Surgical Dermatology

Surgical FAQs

How common is skin cancer?
Skin cancer is the most common form of cancer overall in the US with more than 3.5 million cases diagnosed each year. There are more new cases of skin cancer than breast, prostate, lung and colon cancers combined. 1 in 5 Americans will develop skin cancer at some point in their lifetime.
What are the most common forms of skin cancer?
Basal cell carcinoma is the most common type followed by squamous cell carcinoma (pronounced “squ-AIM-us”) and melanoma. Up to 50% of Americans who live to age 65 will have either type at least once.
Who is at most risk of developing skin cancer?
Those at highest risk of developing skin cancer have the following:
Light colored eyes and hair color
Fair complexion
History of sunburns
Excessive sun exposure
Living in sunny or high altitude climates
Large number of moles or precancerous skin lesions (known as actinic keratoses)
Family history of skin cancer particularly melanoma
Weakened immune system
Exposure to certain substances such as arsenic
 
I lie in a tanning bed or gradually get darker over the summer to get a healthy base tan.
By not burning, I am protected against developing skin cancer, right?
Wrong! First and foremost, there is no such thing as a healthy tan, period. Tanning bed exposure is a known carcinogen and is placed in the same cancer-causing category as plutonium. Would you lie in a plutonium bed? Of course not, then why would you lie in a tanning bed? The Indoor Tanning Association (ITA), created in 1999, has a huge financial stake in fostering an atmosphere that encourages tanning. An estimated 1 million individuals use tanning beds daily creating a 5 billion dollar per year industry. The ITA claims to promote a responsible message about moderate tanning and sunburn prevention. Does this sound familiar (think cigarettes and Phillip Morris!).
Gradual, controlled tanning (whether outside or indoors) does NOT protect you from getting skin cancer. Cumulative sun exposure results in a higher risk for skin cancer.
What are the differences and similarities between basal cell and squmaous cell carcinoma?
Both are derived from the outermost layer of skin called the epidermis and strongly linked to ultraviolet light (both natural sunlight and artificial sources like tanning beds). However, basal cell cacinomas are rarely fatal but can be highly disfiguring if allowed to grow over long periods of time in cosmetically sensitive areas such as the face and neck. Squamous cell carcinoma, unlike most cases of the basal cell carcinoma, can spread through the blood (i.e. metastasize) if left untreated and found in high risk clinical scenarios such as on the ear, lip or previously irradiated sites. An estimated 700,000 cases of SCC are diagnosed each year and result in approximately 2,500 deaths.
What causes skin cancer?
Approximately 90% of basal cell and squamous cell carcinomas are result from exposure to ultraviolet radiation from either natural sunlight or artificial sources such as tanning beds.
What is melanoma?
Melanoma is cancer of the pigment producing cells of the body called melanocytes. Under normal conditions, melanocytes are responsible for giving our skin its color. For instance, the number of melanocytes in Caucasians and African Americans are roughly the same. The only difference is the melanocytes in African Americans produce more pigment (called melanin) and transfer this to the neighboring skin cells. This process takes place only the thickness of a sheet paper below the surface of the skin. If the melanocytes are injured by ultraviolet radiation, they can turn into skin cancer, melanoma. Most melanomas are thin and do not invade deep into the skin. However, the deeper the melanoma cells invade into the skin, the worse the prognosis. Melanoma should be evaluated and managed by a knowledgeable board-certified dermatologist.
I was diagnosed with melanoma and referred to a surgical oncologist or other surgeon. Why?
The depth melanoma cells penetrate into the skin dictates management. If the melanoma cells are superficial, then a dermatologic surgeon can remove the lesion along with a margin of normal-appearing tissue. This is called “wide local excision.” The margins of normal skin around the melanoma are standardized according to a set of guidelines recommended by the National Comprehensive Cancer Network. However, if the melanoma cells penetrate deeper into the skin, Dr. Cowan may refer you to have a wide local excision coupled with a sentinel lymph node examination. Dermatologic surgeons do not perform sentinel lymph node biopsies/examinations.
What is a sentinel lymph node examination?
Lymph nodes are a series of glands that drain a particular body site. The best way to think of lymph nodes is to compare them to plumbing. A house has several sinks, toilets and drains but eventually they all lead to the main pipe exiting your home to either a septic tank or sewer system. In this analogy, the body site (e.g. arm) represents all the series of drains in the house that then must empty into the main drain or lymph node. The sentinel lymph node is the gland the particular body site drains to first. For example, if you are diagnosed with a melanoma on the arm, the first gland the melanoma cells would travel IF THEY METASTASIZE or spread would likely be in the armpit.
I was just diagnosed with melanoma. What are the basics to understand about my prognosis?
