Proper Planning and Execution of Surgical Excisions

15
CHAPTER
andExecution
ProperPlanning
Excisions
of Surgical
BARRYLESHIN
he simple fusiform (elliptical) excisionis the cornerstoneof cutaneoussurgery.Properplanningof
requiresknowledgeof superficialanatprocedure
this
ory, u*ur"ness oi many functional considerationsof
the head and neck, and, in the treatmentof cutaneous
of tumorbiology'Although
understanding
malignancies,
the funda-mentalshave
once
complicated,
seeniingly
beenleiined, the fusiformexcisionis a relativelysimple
procedure that can be performed expeditiouslywhile
iimultaneoustyproviding an excellentcosmeticoutcome. Vital til any surgicalprocedureis adequatepreoperativeevaluation.r'zfnis evaluationmust include
pitient assessment,considerationof risk factors for
and patienteducation.
Lomplications,
B6fore excisionafsurgeryis performed' adequatlata
tention to superficial'inaiomy is imperative'3' This
as
closure,
of
lines
includesdeterminingthe favorable
subunits'
cosmetic
affected
the
well as evaluating
contractionof underlyingmuscles'Although numerous
diagramsof theselines exist, there is considerableindividualvariation.
There are a variety of ways of making an assessment
of the underlying MSU-s around a particular lesion'
The simplestippioach is to pinch the skin in all directionsto ileterminewherethe iension on the skin is least'
Maximalwrinkling occurswith pinchingin the direction
of the short axis of the plannedexcision' Alternatively,
having the patient move the underlying musclesby
grimaiing of smiling may also unmask.these lines. Fiially, it may be besi in somecasesto simply excisethe
lesionas a-circlerather than as an ellipse,undermine
the wound margins,and observethe direction in which
the wound assumesan oval shape.The oval configuration can then be converted to a fusiform ellipse for
woundclosure.s'13
COSMETICUNITS
When performingexcisionson the face, it is critical
that considerationbe given to cosmeticunits. Conceptually, the face can be subdividedinto multiple.topoFAVORABLELINESOF CLOSURE
gtapiti" units. A scar confined to a single unit will'
One of the most important initial stepsin planning ltti-at"ly be lessconspicuousthan one that crossesthe
the ellipticalexcisionis determiningProPelorientation' boundarybetweentwb contiguousunits.6'1aIn many
so ^that instanceithis principle takes priority over MSTLs or
More specifically,the ellipseshouldbe d.esigned
the scar is least noticeable and not likely to affect even the configurationof the lesion being removed.A
function.s-7Orientationof an ellipsein the most favorlonser scar containedwithin a single cosmeticsubunit
conspicuous
less
a
only
yields
not
of
excision
able lines
-ui be less conspicuousthan a scar that crossesthe
thin scar,but alsoone that healsfasterand has a higher boundarybetweentwo subunits.
tensilestrength.This will result in an incisionline that
runs paralleito imaginarylines kngwn-as maximalskin
NATUREOF LESIONREMOVED
tension lines (MSTLs).? Typically, but not always,
If the lesionbeingremovedis benign, it is criticalthat
consruent with' relaxed skin tension lines,E-l2MSTLs
the
ultimate scar be less conspicuousthan the lesion
from
to wrinkle lines and to folds resulting
"onior*
171
Planningthe ElliPse
172
BASICSURGICALCONCEPTSAND PROCEDURES
beins removed and that the amount of normal tissue
be minimal. On the other hand, management
sacri-ficed
malignanciesaddsan additionalconsidercutaneous
of
ation to the proper planning of an ellipse.eFirst, it is
imperative that an excision provide for the complete
removal of the tumor. In addition, when excising a
melanoma,attentionshouldalsobe paid to the direction
of draining lymph nodes.This is particularlyimportant
if a wider resectionor subsequentregional lymphadenectomy might becomenecessary.An improperly orientedinitial excisionmay ultimatelymeanthe difference
between primary closure or a wound graft after the
definitivesurgicalprocedure.15
The configurationof the lesionmay be the key determinant of orientation of the ellipse.If the lesionbeing
excisedis oval in shape,then by placingthe long axis
of the ellipseparallel to the long axisof the lesion,the
overalllengthof the scarwill be shortened(Fig. 15-1).
