Skin lesion removal employs a variety of techniques, from relatively simple biopsies to more complex surgical excisions, to remove lesions that range from benign growths to malignant melanoma.
Purpose
Sometimes the purpose of skin lesion removal is to excise an unsightly mole or other cosmetically unattractive skin growth. Other times, physicians will remove a skin lesion to make certain it is not cancerous, and, if it proves cancerous, to prevent its spread to other parts of the body.
Precautions
Most skin lesion removal procedures require few precautions. The area to be treated is cleaned before the procedure with alcohol or another antibacterial preparation, but generally it is not necessary to use a sterile operating room. Most procedures are performed on an outpatient basis, using a local anesthetic. Some of the more complex procedures may require specialized equipment available only in an outpatient surgery center. Most of the procedures are not highly invasive and, frequently, can be well-tolerated by young and old patients, as well as those with other medical conditions.
Description
A variety of techniques are used to remove skin lesions. The particular technique selected will depend on such factors as the seriousness of the lesion, its location, and the patient's ability to tolerate the procedure. Some of the simpler techniques, such as a biopsy or cryosurgery, can be performed by a primary care physician. Some of the more complex techniques, such as excision with a scalpel, electrosurgery, or laser surgery, are typically performed by a dermatologic surgeon, plastic surgeon, or other surgical specialist. Often, the technique selected will depend on how familiar the physician is with the procedure and how comfortable he or she is with performing it.
Biopsy
In this procedure, the physician commonly injects a local anesthetic at the site of the skin lesion, then removes a sample of the lesion, so that a definite diagnosis can be made. The sample is sent to a pathology laboratory, where it is examined under a microscope. Certain characteristic skin cells, and their arrangement in the skin, offer clues to the type of skin lesion, and whether it is cancerous or otherwise poses danger. Depending on the results of the microscopic examination, additional surgery may be scheduled.
A variety of methods are used to obtain a skin biopsy. The physician may use a scalpel to cut a piece or remove all of the lesion for examination. Lesions that are confined to the surface may be sampled with a shave biopsy, where the physician holds a scalpel blade parallel to the surface of the skin and slides the blade across the base of the lesion, removing a sample. Some physicians use a single-edge razor blade for this, instead of a scalpel. A physician may also perform a punch biopsy, in which a small circular punch removes a plug of skin.
Excision
When excising a lesion, the physician attempts to remove it completely by using a scalpel to cut the shape of an ellipse around the lesion. Leaving an elliptical wound, rather than a circular wound, makes it easier to insert stitches. If a lesion is suspected to be cancerous, the physician will not cut directly around the lesion, but will attempt to also remove a healthy margin of tissue surrounding it. This is to ensure that no cancerous cells remain, which would allow the tumor to reappear. To prevent recurrence of basal and squamous cell skin cancers, experts recommend a margin of 0.08–0.16 in (2–4 mm) for malignant melanoma, the margin may be 1.2 in (3 cm) or more.
Destruction
Not all lesions need to be excised. A physician may simply seek to destroy the lesion using a number of destructive techniques. These techniques do not leave sufficient material to be examined by a pathologist, however, and are best used in cases where a visual diagnosis is certain.
Cryosurgery. This technique employs an extremely cold liquid or instrument to freeze and destroy abnormal skin cells that require removal. Liquid nitrogen is the most commonly used cryogen. It is typically sprayed on the lesion in several freeze-thaw cycles to ensure adequate destruction of the lesion.
Curettage. In this procedure, an instrument with a circular cutting loop at the end is drawn across the lesion, starting at the middle and moving outward. With successive strokes, the physician scrapes portions of the lesion away. Sometimes a physician will use the curet to reduce the size of the lesion before turning to another technique to finish removing it.
Electrosurgery. This utilizes an alternating current to selectively destroy skin tissue. Depending on the type of current and device used, physicians may use electrosurgical equipment to dry up surface lesions (electrodessication), to burn off the lesion (electrocoagulation), or to cut the lesion (electrosection). One advantage of electrosurgery is that it minimizes bleeding.
