Cosmetic Surgery Blog Santa Monica

Sex Matters: Men With Melanoma Have a Worse Prognosis Than Women

We already know that men tend to present to the doctor with melanomas that are on average more advanced than the melanomas found in women. However, a recent study from the Netherlands found that even when you take into account this difference, men overall have a worse prognosis than women as far as melanoma goes. That means even if the melanomas appear to be at the same stage, if it is on a man there is a higher risk it will result in death than if the same melanoma was on a woman. The reasons for this difference are not clear but possibly could be related to androgen levels. Whatever the cause it highlights the need to subdivide different patients as well as different melanomas to get a more accurate prognosis and so guide treatment as well as education and preventative strategies. Certainly it should be a wake up call to men how may be reluctant to visit their doctor for a skin cancer screening exam.

Article Citation:

Journal of the European Academy of Dermatology and Venereology: JEADV
Sex Matters: Men With Melanoma Have a Worse Prognosis Than Women
J Eur Acad Dermatol Venereol 2019 Jun 27;[EPub Ahead of Print], MA El Sharouni, AJ Witkamp, V Sigurdsson, PJ van Diest, MWJ Louwman, NA Kukutsch

A biopsy may not give the whole story

Surely when you get a final pathology report from a biopsy you have a definitive diagnosis? Well not always. While diagnosing a basal cell carcinoma or squamous cell cancer is usually pretty straightforward, the biopsy is only a sample of a larger tumor. So what is seen on the biopsy may not be identical to what is present in the rest of the tumor. This is not to say that what was diagnosed a basal cell cancer could really be a melanoma or anything like that. However there are many different sub-types of basal cell and squamous cell cancer, and some of them are a lot more aggressive than others. So while the biopsy may show a non- aggressive sub-type a more complete analysis may show areas of more aggressive disease that would require a wider surgical margin to remove. This is another instance where Mohs surgery seems to be beneficial. In a recently published study it was found that during Mohs surgery for basal and squamous cell cancers the Mohs surgeon found evidence of more aggressive disease more than 10% of the time. These cases were more likely to need more Mohs stages. Had an other treatment modality been used it is likely that this aggressive component of the tumor would be missed and some cancer be unwittingly left behind.


Histopathologic upgrading of nonmelanoma skin cancer at the time of Mohs micrographic surgery: A prospective review
Rachel L. Kyllo, MDa, Karl W. Staser, MD, PhDa, Ilana Rosman, MDa,b, M. Laurin Council, MDa,c, Eva A. Hurst, MD
JAAD August 2019 Volume 81, Issue 2, Pages 541–547

Too Much or Too Little?

Mohs surgery is considered the gold standard for the treatment of most skin cancers. However, not all Mohs surgeons perform the procedure the same way.

When performing Mohs micrographic surgery for the treatment of skin cancer, the surgeon starts by removing what he/she estimates to be “just enough” tissue to clear the cancer. Obviously, you do not want your surgeon to take too much and create a larger hole than was needed. But at the same time, if he/she takes too little, extra stages will be needed until the cancer is cleared.

Some cancers have subclinical extensions (like the roots of a weed) that go well beyond what is obvious on the surface. In these cases, a Mohs surgeon will need to perform multiple stages to get clear margins. In other cases, the cancer is more limited and a single stage is all that is needed.

So, on average, how many stages of Mohs should a Mohs surgeon be performing overall? A recent study published in JAMA Dermatology indicated that the average rate should be between 1.4 and 2.4 stages.

Many cases only require a single stage, while others need multiple stages. The ability to take the appropriate amount of tissue with each stage is not an exact science. It is something that comes through training, experience, and judgement.

Dr. Ralph Massey is a world-class cosmetic and skin-cancer surgeon. He completed his fellowship in Mohs micrographic and cosmetic surgery at Columbia University and served as an assistant clinical professor at both Columbia University and UCLA.

