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.

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:

• Biopsy

• Wider excision and direct wound closure

• Wider excision with flap and/or graft repairs

• Sentinel node mapping and biopsy

• Lymph node surgery

Biopsy

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.

Go to Skin Grafts
Go to Flap Repairs

Sentinel Node Mapping and Biopsy

A new technique to see if the melanoma has spread to the lymph nodes closest to the melanoma is called “sentinel node biopsy”. A substance containing a small amount of radioactivity is injected into the skin around the tumour. 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 thicker melanomas.

Examination of the “sentinel” lymph node or nodes in a patient with a primary melanoma on the skin very accurately indicates whether it has spread to the regional lymph nodes (such as the groin, the armpit or the neck). This means that patients who are at the highest risk of later developing melanoma-related problems are identified at an early stage of the disease.

Click here to read 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.

Groin Dissection (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.

Side Effects

• 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 in the leg. This may result in gradual swelling of the leg 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.