Question 1: What exactly is a mole? Will it become malignant? Answer: The scientific name of nevus is melanocytic nevus, which is a benign neoplasm formed by melanocytes gathering locally. Almost everyone has it, and it is found at all ages, and those that have it at birth are congenital pigment cell nevus. Some of them are hairy (hairy nevus is not equal to malignant), may protrude from the skin, and the color may be tan, blue-black, black, or close to normal skin color. They are generally categorized as junctional nevi, intradermal nevi and mixed nevi. Performance of benign nevus: stable size and color, consistent color, neat edge, smooth surface. The possibility of malignant transformation of a benign nevus is extremely small (about 1%), so there is no need to worry too much. Figure: Melanocytic nevus, the right picture is a recurrence of nevus even after repeated laser treatments, in fact, laser treatment is no longer recommended for this size of nevus, and surgical excision should be preferred (the blue line on the edge is the demarcation line before surgical excision) However, it is true that quite a portion of malignant melanoma is originated from nevus, and the risk factors include: large size of the nevus (giant nevus), traumatic injury and irritation, excessive sun exposure, aging (malignant transformation mainly occurs in). (malignancy occurs mainly in adults over 30 years of age and in the elderly; it is rare in young people and in children). When a mole becomes malignant, there is often mild local tingling, burning, satellite foci at the edges, sudden increase in size, deepening of color, redness and inflammation, ulceration and bleeding, and vigilance is needed. Possible malignancy or biopsy-confirmed malignancy needs to be surgically excised as soon as possible if possible. The final diagnosis needs to send the lesion to pathological examination after excision, which needs to be differentiated from pigmentation, seborrheic keratosis, basal cell carcinoma, fibroma and so on. Pictures in the upper row: benign nevus, features: symmetry, neat edges, single color, small area, relatively stable Pictures in the lower row: malignant melanoma, features: asymmetry, uneven edges, mottled color, large area, growth and change Question 2: Is it better to have a nevus lasered or surgically excised? A: The two treatments of laser and surgery are for moles of different sizes and depths, and cannot replace each other. If the nevus is small and shallow (less than 3mm, above the superficial dermis), laser treatment can be used because the wound formed after laser cauterization is small and shallow, and the skin can heal by itself. The advantage is that the treatment does not need to extend into normal tissue, no stitches are required, and recovery tends to be faster than surgery. Laser treatment should be thorough, otherwise residual mole cells are prone to recurrence, and repeated laser treatments of more than 3-4 times on the same area are not recommended. For larger and deeper moles (more than 3mm, below the deep dermis), surgical excision is required. At this time, if laser treatment is performed, the traumas formed will be large and deep, and the skin will not be able to heal on its own, and eventually a flaky scar will be formed (similar to larger and deeper burns). Moreover, the diagnosis of large nevus is often complicated, and it needs to be identified with some other lesions. If laser treatment is used, it is not possible to do pathological examination, which is not able to confirm the diagnosis nor to know whether the burn is cleaned up or not, and it is not of any guiding significance to the future prevention and observation. If the area of nevus is relatively large, but the color is light, the location is special, and the patient is very afraid of surgery, laser treatment can be tried once or twice, if it is ineffective, it should not be stimulated repeatedly. Question 3: Will the mole leave a scar after removal? Can it not leave a scar? A: Doctors have only one answer: the surgery will definitely leave a scar. The only international studies that have found no scarring are in lower animals (such as geckos) and fetuses developing in the womb. However, the patient and the doctor are not talking about scarring. When patients talk about scarring, they are often referring to red, wide, prominent, or even pinpointed, centipede-like scars, such as the one on the left in the picture below, which is the result of a traumatic injury with rough stitches. Scars created by a plastic surgeon’s fine sutures, like the right picture below, are more of a “trace”. The scar that forms between the sections of the incision is necessary for the surgical incision to heal, and this internal, invisible scar is like the glue that holds the incision together, as in the case of diabetic and malnourished patients who do not have enough scarring for the incision to heal for a long period of time after