Melanomas are always removed by surgery. The tumour is cut out, along with a small area of normal looking skin from around the melanoma. The amount removed will depend on the size of the melanoma, and may be between 5mm and 3cm. In most cases, the wound can be stitched and will heal in a straight scar.
Surgery can be used as diagnostic tool as well as a treatment.
Sometimes, if the melanoma is at an early stage, the whole melanoma is removed at the initial biopsy and no further treatment is needed.
For a melanoma that has grown deeper into the skin, a larger amount of skin is cut out to make sure all the cancer cells have been removed. This usually involves a general anaesthetic and may require a brief stay in hospital.
Surgical procedures include:
Melanoma can often be diagnosed clinically by its physical appearance and a history of change over weeks or months. Excision of the tumour and examination by the pathologist is required to confirm the diagnosis and assess any risks associated. Excision biopsy usually involves the injection of local anesthetic to numb the area and a brief procedure to remove the suspected tumour with just a few millimeters of surrounding skin. The biopsy wound is usually closed with a few stitches. If melanoma is diagnosed as a result of the biopsy, it will then be staged and its depth and probability of spreading assessed.
Wide Excision and Direct Wound Closure
After the diagnosis of melanoma (typically by excision biopsy), effective treatment requires wide local excision (removal). Although the initial excision biopsy often removes all the recognisable melanoma, wider local excision has been shown to significantly reduce the risk of further problems, especially local recurrence of the melanoma. Wide excision of melanoma usually involves the removal of 1 to 2 cm of apparently normal skin beyond the original melanoma or the excision biopsy wound. The excision margin used depends on several features assessed from the biopsy including tumour depth and level of invasion (how far it has spread into the lower layers of the skin).
Wide local excision is effective in reducing the risk of local recurrence because the surgery removes
Further melanocytes (pigment cells in the skin) adjacent to the melanoma which may be unstable and prone to turning into melanoma
Adjacent tissue which might contain tumour cells which have separated from the primary melanoma
Wider Excision with a Flap and/or Graft Repairs
Many melanoma wide excision wounds can be readily closed by direct suturing. Some wide excision wounds require more advanced techniques such as flaps and grafts to provide the best possible wound closure solution including cosmetic appearance.
Find out more about skin flaps and grafts
Sentinel Node Mapping and Biopsy
Sentinel node biopsy is a surgical technique that determines whether the melanoma has spread to the lymph nodes closest to the melanoma. A substance containing a small amount of radioactivity is injected into the skin around the melanoma. The substance passes into the lymph fluid and is trapped by the sentinel node. That lymph node can be removed and examined to see if there are any cancer cells in it. This technique is only used for melanomas thicker that 1mm.
Find out more about Sentinel Node Mapping and Biopsy
Lymph Node Surgery
The lymphatic system is made up of lymph channels and lymph nodes (lymph glands). The channels link the lymph nodes and are responsible for re-circulating (bloodless) fluid within the body. Major lymph node groups are mainly found in the neck, armpit and groin. They are responsible for activating the immune system (the body’s defences) to help overcome infection and to act as a filter against cancer cells. The spread of cancer cells to the lymph nodes can be detected in several ways
As part of your initial skin cancer treatment
By yourself sometime after your skin cancer is removed
By your doctor during a routine follow-up
Melanoma cells which may have spread from the primary tumour usually occur in the node group nearest to the original skin cancer site e.g. a skin cancer on the hand may spread to the lymph nodes in the armpit, on the foot to the groin, on the trunk it could be to any of the three regions.
Melanoma and Squamous Cell Carcinoma (SCC) are two common examples of skin cancers which can metastasise (spread to the lymph nodes). If the tumour does spread to the regional lymph nodes it can often be cured by surgery to remove all the nodes in that area (armpit, groin, neck etc). This operation is called a regional lymph node dissection. If the cancer has spread to the lymph glands it is important to know whether it has spread elsewhere. This assessment is done via CT and MRI scans.
An axillary lymph node clearance involves the removal of all the lymph nodes and possible tumour-containing tissue from the armpit region.
An axillary dissection is performed under a general anaesthetic so you will not be awake during the procedure. Once you are asleep local anaesthetic will be injected into the area of surgery to provide additional comfort after the operation.
The procedure involves making a varied length incision in the axillary skin. The blood vessels, muscles and nerves of the axilla can therefore be exposed, allowing a complete and relatively safe operation. There are several important structures that run through the axilla (arteries, veins and nerves) and the operation is planned and performed to remove all the lymph nodes and associated tissue without causing damage to these. A minor muscle (pectoralis minor) and minor underarm nerves (intercostobrachial nerves) are removed as part of the operation. This results in numbness in the armpit and down the inside of the arm which is often permanent.
Any large wound produces fluid (like that in a blister) so a surgical drain is placed to collect this. The drain is a soft flexible silicone tube that is connected to a suction bottle and will be checked frequently after the operation and changed as required by the nursing staff (see Fig. 2). This will generally be in place for several days up to several weeks after the operation. The wound is then closed using stitches and/or staples and a dressing is applied. Generally the procedure takes 60 to 90 minutes.
