OMFS Initial Consultation Letter - Lesion Assessment & Surgical Planning

Specialty: Oral Maxillofacial Surgeon **Diagnosis:** 1. Lesion A: Clinical impression of Basal Cell Carcinoma, right temple, 8mm. 2. Lesion B: Clinical impression of benign sebaceous cyst, left jawline, 15mm. **Accompanied by:** Sarah Jenkins, daughter **Referred by:** Dr. Helen Smith, GP **Forms completed:** Medical history questionnaire, Skin lesion assessment form **Reason for attendance:** * Concern about changing mole on right temple, suspected basal cell carcinoma. * Evaluation of recurring lump on left jawline, suspected sebaceous cyst. **Lesion A:** * Site: Right temple. Size: 8mm. Duration: Approximately 1 year. Growth: Slow, but noticeable increase in size over the last 3 months. Bleeding: Occasional, especially after scratching. Pain: None. Colour change: Has become slightly darker. Presence of crust: Intermittent crusting. Presence of lump: Raised nodule. Previous treatments: None. * Examination findings: 8x7mm pearly nodule on right temple with central ulceration and rolled borders. Dermatoscopy revealed arborising telangiectasias. Clinical diagnosis: Suspected Basal Cell Carcinoma. No fixation to underlying structures. **Additional lesions:** **Lesion B:** * Site: Left jawline. Size: 15mm. Duration: Recurrent for 5 years. Growth: Fluctuating, often enlarging before spontaneously draining. Bleeding: Never. Pain: Mild tenderness when inflamed. Colour change: Skin-coloured. Presence of crust: No. Presence of lump: Subcutaneous, firm, mobile lump. Details of any recurrence: Recurred twice after previous incision and drainage. Previous treatments: Incision and drainage x2. * Examination findings: 15x12mm firm, mobile subcutaneous nodule on left jawline with a central punctum. No signs of acute inflammation. Clinical description: Benign sebaceous cyst. No fixation to underlying structures. **Lymph node examination:** Normal lymph node examination of cervical and pre-auricular regions bilaterally. **Skin areas examined:** Full skin check performed; no other suspicious lesions noted. Patient declined offer to examine other areas. **Investigation results:** N/A **Risk factors for skin lesions:** * Previous skin cancer history: None. * Sun exposure: Extensive recreational sun exposure during childhood and adolescence (spent 5 years in Australia, aged 10-15). History of multiple severe sunburns. * Outdoor hobbies or occupation: Gardener for 20 years. * Family history of skin cancer: Father had melanoma at age 65. **Risk factors for oral lesions:** Confirmed negatives: smoking, alcohol, previous mouth skin problems, previous skin problems, eye mucosal problems, steroid therapy. **Skin type:** III **General health:** PS 0 Frailty Score 2 **Medical history:** * Hypertension, well controlled with medication. * Childhood appendectomy, no complications. **Drug history:** * Lisinopril 10mg once daily. * NO BLOOD THINNERS **Allergy history:** NO allergies **Scar formation:** Good healing of skin after previous appendectomy, no abnormal scar formation. **Social history:** Retired gardener, enjoys walking and golf. No specific activities impacting post-operative healing identified. **Assessment and plan:** **Lesion A:** Differential diagnosis: Basal Cell Carcinoma, actinic keratosis, benign adnexal tumour. Surgical treatment planned: LA and IVS, primary wide local excision with curative intent, Lesion A, right temple, 8mm, direct closure. **Additional lesions:** **Lesion B:** Differential diagnosis: Epidermoid cyst, dermoid cyst, lipoma. Surgical treatment planned: LA, excision diagnostic biopsy, Lesion B, left jawline, 15mm, direct closure. **Operation details:** Date of surgery: 1 November 2024, arrival time: 08:00, operation slot needed: 60 minutes. **Procedure codes:** * S0602 (1st excision of malignant lesion head and neck) * S0654 (benign lesion head and neck not scalp) **Second operation:** Date to be confirmed for Lesion B if histology indicates further excision required. **Removal of sutures:** Required. Lesion A: 7 days, by practice nurse. Lesion B: 10 days, by practice nurse. **Review plans:** In person at hospital, 4 weeks post-operatively to discuss histology