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Figure 9.42  Technique 1 dog-ear repair with direct overlap excision.
Figure 9.39  Intradermal (continuous subcuticular) stitch. This technique
may be combined with one or more external bridges to make removal of
the suture easier. The major advantage of this technique is in the
reduction of scar tracks from external sutures.
Figure 9.40  The continuous horizontal suture technique allows better
retention of the skin edges than the intradermal stitch.
Figure 9.41  The intradermal (continuous subcuticular) stitch may be
combined with the anti-pull-through tubing when additional retention is
necessary.

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Figure 9.43  Technique 2 dog-ear repair with hockey stick or back-cut
excision.
Figure 9.44  Technique 3 dog-ear repair with double elliptical excision.
Figure 9.45  Technique 4 dog-ear repair with V–Y excision. This is also
referred to as an M-plasty repair.
Figure 9.46  Technique 5 dog-ear repair with perpendicular T-repair.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 9.47  Leashing the dog ear.
(From Khachemoune, A., Krejci-Papa, N., Lee, D., et al., 2005. Surgical pearl: “Leashing the dog ear”. Am Acad Dermatol 52, 514–516, with permission)
A
B
C
E
D
Subcutaneous layer
Dermis
Leashing the “dog ear”

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99
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et al., 1998. The effects of multiple-
strand suture techniques on the tensile
properties of repair of the flexor digitorum
profundus tendon to bone.
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35. Winters, S.C., Seiler III, J.G., Woo, S.L.-Y.,
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36. Tanaka, T., Amadio, P.C., Zhao, C., et al.,
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FURTHER READING
Bechara, F.G., Al-Muhammadi, R., Sand, M.,
et al., 2007. A modified corner stitch for
fixation of flap tips. Dermatol Surg 33 (10),
1277–1279.
Bezwada, R.S., Jamiolkowski, D.D., Lee, I.Y.,
et al., 1995. Monocryl suture, a new
ultra-pliable absorbable monofilament
suture. Biomaterials 16 (15), 1141–1148.
Chan, J.L., Miller, E.K., Jou, R.M., et al., 2009.
Novel surgical technique: placement of a
deep tip stitch. Dermatol Surg 35 (12),
2001–2003.
Christensen, J.C., 1992. Surgical complications
of the forefoot. In: Butterworth, R.,
Dockery, G.L. (Eds.), Color Atlas and Text
of Forefoot Surgery. Mosby Year Book,
St Louis.
Dockery, G.L., 1992. Principles of forefoot
plastic surgery. In: Butterworth, R., Dockery,
G.L. (Eds.), Color Atlas and Text of Forefoot
Surgery. Mosby Year Book, St Louis.
Dockery, G.L., Christensen, J.C., 1986.
Principles and descriptions of design of
skin flaps for use on the lower extremity.
Clin Podiatr Med Surg 3, 563.
Mackay-Wiggan, J., Ratner, D., Sambandan,
D.R. Suturing techniques: eMedicine
Clinical Procedures. Available at: http://
emedicine.medscape.com/
article/1824895-overview
Macpherson, N., Lee, S., 2010. Effect of
different suture techniques on tension
dispersion in cutaneous wounds: A pilot
study. Australas J Dermatol 51 (4),
263–267.
Moody, B.R., McCarthy, J.E., Linder, J., et al.,
2005. Enhanced cosmetic outcome with
running horizontal mattress sutures.
Dermatol Surg 31 (10), 1313–1316.
Monaco, A., Grumbine, N.A., 1986. Lines of
minimal movement. Clin Podiatr Med Surg
3, 241.
Osmond, M.H., Quinn, J.V., Sutcliffe, T., et al.,
1999. A randomized, clinical trial
comparing butylcyanoacrylate with
octylcyanoacrylate in the management of
selected pediatric facial lacerations. Acad
Emerg Med 6 (3), 171–177.
Quinn, J., Wells, G., Sutcliffe, T., et al., 1997. A
randomized trial comparing
octylcyanoacrylate tissue adhesive and
sutures in the management of lacerations.
JAMA 277 (19), 1527–1530.
Singer, A.J., Giordano, P., Fitch, J.L., et al.,
2003. Evaluation of a new high viscosity
octylcyanoacrylate tissue adhesive for
laceration repair: a randomized controlled
trial. Acad Emerg Med 10 (5), 499.
Tajirian, A.L., Goldberg, D.J., 2010. A review
of sutures and other skin closure materials.
J Cosmet Laser Ther 12 (6), 296–302.
Tierney, E., Kouba, D.J., 2009. A subcutaneous
corset plication rapidly and effectively
relieves tension on large linear closures.
Dermatol Surg 35 (11), 1806–1808.
Tsao, S., Yao, M., Tsao, H., et al, 2011. Light
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10.1111/j.1365-2133.2011.10710.x.
Weitzul, S., Taylor, R.S., 2005. Suturing
technique and other closure materials. In:
Robinson, J.K., Hanke, C.W., Siegel, D.M.,
et al. (Eds.), Surgery of the Skin:
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Yu, G.V., Cavaliere, R.G., 1987. Suture
materials and needles: their properties and
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Zuber, T.J., 2002. The mattress sutures: vertical,
horizontal, and corner stitch. Am Fam Phys
66 (12), 2231–2236.
43. Bunnell, S., 1954. Gig pull-out suture
for tendons. J Bone Joint Surg 36-A,
850–851.
44. Kessler, I., 1973. The ‘grasping’ technique
for tendon repair. Hand 5 (3), 253–255.
45. Krackow, K.A., 1986. A new stitch for
ligament-tendon fixation. J Bone Joint Surg
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46. Christensen, J.C., Dockery, G.L., 1986.
Flap classification and survival factors:
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dog ear”. Am Acad Dermatol 52, 514–516.

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CHAPTER CONTENTS
Phases of wound (incision or injury) healing
101
Compromises to wound healing
102
Intrinsic factors affecting wound healing
103
Extrinsic factors affecting wound healing
103
Conclusion
104
PHASES OF WOUND (INCISION OR
INJURY) HEALING
Wound healing is a complex series of events, which must overcome
many obstacles to eventually result in wound closure that is capable
of withstanding the external forces that could disrupt the scarred
epidermis. There is no demarcation between the various phases of
wound healing; rather the process is a continuum with overlapping
stages. There are three primary phases of wound healing: the substrate
or inflammatory phase, the proliferative or fibroblastic phase and,
finally, the remodeling or maturation phase. Each phase must occur
without interruption or interference in order for the next phase to take
place at its appropriate timing and to its full extent.
The substrate phase begins at the onset of the incision or injury with
the initiation of the coagulation cascade and usually lasts for up to
5–7 days. This phase is marked by both increased vascular permeabil­
ity and chemotaxis and is mediated by both a chemical and a cellular
response. The immediate chemical response to injury involves the
release of histamine during the first 30 min, which increases vascular
permeability of the small venules and allows for the release of
cells and chemical mediators into the extracellular space. The cellular
response involves platelet interaction with both collagen and
thrombin, which adhere to each other resulting in cessation of hemor­
rhage. The platelets also release an elaborate list of growth factors.
These endogenous growth factors are capable of regulating wound
repair. The cellular response continues with the orderly arrival of
various leukocyte cell types to provide the groundwork for the forma­
tion of the collagen matrix or substrate upon which all other phases
rely for wound closure. This cell migration is driven by the release of
cytokines, bradykinins and complement-driven anaphylatoxins in the
area and prostaglandins, specifically PGE1 and PGE2. PGE1 antago­
nizes vasoconstriction, increasing permeability and vasodilatation
and PGE2 is chemotoxic for leukocytes. There are currently ongoing
studies to evaluate the effects of human recombinant basic fibroblast
growth factor and its potential benefits in wound healing. Early
studies have shown accelerated angiogenesis, granulation and epithe­
lialization with improved tensile strength of the wound compared to
control group but still less strength than normal uninjured skin. This
may prove helpful in the healing of skin flaps and grafts with improved
take of the graft.
The early substrate phase is identified by the arrival of both neu­
trophils and macrophages, but neutrophils are in greater number. The
function of the neutrophils is to rid the wound of any contaminates
present, such as foreign body or bacteria. If there are no wound com­
plications, the neutrophil concentration decreases after just a few days
making way for the influx of the monocytes. Monocytes arrive along
with the neutrophils in the early inflammatory stage and quickly
convert to macrophages as the neutrophil population decreases. The
macrophages are the true workhorses of the substrate phase. They
phagocytose and digest pathogenic organisms, scavenge tissue debris
and release biologically active substances such as nitrous oxide that
will aid in the destruction of pathogens, including Staphylococcus
aureus, and increase vascular permeability. These active substances
recruit additional inflammatory cells into the area to aid in decon­
tamination and debridement and also release growth factors necessary
for tissue repair. The growth factors stimulate granulation tissue for­
mation and angiogenesis that provide the foundation for the transi­
tion between the substrate inflammatory phase and the proliferative
phase.
As the wound begins to enter the proliferative phase, the fibroblasts
start arriving in record numbers, reaching their maximum number at
approximately 1 week after the insult occurs. The fibroblast responds
to the chemotactic and growth factors released by the macrophages in
the first phase. This crucial cell type is responsible for the formation
of the connective tissue component of collagen and glycosaminogly­
cans that make up the connective tissue matrix that provides a sub­
strate for the migrating macrophages, fibroblasts and new blood
vessels. These cellular and vascular elements are embedded in the
loose matrix of collagen, fibronectin and hyaluronic acid. Fibronectin
©2012 Elsevier Ltd.
Wound-healing properties
Mary E. Crawford
Chapter
10

102
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and into the remodeling phase. The epithelial cells at the wound edge
begin to proliferate 1–2 days after injury and serve as a population of
migrating cells across the wound. As they migrate, the epithelial cells
undergo phenotype alteration with retraction of intracellular tonofila­
ments, dissolution of majority of intercellular desmosomes and for­
mation of peripheral cytoplasmic actin filaments. This alteration gives
the cells increased motility allowing for epithelialization. Upon com­
pletion, the cells return to their former phenotype and adhere firmly
to the underlying basement membrane.
The process of wound healing is a complex intricate pathway of
both chemical and cellular responses. The cascade of events allows for
the orderly process by which a wound will eventually heal. But what
happens when that pathway is interrupted?
COMPROMISES TO WOUND HEALING
There are many circumstances in the wound environment that may
impede or prevent satisfactory healing and scar formation. Some of
the factors that may have a detrimental effect on wound repair are
enhances fibroblast movement and aids in wound contracture. Fibrob­
lasts also synthesize and secrete keratinocyte growth factor which
stimulates neighboring keratinocytes to migrate in the wound and
differentiate in the epidermis for epithelialization.
The final stage of wound healing begins at approximately 3 weeks
and continues for up to 1 year. Normal uninjured skin is made up of
80–90% collagen I and 10–20% collagen III. The maturation or
remodeling phase is characterized initially by the formation of a thin
layer of collagen III that makes up the scar tissue and is parallel to the
skin and allows the fibroblasts, neutrophils and macrophages to move
easily through it. As the scar matures, the previous highly cellular
granular matrix transforms into a relatively acellular mass of type I
collagen bundles in a lattice network. These bundles provide increas­
ing tensile strength to the residual scar. The scar, however, will never
return to its full strength. At 3 months and beyond, it is approximately
80% of its original strength. Figure 10.1 demonstrates the major cells
involved in the various phases of wound healing and their effects on
normal wound healing.
The process of re-epithelialization is an ongoing process that begins
in the inflammatory phase and continues through the proliferative
phase with the release of keratinocyte growth factor by the fibroblasts
Figure 10.1  Figure demonstrating the major cells involved in the phases of wound healing and their effects on normal wound healing.
(From Li J, Chen J, Kirsner R. Clin Dermatol 2007; 25:9–18.)
Hemostasis
Platelets
Fibrin clot formation

Vasoactive mediator release

Cytokine and growth factor release
Inflammation
Master cells
Platelet-activating mediator release

Vasoactive and chemotactic mediator
Neutrophils and
Chemotaxis, inflammation
Monocytes
Killing and phagocytosis, wound

debridement
Macrophages
Chemotaxis, inflammation

Killing and phagocytosis, wound

debridement, cytokine and

Growth factor release, NO synthesis
Skin resurfacing
Keratinocytes

Reepithelialization
Dermal restoration
Endothelial cells

Angiogenesis
Fibroblasts

Fibroplasia
INFLAMMATION
PROLIFERATION
Keratinocytes
Epidermis maturation
Myofibroblasts
Wound contracture

Apoptosis and scar maturation
Endothelial Cells
Apoptosis and scar maturation
REMODELING
Minutes
Hours
Days
Weeks
Months

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| 10 |
chemotaxis and bacterial phagocytosis, and too little zinc leads to
insufficient collagen deposition. Normal levels of zinc are essential to
stabilizing the inflammatory cell membranes. Crucial amino acids,
arginine and glutamine, as well as vitamin folate, have been shown to
be important for proper protein synthesis and collagen maturation in
the wound healing cycle and may also accelerate wound healing.
As we have seen from other immunocompromised and nutritional
states, oxygen, and the lack thereof, can have a detrimental effect on
wound healing. Any medical condition that results in chronic anemia
or hypoxia to the tissues can have a deleterious effect on wound
healing. This can be seen in all patients who suffer with peripheral
vascular disease (PVD) as well as those with a systemic condition that
results in chronic anemia. PVD results in a reduction of nutrients to
the tissues and cells necessary to fight bacteria. This is also seen in
connective-tissue diseases, such as rheumatoid arthritis, SLE, sclero­
derma and MCTD. These conditions result in a chronic anemic state
that decreases the amount of available oxygen to the tissues, which
increases the opportunity for bacterial colonization. A state of hypoxia
to the tissues is also induced from the extrinsic factor of smoking. The
vasoconstrictive property of nicotine and other chemicals present in
tobacco products will impede wound healing and is a major factor to
consider before surgical intervention.
Ageing has some effect on the phases of wound healing, especially
the remodeling or maturation phase. A study by Bond et al. (2008)
showed that scars produced in younger volunteers, <30 years of age,
demonstrated a prolonged high turnover state and retarded rate of
maturation compared with older subjects of >55 years of age, which
displayed accelerated maturation of the scar. In general, the scars in
older patients in this optimal healing environment were better clini­
cally but this population of patient is not often present in reality, as
the older patient may be nutritionally challenged or systemically ill
with diabetes or other medical conditions that can delay wound
healing.
Extrinsic factors affecting wound healing
One of the most serious extrinsic factors complicating wound healing
is infection. Bacteria compete with the newly forming tissue for nutri­
ents and oxygen and leads to eventual tissue anoxia and starvation.
Tissue anoxia and the lactic acid produced by the bacteria results in a
lower pH and further tissue breakdown, especially in light of what we
have already seen when oxygen levels are low. Aerobic bacteria com­
plicate this environment even further due to their high oxygen con­
sumption. In some cases of poor wound healing, the culprit can be
poor tissue handling by the surgeon.
Tissue that is overexposed to air or hot surgical lights becomes desic­
cated with increased risk of infection. Desiccation results in destruc­
tion of surface cells and inhibits leukocyte phagocytosis of bacteria.
The devitalized tissue also creates an environment conducive for
anaerobic bacterial growth. Inadequate hemostasis during surgery can
also lead to poor wound conditions due to a hematoma, seroma and
edema formation. This is a relatively anoxic environment that is favo­
rable for bacteria, but not for phagocytosis and cellular repair. Some
surgeons will insert drains to combat the formation of a hematoma
or seroma postoperatively, which can decrease PO2. The body may
react to the drain, or any material left in the wound area (i.e. suture),
as a foreign body and attract macrophages to the area, but not enable
them to control bacteria because of the decreased oxygen level.
Probably the greatest extrinsic factor over which both the patient
and the doctor have control, is the use of pharmacologic agents that
can hinder wound repair. Of those agents prescribed, glucocorticoids
have the most devastating effect in several areas of tissue repair. In
general, glucocorticoids break down tissue fat and protein, inhibit
cellular proliferation and inhibit tissue growth by inhibiting DNA
systemic, while others are local processes. Some of the factors are
extrinsic, such as infection, others are intrinsic, such as nutrition. Basi­
cally, any condition that decreases the blood supply to the area
decreases the effectiveness of the inflammatory phase, or results in an
alteration in the repair process leading to the formation of fibrous
adhesions, and this can have a deleterious effect on wound healing.
These conditions can be associated with a patient’s general medical
or nutritional status, pharmacologic agents, the ageing process and
hereditary diseases.
Intrinsic factors affecting wound healing
A multitude of conditions can lead to a diminished medical status
that could result in inadequate wound healing. A patient who is
immunocompromised for whatever reason will exhibit decreased host
resistance to bacteria, thereby requiring a lower number of bacteria to
colonize a wound and impair its healing. Diabetes mellitus is a preva­
lent disease in our society that all too often results in a non-healing
wound with complications. There are two theories as to why diabetes
mellitus impairs the normal wound-healing mechanics. The first
theory is that the wound is reliant on small vessels for nutrients and
blood supply and that these vessels are dysfunctional or occluded in
patients with diabetes. The second theory focuses more on the diabetic
disease itself and postulates that there are metabolic aberrations
related to hyperglycemia, insulin deficiency and insulin resistance.
Hyperglycemia of >200 mg/dL decreases phagocytosis and decreases
the killing of bacteria by white blood cells.
The inflammatory exudate in diabetics is found to be deficient in
white cells and exhibits a poorly-defined inflammatory response. The
fibroblasts also have limited reproductive capability in the presence
of hyperglycemia, thereby resulting in abnormal collagen or an abnor­
mal amount of collagen. Besides the hyperglycemic environment, a
deficiency of insulin also may lead to a decrease in collagen produc­
tion and decreased wound tensile strength, as insulin is required to
enhance both granulation tissue and collagen formation.
Other common causes of an immunocompromised patient are
poor nutritional status, peripheral vascular disease and collagen dis­
eases, such as rheumatoid arthritis, systemic lupus erythematosus
(SLE), scleroderma and mixed connective tissue disease (MCTD).
Nutritional disorders can range from inadequate to inappropriate
food intake and can lead to a complement-deficient state. Both chem­
otaxis and opsonization are complement-dependent factors that,
when defective, lead to a wound environment favorable for bacteria
growth. A state of hypoproteinemia will prolong the lag phase of
inflammation and prevent the onset of the fibroblastic stage, thereby
resulting in a decrease in collagen synthesis and decreased wound
strength. Hypovolemia results in impaired oxygenation of the wound
due to reflex vasoconstriction and fibroblasts are damaged in the
proliferative phase.
Vitamins and minerals in elevated or depleted levels may also alter
the biologic chemistry of the healing wound. Ascorbate and oxygen
are required for hydroxylation of proline on the collagen chain and,
therefore, if deficient, collagen is quickly degraded. Vitamin E in high
doses decreases collagen production, but in insufficient quantity, also
interferes with tissue repair, as it is no longer available as an antioxi­
dant and biologic membrane, and lysosomes are thereby oxidized.
Vitamin A deficiency delays re-epithelialization, decreases collagen
synthesis and decreases collagen stability. Vitamin C deficiency results
in capillary fragility, impairs macrophage migration and neutrophil
function, decreased synthesis of complement and immunoglobulin
and destabilizes collagen. Zinc has received increased press over the
past few years with regard to health maintenance, and its role in
wound management is no exception. Zinc can be detrimental in either
too high or too low a dose. Too much zinc results in a decrease in

