Skin Cancer Surgery Sydney

Benign Skin Lesions Invasive Skin Lesions (Skin Cancers) Reconstructive Plastic Surgery for Skin Cancer Risks & Complications FAQs Pricing

What is Skin Cancer

Skin cancer is when abnormal cells in the outermost layer of skin grow uncontrollably, caused by overexposure to UV rays from the sun. Growth of these abnormal cells sets off mutations that causes the skin cells to multiply and form malignant tumours. Australia has one of the highest rates of skin cancer in the world, mainly because of the ozone hole, the warmer climate that promotes increased outdoor sun exposure, as well as the genetic profile of our population.

Main Types of Skin Cancers

Basel Cell Carcinoma (known as BCC),
Squamous Cell Carcinoma (known as SCC),
Melanoma, and
Merkel Cell Carcinoma (MCC)

Skin Cancer Surgery

Surgery for skin cancer is known as ‘wide local excision’ or ‘surgical excision’ which is also common in breast cancer surgery. A local anaesthetic is numbs the general area then the cancerous tissue is removed along with 2mm – 10mm of surrounding healthy tissue (known as margin). This margin tissue is then pathology checked for cancer cells to make sure the cancer has been completely removed. These results take around a week and if cancer cells are present in the margin then you may need further surgery or radiation therapy.

After this surgery stitches are used to close the wound, so you will have a scar which will become less noticeable over time. As with all scars you will notice the area to be tender and tight for a few days.

If the cancer and margin that’s been removed is large then there are two types of reconstruction that Dr Aggarwal can perform:

Skin flap, where nearby fatty tissue and loose skin is transferred over the wound and stitched, or
Skin graft, where skin from another part of the body is removed and used to repaired where the surgery was.

Merkel Cell Carcinoma often grows and spreads quickly at an early stage.

Usually it spreads first to nearby lymph nodes and then may spread to lymph nodes or skin of various parts of the body, such as the lungs, brain, bones, or other organs. For this reason, before surgery, a biopsy is performed on your lymph nodes to check if the cancer has spread to them. If there are cancer cells in your lymph nodes then they will be removed as well.

Why you may need a Plastic Surgeon for Skin cancer treatment

As a plastic surgeon, Dr Aggarwal treats skin cancers almost on a daily basis, with skin cancers forming a large part of his public and private practice.

Patients see Dr Aggarwal for skin cancers

On the face where cosmesis is of paramount importance
That are of a large size where skin closure may be difficult. This can be in locations where there is already minimal skin elasticity, for example
- On the face – the nose, the eyelids, the ear, where even small skin cancers can require complex reconstruction
- The hands – especially around the wrist, back of the hands or fingers
- The legs especially in areas below the knee where there is minimal skin. At this operative site the issues of swelling and movement are important, and therefore reconstruction can be challenging and may need to be performed as an inpatient.
- The back – especially sites over back of the neck, over the shoulder region and also over the shoulder blades.
- Any other site where cosmesis is important, or closure may be difficult
Where closure is difficult to achieve, Dr Aggarwal’s expertise as a plastic surgeon, allows him to reconstruct using either skin grafts (taken from sites with best colour match) or local flaps borrowing laxity in adjacent areas, whilst also taking care to place incisions in inconspicuous sites.

Skin cancers are generally more common in People:

Who are Fair skinned
Who have blue eyes
Who have a tendency to sun burn rather than sun tan
Who have had a large amount of unprotected lifetime exposure to the sun, with some reports associating increasing rates of childhood sun burns with increased melanoma risk
Who have previously had skin cancers
Who have had radiation
Who have chronic wounds

Skin cancers including melanoma can occur in any racial type of skin, highlighting the importance of:

Sun Protection – this includes
- Covering up as much of the skin to prevent direct sun exposure
- High SPF (greater than 30) sunscreen with frequent re-application especially when swimming
- Hat
- Sunglasses
Avoiding the use of Sun tanning Salons as the machines use UV radiation which is exactly what promotes skin cancer generation in the skin.
Regular Skin surveillance which is performed by:
- Yourself – regularly be aware of any new spots and have any lesions that are growing, not healing, painful, itchy or bleeding, investigated by a medical practitioner
- Medical practitioner: this can be a GP, Dermatologist or Plastic Surgeon who may either perform your regular 6 or 12 monthly check, or investigate any new lesions of concern.

