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Mole Types
and Removal Techniques
(December 1999)
During childhood and early adulthood, many people develop small areas of darkened skin, which often raise up over time. These growths are commonly referred to as moles. Moles are made up of cells called melanocytes. Melanocytes are found distributed throughout the skin and are responsible for the production of skin pigment. Moles occur when these melanocytes grow in clusters in areas of the skin. Moles begin developing during childhood and adolescence and tend to slowly raise up and lighten over a person’s lifetime. The tendency to develop moles is more prevalent in fair skinned people and is partially inherited. Sun exposure has also been shown to stimulate the development of moles.
There are three main issues that bring patients to the dermatologist for their moles. One common patient concern is whether any of their moles are suspicious for or at risk of turning into cancer. Another concern is about moles that protrude and get repeatedly irritated by activities such as shaving or rubbing on clothing. Also, many patients have concerns about the cosmetic appearance of certain moles and may desire removal to enhance appearance.
Evaluation of moles to check for melanoma is an essential part of dermatology today. Melanoma usually develops on previously normal skin, but on occasion may develop in a pre-existing mole. People with many moles are at slightly greater risk of melanoma, especially if the moles are large and irregular. Checking for melanoma is trickier when patients have many moles, the difference between normal moles and melanoma are often subtle and require an expert trained eye. The removal of normal moles does not decrease the risk of developing melanoma. Dermatologists are best qualified to determine which moles are suspicious enough for biopsy. Ideal biopsy technique allows for complete information about the growth with minimized scarring.
Moles that are irritated by activities of daily living are best removed. These moles may interfere with shaving or may rub against clothing. The techniques used to remove these moles are the same as those used to remove moles that are cosmetically undesirable.
There are many people who have one or more moles that they see as detracting from their overall appearance. Not all undesirable moles, however, are candidates for cosmetic mole removal. Figuring out which moles are appropriate candidates requires careful judgment.
There are two main methods used for mole removal. Moles can either be shaved off of the surrounding skin or excised with the underlying and surrounding skin and then stitched. For best results, treatment should be individualized. The shave excision method is the most frequently selected method for mole removal, as it tends to produce optimal cosmetic results for most cases. Shave excision is also generally best for moles that are irritated by clothing or shaving. For shave excision, the skin around and under the mole is injected with lidocaine anesthetic. This takes away any minor pain of the procedure. It also raises and firms the skin treatment site. Then a small sharp scalpel blade, often lubricated with mineral oil, is used to precisely remove the raised and pigmented mole tissue while leaving a cut surface that is flush with the surrounding skin.
The shave removal technique is excellent, but, like all techniques, has limitations. Despite every attempt to cut the mole exactly flush with the skin, minor imperfections of the cut surface may occur. An electrosurgical apparatus is used in these instances to even out the contours of the removal.
With meticulous technique and careful patient selection, shave removal results are generally gratifying to patient and physician. Nevertheless, permanent contour and color imperfections may occasionally result. Contour imperfections may result if the tissue is not cut exactly even with the surrounding skin and may also rarely occur due to changes in skin contours resulting from the healing process.
During shave excision of moles, some of the melanocytes are often left below the even cut surface of the removal site. Usually, these cells pose no cosmetic problem. Moles may, however, regrow at the excision site shortly after removal or years later. The mole cells below the cut surface of the removal site can also cause re-pigmentation of the removal site to a shade much darker than that of the removed mole. This re-pigmentation side effect is particularly problematic for patients with olive skin or dark eyes and hair. Mole regrowth and re-pigmentation occur more commonly in young patients and may result in the desire for re-removal.
Because of these limitations in shave excision of moles, excision of moles with the skin underlying them is sometimes recommended. This technique is often referred to as elliptical mole excision because the mole is usually removed in an ellipse of skin that allows for a flush closure without puckers. Elliptical excision may be recommended if there is a high suspicion of melanoma. It is also useful when the risk of mole regrowth, re-pigmentation or uneven skin contours with shave excision make it a better choice.
Elliptical excision is more time and resource intensive than shave excision. It entails more risk of bleeding and infection. Just as in shave excision, results with elliptical excision depend up on good surgical judgment and careful execution of the finer points of surgical technique. Elliptical excision invariably results in a linear surgical scar that can vary from virtually undetectable to more noticeable than the original mole. In younger patients, elliptical excisions often heal with wide and sometimes unsightly scars due to the tug of surrounding elastic skin.
Careful patient selection is a prerequisite for obtaining good mole removal results. Even when the patients are properly chosen, the results of cosmetic mole removal are very technique dependent. Good technique is the result of training, experience and skill.
Craig Kraffert, M.D.
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