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
broad-spectrum systemic antibiotics also may be detrimental to the
wound as the normal inhibitory flora is annihilated, allowing the
invading bacteria to flourish.
One final pharmacologic agent frequently prescribed that may have
ill effects on wound healing is the anticoagulant, e.g. warfarin and
heparin. The formation of a clot is paramount to the formation of a
fibrin matrix on which collagen is laid to complete wound healing.
Warfarin blocks the formation of vitamin K and vitamin-K-dependent
clotting factors. Heparin inactivates thrombin and inhibits blood clot­
ting. This may lead to impaired clot formation and thereby prevent
the fibroblastic matrix from forming. Salicylates, such as aspirin, may
have similar effects on the prevention of clot formation by decreasing
platelet aggregation. This certainly raises the question of the risk vs
benefit ratio when the surgeon must decide whether to prophylax
their patient for the risk of a thrombus postoperatively.
CONCLUSION
As physicians, multiple decisions must be made in the treatment
and appropriate management of a wound. Owing to the intricacies
of the phases of wound healing, there are many factors that can play
a role in the success or failure of tissue repair. Understanding the
phases and the requirements of the tissues at each stage will enable
us to optimize the wound environment to allow for normal tissue
healing.
synthesis. They also inhibit the inflammatory reaction by decreasing
both the exudate formation and accumulation of inflammatory cells
at the site of the injury and inhibiting prostaglandin E formation.
When the normal inflammatory response is prevented, the cascade
of events will not occur. The recruitment of both neutrophils and
monocytes to the wound in the inflammatory phase is suppressed,
which then delays the debridement of the wound by phagocytosis and
delays the preparation of the wound for the fibroblastic phase. Glu­
cocorticoids also inhibit fibroblast proliferation and epithelialization,
and reduce collagen production by decreasing synthesis of the prote­
oglycans and glycosaminoglycans necessary for collagen formation.
The result is a thin matrix and thin epidermis that is easily damaged
or broken down. Glucocorticoids have their greatest impairment if
given during the inflammatory phase of wound healing. Similar, but
what appear to be much less destructive, results are seen with non-
steroidal antiinflammatory medications, as they may also inhibit the
inflammatory phase of wound healing. This concept is the basis for
the ongoing controversy of prescribing antiinflammatory medications
immediately postoperatively and interfering with the substrate or
inflammatory phase of wound healing.
The use of antimicrobial agents is also commonplace, but can be
controversial in regard to wound healing. Topical antimicrobial agents
that are frequently used in open-wound management include iodo­
phor, acetic acid and hydrogen peroxide. However, all of these agents
are cytotoxic to both the bacteria and the host tissue. This can retard
wound epithelialization and can result in relative necrosis of the
surface cells leading to anoxia and decreased microcirculation. More
FURTHER READING
Andersen, D.K. (Ed.), 1993. Master series
in surgery: advances in wound healing
and tissue repair. World Medical Press,
New York.
Bond, J.S., Duncan, J.A., Sattar, A., et al.,
2008. Maturation of the human scar: an
observational study. Plast Reconstr Surg
121, 1650–1658.
Broughton, G., Jannis, J., Attinger, C., 2006.
The basic science of wound healing. Plast
Reconstr Surg 117 (Suppl), 12S–34S.
Browder, W., Williams, D., Lucore, P., et al.,
1988. Effect of enhanced macrophage
function on early wound healing. Surgery
104, 224–230.
Campos, A.C., Groth, A.K., Branco, A.B., 2008.
Assessment and nutritional aspects of
wound healing. Curr Opin Clin Nutr
Metab Care 11, 281–288.
Chambers, A.C., Leaper, D.J., 2011. Role of
oxygen in wound healing: a review of
evidence. 20 (4), 160–164.
Cohen, I.K., Diegelmann, R.F., 1993. Wound
healing. In: Greenfield, L. (Ed.), Surgery:
Scientific Principles and Practice.
Lippincott, Philadelphia, pp. 86–87.
Cohen, I.K., Diegelmann, R.F., Lindblad, W.J.
(Eds.), 1992. Wound healing: biochemical
and clinical aspects. WB Saunders,
Philadelphia.
Datubo-Brown, D.D., 1990. Keloids: a review
of the literature. Br J Plast Surg 43,
70–73.
Diegelmann, R.F., Cohen, I.K., Kaplan, A.M.,
1981. The role of macrophages in wound
repair: a review. Plast Reconstr Surg 68,
107–110.
Dingfelder, J.R., 1982. Prostaglandins: a review.
N Engl J Med 307, 747.
Glat, P.M., Longaker, M.T., 1997. Wound
healing. In: Aston, S.J., Beasley, R.W.,
Thorne, C.H.M. (Eds.), Grabb and Smith’s
Plastic Surgery, fifth ed. Lippincott-Raven,
Philadelphia, pp. 3–12.
Lawrence, W.T., Diegelmann, R.F., 1994.
Growth factors in wound healing. Clin
Dermatol 12, 157–158.
Li, J., Chen, J., Kirsner, R., 2007.
Pathophysiology of acute wound
healing. Clin Dermatol 25, 9–18.
Lu, W.W., Ip, W.Y., Jing, W.M., et al., 2000.
Biomechanical properties of thin skin flap
after basic fibroblast growth factor (bFGF)
administration. Br J Plast Surg 53,
225–229.
Lynch, S.E., Nixon, J.C., Colvin, R.B., et al.,
1987. Role of platelet-derived growth factor
in wound healing: synergistic effects with
other growth factors. Proc Natl Acad Sci
USA 84, 7696–7700.
McGee, G.S., Davidson, J.M., Buckley, A., et al.,
1988. Recombinant basic fibroblast growth
factor accelerates wound healing. J Surg Res
45, 145–153.
Nanney, L.B., 1994. Biochemical and
physiologic aspects of wound healing. In:
Wheeland, R.G. (Ed.), Cutaneous Surgery.
WB Saunders, Philadelphia, pp. 113–121.
Nanney, L.B., 1990. Epidermal and dermal
effects of epidermal growth factor during
wound repair. J Invest Dermatol 94:
624–629.
Ono, I., 2002. The effects of basic fibroblast
growth factor (bFGF) on the breaking
strength of acute incisional wounds. J
Dermatol Sci 29:104–113.
Ono, I., Akasaka, Y., Kikuchi, R., et al., 2007.
Basic fibroblast growth factor reduces scar
formation in acute incisional wounds.
Wound Rep Reg 15: 617–623.
Peacock Jr., E.E., 1984. Wound repair, third ed.
WB Saunders Co, Philadelphia.
Vermolen, F.J., Javierre, E., 2011. A finite-
element model for healing of cutaneous
wounds combining contraction,
angiogenesis and closure. J Math Biol
10 (1), 1–10.
Zhang, X.J., Chinkes, D.L., Herndon, D.N.,
2008. Folate stimulation of wound DNA
synthesis. J Surg Res 147:15–22.

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CHAPTER CONTENTS
Introduction
105
Uses of photography in practice
106
Equipment
106
Macro format
106
Focal length
106
Optical and digital zoom
107
Resolution
107
Image collection
107
Storage formats
107
Accessories
108
Lighting sources
108
Guidelines for digital medical photography
108
General considerations
109
Operating room images
109
Photographing X-rays and other imaging studies
109
Copying slides
109
Medical presentations
110
Publishing digital images
110
The digital darkroom and photo editing software
110
Conclusion
110
INTRODUCTION
Photography has been used to suit medical purposes for quite some
time, with little change in method until the relatively recent advent of
digital photography. The beginning of digital photography offered
inferior quality to that of traditional photography, with substantially
more expense for the equipment required. However, it is fair to say at
present, that digital technology now offers equivalent or better quality
to that of traditional photography, at similar expense. The savings in
consumable supplies in most cases now makes digital photographs
less expensive. The cost of professional grade equipment has been the
area of greatest improvement.
The essence of the photographic technique has changed little with
the photographic equipment of the digital age. The changes in meth­
odology are however more technical. There is little difference between
the optical aspects of traditional film techniques, the main differences
are primarily with regard to the recording of the light image and the
manipulation of that image thereafter. The film techniques of record­
ing optical images are limited to that of the technology of film and
the chemical processes that follow in order to develop the film. Digital
techniques record the image on an optical sensor. The most common
of these optical sensors is a charge-coupled device (CCD). These
devices record the light image for the purpose of storing this informa­
tion as a picture in a digital format. The data are then processed by
computer hardware and software to allow for display, manipulation
and production of images to be used in printed and video formats. It
should be noted that traditional photography images were limited to
what film allows based on its recording of light. Digital photography
is limited in the same way by the optical sensors recording of light.
Thus, a photographic image from each medium is not exactly the
same. Practically however, in medical photography, they are equal and
inconsequential.
Digital photography is convenient for several traits inherent to the
medium. The images themselves and the quality of the images are
available for viewing and feedback almost instantaneously. With the
advent of digital projectors, presentations can be developed for use in
a short period of time, without the need for complex photographic
services. As mentioned previously, the consumables in traditional
photography, consisting of film and processing, proves to be expensive
over time when comparing the cost of storing information digitally.
Storage hardware continues to increase in capacity while at the same
time decreasing in cost. There is no visible end, at this point, to the
growth of storage technology.
Digital manipulation of pictures is another advantage of digital
photography. On a computer, with instant feedback, an image can be
manipulated to improve its usefulness and to reproduce it in either
an imaging or hardcopy format quickly. This process permits utiliza­
tion of computer technology in place of the darkroom. This allows
©2012 Elsevier Ltd.
Digital medical photography
Christopher J. Lamy
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Macro format
The important considerations in selecting a camera include: macro
capability, speed of the lens, focal length of the lens and resolution.
One must also understand the format in which an image is to be
stored. If there is a need to utilize certain accessories with a camera,
then it is of course necessary to ensure the selected camera has the
specification capability to work with those accessories. Often thought
to be of lesser importance, is the medium in which the digital images
are stored, sometimes referred to as digital film.
Macro capability is one of the most important features to look for
in a digital camera to be used for medical purposes; this is also now
an important consideration for traditional film photography tech­
niques. Macro capability is essentially the ability to focus very closely
on an object without significant distortion. In medical photography
it is often necessary to shoot images close up, e.g. in areas of anatomy
either in the clinical setting or in surgery, or in copying images, such
as X-rays and magnetic resonance imaging (MRI), computerized tom­
ography (CT) or bone scans. In traditional film photography with a
35-mm camera, macro photography usually means getting close
enough to an object so that the picture on the negative equals the
actual size of the object. This would also apply to a slide, where a
picture of an object on a slide is equivalent to its actual size. It is
important to note that at times, the macro feature of a specific camera
or lens may be exaggerated in the product information.
It is best to quantitate what is meant by the term macro. This is
usually displayed as a ratio of the size of the object in relationship to
its size on film. In the traditional definition of macro, this ratio would
be 1 : 1. This essentially means the size of the object on the negative
slide is exactly the same size as the object itself. The ability to get to
a 1 : 1 ratio is only needed for a few applications. An example would
be that of copying a 35-mm slide with a digital camera. This degree
of macro is also helpful for copying the small images of a CT or MRI
scan. For other purposes, generally a 1 : 2 ratio is acceptable. In this
case, in 35-mm photography, the image would be approximately one-
half the size on film as its actual size.
Focal length
A practical method for seeing what ratio a digital camera is capable
of is to focus on a US quarter. This coin is approximately the same
diameter as the height of a 35-mm image (Fig. 11.1). Therefore, if you
can focus on the coin and fill the picture with this object from top to
bottom, this demonstrates approximately a 1 : 1 ratio (Fig. 11.2). Like­
wise, if you can only focus close enough to allow for two of these
coins to fit the height of the picture frame, this demonstrates approxi­
mately a 1 : 2 ratio. It also may be helpful to look at the specifications
of the product information supplied, but beware of exaggeration, as
mentioned above.
Focal length is typically stated differently for digital photography
compared with that of 35-mm film photography. In 35-mm photog­
raphy, a short telephoto lens is ideal for medical application. This
allows enough magnification to distance yourself from the photo­
graphic object. In the operating room, this is especially important
since you want to obtain a close enough image to view detail without
being too close and in danger of contaminating the surgical field. An
example of the focal length of a short telephoto lens would be approx­
imately 100–105-mm lens. In digital photography, the zoom of
the camera is used to describe the focal length. The equivalent of the
short telephoto used in 35-mm photography would be close to the
same as a three times zoom in digital photography. The exception
where a digital camera may measure focal length the same as in
35-mm photography, is with a professional digital single lens reflex
(SLR) camera.
users of the technology greater access to the manipulation process
previously only available to advanced amateur and professional pho­
tographers. Darkrooms required dedicated space, dedicated unique
equipment and chemistry. Common computer equipment is now
used in place of the complexities of the darkroom. The only unique
equipment to processing and manipulating images is the software.
Traditional photography darkroom work required substantial experi­
ence and skill compared with that of digital photography’s digital
darkroom. My personal experience is that skills in the darkroom took
over 4–5 years to master, whereas it took only a few weeks to learn a
digital photograph program.
To utilize this technology effectively, one must understand the
equipment and terminology used in digital photography. It is helpful
also to understand some of the known pitfalls and pearls in taking
and processing digital images. It is the purpose of the following to
provide this basic fund of knowledge. However, it is pertinent to note
that this is a rapidly changing technology and it should be considered
that this information is likely to quickly become dated.
USES OF PHOTOGRAPHY IN PRACTICE
Digital photography has done little to change the spectrum of how
images or photographs are used in the medical field. Digital photog­
raphy has, however, changed the ease and speed with which images
or photographs can be obtained and this, in itself, has increased its
use. The areas where medical photography is best used are for docu­
mentation of patient conditions, copying medical data, making scien­
tific presentations and for medical publication purposes.
In the area of documentation, the quickly available images can be
placed in a chart or sent to a colleague in analogue or digital format.
The ‘turnaround time’ is significantly decreased, making digital tech­
niques more useful in the clinical setting for the purpose of commu­
nication. Digital photography also can be used for quickly copying
images, e.g. for radiologic images or to copy a report for later printing
or reference. Perhaps the greatest use has been in the area of medical
education. With the use of digital presentation programs, a group of
clinical images can be virtually dropped into slides for digital display
shortly before a lecture presentation and the presentation can be
rapidly altered, if necessary, based on any relevant information pro­
vided by the previous speakers. Digital images can also be utilized in
an effort to promote one’s practice to the community or to other
physician groups. Industry has already utilized this technique for
marketing their materials to physician groups.
EQUIPMENT
The principal equipment necessary to begin utilizing digital photog­
raphy of course, is the digital camera. Several technical considerations
are important in choosing a camera for medical photography. Profes­
sional digital cameras costing thousands of dollars are certainly the
best for meeting the demands of medical photography but often an
inexpensive digital camera will be satisfactory and will suit the needs
of most individuals. These digital cameras also have several advan­
tages over more complex professional level equipment. Ease of use
and portability are advantages that have value in medical photogra­
phy. The ability to obtain a large number of images increases the
chance of getting the ideal image and professional photographers
obtain huge numbers of images to get the best image to suit a specific
use. For the purposes of publication, an individual may need a higher
specification camera.

