Dermatologic surgery

Key Features: Shave or punch skin biopsies can be accomplished with minimal trauma and scarring. Excisional surgery is appropriate for removal of benign and malignant cutaneous lesions, including cysts, lipomas, atypical nevi, and some melanoma and nonmelanoma skin cancers. Mohs micrographic surgery is the gold standard for removal of nonmelanoma skin cancers at sites requiring tissue sparing, such as the head and neck, genitalia, and hands and feet. Mohs is also appropriate when cancers are aggressive or high-risk, and these categories include recurrent tumors, tumors larger than 2 cm in diameter, histologically aggressive tumors, tumors associated with ionizing radiation, tumors in immunosuppressed patients, and tumors penetrating below muscular fascia. Mohs is used by some for treatment of melanomas, particularly of in situ melanoma. Melanoma is treated by wide local excision, with depth to muscle and peripheral margin contingent on the Breslow depth of the melanoma. Peripheral margins may vary from 0.5 cm for in situ lesions (these can also be treated by Mohs) to 2-3 cm or greater for deeply invasive lesions. Sentinel lymph node biopsy is becoming a standard of care prognostic procedure for melanoma of depth greater than 1 mm. Bilayered repairs reduce the risk of dehiscence and provide improved cosmesis postoperatively. Local anesthesia, commonly lidocaine with epinephrine, is sufficient for most dermatologic procedures. Topical anesthetics and nerve blocks may be appropriate adjuvant anesthetics in special situations. Surgery in children, such as removal of congenital nevi, may require general ane sthesia.