Mr. Onur Gilleard
Qualifications & Experience
Mr Onur Gilleard is a distinguished consultant plastic surgeon on the GMC specialist register. He previously held an NHS consultant post at St Bartholomew’s Hospital in London, specialising in skin cancer and microsurgical reconstruction. In 2021, Mr Gilleard transitioned from the NHS to dedicate himself fully to private practice, allowing him to focus exclusively on providing personalised, high-quality care to his patients. He is recognised as an expert in laser treatments, having conducted research and developed advanced treatment protocols using cutting-edge laser technology to optimise both clinical outcomes and cosmetic results.
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This clinic does not have reflectance confocal microscopy, and saying so first is more useful than describing it as though it were on the menu. It is a real technique with a narrow and genuine role — two situations, essentially, both of them on the face. Where a patient would be better served by it, the position is to say so and refer rather than to work around its absence.
What the Technique Actually Is
Reflectance confocal microscopy uses a near-infrared laser to image living skin cell by cell, without removing it. A confocal aperture rejects light scattered from every plane except the one being examined, which is what produces the resolution. The result is a horizontal optical slice through skin that is still attached to the patient.
Its reach is limited by physics rather than by engineering. The laser penetrates the epidermis and the papillary dermis — roughly the upper fifth of a millimetre — and no further. Everything below that is unavailable to it.
| Method | What is resolved | Depth reached | Diagnostic status |
|---|---|---|---|
| Naked eye | Colour, border, size, elevation | Surface only | Raises the question |
| Dermoscopy | Pigment network, vessels, structures below the stratum corneum | Superficial dermis, as patterns | Assessment |
| Confocal microscopy | Individual cells and their architecture, in the living patient | Epidermis and papillary dermis | Assessment, at higher resolution |
| Histology | Full architecture through the whole lesion | Entire specimen | Diagnosis |
The row that matters is the last one. Confocal imaging sits between dermoscopy and the laboratory: better than the first, and not a substitute for the second.
The Two Situations Where It Changes a Decision
“Reflectance confocal microscopy gives near-histological resolution of the epidermis and papillary dermis in vivo, and is genuinely useful for two things: mapping the margins of lentigo maligna on the face before surgery, and reducing unnecessary excisions of equivocal facial lesions. Where I think a patient would benefit from it, I’d say so and refer.”— Mr Onur Gilleard, Consultant Plastic Surgeon
Both uses are on the face, and that is not a coincidence. Facial skin is where the cost of an unnecessary excision is highest and where the true edge of a lesion is hardest to see.
- Mapping the margins of lentigo maligna before surgery. Lentigo maligna is a melanoma in situ of chronically sun-damaged skin, characteristically on the cheek, temple or nose of an older patient. Its clinical edge and its true histological edge frequently do not coincide, and the surrounding skin is full of sun-damaged pigment that resembles the lesion. Confocal imaging of the perimeter before surgery can define where the abnormal cells actually stop, which changes where the incision is placed on a face.
- Reducing unnecessary excisions of equivocal facial lesions. A lesion that is dermoscopically ambiguous on the nose or the eyelid presents a genuine dilemma: excising it leaves a permanent mark in a conspicuous place, and not excising it leaves the uncertainty. Higher-resolution imaging can resolve a proportion of those cases without an incision.
Outside those two circumstances, the technique is largely answering a question that dermoscopy has already answered.
What It Cannot Do
- It cannot measure Breslow thickness
- Depth of invasion is measured in millimetres from the granular layer to the deepest tumour cell, and it determines the width of the definitive excision and whether a sentinel lymph node biopsy is offered. An invasive melanoma extends below the papillary dermis, which is below the reach of the laser. Confocal imaging cannot stage a melanoma, so a confirmed invasive lesion still requires excision and histology.
- It cannot replace histology
- Where a lesion is removed on suspicion, tissue is still examined in the laboratory. Imaging informs the decision to operate; it does not report on what was taken out.
- It performs poorly on thick, scaly or heavily pigmented lesions
- The laser has to travel through the tissue above the plane being imaged. A hyperkeratotic surface or dense pigment degrades or blocks the image entirely.
