Topic

• Introduction
• Indications
• Procedure
• Coding Information

Table(s)

• Techniques Incorporated into Fusiform Excision

Figure(s)

• Lines of Least Skin Tension
• Drawing the Fusiform Excision
• Performing Anesthesia
• Skin Incision
• Cutting the Lesion
• Undermining the Wound
• Deeply Buried Subcutaneous Stitch
• Eversion of the Skin Edges
• Principle of Halving

• 1 of the most versatile office surgery procedures. The technique is used to remove benign and malignant lesions on or below the skin surface.
• The technique can be used to remove lesions entirely (i.e., excisional biopsy) or to remove portion of large lesion (i.e., incisional biopsy) for histologic assessment. The major advantage is that the procedure can often afford 1-stage diagnostic and therapeutic intervention.
• Historically has been misnamed elliptical excision. Properly designed fusiform excisions resemble a biconcave lens rather than an oval ellipse. The corners of a fusiform excision should have angles not >30 degrees, and the length of a fusiform excision is 3 times width. The long axis of the wound should be aligned with resting skin tension lines to optimize the cosmetic and functional outcome.
• Incorporates several important dermatologic techniques (Table 12-1). Techniques are combined to reduce subcutaneous hematoma formation, prevent development of seromas beneath wounds, and produce good cosmetic outcomes.

• Removal of pigmented melanocytic nevi to identify melanoma and ascertain depth of lesion
• Small tumors or skin cancers that can be removed with fusiform excision
• Incisional biopsy of large lesion when excision is infeasible
• Flat lesions not readily amenable to shave excision
• Lesions on convex surfaces that are not amenable to shave excision
• Removal of subcutaneous tumors

• Fusiform excision should parallel the lines of least skin tension (Fig. 12-1A). These lines run perpendicular to the long axis of the extremities (Fig. 12-1B) but are more complex on the face (Fig. 12-1C). Wounds that follow (parallel) these lines are less likely to enlarge (i.e., hypertrophy or keloid) and heal faster.
• Draw a fusiform excision on the skin using a skin marking pen before initiating the procedure (Fig. 12-2). A properly designed fusiform excision is 3 times as long as it is wide.
• Pitfall: Many experienced physicians perform fusiform excisions without drawing out skin incision lines. After sterile drapes are placed on skin, the nearby landmarks may be covered, causing the physician to orient the excision incorrectly.
• Pitfall: Many operators want to save as much tissue as possible and draw a fusiform excision with the length only 2 times width. These so-called football excisions create elevations of tissue at the ends (i.e., dog ears); an attempt to excise less tissue produces inferior cosmetic results.
• Perform local (or field block) anesthesia (see Chap. 9, Local Anesthesia Administration, and Chap. 23, Field Block Anesthesia) (Fig. 12-3). Insert needle within the fusiform island of skin to be excised. The operator should not create needle tracts into the surrounding skin that will remain.
• Create smooth, vertical skin incisions using a no. 15 scalpel (Fig. 12-4). Scalpel blade is held vertically at the corner of the wound and punctures skin using the point of the blade. The blade handle is then dropped down, and a smooth, continuous stroke is used to create wound edge. Pass the blade firmly enough to penetrate the entire thickness of the dermis with the first pass.
• Pitfall: Many inexperienced operators make a short pass with the scalpel, stop to inspect the incision, and then make an additional short pass. This creates cross-hatch marks and an irregular skin edge. Smooth, confident passes with the scalpel avoid jagged edges.
• Pitfall: Create incision with the blade vertical to the skin surface. Novice surgeons often angle the blade under the lesion, creating a wedge excision. Angled edges do not evert; create wound edges that are vertical.
• Grasp the corner of the central fusiform island of skin with Adson forceps and elevate the island as the scalpel passes horizontally beneath the lesion in level of subcutaneous fat (Fig. 12-5). After the lesion is cut free, immediately place the specimen in a container of formalin for histologic assessment in the lab.
• Undermining can be performed with a scalpel blade, tissue-cutting (Metzenbaum) scissors, or bluntly using hemostat (Fig. 12-6). Elevate the skin edges using skin hooks, not forceps. The safest level of undermining is in the fat, just below the dermal-fat junction, to avoid damaging nerves that traverse deeper levels of fat. To create 1 cm of wound edge relaxation, 3 cm of undermining is required. Undermine wound corners to release any tethering at these locations.
• Pitfall: Novice physicians frequently are distracted by bleeding (especially from facial wounds) produced by undermining. Closure of deeper tissues using deep, buried sutures almost always stops bleeding. Physicians should move quickly to perform deep buried closure rather than waste time applying gauze to the wound.
• Pitfall: Elevating the skin edges using skin hooks prevents damage and subsequent scarring that often result from handling edges with forceps. A cheap, disposable skin hook can be created by bending the tip of a 1-in., 20-gauge needle with a needle driver.
• A deeply buried subcutaneous stitch closes the dead space, stops subcutaneous bleeding, reduces hematoma and seroma formation, and takes all tension off the skin sutures. The suture begins in the center of the wound and passes beneath the left wound edge to pass back into the center of the wound through the dermis (Fig. 12-7A).
• The needle is placed upside-down and backward into the needle holder. It passes through the dermis into the right wound edge and passes down to the base of the wound (Fig. 12-7B). The needle then grabs a small bit of tissue in the base of the wound (Fig. 12-7C).
• Suture threads need to be on the same side (i.e., toward operator or away from operator) compared with suture thread passing across top of wound. The 2 ends of the suture are pictured on the near side (Fig. 12-7D). The knot is tied, and the suture cut is free just above the knot. The knot buries into the base of the wound. (Fig. 12-7E). Usually, a deeply buried suture is placed in the center and 2 ends of the wound.
• Deeply buried sutures do not evert skin edges. Eversion can be achieved by proper placement of simple, interrupted sutures. By pushing down on the skin edges with the nondominant hand when placing skin stitches (Fig. 12-8A), more of the deep tissue is grasped with vertical entry and exit of suture needle (Fig. 12-8B). This "Erlenmeyer flask'' pass of the suture facilitates eversion when the knot is tied (Fig. 12-8C). Eversion at the time of wound repair results in a better cosmetic outcome, because all scars retract with healing and everted edges become flat (Fig. 12-8D).
• The principle of halving states that sutures should be placed in the center of the wound edge first and next sutures placed in the center of the remaining wound edges (Fig. 12-9). This prevents uneven edges (i.e., dog ears), which can be produced when suturing from 1 end of wound to the other. Antibiotic or other ointments applied to the wound immediately after the procedure help to bathe the wound with "healing juices'' that promote more rapid and improved repair at the site.

• Coding of excision of lesions is determined by the size and location of the lesion. Excision of malignant lesions often yields higher reimbursement than the exact same procedure performed on benign lesions. When a lesion of uncertain nature is excised, it is often beneficial to wait until the pathology report returns before selecting proper billing code.
• The codes listed below include full-thickness excision and simple, 1-layer closure. If 2 layers of closure are required (i.e., deeply buried subcutaneous suture placement), intermediate closure can also be billed. Excision of hidradenitis or skin tags and excision associated with reconstructive or flap closure are billed using alternate codes.
• The billing chart cites the following locations: trunk, arms, and legs (TAL); scalp, neck, hands, feet, and genitalia (SNHFG ); and face, ears, eyelids, nose, lips, and mucous membranes (FEENLMM).

Benign Lesions

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Malignant Lesions

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