Surgical Pearl: Removal of large oval lesions with a smaller round punch

Abstract

M any patients request the removal of common moles and other unwanted lesions with entirely benign clinical features for cosmetic reasons or because they are repeatedly traumatized by clothing, shaving, jewelry, or body movements. The goal is to efficiently remove such lesions while minimizing the chance for recurrence and scarring. A variety of methods for removal of such lesions are available and include: elliptical, round, and shave excisions; shave excision followed by electrodessication; cryotherapy combined with curetting or scissor excision; and punch excision. The standard punch excision technique uses disposable punches, which are available in 3, 4, 5, 6, and 8 mm. Generally, a punch is chosen that is at least .2-mm larger than the maximum diameter of a mole or other benign lesion. Round excision of this type preserves normal tissue, but dog-ears may be produced when the wound is closed. In the case of keratinous cysts, pilar cysts, and lipomas, larger lesions can be removed through a small punch incision opening. We often encounter lesions that are larger in one diameter than the punch that would be chosen based on the narrower width of a lesion. In addition, an oval lesion measuring 6 3 11 mm might be considered too large to remove with the largest 8 mm—diameter punch. Using a modified punch excision technique, lesions with benign clinical appearance that exhibit these features are readily excised. Staff and physician time is preserved by avoiding a freehand wedge excision and the wound created has an oval shape that produces excellent cosmetic results.