Excision Techniques, Staples, and Sutures

  • Mollie A. MacCormack


Excisions are one of the most commonly performed dermatologic procedures. It is estimated that more than 650,000 excisions are performed each year in the United States, with dermatologists accounting for about 58% of this number.1 Excisions are performed for a variety of reasons including diagnosis, the therapeutic removal of malignant and benign growths, as well as simply for improved appearance. While the vast majority of excisions are straightforward in nature, close attention to a few basic tenets will enhance both the efficiency of the procedure as well as overall cosmesis. This chapter will review the basic materials required for a successful excision as well as the most common excision and closure techniques.


Basal Cell Carcinoma Wound Edge Apical Angle Chlorhexidine Gluconate Needle Driver 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Shaffer CL, Feldman SR, Fleischer AB Jr et al. The cutaneous surgery experience of multiple specialties in the Medicare population. J Am Acad Dermatol. 2005;52(6):1045–1048.CrossRefPubMedGoogle Scholar
  2. 2.
    Chang LK, Whitaker DC. The impact of herbal medicines on dermatologic surgery. Dermatol Surg. 2001;27 (8):759–763.CrossRefPubMedGoogle Scholar
  3. 3.
    Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286(2):208–216.CrossRefPubMedGoogle Scholar
  4. 4.
    Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and supplemental medicines used by cosmetic patients: what the plastic surgeon needs to know. Plast Reconstr Surg. 2006;117(2):436–445; discussion 446–437.CrossRefPubMedGoogle Scholar
  5. 5.
    Lewis KG, Dufresne RG Jr. A meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery. Dermatol Surg. 2008;34(2):160–164; discussion 4–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Khalifeh MR, Redett RJ. The management of patients on anticoagulants prior to cutaneous surgery: case report of a thromboembolic complication, review of the literature, and evidence-based recommendations. Plast Reconstr Surg. 2006;118(5):110e–117e.Google Scholar
  7. 7.
    Syed S, Adams BB, Liao W, et al. A prospective assessment of bleeding and international normalized ratio in warfarin-anticoagulated patients having cutaneous surgery. J Am Acad Dermatol. 2004;51(6):955–957.CrossRefPubMedGoogle Scholar
  8. 8.
    Alam M, Goldberg LH. Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy. Dermatol Surg. 2002;28(11):992–998; discussion 8.CrossRefPubMedGoogle Scholar
  9. 9.
    Otley CC, Fewkes JL, Frank W, et al. Complications of cutaneous surgery in patients who are taking warfarin, aspirin, or nonsteroidal anti-inflammatory drugs. Arch Dermatol. 1996;132(2):161–166.CrossRefPubMedGoogle Scholar
  10. 10.
    Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, afsnd Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736–1754.CrossRefPubMedGoogle Scholar
  11. 11.
    Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc. 2003;134(7):895–899.Google Scholar
  12. 12.
    Roberts GJ, Gardner P, Simmons NA. Optimum sampling time for detection of dental bacteraemia in children. Int J Cardiol. 1992;35(3):311–315.CrossRefPubMedGoogle Scholar
  13. 13.
    Sakamoto H, Karakida K, Otsuru M, et al. Antibiotic prevention of infective endocarditis due to oral procedures: myth, magic, or science? J Infect Chemother. 2007;13(4):189–195.CrossRefPubMedGoogle Scholar
  14. 14.
    Carmichael AJ, Flanagan PG, Holt PJ, et al. The occurrence of bacteraemia with skin surgery. Br J Dermatol. 1996;134(1):120–122.CrossRefPubMedGoogle Scholar
  15. 15.
    Sabetta JB, Zitelli JA. The incidence of bacteremia during skin surgery. Arch Dermatol. 1987;123(2):213–215.CrossRefPubMedGoogle Scholar
  16. 16.
    Babcock MD, Grekin RC. Antibiotic use in dermatologic surgery. Dermatol Clin. 2003;21(2):337–348.CrossRefPubMedGoogle Scholar
  17. 17.
    Hurst EA, Grekin RC, Yu SS, et al. Infectious complications and antibiotic use in dermatologic surgery. Semin Cutan Med Surg. 2007;26(1):47–53.CrossRefPubMedGoogle Scholar
  18. 18.
    Garland JS, Buck RK, Maloney P, et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial. Pediatr Infect Dis J. 1995;14(6):510–516.CrossRefPubMedGoogle Scholar
  19. 19.
    Hibbard JS. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. J Infus Nurs. 2005;28(3):194–207.CrossRefPubMedGoogle Scholar
  20. 20.