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Resolution
The other important concept to take into consideration when selecting
a camera is the resolution. This is a quality of the camera, which has
definitely improved over the last few years. The resolution is a speci­
fication of the optical sensors capabilities. The optical sensor is essen­
tially made up of a grid that has multiple small optical sensors, each
of which record a single color. It is the combination of these colors
in the grid that record the image or picture. Each point on the sensors
grid represents a recorded color and is termed a pixel. A picture or
image is typically made up of millions of pixels. To represent the
quantity of 1 million pixels, the term megapixel is used. The propor­
tions of the image are generally similar to that of the 35-mm format.
The proportions of a 1 megapixel optical sensor will have an approxi­
mate grid of 1280 pixels by 960 pixels (Box 11.1).
Professional and advanced amateur digital cameras presently exceed
the 8–10 Megapixel resolution range.
Image collection
Images recorded by the digital camera are stored in memory media
inside the camera. These images are then transferred either to a com­
puter or directly to a printer. There are several methods used to transfer
these data. One method is through a cable transfer, which typically
transfers the image through a cable plug into the camera and into the
computer. Most commonly, these cables plug into the USB port on
the computer, although there are other ports available, including
FireWire, serial and parallel ports, which are also capable of data
transfer. USB is considered the standard to transfer still images, while
motion picture files are transferred by USB but also commonly via
FireWire. Traditional parallel and serial ports are antiquated at this
point. The other commonly used method to transfer the data is by
digital film. With this method, the image is transferred onto a media
chip when the photograph is taken by the camera. The media chip
can then be removed from the camera and placed in a reading device,
typically called a card reader. It may then be copied from the media
chip to the computer. Many computers have a card reader built in.
There are multiple types of digital film media available (Fig. 11.3).
These presently include: CompactFlash, SmartMedia, Secure Digital
and memory sticks. There are also others and some cameras have
internal memory capacity.
The type of media used is not of particular importance when select­
ing a camera, as they all work in a similar fashion. It should be noted,
however, that these media devices have different memory capacities
for data. This makes the capacity for holding the number of images
and the detail of images dependent on the media capacity. The type
of media used by each camera is specific, thus one must recognize that
the type of media to be used will be specific to the camera model.
Storage formats
Images are stored in several formats. These formats include uncom­
pressed files and compressed files. Uncompressed files preserve the
greatest degree of detail of the image data. In contrast, compressed
Optical and digital zoom
It is important also to understand in digital photography, the differ­
ence between optical zoom and digital zoom. Essentially, optical
zoom is the only important consideration. Digital zoom specifically
refers to cropping the picture or image at the time the photograph is
taken. This is essentially useless in medical photography. The digital
zoom should not be utilized at the time of photographing an object
and cropping should be saved for altering the image after it has been
taken and stored. Thus, when choosing a digital camera, only consider
the optical zoom of a camera, which should have a minimum of a
three times zoom quality.
Figure 11.1  Focal length check. A US quarter is approximately the same
diameter as the height of a 35-mm image.
Figure 11.2  Focal length check. If you can focus on a US quarter and fill
the picture, this demonstrates a 1 : 1 ratio.
Box 11.1  Megapixels and grid dimensions
1.0 Megapixel = 1280 × 960
2.1 Megapixel = 1600 × 1200
3.2 Megapixel = 2048 × 1536
4.0 Megapixel = 2288 × 1712
5.2 Megapixel = 2560 × 1920

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
in the first place. Detail obtained in the original recording of an image
is real and altering with digital enhancement software is fabricated.
In the past few years, the image megapixel capabilities of cameras
have increased. This may seem to be an increase in the quality capabil­
ity of the camera. However, at the inexpensive cameras end of the
spectrum, the ability of the cameras to shoot uncompressed images
has become less common. This makes comparing cameras much more
difficult. Previously you could compare uncompressed formats and
get a realistic idea of the resolution the camera has to offer. Now, with
compression being commonly the only format some cameras offer, it
is much more difficult and one must resort much more to evaluation
of the camera and other resources, such as camera reviews. The mid­
range cameras are more likely to offer better image quality. Thus, the
dilemma is between features, size, image quality and price. Choice in
this regard is likely a good thing but makes it more difficult to make
a decision.
Accessories
In addition to understanding the characteristics of the camera and its
storage media, an understanding of dependent accessories is also
important. These include batteries to power the camera, close-up filter
sets and additional light sources. All digital cameras require batteries.
It is characteristic at the time of this writing, that digital cameras have
a particularly high draw of power from the batteries. Consequently, it
is most efficient to use alkaline batteries or rechargeable lithium or
Nickel metal halide (NiMH) batteries.
A close-up filter set may be helpful if your particular digital camera
does not allow for a 1 : 1 macro ratio (Fig. 11.4). The need for using
these sets is less common than in the past, since in almost any price
range, a reasonable macro-like lens can be obtained and the increased
resolutions available allow for more cropping with less loss of detail.
Close-up filters are still of value as an inexpensive tool worthy of
mention. To utilize these filter sets, the camera must have a thread
mount on the front of the lens for attaching the filter lenses. Typically,
the sets include three lenses that will allow for closer photography. It
should be noted that, in order to utilize the filter, the screen display
LCD will be needed to view the subject when taking the picture. These
lenses are relatively inexpensive and may be very beneficial to improve
medical photography techniques.
Lighting sources
Most digital cameras are supplied with a built-in flash. There are times
when an external light source may be helpful. Existing light is often
adequate however and even ideal for obtaining satisfactory images
with digital photography. Digital cameras can often be used in con­
junction with external flashes designed for 35-mm photography. A
helpful alternative is to consider using motion picture lighting, as in
video photography (Fig. 11.5). This allows for previewing the image
with the lighting on the LCD screen before the picture is taken. Video
photography uses the same technology as still photography. Thus,
lighting designed for video is optimized for use in photography
whether still or video.
GUIDELINES FOR DIGITAL
MEDICAL PHOTOGRAPHY
This section is intended to provide guidelines for obtaining images
for medical or practice use. As discussed previously, one should con­
stantly consider the possible uses for these images in consideration of
files allow storage of images in much smaller files. For example, an
uncompressed 2 megapixel image is approximately 2 MB in size. At
the cost of loss in detail, the same 2 megapixel picture can be stored
in a file size <1 MB. Uncompressed files include bit map files and tag
image format files, designated with a BMP and TIFF respectively,
whereas compressed files are primarily joint photographic experts
group commonly called JPEG files (pronounced J-peg). Other com­
pressed files formats include compressed TIF formats and GIF.
The compressed formats include Lossy and Non Lossy or Lossless
types. The Lossy formats are characterized by the loss of image detail
in the compression scheme, whereas, Non Lossy or Lossless do not
involve loss of detail. The most common compression scheme used,
JPEG, is a Lossy form of compression and more image detail is lost
with these files. It is important to understand which file format your
camera and equipment use before you choose to convert to another
format. In other words, it is important to understand the conse­
quences of those files formats.
Ultimately, the image needs to be acquired and stored with enough
detail to make it usable for all intended purposes. Storing in greater
detail requires more storage space and more time and hardware
resources to manipulate and display the images. The clear conse­
quence of both lower resolution discussed earlier and compression,
is the loss of detail in the image. The compromise decided upon
should be based upon the intended use of the images. Keep in mind
that once an image is stored at a particular resolution, the resolution
can never be increased. Using image enhancement software is always
less desirable and less effective than storing the image in higher detail
Figure 11.4  A close-up filter set with three rings.
Figure 11.3  Digital films. Right: Secure Digital Media; left: SmartMedia
media.

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is utilized to fill in this void or deep space. Otherwise, the contrast in
light between the deep area and the superficial area will usually cause
the deep area to appear too dark, thus detail is either diminished or
entirely lost.
Photographing X-rays and other
imaging studies
This discussion will rapidly become obsolete as digital X-rays become
the standard. The images will then be obtained directly from the
radiography software or through screen capture techniques. The ulti­
mate goal when obtaining digital imagery of radiographic studies is
usually to show the pathology that is present. There are several tech­
niques that can help in accomplishing this objective. Often, it can be
helpful to obtain a perspective shot of the image to show the complete
study, and to obtain a close-up image to enhance the pathology. With
many digital cameras, especially non-professional cameras, it is diffi­
cult to obtain an exposure that will detail both an X-ray image of the
forefoot and rearfoot well. This is due to the lack of ability for the
optical sensor to record the spectrum of contrast on the X-ray film. In
many cases, one must choose an exposure that will demonstrate either
the forefoot or the rearfoot but not both. It also may be more effective
to take the images in the non-compressed format, since this will
record the image with less data loss. It may be helpful in reducing the
size of the file after obtaining the image by converting it to a grayscale
image. This allows reduction in the size of the file without loss of
attributes since these radiographic images only have grayscale tones.
When taking images of MRIs and CT scans, reflection off the shiny
side of the film may be an issue. This can often capture a reflection of
the camera and the photographer in the photograph by a subtle reflec­
tion off the film. This can be avoided by flipping the film over and
shooting from the non-shiny side, if there is a difference in gloss
between both sides. Alternatively, shooting the film images in the
darkroom with masking around the film to prevent surrounding light
from the light box reaching the photographer, may also solve this
problem.
Copying slides
In some instances, it may be necessary to transfer material from other
forms of media to digital images. The process of converting an image
to digital format is often referred to as digitizing. With regard to pres­
entations, the media usually is in the form of 35-mm slides, since
presentations in the past were typically given from slides. Devices are
available to digitize these images and produce variable quality. Alter­
natively, a digital camera that has the capability of shooting macro
images at 1 : 1 can be utilized with a light box to obtain effective digital
images from 35-mm slides. This technique involves placing the slide
on a light box and masking it in and then simply taking a photograph
of the slide. It may be helpful to utilize a copy stand, especially when
copying a volume of slides. Also it may be helpful to mask the slide
from the surrounding light on the light box and shoot the image in
a darkened room.
The discussion earlier in this chapter outlined the characteristics of
obtaining digital images at a ratio of 1 : 1. If the particular digital
camera can obtain 1 : 1 images compared with that of a 35-mm slide,
then the slide can be copied with the camera on a light box. If the
particular digital camera is not capable of copying 1 : 1, but can accept
filter ring adapters, then magnifying rings can be used for this purpose
and produce satisfactory images. Some camera manufacturers have
produced adapters to attach to the digital camera, specifically for the
purpose of reproducing 35-mm slides in digital format.
the image quality needed. Medical photography generally has several
common scenarios of what types of images are required and the use
for those images. For example, types of images obtained may include
clinical photographs, intraoperative photographs and duplicating
imaging studies. The uses of these images may include documentation
of a clinical condition, copying of images or reports, presentation
material and publication.
General considerations
It is helpful to take multiple images and consider obtaining these
images with and without a flash. One of the advantages of digital
photography is that there is essentially no cost for obtaining multiple
images that may be eventually discarded. Images deemed to be unnec­
essary or inadequate can simply be erased in storage space. No other
resources are used other than electric power. Lighting conditions can
provide some variability in the images obtained to allow for choice.
Changes in lighting conditions can include obtaining images with and
without a flash or changing the existing light conditions within the
photographic area.
Operating room images
When obtaining images in the operating room, macro capability is
often needed. As mentioned previously, macro is the capability of
working close-up. Incisions and anatomy in the foot are small in size
and this makes it necessary to take advantage of the macro capability
of the camera. In the operating room, a distance must be maintained
from the sterile field in order for it to remain sterile. As a result, not
only is a macro needed, but a short telephoto capability is also helpful.
It is that short telephoto capability that allows for maintaining a dis­
tance from the surgical field through magnification. As discussed pre­
viously, appropriate telephoto capability would be approximately a
three times optical zoom or 100-mm focal length. The flash can play
a role in operating room photography, even although there is an
abundance of light on the subject from the operating room lights. This
is because the detail is often in a deep hole or in a crevice. The flash
Figure 11.5  Video camera lamp. May be used in digital photography for
adjustable lighting.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
essentially replaces the tools of a professional photographer or
advanced amateur photographer with a very sophisticated darkroom.
The degree of expertise required to utilize image editing software
has a much shorter learning curve than that necessary to work in
a traditional darkroom, as previously described. The results are virtu­
ally instant and there are no consumable materials other than the
printing of images and storage of data. Instruction books and courses
are available to quickly develop the skills for utilizing the software
packages.
CONCLUSION
Utilizing digital technology in medical photography is quite useful
and effective in all areas where traditional photography can be used.
Digital imaging has multiple advantages over traditional photography.
These advantages include: virtually instantly obtaining the images in
an end-form that can be immediately utilized; less consumable cost
in producing and storing and use advantages including image manip­
ulation. Utilizing this technology does require an understanding of
the equipment and basic concepts, as discussed above. The area of
digital imaging is developing rapidly. Therefore, much of the dis­
cussion here will become rapidly outdated. This information will,
however, provide a reasonable basis for continuing education in
more detail in the future. At this time, utilizing this technology to its
maximum capability requires expanding upon the basics of this
chapter.
It is of chief importance that the patient’s autonomy, privacy
and confidentiality is respected at all times when medical photo­
graphy is being utilized. In all cases in which photographs and
images contain identifiable information, the patient’s consent for
any potential use of this material is obligatory. Patients should
be aware that with the evolution of electronic publication, once an
image is published, there is no efficient control of its future use.
Physicians and hospitals have a duty to use with discretion any
material kept in the patient’s medical records. Efforts should be taken
to assure that all images and photographs used in teaching and pub­
lication are anonymous, so that such information does not raise
ethical and legal concerns. The measures for using photographs and
images in medical publication and teaching should respect ethical
principles and contain only anonymous information about the
subject.
Medical presentations
The most common purpose for which digital images are used in
medical photography is for producing presentations. These presenta­
tions are given for the purpose of practice promotion, teaching or
conferences. The digital photography has shortened the time to pro­
duction of a lecture and allows for modification of that lecture, essen­
tially up to the point where the presentation is given. Presentation
software allows the combination of importing digital images and
utilizing the software to form word slides without the need for devel­
oping photographic material.
At the time of this writing, nearly all digital cameras available well
exceed the requirements necessary for presentation purposes. A 600 ×
800 pixel image will project very well with a digital projector and rival
any production with 35-mm slides. Greater resolution often does not
increase the image quality at the time of a presentation.
With regards to images used in presentations, usually a relatively
low-resolution image can be used and often is preferable since the
space required for storage within the presentation is smaller. As dis­
cussed previously, smaller images are generally more efficient when
placed in presentation programs. It should be taken into considera­
tion, however, that images may be used for other purposes and it may
be helpful to obtain the images at a higher resolution, and then reduce
them later when incorporating the images into a presentation.
Publishing digital images
Image quality for publishing is one of the most demanding needs with
regards to resolution. Generally, the higher the resolution acquired
the better. To provide a frame of reference, consider that personal
publishing on a laser printer usually utilizes a resolution of 600–
1200 dpi. The image quality of production level for a medical publica­
tion is greater than that. At 1200 dpi, a 5 × 7 photograph would be
6000 × 8400 pixels in size. If you recall our previous discussion of
resolution, this is greater than that produced by the typical 5 meg­
apixel camera.
THE DIGITAL DARKROOM AND
PHOTO EDITING SOFTWARE
One of the greatest advantages of digital image production is the
ability to be able to produce images without photo processing and to
be able to complete custom darkroom work on a computer. This
FURTHER READING
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standards in digital photography. J Plast
Reconstr Aesthet Surg 63 (2), e208.
Benz, C., 2003. Digital photography:
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Int J Comput Dent 6, 249–281.
Berg, D., 2001. A simple tool for teaching flap
design with digital images. Dermatol Surg
27, 1043–1045.
Cerroni, L., Argenvi, Z., Cerio, R., et al., 2010.
J Am Acad Dermatol 63 (4), 647–652.
Cockerill, J.W., 2003. Improving digital imaging.
Plast Reconstr Surg 111 (1), 503–504.
DiSaia, J.P., Ptak, J.J., Achauer, B.M., 1998.
Digital photography for the plastic surgery.
Plast Reconstr Surg 102, 569–573.
Elbeshbeshy, B., Trepman, E., 2001. Digital
photography in orthopaedic surgery. Foot
Ankle Int 22, 67–74.
Galdino, G.M., Vogel, J.E., Vander Kolk, C.A.,
2001. Standardizing digital photography:
it’s not all in the eye of the beholder. Plast
Reconstr Surg 108, 1334–1344.
Hagan, K.F., 2008. Clinical photography for
the plastic surgery practice; the basics. Plast
Surg Nurs 28 (4), 188–192.
Harth, W., Hermes, B., Niemeier, V., et al,
2006. Clinical pictures and classification of
somatoform disorders in dermatology. Eur J
Dermatol 16 (6), 607–614.
Lau, C.K., Schumacher, H.H., Irwin, M.S.,
2010. Patients’ perception of medical
photography. J Plast Reconstr Aesthet Surg
63 (6), e507–511.
Mavroforou, A., Antoniou, G., Giannoukas,
A.D., 2010. Ethical and legal aspects on the
use of images and photographs in medical
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Digital medical photography
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McG Taylor, D., Foster, E., Dunkin, C.S., et al.,
2008. A study of the personal use of digital
photography within plastic surgery. J Plast
Reconstr Aesthet Surg 61 (1), 37–40.
Miller, P.J., Light, J., 1999. A comparison of
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111–117.
Nayler, J.R., 2003. Clinical photography: a
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Niamtu, J., 2001. The power of PowerPoint.
Plast Reconstr Surg 108, 466–484.
Niamtu, J., 2002. Techno pearls for digital
image management. Dermatol Surg 28,
946–950.
Niamtu, J., 2004. Image is everything: pearls
and pitfalls of digital photography and
PowerPoint presentations for the
cosmetic surgeon. Dermatol Surg 30 (1),
81–91.
Nouraei, S.A., Frame, J., Nduka, C., 2005. Uses
and abuses of digital imaging in plastic
surgery. Int J Surg 3 (4), 254–257.
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Photography without film: low-cost digital
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Submitting clinical photographs to
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Thirty-five millimeter versus digital
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Surg 15, 101–109.
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Guidelines for standard photography in
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CHAPTER CONTENTS
Introduction
113
Fusiform ellipse
113
M-plasty
116
Modified M-plasty
117
S-incision (Alvarado double-S)
118
Crescentic ellipse (double elliptical excision)
118
Reciprocal approaches and other variations
119
Mercedes Benz closure
119
O–Z closure
119
O–T and A–T closure
119
Bowtie closure (Alvarado)
121
Combined-V closure (Alvarado)
123
INTRODUCTION
The simple excision, also called the fusiform or elliptical excision,
is the most common excisional procedure in cutaneous surgery. If
the lesion or scar can be removed with this technique then that is
the favored method rather than some complex skin plasty tech­
nique. To carry this procedure out correctly, proper planning and
knowledge of superficial anatomy is required. The surgeon must
consider the numerous functional complexities of the foot and ankle
and, in the treatment of many tumors, an understanding of the phy­
siology and biology of the lesion is necessary. Variations of the
basic fusiform excision are important in certain situations so as to
provide a better cosmetic closure and final scar. These variations
include the S-incision and the crescentic excision. A group of very
unique excisional procedures, called reciprocal excisions, are also
included in this discussion along with detailed illustrations and
examples of usage.
FUSIFORM ELLIPSE
To perform this apparently simple excision technique properly
requires thoughtful consideration to the relaxed skin tension
lines (RSTLs) and the lines of maximum extensibility (LME) (as
discussed in Ch. 4). Determining the proper orientation of the
final incision will be important to allow the incision to rapidly heal
with minimal tension, therefore, diminishing the postoperative
scar and preventing restriction of motion. The precise orientation of
these skin lines can be established by having the patient employ
flexion or extension of the part. This information can also be obtained
by the surgeon wrinkling or pinching the skin at the surgical site
between the thumb and forefinger (Fig. 12.1). In some cases, due to
the nature of the RSTLs and LME on the foot and ankle, it may be best
to simply excise the lesion or scar in a circular fashion rather than in
an ellipse, undermine the margins of the wound, and then observe
the direction in which the defect assumes an oval configuration. The
oval shape can then effortlessly be converted to a fusiform shape for
final closure. This method frequently results in a shorter scar than
would be formed by using the more theoretical ellipse planning
method.
The theoretical design of the fusiform ellipse is essentially a
length : width ratio of 3 : 1. It is composed of two semi-elliptical inci­
sions and the apices should meet to create a 30° angle (Fig. 12.2). In
other words, the length of the excision (long axis) is three times the
width (short axis), but it may vary from 2.5 : 1 to 4 : 1 ratio. The width
of the short axis is determined by the diameter of the lesion plus a
surrounding border of normal tissue added prior to excision. For
example, a 4 mm lesion with 2 mm margins will give a short axis of
8 mm, and this would require the long axis to be approximately
24 mm in length.
Generally, the resultant scar should be less conspicuous than the
original lesion or scar being excised. Furthermore, it is important to
remove as little normal tissue as possible while completely removing
the lesion itself. Premalignant and malignant lesions require signifi­
cant contemplation in planning the excision compared to obvious
©2012 Elsevier Ltd.
Excisional techniques and procedures
G. Dock Dockery
Chapter
12

