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DermNet NZ


Facts about the skin from DermNet New Zealand Trust. Topic index: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


Introduction to skin surgery

Learning objectives
Introduction
Indications for surgery
Scarring
Local anaesthesia
Haemostasis
Activity

Learning objectives

Describe:

Introduction

Many general practitioners perform minor surgery for benign and small malignant skin lesions. We strongly recommend that you attend regular hands-on workshops in skin surgery to develop and maintain surgical skills. This course does not replace the need for practical training and experience.

To ensure safe practice, aim to comply with published office surgery standards, especially those of Standards New Zealand – ‘The Essential Standards for Health and Disability Services’, include:

Indications for surgery

Skin surgery is indicated for the removal of skin lesions that are, or may be, malignant, or if benign, are causing concern because of symptoms or cosmetic appearance.

Patients with large lesions or lesions on the face may be referred to a dermatologist or plastic surgeon for management.

The surgical management of benign and malignant skin lesions may include:

Combinations of these techniques are often used.

The choice of procedure depends on:

Scarring

The aim is for minimal scarring after any surgical procedure. To achieve this, the excision should occur at right angles to the direction of the resultant pull of the muscles or parallel to natural skin creases and wrinkles – the more creases and wrinkles the less obvious the scar.

Scars are initially red and firm. In time (usually 3 to 12 months), the induration and erythema lessen leaving a soft scar, paler than surrounding skin. Scars tend to stretch, especially when there is loss of skin and obvious wound tension. More conspicuous scarring arises in the following circumstances:

Scar after coronary artery bypass
Coronary artery bypass
Scar after wound infection
After wound infection
Scars after gravel abrasions
Gravel abrasions
Hypertrophic scars

Suture marks are more prominent in coarse oily skin, for example on the nose, and less obvious in hairless skin such as the margin of the lips, and are less likely with early removal of sutures.

Local anaesthesia

Topical anaesthesia

Topical anaesthesia may be useful for:

This may be delivered as freezing spray at the time of the procedure (ethyl chloride, nitrous oxide or very light liquid nitrogen), or as a cream applied an hour or two earlier – such as eutectic mixture of prilocaine and lidocaine (EMLA 5% Cream or patch) or amethocaine hydrochloride (Ametop™ Gel).

Intradermal anaesthesia

Most skin procedures require intradermal anaesthetic. Lignocaine (Xylocaine™), an amide, is most commonly used. The onset of action is rapid (one to two minutes) and it lasts one to three hours. The addition of adrenaline 1:100,000 prolongs its duration, reduces toxicity and controls bleeding. The adrenaline should not be used for circumferential block of a digit or penis, or in those with impaired peripheral circulation or serious heart disease.

The maximum safe volume of 1% plain lignocaine in an adult on a single occasion is about 20ml; detailed safety information can be found on manufacturers' data sheets on the Medsafe website. It may be injected using 1 to 5 ml syringe and 23 to 30 gauge needle, or using dental syringe, 30 gauge disposable dental needle and 2.2 ml cartridge.

EMLA cream
EMLA cream
Vasoconstriction from EMLA
Vasoconstriction from EMLA
Infiltrating local anaesthetic
Infiltrating local anaesthetic
Dental syringe
Dental syringe
Local anaesthetic

Haemostasis

Methods of haemostasis include:

Haemostatic solution
Haemostatic solution

Electrosurgery

Electrosurgery is used for haemostasis and desiccation of tissue using high frequency (0.1-1 MHz), high voltage, and low-amperage currents in a modulated manner. It should in general be avoided in those with pacemakers although modern units are probably quite safe in stable patients providing the path of the electric current does not pass through the heart.

For sterility, disposable tips or needles are used with the hand piece inserted in a sterile glove or specific polythene casing. Reusable tips should be sterilised in an autoclave.

Methods include:

Electrosurgery trolley
Electrosurgery trolley
Hyfrecator
Hyfrecator®
Sharp & blunt disposable electrocautery tips
Sharp & blunt disposable tips
Haemostasis
Haemostasis
Electrosurgery

Electrocautery uses red-hot wire to burn the tissue. Hand-held disposable and mains-powered heavy duty units are available.

Hand-held cautery
Hand-held cautery
Geiger® cautery set
Geiger® cautery set
Cautery tips
Cautery tips
Electrocautery
Skin lesion Electrosurgical method
Skin tags, warts, syringomas Gentle electrodessication prior to curettage
Telangiectasia Fine needle electrode and very low power electrodesiccation
Small non-melanoma skin cancers (dermatologists) Shave, curette the lesion prior to electrofulguration / desiccation or cautery (always send specimen for histology)

Activity

 

Page 11 of 15. Next topic: Processing skin biopsies. Back to: Skin lesions course contents.

Related information

References:

On DermNet NZ:

Information for patients

Other websites:

Books about skin diseases:

See the DermNet NZ bookstore

Author: Clin Assoc Prof Amanda Oakley

DermNet NZ does not provide an online consultation service.
If you have any concerns with your skin or its treatment, see a dermatologist for advice.