Dr Aggarwal

Dr Aggarwal is a well regarded, respected, highly skilled and experienced Specialist Plastic Surgeon. Graduating at the top of his class throughout his training, Dr Aggarwal has completed fellowship training at some of the world’s most prestigious reconstructive and cosmetic plastic surgery institutions in Canada and the USA. He continues to publish research is prestigious plastic surgery journals, and is actively involved in the training of future plastic surgeons.

What sets Dr Aggarwal apart from others is his personal, affable and warm nature. Not only does he pay attention to detail, to producing natural, beautiful results but he ensures that the patient’s journey is just as special as their outcome. Dr Aggarwal looks after patients at one of Sydney’s most prestigious public hospital campuses (POWH/SCH/RHW), and operates privately on Sydney’s North Shore. Dr Aggarwal has treated thousands of patients throughout Sydney and beyond who have achieved outstanding results under his care.

Benign Skin Lesions

Not all skin lesions are skin cancers. In fact many are not and can be treated via non-surgical means.

Actinic Keratosis

These lesions are small, irritated areas of the skin usually due to sun damage. They are also known as ‘sun spots’, or ‘solar keratosis.’

One of the most common lesions found on the skin, affecting up to 44% of men and 37% of women aged 20-69yo (in a prevalence study conducted in Nambour QLD). The number of these lesions increases with age.

What do actinic keratosis look like?

They look pink, scaly spots
They can resemble early skin cancers
They are usually not painful or symptomatic
They are often small and multiple

Where do they occur?

They occur on sun exposed areas of the body
This usually means the head and neck area, back of the hands, and forearms

Do they have any symptoms?

They usually have no symptoms
Occasionally there can be prickling, burning and stinging with sun exposure or sweating
A significant amount of redness, thickening or pain can suggest a skin cancer, rather than a sun spot, and these are best checked by a medical practitioner.

What happens to actinic keratosis?

Three things can happen
They regress (disappear)
- Up to a quarter of these can disappear on their own (maybe higher)
- However the rate at which this happens decreases with age.
Some persist without change
Some progress
- A minority of sun spots can progress to frank skin cancers
- The rate is low: 0.025 – 16 % per year.
- Therefore the majority are best treated through monitoring or non-surgical treatment, but regular skin cancer surveillance is paramount to pick up any that may change and look suspicious.

Do skin cancers come from actinic keratosis?

The chance that an individual solar keratosis will develop into an SCC is extremely small
However, the chance that a SCC (squamous cell carcinoma) has arisen in association with solar keratosis is very high

What are the treatment options for actinic keratosis?

Treatments are categorised into three categories:
- Destructive therapy. These include:
  - Cryotherapy (Freezing)
  - Curettage +/- freezing or diathermy to base
- Topical therapy (creams). These treatments are usually prescribed by dermatologists, and GPs. These include:
  - Imquimod 5% cream (Aldara)
  - Diclofenac 3% Gel
  - 5-Fluorouracil (Efudix)
  - Photodynamic therapy (PDT)
- Excision (Surgery)
  - Rarely needed
  - Regular surveillance is important and surgical excision is only recommended for lesions suspicious of or known to be a skin cancer, or early skin cancer (in-situ disease).

Bowen’s Disease

What do they look like?
- These are red patches that can be slowly enlarging
- They can appear quite scaly and form horns
Where do they occur?
- They occur on sun exposed areas of the body
- Common on the lower limbs (legs) especially in females
Do they have any symptoms?
- They usually have no symptoms
- Slowly enlarge over a long period of time
- A significant amount of redness, thickening or pain can suggest transformation to a skin cancer
What happens to Bowen’s disease?
- The cells under the microscope look like cells of SCC but they are confined to layers of the skin without going beyond them
- This implies these are not ‘invasive’ lesions (i.e. have not yet become cancerous)
- However there is a rate of conversion to frank SCC where they can invade surrounding tissue. The rate is unknown and is probably around 30%.
What are the treatment options for Bowen’s disease?
- Treatments are categorised into three categories:
- Destructive therapy
  - Cryotherapy (Freezing)
  - Curettage and diathermy
- Topical Therapy
  - Imiquimod 5% cream (Aldara)
  - 5-Fluorouracil (Efudix)
  - PDT
- Excision (Surgery)

