Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Resection of
Melanoma/Melanoma Scar
Your symptoms, physical exam, and laboratory studies demonstrate a melanoma (a cancer of the pigment
cells of the skin). Without further surgery, the melanoma is likely to recur in the area of the biopsy, spread to
your lymph nodes, or spread throughout your body. Because melanoma is known to be an aggressive cancer,
surgical treatment is required early in the course of the disease to prevent its recurrence.
Description of the Procedure
The operation is usually performed under general anesthesia. An incision is made around the tumor, or scar
of the previous biopsy. The size and extent of the excision is determined by the depth of the tumor as seen
under the microscope. The tumor is removed along with the surrounding skin. The skin is closed and a light
dressing is placed.
Additional Procedures that may be performed at time of Surgery
It is impossible to accurately predict all of the variations that may be encountered during this operation. The
following procedures may be performed in addition to the biopsy, if deemed necessary:
1. Skin graft – a skin graft is common following this operation, and will be needed if a wide area of skin is
removed to successfully excise the tumor.
2. Drain placement – a temporary drain tube will sometimes be placed into a wound that has a large cavity
to prevent collections of fluid or blood.
3. Regional lymphadenectomy – evidence suggests that in certain circumstances, a regional lymph node
removal will improve the outcome for treatment of melanoma.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and
those that are specific for a biopsy. In any medical treatment, it is impossible to predict all the things that
could go wrong. Fortunately, complications are the exception rather than the rule. Every reasonable effort is
made to avoid complications. The most common possible complications are as follows:
Possible complications following any operation
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion during or after this operation is extremely rare.
2. Infection – we take special precautions to prevent an infection, but it is always a possibility. An
infection is a special concern if a mesh is placed.
3. Reactions to medications – this could be many things from a minor rash to possible death
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
5. Poor wound healing – breakdown of the incision.
(see other side)
Possible complications of a melanoma resection
1. Seroma/hematoma formation – this is a collection of fluid or blood beneath the skin over the site of
surgery.
2. Recurrence of the melanoma – this could occur either within the area of the tumor, or elsewhere in
the body.
3. Problems with the skin graft- sometimes, only a part of the skin graft will survive over the area in
which it was placed. This may require repeat skin graft placement to accomplish healing of the
wound. The skin graft donor site may also cause problems with pain or infection, and will be
permanently discolored in relation to surrounding skin.
4. Problems with the lymphadenectomy – various problems may arise after a regional lymph node
removal, including possible temporary or permanent swelling in the operated extremity, and an
increased risk for serious infections in that extremity.
5. Bowel or bladder injuries – these organs may lie immediately next to the hernia opening, or may
even be involved with the hernia sac. Should injury to these structures occur necessary steps will be
taken to repair the injury. It may be necessary to have a second operation for this purpose.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Under most circumstances, you should be able to
return to work the next day. Sutures are removed in seven to fourteen days. If a skin graft is performed,
return to normal activities will usually be delayed for one to two weeks. Further treatments following
surgery are possible and will be discussed as indicated.
Consent for Treatment
I understand my condition to be a melanoma and am aware of its risks if untreated. I have read and
understand the above explanation of the procedure being proposed. My surgeon has answered my
questions, and I choose to proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people with a melanoma will benefit from the proposed operation, I may
not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment risks;
nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on
my behalf.
SIGNATURE _____________________________________________________ DATE ________________
4/04-consent/rev