Fusiform Excision

E.J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

The fusiform excision technique is one of the most versatile and frequently used 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 often affords 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 ≤30 degrees, and the length of a proper fusiform excision is three times the width. 
The fusiform excision incorporates several important dermatologic techniques (Table 49-1). 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. 

Equipment

  • The recommended surgical tray for office surgery is listed in Appendix G. Suggested suture removal times are listed in Appendix J.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

  • Skin preparation accommodations appear in Appendix E.

Indications

  • Removal of pigmented melanocytic nevi to identify melanoma and ascertain the depth of the lesion

  • Small tumors or skin cancers that can be removed with fusiform excision

  • Incisional biopsy of a large lesion when excision is not feasible

  • Flat lesions not readily amenable to shave excision

  • Lesions on convex surfaces that are not amenable to shave excision

  • Removal of subcutaneous tumors

Contraindications (Relative)

  • Severe bleeding disorders

  • Extreme illness that would make wound healing difficult

  • Cellulitis in the tissues to be incised

  • Conditions that may interfere with wound healing (collagen vascular diseases, smoking, diabetes)

  • Concurrent medications that may increase the likelihood of intraoperative bleeding (aspirin, other nonsteroidal anti-inflammatory drugs, warfarin)

  • Uncooperative patient

 
Table 49-1.
Techniques Incorporated into the Fusiform Excision

The Procedure

Step 1

The fusiform excision should be designed so that the long axis of the fusiform parallels the lines of least skin tension (Appendix B) and with an adequate margin (Appendix D). 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. 
  • 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: Some providers want to save as much tissue as possible and draw the fusiform excision with kthe 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 often produces inferior cosmetic results.

Step 2

Perform field block anesthesia (see Field Block Anesthesia). Insert the needle within the fusiform island of skin to be excised. The operator should not create needle tracks in surrounding skin that will not be excised. Plan the anesthesia injections to create a large enough numb area to allow for undermining parallel to the long axis. Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E). 
  • PEARL: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 3

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 dermis. 
  • 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 crosshatch 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 well.

Step 4

Grasp the corner of the central fusiform island of skin with Adson forceps, and elevate the island. Use a scalpel or scissors to horizontally excise the island from the subcutaneous fat. After the lesion is cut free, immediately place the specimen in a container of formalin for histologic assessment in the laboratory. 

Step 5

Undermining can be performed with a scalpel blade, with scissors, or bluntly using a hemostat. Elevate the skin edges using skin hooks, not forceps. If pickups are used, use them only to lift and not to grasp tissue. 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. 
  • PITFALL: Elevating skin edges using skin hooks prevents the damage and subsequent scarring that often result from handling the edges with forceps.

  • PEARL: A cheap, disposable skin hook can be created by bending the tip of a 1-inch, 20-gauge needle with the needle driver.

  • PEARL: Using retractors, or using pickups as a retractor, eliminates damage to the skin edge.

Step 6

Lightly press the edges of the wound together with your fingertips. If it closes with light pressure, it is ready to suture. If it does not close with light pressure, more undermining or a tension reducing suture technique may be required. 

Step 7

Place a deeply buried subcutaneous stitch or a vertical mattress stitch to close dead space and decrease local tension if necessary. Remember that the deeply buried sutures do not evert the skin edges. Eversion can be achieved by proper placement of simple interrupted sutures or vertical mattress sutures. 
  • PITFALL: Inexperienced providers frequently are distracted by the minor bleeding (especially from facial wounds) produced by undermining. The closure of the deeper tissues using 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.

Step 8

To close the wound using the halving principle, place a suture in the center of a wound first. The next sutures are placed in the center of the remaining wound defects. This prevents uneven edges (i.e., dog ears), which can be produced when suturing from one end of the wound to the other. Clean the wound with normal saline. Antibiotic or other ointments applied to the wound immediately after the procedure help to promote more rapid and improved healing at the site. Then apply a sterile bandage. If the excision was on an extremity, gauze may be wrapped around the extremity to apply mild pressure and avoid the pain of tape removal. 

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

  • Incomplete excision of lesion

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit and lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. The maximum recommended dose for lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the patient to gently wash an area that has been stitched after 1 day but not to put the wound into standing water for 3 days. Have the patient pat dry the area thoroughly after washing, and use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain and speed healing. Instruct the patient not to pick at, break, or cut the stitches. 

Coding Information and Supply Sources

All codes listed are for superficial wound closure using sutures, staples, or tissue adhesives with or without adhesive strips on the skin surface. If a layered closure is required, use alternate codes: intermediate closure codes 12031 to 12057 or complex repair codes 13100 to 13160. 
Add together the lengths of wounds in the same classification and anatomic sites. Use separate codes for repairs from different anatomic sites. Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing or when appreciable amounts of devitalized or contaminated tissue are removed. 
If a lesion is removed, use either “Excision—benign lesion” codes (11400 to 11471) or “Excision—malignant lesion” codes (11600 to 11646). 

Bibliography

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