There are various ways that lesions on the skin can be removed, and I will discuss these with you during your consultation and recommend the best option(s) for you.
Mole removal is usually carried out using local anaesthetic, where the skin is numbed with injections. I always clean the skin and surrounding area thoroughly to minimise the chances of infection, and carry out these procedures using proper aseptic surgical technique. I wear magnifying glasses called loupes to ensure that I can clearly see the lesions and perform the surgery accurately.
This is when a mole is sliced off at the base. This is the simplest and quickest way to remove a mole that is raised up from the skin. It may well be the best option where there is little spare skin to enable a wound to be closed without distortion (for example on the nose). Of course, this technique leaves a scar that is the same size and shape as the footprint of the mole; this might not be a problem, and can easily be covered with makeup. Because the base is not removed, there is a chance of the mole re-growing in the future.
I remove the majority of moles in this way. The mole, and the skin beneath it, is completely removed, usually with a very narrow margin around the edge, with the aim of preventing it ever coming back. The resulting wound is usually elliptical in shape, and is closed with stitches. This gives a straight-line scar, which I position in the best possible orientation to ensure that it is as hard to notice as possible once it has healed.
Skin Cancer Removal
Skin cancers are usually removed with a margin of normal skin around them: this is tailored to the diagnosis, taking into account the site on the body and the patient’s wishes. Once the tumour is removed, a reconstruction may be required. Options include skin grafting and ‘flap’ reconstruction. I will discuss what is required, and recommend appropriate options for you. Although this may sound very daunting, the results can be extremely pleasing, even on complex areas like ears, noses and eyelids. Please see photographs here for examples.
Curettage and Cautery
Some superficial skin lesions (e.g. seborrheic keratoses) are removed in this way; they are carefully ‘scraped’ from the surface with a special instrument, and the resulting wound is cauterised to prevent bleeding. The wound is then treated with antiseptic ointment and heals well in a week or two.
What to expect during Mole Removal
Even a small procedure can still be a source of great anxiety. We have an excellent team, and everyone will do their best to make the experience as easy as possible for you.
For a local anaesthetic procedure, you can eat and drink normally. There is no need to fast unless you are having regional or general anaesthesia. Please wear clothes that make it easy to get to the lesion that you are having removed and that are not too delicate. We can provide a gown to wear, but you may prefer to keep your own clothes on.
Please try to arrive in plenty of time – the traffic can be a problem in Bristol, and you don’t want to be stressed about running late. We allow plenty of time for every procedure so that we are often running ahead of time (the most common reason for us over-running is that the patient ahead of you was late arriving). It is often better if you have a companion or friend that can accompany you.
We will sit down together again before your procedure to confirm exactly what we are planning to do. I may draw on you with a pen, and I will ask you to sign a form to say that you wish to go ahead with the surgery. I will remind you of the risks of surgery, which we will usually have discussed already at your consultation.
After this, we will go to the procedure room. There will be a nurse who will assist with the procedure. There are coat hooks and a spare chair that you can put your things on.
After planning the procedure and drawing on you with a pen, I will clean your skin and then perform the anaesthetic injections. These take a few seconds, and this is the part of the procedure that most (but not all) patients find unpleasant. Depending on the site of the lesion, you may find that, for example, your lip goes temporarily numb as well as your cheek, or that you cannot raise your eyebrow for a lesion on your temple. The anaesthetic wears off after about two hours.
I will clean your skin again with an antiseptic solution, this time cleaning a large area. I will then place a drape over the area to ensure that I have a sterile operating field to minimise the risk of wound infection.
I will check that you don’t have any sensation at the site before starting, although you will feel a small amount of ‘pushing and pulling’. Most patients do not find this unpleasant at all, and people are usually surprised that this part of the treatment is relatively quick.
I will select sutures (stitches) to give you the least visible scar. If appropriate I will use absorbable (‘dissolving’) sutures, although these probably don’t result in quite such a good scar as the synthetic ones that need to be removed. Most sutures are removed after seven days, although this does vary with body site. On the face, I use very fine sutures, and on the back, I may use very strong sutures buried under the skin to prevent the wound from coming open (dehiscing) before it is fully healed and to stop the scar from stretching over time.
I always provide a dressing for the wound, and depending on the site of the wound and your preference, this may be ‘steristrips’ (sticky paper dressing strips), glue, or antiseptic ointment, as well as conventional sticky dressings and bandages. The dressing is an important part of the surgery, and I select dressings to optimise the final scar appearance as well as to make your life as easy as possible afterwards.
Patients may feel a little lightheaded immediately after surgery, and so even if you feel fine, we like you to sit down for 10 minutes afterwards and have a drink. You can usually resume normal activities after this, depending on your occupation and plans. I will advise you about specific restrictions, sports and return to work at your consultation.
We will arrange an appointment for removal of sutures with you, and if further follow-up is needed, my secretary will contact you to offer an appointment at your convenience. If samples have been sent away for analysis, I will contact you with the results (usually by post).
Scars take up to two years to fully settle (mature). Initially, your wound is the same colour as your skin, but as it heals, the scar becomes thicker and red, Scar redness usually peaks between four and eight weeks. The scar will then settle gradually. After a year, the scar is usually paler than the surrounding skin.
The process of scar maturation can be speeded up by ‘scar massage’. Once the wound has healed, you should use a little moisturiser and massage the scar. This really means applying pressure to the scar, and this gradually leads to a realignment of collagen fibres to soften and settle the scar. I will show you how to do this.
Scars are sensitive to the sun, and can become hyperpigmented, where they develop a tan, which is darker than the surrounding skin, or doesn’t fade in winter. For this reason, you should use strong factor sun cream on any exposed scars.
Risks of minor surgery
All surgery carries some risks, although we take every care to minimise these. You will be provided with contact telephone numbers so that you have 24-hour access to help if you have any concerns after your surgery. There is no additional cost to you for any further treatment that you might require.
Infection – An infected wound becomes red, hot, swollen and painful, and there could be discharge. I have a personal wound infection rate of less than 1 in 200 cases (0.5%, with only one case in 2015-16). Usually, an infection can be treated simply with antibiotics, especially if detected early. Occasionally an infected wound will need cleaning up or more surgery.
Bleeding – Occasionally patients will have problems with bleeding after minor surgery. Most bleeding stops with pressure applied for 10 minutes. Bleeding inside a wound can lead to a haematoma that might need to be removed. Again my personal rate is less than 1 in 200 cases (0.5%).
Dehiscence – If you are too rough with you wound (or if you are unlucky), then the wound can burst open. Very occasionally this happens (less than 1 in 200), in which case I can resuture the wound. Wounds on the back or the back of the neck are particularly at risk, so I close these wounds with layers of sutures for extra strength.
Scar problems – As above, scars on the back are under tension when you bend over, so the scar can stretch over time. To prevent this I use absorbable (dissolving) sutures that keep their strength for a long period of time. These are buried under your skin so you don’t need to worry about them at all. Some patients may develop unsightly or lumpy scars. I design all my scars to minimise the chances of this. A keloid scar is one where the scar grows to be larger than the original wound. This is more due to the genetics of the patient than anything that the surgeon can control. Keloid scars tend to arise in wounds on the centre of the chest, the shoulder/upper arm area, and the ear. They run in families, particularly those with darker skin. Good treatments are now available for keloid scars, but they remain a difficult problem.