Dermatologic surgery includes all those procedures outpatient dermatological, in particular:
- Removal nevi and other cutaneous benign lesions
- Removal of skin tumors
- Removal of cysts
- Removal of lipomas
- Removal of vascular tumors
This surgery is performed under local anesthesia. Few milliliters of anesthetic are usually necessary. These dosages has no systemic effect and allergic reactions are extremely rare. The anesthetic effect lasts for 2-6 hours depending on the molecule, thus providing a good analgesia in the postoperative. In the following hours pain is minimal, paracetamol and nimesulide are adequate for analgesia.
The procedure lasts few minutes, typically 10-20 minutes depending on the size and the anatomic site.
In case of small lesions, after removal the reconstruction is performed by direct suturing of the wound margins. In this case the length of the scar is 2-2.5 times the length of the lesion.
When direct closure is not possible due to the size of the defect or to the excessive profile distortion, it is possible to perform a local flap or a skin graft. The surgical strategy should be discussed with the patient to achieve an optimal and tailored solution.
Under optimal conditions healing requires one week in the face, two weeks in the trunk and two-three weeks in the lower limb. Sports and heavy physical activities could be resumed in 21 days. Scar consolidation requires a longer time, usually one year. Therefore the scar achieves its final aspect in this time span. During this period is essential to maintain a complete scar photoprotection to prevent uneven pigmentation of the scar (if sun exposure is expected in this period is sufficient to apply a SPF 50 sunscreen on the scar).
Laser removal - my philosophy
The use of lasers to ablate skin lesions is unfortunately widespread. The practitioners that promote this strategy underline the benefits (especially related to a reduced scar) minimizing the disadvantage of this procedure: the inability to have an histological examination. In fact lasers "burn" the lesion, eliminating the possibility to know what has been ablated and informations concerning radicality. Unfortunately often the clinical appearance of skin lesions does not coincide with the histological diagnosis: not-pigmented melanoma can be confused with benign lesions, as well as others skin tumor may appear as trivial spots.
Histological examination is therefore appropriate in most cases and only surgical excision allows this analysis.
The scar produced by simple removal and direct closure is a line. Usually internal sutures are used and their removal is not necessary. In specific areas of the body t is possible to use external stitches (e.g. area under tension, like the lower limb).
In case of hypersensitivity to absorbable suture materials, not-resorbable and inert materials should be employed (such as nylon or polypropylene). These sutures should be removed after 1-2 weeks.
The process of wound healing is extremely variable and subjective and the quality of the scar is somehow unpredictable: some patients may develop hypertrophic scars (raised and erythematous lesion all over the scar) or keloids (same lesion but exceeding the size of the primary scar).
Scar is usually erythematous for the first 6 months after surgery. In 12 months it becomes gradually clearer, similarly to the color of the surrounding healthy skin.
In the first two weeks after surgery, any stress on the scar should be avoided (sports and any other physical activity) to prevent scar widening (diastasis) due to the reduced tensile strength of the scar in this delicate time span.