Mohs' micrographic surgery
The real extent of some lesions may not be readily apparent to the eye, making it difficult for the surgeon to decide where to make incisions. If some cancer cells are left behind, for example, the cancer may reappear or spread. In a technique called Mohs' micrographic surgery, surgeons begin by removing a lesion and examining its margins under a microscope for evidence of cancer. If cancerous cells are found, the surgeon then removes another ring of tissue and examines the margins again. The process is repeated until the margins appear clear of cancerous cells. The technique is considered ideal for aggressive tumors in areas such as the nose or upper lip, where an excision with wide margins may be difficult to repair, and may leave a cosmetically poor appearance.
Lasers
Laser surgery is now applied to a variety of skin lesions, ranging from spider veins to more extensive blood vessel lesions called hemangiomas. Until recently, CO2 lasers were among the more common laser devices used by physicians, primarily to destroy skin lesions. Other lasers, such as the Nd:YAG and flashlamp-pumped pulse dye laser have been developed to achieve more selective results when used to treat vascular lesions, such as hemangiomas, or pigmented lesions, such as café-au-lait spots.
Preparation
No extensive preparation is required for skin lesion removal. Most procedures can be performed on an outpatient basis with a local anesthetic. The lesion and surrounding area is cleaned with an antibacterial compound before the procedure. A sterile operating room is not required.
Aftercare
The amount of aftercare will vary, depending on the skin lesion removal technique. For biopsy, curettage, cryosurgery, and electrosurgery procedures, the patient is told to keep the wound clean and dry. Healing will take at least several weeks, and may take longer, depending on the size of the wound and other factors. Healing times will also vary with excisions and with Mohs' micrographic surgery, particularly if a skin graft or skin flap is needed to repair the resulting wound. Laser surgery may produce changes in skin coloration that often resolve in time. Pain is usually minimal following most outpatient procedures, so pain medicines are not routinely prescribed. Some areas of the body, such as the scalp and fingers, can be more painful than others, however, and a pain medicine may be required.
Risks
All surgical procedures present risk of infection. Keeping the wound clean and dry can minimize the risk. Antibiotics are not routinely given to prevent infection in skin surgery, but some doctors believe they have a role. Other potential complications include:
bleeding below the skin, which may create a hematoma and sometimes requires the wound to be reopened and drained,
temporary or permanent nerve damage resulting from excision in an area with extensive and shallow nerve branches,
wounds that may reopen after they have been stitched closed, increasing the risk of infection and scarring.
Normal results
Depending on the complexity of the skin lesion removal procedure, patients can frequently resume their normal routine the day of surgery. Healing frequently will take place within weeks. Some excisions will require later reconstructive procedures to improve the appearance left by the original procedure.
Abnormal results
In addition to the complications outlined above, it is always possible that the skin lesion will reappear, requiring further surgery.
BOOKS
Fewkes, Jessica L. Illustrated Atlas of Cutaneous Surgery. New York: Gower Medical Publishing, 1992.
Roenigk, Randall K., and Henry H. Roenigk. Roenigk & Roenigk's Dermatologic Surgery: Principles and Practice. New York: Marcel Dekker, 1996.
PERIODICALS
Alster, Tina S., and Amy B. Lewis. "Dermatologic Laser Surgery: A Review." Dermatologic Surgery 22 (Sept.1996): 797-805.
Lener, Elizabeth V., et al. "Topical Anesthetic Agents in Dermatologic Surgery: A Review." Dermatologic Surgery 23 (Aug. 1997): 673-683.
ORGANIZATIONS
American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. <http://www.aad.org>.
American Society for Dermatologic Surgery. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-9830. <http://www.asds-net.org>.
American Society of Plastic and Reconstructive Surgeons. 44 E. Algonquin Rd., Arlington Heights, IL 60005. (847) 228-9900. <http://www.plasticsurgery.org>.
Richard H. Camer
KEY TERMS
Curet—A surgical instrument with a circular cutting loop at one end. The curet is pulled over the skin lesion in repeated strokes to remove one portion of the lesion at a time.
Mohs' micrographic surgery—A surgical technique in which successive rings of skin tissue are removed and examined under a microscope to ensure that no cancer is left.
Shave biopsy—A method of removing a sample of skin lesion so it can be examined by a pathologist. A scalpel or razor blade is held parallel to the skin's surface and is used to slice the lesion at its base.
