Excision of skin lesions
Excision refers to removal of a skin lesion by completely cutting it out. As fellowship-trained surgical dermatologists, we are well-versed in all aspects of scar prevention, reconstructive surgery, layered closures, cosmetic units and other factors that result in an excellent surgical outcome for our patients. No medical provider can guarantee a “scarless” surgery but there are ways to minimize the visibility and best position you for wondeful cosmesis – we utilize and consider all of those factors. Most often it is not necessary to undergo your procedure in a hospital/surgery center or even require sedation, local anesthesia is often quite sufficient and offers you a cost savings.
Why do skin lesions have to be excised?
A common reason why skin lesions are excised, is to fully remove skin cancers such as basal cell carcinoma, squamous cell carcinoma or melanoma. If the cancer is not cut out it may spread to the surrounding skin and to other parts of the body (metastasize). Other reasons that skin lesions are excised include cosmetic appearance, to remove an inflamed lesion, or recurrent infection.
If a lesion is merely of cosmetic concern with no signs or symptoms then is does not have to be removed. That is a purely elective choice to have the procedure by the patient that is not covered by insurance. Please be aware that it does not matter what specialty performs the procedure, a cosmetic procedure is just that (not medically necessary) and should not be billed to insurance. If you are told otherwise then there could be recourse to you or your medical provider by the insurance company.
Will I have a scar?
It is impossible to cut the skin without scarring in some way, so you will always have some sort of scar. Your dermatologist will try to excise the lesion in a way that will keep the scar to a minimum. Some people have an abnormal response to skin healing and these people may get larger scars than usual (keloid or hypertrophic scarring). If this occurs, your dermatologist can counsel you on treatment options.
What is involved in excision of a skin lesion?
Your dermatologist will explain to you why the skin lesion needs excision and the procedure involved. You may have to sign a consent form to indicate that you consent to the surgical procedure. Tell your doctor if you are taking any medication (particularly aspirin or warfarin, which could make you bleed more), or if you have any allergies or medical conditions. Remember, to tell your doctor about any herbal remedies since a number of these can also lead to abnormal bleeding.
The most common type of excision is an elliptical excision. The ellipse is designed so that the resulting scar runs parallel with existing skin creases. This ensures that the scar is as narrow and short as possible. The area to be excised is marked with a colored pen. The dermatologist will then cut around and under the lesion so that it is completely removed. The lesion is placed in formalin and sent to a pathology laboratory. Here, a pathologist will examine the specimen and provide your dermatologist with a report a few days later.
There may be some bleeding in the area from where the lesion has been removed. The doctor may coagulate the blood vessels with electricity or heat. This can make a hissing sound and an unpleasant burning smell. The edges of the ellipse will then be sewn together to make a thin suture line. There may be two layers of sutures (stitches) – a layer underneath that is absorbable and a layer of sutures on the surface which will need to be removed in 4-14 days. Occasionally special skin glue is used to join the edges together, instead of sutures. A dressing might be applied and instructions should be given on how to care for your wound and when to get the stitches out.
How do I look after the wound following skin excision?
Your wound may be tender 1-2 hours after the excision when the local anesthesia wears off. Leave the dressing in place for 24 hours or as advised by your dermatologist. Avoid strenuous exertion and stretching of the area until the stitches are removed and for some time afterwards. If there is any bleeding, press on the wound firmly with a folded towel without looking at it for 15-20 minutes. If it is still bleeding after this time, seek medical attention. Keep the wound dry for 48 hours. You can then gently wash and dry the wound. If the wound becomes red or very painful, consult your dermatologist – it could be infected. The scar will initially be red and raised but usually reduces in color and size over several months. The healing process can take between 3 months to one year.