What conditions do I treat?

I perform a high volume of skin surgery procedures including the following:

• Mohs Surgery
• Facial reconstructive surgery
• Mole removal
• Skin tag removal
• Cyst removal
• Lipoma removal
• Scar revision

If you are unsure whether I am able to help you please contact my practice management team. If necessary I may ask you to send through a photograph so that I can advise you.

Do I need to have a consultation before surgery?

All patients will have a separate consultation appointment prior to surgery. The purpose of this is to ensure that you have had the opportunity to discuss the risks,benefits and alternatives and to identify any potential issues ahead of the surgery. You may also wish for me to perform a skin check.

For very straightforward procedures - such as removal of a skin tag or harmless mole - you may prefer to have your initial consultation appointment remotely prior to surgery. Please inform my practice management team if this is the case.

How should I prepare for the surgery?

• Depending upon the nature the surgery you may need to schedule a few days off work.
• You should buy a new (unopened) tub of plain vaseline which can be applied to the site of surgery after the dressing is removed.
• If you are having more invasive surgery you should purchase some paracetamol for pain relief.
• If you are taking blood thinning medicines such as aspirin, warfarin, apixiban or rivaroxaban you do not need to stop these, however you should tell me ahead of the procedure.
• If you have a pacemaker or implantable defibrillator it is very important to tell me before the date of the surgery.

What should I expect on the day of surgery?

On the day of your procedure I will meet you in the operating room and discuss again the procedure and any additional questions that you might have. I will then ask you to sign a consent form.

Following surgery, a dressing will be applied and you will be given instructions on how to how to look after the site.

Will it hurt?

My goal is to minimize to the greatest extent possible any pain or discomfort that you experience. Usually there will be stinging for a few seconds as the local anaesthetic is injected and you then you will not experience discomfort throughout the remainder of the procedure, although you may feel pressure and the sensation of touching and stretching of the skin.

What are the potential risks of surgery?

Skin surgery is generally very safe and for the vast majority of patients things will go smoothly and the area will heal well. However, as for any form of surgery, there are a number of risks. It is important to emphasize that where complications do arise I have the training and experience to manage these.

Risks of skin surgery include the following:-

• Bleeding: There may be bleeding during the procedure. Rarely there may be delayed bleeding hours or very rarely even days after the procedure.
• Infection: There is a small risk of infection. In some cases this will require treatment with antibiotics.
• Pain: There may be pain during the procedure or afterwards. Rarely pain may persist for a number of weeks afterwards.
• Scar: Skin surgery will always leave a scar. As discussed below this can vary from barely noticeable to more obvious and the final appearance is not always predictable.
• Numbness: Any skin surgery can cause damage to the small sensory nerves that supply touch sensation. Usually this will improve with time but rarely it may be permanent.
• Bruising, blistering, crusting: Occasionally this can be marked, however it resolves with time.
• Should a complication arise there is a risk you will need to take a longer period of time off work / normal activities.
• Non-diagnostic result: occasionally the results of a biopsy are non-diagnostic and it may need to be repeated.

How should I look after the site of surgery?

I will give you detailed instructions at the time of surgery, however in most cases there will be a dressing covering the site of surgery and you should leave this on for 48 hours and keep the area dry.

After 48 hours you can remove the dressing and wash the area in the shower. You should then apply vaseline regularly throughout the day. Vaseline helps to keep the area moist which gives the best scar. It also forms a protective seal that reduces the risk of infection and prevents scabbing. Ensure that you use a new tub of vaseline to reduce the risk of infection and do not put your finger back into the tub after touching the wound as this can introduce infection - you can use a cotton bud or spoon to remove the vaseline from the pot.

Will I need stitches?

Depending upon the type of surgery that is performed you may have stitches. Generally minor procedures such as removal of a harmless mole or skin tag do not need stitches but larger procedures will do. Where stitches are needed you will usually need to return for removal after 7 days.

Do I need to avoid certain activities after surgery?

Depending upon the site of the surgery you may need to schedule a period of time off work. For most procedures you should avoid vigorous exercise for a minimum of one week postoperatively due to the risk of bleeding or (if you have stitches) excessive tension on the stitches which can cause the wound to come apart.

What should I do if there is bleeding after the surgery?

