Excisional biopsy of skin tumors

The most frequently encountered neoplasm in the US is skin cancer. More than 600,000 new cases of malignant skin tumors are diagnosed in the US each year. One standard method of treatment of skin tumors is excisional biopsy. There are seven technical considerations involved in the excisional biopsy of skin tumors: (1) aseptic technique, (2) examination and demarcation of skin lesion, (3) skin biomechanical properties, (4) anesthesia, (5) excisional biopsy, (6) wound closure, and (7) postoperative care. The physician must use aseptic techniques and wear a cap, mask, and powder-free gloves. Hair is a source of wound contamination, and removal of hair prevents it from becoming entangled in suture and the wound during closure. Because surgical electric clippers cut hair close to the skin surface without nicking the skin, we now use only electric clippers to remove hair. The physician's visualization of the wound can be enhanced by magnification (2.5x) loupes. The physician's plan for excisional biopsy is dictated by the suspected pathology of the skin lesion. The ultimate appearance and function of a scar after closure of excisional biopsy can be predicted by the static and dynamic skin tensions on the surrounding skin. Infiltration anesthesia is preferred over regional nerve block because it does not interfere with the muscle movement that causes dynamic tensions, which elongate the configuration of the defect. Most skin lesions are amenable to a circular excision. In these instances, it is worthwhile to use circular-shaped excisions. The reusable metal trephines have been replaced by disposable trephines that have ribbed plastic handles attached to 316 stainless steel circular cutting blades. Wound closure is accomplished in the same direction as the long axis of the elliptical defect by first approximating the midportion of the defect with a 4-0 synthetic CAPROSYN* monofila-ment absorbable suture attached to the swage of the laser-drilled, compound-curved reverse cutting edge needle. Additional interrupted dermal (subcuticular) sutures are placed in each wound quadrant to approximate further the divided edges of the dermis. Compound-curved reverse cutting edge needles have been specifically designed for dermal closure. Reinforced Steri-Strips are then applied transversly across the incision to facilitate further skin edge approximation. Rigorous follow-up examination is essential for any patient with a history of a skin cancer to detect recurrence and prevent further actinic damage. The use of wide diameter trephine biopsy instruments are still not widely used by physicians because most physicians do not have the technical skills to approximate the defect with dermal sutures. Consequently, this need for a rapid dermal skin closure technique that can be used by a primary care physician must be devised before the trephine excisional biopsy technique is widely used by the primary care physician. This goal can be achieved by developing a disposable stapler for subcuticular closure of the skin.