Skin Cancer
Welcome to The Dermatology Institute of DuPage Medical Group in Naperville.
Here you’ll
find some of the latest and most advanced care
for dermatologic conditions and skin cancer.
This progressive center is led by Dr. Ashish Bhatia. Dr. Bhatia is internationally
recognized for his contributions to the field of dermatology. He is a fellowship-trained
expert in all aspects of skin cancer surgery. This includes basal cell carcinoma,
squamous cell carcinoma, malignant melanoma, as well as other forms of skin cancer.
Dr. Bhatia is also an expert in the diagnosis and repair of skin lesions, including
cosmetic reconstruction using skin grafts and skin flaps following skin cancer removal.
Skin cancer is the most common form of all cancers. More than
one million new cases of skin cancer will be diagnosed in the
United States this year alone.
The three most common types of skin cancer are basal cell carcinoma (the most common and least
dangerous), squamous cell carcinoma and melanoma (the least common but most dangerous type).
These names come from the name of the type of cell that becomes cancerous, a basal cell, a squamous
cell, or a melanocyte.
Cancer is a very frightening word that is used to describe many very different diseases with many
very different prognoses. Most cells that make up the body divide and reproduce in an orderly manner
at a set slow pace. This allows the body to grow, replace worn-out tissue and repair injuries. If one of
these cells is injured in some way (for example, by the sun) and becomes cancerous, it begins to replicate
and divide much more quickly. With the cell dividing more rapidly, the body is unable to process all
of the new cells and a mass or ball of these cells is formed. This mass of new cells is called a tumor.
In some tumors, the cells may break away from the mass, travel in the blood or lymphatic stream
and set up in another part of the body and continue growing and invading the tissue. This process
is called metastasizing and is associated with the more dangerous forms of cancer. This almost never
occurs in basal cell carcinomas and is rare in squamous cell carcinomas that are smaller than two
centimeters in width. Although not common with today’s advanced diagnostic and therapeutic
methods, melanoma is most likely to metastasize and spread to other parts of the body such as
the lungs, liver and bones.
Basal Cell Carcinoma
Squamous Cell Carcinoma
Malignant Melanoma
Basal Cell Carcinoma
Basal cell carcinoma is the most common form
of all cancers in this country. It accounts for
approximately 75% of all skin cancers and of
the three skin cancers listed above, has the best
prognosis. Although they are typically seen in
the sun-exposed areas of fair skinned middle to
older aged adults, basal cell carcinomas are being
seen more and more frequently in the younger
population. The name is derived from the type of
cell in the skin that has become cancerous—the
basal cell. Basal cells line the base, or bottom, of
the uppermost layer of skin, the epidermis. When
one of these cells is damaged (by exposure to the
sun or other forms of radiation) and begins to
grow and replicate much more rapidly than it
normally does, it is called a basal cell carcinoma.
Basal cell carcinomas generally start at one particular
spot and grow, very slowly, out and downward in
the skin. The true size and extent of skin cancers
cannot be fully appreciated by simply looking at
the surface of the skin. In fact, the skin cancer has
usually been growing for several months beneath
the skin before it surfaces and can be seen by the
naked eye. Only under microscopic examination
is it possible to determine the extent of the tumor.
Often times, if the tumor is very small, the biopsy
may remove most of the skin cancer and the skin may
appear very normal on the surface. Unfortunately,
there are usually tumor cells beneath this normal
appearing skin that are continuing to replicate and
grow. On the other hand, some basal cell carcinomas
may be quite large. Although it is extremely
unusual for a basal cell carcinoma to metastasize,
if left untreated, these tumors will continue to
grow to very large sizes and may invade bone and
other tissues beneath the skin.
Squamous Cell Carcinoma
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Especially when they
are larger than 2 cm in width, can be a more
serious disease than basal cell carcinomas. The
normal squamous cells are located in the upper
and middle part of the most superficial layer of
skin, the epidermis and tend to be more aggressive
when they become cancerous. These skin cancers
usually grow more quickly, are more likely to invade
structures beneath the skin and may metastasize to
other parts of the body. Still, only approximately
5% of squamous cell carcinomas actually do metastasize,
most often to local lymph nodes. Clinically,
squamous cell carcinomas usually appear as rough
scaly red spots on the skin. Unfortunately, as with
basal cell carcinomas, it is very difficult to judge
the size and extent of the skin cancer by simply
looking at the skin surface. Skin cancers often grow
under what appears to be normal skin to the eye.
