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Chapter 243. Excisional Surgery and Repair, Flaps, and Grafts

Jessica M. Sheehan; Melanie Kingsley; Thomas E. Rohrer

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Excisional Surgery and Repair, Flaps, and Grafts 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 a particular outcome. 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.
  • 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 three basic types of skin grafts are full-thickness, split-thickness, and composite.

The goal of any excisional surgery is to remove the lesion with appropriate margins and leave the least noticeable scar possible. In order to consistently attain aesthetically pleasing results, time must be taken long before the first incision to appropriately plan the procedure. While 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 adenexal 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 (see Chapter 242).

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. 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.

It is important that both the patient and practitioner be aware of the risks of dermatologic surgery. In fact, professional standards dictate that these risks be documented for proper patient consent.1 The main risks of excisional surgery include pain and discomfort; bleeding, bruising, and hematoma formation; nerve damage; wound infection; wound dehiscence; and undesirable scar or contracture.

  • While the injection of local anesthesia is not without pain, there are several ways to minimize the discomfort. Some of the most effective ways to diminish pain on injection is the addition of sodium bicabonate to the anesthetic agent, using ...

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