Melanoma is an intimidating diagnosis. However, most melanomas, if detected early and treated appropriately can be curable. In simplistic terms, the deeper melanoma cells invade into the skin, the worse the prognosis. For instance, thin melanomas (defined as invading into the layers of the skin less than 1 millimeter) have a 95%+ survival rate ten years from the date of the diagnosis.
The length of my scar is longer than the original lesion. Why?
Generally speaking, skin cancers are removed in a manner that leaves behind a circular or oval wound. The ends or poles of the wound would pucker if sutured side to side. These are called tissue redundancies or standing cones. To avoid this phenomenon, small triangular pieces of tissue are removed along the axis the wound will be closed. Removal of the tissue allows the wound to lay down flat creating a better cosmetic outcome while in turn lengthening the surgical closure.
After removal of my skin cancer, the closure of the wound was delayed. Why?
There are many reasons why wounds might not be sutured together the same day Mohs Micrographic surgery was performed. For example, the depth of some wounds necessitates allowing tissue to fill in before a closure, such as a skin graft, is done. Another example is patient fatigue. In rare cases, skin cancers are extensive and require the patient to remain in the office most of the day. If patients are too tired to proceed with the closure the same day the tumor was removed, closure may be delayed a few days. At Bowling Green Dermatology, complication rates (i.e. infection, bleeding, post-operative pain) are NOT higher if the closure is delayed following removal of the skin cancer. The area will be bandaged and the patient will not be asked to care for the wound. If wound care is required, it will be done by our medical staff.
Should I take skin cancer seriously?
Emphatically yes! Allowing skin cancers such as basal cell carcinoma, squamous cell carcinoma and melanoma to grow without treatment can result in death. Recall squamous cell carcinoma and melanoma account for roughly 11,000 deaths each year. Skin cancers will not spontaneously resolve. They require evaluation and management by a highly skilled and knowledgeable dermatologic surgeon.
How common is melanoma?
Approximatley 69,000 melanomas are diagnosed each year and result in roughly 8,600 deaths. One person dies from melanoma every 62 minutes. However, survival with melanoma increased from 49% between 1950 and 1954 to 92% between 1996 and 2003. Melanoma is the 5th most common cancer for males and the 6th most common cancer for females. 1 in 55 Americans will develop melanoma during their lifetime.
The lesion/growth looks like it is gone after the biopsy. What should I do?
The original biopsy, whether performed by Dr. Cowan or a referring physician, is a sampling procedure. The intention is to confirm the physicians’ suspicion that a skin cancer is present. It is NOT intended to remove the entire lesion. If skin cancer is confirmed by the biopsy (see the frequently asked question about biopsies), there are microscopic roots extending deeper into the skin. You can think of the skin cancer as an iceberg. It is estimated only 10% of an iceberg is above the water surface. The same is true for skin cancer. Thus, you should take the advice of Dr. Cowan and have the skin cancer treated definitively.
What is involved in a biopsy?
Simplistically speaking, a biopsy involves taking a sample of tissue from the patient and sending it to a pathologist for microscopic review. Biopsies can be done to rule out skin cancer, diagnose a rash or confirm Dr. Cowan’s suspicion for another skin process. There are two basic types of biopsies, the shave and punch. However, before a description of each type, it is important to note the lesion to be biopsied will be anesthetized (i.e. numbed) using a local injection. Pain is very minimal and most patients are amazed how little discomfort they feel. Shave biopsies involve using a flexible blade to cut the lesion off at the surface of the normal surrounding skin. It is best used to sample lesions/growths that project from the skin. In contrast, punch biopsies involve using a device resembling a round cookie cutter to remove a plug of skin. It is best used to sample lesions that are flat. It usually involves a suture or stitch to secure the wound.
Will the procedure hurt?
Whether you are having a minor biopsy, routine elliptical surgical excision or Mohs Micrographic surgery, we pride ourselves in making the process as painless and comfortable as possible. We add an ingredient to the numbing solution to ease the pain and we only use the smallest needles to inject. Most patients are pleasantly surprised how little discomfort they feel.
Will I have pain after the procedure?
The majority of patients experience little to no pain following surgery. However, this depends upon the extent of the procedure and reconstruction necessary. Tylenol is the preferred method of over-the-counter pain control. Pain relievers such as aspirin and ibuprofen can thin the blood and thus increase the risk of post-operative bleeding. If applicable, Dr. Cowan will provide you with a prescription strength pain medication. We are committed to ensuring your recovery is fast and painless.
What should I do if I continue to have problems following surgery?
If you have any issues with bleeding, pain, signs of infection, etc, contact the office immediately. If issues arise after normal business hours, Bowling Green Dermatology has a 24-hour on-call service. A real person will answer your call and contact Dr. Cowan if necessary. You are never alone following surgery.
Will I have a scar?