Malignant Melanoma
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This is potentially the most serious form of skin
cancer. Malignant melanoma generally appears
as a brown or black patch, with shades of red or
purple in it. They may arise on their own or
develop in a pre-existing mole. Since melanoma
is not often treated with the microscopically
controlled or Mohs surgery, it will not be discussed
further in this text. All information in this brochure
refers to basal and squamous cell carcinomas.
Why People Get Skin Cancer
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Although we don’t know all of the factors that cause skin cancer, excessive exposure to
sunlight is the single most important factor in the formation of skin cancer. Other forms
of radiation, such as ultraviolet light therapy or x-ray therapy, may also contribute to the
formation of skin cancers. Over time (many years), a normal basal or squamous cell may
be transformed into a cancerous cell. As a cancerous cell, it will begin to divide much
more rapidly than the body is used to and a collection of that type of cell will form. This
collection of cells is known as a tumor.
Skin cancers occur more frequently in people with fair complexions (blonde hair, blue eyes),
individuals of Northern European decent and those exposed to a more than average amount
of sun. Darker skinned individuals, who have more pigment to shield their skin from the
harmful rays of the sun, rarely form skin cancers. Although the effect of the sun’s rays is
cumulative, there are usually many years separating the significant exposure to the sun and
the formation of the skin cancer. The majority of sun exposure generally occurs during
childhood through the early twenties, while most skin cancers do not begin to occur until
the forties. The skin never forgets any of the sun it has received.
The best way to protect yourself from future skin cancers is to make a serious attempt
at reducing the amount of sunlight you are exposed to. You should always apply a sun
screen with a Sun Protection Factor (SPF) of 15 or greater (we prefer an SPF of 30),
wear a broad rimmed hat and limit your exposure to the sun during the mid-day
(10 am to 3 pm), when the rays are most intense. You don’t have to change your entire
lifestyle, just alter it intelligently and take the proper precautions. An unfortunate
statistic is that 50% of people who develop a basal cell carcinoma will develop
another one within 5 years.
Treatment & Preparation
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Skin cancers may be effectively treated by several
different methods. The most common ways
include electrodesiccation and curettage (scraping
and burning), cryotherapy (freezing), radiation
therapy (x-rays), traditional excisional surgery
and Mohs, or microscopically controlled surgery.
The treatment of each skin cancer must be
individualized, taking into account the type,
size and location of the cancer, the patient’s
age and whether or not the cancer has been
treated before. Of all forms of treatment for
skin cancers, Mohs microscopically controlled
surgery has the highest cure rate.
Mohs or Microscopically Controlled Surgery
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Microscopically controlled surgery was developed by Dr. Frederick Mohs in the 1940s as a more precise
way to remove skin cancers. Originally, chemicals were applied to the skin and the entire surgical procedure
took several days. The technique has been refined over the years to the point where the skin cancer is now
removed and examined under the microscope for any remaining tumor almost immediately. The basic
principle behind the Mohs technique is to remove the entire skin cancer without taking any more normal
skin than is absolutely necessary.
Often times what can be seen on the skin surface only represents a part of the actual skin cancer, “the tip
of the iceberg” so to speak. With our eyes alone, we cannot see the “roots” of the skin cancer that are under
the skin surface. Instead of guessing approximately how far these “roots” extend under and around the skin
cancer, the microscope is used to trace out and map the exact extent of the tumor. The surgeon may then
remove only the cancerous tissue. This prevents either removing too little and leaving tumor behind to
come back or recur (usually larger) in the future, or from removing too much and creating a larger than
necessary wound. In essence the best of both worlds is achieved. The entire skin cancer is removed and
as much as possible of the normal skin is preserved. The Mohs microscopically controlled technique offers
a cure rate of 98-99%, the highest of any technique available.