In some settings, this compromisesthe principle of
keepingthe scar within a singlecosmeticunit, and the
final analysismay dependon the orientationthat yields
the least noticeablescar.
FUNCTIONALCONSIDERATIONS
When planning an excision,attentionshouldalso be
10'la Two
given to important functionalconsiderations.6'
examplesof this include the need to avoid lower eyelid
malposition when excising a lesion in the periorbital
area and undesirablelip retractionwith excisionsin the
perioral region. In a similar fashion,a fusiformexcision
that is placed in a skin creaseon the forehead may
elevatethe brow. Also, properorientation
inadvertently
of a fusiform excisionon the extremitiesavoidscontracture of an underlyingjoint.
DIMENSIONS
As a generalrule, the length of a fusiform excision
should be three times the width, but the ratio of length
to width may vary from 3:L to 4:1. The lengthof the
short axis of the ellipseis predeterminedby the sizeof
the lesion being removed.For instance,a 4-mm malignant tumor to be excisedwith 3-mm marginswill leave
a short axis of 10 mm, and the long axis will be
approximately 30 mm in length. It is important to
recognizethat even a proportionate and properly designedellipsemay producea closurewith smallstanding
cones,or "dogears,"at eachpole that mustbe removed.
It is also important to recognize that the inherent
elasticity of the skin and the geometry of an ellipse
make a 30-degreeangle optimal for the tips of the
ellipse.
MARGINS
No fail-safeguidelinesexist for determiningadequate
margins.Obviously,the amount of normal tissueincluded in the excision of a benign lesion should be
minimized. When excisinga nonmelanomamalignant
skin tumor, a very rough guideline of 3 to 4 mm of
skin is typically recommended.The
normal-appearing
margins of resection for melanomas require special
1s'16
consideration.e'
FUSIFORMEXCISIONVARIATIONS
There are two very useful variations on the classic
fusiform excision,the S-plastyand the crescenticexcision. The S-plastyis a fusiform excisionin which the
two sides of the ellipse are "lazy Ss." The ultimate
effectof an S-plastyis to increasethe length of the scar
between the two end points of the wound. This is
particularly useful over convex surfacessuch as the
cheek or extremity in which horizontal contractionon
scar.By lengthening
the scarmay resultin a depressed
the scar, the horizontal forces of contractionwill pull
and straightenthe "S," rather than depressthe scar
(Fig. 15-2).1?
The crescenticexcisioncan be accomplishedin two
different ways. The simplesttechniqueis to designthe
ellipseso that one side is substantiallylonger than the
other. By then closing the defect using the "rule of
halves,"a slightlycurvedscar is produced.lsAnother
meansto achievea gently curved scar that matchesa
curvedline of facial expressionis to createa "belly" in
the midportion of the ellipse.This resultsin the wound
havingsidesof equal length but in a configurationthat
yieldsa gentlecurveto the ellipse.le'20
AND MARKINGTHE
SKIN PREPARATION
ELLIPSE
Y
L
-zt
Figure 15-1. By orientingthe ellipseso that the longaxisof the
the longaxisof the ellipse,the lengthof the scaris
lesionparallels
shorter(Y is muchshorterthanX).
significantly
Before designingand marking the proposedskin incision lines, it is desirableto clean the operative site
with a detergentantisepticsurgicalscrub. The incision
lines may then be drawn using any of a variety of skin
markerssuch as gentianviolet, brilliant green, Bonney
blue or Berwick's solution.These may be applied with
a toothpick or a broken wooden applicatorstick. Some
surgeonsfavor a sterile surgical marking pen or a
Sharpiepermanentmarker.21It is critical that the incision lines be drawn before injection of anesthetic,because vasoconstrictionmay substantiallyobscure the
clinical clues that guide margin assessmentand the
anestheticwill distort the tissue.
OF SURGICALEXCISIONS
PROPERPLANNINGAND EXECUTION
^
173
B
Figure1ts2.A, Whena lesionis
scar
excisedon a convexsurface,
contractionwill result in a deoressedscar.B, Scarcontraction
afterS-plastyresultsin straightening of the S. (Modifiedfrom
ZitelliJA:TIPSfora betterellipse.
22:101-1Q3'
J AmAcadDermatol
1990.)
