The fusiform excision technique is one 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 a portion of a large lesion (i.e., incisional biopsy) for histologic assessment. The major advantage is that the procedure can often afford a one-stage diagnostic and therapeutic intervention.
The fusiform technique historically has been misnamed the elliptical excision. Properly designed fusiform excisions resemble a biconcave lens rather than an oval ellipse. The corners of the fusiform excision should have angles no greater than 30 degrees, and the length of the fusiform excision is three times the width. The long axis of the wound should be aligned with the resting skin tension lines to optimize the cosmetic and functional outcome.
The fusiform excision incorporates several important dermatologic techniques (Table 12-1). The techniques are combined to reduce subcutaneous hematoma formation, prevent development of seromas beneath the wounds, and produce good cosmetic outcomes. These various techniques are illustrated in this and subsequent chapters.
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TABLE 12-1. TECHNIQUES INCORPORATED INTO THE FUSIFORM EXCISION |
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INDICATIONS
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PROCEDURE
The fusiform excision should parallel the lines of least skin tension (Figure 1A). These lines run perpendicular to the long axis of the extremities (Figure 1B) but are more complex on the face (Figure 1C). Wounds that follow (parallel) these lines are less likely to enlarge (i.e., hypertrophy or keloid) and heal faster.
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(1) The fusiform excision should parallel the lines of least skin tension. |
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Draw the fusiform excision on the skin using a skin marking pen before initiating the procedure. A properly designed fusiform excision is three times as long as it is wide.
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(2) Draw the fusiform excision on the skin using a skin marking pen before initiating the procedure. |
PITFALL: Many experienced physicians perform fusiform excision without drawing out the skin incision lines. After the sterile drapes are placed on the skin, the nearby landmarks may be covered, causing the physician to incorrectly orient the excision.
PITFALL: Many operators want to save as much tissue as possible and draw the fusiform excision with the length only two times the width. These so-called football excisions create elevations of tissue at the ends (i.e., dog ears); the attempt to excise less tissue produces inferior cosmetic results.
Perform local (or field block) anesthesia (see Chapters 9 and 23). Insert the needle within the fusiform island of skin to be excised. The operator should not create needle tracts into the surrounding skin that will remain.
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(3) Perform local or field block anesthesia. |
P.97
Create smooth, vertical skin incisions using a no. 15 scalpel. The scalpel blade is held vertically at the corner of the wound and punctures the skin using the point of the blade. The blade handle is then dropped down, and a smooth, continuous stroke is used to create the wound edge. The blade should be passed firmly enough to penetrate the entire thickness of the dermis with the first pass.
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(4) Create smooth, vertical skin incisions using a no. 15 scalpel. |
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 the incision with the blade vertical to the skin surface. Novice surgeons often angle the blade under the lesion, creating a wedge excision. Angled edges will 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 the level of the subcutaneous fat. After the lesion is cut free, immediately place the specimen in a container of formalin for histologic assessment in the laboratory.
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(5) 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 the level of the subcutaneous fat. |
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Undermining can be performed with the scalpel blade, tissue-cutting (Metzenbaum) scissors, or bluntly using a hemostat. 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 the deeper levels of the fat. To create 1 cm of wound edge relaxation, 3 cm of undermining is required. Undermine the wound corners to release any tethering at these locations.
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(6) Undermining can be performed with the scalpel blade, tissue-cutting (Metzenbaum) scissors, or bluntly using a hemostat. |
PITFALL: Novice physicians frequently are distracted by the bleeding (especially from facial wounds) produced by undermining. The closure of the deeper tissues using the deep, buried sutures almost always stops the bleeding. Physicians should move quickly to perform the deep buried closure, rather than waste time applying gauze to the wound.
PITFALL: Elevating skin edges using skin hooks prevents the damage and subsequent scarring that often result from handling the edges with forceps. A cheap, disposable skin hook can be created by bending the tip of a 1-inch, 20-gauge needle with the needle driver.
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The deeply buried subcutaneous stitch closes 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 (Figure 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 (Figure 7B). The needle then grabs a small bit of the tissue in the base of the wound (Figure 7C). The suture threads need to be on the same side (i.e., toward the operator or away from the operator) compared with the suture thread passing across the top of the wound. The two ends of the suture are pictured on the near side (Figure 7D). The knot is tied, and the suture cut free just above the knot. The knot buries into the base of the wound. (Figure 7E). Usually, a deeply buried suture is placed in the center and two ends of the wound.
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(7) The deeply buried subcutaneous stitch closes the dead space, stops subcutaneous bleeding, reduces hematoma and seroma formation, and takes all tension off the skin sutures. |
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The deeply buried sutures do not evert the skin edges. Eversion can be achieved by proper placement of simple, interrupted sutures. By pushing down on skin edges with the nondominant hand when placing the skin stitches (Figure 8A), more of the deep tissue is grasped with the vertical entry and exit of the suture needle (Figure 8B). This “Erlenmeyer flask” pass of the suture facilitates eversion when the knot is tied (Figure 8C). Eversion at the time of wound repair results in a better cosmetic outcome, because all scars retract with healing and the everted edges will become flat (Figure 8D).
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(8) Eversion can be achieved by proper placement of simple, interrupted sutures. |
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The principle of halving states that sutures should be placed in the center of a wound edge first and the next sutures placed in the center of the remaining wound edges. This prevents uneven edges (i.e., dog ears), which can be produced when suturing from one end of the wound to the other.
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(9) The principle of halving states that sutures should be placed in the center of a wound edge first, and the next sutures should be placed in the center of the remaining wound edges. |
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.
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(10) Apply antibiotic or other ointments to wound immediately after the procedure to promote rapid and improved repair at the site. |
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CODING INFORMATION
The 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 the proper billing code. The codes listed below include full-thickness excision and simple, one-layer closure. If two 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).
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INSTRUMENT AND MATERIALS ORDERING
The recommended surgical tray for office surgery is listed in Appendix A. Suggested suture removal times are listed in Appendix C. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation acommodations appear in Appendix H.
BIBLIOGRAPHY
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