Excisions

Dermatologic excision surgery involves the surgical removal of a targeted skin lesion or growth, often accompanied by the removal of a small margin of surrounding healthy tissue. This approach ensures thorough treatment while minimizing recurrence and preserving skin aesthetics and function. The procedure is performed under local anesthesia and is used to treat a range of skin conditions.

After the excision, the area is carefully sutured to promote optimal healing. For larger excisions, advanced closure techniques, such as skin grafts or flaps, may be utilized to enhance cosmetic outcomes.

Dermatologic excision surgery is an essential treatment option for a wide range of conditions, including:

• Skin Cancer: Basal cell carcinoma, squamous cell carcinoma, and melanoma
• Precancerous Lesions: Actinic keratoses with foci of early skin cancer or moderately and severely dysplastic moles
• Benign Lesions: Cysts, lipomas, keloids, large scars and other benign growths
• Cosmetic Concerns: Raised benign moles, benign skin tumors, or other skin irregularities causing aesthetic dissatisfaction or physical discomfort

There are several types of dermatologic excision surgeries, each tailored to the nature of the skin lesion being treated:

• Biopsy: A biopsy is a surgical procedure that removes a small sample of the skin for examination under a microscope to determine the skin condition or disease. It is used to confirm or rule out skin cancer and determine the cause of a rash or infection. Depending on the size and depth of the lesion, a biopsy may be performed as a shave biopsy (a “scraping”, punch biopsy (2-4mm circular punch removal of a cylinder of skin) or excisional biopsy. An excisional biopsy removes the entire lesion with some normal skin and stitches are typically needed to close the wound. At Palo Alto Dermatology Institute, we have the education and training to diagnose skin cancers and benign lesions with a variety of biopsy techniquesand complete definitive treatment on the same day or a few days later.
• Excision with permanent margins: A permanent margin excision is a surgical procedure in which a lesion, such as a suspicious atypical mole, tumor, or skin cancer, is removed along with a surrounding margin of healthy tissue to ensure complete excision of the abnormal cells. The term “permanent margin” refers to the careful and thorough pathological examination of the tissue removed during the procedure at an outside dermatopathology laboratory to confirm that all the abnormal or cancerous cells have been completely excised. This pathological examination takes anywhere from 3 to 7 days. This procedure is used treat melanoma where achieving clear margins is crucial to preventing recurrence or spread and frozen tissue techniques are less commonly employed.
• Excision with frozen margins: A frozen section excision is a surgical procedure in which a lesion is removed with a margin of healthy tissue and the removed tissue is examined immediately at Palo Alto Dermatology Institute with frozen tissue instead of permanent tissue. The frozen section analysis takes place in less than 30 minutes and will confirm whether the abnormal or cancerous cells are removed. If the margin is positive, an additional excision of skin can be performed and retested with frozen sections. Once the frozen tissue examination shows no residual tumor, the defect can be sutured closed. Excision with frozen sections ensures a high cure rate prior to the closure of the excision. In contrast, excision with permanent sections may require a follow-up surgery if the margins are reported to still have cancer cells.
• Mohs Micrographic Surgery: A highly specialized excision technique primarily used for skin cancers like basal cell carcinoma or squamous cell carcinoma, offering the highest cure rate with minimal sacrifice of normal skin. This excision technique is performed by a Mohs surgeon who is a specially-trained combination of a dermatologist, dermatopathologist and reconstructive surgeon. In Mohs surgery, the excision is studied with frozen sections where 100% of the excision margin is examined resulting in the highest possible cure rate.  Excisions with permanent margins and excision with frozen margins examine a much smaller amount of the margin and has a slightly lower cure rate. Mohs surgery is the treatment of choice for head, neck, hand, foot and shin skin cancers. For more information, see the Mohs surgery page.

The procedure typically begins with a sterile preparation of the skin and the application of local anesthesia to ensure comfort. Once the area is numb, the dermatologic surgeon removes the lesion along with a small margin of healthy tissue to ensure complete excision. For certain lesions, such as skin cancers, the tissue is evaluated in our laboratory with frozen sections by Mohs surgery for the most accurate pathological analysis to confirm clear margins. After the excision, the area is carefully sutured to in multiple layers to promote optimal healing. For larger excisions, advanced closure techniques, such as flaps and skin grafts, may be utilized to enhance cosmetic outcomes.

Recovery from dermatologic excision surgery is generally straightforward:

• Wound Care: Patients are provided with detailed instructions for cleaning and protecting the surgical site to minimize the risk of infection.
• Healing Time: Most small excisions heal within 1-2 weeks, while larger or more complex procedures may take several weeks.
• Scar Management: Scar appearance is minimized through meticulous suturing techniques and follow-up care, which may include silicone gel or laser treatments.
• Activity Restrictions: Patients are advised to avoid strenuous activities that may stress the surgical site during the initial healing period of 7  to 14 days.

You will receive pre- and post-operative instructions on how to care for the wound. It is essential to follow those instructions to ensure proper healing and prevent scarring.

Palo Alto dermatology Institute offers the broadest range of excision techniques in Northern California for skin cancers that both meet and do not meet Mohs Appropriate Use Criteria so that the highest cure rate can be obtained for ALL skin cancers.