- It is not a screening tool
- Each lesion takes several minutes to image and interpret. Applying it to eighty naevi on a back is not practical, which is why total-body photography and dermoscopy remain the basis of surveillance rather than being superseded by it.
- It depends heavily on the person reading it
- Confocal images look nothing like either a dermoscopic view or a histology slide, and interpreting them is a separate trained skill. The technique in the hands of someone who reads it weekly is not the same technique in the hands of someone who bought the machine last month.
Where It Is Available in the UK
Confocal microscopy is not part of routine NHS dermatology and is concentrated in a small number of academic and specialist skin cancer centres. Most UK patients, including most patients with a lentigo maligna on the face, are diagnosed and treated without it, using dermoscopy and histology.
That context matters when a clinic advertises it. The presence of a confocal microscope is not by itself evidence of a better service, and its absence is not a deficiency in a service that refers appropriately. The question worth asking a clinic is not which machines it owns but who interprets the images and what happens when the answer is uncertain — covered in choosing a mole clinic in London.
What Is Used Here Instead
Assessment at 101 Harley Street rests on four things, in order of how often they settle the question.
- Dermoscopy by a consultant, which resolves the large majority of pigmented lesions — see digital dermoscopy explained.
- Comparison against a previous image, where a baseline exists. Change over time is a stronger signal than appearance at one moment, and it is the reason mole mapping exists.
- Short-interval sequential imaging, where a lesion is equivocal but not alarming. Re-imaging in three months is often a more proportionate response than an immediate excision, and it is one of the ways unnecessary biopsies are avoided.
- Excision with a 2 mm margin and histology, where uncertainty remains. This is the definitive answer, and on the trunk and limbs the cost of reaching for it is small.
Where a lesion sits on the face and the decision is genuinely finely balanced, the honest options are those above or a referral to a centre that images. Both are offered; neither is concealed.
How a Referral Works
If confocal imaging would change what is done, that is said during the consultation rather than afterwards, and a referral is made with the clinical picture, the dermoscopic images and the reason for the request. Where a lesion is suspicious rather than equivocal, referral is not the route — it is excised, and the specimen goes to the laboratory. Imaging is for uncertainty, not for delay.
A lesion that already looks suspicious should be dealt with promptly by whichever route is fastest, including the NHS urgent pathway through a GP. The criteria are set out in removal on the NHS.
Frequently Asked Questions
- Does London Skin Clinic have reflectance confocal microscopy?
- No. Assessment uses dermoscopy, standardised photography, comparison against previous images and, where uncertainty remains, excision with histology. Where a patient would genuinely benefit from confocal imaging, that is said and a referral is made.
- What is reflectance confocal microscopy?
- A near-infrared laser imaging technique that resolves individual skin cells in the living patient, without removing tissue. It reaches the epidermis and papillary dermis — roughly the upper fifth of a millimetre — and no deeper.
- Can it replace a biopsy?
- Not as a general rule. It can reduce excisions of equivocal facial lesions, which is a real benefit in a conspicuous site. It cannot measure Breslow thickness and cannot report on tissue that has been removed, so a suspicious lesion still requires excision and histology.
- Why is it particularly used for lentigo maligna?
- Because the clinical edge of a lentigo maligna and its true edge often differ, and it sits on sun-damaged facial skin full of pigment that looks similar. Imaging the perimeter before surgery can show where the abnormal cells actually stop, which changes where the incision goes on a face.
- Would it be useful for moles on my back?
- Rarely. The advantage is concentrated where an unnecessary scar is most costly, which is the face. On the trunk and limbs, dermoscopy plus excision where doubt persists is both quicker and definitive.
- Could it be used to check all my moles?
- No. Each lesion takes several minutes to image and interpret, so it is a tool for a specific lesion rather than a way of examining a whole skin surface. Surveillance of many moles is done with total-body photography and dermoscopy.
- Is it available on the NHS?
- Not routinely. It is concentrated in a small number of academic and specialist skin cancer centres, and the great majority of UK patients are diagnosed and treated without it.
- Is a clinic with one better than a clinic without?
- Not on that basis alone. What determines the quality of an assessment is who examines you, whether the images are reviewed by that person, and what happens when the answer is uncertain. A clinic that refers when referral is right is doing the job properly.
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