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
within the RSTLs and the final choice of where to place the fusiform
excision may depend upon the direction that yields the least notice­
able final scar.
As soon as the ellipse direction has been decided upon, it should
then be drawn on the skin using a standard skin-marking pen. It is
best to draw an outline around the lesion to be removed and then
draw out the fusiform ellipse shape before infiltration of anesthetic
distorts the skin lines and impairs the assessment of the natural
tension in the region (Fig. 12.4). Once completed, the area may then
be anesthetized with local anesthetic agent and the skin area prepped
sterilely.
Each arm of the ellipse should then be incised with the scalpel,
staying on the outside of the drawn line. This assures that the entire
lesion is adequately removed. The incision is started with the tip of
the blade at 90° to the skin at the apex, then continuing the semi-
elliptical incision with the scalpel blade maintained at a 30–45° angle
to the skin and not beveled. As has been outlined earlier, the incision
edge should be vertical to achieve a smooth closure. As the incision
is being completed on one side, the blade returns to a 90° angle to
the skin near the tip to reduce the risk of cross-hatching. This semi-
elliptical incision is then recreated in a mirror image on the other side
to complete the fusiform ellipse.
The incision is made with the dominant hand while the other hand
puts tension on the skin with the thumb and forefinger during the
entire procedure (Fig. 12.5). A smooth, single incision from one tip
benign lesions. First, it is crucial that there is complete removal of the
entire tumor with specific attention paid to the orientation of the final
closure. An incorrectly placed initial incision may eventually mean the
difference between a primary closure with subsequent suitable scar
and a wound that does not close properly resulting in a larger scar or
wound deficit that will require grafting to close.
The pattern of the original scar or lesion may be the determining
factor in the direction or alignment of the fusiform ellipse. For
instance, if the lesion to be excised is oval or oblong, the overall length
of the resultant scar will be reduced by placing the long axis of
the ellipse parallel with the long axis of the lesion (Fig. 12.3). This
maneuver, however, may compromise the ability to keep the excision
Figure 12.1  Production of RSTLs by manual compression of the skin
between the thumb and forefinger.
Figure 12.2  The basic fusiform ellipse, with the length : width ratio of
3 : 1 and angles at the apices of 30°.
3x
30º
1x
Figure 12.3  Orienting the long axis of the ellipse with the long axis of
the lesion reduces the potential final scar production. The lesion excised
on the Y-axis removes less tissue than the same lesion excised on the
X-axis.
X
Y
Figure 12.4  Fusiform planning. (A) Drawing around the red lesion then
drawing the planned fusiform ellipse. (B) Same concept drawn on the
plantar heel lesion. The skin incision is made on the outside of the drawn
lines.
A
B

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(Fig. 12.10). The wound margins must be handled gently, since unnec­
essary damage to the edges will compromise the final outcome.
Undermining is accomplished by blunt dissection utilizing blunt-
tipped scissors or other blunt instrumentation (Fig. 12.11). Under­
mining with scissors involves placing the blunt scissors into the tented
space and advancing the tips some distance into the tissues. The dis­
tance is determined by the extent of tension or adhesions at the inci­
sion edges. Once advanced appropriately, the scissor blades are spread
apart and, in this manner, the tissues are not cut, but are pushed aside.
The scissors are then pulled out of the wound with the blades open,
which causes additional blunt dissection and undermining of the
tissues.
When the incision is large enough or the tissues are relatively
pliable, the surgeon may use the back of the scalpel handle or the
index finger to undermine the tissues. In some instances, the under­
mining may be done sharply with the scalpel blade, but this has the
potential risk of nerve or blood vessel injury and is recommended
only when conventional blunt techniques are not satisfactory.
Ordinarily, on the lower leg, undermining may be carried out at any
level above the deep-muscle fascia, the middle-to-deep subcutaneous
layers being the most favorable. On the foot and ankle, however,
undermining should be carried out just below the dermis in the
superficial subcutaneous layer, since there is minimal adipose tissue
present in these areas. It is also important to undermine the tips of
the ellipse as well as the sides. This will result in a smoother contour
and reduce the potential for bulging at the ends of the incision.
Tension on the skin edges can be assessed occasionally by using two
of the incision to the other, completely through the dermis on each
side, should be accomplished. Sawing, repetitive strokes of the scalpel
and jerky movements may result in jagged edges, nicks or notches in
the incision line (Fig. 12.6). Cross-hatching, or extension of the inci­
sion past the tips of the ellipse, occurs when the belly of the blade is
used to make the entire incision or when the surgeon incises the area
in an imprecise or rapid manner (Fig. 12.7). One method for eliminat­
ing the risk of cross-hatching is to reverse direction when approaching
the tip so that one incises away from the tip. For a very small ellipse
it is beneficial to use a smaller scalpel blade such as a No. 11 or Beaver
mini-blade No. 67.
A common mistake in performing this relatively simple excisional
procedure is creating a boat-shaped specimen (Fig. 12.8). This occurs
by using the belly of the scalpel for the entire incision, thus making
a shallow start and finish to the cut and by biasing the incision on
the sides rather than keeping it perpendicular. When this happens
there is less tissue removed at the ends of the specimen and the
residual tissue left in the defect may cause protrusions at the ends,
creating a tendency for dog-ears to form, or it may cause a depression
at the center of the wound.
After the two elliptical incisions have been made to the desired
depth on both sides, the ellipse is removed. A skin hook or pick-up
is to be used to gently grasp the tissue on one end. The full-depth
specimen, including the upper subcutaneous fat, is then removed
using the scalpel or dissection scissors (Fig. 12.9).
Once the excision is completed, small fusiform ellipse defects may
be closed directly with side-to-side apposition using sutures or Steri-
Strip tape. Larger ellipses and those with more tension will need
undermining to diminish wound-margin tautness, improve apposi­
tion of the incision edges and evert the wound margins. During under­
mining, the skin edge is elevated using a skin hook or an open pick-up
Figure 12.5  Putting tension on the skin while the incisions are being
made.
Figure 12.6  Improper incision techniques of the ellipse excision.
Notched edge
Nicked edge
Cross-hatched tips
Figure 12.7  Cross-hatching occurs when the incision is made in an
imprecise manner.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
This same technique is useful in the closure of uneven incisions when
the two sides are of slightly different lengths, as in the crescentic exci­
sion procedure. The disadvantage of the simple interrupted sutures
used in the halving process is the potential for railroad-track scarring
and the need to remove the sutures. The use of buried absorbable
continuous running sutures minimizes the suture track effects, but is
not as strong, does not optimally evert the skin edges and does not
evenly distribute the skin tension as well as the superficial simple
sutures.
M-PLASTY
In some situations, it is not always possible to complete a fusiform
excision of a lesion without crossing an important anatomic or cos­
metic line. The use of an M-plasty reduces the extent of the excision
line and also preserves tissue (Fig. 12.13). The M-plasty may be per­
formed at one or both ends of the fusiform excision. It is best to draw
the full fusiform outline around the lesion to be excised and then
outline the M design. The M is drawn at a 30° angle with the M
appropriately placed at that pole of the ellipse for the best closure.
Closure of the incision is with simple interrupted sutures and the apex
of the tip is closed with an apical or three-way stitch.
Another novel use of the M-plasty is in excisional biopsy. Instead
of putting a suture into one end of the specimen, using color dye or
skin markers, or drawing maps to indicate the orientation of the
excised piece, one end of the fusiform excision can be fashioned into
an M-plasty. However, it is important to make sure that the point of
the M does not compromise the planned margin of the lesion to be
excised.
Figure 12.8  Incision technique. (A) Creation of an improper boat-shaped specimen that is shallow at each end and tapered toward the center. (B) A
proper specimen with uniform thickness.
A
B
skin hooks to draw the edges together. Once apposition of the skin
edges is easily performed, the undermining technique is discontinued.
Excessive undermining can result in increased induration of tissue
postoperatively or result in tissues that are too free and this may
produce irregular closure or dog-ear formation.
During the excision of the fusiform ellipse and the undermining
process, superficial blood vessels may be nicked or inadvertently
damaged. To prevent seroma or hematoma formation, the small
oozing vessels should be sealed using a bipolar electrosurgical coagu­
lation unit or direct electrodesiccation. Larger vessels should be
clamped and ligated as needed. Excessive electrosurgery should be
avoided since the charred or damaged tissue may slow wound healing
or create a nidus for wound infection. Minor oozing is usually stopped
by the suture closure process or by the mild compressive bandaging
of the wound after surgery.
Suture closure techniques vary considerably from site to site or from
procedure to procedure, and one technique that may be very appropri­
ate in one area may not be adequate in another area. Whatever the
situation, the suture technique, choice of suture materials and the
timing of suture removal should be modified to achieve a well-
approximated, everted, smooth wound, with a thin non-tender scar
and minimal suture tracks. A variety of suture techniques and materi­
als are reviewed in Chapter 9.
As a fundamental rule for the fusiform ellipse, it is best to use the
method of suture halves. With this method the first suture is placed
in the center of the ellipse, the next sutures are placed on either side
of center and so forth until the wound is closed (Fig. 12.12). This
technique permits the equal distribution of tension along the incision
while it is being closed and decreases the potential for the develop­
ment of dog-ears. When the incision is closed from one end to the
other end, there is a greater tendency for the development of dog-ears.

Chapter
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| 12 |
Figure 12.9  (A) The ellipse may be held with a pick-up or skin hook and
is freed with a scalpel, while gentle tension is placed toward the surgeon.
(B) A pair of dissecting scissors may be used to separate the correct plane
and reflect the ellipse upward.
A
B
ends of the excision. After the skin is excised in a short fusiform shape,
with the shortest possible long axis, a triangular flap is created at each
end by an incision parallel to its long axis and lateral to it on opposite
ends (Fig. 12.14). Actually, the flaps can be fashioned on either side
of the excision and on either or both ends, depending upon the posi­
tion of the excision and its relationship to bordering anatomic
Figure 12.10  The wound edges are elevated with a skin hook or open
pick-up to facilitate undermining with a blunt-tipped instrument.
Modified M-plasty
A modification of the M-plasty utilizes all of the principles used by
the conventional M-plasty, but further reduces the amount of excised
tissue and shortens the overall length of the incision. This is done by
eliminating the initial creation of the two triangular flaps at the two
Figure 12.11  Blunt-tipped dissecting scissors are advanced with the
blades closed and the undermining occurs when the scissor blades are
separated and withdrawn from the wound.
Figure 12.12  Suturing by halves. The sequence of sutures is placed in
accordance with the numbers. This technique decreases the incidence of
dog-ear formation.
1
2
4
3
5
Figure 12.13  Technique for an M-plasty. The dotted line represents the
normal excision line. The 30° angle is cut into the design being careful
not to violate the lesion itself. It is then closed in a similar fashion as a
V–Y-plasty.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
the S. This straightening effect occurs as the horizontal forces of scar
contracture pull on the scar and the design prevents depression from
occurring. Two different directions of the ‘S’ can be selected and this
will give the surgeon a greater ability to pick the position and direction
of the final scar so that it will conform better to the local topography
(Fig. 12.17). When used on the plantar foot, it allows for placement
of the scar in non-weight-bearing areas and reduces contracture prob­
lems (Fig. 12.18). All of the principles outlined for planning, marking,
undermining and closure of the elliptical excision are utilized in the
S procedure.
A simple variation of this S procedure provides a similar end-result.
The modification is a combination of the fusiform excision and the
S-plasty (Fig. 12.19). It offers similar advantages in that there is a rela­
tively small length incision with a ‘hand and glove-type fit’ of the skin
edges. The lesion can be excised without the need for aggressive under­
mining of the deep tissue and tissue edge modification is rarely
needed.
CRESCENTIC ELLIPSE
(DOUBLE ELLIPTICAL EXCISION)
The crescentic ellipse is useful in areas where the RSTLs are not linear,
such as around the foot and ankle. The curvilinear closure may par­
tially reduce the tension and improve the ability to appose incisions
over convex areas. The crescent procedure can result in redundancies
of tissue that may require refinement at the end of the procedures.
Therefore, careful planning and outlining of the procedure is impor­
tant. If the procedure is performed over convex surfaces on the foot
and ankle, correction of excess tissue is usually unnecessary.
There are two ways in which the crescentic ellipse may be formed.
The simplest design is to create the ellipse so that one side is
structures or skin planes. Accordingly, a comparison of the excision of
a lesion using the standard fusiform incision, the M-plasty and the
modified M-plasty will show that the final length of the scar is shorter
for each subsequent procedure by the length of the triangular flaps
that would have been created (Fig. 12.15).
S-INCISION (ALVARADO DOUBLE-S)
With the use of a circular excision, adequate safe margins are obtained
and there is minimal waste of normal skin. However, the main com­
plication with the circular defect is that it is usually very difficult to
close primarily. The standard ellipse excision of lesions followed by
direct closure is one answer to this problem, but it results in a linear
scar. Linear scar contracture may disrupt adjacent anatomy, or run
across the RSTL, rendering negative functional and cosmetic outcomes
in some instances.
The S-plasty is a very useful variation of the classical ellipse excision
procedure and is a modified fusiform excision, in which the two sides
of the ellipse are formed into a double-S design (Fig. 12.16). Other
than creating a curvilinear scar, the two main effects of an S-plasty are
to decrease the amount of normal tissue being removed and to
increase the length of the scar between the two endpoints of the inci­
sion. This is valuable when the tension obtained with a standard
elliptical excision of a skin lesion would be excessive. Instead of resort­
ing to grafts or flaps, it is possible to apply this technique and reduce
the tension, creating a curvilinear profile rather than a linear design.
Additionally, when a lesion is excised on a convex surface, such as on
the lower extremity or foot, scar contracture will result in a depressed
scar, but the scar contracture after S-plasty results in straightening of
Figure 12.14  Modified M-plasty. A triangular flap is created at either or
both ends of the short fusiform excision. As the flaps are mobilized, the
closure can be converted to the V–Y appearance thus reducing the
amount of tissue excised when compared to a typical 3 : 1 ration fusiform
excision.
Figure 12.15  A comparison of the standard fusiform incision and
closure, the M-plasty and closure, and the modified M-plasty and closure.
Note: the final length of the scar is shorter with modified version.
(Redrawn from: Asken, S., 1986. A modified M-plasty. J Dermatol Surg Oncol 12,
369–373.)
Figure 12.16  Drawing of a double-S excision procedure. Also referred to
as a biwinged excision.
Figure 12.17  Double-S-plasty (Alvarado). The shaded areas are excised
from each lesion. (A) The classical S-plasty design. (B) The reverse S-plasty
design.
A
B

