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Excision of common skin lesions: Benign and malignant
Excision of Common Skin Lesions: Benign and Malignant Gerald J. B6champs, MD, FACS
kin lesions are frequently encountered in general sur-
S gery practices based in the community. In the university setting or large urban areas, skin lesions may be seen by a primary care physician and referred to a dermatologist for diagnosis and management. However, in both urban and community-based rural practices, the general surgeon is often requested to manage skin lesions, both benign and malignant. This article, outlines a practical approach to excising skin lesions in an outpatient setting. Many excellent texts and manuals are available for an in-depth discussion of this subject. 1-3
Preparation Excision of skin lesions can be easily performed in a surgeon's office, if properly equipped, or in an outpatient hospital-affiliated setting. In the current atmosphere of
From the General Surgery Division, Winchester Surgical Clinic, Winchester, VA. Address reprint requests to Gerald J. B6champs, MD, FACS, Winchester Surgical Clinic, Ltd., 20 S. Stewart St., Winchester, VA 22601. Copyright 2002, ElsevierScience(USA).All rights reserved. 1524-153X/02/0403-0002535.0010
doi:10.1053/otgn.2002.35338
HMOs, PPOs, and other insurance plans, reimbursement issues may be a factor in determining the location for a minor surgical procedure. Equipment should include a bright flexible light source, a comfortable stool on wheels for the surgeon, and a basic tray of instruments. Instruments should be up-to-date and include, at a minimum, those outlined in Table 1. These can be prepackaged and sterilized for use in the selected ambulatory setting. It is important to plan for unanticipated events or complications that may occur during the procedure. Resuscitative equipment and appropriate medications should be available in the event of an anaphylactic reaction. An assistant is needed to obtain additional materials or sutures but is not required to actually assist with sterile gloves. The assistant may also act as a chaperone and help the patient during the procedure. If a very fine plastic surgery type of procedure is anticipated, then additional instruments, such as a Webster needle holder, tenotomy scissors, and 2-mm skin hooks, may be added to the basic instrument tray. It is also helpful to engage in light conversation with the patient, if possible, to distract the patient from the procedure and help reduce anxiety.
T a b l e 1. Basic Minor Surgery Tray Sponge forceps Two Allis clamps Two curved mosquito clamps Two straight hemostat clamps Two curved hemostat clamps One regular Kelly clamp Two needle holders (one small, one medium) One sponge forceps Two Miller double-end retractors Two small towel clips One #3 knife handle with a #15 blade One straight iris scissors, one curved iris scissors One small Metzenbaum scissors and one regular Metzenbaum scissors One suture scissors Four small tissue forceps One smooth Adson forceps and one Adson forceps with teeth One rat-toothed forceps and one smooth medium forceps One Heiss finger retractor Two medicine glasses Six prep sponges 4 • 4 gauze sponges Four sterile towels
Operative Techniques in General Surgery, Vol 4, No 3 (September), 2002: pp 207-213
207
208
Gerald J. B6champs
SURGICAL TECHNIQUE
1 Skin preparation. In assessing the lesion to be removed, the surgeon must plan the incision carefully to minimize scarring and obtain the best cosmetic result possible. The surgeon ascertains the direction of the wound in relation to the relaxed skin tension lines of Borges and the underlying muscle. An excellent detailed discussion of planning incisions is given in another article in this volume. 4 Particular attention should be paid to the shoulder and sternal areas, which are more prone to keloid formation. If excessive hair is present, electric shaving is preferred over razor preparation as the razor method carries an increased risk of infection. Several products provide disposable blades for electric clippers, reducing the need for cleansing and resterilization after each use. The surgeon should wear a surgical cap, a mask, and sterile gloves. Marking of the prepared incision is optional but advised, because local anesthetic infiltration frequently distorts the planned incision. Skin preparation can be done with an iodine-based antiseptic solution. For a patient with skin sensitivity to iodine, one of the many available noniodinated preparations may be used.
