Skin Cancer Management || Excision Techniques, Staples, and Sutures

Chapter 10

Excision Techniques, Staples, and Sutures

Mollie A. MacCormack

Excisions are one of the most commonly performed

dermatologic procedures. It is estimated that more

than 650,000 excisions are performed each year in

the United States, with dermatologists accounting

for about 58% of this number.1 Excisions are per-

formed for a variety of reasons including diagnosis,

the therapeutic removal of malignant and benign

growths, as well as simply for improved appearance.

While the vast majority of excisions are straightfor-

ward in nature, close attention to a few basic tenets

will enhance both the efficiency of the procedure as

well as overall cosmesis. This chapter will review the

basic materials required for a successful excision as

well as the most common excision and closure

techniques.

Patient Preparation

Patient preparation is of great importance in assur-

ing a successful outcome to any surgical procedure.

Early identification of any potential complicating

factors can greatly reduce the incidence of adverse

events (Table 10.1). Preoperative evaluation should

begin with the assessment of patient comorbidities

that may prevent them from providing informed

consent, lessen their ability to tolerate the proce-

dure, place them at increased risk of infection, or

interfere with appropriate wound healing. All

women of childbearing age should be asked about

potential pregnancy. A complete list of medications

is required, with close attention paid to those med-

ications that may affect the ability to obtain

hemostasis (antiplatelet therapy, anticoagulants)

or potentially complicate wound healing (systemic

corticosteroids or isotretinoin use within the last 6–

12 months). It should be noted that many food

items and herbal supplements can also alter platelet

function.2–4 While in the past it was common prac-

tice to discontinue those medications that can make

hemostasis more difficult, a number of studies have

shown that the actual negative impact of such med-

ications is quite small, while the potential ramifica-

tions of discontinuation on overall health (stroke,

myocardial infarction, pulmonary embolus, etc.)

are devastating.5–9 For this reason, while patients

may be advised to discontinue herbal supplements,

nonsteroidal anti-inflammatory drugs (NSAIDs),

or aspirin taken for primary prevention, it is

strongly recommended that they be maintained on

all medically necessary anticoagulation.

Any existing drug allergies should be recorded

and avoided. Patients should be evaluated for any

electrical devices such as pacemakers, internal car-

diac defibrillators, and nerve stimulators that may

receive interference from electrocautery. In addi-

tion, needle/surgical phobias or simply patient anxi-

ety are not uncommon in the surgical setting and

should be addressed. Often a complete explanation

of the procedure is all that is required to put such a

patient at rest.

Simple nonpharmacologic interventions such as a

peaceful office setting, soothing music, the use of

drapes to minimize visualization of surgical

instruments and the surgical field, as well as dis-

tracting conversation are often quite beneficial.

D.F. MacFarlane (ed.), Skin Cancer Management, DOI 10.1007/978-0-387-88495-0_10,� Springer ScienceþBusiness Media, LLC 2010

125

In the extreme case, premedication with low-dose

anxiolytics such as lorazepam given orally 1 h prior

to the procedure can be helpful (after first ensuring

that the patient will not be driving).

Antibiotic Prophylaxis

The vast majority of dermatologic excisions do not

require pre- or postoperative antibiotics. Updated

guidelines for endocarditis prophylaxis were pub-

lished by the American Heart Association in 2007.

Based upon these recommendations, routine pro-

phylaxis is rarely required and is deemed appropri-

ate only for procedures (including biopsies and

suture removal) involving perforation of the

respiratory tract/oral mucosa or performed in

actively infected tissue in a small subgroup of

patients at highest risk of adverse outcome.10 For

those patients who require prophylaxis, antibiotic

choice should be directed toward the eradication of

viridans group streptococci for procedures invol-

ving perforation of oral/respiratory mucosa and

staphylococci and B-hemolytic streptococci if the

procedure involves infected skin. Should methicil-

lin-resistant Staphylococcus aureus (MRSA) be sus-

pected, clindamycin or vancomycin would be the

drug of choice.

While no official guidelines exist addressing the

issue of cutaneous surgery and prophylaxis of arti-

ficial joints, a joint advisory statement from the

American Dental Association and the American

Academy of Orthopedic Surgeons recommended

against the use of prophylaxis for routine dental

work in patients with artificial joints more than 2

years old—procedures that carry a significantly

higher risk of inducing bacteremia than clean cuta-

neous incisions.11 Tooth brushing alone induces

bacteremia rates of 25%,12,13 while the rate of bac-

teremia induced by cutaneous surgery is less than

3%.14,15 The guidelines are less clear for patients

whose artificial joints are less than 2 years old, as

these joints are noted to be more susceptible to

infection.11 At the current time, there is no evidence

to suggest that prophylaxis is required for the vast

majority of prosthetic joint recipients with clean

cutaneous wounds. However, given the higher risk

of bacteremia associated with procedures involving

mucosal surfaces, adopting the endocarditis pro-

phylaxis guidelines is often recommended for

patients with clean-contaminated wounds.16 As

treatment guidelines for patients who have received

their transplants within the past 2 years are unclear,

many practitioners have also adopted the endocar-

ditis recommendations for this patient subset.17

Please see Chapter 8 for further discussion.