Invasive Skin Lesions (Skin Cancers)

(Invasive) Squamous Cell Carcinoma (SCC)

These are the second most common skin cancers after Basal cell carcinoma (BCC)
BCC and SCC are together referred to as non-melanoma skin cancers
Australia has one of the highest rates of skin cancers in the world, with rates of skin cancer higher in the northern than the southern states
- Incidence is higher in males (at all ages), and increases with age
- People born in Australia have higher risk (although migrants risk increases the longer they have lived here)
What causes SCC (skin cancers)?
- There are both genetic and environmental factors with the latter being the most important
- Environmental risk factors
  - Chronic sun exposure
    - Is the single most important risk factor
    - This is cumulative sun exposure throughout a person’s life
    - Specifically it is the UV radiation (wavelengths A and B) that contribute to skin cancer conversion
    - This highlights the importance of 2 things:
      - Sun protection throughout a person’s life: wearing a hat & sunglasses, covering up as much skin from exposure to direct sunlight, and applying (and regularly reapplying) high SPF sunscreen to sun exposed skin areas when out in the sun especially whilst outdoor swimming.
      - Regular skin checks – especially if one has had a skin cancer. This indicates that the entire skin has had the level of sun exposure (and therefore damage) to sprout a skin cancer that regular skin checks can lead to early detection and simpler treatment.
    - HPV
      - Have been associated with solar keratosis and SCC
      - Likely these viruses change (likely enhance) the effect of UV radiation on skin cells
    - Smoking – some evidence that increases risk
    - Others
      - Arsenic
      - Ionising radiation therapy
      - Scars, sinus tracts, chronic ulcers
      - Immunosuppression e.g.
        
        those with large organ transplants taking immunosuppressive medication
        
        HIV
        
        In general higher dose of immunosuppression and larger dose of immunosuppression are associated with increased risk of non-melanoma skin cancer.
- Genetic
  - In general there are risk factors such as
    - Being fair skinned – who often have skin that burns rather than tans
    - Blonde hair (Red hair also associated with increased risk)
    - Blue eyes
  - Specific Genetic diseases have much higher rates of skin cancer due to aberration in skin cells to repair the damage caused by UV radiation, such as
    - Xeroderma Pigmentosum
    - Epidermolysis Bullosa
What do SCCs look like?
- These are often red and scaly
- Can sometimes have a horn
- Therefore they can be difficult to distinguish from actinic keratosis
- They can be ulcerated with frequent bleeding

Where do SCCs occur?
- Sun exposed sights
- In males the head and neck is the most common site
- In females the upper limbs (hands and arms) are the most common site, followed by the head and neck area
What is the treatment for SCCs
- Surgery is almost exclusively the mainstay of treatment for SCCs
- The timing is often considered more critical than BCCs due to the faster growing nature of these tumour, and the potential to be aggressive and have the capacity to spread beyond the skin (in some cases)
- How much skin is removed?
  - Dr Aggarwal will carefully mark you under bright lights and with loupes to clinically judge the extent of the skin cancer
  - A margin is then marked around the site which is an area of skin that appears normal, but may not be normal under a microscope. This is taken to increase the rate of clearance of the tumour at the primary excision.
- What is the margin? What does it mean for SCCs?
  - A margin is an area of skin around the skin cancer that to the naked eye looks normal
  - However most skin cancers including SCCs extend microscopically beneath surrounding areas of normal skin to a short or moderate distance. The degree to which they do this is related to the subtype of skin cancer.
  - In general for SCCs:
    - That are less than 2 cm wide, a margin of 4mm of skin is taken around the skin cancer
    - Those that are larger than 2cm a margin up to 1cm may need to be taken. In some cases if the lesion is very large an even larger margin may be taken
  - How is the area of excision reconstructed after surgery?
    - This is through several methods:
      - Direct closure
      - Grafts
      - Flaps
    - Please see our section on reconstructive plastic surgery for skin cancer.
  - Can SCCs spread to lymph nodes and around the body?
    - Early detected SCCs are confined to the skin and have not been given the chance to spread beyond the skin
    - However some SCCs do have the potential to spread to lymph nodes and beyond. These include:
      - neglected SCCs that have grown well beyond 2cms
      - SCCs that have invaded deeper structures or nerves
      - recurrent SCCs
      - those that have arisen in radiated fields or chronic scars or wounds
      - Certain subtypes of SCC (these are largely to do with features under a microscope that are reported by a pathologist)
    - In general Dr Aggarwal will examine your lymph nodes at the time of consultation. If there is no suspicion for disease involvement of the lymph nodes, skin surgery is usually all that is needed.

