Skin Cancer Surgery in Ankara, Turkey

Skin cancer excision is a surgical procedure aimed at completely removing malignant skin lesions together with healthy margins. In skin cancers such as basal cell carcinoma, squamous cell carcinoma, and melanoma that are diagnosed at an early stage, excision surgery is the most effective treatment method.

The tissue loss that occurs after tumor removal is repaired with a flap or skin graft in order to prevent aesthetic and functional loss. While small lesions can be closed directly, local flaps or free tissue transfers are preferred in large excision areas.

Flap surgery is an advanced reconstruction technique performed by using nearby healthy tissue and vascular structures. This method ensures the preservation of a natural appearance, especially in aesthetically important areas such as the face, nose, ear, and lips.

In skin cancer surgeries, regional lymph nodes may need to be removed in necessary cases. In this way, it is evaluated whether there is metastasis to the related region and the tumor burden is reduced.

If suspicion of metastasis in the lymph nodes is detected through imaging methods before surgery, all lymph nodes in that region are surgically removed. However, in patients where metastasis is not detected through imaging, sentinel lymph node biopsy is performed instead of removing all lymph nodes. In this procedure, a few lymph nodes where the cancer may first spread are removed.

If the removed sentinel lymph nodes are clean (negative), no additional surgical intervention is required. If metastasis is detected, all remaining regional lymph nodes are surgically removed.

What Is Skin Cancer Surgery?

Skin cancer surgery is the process of completely removing cancerous tissue that develops on the skin through surgical methods. The aim is to remove the tumor with clean margins while preserving healthy tissue as much as possible. The procedure can be performed with local excision, Mohs surgery, or advanced surgical techniques depending on the type, size, and location of the tumor. Surgical treatment performed at an early stage provides a high success rate and a low recurrence risk.

Why does skin cancer occur and what are the risk factors?

The skin is not only the largest organ of the human body but also our first and most important defense line protecting us from the dangers of the external world. However, this barrier function exposes it directly and continuously to environmental factors, wind, chemicals, and most importantly the harmful effects of ultraviolet (UV) rays from the sun. When we examine the main formation mechanism of skin cancers, we see that the leading role is played by the damage accumulated over many years from UV exposure, which causes deterioration in the DNA structure of skin cells. While damaged or aging cells should normally destroy themselves in the biological process, in the cancer development process this control mechanism is disrupted and cells begin to multiply uncontrollably and form tumors.

There are certain conditions that prepare the ground for this cellular deterioration and make a person more prone to skin cancer. Knowing these risk factors is very important for both protection and early diagnosis.

The main factors that increase cancer risk are:

• Fair skin tone
• Light-colored eyes
• Red or blonde hair color
• Tendency to freckles
• Family history of cancer
• Presence of many moles
• Sunburns during childhood
• Long-term sun exposure
• Use of tanning beds
• Weakened immune system
• History of radiotherapy
• Arsenic exposure
• Chronic non-healing wounds
• Old burn scars

What are the most common types of skin cancer?

In our clinical practice and daily life, the skin cancers we encounter most frequently are basically grouped under three main categories. Each of these three groups has different biological behaviors and different levels of aggressiveness, and therefore the treatment strategy, surgical planning, and follow-up process we apply for each are completely different.

The first of these types is called Basal Cell Carcinoma (BCC). This type constitutes the majority of all skin cancers. The reason it is generally known as having a “more innocent” course is that the probability of metastasis, meaning spreading to other parts of the body through blood or lymph, is extremely low. However, this does not mean that BCC is insignificant. If left untreated, it has serious destructive power locally in the area where it is located. It can progress deeply by eroding the skin, the underlying fatty tissue, muscles, and even bone and cartilage.

Symptoms of BCC include:

• Pearl-like shiny bumps
• Fine vascular structures on the surface
• Ulcers with a depressed center
• Non-healing crusted areas
• Frequently bleeding lesions
• Scar-like hard areas
• Reddish patch-like regions

Our second group, Squamous Cell Carcinoma (SCC), presents a slightly different picture. It constitutes approximately one-quarter of skin cancers and can behave more aggressively than BCC. The most important difference from BCC is its potential to spread to lymph nodes and, although rarely, to other organs. It should be monitored more carefully especially when it occurs in areas such as the lips, ear, or scalp. Types that develop on old burn scars or chronic wounds that have not healed for years may progress much faster.