Excision of Common Skin Lesions
209
~
.-,.
2 Local anesthesia. The surgeon should be familiar with the systemic toxicity of local anesthetic infiltration, including toxic dosages, injection sites and absorption rates, and the occasional vasovagal reaction to an injected anesthetic. I prefer lidocaine 0.5% to 1.0% for local anesthesia. Epinephrine 1:100,000 can be incorporated for vasoconstriction in areas of increased blood supply (e.g., face and neck) to reduce bleeding. If longer anesthetic time is anticipated, then bupivacaine 0.25% (Marcaine, Sensorcaine) is a good choice. Rarely is more than 5 mL needed unless a long elliptical incision is being made. A 27- or 30-gauge needle is preferred, and only two skin punctures are necessary to create a four-sided block of local anesthetic approximately 5 to 10 mm away from the edge of the skin lesion. The small-gauge needle minimizes the discomfort from injection of local anesthetic, typically described as a hot, burning-like sensation related to the distention of tissue and the acidity of the solution. The small gauge also minimizes local infiltration into the dermis, where a "wheal" should be raised as the skin is infiltrated. Onset of anesthesia is rapid (1 to 2 minutes), slightly longer if epinephrine is used in conjunction with the local anesthetic.
210
Gerald J. B~charnps
Margin width: 1-2mm Benign lOmm Malianant//.
Excisional biopsy carried to fascial layer for melanomas 3 Excision. In general, well planned, elongated, elliptical excisions that well excede the length of the lesion are preferred. The patient should be advised that the scar will be longer than the lesion that he or she sees on the skin. For excisional biopsy, as opposed to a shave biopsy, the surgeon holds the scalpel perpendicular to the skin while cutting through the dermis. For benign lesions, a margin of 1 to 2 mm is satisfactory on all sides from a usually sharply demarcated edge of a pigmented lesion. The dissection can then be continued directly underneath the dermis in the subcutaneous fat. Ifa lesion is suspected to be melanotic because of its irregular shape, variated color, or punch biopsy-proven diagnosis, then a 1-era margin from the outer edge of the lesion is achieved. In addition, the surgeon should remove all of the subcutaneous fat to the fascial level and a wider base (1 to 2 ram) underneath the skin to incorporate possible lymphatic channels. If a subsequent pathologic examination reveals that the lesion is of greater depth (i.e., Clark's level III to V), then the 1-cm margin on all sides will not interfere with a wider excision with flap closure or skin graft coverage by an experienced general surgeon, plastic surgeon, or surgical oncologist at a later time. 5 Visible vessels can be clamped and tied with 3-0 or 4-0 absorbable suture. Usually, gentle pressure with a gauze sponge is sufficient to stop any minor oozing.
Excision of Common Skin Lesions
211
~rl
Simple interrupted
Subcuticular
4
Vertical mattress
Continuous'over & over
Closure. Although the patient appreciates a lesion being removed for diagnosis and attendant relief of anxiety, the scar remains for life. Therefore, it is important to close the incision carefully while avoiding undue tension and minimizing any suture marks, providing the dermis with optimum conditions to heal with minimal scarring. In the subcutaneous tissue, I prefer 3-0 or 4-0 Polyglactin 910 suture (Vicryl; Ethicon, Johnson & Johnson Somerville, NJ) depending on the depth of the wound. This may have to be done in several layers. On the face, one should use 5-0 or 6-0 Polyglactin 910 suture, which maintains 75% of its original strength at 14 days and 50% at 21 days postinsertion, thus maintaining strength while natural wound healing is occurring. A noncutting needle (SH or round) should be used for this tissue, and the suture technique should be a simple Lembert type to eventually evert the epidermal edges to enhance healing of the dermal scar. There are many options for skirl closure. Many surgeons use nonabsorbable sutures that are removed in a follow-up appointment after an appropriate interval. They may use simple interrupted sutures, vertical mattress sutures for better eversion, or continuous over-andover sutures for large incisions. Overtight sutures can leave scars and cause tissue necrosis, which may be unsightly. Frequently, in an over-and-over suture, an uneven apposition may occur; thus, it is important to start at either end with interrupted sutures to prevent any "dog-ear" formation.