Site Preparation and Anesthesia

Preoperative Antisepsis

The ideal cutaneous antiseptic would provide com-

plete, long-lasting sterilization of the operative field

with no tissue toxicity. A number of choices are

available for antiseptic preparation of the cuta-

neous surface (Table 10.2). The most commonly

Table 10.1 Preoperative patient evaluation

MedicalComorbidities

AnxietyArthritis/Severe musculoskeletaldisease

Artificial heart valves or recentprostheses

Cardiovascular disease/heart valveanomalies

Clotting disordersDementiaDiabetesHistory of endocarditisHistory of poor wound healing/keloid formation

HypertensionMalnutritionPeripheral vascular diseasePregnancy

Medications/Herbalsupplements

AnticoagulantsAntiplatelet agentsAccutane use within the past 6–12months

CorticosteroidsHerbal supplementsImmunosuppressants

Drug allergies

Electrical devices PacemakersImplantable cardiac defibrillatorsBrain stimulators

SocialEnvironment

Patient ability to care for wound/obtain assistance in wound care

126 M.A. MacCormack

used are 10% povidone-iodine, 4% chlorhexidine

gluconate, 70% isopropyl alcohol, and 2% chlor-

hexidine gluconate combined with 70% isopropyl

alcohol. Povidone-iodine has broad-spectrum

activity against bacteria and some viruses; how-

ever, it is easily inactivated as it is only effective

when dry. Chlorhexidine is slower in onset, how-

ever, its overall effect is of longer duration and it

has been demonstrated to be superior to povi-

done-iodine in decreasing bacterial load.18 Com-

parative studies suggest that the 70% isopropyl

alcohol and 2% chlorhexidine gluconate combina-

tion, as well as a combined isopropyl alcohol/

povidone-iodine scrub, provide the best immedi-

ate and persistent antimicrobial effect.19–21 While

generally well tolerated, caution must be taken

when using cutaneous antiseptics. Prolonged,

direct contact with chlorhexidine can lead to ker-

atitis and ototoxicity, while iodine preparations

are often irritating to the skin and can be toxic in

newborns.

Anesthesia

Most cutaneous excisions can be performed

under local anesthesia. The most commonly

used anesthetic is 0.5–1% lidocaine due to its

rapid onset of action and intermediate duration

of effect. The addition of epinephrine not only

provides increased hemostasis but also extends

efficacy. Maximum recommended dose is

4.5 mg/kg for the plain formulation and 7 mg/

kg for lidocaine plus epinephrine.22 While it was

once thought that only plain lidocaine could be

used in anatomic areas such as the nose, ear, or

penis, this is not the case and there are no

absolute anatomic contraindications to epinephr-

ine use.23–25 The use of epinephrine should be

avoided in patients taking propanolol, a nonse-

lective beta blocker, as it could potentially lead

to malignant hypertension.26 True allergy to

anesthetics is rare. It is important to obtain a

complete history of reported allergic reactions

because what many patients interpret as an aller-

gic response is actually a vasovagal episode or

symptoms due to epinephrine effect (palpita-

tions, shaking, sweating, light-headedness). In

the uncommon case of actual allergy, the offend-

ing agent is often the preservative present in

multi-dose vials or a sodium metabolite found

in epinephrine-containing products.27 Should a

true lidocaine allergy exist, an ester anesthetic

such as procaine can be substituted.

The discomfort associated with anesthesia injec-

tion is multi-factorial, in part due to tissue disten-

sion and in part due to the acidity of the anesthetic

(especially in epinephrine-containing formula-

tions). Simply buffering the anesthetic with sodium

bicarbonate in a 9:1 formulation, initiating the

injection in the more distensible subcutaneous tis-

sue, and decreasing the speed of infiltration can

increase patient comfort substantially.28 An

in-depth review of cutaneous anesthesia is provided

in Chapter 9.