Symptoms of SCC include:

• Hard-based masses
• Thick crusted wounds
• Rapidly growing swellings
• Wart-like formations
• Sensitive and painful areas
• Non-healing cracks on the lip

Our third and most dangerous group is Malignant Melanoma (MM). It originates from melanocyte cells that give color to the skin. Although it is seen less frequently than others, it is responsible for the majority of deaths related to skin cancer. There is a risk of spreading throughout the body through blood and lymph even at a very early stage. Therefore, early diagnosis in melanoma is literally life-saving.

Warning signs for melanoma include:

• Asymmetrical moles
• Spots with irregular borders
• Moles containing different color tones
• Lesions larger than 6 mm in diameter
• Moles that change over time
• Bleeding or itching lesions
• Newly appearing dark-colored spots

What does the concept of surgical margin and clean margin mean?

For a plastic surgeon, the most critical moment in the operating room is when the tumor is removed and reconstruction is about to begin. However, before starting reconstruction, there is only one thing we must be sure of: Has the cancer been completely removed? This is where the concept of “Surgical Margin” or “Margin” comes into play. Cancerous tissues can sometimes be like an iceberg; beyond the part you see on the skin surface, they may have microscopic roots spreading into surrounding tissues. The surgeon’s naked eye cannot see these cells. Therefore, we must remove some surrounding tissue that we believe to be healthy together with the tumor as a safety ring around the visible borders.

This safety margin, meaning the amount of extra healthy tissue to be removed, is not determined randomly. Millimetric calculations are made depending on the tumor type, location, and depth. For example, a 3 or 4 millimeter margin of healthy tissue may be sufficient for a small, clearly defined, low-risk Basal Cell Carcinoma. However, in tumors with unclear borders, previously operated but recurrent, or aggressive structures, this distance must be much wider. In cases of Malignant Melanoma, very wide margins ranging from 1 centimeter to 2 centimeters may be required depending on the tumor depth (Breslow thickness).

At this stage, the issue that concerns our patients the most is tissue loss in the facial area. The “H-zone” of the face—nose, around the eyes, lips, and ears—is both aesthetically very critical and anatomically a risky area where tumors can easily infiltrate deeper structures. In these regions, using a method called “Frozen Section,” we cooperate with a pathologist during surgery to instantly check whether cancer cells remain at the edges of the removed tissue. In this way, we ensure the safest cleaning without removing unnecessary extra tissue.

How do aesthetic units of the face affect surgical planning?

Our face is not a random skin covering assembled together. It is a combination of parts that differ in the way they reflect light, skin thickness, color, pore structure, and underlying bone support. We call these parts “Aesthetic Units.” When planning reconstruction, the surgeon’s mental map is shaped according to these units. It is not enough to simply close the hole; the patch or suture must be hidden within the natural borders of these units.

The main aesthetic units of the face are:

Forehead

Periorbital area and eyelids

Nose

Cheeks

Lips and perioral area

Chin

Ears

Neck

Why is this mapping important? Because the human eye is programmed to follow natural boundaries and symmetry. For example, a round patch in the middle of the cheek immediately draws attention. However, a scar hidden in the natural fold between the cheek and the nose may not even be noticed while speaking. At this point, we apply a rule called the “Subunit Principle.” Especially in complex structures such as the nose, if more than half of an aesthetic subunit (for example the nasal ala) is lost after tumor removal, instead of patching only the hole, reconstructing the entire subunit usually gives a much better aesthetic result. Thus, a natural nasal wing appearance is achieved rather than a patch mark.

What are the steps of the reconstructive ladder?

After a skin cancer is removed, how the resulting defect will be closed depends on the surgeon’s experience and a decision-making algorithm called the “Reconstructive Ladder.” This ladder consists of steps progressing from the simplest and lowest-risk method to the most complex and technically demanding technique. As a rule, the simplest method that will give the best result should always be chosen. However, in facial surgery, sometimes the method that is “technically the simplest” may produce the “worst aesthetic result.” Therefore, we sometimes skip several steps and choose a more complex method that yields a better result.

The steps of this ladder are:

Healing by secondary intention

Primary closure

Skin grafts

Local flaps

Distant flaps

Free tissue transfers

The first choice is always primary closure. That means bringing the wound edges together with aesthetic sutures. This provides excellent results in small tumors. However, if the tissue loss is large and the wound edges cannot meet without tension, forcing closure may distort facial structures. It may pull the eye downward, shift the corner of the mouth, or elevate the nasal tip. If such risks exist, we move to higher steps of the ladder—tissue transfers.

What are the differences between skin graft and flap surgery?

