Moles & Lesions : Making a Mountain Out of a Molehill

As a plastic surgeon, I am often asked if I perform lesion and mole removal. The answer is yes, but with a caveat or two. I can assure you that any highly trained plastic surgeon is capable of precisely treating moles and lesions. The typical “mole patient” that I see in my office is someone who has had a previous treatment with an unsatisfactory outcome, and is concerned that it will happen again. They are consulting with me because they feel that they are in better hands with a qualified plastic surgeon, rather than doctors from other specialties who are not as well-known for their surgical finesse. Treatment of a mole on the leg or arm is one thing; but on the face, it is an entirely different situation.

As a general rule, in terms of scarring and appearance, your surgeon controls only about 25% of your outcome. The remaining 75% depends on how you heal (your genetics plays an important role here). Some people just heal better than others. Personally, if I had a lesion in a sensitive area and I wanted the best outcome in terms of scarring, I would visit with a Board Certified plastic surgeon. Having a dermatologist, OB/Gyn, or family doctor treat lesions that are relatively minor or in areas of little concern to you isn’t a problem. To avoid an unfavorable outcome, though, patients should choose the most qualified doctor to address their concern.

In my experience, and over twenty years in practice, the treatment of moles and lesions is quite simple indeed. Patients are very pleased with their outcomes, and the scarring associated with the treatments has been excellent.

In order to make sure that every mole I evaluate in the office is not associated with making a mountain out of a molehill (spending forty minutes educating a patient on why their prior experience is not common), a little education and perspective is in order.

Definitions

First, a mole is typically a small spot, mark, or raised area on your skin. This could be a freckle, skin tag, or any small pigmented patch. A lesion is larger (more than a centimeter) and is often related to something that has grown progressively over time, or is a birth related issue that has persisted or changed suddenly. A lesion may also be a skin cancer. The bottom line is that a lesion, as defined here, is typically more complex to manage than a mole, and that is why it is associated with greater scarring potential and is more costly.

Treatment

Both moles and lesions are treated under local injection anesthesia. A mole is generally treated with a shave and cautery technique. This means that a small knife blade is used to remove the mole at the skin level, and then a cautery device is used to stop any bleeding. They often heal imperceptibly, with little evidence of scarring (not always, but surely 99% of the time). A lesion, as defined here, is more likely to be excised, which means it is cut out with a scalpel and closed with suture material. This will result in a linear scar. The scar length is always longer than the length of the lesion itself, in order to close it without “dog ears” or skin bunches at the ends of the closure.

Cancer Concerns

If there is concern that a lesion or mole may be cancerous, I will recommend that we send the specimen to the laboratory for histological analysis. This means that a pathologist (a doctor trained in examining tissue) will review the specimen and provide a diagnosis.

Treatment Costs

At Westlake Plastic Surgery, we do not accept insurance. Treatment in my office will result in an initial consultation fee, an operative fee, and a pathologist fee (if there is a specimen). If you choose a surgeon who is on your insurance plan, these fees may be covered by your plan. If your primary concern is cost, I recommend that you seek a doctor on your insurance plan. If you prefer to go outside of your insurance and want to “self-pay” because you would prefer to have your service provided by me, I would be happy to see you.

We understand that patients need to know the cost of their treatment. This can only be determined with accuracy after you have been evaluated.

The cost depends on the complexity of the procedure and the number of lesions or moles treated. The consultation fee is 50 dollars. The “average” mole fee is about 75 dollars per mole, and a single lesion can range from $400 to $1200 for treatment. Costs are reduced when there are multiple moles or lesions. I have been told that I charge a heck of a lot less than other doctors (dermatologists and family practice doctors).  This is probably because these minor procedures are simply not a “big deal” to treat, and don’t take much time. The other reason may be that the other doctors have to charge “self-pay” patients the same fee as if they had insurance, and this is typically quite (unreasonably) high.

Scheduling a Treatment

The initial consultation with me is to evaluate your lesion and make a recommendation regarding treatment. In most cases, patients will then schedule their treatment for a future date. In some cases, if the schedule permits, we can offer treatment on the same day.  It usually only takes twenty minutes or so for the service (sometimes longer, depending on complexity).

Scarring Concerns

An unfavorable scar that occurs from a mole or lesion treatment is usually the result of one of the following:

  • inexpert treatment by a doctor,
  • an inherent ability for someone to make poor scars (genetics),
  • a spread scar on the chest, breast, or upper back (this is almost a guarantee),
  • a scar that simply hasn’t had enough time to mature and flatten,
  • a complication in healing (like an infection) that adversely affects the scarring.

spread scar is one of the most common unfavorable scar outcomes from treatment. The scar appears flat but becomes wider over time.

hypertrophic scar is one that gets larger and thicker over time but stays within the boundary of the original mole or lesion.

A “keloid scar differs from a hypertrophic scar because it always grows outside the perimeter of the treatment area and appears to actually “grow” over time.

It is a common misconception among patients that they believe that they have formed a keloid scar. This is often told to them by the treating physician in order to make the patient think that the unfavorable scar outcome was a result of their natural healing and not the manner in which the physician treated the lesion (it’s the patients fault and not the doctor).

Just to make something crystal clear, anytime you cut on the skin to treat a lesion or mole, there will be a scar, and it will be permanent. If the procedure is performed well enough, there may be close to “scarless” wound healing. This is what it’s all about. This is my goal.

Other Treatment Options

Steroids are substances that are injected into scars to make them softer and flatter. They can work wonderfully in the best of hands, but can also be used poorly resulting in a thin, depressed and spread scar (looking like a hole or divot in the skin).

Some patients believe that they need to have their moles cut out, which is unnecessary for most moles. These patients think that they have a cancer, and they want it gone. In most instances, it’s relatively easy for a qualified physician to determine if a mole is cancerous. I would prefer not to live with the scarring associated with a lesion removal by cutting it out when I could have had a more favorable scar with a shave and cautery.

By the way, many dermatologists offer “cryotherapy” treatment for moles, which is similar to shave and cautery, except that the mole is “frozen off.”

Moh’s micrographic surgery is a specialized treatment for some lesions (typically cancers, in sensitive areas on the face). I will recommend this treatment if I feel it is in your best interest. This is performed by dermatologists with specialized training.

I hope that this information will reduce the tendency to make a mountain out of a molehill. I will not offer treatment for your mole or lesion if I think the treatment outcome will look worse than your mole or lesion. I understand that above all, it’s your cosmetic outcome that is your primary concern, and that is why you have chosen me as your surgeon.

— Robert Caridi, M.D.
Certified Plastic Surgeon
Founder of Westlake Plastic Surgery, providing plastic surgery in Austin, TX