    Nishimura C. Comparison of the antimicrobial efficacy of povidone-iodine, povidone-iodine-ethanol and chlorhexidine gluconate-ethanol surgical scrubs. Dermatology. 2006;212(Suppl 1):21–25.CrossRefPubMedGoogle Scholar
  21. 21.
    Hibbard JS, Mulberry GK, Brady AR. A clinical study comparing the skin antisepsis and safety of ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. J Infus Nurs. 2002;25(4):244–249.CrossRefPubMedGoogle Scholar
  22. 22.
    MICROMEDEX® Healthcare Series. In: POISINDEX® Managements: Thomson Micromedex; 2008. http://www.micromedex.com/products/poisindex/
  23. 23.
    Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg [Am]. 2005;30(5):1061–1067.CrossRefGoogle Scholar
  24. 24.
    Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001;108(1):114–124.CrossRefPubMedGoogle Scholar
  25. 25.
    Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119(1):260–266.CrossRefPubMedGoogle Scholar
  26. 26.
    Dzubow LM. Optimizing local anesthesia. The heat is on. Dermatol Surg. 1996;22(8):681.CrossRefPubMedGoogle Scholar
  27. 27.
    Golembiewski J. Local anesthetics. J Perianesth Nurs 2007;22(4):285–288.CrossRefPubMedGoogle Scholar
  28. 28.
    Burns CA, Ferris G, Feng C, et al. Decreasing the pain of local anesthesia: a prospective, double-blind comparison of buffered, premixed 1% lidocaine with epinephrine versus 1% lidocaine freshly mixed with epinephrine. J Am Acad Dermatol. 2006;54(1):128–131.CrossRefPubMedGoogle Scholar
  29. 29.
    Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch Dermatol. 1987;123(3):340–344.CrossRefPubMedGoogle Scholar
  30. 30.
    Breuninger H, Dietz K. Prediction of subclinical tumor infiltration in basal cell carcinoma. J Dermatol Surg Oncol. 1991;17(7):574–578.PubMedGoogle Scholar
  31. 31.
    Salasche SJ, Amonette RA. Morpheaform basal-cell epitheliomas: a study of subclinical extensions in a series of 51 cases. J Dermatol Surg Oncol. 1981;7(5):387–394.PubMedGoogle Scholar
  32. 32.
    Silverman MK, Kopf AW, Bart RS, et al. Recurrence rates of treated basal cell carcinomas. Part 3: surgical excision. J Dermatol Surg Oncol. 1992;18(6):471–476.PubMedGoogle Scholar
  33. 33.
    Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989;15(3):315–328.PubMedGoogle Scholar
  34. 34.
    Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol. 1992;27(2 Pt 1):241–248.CrossRefPubMedGoogle Scholar
  35. 35.
    Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med 2001;344(13):975–983.CrossRefPubMedGoogle Scholar
  36. 36.
    Leibovitch I, Huilgol SC, Selva D, et al. Cutaneous squamous cell carcinoma treated with Mohs micrographic surgery in Australia I. Experience over 10 years. J Am Acad Dermatol. 2005;53(2):253–260.CrossRefPubMedGoogle Scholar
  37. 37.
    National Comprehensive Cancer Network (NCCN) clinical practice guidelines in oncology: melanoma. In: v.1.2008 ed. http://www.nccn.org%3F/. Accessed January 19, 2009.
  38. 38.
    Pollack SV. Electrosurgery of the Skin. New York: Churchill Livingstone; 1991.Google Scholar
  39. 39.
    Martinelli PT, Schulze KE, Nelson BR. Mohs micrographic surgery in a patient with a deep brain stimulator: a review of the literature on implantable electrical devices. Dermatol Surg. 2004;30(7):1021–1030.CrossRefPubMedGoogle Scholar
  40. 40.
    Yu SS, Tope WD, Grekin RC. Cardiac devices and electromagnetic interference revisited: new radiofrequency technologies and implications for dermatologic surgery. Dermatol Surg. 2005;31(8 Pt 1):932–940.PubMedGoogle Scholar
  41. 41.
    Ethicon Wound Closure Manual, Somerville, NJ, Ethicon 2007. http://www.jnjgateway.com/public/NLDUT/Wound_Closure_Manual1.pdf. Last accessed October 29, 2008.
  42. 42.
    Kanegaye JT, Vance CW, Chan L, et al. Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. J Pediatr. 1997;130(5):808–813.CrossRefPubMedGoogle Scholar
  43. 43.
    Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatr Emerg Care. 2002;18(3):171–173.CrossRefPubMedGoogle Scholar
  44. 44.