Excision Margins

Surgical margins vary based on such factors as

tumor type, intent of procedure (diagnostic ver-

sus therapeutic), and tumor size/depth. For basal

cell carcinomas less than 2 cm in diameter

located in low-risk anatomic areas (trunk,

Table 10.2 Antiseptic solutions

Antisepticagent

Advantages Disadvantages

Povidone-iodine Broad spectrum,including fungi

Quickly neutralized by blood, serum proteins, or sputum; irritant; potentialsystemic toxicity with large body surface area

Chlorhexidinegluconate

Prolonged effect Keratitis and otitis

Hexachlorophene Neurotoxicity in infants

Isopropyl alcohol Inexpensive Flammable, must allow it to dry

10 Excision Techniques, Staples, and Sutures 127

extremities), a margin of 4 mm provides a 98%

initial cure rate.29 Larger basal cell carcinomas,

as well as tumors with more aggressive histologic

growth patterns—such as morpheaform and

micronodular tumors—have been shown to

have a much greater degree of subclinical exten-

sion, and thus should be excised with either

greater margins or treated with Mohs micro-

graphic surgery.29–31 Recurrence rates for pri-

marily excised basal cell carcinomas range from

approximately 5–10% at 5 years.32,33 Well-differ-

entiated squamous cell carcinomas less than

2 cm in diameter and located in low-risk ana-

tomic areas excised with a 4-mm margin have a

95% initial clearance rate; however, moderately/

poorly differentiated tumors or tumors greater

than 2 cm in diameter require a 6-mm margin.34

Recurrence is about 8% at 5 years.35 For tumors

in high-risk locations (H-zone of the face, geni-

talia, hand/feet, ears) or very large tumors,

Mohs micrographic surgery may be a better

treatment option due to its higher cure rate.36

Recommendations for the surgical treatment

of melanoma have been made by the National

Comprehensive Cancer Network and are out-

lined in Table 10.337 and further discussed in

Chapter 15.

Specimen Handling

Handling of tissue specimens should be performed

in accordance with the overseeing institution’s poli-

cies. Most specimens should be immediately placed

in formalin to await transport to the lab. To avoid

confusion, it is highly recommended that appropri-

ately labeled containers be prepared prior to the

start of the procedure and that all specimens are

transported directly from patient to jar.

Hemostasis

Obtaining good wound hemostasis is essential for

appropriate field visualization as well as avoidance

of adverse postoperative events. For very small pro-

cedures, simple pressure and suturing may be all that

is needed. However, in general, most excisions pro-

ceedmore smoothlywith the use of an external device

such as a heat cautery unit, hyfrecator, or electrocau-

tery. Heat cautery can be provided either via dispo-

sable handheld units or by a free-standing unit with

sterilizable tips and is a good choice for patients with

pacemakers, implantable cardiac defibrillators, brain

stimulators, or other internal electronic devices as

there is no current that could cause potential inter-

ference. Hyfrecators work via the emission of mono-

terminal, high-voltage, low-amperage current, while

electrocautery units use high-amperage, lower vol-

tage AC electricity to achieve effect (Table 10.4).

Most electrocautery units have ‘‘cut’’ and ‘‘coagula-

tion’’ settings. The ‘‘cut’’ current is a continuous,

lower voltage current producing high levels of heat

that rapidly vaporizes tissue, while the ‘‘coagulation’’

current is a pulsed, higher voltage current that pro-

duces heatmore slowly, leading to blood coagulation

Table 10.3 Recommended surgical margins for melanomaexcision3,7

Melanomadepth

Clinical margin

In situ 5 mm (larger may be required forlentigo maligna)

<1.01–2 mm 1 cm (consider sentinel node)

2.01–4 mm 1–2 cm (consider sentinel node)

>4 mm 2 cm

Table 10.4 Electrosurgical devices

Device Circuit Tissue contact Voltage Amperage

Electrofulguration Monoterminal No High Low

Electrodesiccation Monoterminal Yes High Low

Electrocoagulation Biterminal Yes Low High

Electrosection Biterminal Yes Low High

Electrocautery None Yes Low High

128 M.A. MacCormack

and more diffuse tissue damage.38 Monopolar elec-

trocauteryunits require the use of a ground and entail

passage of electrical current through the patient;

whereas in bipolar electrocautery units the current

should pass only through the tissue placed between

the forceps probe, making it a safer choice for

patients with internal electrical devices.39,40

To obtain hemostasis the wound should first be

blotted with gauze or similar material so that active

sites of bleeding can be identified. The offending

blood vessels can then be treated directly or grasped

with a forceps to which the cautery tip is then

placed. The desired endpoint is a bloodless field,

yet it is important to remember that excessive cau-

tery can delay wound healing and increase risk of

infection. On occasion, some vessels are too large to

be treated with electrocautery and need to be tied

off with suture. As cautery is by its very nature a

destructive process, excessive cautery and treatment

of the skin edge should be avoided.