After marking the skin and infiltrating local anesthetic,the skiniJ then ideallyrepaintedwith an aqueous
any
uniis"pti" surgicalprep solution' Beforeincision'
gauze
a
with
removed
be
should
wetnesi
residualsurfade
sponge.
Removingthe SPecimen
Although seeminglysimple, severalaspectsof specirequiri tlose attentionto providethe best
rn"n r"-&l
outcome.
cosmetic
AVOIDINGCROSS.HATCHING
To avoid unnecessaryinjury' it is desirablethat the
tios of the ellipsemeet at a fine point, without unnecof the incisionbevond that point (Fig'
;il;
it
t'
";;;.id;
isjj^i
when usins the standardNo' 15 blade, the
is
in.iiion initiated wiih the scalpelhandleheld perpe.nto the skin' After the incision is made' the
ei;il;
;;;l;;i handleis then gentlv tilted to a 45-degreeangle
i"i itt.iti"g the remainier of the margin until the other
iio i. r"u.[.d. At that point the blade is then returned
very
to the perpendicularposition' When pertormtng
Cross-hatching
to usea smaller
smallexcisions,it is often advantageous
a No' 11
alt-ernatively,
or,
15c
No'
LfuO" tu.tt as a
blade.
AVOIDINGBEVELEDEDGES
When incisingthe skin, it is preferable to make an
ln"ision perpeniicularly thro-ugh.the dermis into the
By so
unAertyirigiubcutaneousfatT " (Fig' I?iel'
evert
to
likely
doing ihe"wound marginswill-be more
If
closure'
acceptable
for a co"smetically
aoor"opriately
specimen
the
of
base
the
inward,
beveled
are
if,J
"og"t
UJ .o.promised, bringing the -resectionmargins
"un
close to the lages of the lesion being
.rnnecessarlty
.*.it"A. In hair-bearingregions'it is preferableto angle
the incision lines so itrat ttrey are parallel to follicles
(ng. $+ils' 7'18to avoid foilicle transectionand permanenthair lossaround the scar.
PASSESTHROUGHTHE DERMIS
MINIMIZING
The amount of pressureor force used when incising
the skin is learned'only by experience'The force nec.rtuiy io l""ise throug"hthe db.rmisobviously a."q"{:
on the thicknessof dermis' It is desirableto mlnlmlze
the scalpel makes through.lhe
G number of passes
^"staircasing"
t6e wound margins(Fig'
dermisto avoid
1j-j1 anOcompromisingthJapproximationof the edges'
/
Nicked
edges
the
Figure 15-3. Careful incisiontechnique avoids cross-hatching
tipi and nickingthe wound edges.
to the skin
';, A, An incisionis caniedout perpendicular
Fioure1S4.
parallel
is
angled
the'incision
skin,
n"it:bearing
i.lrin"i
r"
;?;
NA:
trom
Swanson
(Modified
transeltion.
iJin" n"-i,torli.lesto avoid
Surgery.Little,Brown,Boston'1987'p 19')
ntas ot-dutaneous
174
BASICSURGICALCONCEPTSAND PROCEDURES
A
4.sa4t_-:
passes
through
thedermis
during
incision
Figure1tsS.Minimizing
(right).
woundmargin
avoidsa staircased
UNIFORMTHICKNESS
There is a common tendencywhen removing an
excisionalspecimento reduce the amount of tissue
removedat the two ends.This resultsin a boat-shaped
specimen(Fig. 15-6). More importantly,the residual
tissueleft in the defectmay causeprotrusionsat the two
The assistant
can put
tips, creating"pseudo-dogears."17
traction on the skin perpendicularto the direction of
the incisionto help provide a smoothcontour to the
incision,therebydecreasingthe effort requiredto make
the incisionto the desiredlevel. After careful incision,
the base of the tissuecan be transectedat the desired
depth with either a scalpelor scissors.
the Defect
Undermining
BREADTHOF UNDERMINING
Underminingthe defectafter removalof the specimen
minimizes teniion on the wound margins, facilitates
vascularcompromise,
everts
closure,avoidsunnecessary
the wound margins, enhancesthe cosmeticoutcome
after scar contraction, and provides a horizontal scar
plate to help minimize the spreadof scarsat sites of
high wound tension.TDead spacecan result from underminingthat producesa seromaor hematoma.Some
although
surgeonsfavor obliterationof this deadspace,22
this is not imperative.'
