I am a member of the Local Skin Cancer Multidisciplinary Team (LSMDT) at Solihull Hospital and regularly undertake excision and reconstruction of non-melanoma skin cancers (basal cell carcinoma and squamous cell carcinoma), as well as post-Mohs micrographic surgery reconstruction. In the final year of my training, I undertook a Training Interface Group (TIG) Fellowship in the Management of Skin Cancer at Leeds Teaching Hospitals NHS Trust and trained in the full remit of skin cancer management including experience with sentinel node biopsy for malignant melanoma. My clear margin rate for non-melanoma skin cancer (NMSC) is in excess of 98% and I have performed over 2,000 skin cancer procedures to date. In a recent survey in my NHS practice, I received the following feedback:

• Satisfaction score (mean) for overall treatment and care: 5/5
• Satisfaction score (mean) for the cosmetic appearance of reconstructive surgery: 4.8/5

The term skin cancer refers to uncontrolled proliferation of cells within the skin to allow the formation of growths or tumours. There are lots of different types, but the commonest are basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs) and melanomas. Other forms, such as Merkel cell carcinomas (MCCs), atypical fibroxanthomas (AFX), pleomorphic dermal sarcomas (PDS) and many others are less commonly seen. As a member of the Local Skin Cancer Multi-Disciplinary Team (LSMDT) at Solihull Hospital (part of University Hospitals Birmingham NHS Foundation Trust), I am well placed to diagnose and treat many skin cancers in the head and neck region.

There are a plethora of techniques used in the management of skin cancer including cryotherapy, topical chemotherapy, curettage & cautery, electrochemotherapy, radiotherapy, chemotherapy, immunotherapy and targeted therapy.

In 2018 I undertook a Training Interface Group (TIG) Fellowship in the Management of Skin Cancer at Leeds Teaching Hospitals NHS Trust, one of only two units in the United Kingdom to offer the placement. This enabled me to be part of a leading Specialist Skin Cancer MDT (SSMDT) working alongside specialists in Plastic and Reconstructive Surgery, Dermatology and Clinical Oncology. As such, I understand that there is no “one size fits all” approach and try to make sure I see the whole patient and not just the skin cancer to decide on the right treatment.

My TIG Fellowship enabled me to gain experience in the full remit of skin cancer treatments, including non-surgical options. I have also been trained in the use of dermoscopy for diagnosis. As a surgeon, the treatment I am most commonly charged with providing is surgical excision.

In conventional surgery, the skin cancer is removed along with a pre-determined margin of normal, healthy tissue. The specimen is sent for examination under a microscope by a dermatopathologist to ensure that the whole lesion is removed. My personal clear margin rate for this type of surgery performed in Birmingham and Solihull is 98.5% for non-melanoma skin cancers (NMSCs).

Removing the lesion is arguably the “easy bit” however. The hard bit is providing a reconstruction using techniques such as local flaps (moving skin from nearby from areas of laxity) and skin grafts. My aim is always to restore form and function and as a clinician who completed higher surgery in Oral and Maxillofacial Surgery along with TIG Fellowships in both the Management of Skin Cancer and Reconstructive & Aesthetic Surgery, I aim to use to use all the tips and tricks at my disposal to provide a result my patients are happy with.

I currently perform around 150-200 skin cancer excisions per year across my practice in Birmingham and Solihull and attend the LSMDT on a fortnightly basis to discuss cases and results. Most of these are provided under local anaesthesia (awake), however I can arrange for surgery to take placed under sedation or general anaesthesia (asleep) if appropriate.

I aim to ensure that the most painful thing about the surgery is my music choice, although I will usually ask patients what they would like to listen to spare them what my nursing staff affectionately describe as “weird jazz”.

All surgery carries risks and skin cancer excisions are no exception. The risks of surgery can include scarring, hypertrophic or keloid scarring (red, raised and/or lumpy scars), temporary or permanent numbness and/or weakness, incomplete excision and need for further treatment. I do my very best to ensure that my patients leave satisfied with the cosmetic outcome of safe resections so that they can forget about the surgery and get on with living life!

A Multi-Disciplinary Team or MDT is a coalition of clinicians from various specialties that come together to discuss cases where there may be no clear-cut answers or where greater degrees of transparency are necessary to ensure standardization of treatment. Skin cancer MDTs can be of two types: Local Skin Cancer MDTs (LSMDTs) and Specialist Skin Cancer MDTs (SSMDT). I am a member of the LSMDT at Solihull Hospital, which means that I treat non-melanoma skin cancers (NMSCs) such as basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) and melanomas up to stage IA. Our LSMDT includes clinicians from specialties as diverse as Dermatology, Otorhinolaryngology and Plastic Surgery. I attend fortnightly as a minimum and ensure all my relevant cases are discussed and benefit from a collaboration of opinions from people I trust and admire.

During my TIG Fellowship I did form part of an SSMDT and was trained in the full range of melanoma care including sentinel node biopsy and block dissections of lymph nodes, as well as the care of patients with rarer skin cancer types. This does not form part of my clinical practice any longer due to my commitment to other sub-specialties, but I am comfortable in making an initial diagnosis and referring onwards to SSMDT colleagues where required for more advanced cancer cases.

Mohs micrographic surgery (MMS) is a technique used for tumours in high-risk areas (e.g. close to the eyelid, involving the nose) and/or tumours that might have more aggressive features. The technique involves examining the specimen in “real time” whereby multiple rounds of surgical excision are employed, interspersed with examination of each specimen under the microscope. This ensures that the resulting defect is kept as small as possible and that more of the margin is examined than in conventional surgery, improving cure rates.

I work closely with a number of colleagues who perform this surgery and provide a reconstructive service for them, repairing the defects created once the margin is clear. I have recently been invited to co-author a chapter on MMS for a leading surgical reference textbook due for publication later this year. As a TIG Fellowship-trained clinician, I can identify who can benefit from this technique and make the necessary arrangements to work in conjunction with Mohs ablative surgeons to ensure that patients have access to MMS when required.

The images below demonstrate the steps involved in the ablative process of MMS.

If you have had a BCC completely excised, we will likely only have one further appointment to make sure you are happy with the cosmetic outcome and to give you the results of your histology. If you have an SCC or melanoma, follow-up provided will be in line with national guidance and either shared between myself and your referring dermatologist or completely under my care if that is your preference.