One of the most confusing topics for patients is the difference between a “patch” and a “flap.” In fact, these two techniques are very different both biologically and aesthetically. Understanding this difference is very important in managing expectations after surgery.

Skin Graft (Patch):

A graft is the transfer of skin taken from another part of the body to the recipient area after completely cutting its vascular connections. You can imagine it like taking a layer of grass from one part of your garden—not with the soil but just the green layer with roots—and placing it onto another bare patch. The graft must survive by receiving nutrition from the underlying tissue of the area where it is placed. It does not have its own blood circulation. Therefore, its survival is more delicate. In the facial area, color and texture match may not always be perfect. It often tends to remain slightly depressed and it may be obvious that a patch was placed. However, it can be life-saving in very large areas.

Common areas where grafts are taken include:

• Behind the ear
• Eyelid
• Above the collarbone
• Inner surface of the arm
• Thigh region
• Flap Surgery:

A flap, on the other hand, is where plastic surgery truly demonstrates its power. A flap is living tissue transferred together with its own blood vessels (pedicle). In other words, the tissue is moved or rotated from one area to another while preserving its feeding vascular connection. You can think of it as moving a flower together with its pot and soil. The flower does not wither because its source of nutrition remains intact. In local flaps, healthy and flexible skin located right next to the tumor removal site is used, and the color match is nearly identical.

Advantages of flap surgery include:

• Excellent color match
• Preservation of tissue thickness
• Faster healing
• No depression in the repaired area
• Own blood circulation
• Ability to nourish exposed bone or cartilage

Which special techniques are used for nasal reconstruction?

The nose is located in the very center of the face, impossible to hide, and directly determines facial expression. At the same time, due to its uneven structure and the presence of both thin and thick skin areas, it is one of the most challenging regions to reconstruct. The goal in nasal surgery is not only to close the defect but also to preserve the openness of the nostrils, maintain breathing function, and recreate the characteristic contour of the nose.

Techniques used in nasal reconstruction include:

• Bilobed flap
• Rieger flap
• Nasolabial flap
• Paramedian forehead flap
• Composite grafts

The Bilobed Flap is very frequently preferred especially for small to medium-sized defects on the nasal tip and alae. This technique is based on moving the skin on the nasal dorsum downward with geometric planning. Thanks to its two-lobed structure, it distributes tension and prevents the nasal tip from being pulled upward.

In larger and deeper defects, especially those involving the entire nasal tip or nasal wings, the gold standard of surgery—the Paramedian Forehead Flap—is used. The forehead skin is the tissue that most closely resembles nasal skin in terms of color, pore structure, and thickness. In this technique, a strip of skin with a vascular pedicle located between the eyebrows is lifted from the forehead and rotated onto the nose. This procedure is usually performed in stages. In the first surgery, the tissue is adapted to the nose and allowed to survive there. Approximately three weeks later, when the tissue has adapted to its new location, the vascular pedicle is divided and the nose is shaped. Although the idea of “taking tissue from the forehead” may initially seem frightening to patients, the results are so natural that once healing is complete it may be almost impossible to tell that surgery was performed.

What should be considered in lip and eyelid reconstruction?

Unlike other facial regions, the lips and eyelids are dynamic structures that are constantly in motion. They function continuously while eating, speaking, or blinking. Even millimetric errors in cancer surgery in these areas can lead to serious functional loss. Therefore, the reconstruction plan is made according to the principle of “function first, then aesthetics,” although in most cases the two are intertwined.

• Lip Reconstruction:

The most important role of the lip is to maintain oral opening and create a seal during eating and drinking. While removing lip cancers, the integrity of the muscle ring (orbicularis oris) that surrounds the mouth and enables contraction must be preserved or repaired. In small losses, reconstruction can be performed with “V”-shaped excisions, while in cases where a large portion of the lip is lost, tissue transfer from the opposite lip is performed.

Methods used in lip reconstruction include:

• Wedge excision
• Karapandzic flap
• Abbe flap
• Estlander flap
• Bernard flap

For example, for a large defect in the upper lip, a piece of tissue from the lower lip is rotated upward while preserving its blood supply (Abbe flap). During this period, the patient may not be able to open the mouth fully for a while, but after the tissue heals, a second procedure separates the lips and a new lip with both sensation and movement ability is created.

• Eyelid Reconstruction:

Here, the only and absolute priority is protecting the eye, specifically the cornea. When the eyelid cannot close (lagophthalmos), the cornea dries, ulcerates, and this condition may progress to blindness. The eyelid consists of an inner smooth membrane, a firm cartilage-like structure in the middle, and very thin skin externally. In reconstruction, each of these layers must be recreated separately.

