Excision and excision biopsy
Excision or excision biopsy is a procedure where a doctor cuts around a skin lesion through the full thickness of skin, usually closing the resulting hole with stitches.

Also known as

surgical removal, excision with suture

How it’s performed

The doctor injects local anaesthetic into the skin around the lesion to make it numb. They then cut around the lesion, usually in an oval shape, about 2 to 3 times as long as it is wide. Once this is done, they peel off the skin, taking the entire lesion with a margin of normal skin around the edge.

Preparation

People taking anticoagulant medications may need to temporarily discontinue them before surgery. People with a history of rheumatic fever or heart valve disease may need to take a course of antibiotics commencing before the procedure. If the area to be excised is hairy, shave at least 5 cm all the way around the lesion at ;east 24 hours before the procedure. People with pacemakers or implanted defibrillators should inform the doctor before the excision procedure.

Side effects and complications

Bleeding, infection, bruising, pain, wound breakdown, scarring

Follow-up

Stitches usually need to be removed, between 5 and 21 days after the procedure (usually 14). After the stitches are removed, be careful not to stretch the wound for several weeks. Scarring can be reduced by a range of measures including taping, silicone gel and low level light therapy.

Contraindications

Warnings

Pregnancy

It's safe to undergo this procedure while you are pregnant.
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Why perform an excision?

Excision is performed to:

  • remove—and usually cure—skin cancers
  • remove suspicious-looking spots so that they can be tested

A doctor would recommend excision if:

  • he or she is confident that a lesion is a skin cancer and must be entirely removed to properly treat it
  • a spot looks like it could be a skin cancer and it needs to be tested to reach a diagnosis. Sometimes, the doctor might choose to remove only part of the lesion, performing a punch or shave biopsy—usually if the lesion looks like one of the less serious skin cancers such as basal cell carcinoma or squamous cell carcinoma. If the spot is suspected of being a melanoma, it’s best to remove the entire lesion for testing.

The procedure

The procedure usually takes approximately 20-30 minutes (although this varies according to the size and complexity of the procedure) and is performed at Spot Check Clinic.

The doctor cuts through the skin around the lesion, usually in an oval shape. Depending on the type of lesion, there will typically be a margin of between 2 and 5 mm of normal skin around the lesion. The cut usually needs to be about 3-4 times as long as it is wide, so that the skin edges can close together after the lesion is removed.

Once the doctor has cut around the lesion, he or she peels off the lesion and surrounding skin. It will be sent to a skin pathology laboratory for analysis. The results are usually available in less than a week. The doctor will make arrangements with you about the best way to get them.

After the skin lesion has been removed, the doctor will reduce any bleeding by applying pressure or sometimes by sealing small blood vessels with a small electric current. This process (called diathermy) makes the tissues hot and you may notice a burning smell, but there should be no pain

When any bleeding is controlled, the doctor will pull the skin edges together and secure them with stitches. The number and type of stitches, and the thickness of the material used, depend on the size of the skin lesion and the location on the body.

The doctor will advise you when the stitches need to be removed.

See the Excision aftercare page for advice on looking after the wound and dressing after your procedure.

Local anaesthetic

Procedures are performed using a local anaesthetic, which makes the area around the skin lesion numb for several hours. There is no sedation, so in most cases, it's safe to drive home after the procedure. The doctor will inject a small amount of local anaesthetic into the area around the spot to be removed. This injection stings for 5 to 10 seconds, but there should be no pain after- wards. (You may be aware of other sensations such as stretching.)

The anaesthetic may contain adrenaline, which helps reduce bleeding but might cause side effects such as nausea, increased heart rate or a feeling of shakiness. These side effects are rarely serious. If you experience them, we suggest that you rest in our waiting room for a while before you leave.

Preparing for an excision or biopsy

Most people don’t need any special preparation for a skin excision, but in many cases simple planning can make the procedure go much more smoothly.

Medications

If you are taking anticoagulant or blood thinning medications such as aspirin, fish oil, warfarin or clopidogrel (Plavix), you may bleed more during or after your procedure. Check with the doctor who prescribed this medication and—only if that doctor approves—you can stop taking the medication a few days before your procedure to minimise bleeding.

If you have certain heart conditions, such as artificial valves, you may need to take a course of antibiotics commencing before your procedure to prevent infections of the heart. Please inform the doctor if you have such conditions in advance of your procedure.

Pacemakers

If you have a pacemaker or defibrillator please make sure the doctor knows before commencing the procedure. There is a small risk that the electric current produced by diathermy may interfere with pacemakers, so we will avoid using it in these cases.