Any surgery and every surgeon will leave a scar. To have expectations of a scar-less surgery is unrealistic. Dermatologic surgeons like Dr. Cowan perform surgery on the face (including eyelids, nose, ear, lip) daily and will take all measures to minimize the appearance of scars by hiding them in existing skin wrinkles and using meticulous suturing technique. Furthermore, it is difficult and unwise to look at another patient’s scar to figure out if yours will be better or worse. There are so many factors at play in the way a surgical site ultimately appears. Obviously, skin cancers that require larger incisions and rearrangement of tissue to cover the defect will differ from simple, small closures. And lastly, the appearance of scars depends largely on how well a patient cares for the site following surgery. Smokers and those who are not consistent with proper wound care will not have as good of outcomes as those who refrain from tobacco use and meticulously care for the wound. Much of the final appearance of the scar is in the patients’ hands.
Do I need to see a Plastic surgeon to remove my skin cancer?
I will answer the question with two questions. Who do you think performs more skin surgery on the face, neck, trunk and extremities on a daily basis? Who do you think has received advanced training in the diagnosis, management and treatment of skin cancer including complex facial reconstructions using local flaps and grafts? The answer to both questions is clearly dermatologic surgeons.

Dermatologic surgeons receive the most training in the accurate diagnosis, management and treatment of skin cancer. We devote our entire careers to the health of your skin. We understand proper margin examination and are uniquely qualified to perform Mohs Micrographic surgery, the gold standard in the removal of skin cancers on the head and neck.
Who should remove my skin cancer?
There are skin specialists for a reason. Just as you would see a cardiologist for a heart condition, a dermatologic surgeon is best equipped to treat your skin cancer. Dermatologic surgeons have specialized in the diagnosis, management and treatment of skin cancer through an intensive 3-year training program. Furthermore, Dr. Cowan is a fellow of the American Society for Mohs Surgery and has been offering this state-of-the-art treatment of skin cancer since 2008. Currently no one else in the area offers this service.
Dr. Cowan belongs to the American Society for Mohs Surgery (ASMS). I am also aware of another organization of Mohs surgeons called the American College of Mohs Surgery (ACMS). What is the difference between the two organizations?
Both organizations are professional medical societies comprised of competent, practicing Mohs surgeons. Each organization encourages high-quality continuing medical education and quality assurance measures for its members.

The American College of Mohs Surgery sponsors its own post-residency fellowship training in Mohs surgery while the majority of American Society for Mohs Surgery members receive their Mohs training in dermatology residency, post-residency training courses and/or preceptorships. Some ASMS members have also completed ACMS sponsored fellowships. ACMS fellowship training is one option which may or may not be necessary, based on the Mohs surgeon’s residency training and/or other non-fellowship training experiences. Dr. Cowan was fortunate to attend Emory University Department of Dermatology and received outstanding Mohs surgery training and experience throughout his 3-year residency. He has been performing Mohs Micrographic surgery since 2008 and, with the help of certified Mohs histotechnicians, provides the residents of south central Kentucky this vital service.
How long will it take to remove my skin cancer?
It depends of what technique is used to remove the skin cancer. For routine excisions, which are usually used to remove skin cancers on the trunk and extremities, an ellipse (or football shaped) incision is made around the tumor. Then bleeding will be controlled and sutures placed. This process usually takes 30 minutes.
For Mohs Micrographic surgery, which is used to treat skin cancers on the head and neck, the process involves removing the skin cancer and examining the specimen microscopically in the office to ensure all the roots have been removed. The tissue must be divided, sectioned, stained and microscopically mapped in real time. This process can range from 2.5 hours to the whole day in certain cases where the tumor is large and in a difficult location. In very rare circumstances, the surgery may be continued the following day.
Will I have to be off work following the removal of my skin cancer?
The majority of patients return to work the following day. Complications such as bleeding, pain and infection are very rare. Most likely you will be required to wear a bandage and the size is dictated by the complexity of the surgery as well as the location. For large skin cancers in certain locations (nose, eyelids, ear, lip), you may be required to miss work.
How do I take care of the surgical site following surgery?
In general, the wound should be gently washed with a solution of ½ peroxide and ½ warm water. Using a Q-tip dipped in the solution to gently roll over the surgical site is the preferred technique. You should then apply liberal amounts of a topical antibiotic ointment called mupirocin or plain petrolatum (Vaseline) as instructed. Moist wounds heal faster and better cosmetically than dry wounds. The adage of “dry to wet and wet to dry” is not only out of date but also scientifically unsound.
Where will the surgery take place?