    Stillman RM, Marino CA, Seligman SJ. Skin staples in potentially contaminated wounds. Arch Surg. 1984;119(7):821–822.PubMedGoogle Scholar
  45. 45.
    Sniezek PJ, Walling HW, DeBloom JR 3rd, et al. A randomized controlled trial of high-viscosity 2-octyl cyanoacrylate tissue adhesive versus sutures in repairing facial wounds following Mohs micrographic surgery. Dermatol Surg. 2007;33(8):966–971.CrossRefPubMedGoogle Scholar
  46. 46.
    Quinn J, Wells G, Sutcliffe T, et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA. 1997;277(19):1527–1530.CrossRefPubMedGoogle Scholar
  47. 47.
    Holger JS, Wandersee SC, Hale DB. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med. 2004;22(4):254–257.CrossRefPubMedGoogle Scholar
  48. 48.
    Toriumi DM, O'Grady K, Desai D, et al. Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery. Plast Reconstr Surg. 1998;102(6):2209–2219.CrossRefPubMedGoogle Scholar
  49. 49.
    Coulthard P, Worthington H, Esposito M, et al. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev. 2004;2:CD004287.PubMedGoogle Scholar
  50. 50.
    Bernard L, Doyle J, Friedlander SF, et al. A prospective comparison of octyl cyanoacrylate tissue adhesive (dermabond) and suture for the closure of excisional wounds in children and adolescents. Arch Dermatol. 2001;137(9):1177–1180.PubMedGoogle Scholar
  51. 51.
    Kuo F, Lee D, Rogers GS. Prospective, randomized, blinded study of a new wound closure film versus cutaneous suture for surgical wound closure. Dermatol Surg. 2006;32(5):676–681.CrossRefPubMedGoogle Scholar
  52. 52.
    Leonard AL, Hanke CW. Second intention healing for intermediate and large postsurgical defects of the lip. J Am Acad Dermatol. 2007;57(5):832–835.CrossRefPubMedGoogle Scholar
  53. 53.
    Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg Oncol 1989;15(1):17–19.PubMedGoogle Scholar
  54. 54.
    Sadick NS, D'Amelio DL, Weinstein C. The modified buried vertical mattress suture: a new technique of buried absorbable wound closure associated with excellent cosmesis for wounds under tension. J Dermatol Surg Oncol. 1994;20(11):735–739.PubMedGoogle Scholar
  55. 55.
    Hohenleutner U, Egner N, Hohenleutner S, et al. Intradermal buried vertical mattress suture as sole skin closure: evaluation of 149 cases. Acta Derm Venereol. 2000;80(5):344–347.CrossRefPubMedGoogle Scholar
  56. 56.
    Zitelli JA. TIPS for a better ellipse. J Am Acad Dermatol. 1990;22(1):101–103.CrossRefPubMedGoogle Scholar
  57. 57.
    Boyer JD, Zitelli JA, Brodland DG. Undermining in cutaneous surgery. Dermatol Surg. 2001;27(1): 75–78.CrossRefPubMedGoogle Scholar
  58. 58.
    Brady JG, Grande DJ, Katz AE. The purse-string suture in facial reconstruction. J Dermatol Surg Oncol. 1992;18(9):812–816.PubMedGoogle Scholar
  59. 59.
    Hoffman A, Lander J, Lee PK. Modification of the purse-string closure for large defects of the extremities. Dermatol Surg. 2008;34(2):243–245.CrossRefPubMedGoogle Scholar
  60. 60.
    Weisberg NK, Greenbaum SS. Revisiting the purse-string closure: some new methods and modifications. Dermatol Surg. 2003;29(6):672–676.CrossRefPubMedGoogle Scholar
  61. 61.
    Hudson-Peacock MJ, Lawrence CM. Comparison of wound closure by means of dog ear repair and elliptical excision. J Am Acad Dermatol. 1995;32(4): 627–630.CrossRefPubMedGoogle Scholar
  62. 62.
    Weisberg NK, Nehal KS, Zide BM. Dog-ears: a review. Dermatol Surg. 2000;26(4):363–370.CrossRefPubMedGoogle Scholar
  63. 63.
    Rogues AM, Lasheras A, Amici JM, et al. Infection control practices and infectious complications in dermatological surgery. J Hosp Infect. 2007;65(3): 258–263.CrossRefPubMedGoogle Scholar
  64. 64.
    Amici JM, Rogues AM, Lasheras A, et al. A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol. 2005;153(5):967–971.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Mollie A. MacCormack
    • 1
  1. 1.Department of DermatologyProcedural Dermatology, Lahey ClinicBurlingtonUSA

Personalised recommendations