Excisional Surgery

A surgical excision is an in-office procedure in which a skin lesion is removed by a dermatologic surgeon.   This technique involves the use of local numbing medicine which is injected into and around the target area and followed by sharp dissection of the lesion from surrounding normal tissue.   The most common scenarios for utilization of this technique include:   treatment of skin cancers, atypical or suspicious moles (nevi), and cysts.

The size of the scar varies depending on the type of lesion removed.   For skin cancers and atypical nevi, a margin of normal-appearing skin is taken along with the abnormal-appearing area in order to maximize the chance of surgical cure.   In addition, to improve the appearance of the surgical scar and avoid “dog ears” or “puckering”, the skin is typically removed in the shape of an ellipse rather than a circle.   This helps the scar lay flat but does increase the scar length.   On average, the length of a scar from excisional surgery of skin cancers and atypical nevi is three to four times the diameter of the lesion that is removed.   On the other hand, for cysts, the scar length is usually approximately equal to the diameter of the cyst.

The gap in the skin where the lesion used to be is called the “surgical defect.”   The defect from a surgical excision is usually repaired using two layers of sutures (stitches) which transform the three dimensional defect into a linear scar.   The deeper layer is composed of absorbable sutures that will self-absorb and not require later removal.   The superficial layer (also known as top layer) is composed of non-absorbable sutures that will need to be removed typically in two weeks for most body sites.   An exception to this rule is for excisions on the face where suture are removed in one week.

Approximately one week after your excision at MassDerm, you will receive a phone call from one of our staff usually confirming that the margins of the excision are clear and no further treatment is required.   In rare instances there are still unwanted cells (cancerous or atypical) on the edges of the removed skin, and an additional excision is required to completely remove these potentially harmful cells.

• For uncomplicated basal cell carcinoma and squamous cell carcinoma:   Approximately 95%
• For melanoma:   Variable (depends on several variables that will be clarified by the dermatopathologist who examines the cancer after it is removed)
• For atypical nevi (moles):   Significantly greater than 99% (these rarely develop into skin cancer after surgical excision)
• For cysts:   Variable (depends on whether the cyst capsule was compromised before the procedure).   When most or all of the cyst capsule is removed, our patients experience cure rates over 90%.

• For nevi (moles) and melanoma, surgical excision is preferred over Mohs surgery because the cells that make up nevi and melanoma (i.e. melanocytes) are better visualized by the “permanent sections” utilized after surgical excision rather than the “frozen sections” utilized in Mohs surgery. In addition, Mohs surgery is better suited for removal of skin cancers that grow in a contiguous pattern (i.e. there are no “skip areas”).   Non-melanoma skin cancers such as basal cell carcinoma and squamous cell carcinoma tend to grow in a contiguous fashion, whereas it is not unusual for nests of melanoma to grow separately from one another (in a non-contiguous fashion).
• For many non-melanoma skin cancers (e.g. non-infiltrative basal cell carcinomas and well differentiated squamous cell carcinomas) that are located on the trunk or extremities, surgical excision is preferred over Mohs surgery because insurance companies will rarely cover Mohs surgery for these straightforward cases, and the cure rates for these non-melanoma skin cancers is only marginally lower (3-4%) with surgical excision than with Mohs surgery.
• For cysts, surgical excision with removal of the cyst capsule is preferred over other treatment techniques (e.g. incision and drainage) which simply drain the cyst contents because removal of the complete capsule significantly reduces the chance that the cyst will recur.

ABSOLUTELY NOT. If you take these medically prescribed anticoagulants, then you should continue them during and after surgery. If you are on Coumadin it is important that you have your INR checked the week before surgery and have the results sent to us so that we can ensure that your INR is within normal range.

If you have had a heart attack, a stroke, a blood clot, or if your doctor tells you that you NEED aspirin, then you should NOT STOP your aspirin for skin surgery.

However, if your doctor told you to take an aspirin each day “just because it is good for you” then please discontinue two weeks prior to surgery. If you are uncertain why you are on aspirin, it is always best to contact your primary care doctor’s office before stopping it.

You can resume your aspirin 2 days after surgery.

YES. Both Mohs surgery and surgical excisions are performed with local anesthesia, i.e. injection of numbing medication (lidocaine) into the skin at the surgical site. You will not have general anesthesia or sedation.

YES. Please eat a light meal prior to surgery.

If surgery will be done on the face or leg it is generally best to arrange for someone to drive you home after surgery.

You should take acetominophen (Tylenol) after surgery. We typically recommend that you take an acetopminophen 500 mg tablet as soon as you get home to decrease your discomfort as the numbing medication wears off. The first evening is when patients generally have the most discomfort and so you may want to take two of the acetominophen 500 mg tablets before bed. Most patients do not need more than Tylenol for pain control, but for more extensive surgeries we do occasionally prescribe Tylenol #3 (Tylenol with codeine).   We recommend that you avoid use of aspirin, ibuprofen (Advil), Aleve or other NSAIDs for pain relief as they may increase risk of bleeding.

In most cases you should not resume exercise until after the sutures have been removed. Exercising immediately after surgery increases the risks of bleeding, breaking open the stitches, and poor wound healing. Please avoid water sports for at least one week and also avoid hiking, camping and other outdoor activities that may expose the wound to dirt and infection.

You should make every effort to protect your wound site from the sun because sun exposure can increase the risk of a darkened scar.

You may experience a great deal of swelling and bruising in the first few days to week after surgery, especially with surgeries done on the forehead, near the eyes, or on the nose.

In many cases swelling cannot be prevented. Sometimes elevation of the head helps. When awake sit or stand upright. At night you may sleep with a few pillows or sitting up in a lazy boy. Sometimes carefully icing the wound can also help.

It is normal to have some bleeding onto the bandage. If the bleeding soaks through the bandage, then use clean dry gauze to apply FIRM, DIRECT PRESSURE FOR 20 MINUTES WITHOUT LIFTING UP TO LOOK AT THE WOUND. Depending on the location of the wound you may need someone to assist with holding pressure. If the bleeding does not stop after 20 minutes of pressure please call the general office number.  If it is outside of normal practice hours, you can press a button to be connected with Dr. Cummins.

Hydrogen peroxide is too abrasive for wound healing. It is preferable to clean the wound daily with mild soap and warm water prior to dressing changes.

Neosporin can cause an allergic reaction in some people. We recommend aquaphor or vaseline petrolatum instead. These may be applied one to two times daily with a clean Q-tip, always from a clean uncontaminated container.

Wound care and bandaging will be reviewed on the day of surgery. In most cases we will recommend a Telfa non-adherent gauze applied with medical tape. For smaller wounds a large bandaid may be sufficient.

This depends on the wound location and the type of repair that you have had. In most cases you will only need to dress it for one to two weeks.

For urgent issues please call the general office number.   If it is outside of normal practice hours, you can press a button to be connected with Dr. Cummins.