the surgery. The “overflow” of scarring on the surface of the incision is visible from the outside, and is aesthetically displeasing. Too much scarring is called “hyperplastic scarring”, which neither the patient nor the surgeon likes to see, and will try to keep it as light as possible. How can we prevent this type of scarring? For a long time, we have been induced by businessmen to believe that scar prevention is as simple as applying some imported/expensive/preferred scar medication, and then everything will be fine, which is extremely wrong and lazy thinking. Scar prevention requires a comprehensive treatment and a joint effort between the doctor and the patient. The doctor should carefully design the incision, fine surgery and suture; The patient should carefully reduce the tension of the incision in the early post-operative period (especially the first 1-3 months), so that the incision can heal as finely as possible; (For details, you can read my other article: No Scar After Surgery? Reduce incision tension is critical! Specific operation method (Figure)) 3-6 months period if the incision has proliferation, you can use some topical scarring ointment, not the more expensive the better. Most patients end their treatment at this stage. A small number of patients need further treatment such as keloid injection and laser if there is still redness, hyperplasia and mild indentation of the incision six months after the surgery, and most of these patients can still achieve more satisfactory results. Therefore, the time cycle of anti-scarring is relatively long, and requires investment of time and energy, patience, can not be lazy, and can not be achieved overnight. Patients often ask: I am a keloid, am I suitable for surgery? In fact, as explained earlier, previous injuries and surgical scars do not mean that you are a keloid, such as the picture on the left below, the hyperplastic scar left after abdominal surgery (some people have more, some have less) is a normal phenomenon, and most people are not keloid. Most people do not have keloid scars. True keloid scarring is characterized by the formation of keloid scars that greatly exceed the original area of injury and grow like a tumor! Now that’s what I call keloid scarring! Question 4: Do moles come back after removal? Will the surgery stimulate the mole to become malignant? A: Recurrence is rare. Since the surgery is to remove all the diseased tissue that can be seen under direct vision (according to the principle of tumor excision, the tumor should be excised in the normal tissue next to the tumor), and there is also pathological examination under the microscope to see whether the edge is cleanly cut after the surgery, therefore, recurrence after surgical excision is very rare. Even if there is a recurrence, do not be nervous, it is only a small part of the nevus cells that were not cut, and the nature of the nevus is generally unchanged, so it can be completely removed again. Surgical excision is the most thorough way to remove diseased tissues, after excision, only normal skin and some scar tissues are left in the original part of the nevus, there are no more nevus tissues, so there is no question of stimulating it to become malignant. Question 5: How long will the incision be after excision? A: This is a question often asked by patients, in fact, it is also a geometric problem, as shown in the figure, let’s review our secondary school homework together 🙂 The diameter of the nevus is set as D a. When the circle is brought together into a straight line, the length of the straight line will be half of the circumference of the circle (can you imagine that?). You can take a rubber band to compare), that is, the circumference multiplied by the diameter divided by 2, for 1.6D, the incision for the diameter of 1.6 times b. The mole is a benign tumor, in accordance with the principle of excision of benign tumors, the incision should be in the mole side G outside the normal skin of 1 to 2mm (directly along the edge of the mole side G cut is easy to cut uncleanly, will need to be operated on again), this time, the incision is increased to 1.6D + 2mm. If the nevus is suspected to be malignant, this distance should be increased. c. If the mole is cut in a round shape, the result of direct suturing of the round wound is that the skin at the two ends will buckle (commonly known as cat’s ears), if you have a piece of cloth at hand, you can try it. In order to avoid the formation of cat ears, the incision will be sewn flat, and both sides of the incision should be extended again to form a pointed pike, with the extension set to E. Combining the above three factors, the actual length of the incision will be 1.6D + 2~3mm + 2E. Examples of two practical calculations Example 1: A 5mm diameter mole, with an E of 2mm, the actual length of the incision will be 1.6X 5mm + 2mm + 2 X 2mm = 14mm, which is approximately the original diameter of the nevus. 