Suture Materials

Sutures are classified into two major categories:

absorbable and nonabsorbable. Traditionally,

absorbable sutures are used for deep closure and

nonabsorbable sutures are used for epidermal repair;

however, many exceptions to this rule apply. For

example, in situations where suture removal is incon-

venient, absorbable suture such as 6.0 fast absorbing

gut is often used for epidermal closure. The choice of

suture material is largely a matter of physician

preference; the major characteristics of the most

commonly used suture materials are outlined in

Table 10.5.41 As a general rule, the smallest suture

providing adequate tensile strength is preferred.

Wounds closed under significant tension will benefit

from suture that maintains its tensile strength,

whereas in low-tension wounds sited in rapidly heal-

ing areas this is much less of a concern. Overly tight

epidermal sutures, as well as failure to remove epider-

mal sutures in a timely fashion, may lead to the for-

mation of suture marks resulting from epidermal

ingrowth/scarring along the suture line. As a general

rule of thumb, facial sutures should come out within

5–7 days, while sutures on the trunk and extremities

should be removed between days 10 and 14.

Staples

Staples provide a rapid, secure means of wound

closure. While sutures typically allow for more pre-

cise alignment of wound edges, in certain areas such

as the scalp, staples can provide an equivalent or even

slightly improved overall cosmetic outcome.42,43

Staples may provide an alternative for poten-

tially contaminated wounds where delayed pri-

mary closure is not elected.44

A variety of disposable stapler sizes are available.

To place a staple, the stapler tip is firmly placed

perpendicular to the wound edge and the handle

depressed. Staplers typically provide excellent wound

edge eversion; however, if additional eversion is

required an assistant can manually evert the wound

edge using two-toothed Adson forceps prior to staple

discharge. Specialized staple removers enable easy

extraction.

Skin Adhesive

Although typicallymore expensive than suturemate-

rial, skin adhesive (2-Octyl cyanoacrylate) can be an

acceptable choice for closure in low-tension wounds.

When used in conjunction with appropriately placed

subcutaneous sutures, cosmetic outcome has been

shown to be excellent in low-tension repairs.45–49

However, in areas of high mobility or tension, epi-

dermal sutures may be a better choice.50

For proper application of skin adhesive, thewound

should first be completely reapproximated with

subcutaneous sutures. The skin surface is cleaned,

the ampoule crushed, the wound edges manually

everted with forceps, and the adhesive is applied

extending at least 1/2 cm beyond the wound edge,

gradually building up to 3 or 4 layers.

As skin adhesive forms its own dressing, minimal

postoperative care is required. Patients should be

instructed to avoid washing the area too vigor-

ously, as this can result in rapid breakdown of the

adhesive.


Skin Tape

Various types of skin tapes are available, typically

composed of nonocclusive, microporous material.

While simple tapes such as Steri-Strip1 closures

(3 M, St. Paul, MN) are more often used to pro-

vide additional support to an already closed

wound, more complex products such as ClozeX1

tape (Clozex Medical LLC, Wellesley, MA), an

adhesive film with multiple interlocking filaments

that allow for wound edge approximation, have

been shown to have good effect.51 To obtain best

adhesive results, the skin should be degreased with

alcohol or acetone and Mastisol1 (Ferndale

Laboratories, Ferndale, MI) or tincture of ben-

zoin applied prior to application.

Table 10.5 Suture materials4,1

Suture Filament

type

Tensile strength Inflammatory

response

Absorption Notes

Absorbable

Surgical gut (Plain) Mono 7–10 days ++ 70 days Collagen from sheep/beef

intestine

Surgical gut (Fast

absorbing)

Mono 5–7 days ++ Treated with heat to speed

absorption

Good for low-tension facial

closures, full thickness skin

grafts

Surgical gut

(Chromic)

Mono 10–14 days ++ 90 days Chromium salts slow absorption

and decrease reactivity

Polyglactin 910

(Vicryl)

Braided

Multi

65–75% at

14 days

20–50% at

21 days

10% at

35 days

– Minimal for

45 days,

complete

by 70

days

Rapid absorption once tensile

strength is lost

Poliglecaprone 25

(Monocryl)

Mono 50–60% at

7 days

20–30% at 14

days

0% at 21 days

– 120 days Very pliable, good for

subcuticular closure

Polydioxanone

(PDS II)

Mono 70% at 14 days

50% at 28

days

25% at 42

days

+ 6 months Lower initial tensile strength,

but longer retention providing

extended wound support

Non

absorbable

Silk Braided

Multi

0% by 1 year +++ +/– 2 years Handles well, high reactivity

Good for mucosal areas (soft)

Nylon

(Ethilon)