The amount of tissuethat needsto be underminedis
that which is sufficientto allow minimal tensionon the
wound marginsso they may be evertedwithout compromising vascularity.It is important to underminecompletely around the defect, including the two ends. By
missingthe two ends,theseareasbecomeunnecessarily
tetheredand may ultimatelyprotrude upwardwith scar
contraction(Fig. 15-7).1?
DEPTHOF UNDERMINING
The recommendeddepth of underminingvarieswith
the anatomic site. In general, underminingshould be
Figure 1$-6. A, A boat-shapedspecimenthat leavesadditionaltissue
at the wound tips may result in pseudo-dogears.8, A specimenof
uniformthicknessavoidsthis Droblem.(Modifiedfrom ZitelliJA: TIPS
for a betterellipse.J Am Acad Dermatol22:101-103,1990.)
as
carriedout usingblunt-tippedscissors
as superficially
possibleto avoid unnecessary
damageto blood vessels
and nerves.Underminingon the scalp is best carried
out belowthe galeato avoidtransectionof hair follicles.
The looseareolartissuebeneaththe galeais an easily
identified,bloodlessplane, and the galeaaponeurotica
easilysupportsthe suturetensionrequiredfor closure
of scalpwounds.The foreheadis best underminedin
the deepsubcutaneous
tissue,sincedeeperundermining
threatenssensoryinnervationto the scalp. To avoid
injury to the superficialmotor nerves,underminingon
the temple,cheeks,and chin should be carriedout in
the superficialsubcutaneous
tissue.On the trunk and
extremities,
underminingcan be carriedout at any level
above the musclefascia, the middle to deep subcutaneousadiposelayersusuallybeing optimal. At sitesof
minimalsubcutaneous
tissue.suchasthe handsandfeet.
A
<z_k_jj+-t_*
, 1 't_L>)
Figure15-7.A, Failureto undermine
the woundtips may resultin
tissueprotrusion
afterclosure.B, Undermining
the tips avoidsthis
problem.(Modified
from ZitelliJA: TIPS for a betterellipse.J Am
1990.)
AcadDermatol
22:101-103.
OF SURGICALEXCISIONS
PROPERPLANNINGAND EXECUTION
175
underminingshould be carried out just below the dermis.7
^--Ouring
undermining, it is also-,importantthat the
crushing
*ounO niutginsbe hanlled gently' Unnecessary
formultitoothed
or
sErrated
;i;h; *ouia edges.with
outcome'
cosmetic
ultimate
the
ceDSmav compromlse
ifi. *obtt"nc^e of handling the wound margins-gently
;iih };;"pt or a skin hoolicannot be overstated'23
woundin a youngerindividual might bestb-eclosedwith
a 6-0 polypropylenesubcuticularsuture' Whateverthe
puii" nl t"t'tin g,' tft" closure technique-includin g wo-und
mater-ials,suture techniques,and timing of su"loru."
ture removal-should be modified to achieve a wellaooroximated, everted wound with minimal suture
tr'*ting. A varietyof suturetechniques(Fig' 15-8)may
be usefll in cutaneoussurgery' with each having clear
2L2e
and disadvantages.18'
advantages
HEMOSTASIS
Care
Postoperative
During incising and underminingof.the skin, blood
vesselsa"reineviiably transectedor nicked' To preve-nt
hematomaformation, hemostasisshouldbe achievedby
.furnpingand ligatinglargevesselsor by pinpointeleciro"dug,itutiono*releitrodesiccation'It is alsoimportant
to uufiO excesselectrosurgery,which results in the
of nonvital, charr6d tissue that may impede
"i"ution
*ounO healingor serveas a nidus for wound infection'
Mil;; uteediilg from transecteddermal capillariesis
ette.tiuetystop-pedby suturesusedfor wound closure'
Closure
SUTURETECHNIQUES
Closuretechniquevariessubstantiallyfrom site to site
in
and from patientto patient.For example,a wound
face
person's
h;;"iiy ;*;-damaged^skin on an elderly
outcomewith a runningcontin.igtti Vi"fOan exc"ellent
uoit S-O monofilament suture' However, the same
Figure 15-8. A to C, A buried
sutureproduces
verticalmattress
eversionol the wound
prolonged
harqin-.(ModifiedbY Permission
of tFe oublisherfrom ZitelliJA'
Mov RL: Buriedverticalmattress
suture.J DermatolSurg Oncol
1989
1989.CoPYright
15:17-19,
by ElsevierSciencePublishing
Co.,Inc.)