Are there alternatives to surgery for SCC?

Yes these include:

Radiation therapy
- This is usually reserved for those cases where conventional surgery is not feasible or particularly problematic. This could be in
  - Multiple –mainly superficial-lesions when impractical to excise
  - when surgery will cause cosmetic or functional morbidity unacceptable to the patient
  - Older patients unfit for surgery or anaesthesia
  - Patients prone to keloid formation
- Radiation causes both acute and chronic changes to skin in the field that is treated. The latter can have implications for blood supply that can make treatment down the track for a skin cancer in the field region problematic as reconstruction can become challenging.
- Radiation also requires multiple visits for treatment as the entire radiation dose is delivered as small fractions at each visit.
- Radiation is used as an adjunct to surgery in some cases where there may be incomplete margins, nerve involvement, lymph node involvement or any scenario where its use is thought to improve local control after surgery.
Destructive therapies: unpredictable, do not provide reliable tissue that can be examined under a microscope but cheap, and quick.
- Curettage and diathermy.

Basal Cell Carcinoma (SCC)

These are the most common type of skin cancers
BCC and SCC are together referred to as non-melanoma skin cancers
Australia has one of the highest rates of skin cancers in the world, with rates of skin cancer higher in the northern than the southern states
- Incidence is higher in males (at all ages), and increases with age
- People born in Australia have higher risk (although migrants risk increases the longer they have lived here)
What causes BCC?
- There are both genetic and environmental factors with the latter being the most important
- Environmental risk factors
  - Chronic sun exposure
    - Is the single most important risk factor
    - This is cumulative sun exposure throughout a person’s life
    - Specifically it is the UV radiation (wavelengths A and B) that contribute to skin cancer conversion
    - This highlights the importance of 2 things:
      - Sun protection throughout a person’s life: wearing a hat & sunglasses, covering up as much skin from exposure to direct sunlight, and applying (and regularly reapplying) high SPF sunscreen to sun exposed skin areas when out in the sun especially whilst outdoor swimming.
      - Regular skin checks – especially if one has had a skin cancer. This indicates that the entire skin has had the level of sun exposure (and therefore damage) to sprout a skin cancer that regular skin checks can lead to early detection and simpler treatment.
    - HPV
      - Likely these viruses change (likely enhance) the effect of UV radiation on skin cells
    - Smoking – some evidence that increases risk
    - Others
      - Arsenic
      - Ionising radiation therapy
      - Scars, sinus tracts, chronic ulcers
      - Immunosuppression e.g.
        
        those with large organ transplants taking immunosuppressive medication
        
        HIV
        
        Isolated limb perfusion (used as treatment for advanced melanoma)
        
        In general higher dose of immunosuppression and larger dose of immunosuppression are associated with increased risk of non-melanoma skin cancer.
- Genetic
  - In general there are risk factors such as
    - Being fair skinned – who often have skin that burns rather than tans
    - Blonde hair (Red hair also associated with increased risk)
    - Blue eyes
  - Specific Genetic diseases have much higher rates of skin cancer due to aberration in skin cells to repair the damage caused by UV radiation, such as
    - Xeroderma Pigmentosum
    - Gorlin’s syndrome
What do BCCs look like?
- These are often pearly or shiny
- They often have thin blood vessels coursing over the lesion called ‘telangiectasia’
- They can look like a depressed irregular scar
- They can be ulcerated with rolled edges

