The elliptical excision is the workhorse procedure to remove cutaneous lesions. Although the term “elliptical” frequently describes the design of excisions in the dermatologic and plastic surgery literature, it inaccurately describes the surgical design in practice. As opposed to an ellipse, which has a curved shape along its entire boundary, a fusiform excision has two sides that taper to a sharp point at each end. Recognizing that most surgeons employ a “fusiform” design, this chapter will use the terms “elliptical” and “fusiform” excisions interchangeably. This chapter will focus on the design and execution of the elliptical excision and its variations. Each of the five individual steps required to successfully complete a surgical excision will be discussed in detail. The skills necessary to design and execute an elliptical excision provide the foundation to progress to more technically advanced surgical procedures, such as cutaneous flaps.
PREOPERATIVE EVALUATION AND INFORMED CONSENT
The surgeon and his or her staff should perform a thorough preoperative evaluation to ensure the patient’s safety and to optimize outcomes of any cutaneous surgical procedure. Especially important items that could alter the surgeon’s practice or affect outcomes include the patient’s history of transmissible disease, whether the patient takes oral anticoagulants, the presence of implantable electrical devices, and concerns regarding antibiotic prophylaxis.1 The reader is referred to other chapters in this book for comprehensive coverage of these topics.
After a thorough preoperative evaluation, the surgeon must obtain informed consent. A careful informed consent sets realistic expectations for the patient and reduces the risk of litigation from consequences that the patient had not expected. The main risks associated with an elliptical excision include scarring, bleeding, infection, and incomplete resection of the lesion. Cosmetic disfigurement and compromised function of critical anatomic structures should occur rarely with a carefully designed and executed elliptical excision. As the risks associated with an elliptical excision are relatively low, informed consent frequently focuses on ensuring that the patient has realistic expectations for the postoperative appearance and recovery. Expected immediate postoperative sequelae after the excision include mild discomfort, swelling, and bruising, which vary in severity according to the size, depth, and location of the procedure. Discomfort is most severe in the first 24 to 48 hours after surgery, swelling usually subsides by 1 week, and bruising usually subsides after 1 to 2 weeks.
Patients should have realistic expectations about the appearance of the scar. Erythema limited to the suture line often persists for 1 to 2 weeks, and eversion of the scar edges can take approximately 3 to 4 months to flatten. Changes in sensation, such as numbness, tingling, and fleeting sharp pains are common for up to several months postoperatively.2 Patients should understand that the appearance and sensation of the scar evolve considerably over the first 3 to 6 months postoperatively. Finally, as wrong-site surgery is the most common reason for malpractice claims ...