Mono 81% at 1 year – Slowly

hydrolyzed

Good elasticity, high memory

Polypropylene

(Prolene)

Mono 2 years – – Does not stick to tissue, good for

subcuticular or other

‘‘pullout’’ closures

130 M.A. MacCormack

Closure Techniques

Second Intention

After an excision has been performed it can be left

to heal on its own (second intention healing), which,

while slow, can be an appropriate choice for defects

in areas where primary closure is prohibited due to

lack of tissue mobility and/or concerns regarding

graft take. In certain instances—for example, con-

cavities such as the medial canthus, nasal alar crease

or conchal bowl, as well as for many mucosal sur-

faces—second intention healing can be the closure

of choice providing excellent cosmesis52 (Figs. 10.1

and 10.2). As second intention wounds contract as

they heal, this type of healing should be undertaken

with caution in areas adjacent to free margins such

as the eyelid, nasal alar rim, and lip, as unwanted

tissue distortion may result.

Layered Closures

The vast majority of excisions are closed primarily

and there are a number of techniques available to

achieve closure. The simplest closure consists of

purely epidermal sutures, a type of repair appropri-

ate only for areas with negligible tension. Should

wound tension be present, a layered closure is a

more appropriate choice. Deep dermal sutures func-

tion to close dead space, approximate wound edges,

and provide wound eversion, while epidermal

sutures act to further refine edge alignment. When

placing dermal sutures, use of the ‘‘buried vertical

mattress technique’’ as described by Zitelli andMoy

provides an excellent result due to prolonged der-

mal support and edge eversion.53 While similar to a

traditional dermal suture, this technique is charac-

terized by a few key differences. To begin, the needle

should enter the base of the skin flap through the

subcutaneous fat, head up toward the superficial

dermis and then dive back down to exit the ipsilateral

skin edge at the level of the deep dermis, the opposite

pattern is repeated on the contralateral side and a

buried knot is placed. When drawn together, the

central portion of the wound is raised up forming a

tightly opposed, well-everted wound (Fig. 10.3a).

Some practitioners have found this technique so

effective that they forgo additional epidermal

sutures.54,55 In the rare situation where significant

eversion is not desired, the dermal suture can be

placed in the dermis without the lateral upward arch.

A myriad of techniques exist for epidermal clo-

sure. Simple interrupted sutures provide good

strength and excellent wound edge alignment, but

are considered time consuming by some (Fig. 10.3b).

To be properly placed, the needle should enter the

skin at 90 degrees within 1–2 mm of the wound

edge, the needle should move smoothly through the

dermis and subcutaneous fat to the contralateral side

following the curve of the needle and exiting the skin

in a similar manner. The two ends of suture are

typically tied using an instrument tie. To perform thisFig. 10.2 Healed wound by second intention, 4 weeks afterinitial surgery. Photograph courtesy of SuzanneOlbricht,M.D.

Fig. 10.1 Wound resulting from surgical removal of squa-mous cell carcinoma. Photograph courtesy of SuzanneOlbricht, M.D.


procedure, a double loop (to help prevent knot slip-

page) should be made around the needle driver tip

utilizing the needle end of the suture. The needle driver

then grasps the short (free) end of the suture and the

two sides are pulled tight. The procedure is then

repeated from the opposite direction to create the

next knot; however, after the first knot is placed, only

a single loop around the needle driver is required.

Depending on the type of suture used, between 3 and

6 knots should be placed to avoid untying (more for

monofilament as opposed to braided suture). Knots

should be tight, but care must be taken to avoid stran-

gulating the skin. One trick is to leave some laxity in

the first 1 or 2 knots to accommodate potential

swelling.

Running epidermal sutures are faster to place, but

sacrifice some precision, run a greater risk of being

pulled too tight leading to tissue strangulation, and are

more vulnerable should the suture break (Fig. 10.3c).

Locked running sutures are similar, allow for slightly

more precision in edge alignment, but carry an even

higher risk of vascular compromise (Fig. 10.3d). Runn-

ing subcuticular sutures are faster to place than simple

interrupted sutures, and with good technique can pro-

vide good wound edge alignment (Fig. 10.3e). Further-

more, if placedwith buried knots and absorbable suture

the need for suture removal is eliminated. Vertical mat-

tress sutures provide excellent wound edge eversion and

are useful in areas, such as the helical rim, where a

depressed scar would be quite visible; however, if not

a)

b)

e)

c)

f)

d)

g)

Fig. 10.3 Various suturetechniques for epidermalclosure (Illustration byAlice Y. Chen)

132 M.A. MacCormack

removed promptly they carry a high risk of leaving

suture marks (Fig. 10.3g). Horizontal mattress sutures

are useful for closing areas under high tension, although

if there is difficulty in edge approximation, an alterna-

tive repair may be a better choice (Fig. 10.3f). High

tension not only increases risk of vascular compromise,

tissue injury, and poor healing, but also significantly

increases risk of scar spread. Even for low-tension

wounds, when tying sutures it is important to use the

minimal amount of tension necessary to obtain edge

approximation.