Where do BCCs occur?
- Sun exposed sights
- 80% of them occur in the head and neck region and in women 75% occur in and around the nasal area. In females the upper limbs (hands and arms) are the most common site, followed by the head and neck area
What is the treatment for SCCs
- Surgery is almost exclusively the mainstay of treatment for BCCs
- The timing is not as critical as SCCs as these are slow growing lesions, however we generally recommend that surgery or definitive treatment is still carried out as soon as is practical.
- How much skin is removed?
  - Dr Aggarwal will carefully mark you under bright lights and with loupes to clinically judge the extent of the skin cancer
  - A margin is then marked around the site which is an area of skin that appears normal, but may not be normal under a microscope. This is taken to increase the rate of clearance of the tumour at the primary excision.
- What is the margin? What does it mean for BCCs?
  - A margin is an area of skin around the skin cancer that to the naked eye looks normal
  - However most skin cancers including BCCs extend microscopically beneath surrounding areas of normal skin to a short or moderate distance. The degree to which they do this is related to the subtype of BCC.
  - In general for BCCs:
    - That are localised, a margin of 2-3mm of skin is taken around the skin cancer
    - Those that are superficial (multifocal) a margin of 3-5mm of skin is taken around the skin cancer
    - Those that are diffuse, a margin of 5mm may need to be taken
- How is the area of excision reconstructed after surgery?
  - This is through several methods:
    - Direct closure
    - Grafts
    - Flaps
  - Please see our section on reconstructive plastic surgery for skin cancer.
- Can BCCs spread to lymph nodes and around the body?
  - BCCs virtually never spread to lymph nodes and beyond
  - Some higher risk sites are considered to be lip and ear, and even then in very advanced cases <1% rate of metastasis has been reported.
  - BCCs are therefore largely a skin problem. However they are nicknamed ‘rodent ulcers’ because they have the potential to ulcerate, and extend deeper and wider if they are neglected and not properly treated.
  - Some BCCs have a higher risk of recurrence at the site of surgery, and these include:
    - neglected BCCs that have grown to a very large size
    - BCCs that have invaded deeper structures or nerves
    - BCCs that are themselves recurrent
    - those that have arisen in irradiated fields
    - Certain subtypes of BCC, such as morphoeic BCC
  - In general Dr Aggarwal will examine your lymph nodes at the time of consultation. If there is no suspicion for disease involvement of the lymph nodes, skin surgery is usually all that is needed.
- Are there alternatives to surgery for BCC? Yes these include:
  - Radiation therapy
    - This is usually reserved for those cases where conventional surgery is not feasible or particularly problematic. This could be in
      - Multiple –mainly superficial-lesions when impractical to excise
      - when surgery will cause cosmetic or functional morbidity unacceptable to the patient
      - Older patients unfit for surgery or anaesthesia
      - Patients prone to keloid formation
    - Radiation causes both acute and chronic changes to skin in the field that is treated. The latter can have implications for blood supply that can make treatment down the track for a skin cancer in the field region problematic as reconstruction can become challenging.
    - Radiation also requires multiple visits for treatment as the entire radiation dose is delivered as small fractions at each visit.
    - Radiation is used as an adjunct to surgery in some cases where there may be incomplete margins (that are difficult to treat with surgery), nerve involvement, large or recurrent disease, or any scenario where its use is thought to improve local control after surgery.
  - Topical therapy in superficial BCC is possible with
    - Imquimod 5% (Aldara)
      - Only for confirmed superficial BCCs
    - Clearance rates from topical therapy are in the order of 60-80% (i.e. lower than surgery)
  - Destructive therapies: unpredictable, do not provide reliable tissue that can be examined under a microscope but cheap, and quick.
    - Curettage and diathermy.

