Melanoma: Surgery

Surgery is the most common way to treat melanoma. It might be the only treatment needed for early stage melanomas. It's often part of the treatment for more advanced cancers. Surgery is done to remove any area that has melanoma cancer cells. The type of surgery often depends on the location, size, and number of melanoma tumors present. Surgery may be done by a healthcare provider specialist, such as a:

• Dermatologist

• General surgeon

• Plastic surgeon

• Cancer surgeon (surgical oncologist)

Types of surgery for melanoma

The types of surgery include:

• Wide local excision. This surgery is done to remove all of the melanoma and some normal tissue around it. The normal tissue is called a surgical margin. It is measured in centimeters (cm). This can help keep the melanoma from growing back. The surgery takes place after a biopsy to confirm the diagnosis of melanoma. The biopsy results also help the healthcare provider decide how much tissue needs to be removed in the surgery. The surgery usually is done in a in a healthcare provider's office or in an operating room in a hospital's outpatient clinic. Surgery for early stage melanomas is usually done with local anesthesia, which numbs the area. For deeper or more advanced cancers, your provider may use general anesthesia so you are asleep during the surgery. If your provider needs to remove a lot of skin, you may need a skin flap or skin graft. For a flap, the surgeon uses nearby tissue to cover the surgical area. For a graft, the surgeon takes skin from another part of your body to replace the skin that was removed. The surgeon typically uses stitches to close small excisions. The tissue removed is sent to a pathologist. They will look under a microscope to make sure the entire melanoma was removed. If not, you may need additional surgery.

• Sentinel lymph node biopsy. You may need a sentinel lymph node biopsy if you have a thick melanoma (more than 1 millimeter) or one with features that make it more likely to have spread. This procedure is usually done at the same time as the wide local excision and removes nearby lymph nodes to check for cancer cells. It’s done because melanoma often spreads first to the lymph nodes. In a group of lymph nodes, cancer is most likely to go to one or two lymph nodes first. These lymph nodes are called sentinel lymph nodes. During the procedure, a surgeon will locate the sentinel lymph nodes(s), inject radioactive substance near the melanoma and then remove a sentinel lymph node. It’s then examined in a lab for cancer cells. If no cancer is found, the other lymph nodes in the group can be left in place. Results of a sentinel lymph node biopsy help your provider figure out what treatment you may need.

• Lymph node dissection. If lymph nodes near the melanoma are enlarged or if cancer is found in the sentinel node, you may need more surgery to remove nearby lymph nodes in the area. This surgery is known as a lymph node dissection. The goal is to remove any disease that may be in other lymph nodes to keep the cancer from spreading or coming back. This may be done using general anesthesia.

• Amputation. If the melanoma is on your finger or toe and would be hard to remove, the surgeon may suggest removing part of or all of the finger or toe. 

• Mohs Surgery. In some cases, Mohs surgery may be considered, but this varies by provider. Mohs surgery is done by a specially trained dermatologist or surgeon. The skin and melanoma is removed in layers. Each layer is then looked at with a microscope. If cancer cells are seen, the surgeon removes another layer of skin. This is a slow process, sometimes taking hours, and is repeated until a layer shows no signs of cancer.

Surgery by stage of melanoma

Some surgeries work better for certain stages of melanoma. For example:

• Stage 0, I, or II melanoma. Wide local excision surgery is the standard treatment. The surgeon removes the tumor and some of the normal tissue around it. Without surgery, melanoma could spread to other parts of your body. For some stage I and II melanomas, the surgeon may advise a sentinel lymph node biopsy. If cancer is found in the sentinel lymph node, the surgeon may also remove more nearby lymph nodes (lymph node dissection).

• Stage III melanoma. You may need a sentinel lymph node biopsy or a lymph node dissection. You'll also have wide local excision surgery to take out the tumor.

• Stage IV melanoma. Your provider may suggest surgery to remove melanoma tumors and limited metastatic tumors (melanoma has spread to only a few distant sites) and ease symptoms caused by advanced melanoma. If surgery is not a treatment choice, it is called unresectable.

Your provider will talk with you about which surgery will work best for your stage of melanoma.

Before and after surgery

Talk with your healthcare provider about what kind of surgery is the best choice for you. Ask any questions and address any concerns you may have. You may still need other types of treatment before or after surgery.

Surgery is most often in a provider's office or a hospital’s outpatient clinic. You’ll be able to go home the same day. For more complex surgery, you may need to stay overnight in the hospital. 

It will take a couple of weeks for your incision to heal. During this time, you may have:

• Bruising

• Minor pain

• Redness and swelling of incision site

• Infection

• Swelling in  an arm or leg (lymphedema) after having lymph nodes removed

• Scarring

Talk with your healthcare team about what to expect. Make sure you know what symptoms to report. If you’ve had skin flaps or grafts, your team will tell you how to take care of them as they heal.