Since Mohs surgery requires highly trained personnel and can be time consuming, it is reserved
only for certain cases. The four most common indications for using the Mohs technique are:
- The tumor is located on a structure that is so important that one wishes to remove only the diseased tissue and preserve as much of the normal skin as possible (face, hand, etc…)
- The cancer has been previously treated and has come back (recurred)
- The margin or extent of the tumor cannot be discerned
- The tumor occurs in an area of the body where it is not effectively curable with other methods
Preparing For Your Surgery
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There is usually no special preparation required before Mohs surgery. We recommend being well rested
and having a good breakfast on the morning of surgery. Unless it is medically necessary, we ask that you
do not take aspirin, vitamin E, vitamin C, or aspirin-containing products, such as Anacin™ and Bufferin™,
for fourteen days prior to surgery unless a physician has prescribed them for you. Ibuprofen or naprosyn
containing products, such as Motrin™, Advil™ or Aleve™ should also be avoided for fourteen days prior to
surgery. You may take acetaminophen products, such as Tylenol™. Take all of your other usual medications
unless directed otherwise. We also require that you do not drink any alcohol for seven days prior to surgery,
since this will cause more bleeding. Smoking also has a negative impact on the healing process and should
be stopped one day prior to surgery and for one week after surgery. You are encouraged to contact your
primary care physician for assistance with smoking cessation.
We recommend washing your hair the night before or the morning of surgery, as your wound and initial
dressing must remain dry for the first 48 hours as directed by your surgeon. We also suggest you wear loose
fitting, comfortable clothing.
The length of the surgery varies greatly depending on the size and location of the skin cancer. You should plan
on spending most of the day with us. You should also arrange to have someone drive you home after surgery.
- EAT A GOOD BREAKFAST
- TAKE YOUR NORMAL MEDICATIONS
- WEAR COMFORTABLE CLOTHING
- ARRIVE 15-30 MINUTES EARLY
- BRING READING MATERIALS
- BRING A SNACK/LUNCH
- (REFRIGERATOR AVAILABLE)
- BRING A PERSONAL MUSIC PLAYER, IPOD, OR DVD PLAYER
What To Expect
Day of Surgery
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Again, eat a good breakfast, take your normal
medications unless directed otherwise, wear
comfortable clothing and be prepared to spend
the entire day. Mohs surgery is a minor surgical
procedure, performed on an outpatient basis in an
ambulatory surgery or office setting. You should
arrive for your appointment 15-30 minutes early
in order to complete any registration and check in
requirements. You will be escorted to a consultation
room where you will be asked a few routine,
pre-operative questions and have all your questions
answered. Once your questions are answered,
your consent for the surgery will be obtained.
Once in the room, a local anesthetic (usually
lidocaine) will be injected to the area. This is
generally the only part of the surgery that causes
any discomfort and it is usually no worse than
what was done when the lesion was biopsied. Once
the area is numb, a small layer of tissue will be
removed and a map of it will be made. The small
amount of bleeding that may occur will be stopped
with a cautery unit and a dressing will be placed
on your wound. The tissue will then be processed.
During this time, the tissue will be frozen, stained
and cut for microscopic slides. Your doctor will
then review these slides under the microscope
and create a map of any tumor remaining. In this
manner, the exact location of any residual tumor
may be determined and then removed, without
having to remove any of the skin that appeared
normal under the microscope.
Although the area should still be numb from the
first stage, a little more anesthetic agent is added
to keep the area numb for further stages and the
reconstruction. Using the microscopic “map” of the
skin cancer, only the area or areas seen as cancerous
are then removed. The process is repeated until
the entire skin cancer is removed. It is this process
of systematically searching out and removing all
of the “roots” of the skin cancer that gives Mohs
surgery its cure rate of 98-99%.
Although some skin cancers are removed in one
stage, the average tumor requires two or three stages
for removal and some require several more. If your
skin cancer should require more than one stage, try
not to get discouraged. The intent is to remove the
entire skin cancer and to preserve any uninvolved
normal skin. To achieve these goals, the tissue must
be removed in very small, conservative layers.
When the tumor has been completely removed,
a decision will be made with you as to the best
method to repair the wound. Depending on the
size and location of the wound, it may be allowed
to heal by itself, closed side to side with sutures,
or closed using a local flap or graft. Although most
wounds are repaired in our surgical suite on the
day of surgery, it is occasionally necessary to utilize
the unique skills of other surgical specialists. In
these cases, the reconstruction will be arranged
to occur on a subsequent day shortly thereafter.
