SURGICAL REMOVAL OF SKIN OBSTRUCTIONS print home print home
Some skin lesions require surgical removal because they are or may become malignant, or because the nature of the lesion is unclear. This is performed under local anesthesia at the dermatology clinic.

BEFORE THE PROCEDURE

• Before the surgery, tell your doctor about all your medications. It is especially important to know if you are taking any blood thinners. Examples of blood thinners include Sintrom (acenocoumarol), Marcoumar (phenprocoumon), Ascal, aspirin (calcium carbasalate), Plavix (clopidogrel), prasugrel, ticagrelor, dipyridamole, eptifibatide, tirofiban, and abciximab.
• You must also inform us if you have a pacemaker or ICD (Internal Cardiac Defibrillator), or if you are allergic to antibiotics, local anesthetic, rubber, latex, or plasters.
• If possible, avoid making an appointment shortly before a holiday (to allow time for the wound to heal and any stitches to be removed).
• You can have breakfast or lunch before the procedure.
• For facial treatments, do not wear makeup or earrings. Leave jewelry at home. Wear comfortable, easily washable clothing that doesn't mind a little blood splatter. For head surgeries, be aware that pressure bandages or large adhesive bandages may be necessary. Bandages can be concealed with scarves, hats, caps, and sunglasses.
• If possible: have someone accompany you; do not go home by bike or car on your own.
• If you smoke: it's wise to avoid smoking or reduce it for one week before and up to four weeks after the procedure to promote wound healing. Smoking constricts blood vessels, which causes wounds to heal poorly.
• Alcohol has a vasodilatory effect: do not drink too much alcohol the first day after the procedure.
• NSAID painkillers such as ibuprofen, naproxen, aspirin, etc. increase the risk of postoperative bleeding. Do not take these on the day of surgery. Paracetamol is permitted.
• You can continue taking blood thinners. In the past, blood thinners were often stopped before surgery. Nowadays, the policy is to no longer stop them for minor surgical procedures.
Surgery for someone taking blood thinners is more difficult, involves more blood flow, can take longer, and carries a higher risk of postoperative bleeding. Nevertheless, blood thinners are no longer routinely stopped, as it is assumed that you were prescribed them for a reason.
If your dermatologist advises you to stop taking blood thinners before the procedure, first consult with the doctor who prescribed them (your general practitioner, cardiologist, neurologist, internist, or vascular surgeon), or with the thrombosis service, to determine whether you are allowed to stop taking them.
• If you are unable to attend your appointment, please let us know as soon as possible.

THE PROCEDURE: WHAT WILL HAPPEN?

• You will take a seat on the treatment table. The abnormality will be examined in good lighting.
• First, the area to be removed is marked with a marker. The area itself must be removed, as well as a small border of healthy skin around it. The size of this border depends on the type of skin lesion (see below).
• The skin is cleaned with a bactericidal liquid (chlorhexidine in alcohol solution).
• The entire area is then numbed by injecting anesthetic fluid at several points outside the marked area. These injections may be painful, but you will feel no pain afterward.
• A surgical drape is placed around the area to be removed.
• The skin is incised along the marked area and the piece of skin is detached from the subcutaneous fatty tissue.
• The piece of skin is removed and usually sent to the laboratory for further examination.
• Small bleeding blood vessels are cauterized. Larger vessels are closed with dissolvable sutures.
• The skin is then sutured. This is often done in two steps: first, the subcutaneous tissue is closed with dissolvable sutures, and then the skin is closed (usually with non-dissolvable sutures, sometimes with dissolvable sutures or skin glue). Non-dissolvable sutures must be removed later.
• The entire procedure takes about 30-45 minutes. Complicated or major procedures may take longer.
• For support, adhesive strips (suture strips, dovetails) are sometimes applied over the wound.
• After the procedure, the wound is dressed with a plaster and, if necessary, a pressure bandage.
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AFTER THE PROCEDURE

• Keep the plaster/bandage dry for two days. You can then remove it. You can also shower normally afterward. Do not take a bath, swim, or use a sauna, as the treated area will become too soft. If adhesive strips were used, leave them on for as long as possible. They will fall off on their own, and it's okay if they get wet. If the ends come loose and curl, cut them off.
• With skin grafts, the entire area is covered for a longer period of time. In this case, you should not remove the bandage yourself.
• The procedure site will feel stiff and numb. This may last for several hours.
• External non-dissolving stitches must be removed after an agreed-upon period. Sometimes this is after 5-7 days, sometimes they need to remain in place for two weeks. Stitches can be removed by your GP or at the Dermatology outpatient clinic. For complex sutures, you will need to return to the outpatient clinic for stitch removal and wound inspection.
• Depending on the size and location of the wound, we recommend taking it easy for two weeks: no heavy lifting, sports, or similar activities. Also be careful when dressing, undressing, and shaving.
• You'll usually have little to no pain after the procedure. If you do experience any pain, it's best to take paracetamol (500 mg four to six times a day). Do not use aspirin, ibuprofen, or similar painkillers that thin the blood unless prescribed by us. Increasing pain can be a sign of an infection (see complications).
• Bruising (contusions) may occur in the first few days. These will disappear on their own.
• The skin heals with scar formation. The scars will be more beautiful in some people than in others. For some, after a few months, they'll be completely invisible.

