Skin Procedures: Surgical Wounds & Healing Time

The post-surgical wound healing process and final scar formation varies depending on an individual’s age, skin condition, wound location, and the type of surgery performed. Despite these variations, there are specific practices an individual can perform to potentiate proper wound healing after a dermatologic surgery.

Various surgical procedures, wounds, and healing times

In 2015, the most common procedures performed by advanced practice professionals were destructions and biopsies of benign and malignant neoplasms.¹ Skin cancers may be removed by electrosurgery, excisional surgery, or Mohs surgery, depending on the size, depth, location, and type of skin cancer. Each of these modalities may have different wound healing protocols.

Skin biopsies are useful and simple procedures that can provide histologic clarification for inflammatory and neoplastic skin conditions.² There are 2 main types of biopsies performed in an office: incisional biopsies (i.e. shave and punch biopsies) sample a portion of a lesion, while excisional biopsies remove the whole lesion for more extensive evaluation.² Shave biopsies are the most commonly used technique, as they are quick to perform, less invasive, less aesthetically damaging, and tend to heal within 1-2 weeks.² Shave biopsies result in removal of a thin sample of epidermis +/- dermis.² Shave biopsies should be kept moist throughout the 1-2 week healing process to reduce scar appearance.² Punch biopsies are the method of choice for suspected pigmented malignancies, inflammatory or bullous conditions, or follicular conditions.² The punch biopsy provides a cylindrical sample of skin that includes the epidermis layer to the adipose (subcutaneous fat) layer, leaving behind a defect that requires closure typically with simple interrupted sutures.² Sutures will be removed 5-21 days later based on the thickness of the skin.²

Electrosurgery, also known as electrodesiccation and curettage (ED&C), is performed with local anesthetic, and involves multiple rounds of electrocautery or “burning” and scraping with a curette.³ This process removes a friable layer of abnormal cancer cells in addition to a safety margin of normal skin cells.³ This minimally invasive surgical procedure results in a ~95% cure rate for superficial non-melanoma skin cancers (NMSC). Unfortunately, the healing process evolves from a circular scab to a thick, sometimes hypertrophic, scar or permanent loss of pigment in the treated area.⁴

Excisional surgery involves greater tissue loss. Following local anesthetic administration, a scalpel is used to remove both the cancerous tumor plus a small area of surrounding skin referred to as a safety margin where the skin is believed to be without cancerous cells; this total area of skin is removed down to the depth of the adipose layer.³ The sample is sent off for histologic testing to ensure that the margins are clear from abnormal cell growth. The surgical defect is either sutured back together or left open to begin the healing process.³ Although most surgical excisions will be sutured, roughly 28% of surgical wounds are left open to heal. This occurs when closing the site poses great risk for infection or when the procedure itself has resulted in heavy tissue loss.⁵ Surgical excision is associated with a 95-99% cure rate of well-defined NMSC and histologic testing to confirm removal. Additionally, when the excision is sutured, the wound will experience rapid healing benefits.⁴

Mohs micrographic surgery (MMS) is the gold standard method for treating NMSC found on delicate or cosmetically-concerning locations of the body, where limited skin complicates a standard closure.³ Thus, it has been dubbed a tissue sparing procedure. MMS involves removing the cancer and minimal margins with immediate histologic examination until negative margins are observed.³ Thus, this procedure is complex, and may require multiple rounds of local anesthesia, tissue removal, and microscopic histological exam.³ This type of precision results in a 99% cure rate. Healing depends on whether the site was closed with sutures, a skin graft (from alternate body location), or left open to heal without sutures.³ A skin graft can be utilized when the defect is too large to be closed.⁶ A split-thickness skin graft (STSG) involves the epidermis and some of the dermis from the donor site, while a full-thickness skin graft (FTSG) includes all of the layers of skin including the epidermis, dermis, and adipose tissue.^6,7 Donor sites for both the STSGs and the FTSGs should be matched to the site in terms of texture, color, thickness, and adnexal structures.⁸ Common STSG sites include skin from the buttocks, thighs, inner arms, and trunk, while common FTSG sites include skin collected from the preauricular area, postauricular area, the inner arm, and the supraclavicular area^.8 Because grafted skin is not connected to a pre-existing blood supply, it relies on imbibition and neo-vascularization to ultimately implant and heal.⁶ The graft will gently be sutured in place along with a bolster, which is an outer covering that supplies uniform pressure over the graft to prevent the formation of a hematoma.^6,9 Since skin grafts are quite complex, they often take longer to heal with the possibility of increased scarring.

Elective/Cosmetic Skin Surgery

While skin surgery is more commonly reserved for the removal of skin cancers, cosmetic removal of benign lesions may require slightly less invasive techniques. Benign appearing skin lesions such as benign nevi or lipomas can be removed with smaller excisions, incisions, shave biopsies, punch biopsies, or electrosurgery.¹⁰

How does the skin repair and regrow?

