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SKIN SURGERY

Removal of skin lesions and correction of scars

Reparative surgery:
This document has been conceived under the authority of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOFCPRE).

DEFINITION

The term of skin surgery or dermosurgery is used for surgical procedures that involve to the skin. Thus, are concerned all lesions (abnormalities) cutaneous (skin), which surgical removal is preferred, as well as abnormal or unsightly scars that require surgical treatment.

OBJECTIVES

For skin lesions, we can distinguish three cases:

Malignancies: cancers of the skin should be removed because, of course, surgery is often the only treatment that permits to obtain a complete cure. The goal is to remove entirely the lesion, allowing a "safety margin” that is passing off on the sides and depth, to give every chance to avoid a recurrence. What has been removed will be routinely subjected to a pathological examination (microscope) to confirm the diagnosis and to corroborate the fact that the lesion was removed entirely.

Suspicious lesions: a simple visual examination of a lesion does not always allow affirming if the lesion is benign or malignant. In this case, surgical removal will aim to bring the lesion to a pathological examination, which would be the only way of confirming the diagnosis.

Benign lesions: some initially benign lesions (such as some "moles") can sometimes transform and progress to malignancy; it is logical to remove them preventively.

Other benign lesions can be removed merely because they are embarrassing, or because of friction or irritation, or for purely aesthetic reasons.

For the scars

It is impossible to completely remove a scar, whether by surgery or by other means (ointments, tattoos, peeling, lasers).

The purpose of revision surgery is to replace a vicious scar (having a defect or anomaly) with a new scar that hopefully would be less burdensome and more discrete. In most cases, only scars stabilized at the end of their natural course (6 months to 2 years) can be treated. In addition, an attempt of surgical correction is permissible only in the following cases:

Retractile scars: very indurated and "curled up", not allowing to be stretch, very unsightly and can sometimes limit certain movements.

Ulcerative scars: their frailty leads to frequent superficial "scrapes", which become permanent, and grow worse.

Hypertrophic scars and keloids: inflammatory, painful, red, swollen, enlarged, and "with relief". Their treatment is very delicate and subject to frequent recurrences.

Non-aesthetic scars: large, colourful, irregular, staggered, sunken and adherent.

It should be noted that treatment of normal scar but simply expanded (a common case) is very uncertain because the enlargement is often due to a patient-specific disorder of wound healing and independent of the surgical technique.

PRINCIPLES

You should know that when surgery penetrates the skin, whatever technique is used to sew or repair it, leaves a scar that can not disappear completely.

The only lesion inflicted to the skin that disappear without leaving any scar are those that concern only the most superficial layer of the affected skin, that is the epidermis.

When an incision run through the dermis, that is to say, the deep part of the skin, and regardless of the surgeon and the quality of care provided by him, the surgery leaves a scar which certainly will diminish, becoming more or less discrete, but never will be completely invisible.

For skin lesions

The aim is to entirely remove the lesion with a margin of safety for malignant lesions which magnitude depends on the type of lesion, and to obtain a scar as discrete as possible.

The basic principle is the elliptical removal followed by a direct suture by approximation of the edges. The integration of the area to be removed in an ellipse (see Figure 1) is essential to prevent the formation of folds at the ends of the scar at the closing, but result in a scar that is larger than the diameter of the initial lesion. In this regard, we must know that if most often the scar is bigger than the initial injury, the fact is that lengthening a scar reduces the tension on each of its edges, this way permitting to obtain in the long-term the best aesthetic result possible.

Also, to obtain a discrete scar will be favoured by the orientation of the incision in the axis of natural folds of the skin (see Figure 2) and an impeccable suture technique.

In cases where the size or location of the lesion render impracticable the closure by direct suture, the covering of the removed area will be provided either by a skin graft taken from another region or by a local plasty, which corresponds to the movement a flap of skin around so that it comes to cover the skin defect (see Figure 3). The scarring from this type of flap is of course more important but, realized in the rules of the art, the aesthetic results will be, in the long-term, often better than a transplant.

In all cases, your surgeon will explain what is the best solution adapted to your personal case.

For scars

In the simplest cases, simply excising the defective scar and closing it with a perfect suture technique in the hope to get a more discreet new scar.

Often, it is necessary to resort to a special path of incision to "break" the main axis of the initial scar and redirect it to a better scar according to the skin natural tension lines, and decreased the strain exerted on the edges of the wound.

