What is a Melanoma Staged Excision?
Lentigo maligna is a type of skin cancer that occurs most commonly on sun-exposed skin. Lentigo maligna,also known as melanoma in situ, by definition occurs in the outermost layer of skin (the epidermis). The majority of lentigo maligna cancers have a prolonged phase of surface growth and generally have a low risk of invasion into the middle layer of skin (the dermis). However, this risk increases with the duration of the tumor.
Although lentigo maligna can be treated with destructive modalities such as cryotherapy (“freezing”) or radiation, surgical treatments are often preferred because they allow for microscopic assessment by a pathologist. These studies can determine if the cancer cells remain at the borders of the tissue or if there is an invasive component within the tumor.
One of the main challenges in treating lentigo maligna is that tumor cells may be present in the neighboring, “normal” appearing skin. In fact, the tumor often has subtle pigment and/or textural changes.The physicians at Laser & Dermatologic Surgery Center use a special approach called “staged excision” as the preferred treatment for lentigo maligna.
Please read this information sheet in its entirety before your surgery. If you have questions, call us at (314 )878-3839.
Staged Excision in the Treatment of Lentigo Maligna
Staged excision is a technique of skin cancer removal that allows for examination of the entire border, which minimizes chance of tumor recurrence.The procedure is performed under local anesthetic. Patients are initially scheduled for 3 surgery visits (often a Monday, Wednesday,&Friday). Our experience has shown that most people require 2 surgery visits in order to completely “clear” or remove the tumor. The 3 rd date is usually reserved for the reconstruction. Depending on the pathology results,you may require only 1 surgery date for tumor removal or possibly 3 or more dates if the tumor is more extensive than initially expected. You should ideally keep your calendar free for two weeks from the start of the surgery.
What to Expect on the Day of the Surgery
Using a special light and magnifying lenses, the tumor is examined and the border is noted with a surgical marker. Next, a surrounding margin of “normal” appearing skin is outlined 5 mm from the border. This is the standard recommended margin for treating this type of kin cancer.
This outlined area is fashioned into a geometric shape such as a square, diamond, or triangle using a surgical marker.This aids in tissue processing.
The entire area is numbed with local anesthetic.Using a scalpel,the outlined area is removed. The bleeding spots are treated with an electric cautery machine. A bandage is applied. The removed tissue is prepared for processing and a special map is made that correlates with the tissue. This tissue is sent to a dermatopathologist for examination. He/she may order special studies to help in making the final diagnosis.It usually takes 24-48 hours to receive the results.
Additional Surgery Date(s): If the pathologist identifies residual melanoma cells at the border, you will need to return for additional surgery/tissue removal. Again, the area will be numbed with local anesthetic. The areas noted to have residual tumor will be outlined with a surgical marker and will include an additional 5 mm margin. Bleeding spots will be cauterized and a bandage will be placed on the wound. Again, the tissue will be processed and submitted for pathology examination. The results are available in 24-48 hours. This surgical and review process will continue until no further melanoma cells are identified by the pathologist.
Reconstruction: Once the lentigo maligna has been entirely removed,you will need to follow-up to determine reconstruction options. Sometimes these wounds are allowed to heal on their own. Other times, a graft of skin or a flap of tissue from the surrounding skin are better options. In some circumstances,we may refer you to a plastic surgeon for the repair.
How to Prepare for Surgery
No real preparation, other than a good night’s sleep, is required.Eat a light breakfast on the day of surgery. If you are currently taking medication, continue as usual unless directed otherwise by your physician. Eliminate aspirin or any medications containing aspirin, such as Bufferin or Anacin, for at least two weeks before surgery. This is because aspirin tends to prolong bleeding during the operation. Also, eliminate medications containing ibuprofen, commonly found in Advil, Nuprin and Motrin, for at least three days before surgery. If you need a pain reliever,you may take acetaminophen,which is found in Tylenol.
It is best to wear a shirt that buttons down the front. No makeup or jewelry should be worn if surgery is to be performed on your face
What to Expect After Surgery
Most patients do not have severe pain, but may experience slight discomfort. If this occurs, we suggest you take two tablets of Tylenol every four hours.
