Best Practices for Removing Benign Skin Lesions: A Surgical Perspective

Excision of benign skin lesions is one of the most common procedures performed by surgeons and dermatologists. While these lesions are non-cancerous, their removal is often warranted for diagnostic purposes, cosmetic reasons, or because of the potential for irritation, discomfort, or changes that might suggest malignancy. This article provides a detailed overview of the indications, preoperative evaluation, contraindications, surgical techniques, postoperative care, potential complications, different techniques, prognosis, and more, designed to be an authoritative guide for professionals in the field.


Indications for Excision of Benign Skin Lesions

The decision to excise a benign skin lesion depends on several factors:

1. Diagnostic Uncertainty: When a lesion presents with ambiguous characteristics that raise concern for malignancy, excision and histopathological examination become necessary.
2. Cosmetic Concerns: Patients may seek removal of lesions that are cosmetically displeasing, especially those located on the face or other visible areas.
3. Functional Discomfort: Lesions that cause pain, bleeding, itching, or recurrent irritation, especially in areas prone to friction, are often excised to improve patient comfort.
4. Growth or Change: Any lesion that undergoes rapid growth, changes in color, or alteration in shape should be excised to rule out malignancy.
5. Psychosocial Impact: Some patients experience significant psychological distress due to the appearance of a lesion, which may warrant its removal.

Preoperative Evaluation

A thorough preoperative evaluation is essential to ensure the safe and effective excision of benign skin lesions. This process involves:

1. Patient History: A detailed history should be taken, including the duration of the lesion, any changes in size or appearance, symptoms such as pain or itching, and any previous treatments.
2. Physical Examination: A complete skin examination should be performed, focusing on the lesion in question. Important features to assess include size, color, border regularity, and texture.
3. Dermatoscopy: This non-invasive technique provides a magnified view of the lesion, helping to differentiate benign from malignant features.
4. Biopsy: In cases where there is significant uncertainty about the nature of the lesion, a biopsy (either punch or shave) may be performed prior to full excision.
5. Patient Counseling: The patient should be informed about the nature of the lesion, the rationale for excision, the procedure itself, potential risks, and postoperative care. Informed consent should be obtained.

Contraindications

While excision of benign skin lesions is generally safe, certain conditions may contraindicate the procedure:

1. Infection at the Site: Active infection at the site of the lesion increases the risk of postoperative complications and may warrant postponing the procedure until the infection is resolved.
2. Bleeding Disorders: Patients with coagulopathies or those on anticoagulant therapy may be at increased risk for bleeding. Preoperative management of anticoagulation and careful surgical technique are required.
3. Patient Refusal: Informed consent is paramount; if the patient refuses the procedure, it should not be performed.
4. Suspicion of Malignancy: If malignancy is strongly suspected, the lesion should be excised with appropriate margins, following oncologic principles rather than standard excision of benign lesions.

Surgical Techniques and Steps

The technique for excising a benign skin lesion depends on its size, location, and the surgeon’s expertise. Here’s a step-by-step guide:

1. Preparation:
   • Mark the lesion and the planned incision line, typically using a surgical pen.
   • Prepare the skin with an antiseptic solution.
   • Administer local anesthesia, ensuring the entire area is adequately anesthetized.
2. Incision:
   • A fusiform (elliptical) incision is commonly used, aligned with the natural skin tension lines (Langer’s lines) to minimize scarring.
   • The incision should extend into the subcutaneous tissue, ensuring complete removal of the lesion.
3. Excision:
   • Using a scalpel, the lesion is excised along with a small margin of normal tissue to ensure complete removal.
   • The excised tissue is then sent for histopathological examination.
4. Hemostasis:
   • Achieve hemostasis using electrocautery or other appropriate methods to control bleeding.
5. Closure:
   • The wound is closed in layers to minimize tension on the skin edges, using absorbable sutures for deeper layers and non-absorbable sutures for the epidermis.
   • Techniques such as subcuticular suturing or skin adhesives may be used to optimize cosmetic outcomes.
6. Dressing:
   • Apply an appropriate dressing to protect the wound and promote healing.

Postoperative Care

Proper postoperative care is crucial for optimal healing and to prevent complications:

1. Wound Care: The patient should be instructed on how to care for the wound, including keeping it clean and dry, and applying antibiotic ointment if recommended.
2. Activity Restrictions: Advise the patient to avoid activities that could stress the wound site, such as heavy lifting or strenuous exercise, especially for lesions removed from areas prone to movement.
3. Follow-up: Schedule a follow-up appointment to assess healing and remove sutures, typically within 5-14 days depending on the location of the lesion.
4. Signs of Complications: Patients should be advised to monitor for signs of infection (redness, swelling, warmth, increased pain) or other complications and to contact the surgeon if these occur.

Possible Complications

While excision of benign skin lesions is generally safe, complications can occur:

1. Infection: Although rare, wound infections can occur, particularly in patients with underlying health conditions or in lesions located in areas prone to contamination.
2. Scarring: All excisions will result in a scar, though meticulous surgical technique and proper postoperative care can minimize its appearance.
3. Recurrence: There is a small risk that the lesion may recur, particularly if not fully excised.
4. Nerve Damage: Lesions located near nerves may be at risk for nerve injury during excision, leading to numbness or altered sensation.
5. Bleeding and Hematoma: Bleeding can occur intraoperatively or postoperatively, and hematomas may develop, requiring drainage.

Different Techniques

The technique used for excising a benign skin lesion may vary based on the location and nature of the lesion:

1. Shave Excision: This technique involves shaving the lesion off at the level of the skin or slightly below it, often used for superficial lesions.
2. Punch Excision: A punch biopsy tool is used to remove the lesion in a circular manner, often used for small lesions.
3. Elliptical Excision: The most common method, involving a fusiform incision and removal of the lesion with a margin of normal tissue.
4. Mohs Micrographic Surgery: Although typically used for malignant lesions, this technique may be employed for benign lesions in cosmetically sensitive areas where tissue conservation is important.

Prognosis and Outcome

The prognosis after excision of a benign skin lesion is generally excellent. Complete removal is typically curative, with a low risk of recurrence. Cosmetic outcomes are also generally favorable, especially when the excision is performed with attention to skin tension lines and meticulous closure techniques.


Alternative Options

For patients who may not be candidates for surgical excision or who prefer non-surgical options, alternative treatments may include:

1. Cryotherapy: Freezing the lesion with liquid nitrogen can be effective for certain types of benign lesions.
2. Laser Therapy: Lasers can be used to vaporize superficial lesions with minimal scarring.
3. Topical Treatments: Some lesions, such as seborrheic keratoses or actinic keratoses, may respond to topical treatments like imiquimod or fluorouracil.

Average Cost

The cost of excising a benign skin lesion can vary widely depending on factors such as the location of the lesion, the complexity of the procedure, and the healthcare setting. On average, the cost can range from $150 to $1,500 or more, depending on these variables.


Recent Advances

Recent advances in the excision of benign skin lesions include:

1. Enhanced Imaging Techniques: Improved dermatoscopic and imaging techniques allow for better preoperative assessment of lesions, reducing unnecessary excisions.
2. Minimally Invasive Techniques: Advances in minimally invasive procedures, including laser excision and cryotherapy, offer effective alternatives to traditional surgical excision.
3. Bioengineered Wound Dressings: These new dressings can promote faster healing and reduce scarring after excision.