Fusiform Incision


Article Author:
Michael Ramsey


Article Editor:
Patrick Zito


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/13/2019 7:37:31 PM

Introduction

Fusiform incision involves cutting out tissue in a manner that results in both ends of the specimen being tapered or made spindle-shaped. Removal of tissue in this manner allows the wound to be closed in a linear, side-to-side fashion with minimal surface irregularity.

Anatomy

This incisional technique may be used on the skin in virtually any anatomic location, but size and depth of the defects are limited by proximity to vital structures and free margins. For example, the defect large fusiform excisions are not generally practical near the eye and should not cross the free margin of the eyelid. In addition, closure of these defects causes some degree of tension. Therefore, the direction of closure should be chosen in a way that will minimize the tension on free margins or vital structures that would result in cosmetic or functional abnormalities.

Indications

Fusiform incision may be used to excise an entire lesion, or it can be used to remove just a portion of involved tissue. The tapered ends of the resulting defect allow primary closure of the wound while minimizing "standing cone deformities" or "dog ears" at the ends of the incision. Modifications of this technique may be implemented to avoid cross free margins such as the eyelid or vermilion border of the lip.

Contraindications

Caution should be exercised in patients on anticoagulant therapy, with bleeding disorders, or those with active skin infections. Consultation with the appropriate physician may be indicated in situations of uncertainty.

Equipment

Essential equipment is minimal and includes the following:

Preoperatively

  • Local anesthetic (typically lidocaine 0.5% with epinephrine 1:200,000 and buffered with sodium bicarbonate)
  • 3 cc syringe(s)
  • 30 gauze needle(s)
  • Antiseptic scrub

Intraoperatively

  • Sterile drape
  • Scalpel with #15 blade
  • Toothed forceps
  • Suture scissors
  • Needle holders
  • Normal saline
  • Sterile gauze
  • Absorbable suture (for subcutaneous/deep stitches)
  • Cutaneous suture (non-absorbable or absorbable)
  • Ideally, an electrosurgical device should be available for hemostasis

Postoperatively

  • Nonstick dressing
  • Sterile ointment (author prefers sterile petrolatum to antibiotic ointment as significant numbers of patients develop allergies to bacitracin and neomycin, while their ability to decrease infection is minimal)
  • Gauze or other material to use in bulky pressure dressing
  • Adhesive dressing, preferably hypoallergenic and stretchy

Personnel

While fusiform incisional surgery can be performed alone, it is very helpful to have a surgical assistant to help with controlling bleeding, cutting sutures, and applying a dressing.

Preparation

The surgical site should be examined with the patient in a neutral or natural position, usually sitting erect. The long axis of the incision is generally chosen to run parallel to the relaxed tension lines. The skin is scrubbed with alcohol, and the planned incision is drawn with a surgical marker. The patient is then placed in a position that is comfortable but allows the surgeon optimal access.

Technique

The tissue is then injected with local anesthetic. For best aesthetic results and to minimize wound, the long axis of the defect is usually oriented parallel to relaxed skin tension lines. While stretching and stabilizing the skin with both hands, the surgeon begins the incision at one end, being sure to start at the desired tissue depth and maintain that depth throughout the incision, including at the other end. Often the tip of the scalpel blade is used to puncture the skin at the tip of the planned incision, and then the curved belly of the blade is used to proceed with the remainder of the incision. The scalpel cutting surface should be maintained perpendicular to the skin surface plane as well, to avoid slanted sides to the defect that would result in an inverted scar after suturing. The undersurface of the specimen is then sharply dissected with the scalpel or with scissors, again maintaining the same plane throughout.[1] If the plane of the defect appears uneven after removal of tissue, additional tissue may be taken to correct this and obtain an even plane.

Once the specimen has been removed, the wound is prepared for closure. After obtaining hemostasis with electrocoagulation, most wounds will be closed in a layered fashion, starting with one or more layers of an absorbable suture in the subcutaneous fat and dermis. If necessary, the surrounding skin may be undermined to allow placement of buried vertical mattress sutures and to provide a degree of tissue mobility. In many instances, little or no undermining is required to obtain optimal closure. Excessive undermining only provides more potential space for hematoma or seroma formation. Deep sutures provide the strength of the closure, and then superficial sutures keep the skin edges flush during initial healing.[2] Superficial sutures may be absorbable or non-absorbable, and in some cases with little tension or movement, tissue glue can be used. In very small or narrow incisions with little tension, one may use only superficial sutures. 

A sterile pressure dressing is placed over the incision for 1-2 days to minimize the risk of bleeding. Sterile petrolatum is applied to the incision site, and is preferable to antibiotic ointments containing neomycin or bacitracin. Those antibiotic ointments have not been shown to decrease the incidence of post-operative infection, but they do pose a significant of causing an allergic contact dermatitis. Fluffed gauze, cotton balls or similar material form the bulk of the dressing that will apply pressure under the adhesive tape. Strips of stretchable bandage material are ideal for placement of these dressings, and the strips should run perpendicular to the incision line so that they help pull skin edges together and take tension off the sutures.

