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).
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.
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
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.
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.
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.
Do not treat small pterygia. If the pterygium extends to the
central optical zone of the cornea, consider consultation with
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.
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).
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 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
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.
Remove the entire tumour and a rim of normal tissue. This is
therapeutic for benign lesions.
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.