Description of Procedure

Elliptical Excision

The majority of excisions are elliptical or fusiform

in design, in large part due to ease of closure. By

designing an excision with a length/width ratio of

approximately 3:1 or with apical angles of no more

than 308 (on a flat plane), the likelihood of standing

cone deformities or ‘‘dog ears’’ is markedly reduced,

resulting in a cosmetically elegant flat scar.

When performing excisions on convex areas, the

desired apical angle is often less than 308, whileon a concave surface, apical angles greater than

308 are often well tolerated.

Cosmesis can be further enhanced by orienting the

long axis of the excision parallel to existing skin tension

lines and/or the intersection of two cosmetic units.

When planning an excision, the borders of the tumor

should first be marked, the appropriate margins deli-

neated, and the incision line drawn, taking care to

place the long axis in the most desirable orientation,

as described previously (Figs. 10.4 and 10.5).

Once anesthesia has been obtained, the proce-

dure may begin. The scalpel handle should be held

firmly between the first and second fingers, similar

to a pencil, with the opposing hand used to provide

skin traction.

In general a #15 blade is used; however, in areas

of very thick skin, such as the back, a #10 blade

may be more effective.

Starting at one end of the excision site, the skin

should be scored in a single pass. This is then

repeated on the opposing side, with care being

taken to cleanly incise the tips. Utilizing firm pres-

sure, the skin should then be incised completely

down to subcutaneous tissue using theminimal num-

ber of passes possible (one to two strokes) (Figs. 10.6

and 10.7).

At all times it is important to hold the blade

perpendicular to the skin surface to allow for good

edge approximation later during closure. For most

tumors, excision to the mid to deep subcutaneous

fat is adequate; however, when excising melanoma

the excision should extend down to fascia. After the

excision edges are freed, the specimen is grasped

with forceps and separated from the wound base

by scalpel blade, scissors, or electrosection. To help

maintain an even base, it is helpful to draw the

Fig. 10.4 Elliptical excision, marking margins

Fig 10.5 Elliptical excision, planned incision line


specimen over the blade or scissors while cutting

(Fig. 10.8). Once freed (Fig. 10.9), the specimen

should immediately be placed in a correctly labeled

container.

Hemostasis should be obtained, if needed, uti-

lizing the techniques described previously to pro-

vide a clear operative field (Fig. 10.10). If the

wound is very small, one can then progress imme-

diately to closure. However, in most cases, wounds

will benefit from undermining as it increases tissue

mobility, decreases tension, and facilitates edge

eversion. The large plate-like scar resulting from

wide undermining may even help in the resolution

of tissue redundancies/dog ear deformities.56 It is

important when undermining to always be aware

of the surrounding anatomy in order to avoid

unwanted injury to adjacent nerves, vessels, or

other structures.

Undermining can be performed via either blunt

dissection or sharp dissection. In blunt dissection,

the wound edge is stabilized in a nontraumatic

manner, such as with a skin hook. A pair of

surgical scissors is inserted with closed blade

Fig. 10.10 Elliptical excision, obtaining hemostasis

Fig. 10.6 Elliptical excision, initial incision

Fig. 10.7 Elliptical excision, incision completed

Fig. 10.8 Elliptical excision, separation from subcutaneoustissue

Fig. 10.9 Elliptical excision, specimen removed

134 M.A. MacCormack

into the wound, parallel to the skin surface. The

blades are then opened, gently separating the sub-

cutaneous tissue. Blunt dissection is a good option

for areas where nerve or vessel injury is a concern

as these structures are often pushed aside rather

than severed. However, blunt dissection can also

lead to an uneven dissection plane and is fre-

quently slower than sharp dissection. In sharp

dissection, either the scalpel blade or one blade

of an open pair of scissors is inserted into

the wound—again parallel to the skin surface—

and the tissue separated either by cutting, pushing

the scissors through the skin in a planing motion,

or blade closure (Fig. 10.11). Sharp undermining

tends to be faster and allows for more control over

the dissection plane. The depth of undermining

varies by anatomic site. In general, undermining

should be performed at the level of the wound

base in the mid to deep subcutaneous fat or

just above the fascial layer, however, exceptions

apply (Table 10.6).57 There are no hard and fast

rules governing the extent of undermining;

each wound must be considered individually with

the goal of creating a tension-free repair.

Once the wound has been completely under-

mined it should be reassessed for hemostasis.

