Surgery

Surgical excision is the recommended treatment for all primary melanoma and most NMSC, although various non-surgical treatments are appropriate for some NMSC subtypes. Preoperative assessment should include whether the patient has allergies to latex and whether they are on medications, such as anticoagulants, steroids or aspirin.

Written consent prior to the procedure is essential. Most common post-operative complications include bleeding, infection and scarring. Surgery is most often carried out using a local rather than a general anaesthetic most often as day case by trained dermatologists or plastic surgeons, although occasionally, very complex surgery as an in-patient may be required. Primary surgery for melanoma involves a number of stages. Initially, a biopsy including a narrow margin of normal skin is taken and the resulting defect can almost always be closed directly. After analysis of the biopsy, a wider excision may need to be performed according to the thickness of the tumour in the biopsy and the resulting defect can often be closed directly but the size or anatomical site of some defects may dictate the use of skin flaps or skin grafts. Increasingly, sentinel node biopsy, a procedure whereby the first draining lymph gland is removed, is performed at the same time as wider excision of a melanoma in order to provide extra prognostic information about the patient. This is performed by specifically trained surgeons only and usually as part of a clinical trial. The same reconstructive ladder applies to NMSC and these tumours are most commonly treated at a single operation. Following the procedure, patients need to be provided with written instructions to assist them in caring for their wound, provide them with information about suture removal and care of grafts and flaps in post-operative period. A number of patients will have surgery that will result in disfigurement particularly if it involves the head and neck area. Sustained psychological support is essential both before and after the treatment to enable patients to adjust psychologically and socially to their disfigurement and to develop coping strategies (NICE, 2006a). After the surgery, patients may need access to prosthetic, camouflage and lymphoedema services.