Ellipse, Ellipse Variations, and Dog-ear Repairs

History

In skin surgery, as in most endeavors which are not by their very nature spontaneous, thorough preparation is paramount. The patient needs a complete and directed medical history as a prerequisite to excellent care and an optimal result (see Chapter 5 ).

Most of the medical history can be obtained on the day of surgery. Two exceptions are information about an artificial heart valve or another condition that may require antibiotic prophylaxis, and whether the patient has a pacemaker or an implantable cardioverter–defibrillator (ICD). Confirmation should be sought from the cardiologist to ascertain whether the patient has a pacemaker or an ICD. Most newer pacemakers have filters that block extraneous electrical current, permitting the routine use of short bursts of electrocautery, but ICDs can adversely be affected by any electrical impulses. The options for these patients include disabling the ICD temporarily, using heat cautery, or using bipolar forceps to confine the current to a very small local area (see Chapter 9 ).

Evaluation

Once the history has been satisfactorily obtained and clearly documented, evaluation of the individual who presents for facial excision should be done under proper lighting, with the patient in a sitting position.

First, any landmarks, cosmetic units, and relaxed skin tension lines that can be used to help camouflage the scar are identified. Inspection, palpation, and gentle manipulation are necessary to confirm relaxed skin tension lines and to determine the impact of a particular repair on adjacent structures. The patient can be asked to “show” their teeth, in preference to being asked to “smile,” as most patients are anxious, and not naturally disposed to cheerfulness when a surgeon looms over them, poised to incise. Observe the patient making specific facial expressions to accentuate the natural facial lines. Pursing the lips and raising the brow are two important maneuvers for studying the lip area and forehead and brow region.

The importance of understanding facial cosmetic units cannot be emphasized strongly enough (see 1.4, 1.5, 1.6, 1.7 ). A longer scar limited to one cosmetic unit will be less noticeable than a shorter one that crosses the border between two units. It is important to recognize potential functional problems, such as the risk of ectropion, elevation or depression of the lip, or collapse of the nasal ala. Often the extent of potential ectropion can be estimated by asking the patient to look upward. This exaggerates the pull on the lower lid as the globe rotates upward. If the proposed repair lacks sufficient laxity under these circumstances, it is likely that an ectropion will result, even if initially it seems the wound is small enough to repair otherwise.

Although relaxed skin tension lines are useful guidelines, variations in skin laxity, previous surgery, and skin texture may often suggest alternative preferred ways to align the scar. If the optimal direction for the ellipse is unclear, it may be helpful to excise the lesion as a simple circle, undermine as needed, and then observe which direction, independent of relaxed skin tension lines or cosmetic units, will provide for the most cosmetically elegant repair. Often, excision of the redundant cones of excess skin will be performed in a way that achieves a well-concealed scar.

Informed consent

Once the surgeon decides on the nature of the excision to be performed, and understands its impact, the risks and benefits of the procedure must be discussed in detail with the patient. First, give a clear description of the diagnosis and the need for the procedure. For cosmetic procedures it should be emphasized that the procedure is not medically indicated; in this circumstance, the risks are especially germane because they are affected by the benefit that accrues to the patient. The greater the medical need, the more risk the reasonable person would assume. Next, simple terms should be used to explain exactly what will happen during surgery and what can be expected during the postoperative period. The use of medical jargon should be avoided. Remember that while the surgeon gives informed consent many times a day and the process may feel routine, for the patient it is all new information. Therefore, care must be taken to avoid words that are likely to frighten or confuse, and all discussions should be direct but compassionate. An instinctive assessment of the patient's level of comprehension should be made. If the risk of infection is 1%, explain that in your experience “only one out of a hundred” patients is likely to get an infection, but add that this can usually be treated easily with antibiotics. Spend a few minutes discussing the issue of “scarring.” This issue is of great concern to patients, often because of an unrealistic expectation of the final aesthetic result and familiarity with others who have had suboptimal skin surgery.

In our experience, scarring is the outcome of greatest concern to most patients. It is important to be explicit about the fact that there will be a scar and that it is the natural consequence of healing. We explain that scarring is actually the end result of the amazing ability of the body to heal. And we explain that the issue is not whether there will be a scar – there will most definitely be one. The issue is whether it will be noticeable. Explained in these terms, we are comfortable that the patient is best prepared for the healing process that will ensue.

As part of the informed consent procedure, we provide a hand-held mirror so that the patient can see the extent of the lesion and probable length of the scar that we outline. It is important to explain the concept of dog-ears and that in order to correct such “darts” (a term well-understood by people who sew), the scar may be lengthened. No-one likes surprises in this situation, which is why it is valuable to give an explicit description of what the surgeon will be doing and why it is good medicine. The informed consent discussion and written consent should include references to the risk of bleeding, infection, recurrence of the lesion, damage to pertinent nerves, and an unsatisfactory cosmetic result. Other treatment options should also be described, at least verbally. Finally, offer to answer any remaining questions and have the patient sign the informed consent. In the case of an adverse outcome, the patient might claim that they did not understand what they were signing, but a proper and detailed discussion can prove such a claim to be false.