REMOVAL OF FACIAL MOLES
Patients frequently request removal of facial moles. They feel this will improve their appearance. Sometimes they are concerned about the possibility of skin cancer.
The medical name for a mole is a nevus. Compound nevi are raised and brown. Sometimes they are nonpigmented. If a lesion shows signs suspicious for malignancy (such as a sore that doesn’t heal, an irregular border, increase in size, nodularity, topical erosion, dark color, or bleeding) it is sent for pathology. A uniform, normal-appearing mole that has not changed in appearance, and is free of such signs, does not necessarily require microscopic examination by a pathologist.
N.I., Age 30
Procedure: Removal of moles from the face and neck
There are numerous methods of treating facial moles. Some of these involve destruction of the tissue, such as cryotherapy (freezing) with liquid nitrogen, electrodessication with cautery, and laser vaporization.
If the tissue is to be sent to the lab for analysis, a tissue specimen is necessary. This means the tissue cannot be destroyed. Surgical excision or at least a “punch biopsy” (a technique that makes use of a small circular “cookie-cutter” device) is necessary. Plastic surgeons prefer to remove facial moles using elliptical excisions. This way the full thickness of the skin is removed, there is a good specimen for the pathologist to examine, and closure yields a fine line that is oriented to blend in with existing skin wrinkles. This treatment is also likely to permanently eliminate the lesion (unlike a punch biopsy), as long as all of the lesion is included in the dissection.
Other techniques that do not include surgical closure tend to leave small divots, like chickenpox scars. These scars can be objectionable, because subtle contour imperfections can be highly conspicuous. It is preferable to avoid saucer-shaped divots and leave less conspicuous linear scars. Plastic surgeons are used to making small incisions and being meticulous with suturing technique to obtain the best cosmetic result.
If the mole is not completely removed, it may grow back. This is called a recurrence. Nevus cells extend deeply into the dermis and may not be completely removed by a partial-thickness treatment. Full-thickness excision provides the greatest assurance that the mole is completely removed.
Sun-Related Skin Lesions
There are other pigmented lesions that are not really moles although they look similar. They are sun-related spots that eventually develop on the skin of most Caucasians on just about any area exposed to photodamage—the face, shoulders, back, and arms. The medical name is “seborrheic keratoses.” These ugly, greasy plaques may be removed by tangential excision (scraped off) using a scalpel blade. The full-thickness of the skin is not penetrated. The wound is treated with silver nitrate, a chemical cautery agent that stops bleeding. A black crust forms. Gradually, the wound heals under this biological dressing. The crust usually separates on its own in 1 to 2 weeks, revealing pink freshly-healed skin underneath. These lesions may be removed under local anesthesia in the office or at the time of other surgical procedures under a general anesthetic.
“Actinic keratosis” are dry, scaly, red spots that do not seem to heal. They can sometimes turn into a skin cancer. Basal cell carcinomas are often nodular, nonpigmented, with little blood vessels on the surface, and need to be completely removed by full-thickness excision to ensure they don’t come back. Melanomas are more serious, of course, and require complete excision and analysis to determine their depth of skin penetration. Superficial melanomas have a good prognosis.
On the face, small sutures are used because they are unlikely to leave suture tracks. These sutures are typically removed between 3 and 5 days after surgery. There may be small puckers at one or both ends of these small incisions that gradually settle down. The scars are red at first. This fades and eventually they turn white, provided they are not exposed to ultraviolet light that can cause them to darken.
Sometimes the wound opens after the sutures are removed. So why not just leave them in longer? Plastic surgeons prefer not to leave sutures in longer than necessary so they don’t leave suture tracks. This is also the reason we use tiny sutures. If the wound opening is small, it may be best just to let it heal in on its own. If the wound is larger or in a cosmetically sensitive area, I may close it with a few sutures in the office. Sometimes wounds break open (called a dehiscence) even before the sutures are removed. Sutures may break, come loose, or get stuck to a bandage and get pulled out. If the wound opens, this is easily remedied with a few sutures in the office.
Infection is always a risk after surgery, but the face has an excellent blood supply, so that infection is unusual and typically clears up quickly with antibiotics and suture removal (infections clear more quickly after the sutures are removed).
Full-thickness skin incisions always leave scars. However, on the face these are usually fine lines that blend in well with the natural skin creases. Patients who are prone to hypertrophic scars or keloids may have objectionable scars.
Any surgical wound exposed to ultraviolet light may respond by producing melanin, causing the scar to darken and become more conspicuous. Sunblock is recommended at least until the redness has faded, or longer if the patient has an olive complexion and may be more prone to hyperpigmentation.
If pigmented tissue is left behind, a new mole may form, possibly necessitating reoperation. Plastic surgeons prefer full-thickness excisions for just this reason—to reduce the risk of recurrence (or more accurately, persistence).
Getting Back to Normal
Keep the wounds clean, apply topical antibiotic ointment twice a day, and avoid UV exposure. Wear a hat and apply sunblock.
Q: Will removal of my mole leave a scar?
A: Yes. The scar will be longer than the diameter of the mole. Plastic surgeons take care to excise the mole in such a way as to orient the scar along natural wrinkle lines. With meticulous surgical technique, and favorable healing, the scar is typically inconspicuous and less noticeable than the mole.