Reconstructive surgery

What does skin cancer surgery involve?

In conventional surgery, the skin cancer is removed along with a pre-determined margin of normal, healthy tissue. The specimen is sent for examination under a microscope by a dermatopathologist to ensure that the whole lesion is removed. My personal clear margin rate for this type of surgery performed in Birmingham and Solihull is 98.5% for non-melanoma skin cancers (NMSCs).

Removing the lesion is arguably the “easy bit” however. The hard bit is providing a reconstruction using techniques such as local flaps (moving skin from nearby from areas of laxity) and skin grafts. My aim is always to restore form and function and as a clinician who completed higher surgery in Oral and Maxillofacial Surgery along with TIG Fellowships in both the Management of Skin Cancer and Reconstructive & Aesthetic Surgery, I aim to use to use all the tips and tricks at my disposal to provide a result my patients are happy with.

I currently perform around 150-200 skin cancer excisions per year across my practice in Birmingham and Solihull and attend the LSMDT on a fortnightly basis to discuss cases and results. Most of these are provided under local anaesthesia (awake), however I can arrange for surgery to take placed under sedation or general anaesthesia (asleep) if appropriate.

I aim to ensure that the most painful thing about the surgery is my music choice, although I will usually ask patients what they would like to listen to spare them what my nursing staff affectionately describe as “weird jazz”.

What is a flap?

A flap involves moving skin from one area to another whilst being still connected at the base to ensure a stable blood supply. In many cases this will be done in a single stage with no requirement for further surgery. Sometimes, flaps will need to be interpolated, being lifted from one area to another and then having the blood supply divided a few weeks down the line when things have settled. I will be very clear at the outset about whether you should expect one or two stage surgery and the implications for the latter on day-to-day life in the interim between stages.

Flaps are used to minimise skin tension and give you the most natural looking results in cosmetically critical areas. Some examples of these are shown below.

[can we source images from Shutterstock and I will eventually replace these with my own?]

What is a graft?

A graft involves lifting skin from an area of excess and transposing this to an area which is deficient in skin. The process relies on “imbibition”, whereby the graft picks up nutrients from the wound bed where it is transplanted. Grafts may be full thickness (typically harvested from the neck and closed primarily) or split thickness (harvested from the thigh as a very thin “graze” level thickness of skin). The graft will enable resurfacing of larger wounds that are not amenable to flaps, whilst causing minimal morbidity at donor sites. Sometimes I will augment this with skin substitutes such as Integra® or Novosorb® BTM where wounds are more challenging to maximise the chance of uneventful healing and favourable contour correction.

If you do require a graft, I can often do this under local anaesthesia, although will ensure this is done in an operating theatre to maintain the utmost cross-contamination control and sterility standards. You will have a dressing sutured or stapled in place and a wound check at 7-14 days with dedicated nurses responsible for your care. I will be available throughout the healing period for any questions or concerns.

My skin cancer is on my nose…how will this be reconstructed?

I have a particular interest in nasal reconstruction as this is one of the more challenging aspects of facial reconstruction following skin cancer surgery. There are many tips and tricks that I have acquired through my training which included Training Interface Group (TIG) Fellowships in Reconstruction & Aesthetic Surgery and the Management of Skin Cancer. These saw me working closely with colleagues in Plastic Surgery and Dermatology, acquiring a full range of skills that are carefully honed to provide you with the most natural looking appearance after ablative surgery for skin cancer on the nose.

I will try to keep things as simple as possible, often using single stage flaps such as the glabellar flap and bilobed flap techniques. Where required however, I can provide more complex surgical options such as interpolated nasolabial flaps and forehead flaps, including internal lining flaps from the nasal septum and cartilage grafts for structural support. These more complex options often require multiple stages of surgery staggered a few weeks apart, but I will personally support you through this journey to full recovery.

Finally, for advanced defects, as a specialist in Oral and Maxillofacial Surgery, I am able to provide osseointegrated implant-supported prosthetic solutions, working in conjunction with leading prosthetists to restore the most natural and unassuming repairs.

What are the risks of surgery?

All surgery carries risks and skin cancer excisions are no exception. The risks of surgery can include scarring, hypertrophic or keloid scarring (red, raised and/or lumpy scars), temporary or permanent numbness and/or weakness, incomplete excision and need for further treatment. I do my very best to ensure that my patients leave satisfied with the cosmetic outcome of safe resections so that they can forget about the surgery and get on with living life!

What happens after surgery?

After surgery you will go home the same day. In many instances you will have a light dressing in place for a few days but if you have a graft the dressing will be secured with sutures (or staples) until the next appointment. Within around 7-14 days you will have a dressings appointment where the wounds will be inspected, any sutures or dressings removed and any issues or concerns addressed by the nursing staff. As always, I am contactable by email or telephone during your recovery period to answer any questions or deal with any problems.

A few weeks later, we will have a clinic appointment to discuss your results. In advance of this appropriate, where required, I will have discussed your results with my MDT to achieve a consensus on further treatment.