WOUND
DRESSING"THE
After cleansingthe skin surfaceimmediatelypostoperativelyto removeany dried bloo1loJ residualantiseptic, the wounddressingisapplied.Typically,this consists
of four layers: an occlusiveantibacterialointment, a
nonadherehtgauze material, an absorbentcushionto
wick blood awayfrom the wound, and tape'
Patientsshouid be instructedto remove the postoperative pressuredressingafter 24 to 48.hours, cleanse
the wound surfacewith fiydrogenperoxide,and reapply
the occlusiveointment' this wbund careis repeatedtwo
io ttrree times daily until the suturesare removed' A
iigttt guut. dressingis optional dependingon the site of
the wound and need for a protectlvedresslng'
SUTUREREMOVAL
The timing of epicutaneoussuture removal is of
bbviously, suturesshouldbe left in
criticalimpor"tance.
:
I
176
BASICSURGICALCONCEPTSAND PROCEDURES
long enoughfor epithelializationacrossthe wound margins to be complete.However, they shouldbe removed
suturetracking.Typearly enoughto avoid unnecessary
ically, sutures are removed from the face at 7 days,
althoughsomesurgeonsfavor earlier removalat 5 days.
Suture removal on the trunk and extremitiesis usually
performedat L0 to 14 days.Certainlythere is significant
individual variability in wound healing. For example,
young, healthy, nonsmoking patients can have their
suturesremovedearlier than older, lesshealthy,sm.oking patientsbecauseof problemswith delayedhealing.
To bolster the wound marginsafter suture removal, it
is advisableto use wound closuretapesfor 5 to 7 days.
Complications
Although complicationsare relatively infrequent in
It is imperativethat
cutaneoussurgery,they do occur.30
patients be informed of the potential complications
before surgeryand educatedas to how such complications might be manifestedimmediately after surgery.
the surgeonmust be
When problemsare encountered,
able to recognizeand managethem adeptly.
NECROSIS
Wound necrosisafter fusiform excisionalbiopsy is
rare. It most typicallyoccurswhen a wound is closed
under significanttension, which compromisesthe vascularity of the wound margins. In this setting, it is
important to remove suture material, debride the necrotic tissue,and allow the wound to heal by second
intention.
SUMMARY
The proper planning and execution of a surgical
excisionare of fundamentalimportanceto the cutaneous
surgeryinsurgeon.Essentialingredientsof successful
cludea masteryof a wide array of principlesthat involve
anatomy,anesthesia,tumor biology, wound healing,
and surgicaltechnique.With attentionto thesedetails,
this procedurecan provide an exceptionallygood cosmetic and functional result both safely and efficiently
and can also yield an appropriatespecimenfor subsequent histologicanalysis.
REFERENCES
HEMATOMA
Hematomastypically occur during the first 48 to 72
hours after surgery and are manifestedas swelling,
at the woundsite.Hematomas
ervthema.and tenderness
shbuld be evacuatedearly by partially or completely
opening the wound, controlling any active bleeding,
and, if treatedwithin 48 to 72 hoursof surgery,resuturing the wound. Alternatively, after evacuationof the
hematoma, the open wound may be left to heal by
secondintention with scarrevisionperformedat a later
date, if necessary.In someinstances,small hematomas
may be managedconservativelywith warm compresses
until resolutionoccurs.
INFECTION
Infection is a rare event in cutaneoussurgery,having
a rate of occurrenceof less than lVo.31When a wound
is frankly infected, it is imperative that all sutures,
including buried sutures,be removed and the patient
begunon antibiotics.Considerationshould be given to
culturing an infectedwound before initiating antibiotic
therapy.
DEHISCENCE
Dehiscenceis the easiest of the complicationsto
recognize,since the wound pulls apart. If there is no
underlying infection, the dehiscentwound can simply
be resuturedif dehiscencehas occurredwithin 48 to 72
hours after surgery. Dehiscenceis more typically a
complicationof an underlyingwound infectionor hematoma, and theseunderlyingproblemsmust obviously
be managedfirst. A dehiscentwound can be allowedto
heal by second intention with delayed scar revision
performedlater, if necessary.
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