14mm, about 3 times the original diameter, isn’t it amazing? Example 2: A 50px diameter mole with an E of 5mm, the actual length of the final incision is 1.6 X 20mm + 3mm + 5mm X 2 = 45mm, about twice the original diameter. These two practical examples illustrate why the smaller the mole, the longer the incision appears after removal. The above is only an ideal calculation of the length of the incision after excision of the simplest round nevus, but in reality, due to the difference in elasticity of the skin in different parts of the body, the specificity of the local structure, the complexity of the shape of the nevus, and other factors, the length of the incision in the end will only be longer than the calculation! However, plastic surgeons certainly do not want the incision to be long, which is almost a professional instinct (most of the various small incisions and minimally invasive cosmetic surgeries that have emerged over the years are the invention of plastic surgeons), and the surgeon will have to make more effort to suture the incision if it is long, which increases the workload. Therefore, the surgeon will definitely use his brain to make the incision as short as possible under the premise of clean tumor removal and smooth alignment. In addition, the final result of the incision depends on the recovery rather than the length of the incision. A long incision is not noticeable if it recovers well; a short incision is not ideal if it recovers poorly and creates a noticeable scar. Some times people also like to ask how many stitches will be taken, this is often the language in literature, the doctor is the least concerned about this issue, the key is to be well stitched, anyway, the stitches on the outside will be removed in the end. Question 6: Will the mole be sunken after removal? Answer: A defect will be formed locally after the mole is removed, but the doctor will pull the tissues on both sides together, so there will be no depression after the mole is removed and stitched up in general size, and the other side of the mole may be lower and flatter than the normal side after the larger mole is stitched up. Question 7: General anesthesia or local anesthesia? Is general anesthesia dangerous and will it affect intelligence? Do I need to be hospitalized? A: The choice of anesthesia depends on the age and size of the mole. Young children younger than 7-8 years old need general anesthesia as they will cry and not cooperate during the surgery, making it difficult to complete the more delicate surgery required. General anesthesia is also required for larger procedures such as skin grafts and dilators. General anesthesia requires hospitalization, while local anesthesia is mainly performed on an outpatient basis and does not require hospitalization. General anesthesia here refers to anesthesia for tracheal intubation. Intravenous anesthesia, which does not control the airway but only administers medication intravenously, is not recommended and will be very dangerous if there is airway obstruction during the operation. Does general anesthesia affect brain function (including intelligence)? This depends on the time and frequency of the drug, because the general anesthesia drug is finally metabolized from the body and excreted, just like drinking alcohol drunk (alcohol has also been used for anesthesia in the past), once a short period of drunkenness on the brain’s effect is minimal, but if often drunk will certainly bring side effects. Q8: What is the right age for children to have surgery? A: It is important to consider both the physical and psychological development of the child. Nowadays, with the advent and development of fetal surgery, there is in fact no restriction on the age of surgery, but why is the age of the child still an important consideration in the final decision? This is because a general anesthesia surgery is a test of the body’s functions (especially the heart, lungs, liver and kidneys), like a middle-distance running, the pediatric organs are immature, relatively fragile, and insufficient response to stress, the surgical risk is increased. In addition, the postoperative observation, nursing care and cooperation with auxiliary treatment of pediatric patients are also difficult. Therefore, if the nevus has not grown rapidly, general anesthesia surgery can be performed after 2-3 years of age. Question 9: What are the surgical methods? How to choose? There are generally three surgical methods as follows 1., direct excision and suture (there are also split excision, dilatation and then excision) Fig.: After excision of the nevus, suture the edges of the wound together and close the wound directly. 2., direct suture is difficult, or will cause deformity of the five senses, then line flap transfer Figure: the defect formed after excision of lesions on the dorsum of the nose is relatively large, it is difficult to directly pull together and suture, then use the loose skin between the eyebrows and forehead to transfer downward to repair the dorsum of the nose trauma, and the flap donor area between the eyebrows and forehead can be directly suture, the incision traces are not obvious after 10 months of operation. 