When all active bleeding has been controlled

the wound is ready for sutures. Dermal sutures

are placed first, preferably utilizing the buried

vertical mattress technique as described pre-

viously. It is often helpful to start at the tips

(areas of lower tension), gradually moving in

toward the center (area of highest tension).

Once the dermal sutures are completed, the

wound should appear as a slightly raised ridge

with the skin edges nicely opposed. The dermal

sutures are followed by epidermal sutures, again

utilizing one of the aforementioned techniques

(Figs. 10.12, 10.13, 10.14, 10.15 and 10.16).

A common variation of the classic elliptical exci-

sion gently curves the ends of the incision resulting in

an S-shaped repair. S-plasty closure has the advan-

tage of decreasing wound tension and may often

result in a more esthetically pleasing scar; however,

the resulting scar is often longer than that created by

a traditional elliptical procedure.

Purse-String Repair

An alternative to the elliptical excision is the purse-

string closure. On occasion, high skin tension pre-

vents immediate closure following elliptical exci-

sion, or the long linear scar that would result from

elliptical excision is undesirable. In such cases a disc

excision with purse-string closure may be a more

acceptable alternative. To perform a disc excision

one begins by marking the desired surgical margin

around the excision site. The lesion is then excised in

a circular or disc-like manner leaving a round

defect. The wound is gently undermined, hemosta-

sis is obtained, and the wound is ready for closure.

Various techniques exist for placing a purse-string

suture. The original publication in the dermatologicFig. 10.11 Elliptical excision, tissue undermining

Table 10.6 Recommended undermining planes

Scalp Subgaleal

Forehead : small Subcutaneous fat

: large Subgaleal

Temple Subcutaneous fat (Need to stayabove superficial temporalfascia to avoid temporal branchCN VII)

Nose Sub-nasalis

Cheek Subcutaneous fat

Jaw/Neck Superficial subcutaneous fat(Avoid marginal mandibularnerve, CN XI)

Trunk/Extremities Deep subcutaneous fat/fascia

Dorsal Hands/Feet

Subdermal


literature described using a nonabsorbable 3-0 or 4-

0 polypropylene subcuticular suture with an epider-

mal knot at 12 o’clock and escape loops placed at 3,

6, and 9 o’clock.58

The author’s preference for purse-string closure is

to use an absorbable suture, such as Vicryl, placed

horizontally in the mid to deep dermis. As the

suture is drawn together and tied, the wound

becomes puckered, much like the top of a draw-

string purse. Once the wound has been maximally

reapproximated, simple interrupted epidermal

sutures can be placed to further speed healing.

On occasion, it is impossible to close the wound

completely and the central area is closed with a

skin graft or is left to heal by second intention.

Another excellent alternative is to place a purse-

string suture utilizing a nonabsorbable suture,

such as polypropylene, using vertically oriented

bites placed approximately 5–10 mm from the

wound edge. The skin edges can then be further

Fig. 10.14 Elliptical excision, dermal sutures completed

Fig. 10.15 Elliptical excision, epidermal sutures

Fig. 10.16 Elliptical excision, final woundFig. 10.13 Elliptical excision, initial dermal suture tied

Fig. 10.12 Elliptical excision, initial dermal suture

136 M.A. MacCormack

reapproximated using buried vertical mattress

sutures and simple interrupted epidermal

sutures59,60 (Figs. 10.17–10.24). All nonabsorbable

sutures should be removed at 5–7 days for facial

wounds and 10–14 days for nonfacial repairs. The

wound will continue to display moderate pleating at

Fig. 10.17 Purse-string closure, margin marked

Fig. 10.18 Purse-string closure, margin incised

Fig. 10.19 Purse-string closure, undermining

Fig. 10.20 Purse-string closure, purse-string suture of 4.0Prolene placed

Fig. 10.21 Purse-string closure, purse-string suture tied

Fig. 10.22 Purse-string closure, further edge approximation


the time of suture removal; however, as long as the

wound is in an area of moderate tension these skin

folds almost always resolve.

Standing Cones (Dog Ears)

On occasion, after elliptical excision the wound

continues to exhibit vertical elevations at the tips

or ‘‘dog ears.’’ Many factors can contribute to the

formation of tissue redundancies including initial

apical angles greater than 308, inadequate under-

mining, failure to maintain a 90-degree incision

angle, or unequal side lengths. When an excision

borders a free margin, such as the lip or ala, such

tissue redundancy presents not as a vertical eleva-

tion, but rather as a pushing distortion of that mar-

gin. Small dog ears, especially in areas of high ten-

sion/tissue mobility, such as the dorsal hand, will

often resolve on their own. Larger redundancies,

however, are often best resolved at the time of the

initial procedure. One of the easiest means of reso-

lution is simply by wound extension. While holding

the redundancy steady, an incision can be made

through the center of the standing cone to its base.

