Minor Surgery - Best treatment › Therapeutic skills
Excisions of the lumps
Excision of the lump may be either diagnostic or curative for many lesions, but requires adequate time, expertise, and suitable equipment to be performed safely and effectively.
Skin biopsy is the removal of a sample of skin for histopathological or other investigation (Chuh AAT, Wong WCW, Wong SYS, Lee A, 2005) . There are several methods to perform such a biopsy including excision, shave or punch biopsies.
In an excision biopsy, the entire skin lesion is removed via an elliptical excision (Fig. 1). The wound is closed by suturing. This is the procedure of choice for relatively small lesions requiring diagnosis as well as for larger or deeper lesions in non-exposed skin areas such as the back (Chuh AAT, Wong WCW, Wong SYS, Lee A, 2005) .
Excision may also be indicated for epidermoid cysts, lipoma, dermatofibroma, keratoacanthoma, or pyogenic granuloma.
Technique of performing skin biopsy (Chuh AAT, Wong WCW, Wong SYS, Lee A, 2005) , (Kunnamo I (ed), 2005)
- Take the biopsy from a suitable site, e.g. from a newly but fully developed lesion (a biopsy sample from a fresh lesion is particularlyimportant in bullous diseases). The underlying structures should not prevent a sufficiently deep incision.
- An ordinary skin biopsy should be taken with a scalpel (No. 15) to include the entire depth of the skin to the subcutaneous fat.
- Incise the skin in the direction of skin folds in order to minimize scar formation. A specimen measuring 0.5 x 1.5 cm is recommended. Its thickness is determined by the site.
- For any biopsy it is preferable to obtain normal skin, at least part of the lesion, and the intervening transition zone, unless removal of the entire lesion is being attempted as excisional biopsy.
- Do not squeeze or tear the biopsy specimen. Use small surgical forceps.
- The tissue sample should be fixed in formalin and submitted to a pathologist. Since histopathological changes for many dermatological problems are non-specific, the clinical history, physical findings and – most importantly – a list of differential diagnoses must be attached. A clinical photograph of the entire lesion in situ accompanying the biopsy specimen may also be helpful to the pathologist.
Excisional surgery is the most common treatment for various benign skin lesions (including suspicious pigmented lesions) as well as low-risk nonmelanoma skin cancers that extend into the reticular dermis (Naylor M, Hitt E) . The latter usually require diagnostic biopsy prior to this definitive treatment (Chuh AAT, Wong WCW, Wong SYS, Lee A, 2005) . Excision results in a higher cure rate than superficial ablative therapy (i.e. curettage, cauterization or cryotherapy [see below]), giving good cosmetic outcome and more rapid healing.
Basic rules (Cracknell ID, Mead MG, 1997) , (Kunnamo I (ed), 2005) , (Naylor M, Hitt E)
- Try to remove small tumours completely. With large cysts you may need to excise an ellipse of skin over the cyst to facilitate skin closure (as shown in Fig. 1).
- You can gauge how deep a tumour is situated by trying to pick up the skin over it: if both skin and superficial fat can be separated from the tumour, it will be a deep one. In this case an incision can be made over the tumour site down to its capsule (as shown in Fig. 2).
- Standard surgical excision should be followed by postoperative pathologic assessment of the removed lesion and its margins. The only exception may be typical seborrhoeic verrucosis and atheromas (with a content of sebaceous mass).
- If the benign nature of a skin lesion is not evident, a biopsy is preferred.
- If the entire lesion cannot be excised, it is also recommended to take the biopsy from its outer part, extending radially to the centre of the lesion. Remember to inform the pathologist about the location of the lesion and the site of the biopsy within the lesion.
- Children have malignant skin tumours seldom if ever. In case of undetermined skin tumours in children, refer them to a specialized unit.
