Surgery for melanoma skin cancer

Most people with melanoma skin cancer will have surgery. The type of surgery you have depends mainly on where the cancer is located and the risk that the cancer will come back (recur). When planning surgery, your healthcare team will also consider other factors, such as your age, your overall heath and how surgery will affect how you look.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour
• repair or rebuild the area where the cancer was removed
• remove lymph nodes
• reduce pain and relieve any symptoms (called palliative surgery)

The following types of surgery are used to treat melanoma skin cancer. You may also have other treatments before or after surgery.

Wide local excision removes the cancer along with some normal tissue around it (called the surgical margin). It is a standard treatment for most melanoma skin cancers. Doctors mainly use wide local excision to treat early stage and locoregional melanoma skin cancer. It may be the only treatment needed for early stage melanoma skin cancer. Wide local excision may also be used to treat melanoma skin cancer that has come back in the same area where it started (local recurrence) or spread to other nearby areas of skin (satellite tumours).

The size of the surgical margin increases with the thickness of the tumour. The following are recommendations used by surgeons for the size of surgical margin when doing a wide local excision of melanoma skin cancer. Sometimes a smaller surgical margin than recommended may be used for thick tumours on the head or neck area.

If melanoma skin cancer is on a finger or toe, sometimes part or all of the finger or toe is removed (amputated) to make sure all the cancer has been removed. Whether amputation is needed or not depends on where the cancer is located on the finger or toe, and how deep it has grown into the skin and other tissue.

For a wide local excision, a local anesthetic is used to freeze or numb the area. The doctor uses a surgical knife (scalpel) to cut out the cancer from the skin. The area is closed using stitches. The tissue removed is sent to a lab to make sure there are no cancer cells in the surgical margin and that all the cancer has been removed.

An SLNB finds and removes the first lymph node (or first few lymph nodes) in a group of lymph nodes to see if it contains cancer cells. It is normally done right before the wide local excision. It is mainly done to help stage the cancer and decide if more treatment would be helpful.

An SLNB is often done when the melanoma skin cancer is more than 1 mm thick. It’s only done if the doctor does not feel enlarged lymph nodes and a lymph node biopsy or imaging tests show that lymph nodes don’t contain cancer cells. Doctors may also consider doing an SLNB for slightly thinner tumours (0.75 mm to 1 mm thick) that are ulcerated or have a mitotic rate of more than 1/mm².

Find out more about a sentinel lymph node biopsy (SLNB).

A complete lymph node dissection is surgery to remove several lymph nodes from the body. It can be done at the same time as a wide local excision or during a second surgery. It is usually done if the doctor feels any enlarged lymph nodes and a lymph node biopsy or imaging tests show that lymph nodes contain cancer cells. It may also be done if a sentinel lymph node biopsy shows there are cancer cells in the sentinel lymph node (or lymph nodes).

Melanoma skin cancer usually spreads to lymph nodes closest to where it started (called the nodal basin or lymphatic basin). The type of complete lymph node dissection done depends on which lymph nodes and how many lymph nodes contain cancer. This may include the following:

• neck dissection to remove lymph nodes from the neck
• axillary lymph node dissection to remove lymph nodes from under the arm (armpit)
• inguinal lymph node dissection to remove lymph nodes from the groin
• pelvic lymph node dissection to remove lymph nodes from the pelvis or deep in the groin

A complete lymph node dissection is done using a general anesthetic in a hospital operating room. The surgeon makes a cut to remove lymph nodes. Other nearby tissue may also be removed.

Find out more about a lymph node dissection.

Reconstructive surgery is done to help improve how the skin looks after surgery to remove the tumour. Sometimes the doctor has to remove a large area of skin to make sure all of the cancer is gone. You may need reconstructive surgery to fix the area and make it look better.

A skin graft is a piece of skin taken from another part of your body (called the donor site) and placed over the area where the cancer was removed. It is usually done by a plastic surgeon at the same time as the wide local excision.

The surgery is done using a local anesthetic (freezing) or general anesthetic (you will be unconscious). The surgeon removes skin from the donor site, such as the inner thigh or buttock. The skin graft is placed over the area where the cancer was removed and stitched in place. Both the skin graft and donor site are covered by a bandage and sometimes you are given stitches or staples. The skin graft usually takes 1 to 2 weeks to heal. Your healthcare team will tell you how to protect and care for the skin graft while it heals.

A skin flap is a thick piece of tissue with its own blood supply. Like a skin graft, a skin flap covers the area where the cancer was removed. A skin flap can be used to repair large wounds on the face.

The surgeon takes the skin flap, which includes skin, fat and sometimes muscle, from an area close to where the cancer was removed. The skin flap often remains partly attached to its original location and blood vessels are still connected. In some cases, the skin flap is completely removed (called a free flap) and the blood vessels of the skin flap need to be connected to vessels at the new site. The skin flap is positioned over the wound and stitched in place.

Surgery may be done to remove melanoma skin cancer that has spread (metastasized) to only one area or a few areas on or just under the skin, or in the lung, liver, brain or small intestine. The type of surgery done will depend on which distant organ the cancer has spread to. Surgery for metastases is often called surgical excision or resection.

Find out more about metastatic cancer.

Side effects can happen with any type of treatment for melanoma skin cancer, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery, where on the body the surgery is done and your overall health. Surgery for melanoma skin cancer may cause these side effects:

• pain, which is often managed with pain medicines
• scarring
• bruising
• changes to skin colour
• wound infection
• numbness
• poor healing
• lymphedema (after a lymph node dissection)

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.