After careful undermining, the two resulting trian-

gular halves can be laid across the initial incision

line and neatly trimmed (Figs. 10.25–10.30). As one

becomes more proficient in dog ear management, it

becomes clear that by utilizing the same principles

the tissue redundancy can be removed from almost

any direction. The same technique can be applied

when performing immediate linear closure follow-

ing disc excision. In fact, this method of surgical

removal has been demonstrated to result in overall

shorter scar lengths than those seen with preplanned

ellipses.61

If a difference in wound edge lengths is appre-

ciated prior to closure it can often be dealt with via

‘‘the rule of halves.’’ The first suture is placed in the

midportion of each side and the wound bisected.

The process is repeated—continuing to divide the

unsutured areas in half until the wound is closed—

ultimately resulting in a curvilinear repair.

An excellent review of dog ear management has

been published by Weisburg, Nehal, and Zide.62

Postprocedure Care

Wound dressings serve a number of functions.

Not only do they act to keep the wound clean

and protected from unwanted exposure, they

also act to provide pressure, limiting postopera-

tive bleeding complications and can help support

and stabilize the wound. While small procedures

require little more than daily cleansing followed

by application of ointment (such as petrolatum

or topical antibiotic) covered by gauze, larger

procedures often benefit from a more substantial

dressing. Many patients prefer a ‘‘leave-on’’

Fig. 10.23 Purse-string closure, final repair

Fig. 10.24 Purse-string closure, 4-month outcome

138 M.A. MacCormack

bandage that requires no wound care on the part

of the patient. One such example is to begin by

applying a thin layer of ointment over the

wound edge. Steri-Strips held in place with

liquid adhesive are then placed perpendicular to

the wound to further enhance edge support. The

next layer is an absorptive material such as a

hydrocolloid (i.e., Cutinova-Hydro1, Smith &

Fig. 10.26 Cutaneous redundancy, initial incision

Fig. 10.27 Cutaneous redundancy, tissue overlap

Fig. 10.28 Cutaneous redundancy, second incision

Fig. 10.29 Cutaneous redundancy, dog ear removed

Fig. 10.30 Cutaneous redundancy, final wound

Fig. 10.25 Cutaneous redundancy


Nephew, London, UK) trimmed to fit the exci-

sion line, which is in turn covered by a breath-

able, waterproof film (i.e., Tegaderm1, 3 M)

allowing the patient to shower. On top of all of

this is a pressure dressing composed of gauze

and tape, which is removed by the patient at

24–48 h.

Complications

When properly performed, surgical excisions

have a very low complication rate. All patients

should be informed preprocedure that some sort

of scarring is inevitable and localized cutaneous

numbness is not uncommon due to transaction of

sensory nerves. With time, typically within 1

year, sensation often returns to normal, and

scar cosmesis can be enhanced via proper plan-

ning and orientation. Appropriate knowledge

of surgical anatomy can prevent inadvertent

injury to surrounding vessels and nerves as well

as tissue distortion. Allergic reactions to topical

antibiotics, dressing materials, or adhesive tape

(Fig. 10.31) are not uncommon and can be easily

addressed by removal of the offending agent and

application of a mild topical steroid. Wound

infection occurs in less than 2% of cases and is

often heralded by an increase in pain63,64 (Fig.

10.32). Risk can be minimized by use of good

sterile technique and appropriate wound care.

Should infection occur, the wound should be

cultured, drained if necessary, and the patient

started on a suitable antibiotic. Bleeding compli-

cations occur in about 3% of cases, but careful

attention to intraoperative hemostasis as well as

use of a good pressure dressing for the first 24–

48 h following the procedure can help to decrease

this risk64 (Fig. 10.33). Wound dehiscence can

occur as a result of excessive wound tension,

hematoma formation, or infection. In such cases

the underlying issue should be addressed and the

wound then allowed to heal by second intention.

Once healed, the scar can be revised, if necessary.

For further discussion on surgical complications

see Chapter 12.

Fig. 10.31 Allergic contact dermatitis to adhesive

Fig. 10.32 Postoperativewound infection

Fig. 10.33 Postoperative hematoma

140 M.A. MacCormack

Summary

Excision remains one of the most frequently per-

formed dermatologic procedures. As time goes on,

advances such as improved topical anesthetics or

the use of confocal microscopy to help better deline-

ate tumor margins may improve patient comfort

and treatment efficacy. However, for the foresee-

able future cutaneous excisions will remain one of

the mainstays of surgical dermatology.

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