Special services offered by this practice include:
Malignant melanoma is potentially the most serious form of skin cancer but the majority are diagnosed and successfully treated at the earliest stage. Excessive exposure to the sun and sensitivity to the sun are considered risk factors that have contributed to the rising incidence of melanoma in this country, but sun exposure is probably not the whole story. Researchers are becoming increasingly aware of the important role that inheritance, or genetic makeup, has to do with the risk of getting cancer. While melanoma may not be totally preventable because of genetic factors, aggressive protection against the harmful effects of the sun can be helpful. Cancer researchers believe that atypical cells are on a journey toward becoming true cancer cells. Not all atypical cells finish the march. From the point of view of cancer prevention, the trick is to identify those cells or growths that are atypical and remove them before they do become cancerous. Regular total body skin checkups and skin self-exam help. When caught in time, malignant melanoma is, in most cases, curable. Self examination, early diagnosis, and immediate treatment can literally save your life. Learn the ABCD's of melanoma (below).
The ABCD method of checking for melanoma has been widely touted for public health purposes. The problem is that some of the changes described in it do not occur early, and we want to catch melanoma early. Nevertheless, we recommend you learn these ABCDs and know them cold. In addition, we include ways to become suspicious of growths even earlier, when the cure rate is potentially higher.
A Asymmetry If you fold the mole over in your mind's eye, the halves do not match.
B Border irregularity The edges of the mole are ragged, notched or blurred, not smooth like normal moles.
C Color The coloration of the mole is irregular. There are shades of tan, brown, and black. Even red, white, and blue can add to the mottled appearance.
D Diameter Any diameter greater than a pencil eraser (about 5-6 millimeters) should raise suspicion. In addition to these broad guidelines, two more, a "C and an "S": Concern. Even if you don't know why, if you sense there is something of concern about a mole, insist your doctor biopsy it. Suspicion. This is one time when it's okay to be suspicious. Doctors call it having a "high index of suspicion." We call it being vigilant. But whatever you call it, when it comes to melanoma, the best rule is "When in doubt, check it out."
- Every adult over forty should have an annual full-body skin exam.
- Public skin cancer screenings at which only sun-exposed areas are examined ARE ABSOLUTELY UNACCEPTABLE if that is the only melanoma check you are getting. Melanoma can and does develop where the sun doesn't shine.
- If you are at high risk for melanoma you should perform a full-body self-exam on a regular basis.
Once the diagnosis of melanoma has been made it is important to know its Breslow depth. The risk that you will develop serious problems with melanoma is directly related to how deep the melanoma is. Any melanoma that is up to 1 millimeter in depth has an excellent chance for cure. The cure rate following simple excision is in the range of 96 to 99 percent. Because it is not 100 percent, it is important to emphasize the need for regular monitoring and follow-up examination.
In order to determine how to treat a patient with melanoma and to make some predictions about prognosis, we categorize melanoma in stages. When a melanoma is up to 1 millimeter in depth, excision with 1 centimeter margins down below the level of fat is all that is required. This procedure can be performed in the doctor's office under local anesthesia.
When the melanoma is between 1 and 4 millimeters thick it is clas¬sified as intermediate and may require margins of 2 centimeters when definitive treatment by excision is done. If the melanoma is more than 4 millimeters deep, the margin of safety around the melanoma should be 2-4 centimeters, if it is technically feasible. In some cases smaller margins may be acceptable. Individual circumstances can vary, and there are certainly situations where it is necessary to be more aggressive than the thickness of the cancer alone would suggest.
Non-Melanoma Skin Cancer
There are two principal kinds of non-melanoma skin cancers: basal cell cancer and squamous cell cancer. Basal cell cancer is the most common cancer in the world. Squamous cell cancer is the second most prevalent skin cancer. Still, basal cell cancer outnumbers it four to one. The good news is that each is easily treated and cured in most cases.
The primary cause of basal cell cancer is overexposure to the sun and those with fair complexions are especially susceptible. For the same reason, it occurs most often on sun-exposed areas of the body, which include the head and neck, the legs in women, and the trunk in men. Basal cell cancer is a cancer that has the least potential to spread in the bloodstream or metastasize. Worldwide there have been only about two hundred reported cases, in total, of basal cell cancer metastasizing, and those have usually been huge, neglected tumors. In part because it tends to be diagnosed early, basal cell cancer has a very high cure rate, if treated with the appropriate techniques. The majority of basal cell cancers occur on the face. For this reason, the treatment that you select will have an impact on your appearance and on how you feel about yourself. In addition, this treatment choice must take into account first and foremost the cure rate.
Squamous cell cancer is another common skin cancer that is thought to result most often from sun exposure. It arises from plate-like cells in the epidermis. Unlike basal cell cancer, squamous cell cancer can metastasize to the lymph nodes and even to internal organs. Squamous cell cancer usually appears as a crusty, scaly, warty bump. It may range in size from pea-sized to chestnut-sized and is usually raised. Although squamous cell cancers grow slowly, the sooner you see your doctor and the cancer is diagnosed and treated, the less complicated the surgery to remove it will be and the faster you will make a complete recovery. The treatment for squamous cell cancer varies according to the size and location of the lesion. The surgical options are much the same as those for basal cell cancer.
