perform them...and the cosmetic and functional results you can expect. If you have any doubts about the outcome, get a second opinion from a plastic surgeon before you begin treatment.

A Word About Reconstruction: The different techniques used in treating skin cancers can be life saving, but they may leave a patient with less than pleasing cosmetic or functional results. Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as your nose, ear, or lip. In such cases, no matter who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques- ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body-can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function.

Preventing A Recurrence:
After you've been treated for skin cancer, your doctor should schedule regular follow-up visits to make sure the cancer hasn't recurred. Your physician, however, can't prevent a recurrence. It's up to you to reduce your risks by changing old habits and developing new ones. These preventive measures apply to people who have not had skin cancer as well.
  • Avoid prolonged exposure to the sun, especially between 10 a.m. And 2 p.m. and during the summer months. Remember, ultraviolet rays pass right through water and clouds, and reflect off sand and snow.
  • When you do go out for an extended period of time, wear protective clothing such as wide brimmed hats and long sleeves.
  • On any exposed skin, use a sunscreen with an SPF (sun protection factor) of at least 30. Reapply it frequently, especially after you've been swimming or sweating.
  • There is also no such thing as a healthy tan! CANSA (Cancer Association of South Africa) has recommended that the Department of Health ban sunbeds and sunlamps as it has been proven through recent research findings that there is a relationship between the use of sunbeds and malignant melanoma, as well as other non-melanoma skin cancers. Sunbeds predominantly emit UVA and UVB both of which can cause damage in the DNA of skin cells.

Finally, examine your skin regularly. If you find anything suspicious, consult a family practitioner, plastic surgeon or a dermatologist as soon as possible.

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Choosing to have plastic surgery requires thorough research and educated decision-making. This website is designed to help guide you get to know a little bit more about my practice and understanding of the procedures and treatments available to you. I look forward to meeting you which will allow you to make a better informed decision around treatments or surgery best suited to you.

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