Monday, May 6, 2013

Skin procedures for the family physician: old and “new”

- Jennifer Middleton, MD, MPH

Seeing a skin procedure on my schedule always makes my day.  I enjoy providing patients with small epidermal (sebaceous) cysts and worrisome lesions the convenience of removal in the office.

Traditionally, epidermal cysts are removed by making an incision parallel to the skin lines over the widest part of the cyst.  The cyst is dissected away from the subcutaneous tissue, and after it’s removed the incision is sutured.  

Traditionally, worrisome skin lesions are removed by inking an ellipse (1:3 ratio of width to length ensures optimal closure) around the lesion.  The ellipse is then incised and lifted away from the subcutaneous tissue and closed with sutures.

In the last year, I’ve learned about an alternative technique for each of these procedures.   They are much faster than the traditional methods above.

Minimal excision technique for epidermal cysts
Make an incision of 2-3 mm over the cyst.  Then use a hemostat to keep this incision open and squeeze out all of the cyst’s contents using your thumbs (wear eye protection!).  Use the hemostat to lift out the cyst shell.  No sutures are necessary given the tiny size of the incision.

(Avoid this technique for cysts that are/were infected or inflamed, as the adhesions surrounding the cyst will make lifting out the cyst shell impossible.)

Thorough technique description and excellent pictures here: http://www.aafp.org/afp/2002/0401/p1409.html

Saucerization (“scoop”) excision for worrisome skin lesions
This procedure uses a common shave biopsy (razor) blade but “scoops” deep into the skin.  The blade should enter the skin at a 45-degree angle and penetrate to at least the mid-dermis.

Thorough technique description and excellent pictures here:

When described to me within the last year, both of these procedures were billed as “new,” yet the AFP articles above cite sources that are more than 10 years old.  It was a bit disconcerting to find how out of date my surgical techniques were.

Given that the dissemination gap between research-based practice recommendations and the actual implementation into clinical practice is around 20 years, though, perhaps I shouldn’t have been so surprised.

Are you using the minimal excision technique and/or saucerization in your practice?  I welcome comments about when you learned about these techniques and how they're working.  Or, if not yet, would these techniques change your practice?

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