HOW BIG WILL THE WOUND BECOME?

This depends on the skin lesion that needs to be removed. If it's a form of skin cancer, simply excising the lesion isn't sufficient; a margin of healthy skin around it must always be included. This safety margin varies per tumor. For moles removed for examination, it's 2 mm. If it's already known to be a malignant mole (a melanoma), the safety margin is 0.5, 1, or 2 cm, depending on the thickness of the melanoma. For a basal cell carcinoma, the safety margin is 3 mm. Some basal cell carcinomas have wispy extensions, or where the extent of the basal cell carcinoma is not so clearly visible from the outside. These are removed with a 5 mm margin. Squamous cell carcinomas are removed with a 5 or 10 mm margin, depending on the type of squamous cell carcinoma.

HOW IS THE WOUND CLOSED?

This depends on the size and location of the lesion. Most skin lesions are cut out in an oval shape, after which the wound is sutured as a line. Sometimes the incision is too large to close, and a small flap is sutured in from another location (in front of the ear, behind the ear, above the collarbone). It is also possible that the wound remains partially open or that skin from the surrounding area is brought in. Sometimes the wound is left open because the tissue removed must first be examined under a microscope to ensure that the lesion has been completely removed. Only then can the wound be closed.

COMPLICATIONS

Most of the time, everything goes well, but complications can arise with any procedure. Read below to find out what could go wrong and what you should do if you do so. Contact the department if necessary.

Opening of the wound

A wound can partially or completely dehisce if the stitches break, come loose, or tear through the skin. This is especially likely to happen with thin, fragile skin (in old age or after using prednisone). This isn't a big deal; the wound will eventually heal, it just takes a little longer. No action is needed for loose stitches. It's not customary to re-stitch in such a situation. Dehiscence can be prevented by applying additional reinforcements such as special adhesive strips (dovetails). And you can help yourself by taking it easy and avoiding movements that put extra stress on the wound.

Post-operative bleeding

After a procedure, post-operative bleeding can occur. This is especially common in people taking blood thinners. Post-operative bleeding often only starts a few hours after the procedure, once the anesthetic has worn off and you're already back home. The anesthetic contains a substance that constricts the blood vessels (adrenaline) to reduce bleeding. After a few hours, this substance wears off, and the blood vessels reopen. In the event of post-operative bleeding, apply pressure to the wound with a clean bandage or clean tissue for at least 20 minutes continuously (check the time with a clock). The bleeding usually stops after this time. If the bleeding doesn't stop, contact the hospital, your GP, or the emergency room. Re-bandaging and applying a pressure bandage often help. Sometimes further measures are necessary, such as reopening the wound and tying off blood vessels. Some people return to work immediately after a procedure. This may seem daunting, but it's very unwise.

Nerve damage

Small nerve branches run throughout the skin, and these can be severed during surgery. The nerve branches that provide sensation to the skin are very thin and run very superficially. These are often severed, resulting in prolonged numbness and loss of sensation on one side of the scar (weeks to months). In addition to sensory nerves, nerves that control muscles can also be damaged. This rarely happens because they lie much deeper. It can occur with large and dangerous skin tumors, such as squamous cell carcinomas and melanomas, where a large safety margin must be maintained for healthy skin. In the face, it can occur with the facial nerve that supplies the eyelids and the corners of the mouth. Surgery is always performed with caution, but sometimes the tumors are deep and located precisely where these nerves run. Damage can cause an eyelid or a corner of the mouth to droop, and this sometimes does not heal completely, or only after many months.

Infection of the wound.

Bacteria can enter the wound. Signs of a wound infection include pain, redness, and swelling, sometimes pus oozing from the wound, a foul odor, or fever. In that case, contact the department. Antibiotics will often be prescribed. Sometimes antibiotics are prescribed preventatively, for example, in patients with a weakened immune system or for surgeries involving areas prone to infection (e.g., ears, groin, armpits).

Failure of transplants to take

For large wounds, a piece of skin from another location can be transferred to the wound, or pulled towards it. The goal is for this to heal neatly. Sometimes a piece of transplanted skin doesn't take root, or not at all. A section then becomes blue, crusty, or black. In that case, it's best to wait for spontaneous healing. Every wound eventually heals.

Ugly scar

Scars sometimes become beautiful and barely visible, and sometimes they become unsightly. This varies by procedure, location, and person. Scars on the chest and back often don't look as good, likely because the skin is constantly moving with breathing. It's important not to judge a scar too quickly. The body naturally remodels and smooths scars, but this can take up to a year.
Permanently unsightly scars can be corrected at a later stage. Some patients suffer from excessive scar formation, called keloids or scar hypertrophy. They develop thickened scars, and unfortunately, there's little that can be done about this.

TO ASK ?

In the event of an infection (increasing redness, pain, pus discharge, fever) or persistent postoperative bleeding despite 20 minutes of continuous pressure, always contact the dermatology outpatient clinic at 020-5662530 for consultation. Outside office hours, for emergencies, please contact the dermatologist on duty via the switchboard at 020-5669111, or the AMC emergency department at 020-5662222.

If you live far from the AMC, it is wiser to contact a GP out-of-hours clinic or emergency department in your area for acute problems such as postoperative bleeding.
Source: www.skin-diseases.eu 2023
18-09-2025 ( JRM ) www.skin-diseases.eu pocketbook

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