If you have been diagnosed with a basal cell cancer or a squamous cell cancer, a variety of treatments are available, all of which yield a far less noticeable scar than you might fear-as long as the cancer is treated early. The best treatment approach depends on the type of cancer, its location, your age, and whether the cancer is recurrent or not. Most of the treatment options are surgical and have varying cure rates.
- Surgical Excision
In surgical excision, which is really a simple form of plastic surgery, the skin cancer and the area around it are numbed with a local anesthetic such as lidocaine. The doctor then makes an incision through the full three layers of the skin around the obvious area of the skin cancer. The specimen is removed and the edges of the wound are pulled together using plastic surgery techniques. The benefits of surgical excision include an improved cosmetic result, compared with scraping and burning. The cure rate with this technique is in the 90 percent range for a first-time basal cell cancer. If, after the specimen has been removed and has been evaluated by a dermatopathologist, it turns out that residual cancer cells are present at the margin, meaning that it has not been completely removed, further treatment is often necessary.
- Scraping and Burning
For basal cell cancers that are superficial and confined to the top layer of the skin, a simple treatment is available that has an 80 to 90 percent cure rate. Scraping and burning, also known as electrodessication and curettage, is a quick and easy technique for removing a skin cancer. It should be used only for superficial basal cell cancer and small nodular basal cell cancer on the arms, legs, and trunk. It will usually leave an innocuous round pale scar. Scraping and burning is not appropriate for morpheaform basal cell carcinomas, recurrent basal cell carcinomas, or large, nodular basal cell carcinomas.
- Mohs Micrographic Surgery
The most thorough method for treating basal cell cancer and squamous cell cancer is a technique called Mohs micrographic surgery. Mohs micrographic surgery is a tissue-sparing method. Therefore, it has the best cosmetic outcome. The Mohs technique is based on the notion that normal pathology specimens, cut like a bread loaf, evaluate only about 3 percent of the total surface area of the margins of the cancer. By contrast, the Mohs technique allows evaluation of the complete surface area. This is important because many basal cell cancers grow with fingerlike projections or roots, and the random sampling of the specimens used by conventional pathology may not permit a thorough assessment of residual cancer. Mohs surgery has the highest cure rate of any of the methods mentioned, approaching 98 to 99 percent in most cases. Click here to read more about Mohs Micrographic Surgery, Total Skin: The Definitive Guide to Whole Skin Care for Life, Copyright © 2000, Chapter 23, pages 262-267, David J. Leffell, MD. All rights reserved.
Full Body Skin Exams for Organ Transplant Recipients
Recipients of solid organ transplants are at an increased risk of developing skin cancer compared to the general population. Although most transplant recipients will develop a few skin cancers that are easily treated, some transplant recipients may develop hundreds of skin cancers, some of which can even be life threatening.
Prevention and early detection of skin cancer is vitally important to the optimal care and long-term outcomes of transplant recipients. In addition to skin cancers, transplant recipients may develop dermatologic conditions such as acne, fungal infections of the skin and nails, and viral infections such as warts and shingles.
In the Section of Dermatologic Surgery and Cutaneous Oncology at the Yale School of Medicine, we also offer the latest techniques for skin rejuvenation. Our range of expertise includes removal of benign growths such as skin tags and cysts to laser treatment of facial telangiectasias to the precise placement of fillers to create a youthful appearance. Below are the services we offer our patients:
In our section, patients are always treated by a board certified physician in dermatology who has the training to safely use the laser and light systems we offer. For the treatment of broken capillaries on the face due to sun damage, aging and rosacea we have a pulsed dye laser which works to specifically target and destroy these blood vessels. There is usually minimal bruising that can be covered with make-up making this procedure a success with little downtime. This laser is also used for the treatment of port wine stains and hemangiomas. For hair growth, we offer two types of lasers that work either in light or dark skin tones with medium to dark colored hair. Over a series of treatments depending on the site, a significant reduction in hair growth is achieved. We also offer tattoo removal for all tattoo colors. Depending on the color of the tattoo, complete removal is often achieved after 4 - 5 visits. There is usually redness and some swelling in the area which we advise patients to keep covered for the first week after treatment.
Fillers are a generic term used to describe an injectable material that can be placed in the skin to replace volume loss that leads to an aged appearance or to fill in crevices caused by wrinkles. Common places to use fillers include the lips, smile lines, smoker’s lines and in the cheeks. We currently offer a range of hyaluronic acid fillers including Juvéderm®,Restylane®, and Perlane® which last up to 6 months as well as more permanent fillers such as Sculptra™ and Radiesse®. Prior to injection of any filler, we perform a cosmetic consultation to assess the patient’s expectations and areas of concern to provide the best correction possible.
In our practice, the physicians have an expertise in facial anatomy and perform Botulinum Toxin A injections for patients to improve dynamic wrinkles that occur with facial expression. The result is a softening of creases and an overall “relaxed” appearance. In addition to the face, these injections can also be placed to improve neck bands and excessive sweating in the armpits, hands or feet.
In addition to procedures for facial rejuvenation, our practice offers sclerotherapy for small and medium sized varicose veins of the legs. During initial consultation, the anatomy of the leg is mapped and the patient is checked for vein competency. In subsequent visits, the protruding vessels are injected with material that causes them to collapse and thus disappear. Patients are advised to wear compression stockings for a period of time after the procedure which usually takes no more than one hour. There is risk of bruising, but no functional downtime.