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significantly longer than the other side (Fig. 12.20A). One incision is
made as a broad arch, much like the semi-elliptical incision but more
pronounced. The other incision is a relatively straight line connecting
the first incision at the tips. This results in an incision with two sides
of unequal length. By closing the defect using the rule of halves, a
slight curved scar is produced. The other technique is to create a cres­
cent design in which both incisions are arced (Fig. 12.20B). The first
incision is made as above and the second incision is slightly arcuate
with a slope paralleling the first arc. This results in a final closure
having sides of equal length but in a configuration that yields a gentle
curve. The arcs should parallel the curvature of the RSTLs in the area
if possible. When the procedure yields a final wound with sides of
unequal length, the size of tissue redundancies can be minimized by
closing the curvilinear defect using the rule of halves and by slanting
or angling the sutures at correcting angles (Fig. 12.21). The overall
effect is that dog-ears are rarely a problem.
RECIPROCAL APPROACHES AND
OTHER VARIATIONS
When the excision of a lesion results in a circular defect, there are
numerous closure techniques that can be performed to close these
defects without having to excise additional tissue, create an exotic or
complex flap, or perform a graft procedure. If there is sufficient mobil­
ity of the tissues and undermining is possible, then one of the follow­
ing closures may be suitable for use on several locations on the lower
extremity.
Mercedes Benz closure
The Mercedes Benz closure technique is a modification of the purse-
string suture closure. The classical purse-string suture closure is at high
risk of wound dehiscence because of strangulation of tissues by the
Figure 12.18  Double-S-plasty (Alvarado). (A) The S design is outlined with a skin marker on the plantar foot. (B) The lesion and reciprocal sides are
excised. (C) The final suture closure shows that the resultant scar will not be in the weight-bearing area of the foot.
A
B
C
single suture supporting the closure. The Mercedes modification is a
technique that allows closure from three points at once. This three-
point anchoring suture style shares tension in several directions and
decreases the strangulation effect while advancing the surrounding
tissue toward the center, creating the symbol of Mercedes Benz (Fig.
12.22). This tripod closure results in small dog-ears in each arm that
must be removed.
Larger wounds, especially on the calf area, may be closed with the
advantage of being able to plan where the three limbs will lie; there­
fore, avoiding larger flaps and so the need to remove excessive normal
tissue and avoiding a long linear scar. The disadvantage of the Mer­
cedes closure is that there may be more tension on the wound than
there would with a linear closure and the unusual scar may be more
difficult to conceal in the natural skin lines, thereby being more
visible.
O–Z closure
One of the simplest closures of a circular defect involves arcuate inci­
sions from opposite poles of the circular defect, to create two small
rotational flaps that will close in a Z-pattern (Fig. 12.23). These flaps
are rotated into the defect and closed side by side. This is very useful
when there is insufficient tissue for a unilateral rotation flap or other
closure of a circular defect is not as practical. The surgeon can often
place the Z very nicely within the skin lines, especially on the toes and
ankle area. The wider the arc of the incisions, the less tension will be
placed on the closure and the wider the diameter of the circle that can
be closed. Because of the Z formation of the final scar, this closure is
preferable when tension is a problem.
O–T and A–T closure
The O–T closure can be created by extending the circular defect at
either side of the base, and then advancing the flaps to cover the defect
by meeting at the midline (Fig. 12.24). The O–T closure frequently

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 12.19  (A) Chronic ulcer located directly under the cuboid bone. (B) Modified S-incision with excision of ulcer. (C) The flap approximation should
be without any tension to the edges. Suture buttressing should not be necessary for this type of closure. (D) At 3 weeks postoperative. (E) Fully healed
at 6 weeks postoperative. (Courtesy of Dr Al Kline.)
A
B
C
D
E
Figure 12.20  Crescentic ellipse. (A) The arc is more pronounced than in
a classical ellipse and the bottom incision is roughly a straight line. (B)
The main arc is made the same way as in (A) and the second incision is
slightly arcuate paralleling the first arc.
Main arc
Main arc
Straight incision
Sight arc
A
B
Figure 12.21  Closure of uneven arch using the rule of halves suture
technique and with angulation of the interrupted sutures to decrease
tissue redundancy and prevent dog-ear formation.
1
1
2
3
1
2
4
6
5
7
3

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Figure 12.22  Mercedes Benz closure. (A) A roughly circular defect is first
undermined followed by the placement of three-point buried absorbable
suture at 120° intervals. Local skin lines, tissue laxity and underlying
structures determine the placement of the suture anchor points. (B) After
the absorbable knot is tied, the three arms become visible between the
points of entry of the buried suture rather than over them. (C) The
redundancies are repaired by excision of the tips. (D) The final
appearance of the closure following skin sutures.
A
B
C
D
Area of undermining
Knot to be pulled tight
Absorbable suture placed
at 120º intervals in dermis
Completed purse string knot
Tissue redundancy
Redundancy removed
at all tips
Figure 12.23  O–Z-plasty closure. (A) Arcuate incisions are made
on either side of the circular defect and the flaps are undermined.
(B) The flaps are pulled in place and sutured in a Z closure (a meets b;
c meets d).
a
a
b
b
c
c
d
d
A
B
Figure 12.24  O–T closure. (A) Defect and design of incisions (dotted
line). (B) The side incisions are completed and the circular defect is lifted
with a skin hook. (C) The flaps are undermined and then sutured in
position. A small dog-ear may develop at the top, which is easily
removed.
A
B
C
Figure 12.25  A–T closure. (A) The defect is cut out in a triangular
fashion and the flap is designed (dotted line). (B) The flaps are
undermined, mobilized and then sutured in position closing the defect.
A
B
produces a small dog-ear that may not even need to be excised. If the
dog-ear is large, however, an appropriate excision is necessary and the
O–T becomes an A–T closure.
The A–T closure is created by similar incisions at the base of a tri­
angular defect instead of a circular defect. Thus, advancing the flaps
to the midline and suturing the edges creates the T shape (Fig. 12.25).
Both of these closures have the benefit that the flaps are broad
based and there is little risk of vascular injury. They are predominantly
useful along the nail border (Fig. 12.26), along a natural skin crease
or skin line, or at the junction of the thick skin of the plantar foot
(Fig. 12.27).
Bowtie closure (Alvarado)
The bowtie closure is designed for small-to-intermediate-sized lesions
that can easily be converted to circular defects (Fig. 12.28). The tissue
should be quite elastic, but it can be used in tissues of different thick­
nesses, such as on the plantar foot (Fig. 12.29). Once the bowtie has
been excised, manual manipulation of the tissue will reveal that there

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Figure 12.26  A–T closure along the proximal nail border. (A) The circular lesion is located at the proximal nail fold making regular excision difficult.
(B) The planned incision of the A–T flap is designed and the lesion is excised. (C) Flaps are mobilized and sutured in position.
A
B
C
Figure 12.27  A–T closure. (A) The lesion is marked in red and the A–T design is drawn around the lesion. (B) The triangular section with the lesion is
excised and the side incisions are completed. (C) The flaps are mobilized and sutured together closing the wound.
A
B
C

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are actually two ways in which to approximate the skin edges. One
way is usually easier than the other and will close with less tension.
Combined-V closure (Alvarado)
The combined-V closure is a modification of the bowtie closure (Fig.
12.30). This technique may be used in larger defects in which the skin
is fairly elastic. Also, no additional adjacent ‘normal’ tissue is wasted
with this procedure because only the defect tissue is excised. The
Figure 12.28  The bowtie closure (Alvarado). (A) The triangular lines are drawn on each side of the circular defect. (B) The defect and triangles are
excised and undermined. (C) The flaps are approximated and sutured. Note: there are two ways to approximate the edges.
A
A
B
C
B
C
D
A
B
B
D
C
A
B
D
C
A
C
D
A
B
Figure 12.29  The bowtie closure (Alvarado). (A) Circular defect with bowtie drawn in. (B) Excision of tissue with undermining.
procedure borrows tissue from opposite sides of the defect, as does
the rhomboid flap. However, the length of each limb of each V in this
incision is only equal to the radius of the circular defect, which means
that the combined area of the flaps is small in relation to the total
area of the circular defect. Therefore, a significant amount of direct
advancement must be accomplished in order to close a wound. This
works well when one side of the defect is elastic and the other side is
less mobile, as on the sides of the foot at the junction of the plantar
and dorsal foot (Fig. 12.31).

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Figure 12.30  Combined-V closure (Alvarado). This incision gives the same final appearance as the bowtie closure without removing any additional
adjacent normal tissue. (Compare with Figure 12.28.)
A
A
B
C
B
C
D
A
B
B
D
C
A
C
D
(C) Approximation of skin edges of flap; choosing the best option for closure. (D) Final closure of the flaps with the least
tension present.
C
D
Figure 12.29, Continued

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A
B
C
D
Figure 12.31  Combined-V closure. (Alvarado) (A) Circular lesion on junction of side of foot with plantar foot. (B) Combined-V limbs drawn on
opposite sides of lesion. (C) Lesion excised and limbs incised. (D) Undermining flaps. (E) Flaps transposed and sutured.
E

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FURTHER READING
Alam, M., Goldberg, L.H., Berkes, B., 8 July
2002. Basic Excisional Surgery. eMedicine
Online. Available:
com/derm/topic827.htm
Alvarado, A., 1981. Reciprocal incisions for
closure of circular skin defects. Plast
Reconstr Surg 67, 482–491.
Arpey, C.J., Whitaker, D.C., O’Donnell, M.J.,
1997. Cutaneous surgery: illustrated and
practical approach. McGraw-Hill, New York,
pp. 15–71.
Asken, S., 1986. A modified M-plasty.
J Dermatol Surg Oncol 12, 369–373.
Barth, G.A., 2005. Modified Burow’s
advancement flaps for two circular
adjoining cutaneous defect: the ‘8’- to
‘S’-plasty. Dermatol Online J 11 (1), 10.
Baumann, D.P., Chang, D.W., 2009. Free
flap reconstruction for complex lower
extremity wounds. Tech Orthop 24 (2),
130–138.
Bennett, R.G., 1988. Basic excisional surgery.
In: Fundamentals of cutaneous surgery.
Mosby-Yearbook, St Louis, pp. 355–443.
Bhatti, A.Z., Adeshola, A., Ismael, T., et al.,
2007. Lower leg flaps comparison between
free versus local flaps. Internet J Plast Surg
3 (2), 132–134.
Boyer, J.D., Zitelli, J.A., Brodland, D.G., 2001.
Undermining in cutaneous surgery.
Dermatol Surg 27 (1), 75–78.
Buckingham, E.C., Quinn, F.B., Calhoun, K.H.,
2003. Optimal design of O-to-Z flaps for
closure of facial skin defects. Arch Facial
Plast Surg 5, 92–95.
Dayton, P.D., Griffiths, T., 1996. Biwinged
excision for round pedal lesions. J Foot
Ankle Surg 35, 244–249.
Dockery, G.L., 1992. Principles of forefoot
plastic surgery. In: Butterworth, R., Dockery,
G.L. (Eds.), Color Atlas and Text of Forefoot
Surgery. Mosby-Yearbook, St Louis,
pp. 7–34.
Dunlavey, E., Leshin, B., 1998. The simple
excision. Dermatol Clin 16 (1), 49–64.
Eedy, D.J., Breathnach, S.M., Walker, N.P.J.,
1996. Surgical dermatology. Blackwell
Science, Oxford, pp. 92–103.
Goldberg, L.H., Segal, R.J., 1996. Surgical
pearl: a flexible scalpel for shave excision
of skin lesion. J Am Acad Dermatol 35,
452–453.
Hanke, C.W., 1987. Repair of surgical defects.
Dermatol Clin 5, 287–302.
Hirshowitz, B., Kaufman, T., Amir, I., 1980.
Biwinged excision for closure of rounded
defect. Ann Plast Surg 5, 372–380.
Hussain, W., Salmon, P.J., Mortimer, N.J., 2010.
The ‘crossover’ tip-stitch in O-T flap repair.
Br J Dermatol 162 (1), 219–220.
Keser, A., Sensoz, O., Mengi, A.S., 1998.
Double opposing semicircular flap: a
modification of opposing Z-plasty for
closing circular defects. Plast Reconstr Surg
102, 1001–1007.
Kline, A., 2007. Cuboid decompression for
treatment of plantar ulcers in Charcot
arthropathy. Podiatry Management 26 (9),
223–242.
Kraft, J., Murray, C.A., 2011. The fusiform skin
excision: one recipe for success. J Cutan
Med Surg 15 (5), 245–249.
Krishnan, R., Garman, M., Nunez-Gussman, J.,
et al., 2005. Advancement flaps: a basis
theme with many Variations. Dermatol Surg
31 (8), 986–994.
Lapins, N.A., 1988. The crescentic ellipse
revisited. J Dermatol Surg Oncol 14,
935–936.
Lee, T.S., Murakami, C.S., Suryadevara, A.C.,
2011. Tissue conservation using circular
defect with dog-ear deformities excision
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2299–2304.
Leffell, D.J., Brown, M.D., 1997. Basic
excisional surgery. In: Manual of skin
surgery: a practical guide to dermatologic
procedures. Wiley Liss, New York,
pp. 149–180.
Leshin, B., 1994. Proper planning and
execution of surgical excisions. In:
Wheeland, R.G. (Ed.), Cutaneous Surgery.
WB Saunders, Philadelphia, pp. 171–177.
Leventen, E.O., 1986. Charcot foot: A
technique for treatment of chronic plantar
ulcer by saucerization and primary closure.
Foot Ankle 6 (6), 295–299.
Paris, G.L., 1979. The O-to-Z plasty.
Ophthalmic Surg 10, 41–43.
Paolo, B., Stefania, R., Massimiliano, C.,
et al., 2003. Modified S-plasty: an
alternative to the elliptical excision to
reduce the length of suture. Dermatol Surg
29, 394–398.
Peled, I.J., Wexler, M.R., 1986. Crescent
excision of skin lesions. J Dermatol Surg
Oncol 12, 1214–1215.
Robbins, T.H., 1978. Double rotation skin
closure: an alternative to elliptical closure.
Aust NZ J Surg 48, 650–652.
Salasche, S.J., Roberts, L.C., 1984. Dog-ear
correction by M-plasty. J Dermatol Surg
Oncol 10, 478–482.
Swanson, N.A., 1987. Basic techniques. In:
Atlas of cutaneous surgery. Lippincott
Williams Wilkins, Philadelphia, pp. 1–68.
Swanson, N.A., Tromovitch, T.A., Stegman, S.J.,
et al., 1980. The M-plasty as a means of
orienting a surgical specimen for the
pathologist. J Dermatol Surg Oncol 6,
706–708.
Tamir, G., Birkby, C.S., Berg, D., 1999. Three
point-advancement closure for skin defects.
J Cutan Med Surg 3, 288–292.
Tremolada, C., Blandini, D., Beretta, M., et al.,
1997. The round block purse-string suture:
a simple method to close skin defects with
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126–131.
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Elliptical excision. In: Skin surgery. A
practical guide. Mosby-Yearbook, St Louis,
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Warren, S.E., Snell, G.F., 1986. Complex
wound closure, excisional biopsy, and
use of simple flaps. Prim Care 13,
433–445.
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et al., 1976. M-plasty techniques.
J Dermatol Surg 2, 393–396.
Williams, F.C., 2008. The geometry of skin flap
movement. J Oral Max Surg 66 (Suppl. 1),
Poster 044.
Wu, T., 2006. Plastic surgery made easy
– simple techniques for closing skin defects
and improving cosmetic results. Aust Fam
Physician 35 (7), 492–496.
Yildirim, S., Taylan, G., Akoz, T., 2007.
Freestyle perforator-based V-Y advancement
flap for reconstruction of soft tissue defects
at various anatomical regions. Ann Plast
Surg 58 (5), 501–506.
Zitelli, J.A., 1990. TIPS for a better ellipse.
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Physician 67, 1539–1544.