212
Gerald J. B6champs
J t
il ::; j_
-! I,
22~ 21 ,',! .I
;;' 2-r
5 I prefer to use a subcuticular suture of either absorbable Polyglactin 910 3-0 or 4-0 gauge on a cutting PS 2 needle (Ethicon) or a polypropylene suture (Prolene; Ethicon). These sutures should be placed with a sharp cutting needle into the dermis in short tissue bites in a zigzag fashion so that when both sides are pulled together, the incision is a straight line. The ends can be secured with a simple slip knot or with Steri-strips (3M, St. Paul, MN). If the patient is to return for follow-up and discussion, 1 prefer to use Prolene 3-0 or 4-0, depending on the thickness of the skin or the location of the excisional biopsy, because this material slides m u c h easier than nylon through the dermal closure. In addition, I use a slipknot at either end to secure the suture and keep it from sliding loose with activity and leaving a gaping wound. W h e n sutures must be left in for longer than four to five days, subcuticular closure can minimize suture marks. Subcuticular suture does not guarantee a narrow scar, but good technique and postoperative w o u n d care help considerably. Absorbable sutures in the subcuticular position left for a long period can cause an inflammatory response and yield a persistent raised reddish scar. Therefore, the surgeon must be careful to use a suture size no. larger than is needed. Subcuticular sutures reinforced with Steri-strips work quite well for children. The w o u n d can be reinforced periodically with Steri-strips if the patient is not returning for follow-up visits.
Excision of Common Skin Lesions
Postoperative Care A topical antibiotic is applied to the skin surface and covered with a light, small gauze dressing. Instruct the patient to keep this dressing dry for 48 hours to allow the eschar to establish. W h e n the dressing is removed, the patient may bathe gently with a soap of choice. A subsequent dressing is not necessary unless the suture interferes with clothing or function. Antibiotic ointment can be applied daily but is optional. Sutures in the facial area should be left in for a m a x i m u m of five days, to avoid suture holes and scarring. Steri-strips can be applied for an additional seven to ten days to relieve tension on the underlying healing tissue. Extremities and trunk sutures can remain longer (up to 14 days) because of increased tension and activity, but one must be cognizant of potential suture scars if left in place too long. Foreign body reaction developing around the suture holes can leave permanent scarring. Nonabsorbable subcuticular sutures can be removed in seven to ten days and the wound reinforced with Steristrips for another two weeks to minimize scarring. Application of antibiotic ointment or a dressing is not necessary at this time. The wound should be protected from sunburn for six months or more until the scar has matured.
213
Analgesia is rarely necessary. If a deep incision or extensive dissection has been done, an analgesic appropriate for the magnitude of the operation and the patient's own anticipated anxiety can be prescribed. In most cases, an adult dose of acetaminophen is satisfactory. Summary
Skin lesions, whether benign or malignant, are commonly encountered in a general surgeon's practice. Only with proper planning of incisions, equipment, local anesthesia, operative technique, and pre- and postoperative management will an excisional biopsy be a simple and gratifying surgical experience for both the patient and the operating surgeon.