With the adequate placement of buried sutures, superficial sutures on the face can be removed in one week, and often sooner. On the trunk and extremities, it is generally safer to allow 10-14 days, depending on the tension on the wound and the patient's level of activity. If using absorbable sutures for the superficial closure, one should choose suture material that will remain in place for an adequate period of time.

Complications

As with other forms of incisional surgery, the main risks include bleeding, scar formation, and infection. Other risks include damage to underlying structures such as nerves, aesthetic disfigurement, and functional impairment. Careful preparation and attention to detail minimize these risks.

Clinical Significance

Fusiform incision is commonly used to remove lesions that are roughly round or oval. The technique begins by determining the necessary margins around a given lesion, and those margins are drawn with a marker, forming a circle or an oval. The fusiform incision will include the tissue within the marked boundaries as well as additional tissue at either end to allow for the desired tapering. Fusiform incision may be performed in several variations, but two forms are most typical. The most common form portrayed in textbooks has two sides that are rounded from end to end of the incision. A more efficient method employs straight sides on the ends of the incision, resembling a rhomboid shape.[3][4][3] In this variation, the only curved component of the defect is in the middle and corresponds to the margins around the lesion. Straight lines are drawn to meet at the rounded portion of the defect and the ends. The straight sides provide a more narrow, or acute, angle at the ends of the incision, and thus less redundant tissue is present to form a "dog ear," or standing cone, of protuberant tissue. A more narrow defect angle is less prone to tissue redundancy, but these more acute angles require a greater overall length of the defect. A 30-degree angle is suitable in most circumstances. As a general rule of thumb, a 3:1 length to width ratio often provides an approximately 30-degree defect angle without taking an excessive amount of tissue, although this may vary depending on the characteristics of the tissue and the topography in a given location.[5]

In some instances, the fusiform incision may be used to obtain a cross-section of a larger area of tissue, particularly when one wants to see histologically the transition from normal to abnormal skin or to see the architecture of a large skin neoplasm. For example, it can be used at the periphery of a keratoacanthoma to provide a large cross-section for pathologists to examine the architecture that helps to differentiate this from a more aggressive squamous cell carcinoma. In these circumstances, a longer and more narrow specimen may be harvested, allowing maximal cross-sectional tissue for examination with little tension in defect closure. Likewise, a full cross-section may be obtained in a large pigmented lesion, providing the pathologist substantial tissue for examination without creating a large defect.[6]

Enhancing Healthcare Team Outcomes

A few tips can optimize the successful performance and clinical and aesthetic results of an elliptical excision:

  • Incise straight lines running tangential the circular or oval lesion and required margins, rather than rounding all lines. This will result in more acute angles at the ends of the wound, with less chance of standing cones.
  • When performing the incision, rest both hands on the patient and stretch the skin in three directions, using the hand holding the scalpel as one "point" and using two fingers on the other hand as the other two points.
  • Start the incision with the tip of the blade at the end of the defect, then use the rounded belly of the blade for the remainder of the excision. Try to maintain an even plain of cutting, using as few passes of the blade as possible.
  • Use only as much undermining as necessary. Often, no undermining is needed at all, or just enough to allow proper placement of buried vertical mattress stitches. More undermining creates more "dead space" in which hematomas may collect.[7]
  • When bandaging linear incisions, make sure to run tape strips perpendicular to the incision line, thus minimizing tension across the incision line.

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Fusiform Incision - Questions

Take a quiz of the questions on this article.

Take Quiz
Fusiform incisions may be performed to remove lesions. What is the largest apex angle that will NOT create a dog-ear deformity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about fusiform incision is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not considered a common risk of fusiform incision?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following circumstances might be ideal to use a narrow fusiform incision to sample a portion of a lesion?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which statement is correct?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which statement regarding fusiform incision is false?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Fusiform Incision - References

References

Skin waste, vertex angle, and scar length in excisional biopsies: comparing five excision patterns--fusiform ellipse, fusiform circle, rhomboid, mosque, and S-shaped., Raveh Tilleman T,Tilleman MM,Krekels GA,Neumann MH,, Plastic and reconstructive surgery, 2004 Mar     [PubMed]
Elliptical excisions: variations and the eccentric parallelogram., Goldberg LH,Alam M,, Archives of dermatology, 2004 Feb     [PubMed]
Fusiform incisional biopsy for pigmented skin lesions., Pardasani AG,Leshin B,Hallman JR,White WL,, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2000 Jul     [PubMed]
Vujevich JJ,Kimyai-Asadi A,Goldberg LH, The four angles of cutting. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2008 Aug     [PubMed]
Miller CJ,Antunes MB,Sobanko JF, Surgical technique for optimal outcomes: Part II. Repairing tissue: suturing. Journal of the American Academy of Dermatology. 2015 Mar     [PubMed]
Moody BR,McCarthy JE,Sengelmann RD, The apical angle: a mathematical analysis of the ellipse. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2001 Jan     [PubMed]
Miller CJ,Antunes MB,Sobanko JF, Surgical technique for optimal outcomes: Part I. Cutting tissue: incising, excising, and undermining. Journal of the American Academy of Dermatology. 2015 Mar     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.