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CHAPTER CONTENTS
Introduction
127
General considerations
127
Biopsy indications
128
Patient preparation
128
Biopsy guidelines
129
Shave and saucerization biopsy
130
Scissor biopsy
133
Punch biopsy
133
Elliptical excision as a biopsy technique
136
Incisional biopsy
136
Pathology
138
INTRODUCTION
Biopsies are diagnostic techniques, which utilize a representative
sample of tissue taken from a disease process for the purpose of
histopathologic analysis. In the skin and subcutaneous soft tissue,
these procedures are among the most important diagnostic tech­
niques available to guide the surgical and medical management of
inflammatory and neoplastic conditions. Because of the direct acces­
sibility of the skin, these techniques are exceedingly simple and
straightforward and have allowed diseases of the skin to be charac­
terized more precisely than those of the viscera, bone, or more
deeply seated soft tissue. Skin biopsy techniques include, but are not
limited to punches, shaves, saucerizations, curettage and scissor tech­
niques. The word biopsy comes from the Greek ‘to view life’. In the
context of skin bio­psies, pathologists accomplish exactly that by
cutting a 5-micron thick section of the submitted tissue, staining it
with hematoxylin and eosin (H&E) and examining it under light
microscopy.
GENERAL CONSIDERATIONS
Biopsies may be excisional or incisional, depending on the magnitude
of the technique. When performing excisional techniques, the entire
lesion in question is removed for analysis. This technique is predomi­
nantly performed in the context of cutaneous neoplasia. Although
biopsies may be performed by elliptical or fusiform excision, this is a
more complicated and time-consuming procedure, which carries with
it an increase in patient morbidity. For this reason, excisional biopsies
should be reserved for cases where malignancy is strongly favored
based on clinical parameters and not for routine biopsies.
In contrast, incisional techniques use only a small portion of an
uncharacterized disease process. The five principle incisional biopsy
techniques which must be mastered include the shave, saucerization,
curettage, scissor and punch. Which incisional technique is selected
depends entirely on the condition in question. Small samples of much
larger processes are taken using the punch technique; superficial or
papule-forming neoplastic processes are ideally sampled using the
standard shave technique; pedunculated lesions may be sampled
using the scissor technique and flat or more deeply reaching neoplas­
tic processes may be better sampled using the saucerization technique.
Each of these incisional techniques will be discussed in detail within
this chapter.
Several features, with regard to the lesion in question, must be
considered when deciding which type of biopsy technique is most
suitable. The principle determinants are anatomic location of the
lesion, the structures underlying the lesion, the lesion’s morphologic
features and the clinical differential diagnosis. Obviously, an adequate
specimen is necessary to make an accurate diagnosis. In many
instances, errors that are made during histopathologic analysis occur,
in part, due to inappropriate delays before performing a biopsy,
improper technique selection or the submission of an inadequate
sample. Understanding the surgical anatomy and knowing the under­
lying structures at the biopsy site will allow the surgeon to take an
adequate specimen while minimizing trauma to the patient.
On the pathology requisition, it is helpful to note the appearance
of the lesion before biopsy, especially if a partial specimen is being
©2012 Elsevier Ltd.
Biopsy techniques
G. Dock Dockery, Bradley W. Bakotic
Chapter
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When it comes to pigmented lesions of the skin, the driving force
behind skin biopsies is the potential of melanoma. Of course,
melanoma is a malignancy, which is largely unforgiving when ignored,
metastasizing early and eventually resulting in extremely high mor­
bidity once metastases have occurred. Because melanoma lies within
the differential diagnosis for all ‘pigmented lesions of skin’, when
evaluating these lesions, there are far more absolute indications for
biopsy than those that are relative. In some instances, clinicians may
simply need to confirm a suspected benign or malignant diagnosis,
where in others, the biology of the lesion in question is entirely
unknown. The clinical criteria that are widely used to define atypia
among pigmented lesions of the skin have been applied for roughly
40 years and are still used today. These criteria have been referred to
as the ABCDs of melanoma. Lesions that exhibit (A) asymmetry in
shape or pigment distribution, lesions with irregular or indistinct (B)
borders, lesions with variegation in (C) color and pigmented lesions
that measure 6 mm or larger in (D) diameter, should prompt strong
consideration for a biopsy.
In contrast to those tumors that are pigmented, there is appreciably
more subjectivity when managing non-pigmented cutaneous masses,
though here too, absolute indications may apply. Subjective features
include an inability to explain the presence of the lesion, particularly
over a long duration (months) and recalcitrance to therapy. Rapid
growth is another such criterion. Possibly the most commonly docu­
mented clinical feature involving aggressive cutaneous neoplasms,
which, as the result of a missed diagnosis, leads to a bad patient
outcome, is spontaneous hemorrhage or ulceration. Spontaneous
ulceration connotes a propensity to destroy adjacent tissue. Such
behavior is simply not expected in association with benign neoplasms.
For this reason, potential neoplasms that exhibit ulceration or hemor­
rhage without a clear history of trauma should be biopsied with
absolute consistency.
The fundamental principle that underlies the indications for all
masses and pigmented lesions of the skin is that if a malignancy is in
the clinical differential diagnosis (no matter how slight the chance),
a biopsy should at least be considered. Incisional biopsies (taking
only a small part of a larger lesion) may be used to guide future exci­
sions by documenting the need for such an excision and allowing for
appropriate surgical planning. The recommended margins of excision
(the width of surrounding uninvolved skin) will vary depending on
the neoplasm in question. Establishing the tumor type and depth of
invasion will ensure that any such excision is consistent with the
standard of care for that particular tumor type. In contrast, excisional
biopsies (excising an unknown lesion entirely to obtain a diagnosis)
have the advantage of allowing surgeons to document the complete
removal of a tumor through the histopathologic analysis of the
peripheral margins of the excision specimen to ensure that all the
diseased tissue has been excised, e.g. the excision has ‘negative
margins’. Such excisional biopsies may be both diagnostic and thera­
peutic in that the skin tumor in question may be completely removed
during the biopsy procedure. However, excisional biopsies have the
potential disadvantages of: (1) being a more cumbersome procedure
with increased patient morbidity and (2) it may not always obtain the
recommended margins of excision. The latter potential disadvantage
may mean that an additional excision of the site in question is neces­
sary once the diagnosis is known.
PATIENT PREPARATION
As is the case with all surgical procedures, the status of the patient’s
general health should be ascertained prior to biopsy procedures. Simi­
larly, whatever specific considerations that might be given for other
minor surgical procedures should be addressed here. Information
submitted. The lesion’s location and size may be crucial bits of infor­
mation for the pathologist when the histopathologic features are
ambiguous or unclear. In addition, it is beneficial to note the sus­
pected diagnosis or, at least, the differential diagnoses. Care should
be taken to avoid listing poorly conceived differential diagnoses,
however, as they may serve as red herrings and lead pathologists to
incorrect conclusions. If the lesion’s features are difficult to character­
ize, submission of a clinical photograph can be extremely helpful.
The more knowledge that the surgeon has about the biology of the
different classes of skin disease, the better the chance that the biopsy
will be taken in such a manner as to include representative features
of the condition in question and, consequently, the more likely that
the biopsy will provide the pathologist with sufficient information to
formulate an accurate pathology report.
An important consideration when performing biopsies for the
purpose of characterizing conditions of the skin, involves not only the
technique itself, but the subsequent histopathologic analysis which is
performed on the sampled tissue. Within the field of pathology, like
most healthcare professions, there are areas of specialization. Dermat­
opathology is the field within pathology that focuses specifically on
the histopathologic analysis of skin. Finding a pathologist who is
well-versed in dermatopathology may be extremely important because
in some instances, the criteria that are used to distinguish benign
lesions from those that are malignant may be extremely subtle. In
addition, precise diagnoses when dealing with inflammatory condi­
tions of the skin may require an understanding of basic dermatology,
which is not offered during a standard pathology residency.
BIOPSY INDICATIONS
The indications that apply for cutaneous biopsies are highly variable
depending on the dermatologic manifestations that have presented
themselves. In other words, the criteria that should be applied when
physicians are faced with characterizing inflammatory conditions
(dermatitides) are very different from those that should be used when
managing pigmented neoplasms. As a continuation of this premise,
those criteria that are used when assessing the need for biopsying
pigmented lesions are very different from those that are applied when
reviewing non-pigmented cutaneous lesions or subcutaneous tumors.
The one common denominator, which may be considered in all clini­
cal cases when a biopsy is being considered, is: ‘will a definitive his­
topathologic diagnosis alter medical therapy?’ or, ‘is such a diagnosis
necessary to guide surgical therapy?’
Biopsies may be considered for inflammatory conditions when the
clinical features are not specific enough to allow the clinician to for­
mulate a reasonable differential diagnosis, or when the ‘reasonable’
differential diagnosis happens to include multiple conditions, each of
which has its own unique first-line of therapy. Histopathologic analy­
sis may replace empiric therapy for patients who exhibit established
frustration over their persistent symptoms or for those who possess
conditions that have proven themselves to be debilitating. Alterna­
tively, biopsies may be ideal for skin conditions that are recalcitrant
to an initial course of empirical therapy. Additionally, biopsies may
be a useful means of assessing the therapeutic value of a prescription
that is already in use. For example, when the clinical differential diag­
nosis includes both tinea and eczematous (nummular) dermatitis,
especially for conditions outside of the intertriginous areas, care
should be taken not to uniformly default to anti-fungal therapy. It so
happens that from a clinical perspective, most such localized erup­
tions are indeed not tinea. In addition, in many such cases, preemp­
tive antifungal therapy may compromise the results of any future
biopsy.

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The biopsy site may then be draped with a sterile disposable aper­
ture sheet or left exposed. Once the lesion has been marked, anesthe­
sia injected and the skin prepped, the biopsy procedure can then be
performed. Most surgeons prefer wearing sterile gloves and using
sterile instruments throughout the biopsy procedure. Masks may be
used when more complicated elliptical excisions are performed but
are not necessary for most incisional biopsies.
BIOPSY GUIDELINES
There are several broad guidelines, which may be followed in relation
to biopsies. In the case of inflammatory conditions (dermatitides),
fully evolved or ‘active’ lesions are ideal targets for sampling because
should be obtained about the patient’s allergies, medications (particu­
larly anticoagulation therapy/aspirin), cardiac disturbances, uncon­
trolled hypertension and diabetes mellitus. Patients also should be
asked about, and examined for the possibility of, conditions such as
peripheral vascular disease, peripheral edema, vasculitis, tobacco use
and any history of alcoholism. These conditions could signal a pro­
pensity toward complications at the biopsy site and thus, convey a
need for a degree of caution. Based on the presence of such disorders,
clinicians might elect to first treat the condition empirically, minimize
the magnitude of the procedure itself, or allow for more diligent
follow-up after the procedure has been performed.
When the intention is to perform an excisional biopsy on poorly
delineated tumors, it is recommended to outline the lesion in ques­
tion, or the extent of the proposed biopsy, carefully with a skin marker
prior to prepping the skin or injecting the area with local anesthetic
agent. This prevents the skin paint or anesthetic-related tissue disten­
tion from obscuring the limits of the pending biopsy. Detailing the
biopsy site may also be a useful technique when performing other
biopsy procedures. As an example, for biopsy procedures which must
be taken at a precise anatomic location, such as epidermal nerve fiber
density (10 cm above the lateral malleolus), marking the exact site
may be important so to avoid losing track of the focus which has been
anesthetized. After the biopsy has been planned and marked, the site
and the adjacent skin should then be cleansed of obvious dirt or
superficial debris and then prepped.
The skin prep can be accomplished with isopropyl alcohol,
povidone-iodine scrub or chlorhexidine. Isopropyl alcohol may be
applied to the biopsy site with small cotton balls or alcohol wipes.
Alcohol works rapidly, reducing most of the skin flora within 1 min
and it is more cost-effective. A 10-second isopropyl alcohol prep is
equivalent to a 5-minute povidone–iodine or chlorhexidine prep.
Povidone–iodine is slightly more active but it has a slower onset of
action, stains the skin, causes contact dermatitis in some patients and
may inhibit wound healing. Chlorhexidine has a rapid onset and
sustained activity level for several hours and is preferred in longer
procedures or in immunocompromised patients. Research has shown
that from a purely practical point, a simple alcohol prep is just as
effective in limiting postoperative infections as its more cumbersome
and costly counterparts.
A local anesthetic agent, commonly lidocaine, is usually used to
anesthetize the biopsy site. The local anesthetic may be a plain solu­
tion or with epinephrine 1 : 100 000 (to promote vasoconstriction and
hemostasis at the biopsy site). Concentrations of epinephrine as high
as 1 : 50 000 may be used for small punches and shaves on open flat
surfaces of the foot and lower extremity with minimal risk, as an
exceedingly small amount of anesthetic is necessary in such cases. The
use of epinephrine allows for a cleaner surgical field during the pro­
cedure, thereby allowing better visualization of the lesion to be biop­
sied and consequently limiting inadvertent trauma to the specimen
during removal. Because of its benefits with minimal associated risk,
epinephrine is used in most cases, with the exception of instances
when the patient has a known epinephrine allergy. To decrease the
burning sensation associated with the local anesthetic and epine­
phrine, a small amount of sodium bicarbonate (8.4%) can be added
to the solution prior to injection.
The injection is usually given with a 1-mL locking syringe and a
27–30 gauge 5/8˝ needle. The syringe is held at about a 30–45° angle,
with the bevel of the needle tip pointed down. The injection is per­
formed within the dermis and subcutaneous layers in an appropriate
pattern to allow complete nerve block of the surgical site. This anes­
thetized field need only be large enough to encompass the biopsy site
itself and thus allow for complete patient comfort during the proce­
dure. Raising a wheal at the biopsy site is usually preferable to a
regional block (Fig. 13.1).
Figure 13.1  Local anesthesia wheal block for biopsy. (A) Sublesional
anesthesia wheal. (B) Close-up after block. As the lesion may be
obscured by the prep or distorted by the injection fluids it is advisable
to mark the area of biopsy before the procedure begins.
A
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
It is widely held that there is no place for superficial shave biopsies
when sampling pigmented lesions if there is a high suspicion of
malignancy. This is due to the fact that superficial shaves run the risk
of incomplete removal, leaving the deep component of the tumor in
vivo. This will not allow for an accurate depth measurement of the
lesion in question for microstaging purposes. Even though, upon exci­
sion of the remaining neoplasm, the depth of invasion may be esti­
mated by adding the tumor thickness in the biopsy to that of the
neoplasm within the subsequent excision; such additive measure­
ments lack both accuracy and precision. Of course, errantly shallow
measurements could potentially result in the omission of specialized
staging techniques or therapy that might be considered ‘standard of
care’, such as sentinel lymph-node biopsy or adjuvant immunologic
or chemotherapy, respectively. On the other hand, saucerizations will
often allow for complete excision while providing more tissue for
histopathologic examination than would a superficial shave, thereby
minimizing histopathologic miscues. Biopsies obtained by sauceriza­
tion technique will also more effectively guide future surgical therapy
when necessary. Because, when surgically managing melanoma, there
is a direct relationship between the depth of intra-dermal invasion
and the recommended margins of the excision (the amount of unin­
volved skin that should be removed with the lesion), whether initially
diagnosed by saucerization technique or elliptical excision, subse­
quent re-excision of the biopsy site is usually required.
It is our opinion that, if possible, when there is a high suspicion of
cutaneous melanoma, the lesion should be sampled in a manner that
will offer the entire lesion for histopathologic analysis. This will give
the dermatopathologist the opportunity to review the entire lesion
and thus will allow for the best possible histopathologic interpreta­
tion. Such sampling will also allow for a more detailed report, which
will include all the various prognostic parameters necessary for
optimal patient care. In summary, when there is a high degree of
suspicion for melanoma, we recommend excisional biopsy whenever
possible, using the saucerization technique or elliptical excisions,
instead of a superficial shave. Punch biopsies may be used when
complete excision is not possible. Potential punch biopsy targets are
the most elevated focus, which corresponds to the deepest point of
invasion and/or the darkest part of the lesion.
SHAVE AND SAUCERIZATION BIOPSY
Of all the biopsy techniques, the shave and saucerization biopsies are
among the quickest and easiest to perform. The shave technique is the
more superficial of the two methods, often sampling only to the level
of the superficial reticular dermis. Saucerization is considered to be
an alternate form of shave; however, because of the arciform shape of
the blade used for the procedure, it is substantially better suited for
sampling flat or more deeply invasive cutaneous neoplasms. Sauceri­
zation may thus be conceptualized as a more aggressive technique
than would be a standard shave biopsy. In contrast, because of the
natural limitations of a straight blade/scalpel, standard shaves are
traditionally used for papules or small nodules, which may be simply
shaven off flush. The same may apply to the sampling of pedunculated
lesions.
Where traditional shaves are usually performed using either a No.
10 or No. 15 scalpel, saucerization requires a malleable, specialized
blade such as BiopBlade™ (Miltex®, York, PA, USA) (Fig. 13.2) or half
of a standard two-sided razor blade (Fig. 13.3). The benefit of both
standard shave biopsy and saucerization technique is their ability to
sample the full diameter of relatively superficial skin lesions, espe­
cially if those lesions arise within the epidermis or papillary dermis.
they are most likely to exhibit histopathologic features that are specific
for the condition in question. When possible, two samples may be
taken, thereby capturing the disease process at two dissimilar stages
in its life and further increasing the diagnostic yield. It is generally not
necessary to obtain normal tissue when biopsying inflammatory con­
ditions. Punches are the techniques of choice when sampling all lower
extremity dermatitides. Of course, when there is a strong suspicion of
dermatophytosis, a full thickness punch may not be necessary. In this
setting, a positive potassium hydroxide (KOH) preparation or periodic
acid-Schiff (PAS) reaction performed on surface keratin will allow for
appropriately guided therapy. It should be noted, however, that the
absence of dermatophytes in a keratin sample is entirely non-specific.
In this scenario, even occult dermatophytosis remains a clinical
possibility.
Although there is not a 100% consensus on this next guideline, it
is generally thought that some anatomic locations are best suited for
certain types of biopsy procedures. For example, the plantar aspect of
the foot is usually biopsied by punch or excisional technique. This is
due to the fact that the thicker stratum corneum and underlying viable
epidermis of the sole can make obtaining sufficient diagnostic tissue
from a superficial shave exceedingly challenging. Shave and sauceriza­
tion techniques may be used on volar (plantar) skin; however, care
must be taken to penetrate through the stratum corneum entirely in
order to obtain diagnostic tissue. Such techniques are far less challeng­
ing on the glabrous (non-hair-bearing) surfaces of the extremities.
When biopsying verrucous lesions or other tumors on the volar
surface by shave or saucerization technique, it is important that the
bed of the biopsy site bleeds/weeps across its entire surface. This
ensures that the dermal capillaries have been exposed and thus
the surgeon can be reasonably sure that diagnostic tissue has been
obtained.
Solitary papules (elevated skin lesions ≤5 mm); nodules (elevated
skin lesions >5 mm); macules (flat areas of altered skin pigment
<1 cm) and lesions for which there is a low clinical suspicion of
malignancy, are best suited for the shave or saucerization technique.
Saucerization technique is often relegated to sampling those lesions
which require a section of tissue significantly deep compared with
the adjacent uninvolved skin. This would include lesions that lack
an exophytic (outward growing) component or those that are believed
to have prominent endophytic (inward growing) growth. Peduncu­
lated lesions also may be sampled using shave technique, however,
such lesions are also suitable for scissor biopsy technique, particularly
those with a tapered stalk. As a general rule, large plaques (plaques
defined as elevated flat-topped lesions >5 mm) are best sampled
with full-thickness punch biopsies; however, when plaques are small
(particularly <1 cm), shaves or saucerization techniques may be
preferred.
As noted above, inflammatory conditions are also best biopsied
using a punch technique to ensure transdermal sampling. As their
designation denotes, dermatitides are fundamentally inflammatory
conditions of the dermis, although often their clinical manifestations
are related to changes that occur within the overlying epidermis as a
direct result of the more deeply seated inflammation. Because some
conditions, such as lupus, histopathologically define themselves by
the pattern of inflammation within the superficial and deep dermis,
a full thickness sample of tissue is always preferred when sampling
inflammatory conditions. Pigmented lesions, especially when harbor­
ing significant atypia, should be completely removed (excisional
biopsy) when possible. This may be accomplished with large punches,
shaves, saucerizations or elliptical excisions. Of these techniques, sau­
cerization or elliptical excision most consistently allow for complete
removal. For small pigmented macules with minimal atypia, shave or
saucerization techniques are usually preferred.

