Excisional Surgery: Margins, Closure Techniques

Overview / Definition Excisional surgery refers to the surgical procedure where a lesion is removed along with a margin of surrounding healthy tissue. This technique is commonly employed for skin cancers, benign lesions, and other dermatological conditions requiring complete excision. The primary goal is to achieve clear margins while maintaining function and aesthetics. Epidemiology Skin cancer is the most prevalent type of cancer in the United States, with over 5 million cases treated annually. The most common types necessitating excisional surgery include: Basal cell carcinoma (BCC) - accounts for approximately 80% of skin cancers. Squamous cell carcinoma (SCC) - represents about 16% of skin cancers. Melanoma - while less common, it is significantly more lethal. Pathophysiology / Mechanism The pathophysiology underlying the need for excisional surgery varies by lesion type but generally involves uncontrolled cellular proliferation. For malignant lesions, such as melanoma and non-melanoma skin cancers, excision is critical to remove not only the tumor but also any potential microscopic extensions into surrounding tissues. Clinical Presentation Lesions requiring excisional surgery may present in various forms: Asymptomatic nodules - often seen in BCC and SCC. Ulcerated or bleeding lesions - common in advanced skin cancers. Changing moles - particularly concerning for melanoma. Diagnosis / Workup The diagnosis typically involves: Clinical examination - assessing lesion characteristics. Dermatoscopy - enhancing visualization of skin lesions. Biopsy - excisional or punch biopsy for histological confirmation. Treatment / Management The management of lesions requiring excisional surgery involves several critical steps: Preoperative assessment - evaluate patient comorbidities and medications. Marking the excision margins - adequate margins are crucial; typically, 3-5 mm for BCC and SCC, and 1-2 cm for melanoma. Excision technique - use of scalpel or electrosurgery. Closu