Facial Skin Lesions

ABOUT THE CONDITION

What is a facial skin lesion?

A facial skin lesion is an abnormal feature of the skin of the face. This could be a lump, a break in the skin, an ulcer or a discoloured patch of the skin that is not normally present.

A lesion is called benign when it is harmless. It is called malignant or cancerous when it is a sign of skin cancer and is potentially serious. Most skin lesions are benign.

What are the most common types of benign facial skin lesions?

The following can also be present on the skin of the rest of the body and not just the face.

• Naevi is a medical term for skin moles. They are often darker than the surrounding skin (brown or brown/black) because they contain more pigment (colour). Rarely, some moles can turn into a cancer called melanoma especially when they are exposed to a lot of sunlight.
• Capillary Haemangiomas are also known as strawberry birthmarks. They can grow larger or smaller as the baby / child grows. They are pink or reddish purple in colour because they contain enlarged blood vessels.
• Papillomata are wart-like skin swellings.
• Seborrhoeic keratosis is also known as senile keratosis because it usually occurs in older patients. They appear as yellowish or brown raised lumps.
• Fibromas of the skin are raised swellings. They are seen on skin that has been injured repeatedly.

What are the most common types of cancerous facial skin lesions?

Basal cell carcinoma or BCC is the most common skin cancer and usually occurs from sun damage. These lesions grow slowly and do not spread to other parts of the body. Early tumours appear as clear, pearly nodules or lumps (figure 1) and eventually turn into an ulcer. It is often known as a ‘rodent ulcer.’

Squamous cell carcinoma can occur in sun damaged skin or normal skin. It shows up as an ulcer. It tends not to spread to other parts of the body, but some may spread to local lymph nodes, making it potentially dangerous.

Malignant melanoma is a cancer that begins in pigmented cells in the skin. They are often brown or black. It can spread to other parts of the body. Melanoma is much less common than basal cell and squamous cell skin cancers, but it is far more serious.

ABOUT THE PROCEDURE

What is surgical removal of lesion?

The exact treatment will depend on several factors. These include:

• Where the lesion is
• The size of the lesion
• Your age and fitness
• Cosmetic considerations
• Your doctor’s recommendations
• Your own preferences.

Surgical removal means that the lesion is cut out with a bit of normal skin around it. Most operations are done under local anaesthetic as a day case. You will remain awake during the whole procedure. The area surrounding the lesion is numbed with an injection so that you do not feel any pain during the operation. You will feel a slight pressure sensation.

The surgeon will remove a slightly wider area of skin surrounding the lesion to make sure that that none of the lesion is left behind. They will stitch the wound together or cover it with a flap of skin usually taken from the area next to the wound. Sometimes the surgeon will need to use a skin graft. This is where skin is taken from another part of the body to cover the area where the lesion has been removed.

Are there any alternative treatments?

For benign lesions:
Most benign facial lesions do not need any treatment at all. Some benign skin lesions may be unsightly or may cause symptoms from repeated trauma for example during shaving, and therefore may need treatment.

Non-surgical treatments, such as curettage or cryosurgery are used in certain lesions, as an alternative to surgery. You may need several sessions to treat a single lesion.

• Curettage means scraping the lesion and allowing the wound to heal itself.
• Cryotherapy means freezing the lesion using liquid nitrogen and allowing the wound to heal itself.

In certain cases, you may be offered other non-surgical treatments like photodynamic therapy (PDT), radiotherapy and electrochemotherapy.

For pre-cancerous lesions or superficial BCC:
Anticancer creams like 5-FU (also called Efudix), can selectively destroy sun-damaged skin. You may be prescribed it if you are being treated for pre-cancerous skin lesions or superficial basal cell cancer. Common side effects include skin rash and irritation of normal surrounding skin as the cream is designed to remove cancer cells.

For cancerous lesions:
Surgical excision is the best way to remove the lesion and examine it. In some cases, you may be offered a type of surgery known as Moh’s surgery. Not all hospitals in the UK offer this form of surgery. The cancer is cut in several stages over the course of a day. The skin removed is examined under the microscope straightaway to decide whether more skin needs to be removed. This type of surgery helps preserve as much healthy surrounding skin as possible.

Radiotherapy, which is a special kind of X-ray treatment, is used in some cases of skin cancer.

Deciding whether to have the treatment.

The decision to have surgery is based on your doctor’s recommendation and your own wishes. Your circumstances will also be considered. You may wish to change your mind about the surgical procedure at any time and signing a consent form does not mean you must have the procedure.

If you would like to have a second opinion regarding the treatment, you can discuss with your specialist, or you may wish to ask your own GP to arrange a second opinion with another specialist.

What can I expect after the operation?

The surgeon may put a dressing over the stitches or leave it uncovered, depending on the site of the surgery. Try to keep the area dry for the first 48 hours. After the operation, you can take a shower but gently pat the area dry and do not rub the wound.

You may have some discomfort once the local anaesthetic wears off. Please take the painkillers you normally use, or the ones prescribed by your surgeon. You should not expect severe pain after this type of surgery.

There may be some swelling or bruising in the first few days but that usually settles down.

What will the scar look like?

The scar is usually noticeable for the first 3 to 6 months and then starts getting flatter and paler. It takes at least 12 months to fade.

Massaging the scar with a moisturizing cream two or three times a day in the first few months (once the wound has healed) helps this process. You can also buy a silicone gel from your local pharmacy to help soften the scar further. The scar should be protected from direct sun during this early period.

ABOUT THE RISKS

Are there any risks to this operation?

Most patients who have this operation recover well.

The complications and risks of any surgery are grouped into the following categories.

Your surgeon will be able to tell you their own complication rate.

Bleeding from the wound is uncommon. You can usually stop any bleeding by applying pressure over the area for 5 minutes using a clean dressing. If it does not stop after a few attempts, you should see a doctor.

Infection is also uncommon. Your surgeon will give an antibiotic ointment or tablets if he or she thinks there might be an infection following the operation. It is important to remember that your wound may not heal as well if you smoke before and after the operation.

You may need repeat surgery if the cancer has not been fully removed or the margins are close when examined under a microscope. This is to prevent the cancer coming back or spreading elsewhere in the body.

The surgical team might decide to use a general anaesthetic for very anxious patients and in larger and more complex operations.  Problems of a general anaesthetic can include blood clots in the legs (called deep vein thrombosis) or lungs (called pulmonary embolism), heart attack, chest infection, stroke, and death. These complications are all rare. However, some patients have other medical conditions that make them more likely and increase the risks of a general anaesthetic. The pre-assessment team and anaesthetist will explain what occurs during a general anaesthetic and the associated risks that are relevant to you. This link summarises the common events and risks of a general anaesthetic.

AFTER THE SURGERY

How long will I be in hospital?

Most people will be able to go home within two hours of the operation.

How long will I be off work?

You should be able to return to work the next day. You should leave a dressing on the wound if you work in a dusty or dirty environment.

Will I have a follow-up appointment?

Your surgeon will let you know if the stitches will dissolve or need to be removed. Stitches that need removal will normally need to be taken out between 5 to 7 days after the operation. The surgeon will let you know whether you will have your stitches removed at your GP’s surgery or at the hospital.

The surgeon may send the skin lesion to the pathology department for further examination, to find out whether the lesion is benign or malignant. It takes a few weeks to get the report. Your surgeon will write to you once the result is available and advise you if you need any future follow-up appointments.

Disclaimer: This publication is designed for the information of patients. Whilst every effort has been made to ensure accuracy, the information contained may not be comprehensive and patients should not act upon it without seeking professional advice.