Skin Cancer Surgery: Types, Techniques, and Management

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Skin cancer surgery is a critical component in the management of malignant skin lesions, aimed at achieving complete removal while preserving function and aesthetic outcomes. The choice of surgical technique depends on the type of skin cancer, lesion size, depth, location, and patient factors.

The three most common types of skin cancer are:

1. Basal Cell Carcinoma (BCC)
    
   • The most common, slow-growing, and rarely metastasizing.
   • Typically presents as a pearly, ulcerated, or nodular lesion.

1. Squamous Cell Carcinoma (SCC)
    
   • Faster-growing with a higher potential for metastasis compared to BCC.
   • Presents as scaly, crusted, or ulcerative lesions, often in sun-exposed areas.

1. Melanoma
    
   • The most aggressive type with a high risk of metastasis.
   • Identified using the ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving nature).

Surgical intervention is the primary treatment for most non-melanoma and melanoma skin cancers. The choice of technique is based on tumor type, depth, and anatomical location.

• Indicated for small to medium-sized lesions with adequate surrounding tissue.
• Margins vary depending on the type: 
  • BCC: 3-4 mm margins for low-risk lesions.
  • SCC: 4-6 mm margins for low-risk lesions.
  • Melanoma: Wide local excision margins depend on Breslow thickness (e.g., 1 cm for melanoma <1 mm depth, 2 cm for >2 mm depth).
• Primary closure is performed when feasible, ensuring minimal tension on the wound.

• Used when direct closure is not possible due to large defects or location constraints (e.g., scalp, lower legs).
• Types of skin grafts: 
  • Split-thickness skin graft (STSG): Includes the epidermis and a portion of the dermis, commonly used for large defects.
  • Full-thickness skin graft (FTSG): Includes the entire dermis, preferred for cosmetically sensitive areas (e.g., face).
• Requires a well-vascularized recipient bed for graft survival.

• Indicated for defects where skin grafting may lead to poor aesthetic or functional outcomes.
• Common types of flaps: 
  • Rotation Flaps: Uses adjacent skin rotated to close a defect.
  • Transposition Flaps: Moves skin from an adjacent area to cover the defect at a different angle.
  • Advancement Flaps: Advances tissue directly over the defect.
• Provides better color and texture match compared to skin grafts.

• A specialized technique used for high-risk BCC and SCC, especially in cosmetically and functionally critical areas (e.g., eyelids, nose, lips).
• Involves staged excision with real-time histological examination to ensure complete removal while preserving healthy tissue.
• Provides the highest cure rates while minimizing tissue loss.

• Histopathological Analysis: Confirms margin clearance and tumor characteristics.
• Wound Care: Varies depending on closure type; involves proper dressing, infection prevention, and scar management.
• Follow-Up: Regular skin checks to monitor for recurrence, especially in high-risk patients (history of multiple skin cancers, immunosuppressed individuals, or those with high UV exposure).
• Patient Education: Emphasis on sun protection, regular skin examinations, and early detection of new lesions.

Surgical management remains the cornerstone of skin cancer treatment, with various techniques tailored to ensure complete tumor removal, optimal healing, and preservation of function. A patient-specific approach, incorporating the appropriate surgical method, ensures the best oncologic and aesthetic outcomes. Regular follow-up and preventive measures are essential to reduce recurrence and improve long-term prognosis.