Face excisions

Penington's favoured excision lines, with major areas of contention in red

General advice:

• Never pull down the lower eyelid, which will lead to ectropion
• Glabella - vertical scars

Forehead:

• Small lesions, or those on mid to upper forehead, should come off with a horizontal excision
• Just be aware of the danger of pulling the eyebrow upwards. Some excisions lower down or with bigger lesions should have a vertical ellipse.
• Be careful of temporal branch of facial nerve in the temporal region, which is quite superficial.

Nose

• Skin becomes more loose superiorly, and can be transferred for local flap closures

Ear

• General considerations
  • Avoid sharp angles in cartilage - tend to become more prominent over time
  • A smooth continuous helical rim is the most important feature to aim for
• Superior margin of helix:
  • Ring block to ear
  • Excise wedge of lesion, including cartilage (to avoid positive deep margin). Can use scissors to go through cartilage and posterior ear skin. A true wedge resection goes deep into the ear, to allow the helix to come back together without being distorted. According to Farquharson's, need to take a slightly wider rim of cartilage than skin to allow easy re-approximation.
  • Direct pressure or diathermy to bleeding
  • Adjacent through-and-through silk sutures, kept long and clipped, to allow manipulation of ear
  • Interrupted 4/0 Monocryl/Vicryl Rapide to anterior skin
  • Flip ear and consider putting a few sutures in the cartilage - not essential according to Murtagh, Farquharson also says unnecessary.
  • Trim back cartilage so it can be fully covered by skin
  • Suture posterior ear skin with more interrupted
  • Chlorsig ointment BD
  • Sutures out in a week if non-absorbable