131
Figure 13.2  BiopBlade™ (A) The unit. (B) The correct position to use for saucerization biopsy.
A
B
A
B
C
Figure 13.3  Double edge blade. (A) Standard double edge disposable
stainless steel razor blades. (B) Using a blade breaker or the blade can be
broken by bending the blade along its longitudinal axis. (C) The broken
blade is easily separated into two sections. (D) Securing the blade
between the thumb and finger provides curving of the blade to facilitate
excision. (E) The saucerization technique is fast and easy. This clean blade
does not need to be sterilized before it is used.
D
E

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
and other similar instruments are designed to accomplish the same
procedure with greater ease and personal safety. Regardless of the
blade type that is selected, saucerization is performed in the same
manner. The clinician will use their non-dominant thumb and index
finger to press down upon the skin on either side of the biopsy site.
Then the central aspect of the blade’s arch is moved in a saw-like
motion, entering the skin along the near side on the lesion to be
sampled. In most instances, the blade need only be angled into the
skin 10–15° off parallel. The entire lesion is undermined using the
arc of the saucerization blade to adjust the width of the specimen.
The more widely used variation of shave technique is the standard
shave biopsy, which utilizes a standard scalpel and No. 10 or No. 15
blade. This is an ideal technique for papular or small nodular neo­
plasms, where following the prep and anesthesia, the lesion is simply
shaven off flush with the adjacent skin. The first cut is made just
outside of the leading border of the lesion to be sampled. When an
excisional shave biopsy is desired, the skin is scored roughly 1–2 mm
to the outside of the lesion to be removed. Again, the blade is posi­
tioned at an extremely acute angle relative to the adjacent surface
epithelium. Once the incision has been initiated, the newly formed
epidermal ‘lip’ may be grasped with pick-up forceps so that the
surgeon can more easily use the belly of the blade to undermine the
lesion in question. In this manner, the tissue to be removed for his­
topathologic analysis is simply ‘peeled back’, using a mid-dermal
plane of section (Fig. 13.5). Because re-epithelialization of superficial
ulcers is partly accomplished with the aid of residual eccrine structures
beneath the ulcer’s base, the surgeon should avoid removing the entire
dermal layer, as this will slow re-epithelialization and delay healing.
Moreover, when dermal collagen is removed, it will invariably be
replaced by scar, which can also pose problems, particularly when on
the plantar surface. If it is suspected that small portions of the original
lesion are not removed at the edge of the biopsy site, such foci may
be obtained by curettage or using a small electrosurgical loop elec­
trode set at 1.5–2.0 units.
Following the procedure, hemostasis may be attained using a com­
bination of direct pressure and topical chemocautery. The base of the
biopsy site may be cauterized with 20% aluminium chloride hexahy­
drate solution (Drysol®, Person & Covey Inc, CA, USA) applied with
a cotton-tipped applicator. Other topical styptics may also be used;
A generous sampling of the dermal-epidermal interface may be par­
ticularly important when assessing pigmented lesions, because nevi
are distinguished from melanomas based largely on their histopatho­
logic features along that junction. Insufficient sampling of this region
may limit the dermatopathologists’ ability to apply the necessary
histopathologic criteria and ultimately result in misdiagnoses.
As aforementioned, the biggest limitation of traditional shave tech­
niques is depth. If the lesion in question extends deeper than the
superficial reticular dermis, it may in part remain in vivo at the base
of the biopsy site. Due to the thickness of both the stratum corneum
and epidermis of the volar surfaces, shave biopsies performed on these
surfaces may be additionally challenging. Extremely shallow shave
biopsies, particularly when performed on acral surfaces, may not
include the full thickness of the epidermis and thus may be difficult,
or even impossible, for the dermatopathologist to interpret. Such
biopsies may result in vague descriptive histopathologic interpreta­
tions, rather than those that are specific. Such imprecise diagnoses
may be useless from a therapeutic vantage point.
Skin conditions that are suitable for the shave biopsy technique
include those which resemble acquired digital fibrokeratoma,
dermatofibroma, verruca vulgaris, molluscum contagiosum, acrochor­
don (skin tag), seborrheic keratosis, neurofibroma, melanocytic nevus
(all forms), actinic keratosis, keratoacanthoma, squamous cell carci­
noma and basal cell carcinoma (if the shave biopsy is sufficiently
deep). In addition, all small and intermediate-sized pigmented
macules may be easily sampled by shave techniques. Inflammatory
conditions and deeply invasive neoplasms or subcutaneous-based soft
tissue masses should not be sampled by means of the shave technique.
The preparation technique for the shave biopsy involves marking out
poorly delineated lesions with a skin marker or pen, prepping the skin
over the lesion with isopropyl alcohol or povidone–iodine and
administering local anesthetic (usually with epinephrine). Ideally, the
lesion is entirely raised in a wheal in addition to a 0.5–1.0 cm of
peripheral skin.
When performing saucerizations, a double-edged razor blade, that
has been broken in half longitudinally, may be held between the
middle finger and thumb and can be used to remove skin lesions.
When readying the blade, the index finger is used to ‘bow’ and stabi­
lize the blade by applying dorsal pressure (Fig. 13.4). The BiopBlade™
Figure 13.4  Saucerization biopsy. (A) The raised lesion has been anesthetized and prepped and the surgeon is placing tension on the adjacent skin.
(B) The lesion is saucerized quickly and mild compression is applied to the biopsy site. Topical Drysol® solution may be applied to stop any superficial
bleeding.
A
B

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however, clinicians should be aware that many silver and iron-based
agents will lead to the deposition of pigmented metal salts within
the wound and a ‘tattoo’-like alteration of pigment within the scar.
Caution should be maintained when using Monsel’s solution (20%
ferric subsulfate) for this reason. During the early phases of postopera­
tive care, moist healing is recommended to prevent scab formation.
This may be accomplished by using an antibiotic ointment initially
followed by lubricating lotions or creams.
SCISSOR BIOPSY
Scissor biopsy is a less commonly used technique, which shares
some indications for use with those of shave biopsies. Very super­
ficial lesions and all of those that are pedunculated and stalked are
suitable for scissor excision. The most obvious lesions on the lower
extremity are skin tags (acrochordons), acquired acral fibrokeratomas,
small filiform warts and pyogenic granulomas with small bases. In
most cases, there is no need for local anesthesia unless the lesion is
very sensitive to touch or manipulation. Larger lesions that have wider
bases may be more difficult to remove with this technique and shave
or other excisional procedures may be required.
For performing biopsies using the scissor technique the only instru­
ments that are needed are fine-toothed forceps and a pair of small
tissue scissors, which may be either straight or curved (Fig. 13.6). The
lesion is grasped with forceps and gentle upward traction is applied
to allow for visualization of its base. The scissors are positioned to
remove the lesion so that the base of the stalk is flush with the adja­
cent skin. Often, the lesion can be lifted up with the tips of the scissors
and the use of forceps is not even needed. As a general rule, once the
base has been cleanly divided there is minimal bleeding present;
however, exceptions can occur. In such instances, as with shave biop­
sies, the base may be cauterized with aluminium chloride solution
and a small bandage may be applied.
PUNCH BIOPSY
The punch biopsy is considered the ideal technique to obtain a full-
thickness skin specimen when such is required for an accurate diagno­
sis. It is a quick and safe procedure, which provides excellent cosmetic
results. Unlike the scissor technique, the punch technique uniformly
requires local anesthesia. The indications for the punch biopsy include
most dermatoses, most forms of dermatitis, solitary patches, plaques,
nodules too large to be removed using the shave technique, small
inclusion cysts and all lesions that can be removed entirely using the
punch technique (excisional biopsy). The skin preparation and
anesthesia are standard for the procedure. We recommend using local
anesthetic with epinephrine for punches because it greatly assists in
hemostasis; allowing good visualization of the specimen for easier
extraction from the biopsy site.
The punch biopsy instruments may be reusable or disposable. It is
our opinion that the disposable biopsy tools are better in that they
Figure 13.5  Scalpel blade shave technique. (A) The procedure begins by
making a shallow incision away from the lesion to be removed. A forceps
is used to grasp this normal edge of skin. (B) The scalpel technique
continues to peel the lesion off with care to avoid cutting deep into the
subcutaneous layer. This process continues until the lesion is shaved off.
(C) This process is a quick and easy technique to remove superficial
lesions.
A
B
C

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
are always sharp, sterile and relatively inexpensive (Fig. 13.7). The
reusable tools become dull quickly, requiring constant resharpening,
meticulous cleaning and careful wrapping for sterilization. The size of
the diameter of the cutting blade of the punch tool ranges from 1 to
8 mm. The 2.0, 3.0, 3.5 and 4 mm diameter punches are most com­
monly recommended for the skin of the lower extremity. Larger sizes
(8.0 mm) are usually employed when the punch is to be used as an
excisional technique.
The punch biopsy technique is straightforward and is begun by
placing traction on the skin on either side of the biopsy site, using the
thumb and forefinger of the non-dominant hand. The skin is stretched
at 90° to the natural skin lines or relaxed skin tension lines. The punch
is inserted into the skin by pressing gently while rotating the instru­
ment back and forth between the thumb and fingers of the dominant
hand (Fig. 13.8). The blade of the punch should cut through the skin
as it is rotated back and forth. Simply pushing the blade through the
dermis will create artefacts in the specimen, which may, in some
instances, compromise the subsequent analysis.
The punch should be pushed through the reticular dermis, usually
penetrating deep enough to obtain subcutaneous fat at the base of the
biopsy specimen (Fig. 13.9). It is important to be aware of the under­
lying anatomic structures prior to performing a deep punch to prevent
damage to nerves, blood vessels and tendons. Of course, this is par­
ticularly important upon the dorsal surface of the foot. Many surgeons
have been erroneously taught that the punch biopsy is always buried
Figure 13.6  Scissor biopsy. (A) A small elevated and slightly pigmented lesion is present. (B) The curved tissue scissors are positioned with the tips
under the edge of the lesion and the cut is started. (C) The scissors are closed to completely sever the underlying stalk of the lesion. (D) The lesion is
removed by the scissors without the need of tissue forceps.
A
B
C
D
Figure 13.7  Disposable punch biopsy tools. Individually packaged and in
a variety of sizes, the punch tool is very useful in the clinical setting.

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to the hub of the cutting surface; however, this is not always necessary,
especially on the dorsum of the foot. Physicians can usually pinpoint
when the punch instrument penetrates the dermis, because of the
decrease in resistance that can be felt as the blade enters the subcuta­
neous fat layer. After the punch instrument has entered the subcutis,
the downward pressure is stopped regardless of how much of the
metal cutting barrel has entered the skin. Once the punch biopsy is
completed, the punch instrument is withdrawn and the specimen is
removed carefully by using a fine-needle or fine-toothed forceps, by
gently grasping the base of the specimen or subcutaneous tissue. Care
must be taken not to introduce crush artefact into the specimen as
this will compromise its diagnostic utility. Once the plug has been
distracted from the biopsy site, a sharp iris or tissue scissors are used
to cut the connective tissue attachment at the biopsy base (Fig. 13.10).
Occasionally, the tissue plug remains in the punch instrument and
will require extraction. This is an increasingly common finding when
A
B
Figure 13.8  Punch biopsy. Skin marking to illustrate the principle of
creating an ellipse following a circular punch. (A) The skin is stretched
perpendicular to the relaxed skin tension lines as the marking
instrument is placed firmly at the biopsy site. (B) With continued
traction on the skin the biopsy site is circular in appearance. (C) Once
the tension is released the circular defect will relax into an oval for
easy closure with Steri-Strips or sutures.
C
using punches of smaller diameter, particularly when those biopsies
are taken from heavily keratinized skin.
The defects left by punches of small diameter (2.0–3.0 mm), do not
usually require closure. When closure is desired, usually one or two
Steri-Strips will suffice. Larger punch biopsy sites (≥3.5 mm) can be
closed with one or two sutures and normally produce only a minimal
scar. In many cases, it might be advisable to obtain two 2.0 mm punch
biopsies from a single skin lesion on the lower extremity (especially
on the foot and ankle region) rather than one larger biopsy. The rea­
soning is simple in that two small punches from the same lesion more
thoroughly sample the condition and the smaller size avoids suture
closure with rapid granulation and reepithelialization (Fig. 13.11).
Once the punch biopsy is completed and hemostatic agent applied,
the punch site is then covered with a spot dressing or small bandaid
and the patient is instructed to keep the dressing intact, dry and clean
for the next 24–48 h. Daily showering is then permitted; however,

136
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
ELLIPTICAL EXCISION AS A
BIOPSY TECHNIQUE
This form of excisional biopsy technique is the same as described
earlier in Chapter 12 under the section on fusiform ellipse technique.
Indications for excisional biopsy include subcutaneous masses and
pigmented tumors of the skin, where there is a high suspicion of
malignancy. Elliptical excision is not contraindicated when perform­
ing excisional biopsies on smaller lesions or those where there is a
low index of suspicion for malignancy; however, shave excision tech­
niques are quicker to perform, result in less patient morbidity and do
not require suture removal, yet can provide identical histopathologic
information. Excisional technique is designed to remove the entire
skin lesion along with a perimeter of uninvolved skin, e.g. ‘clear
margins’ on all sides. Because the recommended width of the unin­
volved skin to be excised varies depending on the precise diagnosis,
less complicated biopsy techniques are often initially performed to
establish a diagnosis, after which the appropriately directed elliptical
excision is performed as the definitive therapy. The desired margins
of the excision should be outlined with a skin marker prior to infiltra­
tion with local anesthetic, as this injection distorts the tissues making
the limits of the lesion difficult to discern afterwards (Fig. 13.12).
Another method of marking the excision site is to draw a circle around
the peripheral limits of the lesion to be excised and then making the
resultant circle the center of the ellipse (Fig. 13.13). The shape of the
lesion may suggest the direction of the fusiform ellipse but, whenever
possible, the longitudinal axis of the excision should lie within or
parallel to the relaxed skin lines.
INCISIONAL BIOPSY
Incisional biopsies are by definition those that only partly remove the
lesion or condition in question (Fig. 13.14). These techniques are
appropriate when there is extensive cutaneous involvement by multi­
ple lesions (such as in psoriasis), or when the primary lesion is much
too large to be removed by excisional techniques (advanced melanoma
in situ). Inclusion of the interface between the lesion and the adjacent
normal skin may be useful when histopathologically assessing pig­
mented lesions; however, it is of no usefulness when sampling der­
matitides. In such cases, clinicians should target the most active part
of the lesion, making it easier for the dermatopathologist to evaluate
the full extent of the pathologic changes.
For lesions that have a component that is elevated above the sur­
rounding skin (plaques, nodules, papules), samples are best taken
from the most elevated focus. Such foci most commonly correspond
to the deepest point of tumor invasion. For large flat pigmented
lesions (patches), the darkest area should be sampled. When an ellip­
tical incision is performed, orientation of the biopsy at right angles to
the edge of the lesion will allow histopathologic assessment of the
change from abnormal to normal tissue (Fig. 13.15). When small
punches are the incisional technique of choice, however, taking half
affected and half unaffected skin is ill-advised, as this practice may
lead to poor tumor sampling in histopathologic sections.
Elliptical incisional biopsy, like its excisional counterpart, should
be through the full thickness of the skin to the level of the upper
subcutis. This will optimize the quality of the specimen from a his­
topathologic perspective. For deep inflammatory conditions, such as
the panniculitides, the full thickness of the subcutaneous fat should
be included with the biopsy specimen. The required depth of the
incisional biopsy will obviously be determined by the type of lesion
in question and its anatomic location. It is best to hold the underlying
bathing should be discouraged until after the defect has closed. After
showering, the bandage should be changed with re-application of the
topical antibiotic of choice. When sutures are used, they should be
left in place until healing has occurred. This duration may vary
depending on patient parameters, the punch size and the location of
the biopsy site. The lower leg and ankle tend to heal much sooner
(roughly 4–6 days for 3 mm punches) than sites on the foot, particu­
larly the plantar surface, which may take 2–3 weeks.
Figure 13.10  Punch biopsy. Removing the core of biopsy with forceps
carefully placed below the lesion into the subcutis layer. A fine-needle,
like that used to anesthetize the area, may be used to lift the specimen
out so that it may be cut with the scissors.
Figure 13.9  Punch biopsy. Showing full depth of instrument
recommended in most cases. Obviously, this depth is not always
achievable and depends upon the underlying anatomical structures.

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A
B
C
D
E
F
Figure 13.11  Punch biopsy using two 2.0 mm punches. (A) Biopsy sites are both injected with small wheal of local anesthetic. (B) Biopsy sites are
wiped with alcohol. (C) Two separate biopsies are performed. (D) The specimens are either removed from the biopsy unit with the unit plunger or, if
still attached, carefully removed without crushing the skin. (E) The specimens are placed into the pathology delivery cup containing 10% buffered
formalin. (F) The sites are touched with Drysol® to prevent bleeding.

