“Keep your face always toward the sunshine — and the shadows will fall behind you,” Walt Whitman once wrote. But what the poet didn’t account for is that years of regular sun exposure can cast a shadow of their own, in the form of skin cancer.
The face is a common area where skin cancer develops. That primarily has to do with too much exposure to the sun and tanning bed use.
Fortunately, most skin cancers, regardless of location, have an excellent prognosis. But that doesn’t mean you shouldn’t carefully weigh all of your options, says Memorial Sloan Kettering dermatologic surgeon Erica Lee. It is your face, after all, and the outcome of your care can affect how you feel about yourself.
To learn more, we spoke with Dr. Lee about what she thinks people with facial skin cancer need to know before they seek care.
1. Know which type of skin cancer you have.
One of the most important things to know about skin cancer is that there are different types. Knowing which one you have will inform your doctor’s treatment recommendations.
The vast majority of skin cancers on the face are either basal cell carcinoma or squamous cell carcinoma. “Basal cells tend to grow slowly, but some subtypes may grow deeper than others,” says Dr. Lee. “If you have a basal cell carcinoma, get it treated in a timely way, but there’s no need to rush to the doctor that same week.” Certain forms of squamous cell carcinoma can grow quickly, she says, so it’s important to discuss timing with your doctor.
Melanoma is less common but more serious. “Melanoma is a different situation entirely,” Dr. Lee cautions. “If you have melanoma, make an appointment with a specialist right away. Early treatment is usually recommended.”
2. Consider getting a second opinion on pathology.
The first step in diagnosing skin cancer is a skin biopsy. The tissue sample taken during the biopsy is sent to a pathologist, who then examines the cells under a microscope. Pathologists are usually certain about their diagnoses. But there are instances when the cancer cells look unusual or the pathology is inconclusive for some other reason.
How do you know if you need a second opinion if no one has told you to get one? “Start by asking your doctor,” says Dr. Lee. One way you might phrase the question is, “Was the pathology definitive?” If the doctor says no, that’s your cue to seek out a second opinion on your pathology.
You can also review the pathology report yourself. Sometimes the report will say the diagnosis is inconclusive. Also be on the lookout for phrases such as “most in keeping with” or “features of,” says Dr. Lee. This is terminology indicating that the pathologist formed a hypothesis but wasn’t absolutely certain.
“One of the benefits of coming to MSK for care is that we review the pathology,” says Dr. Lee. “Most of the time we confirm the original diagnosis, but occasionally we do see differences.”
3. Start your care with a fellowship-trained dermatologic surgeon.
This may seem like a no-brainer, but when it comes to skin cancer treatment, you’re better off beginning your care with a board-certified dermatologist. Choosing a dermatologist with fellowship training in skin oncology and dermatologic surgery is also important.
“Sometimes people go right to a plastic surgeon when they have something on their face,” Dr. Lee explains. “But skin cancer can grow wider than anticipated, making complete removal tricky.”
One way to ensure that you get the best cosmetic outcome is to seek out a dermatologist with experience in treating facial skin cancer. “Dermatologists who have completed a dermatologic surgery fellowship tend to have the most experience with facial cancers,” Dr. Lee says. “Ask your dermatologist for a referral to a dermatologic surgeon or seek treatment at a medical center with dermatologic surgeons on staff.”
Fellowship-trained dermatologic surgeons are experts in delicate skin-sparing procedures that can better preserve your appearance while also making sure that all of the cancer is removed. They are also skilled in reading pathology, Dr. Lee points out, which gives them an excellent understanding of how cancer grows so they can ensure that they are removing all of it.
And if you do need a plastic surgeon, a dermatologic surgeon will be able to advise you.
4. Ask about your skin cancer treatment options.
Among the most common treatments for facial skin cancer is Mohs surgery. Mohs involves removing the cancer in thin layers. This approach helps preserve surrounding healthy tissue and has a very high cure rate.
“Mohs can be a lengthy process, taking several hours or longer,” says Dr. Lee. “I do everything I can to keep my patients comfortable and inform them of how things are going at each step.”
Dr. Lee adds that not everyone with skin cancer on the face will need Mohs surgery. “There may be other treatment options that are right for you. It’s OK to ask. And if you do have options, ask your doctor to explain the pros and cons of each before you make your decision,” she says.
Sometimes Mohs really is the best option for facial cancer, however. That’s typically the case with skin cancer on the nose or eyelid. “The nose and the eyelid are tougher areas to treat for a variety of reasons,” says Dr. Lee. “It takes finesse to achieve excellent cosmetic results in these areas. Removing a cancer from the eyelid also has a lot of challenges related to how the eyelid functions and feels to the patient after the surgery.”
5. Seek comprehensive care if your skin cancer is complicated to treat.
Complicated skin cancer may require the expertise of multiple specialists. Plastic surgeons may get involved when the cosmetic challenges are significant. An ocular surgeon or an oculoplastic specialist may be needed if you have an especially difficult-to-treat skin cancer close to the eye. A head and neck surgeon may join your care team if there is nerve involvement or if the cancer is too extensive for local anesthesia.
“The beauty of a comprehensive cancer center like MSK is that the expertise is all here,” says Dr. Lee. “We have a multidisciplinary program especially for people with complex skin cancer. You can usually see all of your doctors on the same day and in the same location. The dermatology team works with you to coordinate your appointments with your schedule.”