Hemostasis, inflammation, proliferation, and remodeling are four carefully orchestrated stages of wound healing that occur after injury or surgery.¹¹ Hemostasis occurs at the time of injury, and coordinates the release of pro-inflammatory cytokines and growth factors, which contribute to epidermal growth.¹¹ The release of these molecules signal for the accumulation of neutrophils, lymphocytes, and macrophages (inflammation).¹¹ In the proliferative phase, fibroblasts and endothelial cells lay down collagen and other elements of the extracellular matrix to promote re-epithelialization. Lastly, these elements are remodeled to form a strong epidermal barrier.¹¹

What affects the ability of the skin to heal?

When any of the four stages of the normal skin healing process are interrupted by local or systemic factors, the healing of the skin can be affected.¹¹ Local factors include oxygenation, infection, foreign body, and venous sufficiency, while systemic factors include age, gender, hormones, stress, ischemia, comorbidities, medications, high risk behaviors, and nutrition.¹¹ Age plays a large role in wound healing because thinning skin has decreased collagen content, which poses the risk of skin tearing when sutured shut.¹¹ Similarly, overall physiologic effects of stress (from comorbidities and/or medications) can greatly impact the healing process.

How do we aid this healing process?

Tip #1 Proper hand washing and cleansing of the area during dressing changes

An initial dressing should stay in place for 24-48 hours. Before changing their dressing, the patient should wash their hands thoroughly with an antibacterial soap and water on a clean workspace. The old dressing should be discarded promptly to decrease the risk of infection or contamination.¹² Once the bandage is removed, the patient should take a moment to observe the condition of the wound, noting any pain, excessive redness, or odor.¹² The surgery site can be gently cleansed with warm soap and water. The popular home remedy of hydrogen peroxide (H2O2) use in wound care is controversial as there is conflicting evidence that H2O2 can be damaging to developing granulating tissues and has not been proven effective in reducing bacterial levels.¹³

Tip #2 If the wound is left open to heal, do not let the tissue “dry and die”

Secondary intention, the process of an open wound healing, needs to be constantly treated with moisturization. A moist and greasy surface allows the underlying tissue to stay soft and hydrated in the absence of our innate external waterproof barrier.¹⁴ Plain petroleum jelly is the preferred ointment as it is bland and does not contain ingredients that can cause allergic contact dermatitis.¹⁴ The frequently used Neosporin® triple antibiotic ointment (neomycin-polymyxin-bacitracin) can create allergic contact dermatitis at the site of the wound, particularly on the hands.¹⁵ Often times this will be misdiagnosed as an infection, and improperly treated.¹⁵

Tip#3 If the wound is closed, do not over stress the skin 

Tension on suture sites should be avoided to reduce dehiscence (suture separation) and potential infection.¹⁴ Warm soap and water are enough to gently clean the site; however, care should be taken to avoid soaking the sutured skin for too long, as it increases the risk of the loosening the knots.¹⁴ Ointment is not necessary on a closed wound, although a thin layer of bland ointment can be applied if preferred. It may reduce scarring by encouraging faster re-epithelialization.^14,16 Scar prevention methods can be initiated as soon as soon as 48 hours after the procedure and initially consist of antibiotic application to keep the site clean and moist, but it is unclear which aspect of the antibiotic application, the antibacterial properties, or the moisture provided is actually responsible for reduction in scar formation.¹⁶ Once the re-epithelialization of the wound has occurred, scar products containing silicone may be applied to the wound to minimize hypertrophy.¹⁶ After 2-3 weeks of scar formation, the scar will have developed enough strength that scar massage can be initiated  to soften the scar and reduce the amount of excess collagen.¹⁶ Of note, for the first 18 months, the scar is at increased risk for penetration of UV radiation penetration, so proper sun protection should be discussed.¹⁶   

When to consider infection protocol or further work up

Once the patient is sent home with their wound care instructions, they will likely have new concerns as the wound begins to heal. It is crucial for patients to discern between an expected or urgent situation. Patients should follow up with their doctor if:

1. There is a steady flow of blood from the wound that cannot be stopped with elevation and firm, constant pressure for 20 minutes.¹⁷
2. The patient is complaining of numbness, burning, severe pain, paralysis, muscle weakness, or dry mouth as the procedure may have damaged underlying structures.¹⁷
3. The patient received local anesthetic and is experiencing tingling of the mouth, metallic taste, double vision, muscle twitching, increased heart rate, or chest pain.¹⁷
4. The patient has taken over the counter NSAIDs for pain relief after the procedure, and experiences unrelenting pain, stomach upset, headache, rash, or dizziness.¹⁷
5. Patient reports spreading redness, warmth to the touch around the wound, oozing of pus, foul odor, and increasing pain as the days pass, indicating infection. This will typically occur 3-5 days after surgery, and antibiotics may be required.¹⁷

Key Takeaways

1. Skin biopsies, ED&C, excisional surgery, and Mohs micrographic surgery are amongst the most common procedures performed to diagnose and remove various skin cancers, and each of these procedures have variable healing times and results.
2. We can help patients during their healing process by encouraging proper hand washing and cleaning of the area, encouraging the patient to keep the site moist if left open to heal, and stressing the importance of not overworking the area if it is sutured closed.
3. Ensure that the patient is familiar with what symptoms could be suggestive of an adverse reaction to the anesthetic, procedure process itself, or post-procedure medication. Also ensure that they know what signs of infection to look for and when to seek help.