Skin Surgery

Skin Surgery
Cancer of the skin is seen in blond, blue-eyed, fair-skinned people who live where the sun is , fierce, and who by virtue of occupation or hobby are out in the sun all day. Basal cell carcinoma
accounts for about 50%, squamous cell for about 25%, and melanoma for 15%.. .or more “n’ (incidence is going up). They have preferred presentations (detailed below), but diagnosis in all of them is done by full-thickness incisional (or punch) biopsy done at the edge of the lesion
(including normal skin). Because they share etiology, they often coexist, and patients frequently ‘ have multiple lesions over the years.
Basal cell carcinoma may show up as a raised waxy lesion, or as a nonhealing ulcer. It has a pref erenc for the upper part of the face (above a line drawn across the lips). It does not metastasize, but can kill by relentless local invasion (“rodent ulcer”). Local excision with negative margins (1 mm is enough) is curative, but other lesions may develop later.
Squamous cell carcinoma of the skin shows up as a nonhealing ulcer, has a preference for the ? lower lip (and territories below a line drawn across the lips), and can metastasize to lymph
nodes. Excision with wider margins is needed (0.5 to 2 cm), and node dissection is done if they are involved. Radiation treatment is another option.
Melanoma usually originates in a pigmented lesion. A mnemonic to identify them is ABCD. ‘ They are asymmetric (A), have irregular borders (B), have different colors (C) within the lesion, and have a diameter (D) that exceeds 0.5 cm. They should also be suspected in any pigmented
lesion that changes in any way (grows, ulcerates, changes color and/or shape, bleeds, etc.). The
biopsy report must give not only the diagnosis, but also the depth of invasion. Lesions less than
, 1 mm deep have a good prognosis and only require local excision. Deeper lesions require exci sion with wide margins (2—3 cm). Lesions larger than 4 mm have a terrible prognosis. Lesions ‘ between 1 and 4 mm benefit most from aggressive therapy, including node dissection.
Metastatic malignant melanoma (from a deep, invasive primary) is a bizarre, unpredictable, and
fascinating disease. Melanoma metastasizes to all the usual places (lymph nodes, liver, lung, brain, and bone), but it also is the all-time champion for metastasizing to weird places (the muscle of the left ventricle, the wall of the duodenum.. .anywhere!). Furthermore, it has no predictable time table Some patients are full of metastases and dead within a few months of diagnosis, others go 20 years between the resection of their primary tumor and the sudden explosion of metastases.