For very large scars, several techniques can be used, alone or in combination:

Multistage excisions, to allow the skin to relax between two operative times (so-called principle of iterative excision)

Skin grafts taken from another region

Local plasty(flaps), with displacement of a flap of skin around, so that it comes to cover the scar area

Skin expansion, done with inflatable balloons placed under the surrounding healthy skin, for gradually stretching (several weeks) to use the excess skin obtained after the removal of the balloon to cover the scar area.

Also, your surgeon will explain you the best solution adapted to your personal case.

BEFORE THE OPERATION

Your surgeon will complete an interrogation followed by an examination of the offending skin lesion or scar, to specify the different surgical options.

In cases of anaesthesia other than purely "local", a pre-anaesthetic check-up can be prescribed and a preoperative consultation must be scheduled with the anaesthesiologist.

Smoking cessation is recommended, one month before and one month after the intervention (smoking can cause a delay of healing).

No medication containing aspirin should be taken within 10 days prior to surgery.

Depending on the type of anaesthesia, you may be asked to fast (not eat or drink) 6 hours before surgery.

TYPE OF ANAESTHESIA AND HOSPITAL STAY

Type of anaesthesia

Three methods are possible:

Local anaesthesia, an analgesic product is injected to ensure the insensitivity of the surgical area. This is the most common case for basic dermatological surgery.

"Vigil" anaesthesia (local anaesthesia deepen by tranquilizers), during which you can stay awake or relaxed but which may result in some amnesia of the procedure. It may be preferred for reasons of personal comfort or when using some complex flaps, especially on the face.

General classic anaesthesia, in which you sleep completely, in fact rarely used in dermatological surgery.

The technique will be chosen after a discussion between you, your surgeon and the anaesthesiologist.

Hospital stay

Basic dermatosurgical interventions, especially if they are performed under local anaesthesia, does not necessarily require hospitalization and may, like dental care, be made in the office, to the extent that all necessary equipment is available.

If the intervention is performed in a clinic or hospital, it can usually be do in an external basis, that is to say, with an admission just before the operation and the discharge just after it, or as outpatient, that is to say, a day hospitalization with a same-day discharge after a few hours of monitoring.

The traditional hospitalization, spending one night in the hospital is exceptional for this type of surgery.

AFTER THE OPERATION: POSTOPERATIVE CARE AND FOLLOW-UP

Some discomfort with a feeling of tension on the scar may be seen, but actual disabling pain is rare.

The first days it is important not to "force" on the scar. Caution should be exercised relative to the movements that would force the surgical area.

In the hours after surgery, a slight oozing of blood (red) or lymph (yellow) can possibly lightly stain the dressing. In the first 48 hours, the operated area can also sometimes reveal an edema (swelling) and small bruises (blues) that are only transitory.

The itching is also quite common during the healing phase. All these findings are disturbing and should be considered as "normal" consequences.

The sutures, when they are not absorbable, are removed between the 5th and 15th day.

The scar could be then massaged, as instructed by your surgeon.

Regarding the usual scar evolution, it should be noted that initially the scar is usually red or pink, then it may turn brown and become fibrous, indurated, before enlighten and soften in a few weeks to months, most often beyond the third month after the intervention.

Concerning sun exposure, while the scar is still dark it is better to avoid any sun exposure and to use a total sun block.

THE RESULT

A delay of several months (sometimes up to one to two years) is needed before assess the final appearance of the scar.

It is necessary to understand that healing is a random phenomenon whose quality cannot be guaranteed. The perfect technical mastery of a qualified plastic surgeon specifically trained for this type of intervention will bring all the odds in your favour but do not remove completely this randomness.

As part of surgical correction of abnormal scarring, it is essential to regularly monitor the evolution and appearance of the scar. It is the only way to be sure that the potential healing problems will be identified in time in order to apply appropriate treatment.

POTENTIAL PROBLEMS

Although every effort is implemented during and after the intervention to make the scars inconspicuous, sometimes the healing wont take place according to the amount of effort taken, and that the resulting sequelae are more visible than what was hoped. Indeed, the quality of healing is eminently variable according to age, body parts, environmental factors, and one patient to another. This is due, as we have seen, by the fact that the healing process involves quite random phenomena, sometimes unpredictable and imperfectly controlled. In this regard, we must not forget that if it is the surgeon who carries out the sutures, the scar, it is the fact of the patient. The occurrence of an unsightly scar, however, must be submitted to your surgeon as it may lead to considering the use of certain treatments.