All skin cancer removals, whether routine elliptical excisions, electrodessication & curettage or Mohs Micrographic surgery, are done in our clean, state-of-the-art building and surgical suites. Each room is equipped with a comfortable power exam chair, surgical lighting and the latest instrumentation. Studies have shown surgical procedures done in the office setting are safer and have less post-operative complications (infection, pain) than if done in a hospital setting. You will NOT be placed under general anesthesia, which carries a low but real risk of serious complications. And in terms of cost, procedures done in the office setting are generally much cheaper.
Will insurance cover the removal of my skin cancer?
Yes. We precertify all skin cancer removals and have yet to encounter a problem with insurance covering this service. However, skin cancer removals (i.e. elliptical excisions, electrodessication & curettage, Mohs Micrograph surgery) represent procedures and are applied to your deductible. That means if you have a deductible that has not been met for the year, you will be required to pay a specified amount before insurance ‘kicks in.’ Our billing office will answer any questions you may have. Contact them at billing@bowlinggreendermatology.com.
I have another surgeon (Plastics, general surgeon) who is going to remove my skin cancer by taking me to the operating room or outpatient surgery center. They are going to review the area around the skin cancer while I am under general anesthesia to make sure it is all gone. This is a better way to remove skin cancer than Mohs Micrographic surgery, right?
Not exactly. Mohs Micrographic surgery is the only method that attempts to examine 100% of the side and deep margins/edges of the skin sample removed. Thus any other procedure, regardless what type of surgeon does it or if it is done in a hospital setting, only examines a small portion of the sample for residual skin cancer. The results are then extrapolated or applied to the entire specimen. The best way to think about this is to imagine a loaf of bread. Mohs Micrographic surgery examines all slices of the loaf whereas any other procedure may only look at 1 or 2 slices in the entire loaf. The latter technique is acceptable under certain circumstances whereas Mohs Micrographic surgery is the gold standard for skin cancers meeting certain criteria.
I was diagnosed with skin cancer. Am I at higher risk of developing more?
Yes. Patients with a history of basal cell, squamous cell or melanoma are at a higher risk of developing additional skin cancers. This is partly due to the fact the original factor giving rise to the first skin cancer, cumulative sun exposure, can cause additional skin cancers as well. This is why routine skin cancer checks are important. Patients with a history of skin cancer are encouraged to have at least one skin examination per year and, in some cases, several times per year.
How long must I wear the bandage following surgery?
The answer to this question depends on the location of the surgery. For example, bandages applied to surgical sites on the ear and nose may be left in place longer than areas on the arm, leg or back. Generally speaking, bandages are left in place for 24 to 48 hours. The bandage can then be removed and the patient can shower. We will discuss the additional steps for wound care at your appointment and you will be given a handout as well.
Can I shower after the surgery?
Again, it depends on the location of the surgery. For locations such as the scalp, head and neck, it is fine to take a bath the same day of the surgery while trying to avoid getting the bandage wet. For surgeries on the arm or leg, you can cover the site with a plastic garbage bag and apply tape to create a watertight seal. Generally speaking, we encourage patients to wash the surgical sites with mild soap and water being careful not to scrub when given permission to remove the bandage. However, skin grafts and flaps are a special situation and require special care. We will discuss the care of grafts and flaps at your appointment as well as providing a detailed handout.
How long before I can return to exercising after the surgery?
2 weeks or longer, depending on the location. You only get one chance to heal correctly but will have plenty of time to continue your exercise regimen. Thus, you should take it easy regardless of the location of the surgery. The appearance of your scar depends as much on how you care for the wound as what is done during the surgery. If you want good results, you must do what the physician asks during the healing process. Surgeries on the leg, arm, or trunk (abdomen, chest, back) require even more care. These sites are under a tremendous amount of tension and additional movement in the form of exercise can stretch the wound causing, in some cases, the surgical site to pull apart.
Can I eat before surgery?
Yes. Skin surgery, whether a routine excision or Mohs Micrographic surgery, does NOT require general anesthesia. This is one of the features that make office-based surgery more efficient and safer. We encourage patients to eat a small meal before their surgery.
Can my family be in the procedure room while the surgery is being performed?
Except under special circumstances (treatment of small child/minor, disabled or mentally impaired patient), we ask the family to remain in the reception area while the surgery is performed. Our surgical suites can get crowed if too many people are in the room. We also do not allow personal cameras or unauthorized photographs to be taken during surgery. We reserve the right to ask family members to leave the room if in the best interest of the patient and the medical team.
Should I stop smoking before and after surgery?
Yes, if possible. We understand smoking cessation is a difficult task. However, nearly all post-operative complications in the form of skin graft failure or skin flap necrosis occur in smokers. Therefore, if you want the surgical scar to have the best chance to heal well, you should stop smoking. We will be happy to provide you with a nicotine patch to aid you during the time before and after surgery. Even if you can stop smoking for 1 to 2 weeks following the surgery, the site will do better.