Bleeding after the procedure is very uncommon. Rarely it can occur hours after the surgery when adrenaline in the local anaesthetic wears off. The important thing to remember is that in all cases bleeding after skin surgery will stop with pressure. If you experience bleeding then apply firm pressure with tissue paper or a cloth for 15 minutes by the clock. If bleeding continues then apply pressure for another 15 minutes. In the incredibly unlikely event that bleeding does not stop with pressure then you would need to attend A&E urgently.

What do I need to look out for after surgery?

After the first 24 hours, the main thing to look out for is infection. The risk is low (around 1-2 percent) and if it occurs it can be treated with antibiotics, however it is better to pick it up as early as possible.

The main signs of infection are increasing redness, swelling or pain at the site of surgery. It is natural to experience some swelling and tenderness as part of the healing process, however this should gradually diminish over the first week. If you find that it is increasing rather then decreasing then this may be a sign of infection and you should contact my practice management team.

What if I experience pain after the operation?

Some degree of discomfort after surgery is normal. For bigger procedures including Mohs surgery or skin cancer excision this may require painkillers. In the days after surgery the preferred painkiller is paracetamol or for more severe pain co-codamol. You should avoid non-steroidal painkillers such as ibuprofen, naproxen, nurofen, aspirin and diclofenac as these thin the blood and increase the risk of bleeding.

Will the sample be sent for analysis?

In almost all cases I will send the sample that is removed for pathological analysis. This is obviously essential for a suspected skin cancer, however very rarely a lesion that appears clinically benign (harmless) may in fact be a rare manifestation of a skin cancer and it is very important not to miss this. I work with highly experienced pathologists and in most cases the final result will be sent to you within 1-2 weeks.

How long will it take to heal?

The initial phase of healing will generally last 1-2 weeks. After this period the skin will have healed over and you will not need to apply vaseline or cover with a dressing. At this stage it is usual for the scar to appear red and sometimes lumpy. This is a natural part of healing so do not worry about this.

By approximately 3 months you will have an idea what the final appearance of the scar will be. It is at this stage that if there is any problem with the scar I would consider surgical or laser scar revision.

The scar does continue to remodel for a total of 18 months after surgery and often improves substantially in appearance over this time period. However, after 18 months it is unlikely that you will see significant further changes in the appearance.

What will the scar look like?

I will give you an indication of the likely appearance of the scar during your preoperative consultation. The type of scar will depend upon the lesion is removed by cutting and stitching or shaved off parallel with the skin surface. In the first case the scar is anticipated to be a thin, narrow scar that is on average 3 times longer than the lesion that was removed. In the second case there will be a flat scar the same size as the lesion that is removed.

Any skin surgery will leave a permanent scar at the site of treatment. My goal is to give you the best cosmetic result possible and to hide the scar to the maximum extent possible. In most cases the scar will heal well and in some cases can be almost invisible, however the final cosmetic appearance cannot be guaranteed. The reason for this is that the healing process is unpredictable and identical surgery can lead to an excellent scar in one patient but a noticeable scar in another.

There is a risk that the scar may be raised or lumpy or that a keloid scar may form. The scar may be depressed, different in color (redder/lighter/darker), or different in texture (for example more shiny) in comparison with the adjacent skin. It is important to inform me if you have previously suffered from lumpy (hypertrophic or keloid) scars as there is an increased risk that this will occur again.

What if I am not happy with the scar?

If you are unhappy with the appearance of the scar then there are many options for improving things and I will advise you as to the best option. This includes the following:

• Massage: Where a scar is lumpy or irregular, firm massage for 10 minutes per day with vaseline as a lubricant can lead to very substantial improvement as collagen remodels over a period of several months.
• Surgical revision - i.e. performing further surgery under local anaesthetic to modify the appearance of the scar.
• Steroid injection - this is used for raised lumpy or keloid scars to help them to flatten.
• Pulsed dye laser: This is helpful for scars that appear red due an increased prominence of blood vessels during the healing process.
• Carbon dioxide laser: This can be used to blend the edges of the scar to make it less noticeable.

Summary

Skin surgery is safe and generally the treated area will heal well. If at any point either before or after surgery you have concerns or questions you should have no hesitation in contacting my practice management team.