In addition, he has enjoyed years of experience and is now recognized by many as the “go to” surgeon for skin-cancer management. Contact our office today and set up a consultation to find out more about Mohs surgery and what it can do for you.


Outlier Practice Patterns in Mohs Micrographic Surgery Defining the Problem and a Proposed Solution
Aravind Krishnan, BA1; Tim Xu, MPP1; Susan Hutfless, PhD2,3; et al and the American College of Mohs Surgery Improving Wisely Study Group
JAMA Dermatol. 2017;153(6):565-570.

You don’t need to be White to get Skin Cancer!

While the vast majority of skin cancers occur in whites, nonwhites are not immune. A recent retrospective study showed that in whites and Hispanics basal cell carcinoma was the most frequent skin cancer diagnosis, however in blacks and Asians, the potentially more ominous squamous cell carcinoma (SCC) was more common. Also, as opposed to whites, the majority of the SCCs in blacks occurred in sun-protected areas (in particular, the anogenital region). Many of these may be related to human papilloma virus (warts), a small subset of which are know to be carcinogenic. Its important that dermatologists be aware of the potential for skin cancer in these populations, and when performing skin cancer screening they should examine sun protected areas as well as the exposed parts.


Journal of the American Academy of Dermatology
Risk Factors for Keratinocyte Carcinoma Skin Cancer in Nonwhite Individuals: A Retrospective Analysis
J Am Acad Dermatol 2019 Jan 28;[EPub Ahead of Print], KS Nadhan, CL Chung, EM Buchanan, C Shaver, S Shipman, RM Allawh, ML Hoffman, G Lim, M Abdelmalek, CA Cusack

Melanomas are not always dark

Most people would be concerned about a mole that became very dark. Any we know that the vast majority of melanomas are pigmented, that is they look black, brown or maybe dark blue and often more than one shade or color. However “amelanotic” melanomas are uncommon form of melanomas that have no pigmentation. They may appear as a pink bump or patch, or sometime a raw looking pink nodule. A recent study highlight why we need to be especially vigilant in looking out for these. In this retrospective study it was found that amelanotic melanomas are more likely to be misdiagnosed and diagnosed at an older age with more aggressive features and shorter survival. More awareness and a lower threshold for biopsy may help detect these potentially deadly lesion before it is too late.


Journal of the American Academy of Dermatology
Clinicopathologic, Misdiagnosis and Survival Differences Between Clinically Amelanotic Melanomas and Pigmented Melanomas
J Am Acad Dermatol 2019 Jan 14;[EPub Ahead of Print], LC Strazzulla, X Li, K Zhu, JP Okhovat, SJ Lee, CC Kim

Extremity moles linked to increase skin cancer risk.

The association between having lots of atypical moles all over your body and subsequent melanoma is well established. In a more recent prospective study the risk of moles on the extremities (arms and legs) was specifically looked at. Patients with more than 15 moles on their arms and legs had an almost 3 times risk for melanoma. These melanomas could occur anywhere on the body not just on the extremities, but having more than 15 extremity nevi (moles) identified patients who were at heightened risk.(There was also a small increase risk for basal cell carcinoma also noted but no increase risk of squamous cell cancer in this population). So take close look at your arms and legs and see if you can count to 15, it may be time to get checked!


Journal of the American Academy of Dermatology 2019
Extremity Nevus Count Is an Independent Risk Factor for Basal Cell Carcinoma and Melanoma, but Not Squamous Cell Carcinoma
J Am Acad Dermatol 2019 Jan 31;[EPub Ahead of Print], EX Wei, X Li, H Nan

Melanoma in US Hispanics

While it is true that the darker your natural skin pigmentation the lower your risk of melanoma, no one is immune. In Hispanics, as expected the rate of melanoma is lower than non-Hispanic whites. However the melanomas that are diagnosed in this patient population are on average more advanced and the melanoma-specific survival is lower for Hispanics than for non-Hispanic whites. The reasons for this disparity are multi-factorial. Certainly providers may not consider the diagnosis of melanoma as readily in Hispanic patients and so hesitate to biopsy a lesion that they would have biopsied in a higher risk group. However discrepancy in the quality of care once the diagnosis is made is likely a factor in the poorer overall outcomes.