After Surgery
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Detailed written instructions on wound care will
be given to you and reviewed upon completion of
the surgery. Essentially, you will leave the original
bandage on for the first 48 hours and then you
will clean the wound twice a day, place an ointment
(Aquaphor Healing Ointment™/Polysporin
Ointment™) on the wound and then cover it with
a small dressing. This will be continued until
the sutures are removed (usually 7 to 14 days after
the surgery). It is very important to keep the
wound moist with ointment and not to let it dry
out. When a wound dries and a scab forms,
it will take longer to heal and is more likely
to form a much more noticeable scar.
Most patients report minimal amount of discomfort
the first day or two following surgery. This discomfort
usually responds readily to Tylenol™ in its usual
dosage. We do not want you to take any aspirin,
naprosyn or ibuprofen containing products for three
days following surgery. There may also be a normal
sensation of itching or tightness that is experienced
in the immediate post-operative period.
Often times patients will have “black and blue”
marks and swelling around the surgery site.
This reaction is particularly frequent and exuberant
around the eyes. Most of this is your body’s reaction
to being wounded. Cells from other areas come to
the wound to help repair it. In doing so, they create
swelling. This usually gets worse for the first three
days after surgery and then slowly begins to improve.
You may also experience some numbness around
the area that was operated on. There are many
small nerves that carry sensation to the skin.
Some of these may be cut during surgery and
it may take 6-12 months before full sensation
returns. Rarely the skin cancer involves larger
nerves. When these are cut, the loss of sensation
or muscle weakness may be permanent.
Remember, every surgical procedure produces
some form of a scar. Although every attempt will
be made to minimize and hide the scar, the extent
of the scarring depends on the location, size and
depth of the skin cancer and the healing properties
of the individual. The scar will continue to improve
for 8-18 months. After the first three months
the area can be gently massaged, as directed by
your dermatologist, if it feels thick or lumpy.
You will be seen for suture removal seven to
fourteen days after surgery and in many cases a
few months after surgery to make sure everything
is healing according to schedule. After the three
month visit, you should be monitored every six
months to a year for new skin cancers. Although
the chance of having the skin cancer recur after
Mohs surgery is only 1-2%, it does happen and
the area should be monitored. Even more importantly,
there is a good possibility that a new skin
cancer may develop in other areas in the future.
Remember that 50% of patients will have a second
skin cancer within five years of their first. This is
why it is very important to protect yourself from
the sun’s rays and to have a dermatologist follow
your skin closely. If you should notice any new
lesions and suspect they might be skin cancers,
you should schedule an appointment promptly
and not wait the six or twelve months before
the next scheduled visit.
If you have any questions before, during, or after your surgery, please do not hesitate to ask them
Frequently Asked Questions
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Q. What is MOHS surgery?
A. A tissue sparing process, the goal is to remove the skin cancer without taking any normal skin than necessary.
Q. Now that I have a skin cancer, how often do I need to have full skin exams?
A. Full skin exams should be performed every 3-6 months due to the 50% chance of developing another skin cancer within the next 5 years.
Q. What is the cure rate with MOHS surgery?
A. The cure rate is 98-99%, which it is the only technique available with that high of a cure rate.
Q. Is there any preparation the night/morning before the surgery?
A. It is recommend you wash your hair the night or morning before your surgery d/t the dressing that will be applied that will need to stay in place for 48 hours after the surgery.
No fasting is required prior to surgery, we recommend to eat a healthy breakfast.
Q. How long will the surgery take?
A. Plan on spending the entire day with us. The length of the day depends on the size and location of the cancer.
Q. Do I need to stop my prescription medications?
A. You make take your prescription medications as directed by your physician. We do ask that you avoid aspirin, vitamin E and C, anacin, bufferin, IBU, naprosyn, motrin, and aleve 14 days prior to your surgery unless it is medically necessary.
Q. Do I need a driver?
A. It is not required you have a driver. If you think medication is needed to help you relax a driver is necessary.
Q. Will I have stitches when I leave?
A. Once the tumor is cleared the physician will discuss repair options. Most likely you will have stitches that will be removed in 7-14 days depending where the surgical site is located.
Q. Do I have any restrictions after surgery?
A. You will not be able to bend over or lift any heavy objects for 1 week after surgery. You will also be restricted on physical activity for 1 week.
Blood thinning products will need to be avoided 1 week after the surgery.
Q. Are there any side effects from the MOHS surgery?
A. There is a chance for bruising, swelling, and possibility of infection.
