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AT-A-GLANCE

AT-A-GLANCE

  • Excisional surgery is one of the most common surgical procedures in dermatology.

  • The goal of excisional surgery is to remove the lesion with appropriate margins and obtain the best cosmetic result.

  • The planning and execution of dermatologic surgery procedures must balance risk and benefit and consider all options to achieve an optimal outcome. Wounds should be closed under minimal tension, with scars placed along cosmetic unit junctions or skin tension lines, contained within as few single cosmetic units as possible, without distorting critical anatomic structures and landmarks.

  • The closure must preserve sensory and motor nerve function.

  • An elliptical or fusiform excision is the fundamental procedure in dermatologic surgery and typically allows for a linear, side-to-side closure.

  • Flap or graft repair may be considered when linear closure is not feasible.

  • Flaps are commonly classified according to their primary movement as advancement, rotation, transposition, or interpolation.

  • The 3 basic types of skin grafts are full-thickness, split-thickness, and composite.

BACKGROUND

The goal of any excisional surgery is to remove the lesion with appropriate margins and leave the least noticeable scar possible. To consistently attain aesthetically pleasing results, time must be taken long before the first incision to appropriately plan the procedure. Although excisional surgery is as much an art form as it is a science, there are many principles to keep in mind when planning the surgical excision and closure. Wounds should be closed under minimal tension, with scars placed along cosmetic unit junctions or skin tension lines, without distorting critical anatomic structures and landmarks (eyelid, eyebrow, nose, lip, hairline, etc). Biologically, the closure must be such that the mobilized skin and associated adnexal structures are viable, and there is maximal preservation of sensory and motor nerve function.

Knowledge of underlying anatomy is critical in both the design and execution of the excision (Chap. 201).

The planning and execution of dermatologic surgery procedures varies from case to case. A skilled surgeon evaluates the risks and benefits of various options in each patient and anticipates potential complications. The main risks of excisional surgery include pain and discomfort, bleeding, bruising, hematoma formation, nerve damage, wound infection, wound dehiscence, and undesirable scar or contracture. Key elements of dermatologic surgery procedures include proper patient selection and preparation; comprehension of risks and necessary precautions; obtaining effective local anesthesia; use of sterile or clean technique; informed procedure design and meticulous technique in performing the incision and repair; diligent postoperative wound care and patient education (Chap. 202).

EQUIPMENT

Prior to surgery, it is essential to have all the necessary instruments and equipment available and set up in an organized, accessible, and safe manner.

PROCEDURE ROOM

  • Basic: mechanical table, powerful overhead procedure lights, electrocautery, vital signs monitor, Mayo stand (1 or 2), receptacle for contaminated waste, and a sharps container.

  • Optional: ...

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