After the operation a pathologist assesses the tissue removed from the axilla. The detailed pathological examination of this tissue takes about seven working days. Information from this analysis is important regarding your ongoing care and may determine the need for radiotherapy and other treatments.
Inguinal lymph node clearance
The lymph nodes in the groin are divided into two groups, the inguinal region and iliac (pelvic) regions. If required, it is possible to remove the lymph nodes from either or both of these regions. These operations are known as an inguinal node dissection or an ilio-inguinal (groin + pelvis) node dissection. Your specialist will discuss with you which is the most appropriate operation.
The operation is carried out under a general anesthetic (i.e. you will be asleep). It involves a cut 20 -30 cm long over the groin. When you wake up you will have drains (tubes from the wound) to remove the excess fluid which accumulates. There will also be a temporary catheter (a tube passing into your bladder) which saves you from passing urine. You will be required to stay in bed for approximately 5-7 days after your operation. There will inevitably be some discomfort at the operation site but you will be provided with medications to control any pain.
Ilio-inguinal node dissection
This operation is slightly different to an inguinal node dissection. In order to remove the additional pelvic nodes the bowel needs to be displaced. This often has the effect of putting the bowel to sleep for a few days after the operation, which results in constipation. Patients are placed on a limited diet afterwards until the bowel starts functioning again. If the bowel is slow to wake up it can be corrected with medication.
Most people cope with the operation very well and have few problems. The most common problems relate to prolonged lymph drainage, fluid collection in the axilla, or minor wound infections. These problems are usually managed simply, without needing re-admission to hospital.
Your surgeon will have discussed the benefits and the risks of the procedure at your pre-operative consultation and this document is not intended to replace that discussion. However, possible side effects are as follows:
Occasionally there may be problems with healing of the wound edges. This may require regular dressings or further surgery. There will be staples or stitches which may need to be removed and there will be a scar.
Some patients also notice loss of sensation in the area which may be permanent.
Infection is uncommon, but if it occurs will be treated with antibiotics.
Despite the drains, fluid occasionally collects at the wound and this may need to be removed in clinic.
Any major operation carries a risk of developing DVT (deep vein thrombosis) or blood clot within the blood vessels of the leg. If this occurs it is likely to be within the first couple of weeks after the operation. This would cause the leg to swell and it may change colour slightly. Treatment includes the use of drugs including heparin and warfarin to thin the blood. Very rarely, if a clot dislodges it can be fatal.
The removal of the lymphatic channels and the lymph nodes interferes with the re-circulation of fluid. This may result in gradual swelling after the operation (known as lymphoedema). Although the majority of patients are not severely troubled with this side effect, it may require them to wear a firm supportive stocking over the whole leg. A small number of patients develop very significant swelling in the leg which can impose substantial limitations on their mobility.
Reconstructive surgery involves the repair of body parts of patients whose tumour has required surgery to remove (resect or excise) areas of the body which significantly affect the patient’s appearance or bodily function. This surgery is carried out by plastic surgeons who have particular experience and expertise in the management of melanoma.
A/Prof Jonathan Stretch is a plastic surgeon who is affliated with Melanoma Institute Australia and has specialised in the care of melanoma patients for over a decade. A considerable proportion of patients treated, especially those with facial melanoma, is managed by our plastic surgeons. Plastic surgery can contribute to the removal and optimal repair of many tumours in a wide range of body parts, particularly where there are cosmetic or functional issues.
Managing a Wide Excisional Defect
If a wound is too big for stitches, a skin graft will be used to cover the wound. A piece of skin is taken from another part of the body and put over the area when the skin tissue is removed. The skin graft may be taken from the thigh or bottom.
Skin grafts can be of either full or partial (split) thickness areas of skin.
Split skin grafts are usually used to resurface larger areas where aesthetic considerations are not essential. Split skin grafts use a partial thickness of skin to resurface areas and generally result in a contour defect. Although initially marked, the contour improves substantially over several months as local tissue growth factors modify the region.
Full thickness skin grafts are used mainly on the face. Reconstructing an excisional defect with a full thickness of grafted skin can result in an excellent repair as essentially the same tissue that is removed is replaced with donor skin of similar characteristics.
Flap surgery involves repairing a defect in an area of skin deficiency by moving tissue from an adjacent area with relative skin laxity. Flaps are defined by the fact that they maintain a continuous blood supply to nourish the tissue used for the repair. They are commonly described as being rotation, transposition or advancement flaps.
Flap repairs can have many advantages.
They utilise repairs from adjacent areas of skin so the colour and texture of the wound closely matches the tissue removed.
They also carry with them a functioning blood supply and heal quickly.
Skin grafts usually need to be protected (splinted) for some time whilst the transferred skin fuses with the wound and re-establishes a blood supply to nourish the tissue. Skin grafts on the lower leg are especially problematic as they usually require the patient to rest in bed with the leg elevated for several (3 -7) days while the blood supply is established. Flaps, such as illustrated below, have the advantage of faster mobilisation (less time in bed) and a better cosmetic result. Unfortunately not all wounds and legs are suitable for these flaps, but where possible offer improved outcomes.