Benign Skin Lesion Excision

What is benign skin lesion excision?

Skin lesions can be benign or malignant. In some cases, a small piece of the lesion is taken as a biopsy to confirm the diagnosis before removal. However, for some lesions, the appearance is classical, and a biopsy is not required.

The lesion is removed through as small a scar as possible, and scars are hidden wherever possible in skin creases or wrinkles. The tissue is removed and sent to be analysed under a microscope to confirm the nature of the lesion and whether it has been completely excised.

Occasionally, further surgery is necessary dependent upon these results. Benign lesions do not have to be removed but patients often request removal if they are growing, cause symptoms or for cosmetic reasons.

Removal of skin lesions may be accomplished by alternative treatments, which include:

  • Liquid nitrogen (freezing).
  • Lasers.
  • Topical medications.
  • Electrocautery.

Each modality has its own risks and complications and these need to be considered when deciding on the best option.

The operation can be performed under a local anaesthetic injection (you are awake, but the area is numb) or general anaesthetic (you will be fully unconscious). It is commonly performed under local anaesthetic in the procedure room at Cayman Surgery. The area is numbed with an injection, and the procedure takes approximately 40 minutes to perform.

The lesion is excised with a small margin of normal skin to ensure its complete excision. It will be sent for histology to confirm the diagnosis and ensure that it has been completely removed.

In most cases, the lesion is removed as an elliptical excision and closed as a straight scar. However, if the lesion is adjacent to a cosmetically sensitive area (such as the mouth or eye), the closure would be too tight, then an alternative method of skin closure is needed.

The options are:

Local flaps: These are created by freeing a layer of surrounding tissue with its blood supply intact and then moving the freed layer to fill a defect. The skin where the flap is “borrowed from”, called the donor site, is closed directly. This method of reconstruction is highly effective, as it ensures that the replaced skin matches in colour, texture, and thickness, resulting in well-settled and inconspicuous scars.

Skin grafts: These consist of skin being taken from one area of the body, to cover an area where skin is missing or damaged. Unlike ‘flap’ reconstruction (which has its own intrinsic blood supply), a skin graft is a free piece of tissue, which receives blood supply from the bed onto which it is grafted. Therefore, the skin’s survival relies on the integrity of the underlying wound bed. There are two types of skin graft that I perform:

    • A split-thickness skin graft removes a thin layer of skin from the thigh (donor site) and it is used to close the skin excision site that needs to be covered (recipient site). The skin graft is secured on the recipient site with sutures and a pressure dressing. The tissue gets nutrients from the tissue bed until it establishes its own blood supply and heals the defect.

The donor site is like a carpet burn and it is covered with a dressing that is left in place for 2 weeks. When the dressing is removed it should all be healed, and it will leave a patch of shiny pink skin. With time this donor patch may become paler than your normal skin.

The recipient site should be healed within 5 days and will leave a patch of pale skin with a slight depression.

    • A full thickness skin graft (FTSG) is taken by removing all the layers of the skin down to the fat with a scalpel and is done in a similar way to a skin excision. The piece of skin is cut into the correct shape, then applied to the wound. This type of graft is often taken from the inner upper arm, neck, in front of or behind the ear, where there is more laxity in the skin to facilitate closure of the donor site.

Since it includes the full layer of dermis, it has a better cosmetic outcome than a split-thickness graft, less contraction (shrinkage) over time, and more resistance to subsequent trauma. However, due to the increased thickness of this graft, FTSGs initially have a lower chance of survival. They are also limited by the size of the donor site, as harvesting leaves a full-thickness defect that must, itself, be managed and stitched closed.

The incision is sutured with dissolvable stitches in the trunk and limbs, whilst those on the face are non-dissolvable and require removal after 5 days. You can go home immediately after surgery and return to work the following day.

Complications are infrequent and usually minor. However, all surgery has risk, and it is important that you are aware of the possible complications. All the risks will be discussed in detail with you at your consultation. However, if you have further questions or concerns, please do not hesitate to discuss them with me. Decisions about surgery should never be rushed.

These risks can be divided into those specific to the surgery and those that relate to the anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

  • Unintended intraoperative awareness, which is very rare.
  • Dizziness and nausea.
  • Sore throat.
  • Damage to teeth or mouth.
  • Nerve injury due to body positioning.
  • Allergic reaction or anaphylaxis.
  • Malignant hyperthermia, which is a rare life-threatening condition.
  • The anaesthetist will go through these risks in more detail prior to your surgery.

Scars: These tend to settle remarkably well; however, some people heal with thicker scars than others and this can make them more noticeable.

Bruising and swelling: This is very common and may take approximately 2 weeks to resolve.

Haematoma: This can happen if a bleed occurs under the skin, allowing a large blood clot to form. If a haematoma develops, it is likely to do so within 4 to 6 hours post-surgery. Any increase in swelling or pain should be reported immediately so that timely treatment can be given. Sometimes patients need to have this collection of blood removed with another short operation.

Infection: This is rare, but you may require antibiotics if there are any concerns.

Numbness, reduced sensation or oversensitivity: These can occur around the scar. They are usually temporary, but occasionally the changes can remain to some degree.

Wound healing problems: These healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, resulting in skin loss. People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Dog-ears: These are soft tissue prominences where the scar stops. In most cases these settle over the course of 3 months. A small local anaesthetic procedure may be required to remove any excess that remains.

Recurrence: Even when a lesion is completely excised, it is possible that it could recur, or a new one can grow in the area.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and move to your lungs. If the blood clot is large enough it could prove fatal. To reduce any risks of this, we give you special stockings to wear in bed and a blood thinning injection if you are not mobile.

All the risks outlined above will be discussed in detail at your consultation with me. However, if you have further questions or concerns, please do not hesitate to ask me.

Depending on the area of your surgery, your incisions are closed with either dissolvable or non-absorbable sutures.

Dissolvable sutures under the skin do not require removal whereas the non-absorbable sutures will need to be taken out after 5 days. You normally have a waterproof dressing to enable you to shower.

Before you leave the clinic, you will be given a follow up appointment to see the nurses at one week post-operatively to check your incisions and an appointment to see me in Clinic after 2 weeks.

Scar advice
Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection.

The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

Recovery times vary from one person to another, but most patients return to work the next day. I recommend that you avoid swimming and strenuous activities for 1 to 2 weeks.

Many patients having skin lesion removal are covered by health insurance. However, there is normally a co-pay of 20%. This means you are likely to have to pay towards the cost of your surgery. Any co-pay fees will be calculated, and you will be informed of the potential fees at your consultation.

For those patients who are self-funding, surgical fees are a combination of the hospital costs, the surgeon, anaesthetic fees and any consumables. I do not charge additional fees for post-op appointments. You will be given a quotation for surgery approximately 48 hours following your consultation.