REFERENCES 1. Moody FG (ed): Atlas of Ambulatory Surgery, Philadelphia, PA, WB Saunders, 1999 2. Schirmer B, Ratner D (ed): Ambulatory Surgery. Philadelphia, PA, WB Saunders, 1998 3. Klipple AP, Anderson CB: Manual of Emergency and Outpatient Techniques. Boston, MA, Little, Brown, I979 4. Waldorf J, Perkidi's G~ Terkouda SP (ed): Ptanning incisions, Op Tech Gen Surg, 4:199-206, 2002 5. Balch CM, Milton GW: Cutaneous Melanoma Philadelphia, PA, JB Lippincott, 1985
kin lesions are frequently encountered in general sur-
S gery practices based in the community. In the university setting or large urban areas, skin lesions may be seen by a primary care physician and referred to a dermatologist for diagnosis and management. However, in both urban and community-based rural practices, the general surgeon is often requested to manage skin lesions, both benign and malignant. This article, outlines a practical approach to excising skin lesions in an outpatient setting. Many excellent texts and manuals are available for an in-depth discussion of this subject. 1-3
Preparation Excision of skin lesions can be easily performed in a surgeon's office, if properly equipped, or in an outpatient hospital-affiliated setting. In the current atmosphere of
From the General Surgery Division, Winchester Surgical Clinic, Winchester, VA. Address reprint requests to Gerald J. B6champs, MD, FACS, Winchester Surgical Clinic, Ltd., 20 S. Stewart St., Winchester, VA 22601. Copyright 2002, ElsevierScience(USA).All rights reserved. 1524-153X/02/0403-0002535.0010
doi:10.1053/otgn.2002.35338
HMOs, PPOs, and other insurance plans, reimbursement issues may be a factor in determining the location for a minor surgical procedure. Equipment should include a bright flexible light source, a comfortable stool on wheels for the surgeon, and a basic tray of instruments. Instruments should be up-to-date and include, at a minimum, those outlined in Table 1. These can be prepackaged and sterilized for use in the selected ambulatory setting. It is important to plan for unanticipated events or complications that may occur during the procedure. Resuscitative equipment and appropriate medications should be available in the event of an anaphylactic reaction. An assistant is needed to obtain additional materials or sutures but is not required to actually assist with sterile gloves. The assistant may also act as a chaperone and help the patient during the procedure. If a very fine plastic surgery type of procedure is anticipated, then additional instruments, such as a Webster needle holder, tenotomy scissors, and 2-mm skin hooks, may be added to the basic instrument tray. It is also helpful to engage in light conversation with the patient, if possible, to distract the patient from the procedure and help reduce anxiety.
T a b l e 1. Basic Minor Surgery Tray Sponge forceps Two Allis clamps Two curved mosquito clamps Two straight hemostat clamps Two curved hemostat clamps One regular Kelly clamp Two needle holders (one small, one medium) One sponge forceps Two Miller double-end retractors Two small towel clips One #3 knife handle with a #15 blade One straight iris scissors, one curved iris scissors One small Metzenbaum scissors and one regular Metzenbaum scissors One suture scissors Four small tissue forceps One smooth Adson forceps and one Adson forceps with teeth One rat-toothed forceps and one smooth medium forceps One Heiss finger retractor Two medicine glasses Six prep sponges 4 • 4 gauze sponges Four sterile towels
Operative Techniques in General Surgery, Vol 4, No 3 (September), 2002: pp 207-213
207
208
Gerald J. B6champs
SURGICAL TECHNIQUE
1 Skin preparation. In assessing the lesion to be removed, the surgeon must plan the incision carefully to minimize scarring and obtain the best cosmetic result possible. The surgeon ascertains the direction of the wound in relation to the relaxed skin tension lines of Borges and the underlying muscle. An excellent detailed discussion of planning incisions is given in another article in this volume. 4 Particular attention should be paid to the shoulder and sternal areas, which are more prone to keloid formation. If excessive hair is present, electric shaving is preferred over razor preparation as the razor method carries an increased risk of infection. Several products provide disposable blades for electric clippers, reducing the need for cleansing and resterilization after each use. The surgeon should wear a surgical cap, a mask, and sterile gloves. Marking of the prepared incision is optional but advised, because local anesthetic infiltration frequently distorts the planned incision. Skin preparation can be done with an iodine-based antiseptic solution. For a patient with skin sensitivity to iodine, one of the many available noniodinated preparations may be used.
Excision of Common Skin Lesions
209
~
.-,.
