Non-melanoma skin cancer

• Rapid enlargement, pain, ulceration, bleeding, or crusting raise suspicion for SCC, particularly in sun-damaged skin.

• SCC risk increases with size, poor differentiation, ear/lip location, recurrent disease, and immunosuppression.

• Infiltrative, morphoeic, micronodular, and basosquamous BCCs behave more aggressively and require wider margins or referral.

Melanocytic lesions

• All Spitz and Reed naevi should be excised due to diagnostic uncertainty.

• Dysplastic naevi management:

  • Mild atypia: observation acceptable

  • Moderate atypia: narrow excision

  • Severe atypia: wider excision

• Lentigo maligna frequently extends beyond visible margins.

• Modern MIS margins are wider than traditionally taught.

Keratoacanthoma & chronic ulcers

• Keratoacanthoma should be excised to exclude SCC and prevent destructive scarring.

• Chronic leg ulcers that fail to heal or improve should be biopsied; malignant transformation is not rare.

Core principle: Change over time and failure to heal are diagnostic clues.

• Begin facial skin examinations at the inner canthi and eyelids to avoid missed peri-ocular lesions.

• Encourage patients to identify lesions of concern; patient awareness often highlights subtle change.

• Photograph lesions ≥10 mm using a scale or ruler for documentation, follow-up, and insurance requirements.

• Use calipers or pathology rulers for accurate margin planning.

• When prior biopsy sites are unclear:

  • Dermal local anaesthetic may recreate blistering at the original site

  • Tangential lighting can reveal subtle textural scars

  • If uncertainty remains, re-biopsy rather than guess

Core principle: Certainty before incision prevents wrong-site surgery.

• Perform a deliberate time-out immediately before surgery.

• Confirm patient identity, lesion, diagnosis, site, margins, and planned closure.

• Mark lesions clearly before skin prep.

• Place a 12-o’clock orientation nick or suture while the lesion is still attached.

• Orientation marks are particularly important for:

  • Re-excisions

  • Infiltrative tumours

  • Complex closures

• Align incision markings so closure lines up accurately after excision.

Core principle: Orientation errors are technical failures, not bad luck.

• Plan incisions according to functional skin tension, not textbook diagrams.

• Perform pinch testing in multiple directions, ideally on the contralateral side.

• For punch biopsies, stretch skin perpendicular to RSTL to create an oval defect.

• Incise slightly outward rather than vertically to improve histological clearance and wound eversion.

• Avoid short, wide excisions; they inevitably create dog-ears.

• If dog-ears develop:

  • Stretch the wound longitudinally

  • Allow time for tissue relaxation

• Avoid horizontal facial excisions that risk brow elevation or ectropion.

• Preserve a narrow tissue bridge adjacent to the alar groove to facilitate suturing.

Core principle: Geometry, tension, and time solve most closure problems.

• Buffer lignocaine with bicarbonate to reduce injection pain.

• Warm local anaesthetic solutions where possible.

• Inject slowly using fine needles.

• Dental cartridges are practical for small biopsies.

• Allow sufficient time (≈15 minutes) for adrenaline vasoconstriction.

• Anticoagulants should generally not be stopped unless advised by the prescribing clinician.

• Expect increased bleeding with clopidogrel, particularly when combined with other agents.

Core principle: Gentle anaesthesia improves both patient experience and surgical precision.

• Firm gauze pressure at the dissection edge often produces a dry field.

• Chalazion clamps are effective for controlled haemostasis on the lip and distal nose.

• Larger clamps are generally more useful than small ones.

• Bipolar cautery causes less collateral tissue damage than monopolar.

• Insulated hyfrecator tips reduce unintended thermal injury.

• Avoid blind cautery; identify bleeding points clearly before coagulation.

Core principle: Control bleeding without destroying tissue.

Suture selection & handling

• Longer sutures (e.g. 75 cm) reduce compromise during closure.

• Cut free ends short to maintain control.

• Plan for one additional suture beyond your initial estimate.

• The first throw should cross the incision to prevent lateral draping.

• Deep sutures should align tissue layers, not cinch them.

Suture materials

• Nylon and other monofilaments retain memory; stretch under tension to straighten.

• Slippery sutures may require additional throws for knot security.

• Use blue sutures in hair-bearing areas for ease of removal.

• Mixed suture materials are acceptable if duration requirements are met.

Knots & comfort

• Secure knots by fixing one end and drawing the other.

• The first knot should be firm but not strangulating.

• Leave mucosal sutures long; short ends are more irritating.

Core principle: Tension belongs deep; skin sutures align edges.

• Wounds heal best under waterproof dressings.

• Clean skin with acetone or adhesive prep to improve tape adhesion.

• Tape facial wounds after suture removal to provide ongoing support.

• Provide spare tape for patient use.

• Stretchable tapes can provide traction support.

• Fully healed, sealed wounds do not require sterile strips.

Core principle: Mechanical support continues after closure.

• Mesh gauze and paper tape effectively control scalp hair.

• Place gauze beneath adhesive drapes to prevent hair avulsion.

• Trim hair only when necessary.

• Cotton pledgets protect the external auditory canal during ear surgery.

Core principle: Field control saves time and frustration.

• Surgeons should control theatre layout and equipment selection.

• Avoid floor lamps; LED lighting provides superior illumination.

• Use multiple light sources to eliminate shadows.

• Aluminium foil or sterile wrappers can adjust lighting angles when operating solo.

• Bread tags can label cables and cords.

• Towel clamps function as versatile retractors and wound stabilisers.

Core principle: Workflow design is a surgical skill.

• Never recap needles using both hands.

• Use forceps or a bench technique for recapping.

• Retrieve dropped needles using magnets, tape, or suction methods.

• Invert gloves during removal to contain sharps and debris.

Core principle: Sharps injuries are preventable.

• Nose: intranasal antibiotic ointment reduces postoperative infection risk.

• Fingers: glove-finger tourniquets can be used but must be secured.

• Toes: gauze slings isolate digits effectively.

• Umbilical lesions: place deep sutures early to control eversion and depth.

Core principle: Small anatomical adjustments prevent large complications.

• UV damage accumulates over a lifetime but manifests later.

• UVA penetrates glass and contributes to photoaging and malignancy.

• Sunglasses reduce periocular UV exposure.

• Consistent sunscreen use reduces SCC and melanoma risk.

Core principle: Surgery treats disease; education prevents recurrence.

• Use the BLAST framework for complaints:

  • Believe

  • Listen

  • Apologise

  • Solve

  • Thank

Core principle: Professional response matters as much as technical skill.