Pain. Most patients do not have severe pain, but may experience slight discomfort. If this occurs, we suggest you take two tablets of Tylenol every four hours.
Bleeding.Occasionally, bleeding follows surgery. If this happens,do not become alarmed. Lie down and place steady, firm pressure over the wound as close as possible to the bleeding area. Apply the pressure continuously for 20 minutes (timed). Do not lift the bandage to check on the bleeding. If bleeding persists after 20 minutes of steady pressure, apply pressure for an additional 20 minutes. If bleeding still continues, call our office at (314) 878-3839, or go to the nearest hospital emergency room.
Swelling.Swelling is very common following surgery, particularly when it is performed near the eye. All wounds swell a little. Usually this is not a problem, and the swelling diminishes as the wound heals. Ice packs may help to reduce the swelling.
Drainage.All wounds will drain to some extent during the first week or two. This is why frequent dressing changes are necessary.
Infection.Infection of the wound is unusual. However, if you see thick, foul-smelling fluid coming from the wound, call our office immediately. An antibiotic maybe necessary.
Redness. disappears gradually. If the area becomes extremely red and itchy you may be allergic to either the ointment or tape. Call our office if this condition develops.
Scarring. All surgeries leave a scar. However,your scar will improve and become less noticeable as time passes.
Stitches and skin grafts. If we close the wound with sutures (stitches) or place a skin graft, you should keep the area clean and dry untilthe next visit.
What to Expect After the Wound Has Healed
You may experience some tightness, or drawing, as the wound heals. This is normal and usually lessens with time. Patients also commonly experience some itching after their wounds have healed. Rubbing a small amount of plain petroleum jelly on the scar often relieves this. Frequently, tumors involve nerves, and it may take up to a year, or even two years, before normal feeling returns to an area. Sometimes the area remains numb permanently. Only time will tell.
The scar tissue that grows over the wound contains many more blood vessels than the skin that was removed. This results in a red scar that may be sensitive to temperature changes. This sensitivity improves with time and the redness gradually fades.
Sometimes, the scar is unacceptable to the patient and the patient’s family. If this is the case, surgical scar revisionmay beconsidered. However, we usuallyadvise patients to wait 12months before having the scar revision performed. This is because the scar continues to improve in appearance and becomes less conspicuous up to one year after surgery.
Other Considerations for Patients with Lentigo Maligna
Patients with lentigo maligna are encouraged to follow-up with their primary care physicians for a general check-up. In the event that an invasive component is identified(that is, the melanoma has invaded the middle layer of skin),you may be advised to have a baseline chest X-ray and blood work. Chemotherapy, CT scans, and adjuvant radiation therapy are not needed in patients with lentigo maligna or thin, localized melanomas.
In some cases, the tendency for melanoma is hereditary as is the tendency for having sun damage. You are encouraged to discuss your diagnosis with your first degree relatives so that they can seek evaluation for signs of sun damage and skin cancer.
Defense Against Future Skin Cancer
The most important thing you can do to lessen the possibility or developing future skin cancers is to protect your skin from further sun damage. This is easily achieved by the daily application of sunscreens to all exposed skin, including the tops of the ears. You also may wish to obtain further protection by wearing a broad-brimmed hat and appropriate protective clothing.
Apply the sunscreen 15 minutes before you go outdoors. It may wash off with water or heavy perspiration, so be sure to reapplya sunscreen afterswimming or exercise, and usea sunscreenlabeled “waterproof.”Sunscreens that containa physical blocker such as zinc oxideare preferred because theyare bettersuited to block the tanning and photo-aging raysaswellas the burning rays. A number of excellent sunscreens are available. Whatever sunscreenyou choose, it should have a sun protection factor (SPF) of at least 30, but referably higher.
Once your surgery is over, periodic follow-up exams by your referring physician are important.These visits can help with early detection and treatment of new skin cancers that may develop as well as the rare recurrence of the skin cancer that was treated. It is also recommended that you perform monthly self skin examinations to identify new or changing, suspicious areas. If you notice any suspicious areas between visits, it is best to check with your doctor to see if a biopsyis needed.