2 Local anesthesia. The surgeon should be familiar with the systemic toxicity of local anesthetic infiltration, including toxic dosages, injection sites and absorption rates, and the occasional vasovagal reaction to an injected anesthetic. I prefer lidocaine 0.5% to 1.0% for local anesthesia. Epinephrine 1:100,000 can be incorporated for vasoconstriction in areas of increased blood supply (e.g., face and neck) to reduce bleeding. If longer anesthetic time is anticipated, then bupivacaine 0.25% (Marcaine, Sensorcaine) is a good choice. Rarely is more than 5 mL needed unless a long elliptical incision is being made. A 27- or 30-gauge needle is preferred, and only two skin punctures are necessary to create a four-sided block of local anesthetic approximately 5 to 10 mm away from the edge of the skin lesion. The small-gauge needle minimizes the discomfort from injection of local anesthetic, typically described as a hot, burning-like sensation related to the distention of tissue and the acidity of the solution. The small gauge also minimizes local infiltration into the dermis, where a "wheal" should be raised as the skin is infiltrated. Onset of anesthesia is rapid (1 to 2 minutes), slightly longer if epinephrine is used in conjunction with the local anesthetic.
210
Gerald J. B~charnps
Margin width: 1-2mm Benign lOmm Malianant//.
Excisional biopsy carried to fascial layer for melanomas 3 Excision. In general, well planned, elongated, elliptical excisions that well excede the length of the lesion are preferred. The patient should be advised that the scar will be longer than the lesion that he or she sees on the skin. For excisional biopsy, as opposed to a shave biopsy, the surgeon holds the scalpel perpendicular to the skin while cutting through the dermis. For benign lesions, a margin of 1 to 2 mm is satisfactory on all sides from a usually sharply demarcated edge of a pigmented lesion. The dissection can then be continued directly underneath the dermis in the subcutaneous fat. Ifa lesion is suspected to be melanotic because of its irregular shape, variated color, or punch biopsy-proven diagnosis, then a 1-era margin from the outer edge of the lesion is achieved. In addition, the surgeon should remove all of the subcutaneous fat to the fascial level and a wider base (1 to 2 ram) underneath the skin to incorporate possible lymphatic channels. If a subsequent pathologic examination reveals that the lesion is of greater depth (i.e., Clark's level III to V), then the 1-cm margin on all sides will not interfere with a wider excision with flap closure or skin graft coverage by an experienced general surgeon, plastic surgeon, or surgical oncologist at a later time. 5 Visible vessels can be clamped and tied with 3-0 or 4-0 absorbable suture. Usually, gentle pressure with a gauze sponge is sufficient to stop any minor oozing.
Excision of Common Skin Lesions
211
~rl
Simple interrupted
Subcuticular
4
Vertical mattress
Continuous'over & over
Closure. Although the patient appreciates a lesion being removed for diagnosis and attendant relief of anxiety, the scar remains for life. Therefore, it is important to close the incision carefully while avoiding undue tension and minimizing any suture marks, providing the dermis with optimum conditions to heal with minimal scarring. In the subcutaneous tissue, I prefer 3-0 or 4-0 Polyglactin 910 suture (Vicryl; Ethicon, Johnson & Johnson Somerville, NJ) depending on the depth of the wound. This may have to be done in several layers. On the face, one should use 5-0 or 6-0 Polyglactin 910 suture, which maintains 75% of its original strength at 14 days and 50% at 21 days postinsertion, thus maintaining strength while natural wound healing is occurring. A noncutting needle (SH or round) should be used for this tissue, and the suture technique should be a simple Lembert type to eventually evert the epidermal edges to enhance healing of the dermal scar. There are many options for skirl closure. Many surgeons use nonabsorbable sutures that are removed in a follow-up appointment after an appropriate interval. They may use simple interrupted sutures, vertical mattress sutures for better eversion, or continuous over-andover sutures for large incisions. Overtight sutures can leave scars and cause tissue necrosis, which may be unsightly. Frequently, in an over-and-over suture, an uneven apposition may occur; thus, it is important to start at either end with interrupted sutures to prevent any "dog-ear" formation.
