Excisional Surgery

Excisional Surgery - Cut & Close Basics

• Definition: Surgical procedure involving full-thickness removal of a skin lesion, extending into the subcutaneous fat layer.
• Purpose:
  • Diagnostic: To obtain tissue for accurate histopathological examination and diagnosis.
  • Therapeutic: For complete removal of various benign or malignant skin lesions.
• Common Indications:
  • Malignant lesions: Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC), Melanoma.
  • Benign lesions: Epidermal cysts, Lipomas, symptomatic Nevi.

⭐ For suspected melanoma, excisional biopsy with narrow margins (typically 1-3mm) is the preferred initial approach for accurate staging.

Excisional Surgery - Pre-Op Power Plan

• Patient Evaluation:
  • Thorough history (comorbidities, allergies).
  • Medication review: Focus on anticoagulants/antiplatelets (target INR < 1.5).
• Informed Consent:
  • Essential: Discuss risks, benefits, alternatives; obtain signature.
• Anesthesia Selection:
  • Local: Lignocaine (Max: $4.5 \text{mg/kg}$), with Adrenaline (Max: $7 \text{mg/kg}$).
  • Consider: Topical, field block based on lesion.
• Site Preparation:
  • Antiseptic cleansing (povidone-iodine/chlorhexidine), sterile draping.
• Lesion & Incision Marking:
  • Clearly outline lesion margins.
  • Plan incision along Langer's lines for optimal cosmesis.

⭐ Adrenaline in local anaesthesia prolongs its duration and provides hemostasis, but must be used with caution in acral areas (fingers, toes, nose, penis) due to risk of vasoconstriction.

Excisional Surgery - Precision Slice Time

• Types:
  • Elliptical Excision: Most common. Length:Width ratio 3:1 to 4:1; 30° angle at apices.
  • Wedge Excision: For lip, ear.
  • Saucerization/Shave Excision: Superficial lesions (e.g., SKs, superficial BCCs).
• Surgical Margins (mm): 📌 Mnemonic: "B3-5 S4-6 M-Depth"
  • BCC: 3-5mm
  • SCC: 4-6mm
  • Melanoma: Based on Breslow depth.
• Instruments: Scalpel (#15 blade), forceps, scissors, curette.
• Specimen Handling: Orient & mark for pathologist; appropriate transport medium.

⭐ The long axis of an elliptical excision should ideally be parallel to relaxed skin tension lines (RSTLs) for better cosmetic outcome.

Excisional Surgery - Suture Smartly Now

• Layered Closure: Essential for healing; uses deep (absorbable), dermal, and epidermal sutures.

• Suture Materials:

  Suture Type	Absorbability	Tensile Strength (Retention)	Common Use
  Vicryl	Absorbable	Good (2-3 wks)	Deep, Subcuticular
  Monocryl	Absorbable	Fair (1-2 wks)	Subcuticular
  Prolene	Non-absorbable	Excellent	Skin, Vascular
  Nylon	Non-absorbable	Good	Skin

• Suture Techniques: Simple interrupted, continuous (running), mattress (vertical/horizontal), subcuticular.

• Alternatives: Skin staples, adhesive tapes, tissue adhesives (e.g., cyanoacrylates).

• 📌 Suture Removal Times: Face: 3-5d, Scalp: 7-10d, Trunk/Limbs: 7-14d, Joints: 10-14d.

⭐ Eversion of wound edges during skin closure is crucial for minimizing scar depression and achieving a better cosmetic result.

Excisional Surgery - Aftercare Ace

• Post-op Instructions: Keep wound clean & dry initially. Gentle cleansing as advised. Limit activity. Pain relief (e.g., paracetamol). Monitor for infection signs: redness, increasing pain, swelling, pus, fever.
• Suture Removal Times: Face: 3-5 days; Scalp/Trunk: 7-10 days; Limbs: 10-14 days.
• Complications:
  • Early: Bleeding, hematoma, infection, wound dehiscence.
  • Late: Scarring (hypertrophic, keloid), nerve damage, recurrence.
• Follow-up: Crucial for monitoring healing and detecting late complications; schedule as advised.

⭐ Prophylactic antibiotics are generally not required for routine excisional surgery in healthy individuals but may be considered for high-risk sites or patients.

Table: Common Early Complications & Management

Flowchart: Managing Suspected Wound Infection

High‑Yield Points - ⚡ Biggest Takeaways

• Indications: Malignant lesions (BCC, SCC, melanoma) and symptomatic/cosmetic benign lesions.
• Surgical margins are crucial for malignancy (e.g., 3-5 mm for BCC).
• Elliptical excision along RSTLs with a 3:1 length-to-width ratio for optimal scarring.
• Layered closure (deep and superficial) minimizes tension for better cosmesis.
• Key complications: infection, bleeding, hematoma, dehiscence, adverse scarring.
• Primarily uses local anesthesia (lidocaine ± epinephrine).
• Adequate hemostasis pre-closure prevents hematoma_._