Surgery to remove skin lesions

A plastic surgeon can offer specialised techniques for removal which will minimise scarring and promote healing.

Most small skin lesions can be excised under local anaesthetic in the consulting rooms unless they are in difficult areas, multiple or the patient cannot cope with local anaesthetic injections e.g. children. The procedure takes 30-60 minutes. The only discomfort will be when the local anaesthetic is injected. This may sting for up to 1 minute. After this there's a 5-10 minute wait whilst the local anaesthetic numbs the region.

Larger or multiple lesions or if they are in difficult areas (ears, eyelids and nose) may require admission to hospital for excision. Reconstruction with a flap or skin graft may be required to provide skin cover for the defect left by excision of the lesion.

 An elliptical excision is the technique most often used. The ellipse usually runs along a wrinkle or skin crease line and is two to three times longer than the lesion. This means the scar will be longer than the lesion that is being removed. If the area is excised as a circle around the lesion, when the skin is sewn up it would bulge out at each end. This is called a "dog ear" and is unsightly.  

 If your incision is on the face, the skin is usually stitched up with nylon sutures that will need to be removed 5 to 7 days later. On other areas of the body dissolving sutures under the skin are usually used. 

A skin graft is a procedure performed where a layer of skin is removed from one area of the body, the donor site, and transplanted to another, the recipient site. The skin graft has no blood supply however over the following week new blood vessels will grow into this free piece of skin and provide it with blood again. There is always a small chance that not all the skin will take (come alive again) if blood accumulates between the skin graft and the underling tissue or if infection develops.

There are two main types of skin grafts and they are:

• Split or partial thickness graft – The epidermis (the top layer of the skin) and part of the dermis (the middle layer of the skin) are shaved from the donor site (usually the thigh) and transplanted onto the defect. It is used when a large amount of skin is required. Skin on the donor site can grow back from sweat glands and hair follicles.
• Full thickness graft – The entire epidermis and dermis are transplanted to the recipient site. The cosmetic effect is good (better than a split thickness graft), but they are only suitable for small defects. The donor site is closed as a single straight line wound. The areas of the body that are most commonly used as donor sites for full skin grafts are the area of skin behind the ear, the neck and inner arm. Sometimes other tissue is taken with the skin e.g. cartilage to provide greater thickness or support for the skin (Composite graft).

 A flap is a piece of tissue (skin, fat +/- muscle) that is still attached to the body by an artery and vein. This piece of tissue with its attached blood supply is used in reconstructive surgery by being set into the defect. There are several different types of flaps depending on where they are moved to in relationship to where they came from.

• Local flaps – This is when the donor site is immediately adjacent to the recipient site. The required area of skin and tissue is moved without interrupting the blood supply. The tissue may be rotated, advanced or transposed into the new position.
• Distant flaps – This is when a piece of tissue is transferred from an entirely different area of the body, for example, a flap taken from the abdomen might be used to reconstruct a defect on the head or neck. The most common type of distant flap now days is a free flap. A Free flap is where microsurgery is used to join the blood vessels establishing immediate blood flow.

The wound is covered whenever possible with a waterproof plastic patch so that you may shower. Strenuous exercise or work should be avoided for 7-14 days afterwards to minimize bleeding or splitting open the wound.

After one week you will be seen, the dressing will be changed and/or stitches removed. The lesion will have been sent for testing (histopathology) to check what it was and that it is adequately removed. You will be given the results at this appointment. The wound will usually be covered with a further dressing or tape for another few days to weeks depending on where the wound is and whether it is fully healed or not.

Over the following months you need to massage the wound with Bio-oil or scar gel twice a day. In the first week massage the cream in very lightly to moisturize the wound. After that apply light pressure as you massage to help break up the scar tissue.  We will usually arrange a time for you to return to the surgery after 4 to 6 weeks to check on how the scar is settling. At that time further scar management may be commenced if required, such as silicone gel scar patches or gel, ultrasound or a cortisone treatment to further improve your scar.

1. Infection of the wound. Treatment with antibiotics may be necessary.
2. Bleeding from the wound may require an early change of dressing, further treatment to stop the bleeding, or additional suturing.
3. Haematoma or Seroma is a collection of blood or serum beneath the wound. It may require extra visits to drain the fluid or reopen the wound to allow removal of the blood and stop the bleeding.
4. Wound breakdown; although the wound usually heals well in two weeks or so, complete healing may take weeks or months. Even after the stitches have been removed, strenuous activity or unexpected pulling may cause the wound to reopen. This can usually be avoided by ensuring that the area is not under physical stress for several weeks.
5. Allergy to tapes; some patients develop an itchy rash or blistering from the dressing. This usually settles within a few hours to days of removing the dressing without permanent damage.
6. Incomplete excision of the lesion requiring wider re-excision of the scar or other treatments such as radiotherapy or creams when appropriate.