ENPatients usually come for melanoma surgery in Germany with the mole already removed and a report containing the word «melanoma». Their main question is: «It has been cut out already, why operate again?» This page is the answer.
It explains why melanoma almost always means two operations, not one, why the sentinel lymph node is looked for, how the defect is closed after a wide excision and what is done about metastases; see also melanoma treatment in Germany.
Why there are two operations
The first operation is diagnostic: the suspicious lesion is removed whole for the pathologist, since only a microscope can measure the tumour’s thickness (the Breslow thickness) and depth of growth. Neither the naked eye nor dermoscopy can.
The second is therapeutic: a strip of healthy skin around the scar is removed to lower the risk of the disease returning there. Its width depends on the Breslow thickness and the site: under the German S3 melanoma guideline (2020 version, meant to last at most five years; none newer yet), the margin is 1 cm for tumours up to 2 mm thick and 2 cm for thicker ones.
In practice: in Germany the histology is always reviewed before surgery, so bring the slides and paraffin blocks, not only the report, because the extent of surgery depends directly on the reviewed thickness (see biopsy in Germany). Sometimes the review finds no melanoma at all, or a basal cell carcinoma, a different disease with different surgery (see basal cell carcinoma treatment in Germany).
The sentinel lymph node: why it is looked for
It shows whether tumour cells have left the skin: lymph from a patch of skin drains first into one particular node, the sentinel, so spreading cells reach it first. Before surgery a weak radioactive marker and a dye are injected beside the scar; in the operating room a probe finds the node that took them up, and only that node is removed (or those, if several did).
Why, if the nodes feel normal? The sentinel node result moves the disease into a different stage, and the stage decides whether drug therapy follows surgery. So the biopsy is not treatment but a fork in the treatment plan; see melanoma immunotherapy.
What surprises many: today, with tumour cells in the sentinel node, the whole group of nodes is in most cases not removed as it used to be; ultrasound surveillance and drug therapy are arranged instead. A board of dermato-oncologists, surgeons and other specialists decides, and the extent of surgery is discussed beforehand, not afterwards.
How the defect is closed
On the back or thigh the edges can usually simply be stitched; on the face, ear, a finger or the lower leg there is not enough skin, so a local flap (skin moved from the neighbouring area) or a free skin graft from elsewhere is needed. The surgeon plans this with the dermatologist, sometimes a plastic surgeon, in advance, not on the table.
This affects the length of stay, the look of the wound, the dressing schedule and, with a graft, sparing the donor site: ask about it before surgery. Some operations are day cases, others need a few days in hospital; the hospital gives the figure. Melanoma is operated on in dermato-oncology departments: AlenMed’s partners include University Hospital Frankfurt, whose Department of Dermatology, Venereology and Allergology is headed by Prof. Bastian Schilling, and Cologne University Hospital with its Department of Dermatology and Venereology under Prof. Esther von Stebut; see also dermatology in Germany.
What is done about metastases
A single metastasis, in the skin, a lung or a lymph node, is sometimes removed surgically, but a tumour board decides, not the surgeon alone. In widespread disease drugs usually matter more than the scalpel, and «drugs first, surgery later» is as common as the reverse.
Surgery may also follow drug therapy once the tumour has shrunk, to remove the remainder. Conversely, an operation may be technically possible but give the patient nothing, so it is deliberately not done: declining to operate can also be a decision in the patient’s favour, not a refusal of help.
After surgery: histology, follow-up, timing
The final pathology report arrives several days after surgery, not on the day, and decides whether drug therapy is needed and what follow-up to plan. Leaving before it arrives is not advisable; if unavoidable, ask for it to be sent on and translated.
The follow-up plan then includes skin and lymph node examinations, ultrasound and, at certain stages, imaging; the hospital sets frequency and duration under the current guidelines. Sun protection and the skin self-examination taught at the appointment are part of it.
Frequently asked questions
Why not remove the mole with a wide margin straight away?
Because the thickness, on which the margin depends, is unknown before the histology. The German guideline also warns that a wider first excision destroys lymph drainage pathways and makes the sentinel node harder to find later. A suspected melanoma is therefore first removed whole with a narrow margin.
What if the wider excision has already been done at home?
Bring the slides, blocks and reports from both operations: the German pathologist checks the thickness and the edges, and the doctor says whether the margin was enough. A sentinel node biopsy is still possible afterwards, though less reliable if the wound was closed with a flap.
How many days does the trip for surgery take?
The hospital names it after reviewing the documents: it depends on histology review, a sentinel node biopsy and any flap or graft; some operations are day cases, others need a few days in hospital. Add time for stitch removal and the final pathology report.
How AlenMed arranges melanoma surgery
It starts with the documents: the biopsy slides and blocks are sent to a dermato-oncology department, the pathology report, photographs of the area, ultrasound results and images as files. The doctor answers whether the histology needs reviewing before the trip, whether a sentinel node biopsy is planned, whether the defect will need reconstruction and how many days the trip will take. Then: a written estimate, a visa invitation, an interpreter at appointments and at the histology discussion; how the sum is made up is on the cost of melanoma treatment page.
Plan days between the operation and the flight home for stitch removal and the histology, discuss dressings for the journey, take a written follow-up plan and have the final documents translated for your home doctor.
This material is for information only and is not an offer; a doctor decides on the indication for surgery and its extent in person.
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