SPECIFIC PROCEDURES

Skin and subcutaneous lesions

Incise the skin with a scalpel parallel to the direction of the skin lines. Use elliptical incisions making the long axis large enough to close the skin without deformity. To accomplish this, make the long axis twice the length of the short axis and close the incision with two equally spaced sutures. For long incisions, place simple sutures at each end prior to closure. Plan the incision to avoid the need for rotation flaps, v-plasties or grafts (Figure 5.56).

Figure 5.56

Excise subcutaneous lesions after gaining access through the skin incision (Figure 5.57). Do not remove skin unless the subcutaneous mass is adherent. Epidermal inclusion cysts are subcutaneous in location but are epidermal invaginations with a visible punctum on the skin surface where they originate. Failure to remove the punctum with an elliptical incision will result in cyst rupture during excision and possible recurrence due to incomplete excision.

Figure 5.57

Lipomas, benign fatty tumours, are usually subcutaneous and often bother patients because of their inconvenient location or large size. Remove by dissecting the mass from the surrounding subcutaneous tissue. If the mass is large, it is usually difficult to close the subcutaneous tissue without deforming the skin. In this case, use a small latex drain or a pressure dressing to close the dead space instead of subcutaneous sutures.

Send all lesions for pathological examination to check for malignant tissue. Obvious lipomas, epidermal inclusion cysts and ganglions of the wrist are perhaps exceptions.

Basal cell and squamous cell carcinomas are secondary to excess exposure of sensitive skin to the sun. Nordic people and albinos are at particular risk. Because of its benign behaviour, basal cell carcinoma does not require wide excision. Squamous cell carcinoma, however, is life threatening. Treat it with wide local surgical excision.

Naevi are benign tumours of the pigment producing melanocytes; melanomas are malignant tumours from the same cell line. Both are associated with excessive sun exposure but melanomas also occur on the plantar surface of the foot. Melanoma is a life threatening malignancy. Biopsy all suspicious lesions and send to a pathologist for examination. If malignancy is confirmed, arrange for specialized surgical treatment.

Lymph node biopsy

Lymph nodes are located beneath fascia and therefore require deeper dissection than skin or subcutaneous lesion biopsies. A general anaesthetic may be required. Make a cosmetic incision in the skin lines and dissect through the subcutaneous tissue, controlling bleeding as you go. Identify the lymph node with your fingertip and incise the overlying superficial fascia. Dissect the node from surrounding tissue without directly grasping it. Instead, grasp the attached advential tissue with a small artery forceps or place a figure-of-8 suture into the node for traction. Separate all the tissue attached to the node. Control the hilar vessels with forceps and ligate them with absorbable suture after the node has been removed. If you suspect an infectious disease, send a portion of the node for culture (Figure 5.58).

Figure 5.58

Neck and thyroid

Remove skin lesions in the neck as elsewhere in the body. Lymph nodes, congenital cysts, thyroid cysts and tumours are more complex and require a qualified surgeon. Consider using a fine needle aspirate (FNA) for diagnosis of these lesions (see page 5–33). FNA is not useful in the diagnosis of lymphoma as a histological diagnosis is required. FNA of degenerative thyroid cysts is often therapeutic.

Oral cavity

Lesions of the aerodigestive tract present as a white patch (leukoplakia) which is due to chronic irritation, as a red patch (erythroplakia) which may be dysplastic or a squamous cell carcinoma in situ. Abuse of alcohol or tobacco or an immunodeficiency syndrome increases the chance of oral malignancy. Perform a complete physical examination of the head and neck, including a mirror examination of the oropharynx. Biopsy questionable lesions. Excise areas of erythroplakia and close the defect with absorbable sutures. If the lesion is large, remove a wedge of tissue including a rim of adjacent normal tissue.

Eye

Chalazion is a chronic inflammatory cyst 2–5 mm in size within one of the tarsal glands of the eyelid. Surgery is indicated if the swelling is long-standing and does not respond to local medical treatment. The condition sometimes recurs in adjacent tarsal glands. After establishing topical anaesthesia with 0.5% tetracaine, inject 1–2 ml of 2% lidocaine around the chalazion through the skin. Apply the chalazion clamp with the solid plate on the skin side and the fenestrated plate around the cyst, tighten the screw, and evert the lid. Incise the cyst at right angles to the lid margin and remove its contents with curettes (Figure 5.59). Remove the clamp and apply pressure on the lid until bleeding stops. Apply antibiotic eye ointment, and dress the eye with a pad and bandage. Apply ointment daily until the conjunctiva heals.

Figure 5.59

Do not treat small pterygia. If the pterygium extends to the central optical zone of the cornea, consider consultation with an opthalmologist.

Breast biopsy

Breast biopsy is indicated for palpable breast masses and non-palpable lesions visualized on mammography. Excise palpable lesions under local anaesthesia. Non palpable lesions require a specialized surgical technique with the radiological facilities for lesion localization. Treat breast cysts with needle aspiration. If there is a residual tumour noted after cyst aspiration, follow with an excisional biopsy.

Needle aspiration

Use FNA and cytology to make the diagnosis of malignancy in solid tumours of the breast. Insert a 21-gauge needle into the mass and aspirate several times; remove it from the tumour. Take the needle off the syringe and fill the syringe with several millilitres of air. Return the syringe to the needle and use the air to empty the cells within the needle on to a slide. Fix the cells using cytospray or as directed by your local pathologist. (Figure 5.60).

Figure 5.60

A positive result confirms malignancy while a negative result is non-diagnostic and may be due to sampling error. Repeat the procedure or perform an open biopsy if the result is negative.

Needle biopsy

Needle biopsy is similar to FNA except a core of tissue is removed from the lesion. This is a good method to confirm the clinical impression of a malignancy but, like all needle procedures, is valid only when malignancy is confirmed. (Figure 5.61).

Figure 5.61

Open biopsies

Use excisional or incisional biopsies to obtain breast tissue for histological examination. Place the skin incision in the skin lines. Curvilinear circumareolar incisions give the best cosmetic results but, when making the biopsy approach, consider subsequent surgery, mastectomy or wide excision.

Excisional biopsies

Remove the entire tumour and a rim of normal tissue. This is therapeutic for benign lesions.

Incisional biopsies

Use in large tumours when only a portion of the tumour is being removed. Avoid a biopsy of necrotic tumour as it will be non-diagnostic.

Close deep layers with absorbable sutures and skin with non-absorbable sutures. Subcutaneous sutures may improve the appearance of the final incision. Place a small latex drain at the site and bring it out through the incision. Remove it at 48 hours.