Take home message, whatever your skin type, if a lesion looks suspicious have it checked by a dermatologist. If a diagnosis of skin cancer is made have it treated by a dermatologist who specializes in the management of skin cancer.


Melanoma in US Hispanics: Recommended Strategies to Reduce Disparities in Outcomes
Cutis 2018 Apr 01;101(4)243-246, VM Harvey

Facial exercise can make you look younger!

Mature woman sitting in countryside

You already know that working out your body can make you look and feel better. Now evidence that facial exercises can make you look younger. In this study, women aged 40-65 years old were given facial exercises to perform for 30 minutes for at least 3-4 times per week, for a total of 20 weeks. Of 27 enrolled volunteers 11 dropped out. (It takes a lot of commitment to work out your face for 30 minutes each day!). However the remaining 16 patients had a statistically significant effect. Comparing before and after photos the the women looked about 2 years younger. (Mean estimated age before study 50.8 years, mean estimated age after study 48.1). Admittedly not be a huge difference and maintaining a regimen of 30 minutes daily facial exercises my be too much of a commitment for many people. However for those who can keep it up, there is a free, non-invasive way to take a couple of years off!


Association of Facial Exercise With the Appearance of Aging
Murad Alam, MD, MSCI, MBA1,2,3; Anne J. Walter, MD, MBA1,7; Amelia Geisler, BS1; et al Wanjarus Roongpisuthipong, MD1,4; Gary Sikorski5; Rebecca Tung, MD6; Emily Poon, PhD1
JAMA Dermatol. 2018;154(3):365-367. doi:10.1001/jamadermatol.2017. 5142

Beware of those Cosmic Rays!

Sunrise over Thailand out of a plane.

I often see pilots and cabin crew as patients for skin cancer treatment, and have suspected that the increased UV and cosmic radiation exposure at altitude with every flight might be a contributing factor. A recent analysis published by the British Journal of Dermatology confirms these suspicions. It seems that pilots and cabin crew have approximately double the risk of melanoma and keratocytic skin cancer (basal cell and squamous cell cancer) compared with the general population. While some of this risk may be theorized to be related to lay over days spent on the beach at exotic destinations, the magnitude of the increased risk implies that the repeated long hours at altitude is a significant factor. Flight crew, even more than the average person need to be especially vigilant in checking their own skin and see their dermatologist routinely for skin cancer screening.


Do airline pilots and cabin crew have raised risks of melanoma and other skin cancers? Systematic review and meta‐analysis.
K. Miura C.M. Olsen S. Rea J. Marsden A.C. Green
First published British Journal of Dermatology: 26 December 2018 https://doi.org/10.1111/bjd. 17586

Indoor Tanning: Its worse than you think!

We already know that the extra UV exposure from indoor tanning increases your risk of skin cancer. New research now show that melanoma patients who had previously used indoor tanning had a much higher risk of developing a second melanoma and developed that second melanoma sooner than others. Approximately 65% of patients exposed to artificial UV (tanning beds) were diagnosed with a second primary melanoma within 1 year of the first diagnosis, compared with 28% of non-tanners. The median time to diagnosis of second primary melanoma in tanners vs non-tanners was 225 days vs 3.5 years, respectively. So avoid those tanning beds even if they try and tell you its safe, the effects may come back to haunt you years latter.

Article Citation:

Journal of the American Academy of Dermatology
Second Primary Melanomas: Increased Risk and Decreased Time to Presentation in Patients Exposed to Tanning Beds
J Am Acad Dermatol 2018 Oct 19;[EPub Ahead of Print], Y Li, M Kulkarni, K Trinkaus, LA Cornelius

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