results for both lesions and wound check. **Pre-operative preparation:** * Investigations planned: N/A * Informed consent commenced: Discussion of wide local excision and cyst excision, potential risks (bleeding, infection, scarring, nerve damage, recurrence), benefits (removal of suspicious lesion, definitive diagnosis), alternatives (observation, non-surgical treatments for BCC were discussed but not recommended given suspicion). Information given about digital consent. **Given to the patient:** * Advice: Keep wounds clean and dry, avoid strenuous activity for the first week post-op. * Leaflets: Basal Cell Carcinoma information, Sebaceous Cyst information, Post-operative wound care instructions. * Prescriptions: N/A **Post-operative care:** * Expected hospital stay: Day case. Pain management: Over-the-counter analgesia (Paracetamol/Ibuprofen). Wound care: Keep dressings dry for 48 hours, then daily dressing changes. Follow-up appointments: Practice nurse for suture removal, consultant for histology review. * Optimising healing post-operatively by avoiding swimming and contact sports for 2 weeks. **Concerns and expectations:** Patient concerned about scarring on the face, discussed strategies for optimal scar healing and acknowledged surgical scar will be present. Patient also expressed desire for definitive diagnosis for both lesions. **Other outcomes:** N/A **Plan:** * Lesion A: LA and IVS, primary wide local excision with curative intent, right temple, 8mm, and direct closure. (S0602) * Lesion B: LA, excision diagnostic biopsy, left jawline, 15mm, and direct closure. (S0654) Date of surgery: 1 November 2024, Day Surgery Unit at Mount Alvernia Hospital, arrival time: 08:00, surgery to take place around 30 minutes later. No specific instructions about stopping or continuing medication. No tests needed before surgery. "Thank you for coming to see me today in the company of Sarah Jenkins, your daughter at the kind suggestion of Dr. Helen Smith. Thank you Helen." You have two areas we need to address today. First, a mole on your right temple that has been changing. We believe this could be a type of skin cancer called a Basal Cell Carcinoma (BCC), which is common and usually grows slowly but needs to be removed. Second, a recurring lump on your left jawline, which we suspect is a sebaceous cyst, a benign sac under the skin that can fill with dead skin cells and oil. For the mole on your temple, we plan to remove it completely using a small surgical procedure under local anaesthetic and some sedation to keep you comfortable. For the lump on your jaw, we will excise it to confirm the diagnosis and prevent future recurrence. Both procedures will involve stitching the skin together directly afterwards. "We looked together at a drawing of what the possible surgery would involve, and a copy is enclosed here. We have taken clinical photography for thorough documentation purposes. We have a plan as above and I have given you some local anaesthetic cream and written information on your procedure. Mount Alvernia Hospital uses a consent form system called Concentric and you will also receive a link to a digital consent form with helpful information, which we would be grateful if you could complete if you are happy to proceed. **<u>Please can you sign it before the day of surgery.</u>** I look forward to seeing you then and please do let me know if you have any further questions." BW CN cc GP cc Dr Pink <u>DRAWING FOR PATIENT</u> **Enclosures to letter:** Drawing of proposed surgery, BCC leaflet, Sebaceous Cyst leaflet, Post-operative wound care instructions. **Tasks for office:** * Date of surgery: 1 November 2024, arrival time: 08:00, operative slot time: 60 minutes, venue for surgery: Day Surgery Unit at Mount Alvernia Hospital. * Procedure codes: S0602, S0654. FPP CN Fee £ 450 * Type of review: Face to face, 4 weeks post-operatively with pathology results for both lesions. Office needs to ensure pathology results are available for review. * Pathology form needed: Yes, for BALA. * Data sheet needed: Yes. * Patient discharge status and notes management: Patient is undergoing surgery for a suspected skin cancer (BCC) therefore notes should be kept.