Melanoma

BCC and SCC are together referred to as non-melanoma skin cancers and these are by far much more common than melanomas.
Australia has one of the highest rates of skin cancers, and therefore melanoma, in the world, with rates of skin cancer higher in the northern than the southern states
What causes Melanoma?
- There are both genetic and environmental factors with the latter being the most important
- Environmental risk factors
  - Sun exposure
    - Is the single most important risk factor
    - There is some evidence blistering sunburns especially at young age may have an association with melanoma
    - Specifically it is the UV radiation that contribute to skin cancer conversion
    - This highlights the importance of 2 things:
      - Sun protection throughout a person’s life: wearing a hat & sunglasses, covering up as much skin from exposure to direct sunlight, and applying (and regularly reapplying) high SPF sunscreen to sun exposed skin areas when out in the sun especially whilst outdoor swimming.
      - Regular skin checks – especially if one has had a skin cancer. This indicates that the entire skin has had the level of sun exposure (and therefore damage) to sprout a skin cancer. Regular skin checks can lead to early detection and simpler treatment. Once a melanoma has diagnosed and treated, follow up needs to occur more closely than routine skin cancer checks.
    - Immunosuppression
    - Exposure to chemicals
  - Genetic
    - In general there are constitutional risk factors such as
      - Being fair skinned – who often have skin that burns rather than tans
      - Hair colour
      - Large number of moles (naevi) especially if they are large and atypical in appearance
    - Specific Genetic diseases have much higher rates of skin cancer due to aberration in skin cells to repair the damage caused by UV radiation, such as
      - Xeroderma Pigmentosum
What do Melanomas look like?
- Melanomas are distinguished from the ordinary mole by looking for atypical appearance which is summarised as ‘the ABCD rule’:
  - A – Asymmetry
  - B – Irregular borders
  - C – Uneven colour
  - D – Diameter>6mm

Where do melanomas occur?
- Tend to occur on sun exposed sights
- However any part of the skin can develop melanoma, highlighting the importance of regular thorough skin checks.
What is the treatment for Melanoma
- Surgery is the mainstay of treatment for Melanomas
- The timing is critical and surgery should take as soon after the diagnosis as possible
- How much skin is removed?
  - Surgery for melanoma is often performed in two stages
  - The first stage is to establish the diagnosis as without actual tissue the diagnosis is only suspected or presumed based on clinical findings. In some cases the diagnosis can be assisted by special examination of the skin such as confocal microscopy or by dermatoscopy.
  - Initially a narrow margin of 2mm of skin is taken around the suspected lesion. The skin is closed as an ellipse and the tissue is sent for histological examination (examination under the microscope).
  - Once the diagnosis is established a wider margin may need to be taken, along with testing of lymph nodes.
- What is the margin? What does it mean for Melanomas?
  - A margin is an area of skin around the melanoma that to the naked eye looks normal
  - Initially a 2mm margin around the pigmented area of concern is taken
  - A further margin will depend on the diagnosis
    - If the lesion returns as a changing mole (dysplastic naevus) no further treatment is necessary
    - If the lesion returns as a melanoma in situ a further clinical margin of 5mm may need to be taken around the scar
    - If the lesion returns as a melanoma a further clinical margin of 1-2cm may need to be taken, as well as examination of the draining lymph nodes (sentinel lymph node biopsy)
- How is the area of excision reconstructed after surgery?
  - This is through several methods:
    - Direct closure
    - Grafts
    - Flaps
  - Please see our section on reconstructive plastic surgery for skin cancer.
- Can Melanomas spread to lymph nodes and around the body?
  - Melanomas have the propensity to spread to lymph nodes as well as further beyond which is why they are treated expediently, aggressively and with strict guidelines.
  - The propensity of melanomas to spread beyond the skin is related to the thickness of melanoma under the microscope (called the Breslow thickness)
  - There are many other features under the microscope that are examined, which are associated with high risk melanomas.
  - Melanomas thicker than 1mm are associated with higher risk of spread to lymph nodes and these are usually the patients who are offered sentinel lymph node biopsy.
- What is sentinel lymph node biopsy (SLNB)?
  - Sentinel lymph node is the first lymph node that receives lymphatic fluid from the area of a melanoma
  - Retrieval of this lymph node and its examination is referred to as sentinel lymph node biopsy
  - Please note that Dr Aggarwal does not perform sentinel lymph node biopsies, and if required in the course of treatment of your melanoma, you will be referred to a melanoma specific surgeon – there is good evidence to show that SLNB should be performed by surgeons who routinely perform this procedure in centres that routinely examine sentinel nodes.
  - In brief, the sentinel node biopsy procedure involves injection of a radioactive dye at the site of the melanoma, as well as a blue dye. The lymph nodes are then examined in surgery to locate the most blue and radioactive lymph node which is then removed for histopathological examination.
  - Sentinel lymph node biopsy may not be required if:
    - the lesion is not a melanoma
    - the lesion is a melanoma less than 1mm thick
    - the patient is elderly
    - retrieval of the lymph node poses other significant risks (for example this may be the case in head and neck melanoma, where the lymph node may be located near the facial nerve, and in this case a decision may be made to monitor the lymph node via ultrasound rather than to remove it)
  - Once the results of SLNB are received it is usually discussed in a multidisciplinary setting to determine further course of treatment. This will usually occur in a melanoma centre.
- Are there alternatives to surgery for melanoma? In general no, but the following are used as adjuncts:
  - Radiation therapy
    - Used as an adjunct to surgery in some cases where there may be incomplete margins (that are difficult to treat with surgery), nerve involvement, large or recurrent disease, or any scenario where its use is thought to improve local control after surgery.
  - Chemotherapy – localised to a limb or used for the whole body
  - Newer systemic therapies – often immunotherapy