212
Gerald J. B6champs
J t
il ::; j_
-! I,
22~ 21 ,',! .I
;;' 2-r
5 I prefer to use a subcuticular suture of either absorbable Polyglactin 910 3-0 or 4-0 gauge on a cutting PS 2 needle (Ethicon) or a polypropylene suture (Prolene; Ethicon). These sutures should be placed with a sharp cutting needle into the dermis in short tissue bites in a zigzag fashion so that when both sides are pulled together, the incision is a straight line. The ends can be secured with a simple slip knot or with Steri-strips (3M, St. Paul, MN). If the patient is to return for follow-up and discussion, 1 prefer to use Prolene 3-0 or 4-0, depending on the thickness of the skin or the location of the excisional biopsy, because this material slides m u c h easier than nylon through the dermal closure. In addition, I use a slipknot at either end to secure the suture and keep it from sliding loose with activity and leaving a gaping wound. W h e n sutures must be left in for longer than four to five days, subcuticular closure can minimize suture marks. Subcuticular suture does not guarantee a narrow scar, but good technique and postoperative w o u n d care help considerably. Absorbable sutures in the subcuticular position left for a long period can cause an inflammatory response and yield a persistent raised reddish scar. Therefore, the surgeon must be careful to use a suture size no. larger than is needed. Subcuticular sutures reinforced with Steri-strips work quite well for children. The w o u n d can be reinforced periodically with Steri-strips if the patient is not returning for follow-up visits.
Excision of Common Skin Lesions
Postoperative Care A topical antibiotic is applied to the skin surface and covered with a light, small gauze dressing. Instruct the patient to keep this dressing dry for 48 hours to allow the eschar to establish. W h e n the dressing is removed, the patient may bathe gently with a soap of choice. A subsequent dressing is not necessary unless the suture interferes with clothing or function. Antibiotic ointment can be applied daily but is optional. Sutures in the facial area should be left in for a m a x i m u m of five days, to avoid suture holes and scarring. Steri-strips can be applied for an additional seven to ten days to relieve tension on the underlying healing tissue. Extremities and trunk sutures can remain longer (up to 14 days) because of increased tension and activity, but one must be cognizant of potential suture scars if left in place too long. Foreign body reaction developing around the suture holes can leave permanent scarring. Nonabsorbable subcuticular sutures can be removed in seven to ten days and the wound reinforced with Steristrips for another two weeks to minimize scarring. Application of antibiotic ointment or a dressing is not necessary at this time. The wound should be protected from sunburn for six months or more until the scar has matured.
213
Analgesia is rarely necessary. If a deep incision or extensive dissection has been done, an analgesic appropriate for the magnitude of the operation and the patient's own anticipated anxiety can be prescribed. In most cases, an adult dose of acetaminophen is satisfactory. Summary
Skin lesions, whether benign or malignant, are commonly encountered in a general surgeon's practice. Only with proper planning of incisions, equipment, local anesthesia, operative technique, and pre- and postoperative management will an excisional biopsy be a simple and gratifying surgical experience for both the patient and the operating surgeon.
REFERENCES 1. Moody FG (ed): Atlas of Ambulatory Surgery, Philadelphia, PA, WB Saunders, 1999 2. Schirmer B, Ratner D (ed): Ambulatory Surgery. Philadelphia, PA, WB Saunders, 1998 3. Klipple AP, Anderson CB: Manual of Emergency and Outpatient Techniques. Boston, MA, Little, Brown, I979 4. Waldorf J, Perkidi's G~ Terkouda SP (ed): Ptanning incisions, Op Tech Gen Surg, 4:199-206, 2002 5. Balch CM, Milton GW: Cutaneous Melanoma Philadelphia, PA, JB Lippincott, 1985