Preparing the area

If the area to be excised is hairy, it is very helpful to shave the region at least 24 hours before your procedure. (Unfortunately we can't shave it on the day, as this would increase the risk of infection.) You should shave at least 10 cm around the lesion so there is plenty of room for adhesive dressings.

Reducing stress

Some people have needle phobias or feel anxious about undergoing procedures. These strategies might help:

  • Purchase some EMLA cream from a pharmacy and apply it to the lesion and surrounding area at least an hour before your procedure. This cream can help to make the area numb and helps reduce the discomfort of the local anaesthetic injection.
  • Bring a portable music player or your phone with your favourite music or podcasts
  • Have a calm and responsible support person with you. If you like, this person can sit in the treatment room and talk to you while you are having the procedure.

Complications

Excision is a surgical procedure with potential complications like any other surgery. It is very important to understand the risks before you proceed with the excision. Ask the doctor or nurse if you have any concerns.

Scarring

Your procedure will leave a scar. Some lesions and some sites on the body scar more than others.

In most cases, there will be a red or pink mark at the site of the excision for several months. This is considered normal and it will gradually fade.

After that, there will usually be a fine line, or some times an oval-shaped mark which will persist long term.

The doctor will attempt to minimise scarring as much as possible, but you can help by not stretching the wound and taping it or applying silicone ointment.

Pain

Sometimes the local anaesthetic does not completely control the pain during the procedure. If this occurs, an extra dose of anaesthetic should eliminate any discomfort.

It is unusual to experience pain after a skin lesion excision as the wounds are usually quite small and shallow. If you do have pain, simple painkillers such as paracetamol or paracetamol/codeine should be sufficient. Avoid aspirin and ibuprofen as they might increase bleeding.

Pain occurring days after the procedure could be a sign of infection.

Bleeding and bruising

The doctor will minimise bleeding during the procedure, but in some cases there will be some bleeding afterward. This is more common when

  • you are taking medication that increases bleeding, such as aspirin, warfarin, clopidogrel (Plavix) or fish oil
  • the wound is large or blood vessels were cut during the procedure
  • you are older (usually over 60)

If there is a risk of bleeding after the procedure, we will usually apply a firm bandage to apply pressure over your dressing.

It's very common for blood to appear on the dressing in the hours following a procedure, and in the morning if you have slept on the wound overnight. This is not necessarily a problem. However, if the dressing is soaked with fresh blood, you should consult a doctor.

Bruises settle without treatment, but low level light therapy can speed recovery.

Wound breakdown

The skin on each side of the excision site is held together by stitches while it grows together. If the wound is stretched too much, the stitches can break, causing the edges of the wound to pull apart. This can also happen even after the stitches have been removed, as the skin takes several months to reach maximum strength after an excision.

This is usually an inconvenience and not a significant medical problem.

When a wound pulls open, the usual management is to let it heal from the bottom up without restitching it. The wound may need to be dressed repeatedly by a nurse, requiring multiple visits to the clinic. Most wounds heal well, but this process may take several weeks. Scarring is generally worse than it would otherwise have been.

You can reduce the chance of wound breakdown by avoiding stretching and heavy lifting for several weeks after the excision.

Infection

Approximately 5 per cent of excisions become infected. Signs of infection include:

  • pain and tenderness of the wound and surrounding area
  • redness spreading out from the wound
  • pus or an odour coming from the wound
  • fever

Most infections are minor and respond well to antibiotics, either oral or applied to the wound as a cream. However, if you think your wound is infected you must not use any antibiotics or medications you have at home. These might not be suitable for the specific bacteria that cause skin infections.

If you think your wound is becoming infected, a doctor or nurse should be able to assess the situation and recommend the best course of treatment.

Insufficient margins

When performing an excision, the doctor aims to remove the entire skin lesion with a margin of normal skin around it. By ensuring that there is normal skin surrounding the lesion, we can be sure that none of it remains behind.

The usual margin is 2 mm at first, but sometimes after a lesion is confirmed to be a skin cancer, you need re-excision with a larger margin. For example, melanoma may require a margin of 5mm to several cm depending on its size and depth.

Sometimes the skin pathology result shows that the margins around the removed lesions aren't wide enough. When this happens, in some cases the wound might need to be re-excised.

Nerve damage

Damage to nerves is a rare complication of excisions. It occurs when the doctor cuts a nerve in the process of cutting out a lesion. In practice, nerve damage occurs almost exclusively when lesions are being removed from the face. If your lesion is in an area where nerves might be damaged, your doctor will discuss the risks before your procedure.

References

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