Surgery and Reconstruction

Your surgeon will have two main objectives in managing your skin cancer: firstly to remove the tumour with an appropriate margin of safety and secondarily to ‘fill the hole’ with a good aesthetic reconstruction. 

The complexity and the ease with which this can be achieved depends upon the size and site of the defect and and other medical conditions the patient may have. 

Your surgeon will guide you about the choices to rebuild a wound following tumour removal. They will explain the risks and complications of surgery, what to expect and the recovery time. Surgeons choose from a variety of different techniques to give the best reconstruction – one that works well and looks good

Reconstructive Options

1. Healing by secondary intention 
This is the simplest approach following used if the wound created is small and/or relatively superficial. Other factors include how well the patient is – they may not be well enough for anything more complex. The main advantage of this approach is its simplicity but does require extended time for dressings. Some sites of the body heal very well by this approach, eg the forehead and inner aspect of the eye.

2. Direct closure
Suturing the wound is the next easiest approach providing there is enough skin to allow the wound to be pulled together with stitches. Your surgeon will try, if possible, to blend your resulting scar into your skin folds to make it look as natural as possible. The main advantage of a direct closure is that the wound will heal quickly whilst keeping the scar length as short as possible.

3. Skin grafting (SG)
Skin grafts can be used if the wound cannot be sutured and involves ‘borrowing’ or harvesting skin from one part of the body to rebuild a wound in another. Skin grafts are either thin ‘split thickness’ (STSG) or thicker ‘full thickness’ (FTSG). Skin grafts need to pick up a new blood supply at the site of reconstruction and will only work if there is a good blood supply at the base of the wound. Therefore, some sites are not appropriate for a skin graft, such as bare bone, or foreign materials.

Split Thickness Skin Grafts (STSGs)

Split thickness skin grafts consist of shaving a thin layer of skin, usually tissuepaper thick, from a site which will usually heal well, such as the thigh, buttocks or calf. This ‘donor site’ will require a dressing and is usually healed by two to three weeks (much like a graze). The area will remain pink for some months afterwards but usually fades eventually to a barely perceptible scar.

Your surgeon may put small holes into the graft to help the skin graft to survive. After the graft is secured to the wound, a dressing is applied to hold the graft in place to help healing. The donor site where the graft has been taken is also dressed. After five to seven days, the skin graft will be checked to see if it is healing. The donor site is left for longer, usually two to three weeks, to fully heal.

Full Thickness Skin Grafts (FTSG)

Full thickness skin grafts differ from split thickness skin grafts in that the full thickness of the skin is removed rather than a shaving. The donor site is directly closed and not left as a surgical graze as in the split thickness skin graft approach. Typical sites of the body used for harvesting a full thickness skin graft include the neck, behind the ear, the upper arm, and the groin. A FTSG finds it harder to pick up a new blood supply, because it is thicker and so it is even more important to leave the dressing intact until it is removed by the surgical team, five to seven days later.

Composite Grafts

Composite grafts are more complicated grafts that contain more than one tissue type and are often used to reconstruct difficult areas around the nose or eyelid. These types of grafts can take longer to heal.

Local Flap Reconstruction

A ‘flap’ brings with it its own blood supply and so does not rely on the wound bed for a blood supply to heal like a skin graft does. Flaps give a good colour match and fill a wound well. Local flaps use skin from next to the wound, and move it into place. There are lots of types of local flaps named after their shape or type of blood supply. The vast array of flaps that have been developed over the years of plastic surgery is exhaustive and beyond the scope of this handbook, so only some of the more common flaps are described here. Many of these flaps can be performed under a local anaesthetic. Your surgeon will guide you about what will work best for you.

Types of Flaps

The Transposition Flap
This flap is often used on the head and neck region and its name is based on the fact that the flap of skin used to rebuild the wound approximates a rhomboid shape. Your surgeon will design the flap, to make use of adjacent spare tissue to fill the defect, whilst trying to arrange the scars to blend into the normal creases and lines of the face

The Keystone Flap
This flap is useful for closing wounds on the arms and legs

The V-Y Advancement Flap
This flap is also used for closing a wound on the face, but can also be used on other parts of the body. It is called a V-Y flap because the flap is developed as a ‘V’ shape and after it is advanced forward to close the wound by the surgeon it takes on a ‘Y’ shape. It is particularly useful for defects along the side of the nose

Flaps from Further Away – Regional Flap, Free Flap
Occasionally, it is necessary for the surgeon to perform a more complicated reconstruction operation, owing to the size of the wound following tumour removal or a lack of other simpler options. Regional flaps come from further away from the wound and can bring with them other tissues such as muscle if needed.

Occasionally your surgeon will advise you that a ‘free flap’ is needed to rebuild a wound. This is a more complex operation and involves raising a large area of tissue with its own blood vessels, before completely freeing it to move it to the wound. The isolated blood vessels are then reconnected to the nearby blood vessels to carry blood into and out of the flap. This operation can take a number of hours to complete and patients are watched very closely for the first few days to ensure all goes smoothly.

Read More

Skin anatomy and types of skin cancer
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Lymph node surgery
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