Moles

Moles are collections of melanocytes which are the cells which produce pigment (the brown skin colouring) in the skin.  Moles may be any colour between pale pink and dark brown to black.  They are also sometimes called naevi.  Most moles can be safely left alone but many people seek to have them removed for cosmetic reasons.  These may be removed by tangential excision or elliptical excision (see below for explanation).

‘Moles’ that enlarge, change, have variable colouring, irregular borders, that bleed, itch should be assessed by a doctor to ensure they are not a melanoma which is a serious form of skin cancer.

Moles and other lesions may be removed for several reasons. Diagnostic, symptomatic, preventative or cosmetic.

Diagnostic i.e. What is it? Could it be serious?

A skin lesion, such as a mole, may difficult to distinguish from a serious condition such as a skin cancer. Some skin cancers, for example melanoma, can be very serious. Removing the mole for assessment in the laboratory may be necessary to make a diagnosis. This is called an excision biopsy.

Symptomatic i.e. My mole is a nuisance I would like it removed!

Some moles and other lesions can cause problems. They may itch or even be painful. They may bleed or catch on clothing. They may become infected from time to time. These would be considered symptomatic and this may be a reason to remove them. Symptoms may also raise the question of diagnosis and whether it should not be removed to be sure it is benign.  Some lumps are tender or painful and removing them may relieve the discomfort.  Lumps which suddenly appear, start growing or are painful should be checked by a doctor.

Preventative i.e. This mole is likely to cause a problem in the future.

Lesions that repeatedly cause problems or where there is a concern that they may change into a more serious problem later may be removed to prevent them doing so. This would be preventative or prophylactic surgery.

Cosmetic i.e. I do not like it and I would like it removed.

Moles and other lesions are frequently considered unsightly and many people ask for them to be removed for cosmetic reasons. It must always be appreciated that the lesion will be exchanged for a scar. Scarring varies from one person to another and so the outcome of a scar must always be considered uncertain.

There are two main techniques for removing moles and skin lesions. These are tangential excision and elliptical excision. Large moles may require more complex approaches such as serial excision (more than one operation) and may rarely require local flaps or skin grafts. 

Tangential excision & cautery

Tangential excision involves removing the lesion flush with the skin surface.  This leaves a circular area, which is usually cauterised to prevent bleeding.  The area left behind is usually slightly larger than the original lesion (e.g. mole).  A dry crust forms under which the skin heals.  The crust falls off after about 5-10 days leaving a pink mark.  The pink mark usually fades over several months, but can stay pink for longer. Tangential excision does not remove hair roots so if hair growth was an issue prior to surgery it should be assumed that hair will still grow following surgery.

This is similar to curettage and cautery, or shave excision and some people would consider them equivalent.

Elliptical excision – (Surgically cut out the whole mole)

With an elliptical excision the skin is removed with an ellipse of skin.  The elliptical incision is then closed with stitches.  The stitches may be absorbable (dissolving) and placed under the skin or may be on the surface and need to be removed, usually after about one week.  For moles the scar is usually about 3 times as long as the original mole was wide. 

Recovery varies with the technique used to remove the mole.

Tangential excision

This leaves a circular area which is usually cauterised to prevent bleeding.  The area left behind usually slightly larger than the original lesion.  A dry crust forms under which the skin heals.  The crust falls off after about 5-10 days leaving a pink mark.  The pink mark usually fades over several months, but can stay pink for longer.

Elliptical and linear excision

The area will be tender for a few days.  There may be some swelling and bruising.  This usually settles over 7-10 days.  Sometimes bruising can last longer.  Stitches may need to be removed after about one week.  The wound should be considered weak for 4 weeks and should be protected.  After 8 weeks it reaches its full strength.

Scars that are less than a year old should be protected from the sun.

The following describes the principal complications of skin lesion removal type procedures; it does not cover all possible complications.  Patients who smoke or who have medical problems such as diabetes are more likely to suffer complications.

Bleeding and haematoma (build-up of blood under the skin)

Occasionally bleeding does occur after the operation and a second operation may be necessary to remove the build-up of called a haematoma.  If this does occur a normal recovery usually takes place after the blood has been removed.

Infection and wound break down

Infection may complicate any operation.  It is unusual in facial operations as the facial skin has an excellent blood supply. Infected wounds can open up or require opening up. Infection can result in a worse scarring, deformity and a worse result.

Poor scarring

Scars can stretch, be lumpy, stay pink or become brown (pigmented).  Hypertrophic scars are thick red lumpy scars which may take months or even years to settle and fade.  Keloid scars are like hypertrophic scars but grow beyond the area of the original scar.  Keloid scars are difficult to treat although they may respond to steroid injections.

Incomplete excision and recurrence

The laboratory report may indicate that a mole or lesion has not been completely removed.  If it was a benign lesion then it is usually best to wait and see if it grows back (usually it does not).

Sometimes a lesion grows back, even where the laboratory report indicates they have been completely removed.  If this happens it is advisable to have it checked by a doctor.

Altered sensation, numbness, tingling, tenderness and pain

With surgery of the skin it is rare that nerves in the area are permanently affected. However, is possible to find the area where a lesion is removed feels different or numb. It can also be tingling, tender or even painful. Usually these symptoms settle down over a few weeks but sometimes they can take longer or even become long lasting.

Residual brown colouring (pigmentation) and recurrent hair growth

Some pigmentation may remain with tangential excisions.  Tangential excisions usually will not prevent hair growth if the original mole was hairy. 

Excision leaving a depression

Tangential excision may leave a permanent depression at the site of the excision.

Moles and lumps are routinely sent for analysis in a laboratory where they are examined by a consultant pathologist (doctor trained in the analysis of tissue samples).  This is called histopathology. It typically takes 10 to 14 days although can take longer if specific tests are required.

Histopathology increases the costs.  Under some circumstances with moles or lesions that have entirely benign features you can discuss with your surgeon if histopathology is necessary. If you may ask that the sample is not sent for analysis there is a small risk that an opportunity to make an important diagnosis, such as skin cancer, is missed and that the cancer is not adequately removed.

There are alternatives to surgical removal of a mole or other skin lesion.

Do nothing

Benign moles, cysts and other small lumps may not need to be removed for medical reasons.

Cosmetic camouflage

Cosmetic camouflage can be effective in covering up some skin marks.

Laser treatment

Laser treatment may be helpful for some skin lesions.  Caution should be exercised with any brown/pigmented lesion as a diagnosis should be made before treatment.  Some marks caused by blood vessels may respond well to lasers.