Different medical specialties often share some areas in common. One example would be hand surgery. General surgeons, orthopedic surgeons, and plastic surgeons all receive some training in hand surgery during their respective residencies. Some go on to specialize in this area. Skin cancer is another area that straddles specialties with general surgeons, plastic surgeons, and dermatologists all offering their services to patients with skin cancer. So, who should you go to?
Skin cancer, of course, is primarily a disorder of the skin and so it would seem obvious to go to a dermatologist for this. Dermatologists treat a lot of skin cancers and, indeed, some subspecialize in this area. Dermatologists can treat most skin cancers. They may offer freezing, burning, scraping, laser, and surgery. For the last one, dermatologists often use a technique called Moh’s surgery to remove skin cancers. This technique dates back to the 1930’s and is still considered the “gold standard” by the specialty.
In Moh’s, the dermatologist removes the cancer, cutting very closely along the margins of the lesion, then examines the tissue carefully to determine that the cancer has been totally removed. If there is cancer in the specimen margin(s), otherwise known as a positive margin, they will go back and take a little more and repeat the process until the margins are clear. The good side of Moh’s is that very little normal skin is removed, creating the smallest possible wound while removing the cancer fully. The bad side is that it is very tedious and time consuming for patients, often requiring 3, 4, or more excisions that can stretch out for several hours. And, that is just for the excision portion of the procedure. When that’s done, the wound created by the surgery must be closed. A simple closure with sutures is easiest and, when possible, any surgeon can do this. Some of the wounds are too extensive and require skin grafts and/or skin flaps to close them. Most dermatologists who perform Moh’s are able to do small skin grafts and flaps, but for larger defects, or defects in a critical location, they will refer patients to a plastic surgeon for the reconstruction. This may delay the whole process by several days to a week or more because the plastic surgeon has to see the patient and schedule time for this surgery. Such a delay could be critical in some situations, such as when there is exposed cartilage in the wound. Cartilage that is exposed rapidly dies and can be a source of infection.
Plastic surgeons do things a little differently. We do an excision with frozen section- there is no one’s name attached to this procedure. The cancer is excised and the specimen sent to a pathologist to examine for the margins. It takes about 20-25 minutes to get this back. Unlike Moh’s, most of the time the first excision provides a clear margin because we don’t try to cut so close to the cancer. Because we are a “one stop shop” so-to-speak, once clear margins are confirmed we can proceed immediately to reconstruction. In my experience, over 95% of skin cancers have been removed in one excision, and reconstruction accomplished, all in 1 hour or less. Because board certified plastic surgeons are required to operate in accredited facilities, we can provide patients with intravenous sedation, in addition to local anesthesia injections, making the surgery more pleasant and less stressful.
Some situations dictate that skin cancer surgery be performed in a hospital. The cancer may be very large and/or the patient’s medical condition may be so poor that it is simply safer to do this where all possible resources are readily available. Very few dermatologists do surgery in a hospital whereas most plastic surgeons hold hospital privileges for surgery.
Most skin cancers can be handled quite competently by any surgeon. Moh’s is a reasonable option for skin cancers in critical areas, such as the eyelids, lip, nose, and ears. Most Moh’s surgeons work closely with plastic surgeons and use our services for complicated reconstruction. Excision with frozen section can be used for any skin cancer very effectively and efficiently. Cancers that are obviously very large and/or those in older, sicker patients are probably better handled by a plastic surgeon in an accredited ambulatory surgery center or in the hospital. When the cosmetic outcome is critical I feel that a plastic surgeon’s specialized training clearly give us an edge over other specialists.
The above discussion is primarily concerning the common basal cell and squamous cell cancers, the two most common forms. Melanoma cancer is another matter entirely. Even small melanomas can be life threatening. In many cases, treatment of the melanoma requires that lymph nodes be biopsied as well. Dermatologists do not do this type of surgery so the appropriate specialist would be a plastic surgeon. Melanomas in non-critical areas can be managed by general surgeons, who are certainly competent to remove them and biopsy lymph nodes but for most melanomas, I would submit that a plastic surgeon is still your best choice. What can I say? I just feel that we do a better job overall.