Reconstructive Plastic Surgery for Skin Cancer

A variety of techniques are used by Dr Aggarwal to reconstruct the defect after the skin cancer is removed.
At all times the treatment of skin cancer is paramount, taking appropriate margins and performing the reconstruction that offers the best long term cosmetic result.

Direct Closure

If there is sufficient loose skin at the site of surgery, it may be possible to close the area directly
However if a circle is excised in skin and closed, this would leave pleats in the surrounding skin
The circular excision is therefore converted to an ellipse, with darts on either side. The length of the scar can therefore be up to 3 times as long as the circle that was excised for skin cancer treatment
Wherever possible the scar is placed in the skin crease lines for the best long term cosmetic result

Flaps

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A flap is a block of tissue that has its own blood supply
Flaps can be local, regional or free.
Local flaps
- These are the most common type of flap used in skin cancer
- Local flaps mean the block of tissue used for reconstruction comes from the area immediately next to the site of reconstruction
- Local flaps have the advantage of using skin that is similar colour, and texture to the area of skin being excised
- Can offer better cosmetic result than grafts, especially in the short term
- Are easier to look after than grafts during the healing process, and are often healed within 2 weeks of surgery
- When designed well, the scars from the local flap hide within skin crease lines
- Dr Aggarwal will give you detailed instructions on how to look after your local flap reconstruction and guide you through the recovery process.

Regional and free flaps – these are more complex plastic surgical procedures needed only for very complex reconstructions where simpler options don’t exist.

Skin Grafts

By definition grafts do not have their own blood supply
They are used to reconstruct areas where local flaps are not available or will cause distortion
Grafts are often used on the nose (especially the tip and nasal ala), ear, scalp and the lower leg close to the ankle and foot.
The skin used for reconstruction is carefully selected to match the colour of the site of reconstruction. For the face this is often another site on the face or neck which often has had the same level of sun exposure and therefore tanning.
Skin grafts take 4 to 6 weeks to heal and therefore take longer than flaps to achieve a good cosmetic result.
A new blood supply needs to be established for the skin graft to survive and therefore they must be kept still, and in contact with the base on which they are placed. This usually means a tie over dressing using a foam is stitched over the graft, and this area must be kept dry for the first week.
Dr Aggarwal will give you detailed instructions on how to look after your graft site and donor site after surgery and guide you through the recovery process.

Risks & Complications

Every surgery carries risks, and therefore one must consider if risks outweigh the benefits for your own personal situation. If they do then the surgery may be well worth it. Dr Aggarwal will discuss the pros and cons of surgery with you during your consultation.

General Complications

Risks of anaesthetic – most skin cancer surgeries are performed with local anaesthetic or assisted local anaesthetic (with sedation). Few are performed under general anaesthesia. The risks of a general anaesthetic are often low in patients who are otherwise fit and healthy but can be higher in those with many medical problems.
Bleeding – the risk is higher in those on blood thinning medication. Dr Aggarwal will discuss with you what you need to do with blood thinners and discuss the pros and cons of ceasing or continuing your medication. Dr Aggarwal may need to consult with your GP, cardiologist or other physicians involved in your care before a decision to change your medication is made. Any bleeding is controlled during surgery however unexpected bleeding can occur in the immediate postoperative period. If this occurs it can usually be controlled through direct sustained pressure.
Infection– this is rare. You may be given a course of oral antibiotics after your surgery, depending on your reconstruction, to keep this risk to a minimum.