After removal of a malignant skin lesion, histological examination under a microscope can sometimes conclude that the safety margin at its periphery has been insufficient and that the lesion, where the boundaries are blurred and sometimes very difficult to determine precisely by naked eye, would therefore can not be removed entirely or with a safety margin. Revision surgery to remove any remaining tumour or to spend more of the former lesion is usually needed.

Even if the removal of a lesion was considered complete, including the pathological examination, sometimes, even years later, a "recurrence" of the local lesion can happen. This is explained by the fact that some lesions are "multifocal", that is, they have several developing buds, some of which may be small, undetectable during the first intervention, and not contiguous with the main lesion. They may be spared initially and then develop on their own.

POSSIBLE COMPLICATIONS

Dermatological surgery includes “surface” surgery that concern only the skin and are therefore are not very "heavy". They have however, like any medical procedure no matter how minimal is, a number of uncertainties and risks.

Choosing a qualified and competent Plastic Surgeon, trained specifically for this type of techniques, you may limit at maximum the risks, although they don’t disappear completely.

Fortunately, significant complications are rare following skin surgery performed according the rules. In practice, the vast majority of interventions go without any problem and patients are fully satisfied with their operation.

However, despite their rarity, you should know the possible complications:

Anaesthetic complications: we must be aware that any anaesthesia whatsoever (even local) induce reactions in the body sometimes unpredictable and more or less easy to control. It is unnecessary and impossible to mention all these complications, but we encourage you to discuss with the anaesthesiologist (if it is the case) during the preoperative consultation and ask him on that occasion, all the information you deem necessary. However, keep in mind that the techniques, anaesthetic drugs and monitoring methods have made great progress these past years, and that the risks have become almost negligible, especially when the operation is carried out not in an emergency basis and in a person free from any disease When it comes to local anaesthesia the very rare reactions are often limited to a simple little minor discomfort.

Small bleeding: it can occur even several days after surgery. They are usually easy to control.

Haematoma: most of the time without gravity may need to be evacuated if is too important.

Infection: may be linked to a form of intolerance to the sutures or be favoured by the presence of small haematomas. It is manifested by intense pain and localized redness with purulent discharge. The use of antibiotics or simple local care, permits, most of the time, to solve the problem, sometimes with adverse consequences on the quality of the scar.

Skin necrosis: it is a death of the skin because a defect of its blood supply. It is exceptional and occurs only in extreme cases of tension on the edges of the scar or in the realization of a flap with precarious blood suppl. It can sometimes complicate a haematoma or infection. It is clearly favoured by smoking. It undermines the very aesthetic result.

Failure of take: the success of a graft is never 100% certain. Sometime a necrosis of the graft can happen, mostly partial.

Abnormal wound healing: beyond the already noted unsightly scars, usually focus on the very rare but dreadful real keloid scars, whose treatment is very delicate and often disappointing.

Injury to nearby nerves: most often are concerned the sensory nerves that, leading to a localized disorder of the sensitivity (anaesthesia, tingling). Exceptionally in the face, it can be a motor branch, leading to a partial paralysis of the concerned facial part (for instance, of the forehead). Fortunately most of the time these problems are transient and disappear spontaneously in a few weeks.

All things considered, the risks must not be overestimated, but you must be conscious that an operation, even a minor one, always has some degree of unforeseeable unknown factors.

You can be assured that if you are operated on by a qualified Plastic Surgeon, he will have the experience and skill required to avoid these complications, or to treat them successfully if necessary.

These are the facts that we wish to bring to your attention, to complement what you were told during the consultation.

Our advice is for you to keep this document and to read it and think it over carefully after your consultation.

Once you have done this you will perhaps have further queries, or require additional information.

We are at your disposal should you wish to ask questions during your next consultation, or by telephone, or even on the day of the operation, when we will meet in any case, before the anaesthesia.


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Authorization for reproduction of March 10, 2009, for: MCEI (www.chirurgiens-plasticiens.info).


This factsheet has been designed under the auspices of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOF.CPRE) as a complement to your first consultation; to try to answer any questions you can ask yourself if you intend to use a surgical lipo-filling.

The purpose of this paper is to bring you all the information necessary and essential for you to make your decision with full knowledge of the facts. So is it advisable to read with the greatest attention.