Eyelid techniques include:

• Tenzel flap
• Mustarde flap
• Hughes flap
• Tripier flap
• Skin grafts

Especially in large lower eyelid defects, a wide tissue segment lifted from the cheek (Mustarde flap) is transferred under the eye, which both lifts the cheek and reconstructs the eyelid.

When is microsurgery and the free flap method necessary?

In some cases, the tumor spreads over such a large area or penetrates such deep tissues (bone, nerves, large muscle groups) that the local tissues of the face or neck are insufficient to close the defect. Local flaps are not long enough, and there is not enough skin. At this point, microsurgery and free flap applications—considered the pinnacle of plastic surgery—come into play. This is the technology that allows the closure of wounds once considered “impossible.”

In the free flap method, the required tissue block is taken from a completely different and distant part of the body. This tissue may consist only of skin or may include muscle, bone, or all of them together. The harvested tissue is completely detached from the body together with the main vessels that feed it. It is then transferred to the recipient site on the face and connected to vessels in the face or neck under a microscope using sutures thinner than a strand of hair. This process restores life and blood flow to the tissue.

Common free flap donor areas include:

• Forearm region
• Anterolateral thigh
• Fibula bone (leg)
• Back muscle
• Abdominal tissue
• Scapular region

For example, if the entire lower jawbone must be removed due to a tumor, bone and skin tissue taken from the leg (fibula) can be shaped into the jaw and transplanted to the face. In this way, the patient regains a jawbone, becomes suitable for dental implants, and the inner mouth lining can also be reconstructed with the transferred skin.

What is malignant melanoma and sentinel lymph node biopsy?

Malignant melanoma surgery is not limited to removing the tumor visible on the skin—the visible part of the iceberg; it also requires mapping the spread of the disease in the body. The most common and first pathway through which melanoma spreads is the lymphatic system. In the past, lymph nodes in the area where the tumor was located (armpit, groin, or neck) were completely removed “as a precaution.” However, this procedure caused serious lymphedema (swelling of the arm or leg) in patients and was often unnecessary.

Today, this approach has changed. We now use a much more precise method called Sentinel Lymph Node Biopsy (SLNB). This procedure is essentially an intelligence study. The logic is simple: Which node is the first “sentinel” station that a cancer cell would encounter after entering the lymphatic system? If this first station is clean, it means the other stations behind it are also clean.

The stages of the procedure are:

• Preoperative mapping with lymphoscintigraphy
• Blue dye injection
• Scanning with a gamma probe
• Identification and removal of the sentinel node
• Pathological examination

During surgery, the surgeon locates this sentinel node using a special detector and blue dye and removes only that node. The pathologist examines it. If the result is clean, the patient is spared from a large lymph node surgery and the lifelong risk of arm or leg swelling. If involvement is detected, the treatment plan is reorganized together with oncology.

What are the ways of scar management and protection after surgery?

The greatest and most understandable concern of every patient undergoing facial surgery in plastic surgery is whether a scar will remain. An honest and realistic medical approach is very important here. In any procedure where the skin is cut through its full thickness and touched by a scalpel, a scar will inevitably remain. There is no such concept as “scarless surgery” in the world; there are “indistinct scars” or “well-hidden scars.” Our task is to hide this scar within the natural folds of the face and make it fade over time.

Wound healing is not a process that ends on the day the sutures are removed. On the contrary, it begins on that day. The maturation of a scar and reaching its final form takes an average of one year depending on the person’s genetic structure. In the first months, scars may appear red, slightly raised, and firm. This shows that the body is producing intense collagen to repair the area. Over time, usually after the sixth month, the color begins to fade, the tissue softens, and it starts to match the skin tone.

Methods used in scar treatment include:

• Silicone-based gels
• Silicone sheets
• Steroid injections
• Laser treatments
• Dermabrasion
• Microneedling
• Absolute sun protection
• Massage applications

Perhaps the most important issue is future protection. A patient who has had skin cancer once has proven that their skin is sensitive to the sun and genetically or structurally prone to DNA damage. For these patients, sun protection should become a daily routine like brushing teeth rather than just a “summer vacation” precaution.

Protection measures include:

• Using high-factor sunscreen
• Wearing wide-brimmed hats
• Staying in the shade during midday hours
• Full-body mole examination once a year
• Self skin examination