Specific Complications

Positive margins – any skin cancer surgery carries the risk of positive margins. This occurs when the skin cancer excised is examined for complete excision. The margin of ‘normal’ skin taken is to reduce the risk of this occurring however when the skin is examined under a microscope additional information is visible which is not possible to be seen through the naked eye or loupe magnification. The report from the pathologist usually takes a few days to arrive and the results will be discussed with you when you come for your post-operative appointment. The chance of positive margins is <5% in most cases but when it occurs re-excision is usually needed.
Close margins – this is when the clearance of the skin cancer is complete however the margin under the microscope is close. Dr Aggarwal will discuss this with you if it occurs, and further management if required.
Hypertrophic or poor scars – How one’s body behaves to scarring is individual and largely genetic. Some types of skin are more prone to hypertrophic or keloid scarring, and some individuals and families are more prone to this. We will routinely advise you on how to improve the quality of scars over time. You should also discuss any history of abnormal scarring with Dr Aggarwal preoperatively.

FAQs

Do I need a referral for skin cancer surgery?

Yes, firstly it is possible to claim a Medicare rebate of approximately $73 for the consultation if you have a referral
Furthermore, skin cancer surgery is associated with Medicare Item Numbers – therefore rebates will be available from Medicare if the surgery is performed in rooms, or from both Medicare and health fund if it is performed in a day surgery or hospital.

Where can I see Dr Aggarwal?

You can see us at our main practice at Gordon, or at our other locations at Hornsby, Hunters Hill or Camperdown.
Please scroll to the bottom of the page to find out more information about these locations.

Where will I have my operation?

Surgery may be performed in our Gordon rooms – Dr Aggarwal will advise if this is possible
Otherwise it will be performed at any of the hospitals where Dr Aggarwal works – Sydney Adventist Hospital, SAN Day Surgery, Hunters Hill Private Hospital or Chris O’Brien Lifehouse.

What can I do to prepare for surgery?

Cease fish oil, and other supplements such as Ginkgo, Ginseng.
Please discuss with Dr Aggarwal if you are on blood thinning medications as he will discuss with you if these should be continued or temporarily stopped or altered.
Stop smoking around the time of surgery and recovery.

After surgery, will I need to use any special creams or ointments?

You will be given written instructions regarding these.
It is common to use Chlrosig ointment for both graft sites, and local flaps.
Dr Aggarwal will give you instructions on scar management to improve the cosmetic results once things have healed.

Will I be able to exercise after surgery?

In general it is best to avoid any activity that raises blood pressure for 48-72 hours after surgery.
If surgery is performed on your lower limb (leg or foot) it is best to avoid walking as much as possible and elevate the leg whenever you are still to the level of the hip.

Will I need special medications after surgery?

Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.

Can I travel in an airplane after surgery?

Yes
However we always encourage patients not to be away overseas shortly after having a procedure, and you are best to advise Dr Aggarwal of this preoperatively so the best timing of surgery can be planned.

When will I be able to swim after surgery?

You may do gentle swimming in a pool or beach after 2-3 weeks once all wounds have healed. This may be longer for graft reconstructions.

When will I be able to drive after surgery?

It is best to not drive for the first 1-2 days after sedation or general anaesthetic (if this was used in your skin cancer treatment).
You may be restricted from driving for longer if your surgery was on your legs.

Do you offer local anaesthetic for skin cancer surgery?

Yes absolutely.
This can be performed in our Gordon rooms or in a day surgery setting.

Are there any alternatives to surgery for skin cancer treatment?

There are for some skin cancers
Please read the sections on individual types of skin cancers for further treatment

Procedure Pricing

The cost for skin cancer surgery is determined by the size of the lesion, as well as the nature of reconstruction.
In general at Mode Plastic Surgery, we follow the guidelines for fees set out by the Australian Medical Association.
For pensioners, we offer known gap pricing if you are in a suitable fund (the exception being NIB insured patients).
We will provide you with a written quote before proceeding with surgery.

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If sedation or general anaesthetic is required, it is delivered by an accredited anaesthetist

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