3., the trauma is too large, the flap can not be used, then choose the skin graft Figure: facial mass excision left a large trauma, take the skin graft to cover the trauma, the lower row for the skin graft after the survival of the photo, note that the skin piece and the neighboring surrounding skin is still different from the principle of selection of surgical methods: can be solved by simple methods do not take complex methods, the selection of the order of 1 ¡ú 2 ¡ú 3, and sometimes a combination of 2-3 kinds of methods. Question 10: What psychological preparation should be done before treatment? A: It is also important to recognize the disease objectively and correctly and to build up a good psychology. A healthy mind is definitely conducive to a smooth recovery and a rational view of the problems that may arise in the treatment and the results of the treatment. The following types of patients need to first adjust the mind, otherwise it is not suitable for treatment. Sighing type: Thinking that I am unlucky, God gave me the mole, others are bright and beautiful. I don’t know that no one is born perfect, when God closes a door for you, at the same time will open a window for you, you must also have the advantages that others don’t have. Suspicious type: Thinking that only you are concerned about your condition and that doctors have other plans. In fact, in the fight against diseases, doctors and patients are absolutely of the same mind, they both hope that the treatment effect is good, the cost and risk is low, that is, the gain is greater than the loss, the patient’s thought is also the doctor’s thought, the doctor must also hope that the nevus is cut cleanly, no recurrence, sewn smoothly, no cat’s ear, no deformation, and the scar is not obvious in the restoration. The only difference is: the patient will have a more emotional response, whereas the doctor has specialized knowledge, he performs these treatments every day, he is familiar with the various situations, and he also needs to build a professional reputation through successful treatments. The doctor also has to conduct scientific research on difficult problems that cannot be solved at the moment, exploring issues that are closely related to the disease. The risk-taking type: Requires 0 risk and guarantees 100% return. Disease treatment, like all other human behavior, have some kind of uncertainty and risk, can only do our best to avoid the risk, but the demand for 0 risk ……, the only no treatment is no risk of treatment. Perfectionism: Can not understand the treatment and recovery time process, as well as the process will bring some of the discomfort experience, the requirements of the surgical results can withstand a variety of light (from the dark light to the sun glare) under the examination, 360-degree dead angle, like to go to some of the so-called “success stories” for comparison. After all, surgery is not PS, some kind of discomfort is unavoidable. After removing a mole, you can only compare the recovered result with the original mole, not with normal skin. You have to compare yourself vertically with your past, not horizontally with others. Self-talking type: You have already heard some information from others or on the Internet, and you have some stubborn ideas. They come to the doctor just to get a final confirmation from the doctor, do not listen to the doctor’s different opinions, and refuse to seriously cooperate with the doctor’s instructions after the operation. In the consultation before, also like going to the temple Zen, first to vacate themselves, put down the existing concepts, pay attention to listen to the doctor’s analysis of the condition and explanation of the treatment plan, the doctor due to experience and technical differences will tend to be different treatment options, if you listen to the feeling of doubt, it may be worthwhile to see a few more doctors, and listen to both is clear, generally will be generally formed a preliminary treatment plan overview, and then combined with their own actual situation and tendency to choose. Then, you can make a choice according to your actual situation and inclination. If you have a mole, you may be worried about the change, or it may affect your appearance, and you should know the difference between a mole and a fish. If it is your own child, you may wish that the mole grows on your own body and suffer on behalf of your child. However, a treatment or an operation is also a special journey in life, which will increase our experience, grow our courage, and give us a chance to understand ourselves from a unique perspective. I wish all of you the best of luck in your journey to meet your better self!