Assess the duration of time the lesion has been present, location, presence of infected tissue around planned biopsy site, allergies, bleeding disorders, and ensure the patient is aware that all biopsies result in a scar.

Assess for risk factors for poor wound healing:
• impaired nutritional status
• advanced age
• medications
• diabetes
• peripheral vascular disease
• autoimmune disease
• immunosuppression
• COPD
• CHF
• anemia
• smoking
• substance use

To achieve the least noticeable final scar, the ellipse should be drawn parallel or within relaxed skin tension lines. Relaxed skin tension lines can be better visualized when the patient is positioned in an anatomically neutral position when the ellipse is being drawn.

Appropriate margins around the lesion must be defined before removal can be done. Benign lesions are typically removed with a 1 to 2 mm margin. Malignant lesions should be excised with a wider margin and referral to dermatology should be considered.

Marking the intended lesion is also helpful as it may temporarily be distorted following injection of the anesthetic.

When marking the site, pay attention to the skin tension lines and orientate the elliptical incision so that it is parallel to these lines. This allows the wound to close more easily and cosmetically than incisions done at right angles to skin tension lines.

The appropriate margins should be marked using a skin marking pen and then the ellipse drawn around this. Once the axis of the ellipse has been determined, the provider can mark the lines connecting the circle and the tips of the ellipse. The angles at each end should be about 30 degrees and the length-to-width ratio about 3:1 to 4:1.

Wound cleansing reduces risk of sepsis to the wound site. Cleanse a wide area around the wound to prevent contamination of suture material and surgical instruments during the procedure.

See the chapter titled “Local Anesthesia” for the full procedure. Using anesthetic with epinephrine will constrict blood vessels and decrease bleeding during the procedure. Avoid use of epinephrine in the digits, ears, and nose due to the risk of ischemia.

Prepare an area measuring approximately 3 inches wide around the edges of the wound or planned incision.

Follow the marked incision line to the other apex. As the incision progresses, use more of the belly of the blade, and then raise it so that the tip is perpendicular to the skin as you reach the next apex.

The end incision must extend through the entire thickness of the dermis and be deep enough to see subcutaneous tissue when the sample is removed. The full thickness incision does not need to be achieved on the first stroke and multiple strokes may be required.

Grasp the dermis with forceps and excise the tissue within the incision at the level of the subcutaneous fat with a scalpel or scissors. Take care not to crush the tissue as this will affect pathology results.

Using a scissor, undermine the subcutaneous plane beneath the dermis to allow the skin to glide together and reduce tension on the sutures:
a. Advance the closed scissors under the wound edge where the dermis meets the subcutaneous tissue
b. Quickly spread the scissors open
c. Continue this around the entire wound

Approximate the wound edges using sutures. The horizontal mattress or vertical mattress sutures offer deep closure support and are recommended to prevent dead space and hematoma formation. See chapter titled “Suturing of Uncomplicated Lacerations” for full procedure.

Apply an occlusive dressing to facilitate a moist environment and speed wound healing. Occlusive dressings can be made by using a topical antibiotic ointment or petroleum jelly on the wound and then covering with non-adherent gauze and tape, or a dressing such as Mepore.