There are several reasons to remove moles. Sometimes they can appear to be a disfigurement, or they may prove to be an inconvenience for example, for men while shaving. In other cases, they can form the basis for suspicion of skin cancer. Reasons to think of skin cancer are collected in the mnemonic “ABCD”: Asymmetrical shape, irregular Boundary, a different Colour when compared to the standard brown (e.g. blue or very black) and Diameter larger than 6mm. In such cases, it is advisable to remove the mole and send it away to be investigated. This will often be reimbursed. If the mole is to be removed for cosmetic purposes, the costs will not be reimbursed. If a mole is removed, you will almost always be left with a scar. The trick is to apply a number of tricks to make the scar as inconspicuous as possible. Plastic surgeons are especially trained to use these tricks. A number of important considerations when creating the best looking scar are: planning the direction of the scar, tissue sensation (tissue handling), suture material and the technique.
Planning of the direction of the scar
When drawing up the mole removal, the first thing to do is look at the so-called “skin lines”. These are the lines in which the skin tends to bend. The crow’s feet at the corners of the eyes and the smile crease from the nostril to the corner of the mouth are examples of easily recognisable skin lines. In other places, such as the chin or the back, skin lines can be more difficult to detect, but they are always there. A scar heals best when it is parallel to the skin lines. Then the scar can be hidden away between the lines in the skin. Moreover, the face is organised into so-called “aesthetic units”. This means that it is made up of different parts, for example: the nose is a different “unit” than the nostril. Scars are least noticeable when they are located on the boundaries of these units. A scar along the rim of the nostril will be almost invisible, while a scar across the nostril, is much more noticeable. All of this will be taken into account when planning the removal of the mole and the direction of the stitches.
A sharp wound usually heals better (and therefore, more attractively) than a rough wound. Therefore, when cutting into the skin, it is important to create an attractive, straight, sharp edge to the wound. Furthermore, it is important to work with delicate instruments – these are best since it often concerns small areas that need to be removed. The rougher the tissue is handled, the more uneven it will heal. A plastic surgeon is trained to handle tissues carefully so that the most attractive finish can be achieved.
Suture material and technique
Finally, it is important to work with very fine needles and threads. If possible, sutures will be placed under the skin to avoid accidental needle punctures in the skin. Sometimes dissolvable sutures will be used, sometimes not; this will depends on the location of the wound (in the face, wounds tend to heal better with insoluble sutures; on the chest, soluble sutures are often better), the tightness of the skin, etc. All of these things are taken into consideration when choosing the type of suture that is to be used and the bonding technique applied.
Larger moles/skin cancer
If skin cancer is suspected, it may be necessary to remove more skin. If the affected area is located on the back or the abdomen, the wound can often be closed, but a 1x1cm wound on the nose presents a different challenge. A trick must be applied to close the wound attractively. This is possible with a skin graft, whereby a piece of skin is removed from somewhere on the body and placed over the wound in order to grow. This does not lead to the most attractive scar. Also, the skin on your face is often a slightly different colour and texture than the skin from your abdomen. As plastic surgeons, we always try to use the skin from around the wound. This is also known as “Replace like for like”; replacing that which has been removed with that which resembles it the most. We do this by applying certain plastics. Again, taking into account the skin lines, skin blood flow, places where there is excess skin that can be easily moved, tensile direction, etc. On the skin of the forehead, the lines are quite horizontal for example. This means that scars on the forehead will also run horizontally so that you hardly see them. If there is a serious defect because a mole or skin cancer has been removed, it is best to close the wound on the forehead with skin from the forehead, which is often shinier and thicker than skin from elsewhere on the body. In order to make the scarring as horizontal as possible, a so-called “H-plastic” is used.
Different rules apply to the nose. Here you want the scars to run along the borders of the aesthetic units because there they are harder to spot. As the units of the nose often have rounder shapes, a defect on the nose will usually be closed with rounded plastic; a so-called “bilobed flap” (because it has two “lobes”). This is a kind of pivot door, where skin is removed from a place where it is abundant (the bridge) and moved to a place where it is sparse (the tip of the nose).
These plastics are rarely, if ever, required when a mole is removed and only really necessary for skin cancer. The plastic surgeons working at Blooming are all closely involved in the treatment of skin cancer in the hospital at RKZ Beverwijk or KG Haarlem. The experience they have built up there in treating skin cancer and carrying out the associated reconstructions is particularly valuable when applied to the treatment of other skin disorders.