138
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
anatomic site from which it was taken. Tissue that is intended for
histopathologic analysis should not be left on the surgical table or
instrument stand for long periods after it is removed, as this will lead
to desiccation, a process that will greatly compromise the quality of
the specimen. It is imperative that a description of the technique that
was performed and basic clinical information be included on the
requisition form. Knowing whether the specimen is a shave, punch
or elliptical excision and whether the procedure is intended to be
excisional or incisional may guide the dermatopathologist in their
handling of the specimen. In addition, a clinical description of
the lesion should be included. Pertinent clinical facts include the
anatomic site of the lesion, a clinical description of the lesion(s) itself,
the clinician’s suspected diagnosis, pertinent clinical history and a
differential diagnosis when possible. Finally, special instructions
surface of the incisional biopsy specimen with a skin hook to prevent
crush injury to the skin being submitted for examination.
For inflammatory lesions (dermatitides) that vary in clinical appear­
ance from one region to another, it is advisable to obtain an incisional
biopsy from each different site. As some inflammatory conditions are
only diagnostic at a particular stage in their evolution, sampling
various locations may allow for a more precise histopathologic
diagnosis. The same principle applies when sampling large patches
(large flat areas of altered pigment). As previously mentioned, when
sampling pigmented and suspected malignant neoplasms, excisional
biopsy is preferred when surgically possible. As with other full-
thickness biopsy techniques, closure depends upon the size of the
specimen removed and may be as simple as Steri-Strips or may require
more complex suture closure.
PATHOLOGY
All tissue samples removed for pathology should immediately be
placed in tissue fixative (usually formalin) and labelled with the
patient’s name, age, sex, identification number, date of biopsy and
G
H
Figure 13.12  Skin marking for biopsy. (A) Area of lesion outlined with
skin marker prior to local anesthesia and skin prep. (B) The lesion in this
case was injected with local anesthetic and the skin was painted with
povidone–iodine without marking it first and subsequently it is impossible
to tell where the original lesion is located.
A
B
(G) The site is covered with an antibiotic
ointment and a bandaid. (H) Appearance of biopsy sites in 2 weeks.
Figure 13.11, Continued

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Figure 13.13  Lesion marking before biopsy. (A) The lesion in question is an elevated and pigmented area on the medial aspect of the fifth toe. (B) A
circle is drawn around the lesion to be excised and this is used as the center of the ellipse drawing. (C) The excisional biopsy removes the lesion with
2 mm margins. It is then sutured and bandaged in the usual manner.
A
B
C
Figure 13.14  Incisional biopsy. Extensive areas of involvement of the
lesion are present and an incisional biopsy is being performed to include
pathologic and border of lesion.
Figure 13.15  Incisional biopsy. Orientation of the biopsy at right angles
to the border of the lesion. There is no reason to take normal tissue with
the biopsy but it is often advisable to take the edge of the lesion.
must be plainly written. Depending on the clinical scenario, such
instructions could include requests for margin evaluation, directions
regarding specimen orientation and requests for special studies
such as molecular genetics, immunohistochemistry or microbio­
logy. Any additional information that might be useful to the dermat­
opathologist should also be included. The clinician’s description
serves as the ‘eyes’ of the dermatopathologist.
The pivotal role that clinicians play in assuring the correct his­
topathologic diagnosis cannot be overstated. The clinical and techni­
cal information provided by the submitting clinician will greatly assist
the dermatopathologist by conveying appropriate perspective. As an
example, a skin biopsy that discloses non-specific spongiotic derma­
titis can be more precisely designated as nummular (eczematous)
dermatitis if the clinician effectively conveyed that the primary lesion
consisted of a coin-shaped rash on the leg. More significantly, a
‘severely atypical nevus’ might be more extensively sectioned in search
of melanoma if the dermatopathologist is aware that the biopsy is but
a small part of a much larger lesion. A helpful way to ensure inclusion
of all pertinent clinical information on pathology requisition forms
is to think of the subject categories as the ‘5 Ds’. There are five catego­
ries of information that when possible should be submitted in writing
with a skin biopsy. These categories all start with the letter D and

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
dermatopathology labs, as some hospital-based practices and general
reference labs also have dermatopathologists on staff. That being
stated, it is imperative that clinicians verify that the pathologists
reviewing their tissues are indeed board certified in dermatopathol­
ogy. Neither experience alone nor unregulated ‘fellowship training’
in any way substantiates a pathologist’s skills in dermatopathology
or qualifies them as subspecialists in dermatopathology. Moreover,
clinicians should be cautious when dealing with pathologists who
boast fellowship training, but lack board certification. This is because
accredited dermatopathology fellowships uniformly bestow board
eligibility upon their graduates who then routinely become board
certified.
include the physical description, the patient demographics, the lesion’s
duration, the lesion’s diameter and the suspected diagnosis of the
specimen.
Typically, the solution used for the transportation of the sample is
one of 10% buffered formalin. It is customary for pathology labs to
supply medical offices with specimen bottles containing the appropri­
ate fixative, along with identification labels and requisition forms.
Pathology labs also provide for specimen transportation whether
through courier services or prepaid mailing containers.
Finally, it is our opinion that dermatologic specimens should be
directed only towards board-certified dermatopathologists. This is not
intended to imply that such tissues must be sent to specialized
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CHAPTER CONTENTS
Introduction
143
Flap classification
143
Vascular anatomy of the flap
144
Angiosomes
144
Flap design
147
Flap failure and survival factors
148
Conclusion
149
INTRODUCTION
… flaps are vicarious, mischievous, and frequently
insubordinate reconstructive agents. They demand
thorough understanding and meticulous attention for
successful employment.
(Hoopes 1976)
The use of skin flaps and grafts to cover tissue defects on the lower
extremity can be a rewarding, but occasionally frustrating, procedure
when wound complications develop postoperatively. Many of the
failures or problems that occur can be prevented with appropriate
perioperative planning of incisional approach, proper tissue handling
and postoperative management. Some wounds are best left to heal
secondarily, while others respond well to soft tissue coverage with
better long-term results of scarring, tissue sensibility, durability and
cosmesis.
FLAP CLASSIFICATION
The surgeon must consider several factors in the decision of wound
coverage. Besides the overall health of the patient and vascular status
of the area, the surgeon must also consider the tissue quality available
for transfer, the recipient site and the type of flap that would provide
the best coverage with the least potential risk. Skin flaps and grafts
differ in the blood supply available for the transferred tissue. A skin
graft is a transfer of tissue without its own blood supply and survival
of the graft depends entirely on the blood supply from the recipient
site. Examples of skin grafts are split-thickness or full-thickness skin
grafts that rely on the recipient wound bed for vascular perfusion. A
skin flap, on the other hand, is a flap of tissue that is transferred with
its own blood supply intact. There is a variety of skin-flap designs
commonly employed for coverage of defects in the lower extremity.
There are different categories by which a skin flap can be classified.
Skin flaps may be classified by the source of blood supply to the flap,
or by the different anatomical structures included in the flap, or by
the location of the donor site. One of the most common flap types is
a random cutaneous flap (Fig. 14.1). The flap is classified as random
because the source of blood supply to the flap is by random intrader­
mal or subdermal plexus through the pedicle of the flap. The random
flap usually requires no greater than a 1 : 1 length to width ratio to
assure adequate blood supply to the flap. There are two broad types
of random cutaneous flaps based on design and movement of the
flap. A rotational, transpositional or interpolation flap is a random
flap that rotates about a pivot point while a pedicle, bipedicle, or V–Y
random flap is an advancement flap. Conversely, an axial pattern flap
receives its source of blood supply through an anatomically recogniz­
able arteriovenous system along the long axis of the flap (Fig. 14.2).
This permits a much greater arc of mobility, since the blood supply is
entering directly through a known artery and vein, which permits a
longer length to width ratio and increases perfusion pressure to the
flap. There are essentially three subtypes of axial pattern flaps: the
peninsular axial pattern, which has a direct cutaneous artery and vein
that supply the dermal-subdermal plexus and run along the longitu­
dinal axis of the flap, the island axial pattern, which is supported
exclusively by the direct cutaneous vasculature supply because the flap
has been dissected out, and the free flap pattern, which is an island
flap in which the blood supply has been divided from its base, prior
to being moved to another site on the body.
As stated above, the island flap is an axial pattern flap that has had
most of the soft tissue of the pedicle dissected away from the vascular
bundle. Since the soft tissue, including the skin is removed from the
vascular bundle there is even greater mobility of this flap when com­
pared with the axial flap. However, there may be greater risk of loss
©2012 Elsevier Ltd.
Flap classification and survival factors
Mary E. Crawford
Chapter
14

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
that rotates about a pivot point into an adjacent area and moves as
an arc. A transposition flap is a transfer of tissue laterally about a pivot
point, usually designed as a rectangle and the flap is usually longer
than the defect. Transposition decreases length upon rotation; an
example would be a Z skin plasty or rhomboid flap. A final local flap
is an interpolation flap that rotates about a pivot point into a nearby,
but not adjacent, defect with a pedicle passing above or below a skin
bridge. An example of an interpolation flap would be an island pedicle
flap (see Fig. 18.23).
A distant flap is tissue that is transferred from an incontiguous
anatomic site, such as from a different part of the body. A pedicle flap
is a distant flap with the flap still attached to the original blood supply
and a free flap is a pedicle flap from which the native blood supply
is physically detached from the donor site and reattached to vessels at
the recipient site. Clearly, there is significant overlap in the classifica­
tion of skin flaps and the best system to describe one flap design
may not fully distinguish another type, so multiple classifications can
be used.
VASCULAR ANATOMY OF THE FLAP
To really understand the varying designs and unique character of
specific flaps, the vascular anatomy must be clearly understood to
properly implement the flaps into each situation. Both the microcir­
culatory and macrocirculatory patterns of the skin affect the flap’s
potential for survival. The macrocirculation is comprised of the seg­
mental, the perforator and the cutaneous vasculature. The segmental
vessel is deep to the muscle. The perforator vessel branches off the
segmental and supplies the muscle. The cutaneous vasculature
branches off the perforator and consists of musculocutaneous branches
or arises directly from the segmental vessel to provide direct cutaneous
vessels. The musculocutaneous vessels are perpendicular to the skin
and the direct cutaneous vessels are aligned parallel to the skin surface.
The direct cutaneous vessels are accompanied by the venae comi­
tantes. The dermal blood distribution is this extensive network of
direct cutaneous and musculocutaneous arteries that form the dermal
and subdermal plexi (Fig. 14.3).
The microcirculation of skin flaps involves the smallest terminal
vessels of the circulatory system and includes the arterioles, the
venules, capillaries and arteriovenous anastomoses. These small ter­
minal vessels rise from the dermal and subdermal plexi of arteries
described above, which then go on to terminate in skin capillaries at
the papillary ridge and dermal epidermal junction. Blood flows into
the capillary network and then into the postcapillary venules and then
collecting venules. There are also arteriovenous anastomoses between
the arterial and venous systems that can bypass the capillary system.
Lymphatic vessels are also involved in microcirculation and if dis­
rupted can lead to flap edema. The microcirculation is responsible for
the waste removal, nutrient exchange, thermoregulation, and local
regulation of blood flow. Though the cutaneous circulation is rich and
vast, the metabolic demands of the skin elements are low so that only
a small fraction of the potential cutaneous circulation is necessary for
skin viability. This fact is highly pertinent to the design and survival
of various skin flaps.
ANGIOSOMES
To truly appreciate the intricate vasculature of the skin and soft tissue,
it is critical to understand the location and importance of the angio­
somes of the foot, ankle and leg. An angiosome is a specific three-
dimensional block of tissue supplied by a given source artery and can
of this flap if the vasculature is damaged due to more extensive
dissection.
Classifying flaps based on the type of tissue being transferred also
clearly defines the flap and the potential risk involved with each class.
A fasciocutaneous flap has been shown to be very efficacious for cover­
age of a large defect. The fasciocutaneous flap is a composite flap
comprised of skin, subcutaneous, and fascia, but not the muscle adja­
cent to the area. The flap is based on the vascular plexi of the deep
fascia.
There are several advantages of the fasciocutaneous graft over a
muscle or musculocutaneous flap, such as ease of elevation, less bulk
and easier transfer with no functional impairment. The musculocuta­
neous flaps are comprised of skin, subcutaneous tissue, and muscle
supplied by a dominant vascular pedicle. This flap can be used as an
peninsular or island flap or as a free flap. A free flap is an axial flap
with the vascular bundle severed, and the entire flap and blood supply
is transferred to the recipient site and reattached to the vasculature
available at the recipient site. There is increased risk of failure of this
flap due to the possible thrombosis at the anastomosis site. In some
unique situations, the nerve may also be transferred along with the
vascular bundle to allow sensation to be maintained to the flap. This
is especially useful in high-pressure areas.
A final classification system for skin flaps takes into consideration
the location of the donor site. A local flap is a transfer of tissue from
an area adjacent to, or nearby the defect. There are four major types
of local flaps based on the predominant type of movement of the flap.
An advancement flap moves directly forward without lateral move­
ment. An example of this would be the V–Y advancement flap. A
second type of local flap is a rotation flap, which is a semicircular flap
Figure 14.1  Drawing of random cutaneous flap.
(Reproduced with permission from: Dockery, G.L., Christensen, J.C., 1986. Principles
and descriptions of design of skin flaps for use on the lower extremity. Clin Podiatr
Med Surg 3, 563–577.)
Dermal-subdermal plexus
Segmental artery
Musculocutaneous
and perforator artery
Muscle
Figure 14.2  Axial pattern flaps. (A) Peninsular axial pattern. (B) Island
axial pattern. (C) Free flap axial pattern.
(Reproduced with permission from: Dockery, G.L., Christensen, J.C., 1986. Principles
and descriptions of design of skin flaps for use on the lower extremity. Clin Podiatr
Med Surg 3, 563–577.)
A
B
C

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Flap classification and survival factors
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| 14 |
branches off at approximately the same level and supplies the heel.
The boundaries of the medial calcaneal artery angiosome extend
from the posteromedial heel, entire plantar heel and ends at the con­
tralateral glabrous junction between the lateral posterior and plantar
heel. The medial plantar artery angiosome encompasses the instep
be comprised of one or more of the following components: skin,
connective tissue, muscle and bone. A venosome is a three-dimensional
territory drained by a named vein and is connected to neighboring
venosomes by ‘oscillating’ veins. Angiosomes and venosomes tend to
overlap a territory known as an angiotome. Each angiosome covers a
specific area, but can communicate with other nearby angiosomes via
true anastomoses of normal calibre vessels or via ‘choke’ vessels.
Choke vessels are small, reduced calibre connecting branches that are
usually closed between the angiosomes. If the pressure gradient falls,
however, and there is a decrease in blood flow through a specific
source artery or angiosome, then these vessels open up to allow blood
flow from one angiosome to another, thereby reestablishing blood
flow to a decreased vascular area.
There are five distinct angiosomes fed by the following three source
arteries in the foot and ankle: (1) the anterior tibial artery, which
becomes the dorsalis pedis; (2) the posterior tibial artery, which gives
rise to the calcaneal branch and the medial and lateral plantar artery
and (3) the peroneal artery, which provides the anterior perforating
branch and the calcaneal branch of the peroneal artery. In overview,
the posterior tibial artery supplies the medial and medial posterior
ankle, the heel, and the sole of the foot (Fig. 14.4). The anterior tibial
artery supplies the anterior ankle and then the dorsum of the foot via
the dorsalis pedis (Fig. 14.5). The peroneal artery supplies the lateral
anterior upper ankle, and the lateral and plantar heel (Fig. 14.6).
Evaluating and understanding the precise detail of each of the angi­
osomes of the foot and ankle and their source artery blood supply is
critical for the reconstructive surgeon. The posterior tibial artery gives
off the posterior medial malleolar branch that anastomoses with the
anterior medial malleolar branch of the dorsalis pedis artery. This
supplies the medial malleolar area. The medial calcaneal artery
Figure 14.3  Drawing of the relationship of the superficial and deep
vascular plexuses and branching of perforating and direct cutaneous
vessels.
Epidermis
Papillary
dermis
Subcutaneous
fat
Superficial
vascular
plexus
Deep
vascular
plexus
Reticular
dermis
Figure 14.4  The angiosome of the posterior tibial artery and its
branches. The posterior tibial artery’s angiosome in the lower leg extends
from the medial lower leg to the medial half of the posterior calf. The
central raphe along the Achilles tendon demarcates its lateral border, and
the medial anterior border of the tibia demarcates its anterior border.
(Reproduced with permission from: Attinger, C., Cooper, P., Blume, P., et al., 2001.
The safest surgical incisions and amputations applying the angiosome principles and
using Doppler to assess the arterial–arterial connections of the foot and ankle. Foot
Ankle Clin 6, 745–799.)
A
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
The anterior tibial artery supplies the anterior compartment of the
leg and at the ankle, and gives off the lateral malleolar artery that
anastomoses with the anterior perforating branch of the peroneal
artery. At this same level, it gives off the medial malleolar branch to
anastomose with the posterior medial malleolar artery of the posterior
tibial artery. The anterior tibial artery then continues and becomes the
(Fig. 14.7). The boundaries are proximally, the anteromedial edge of
the plantar heel; laterally, the midline of the plantar foot; distally, the
posterior edge of the plantar forefoot and medially, an arc above the
glabrous junction. In some cases, the anterior boundary can vary and
extend all the way to the hallux.
The lateral plantar artery angiosome includes the lateral plantar
surface in addition to the plantar forefoot. The boundaries of the
lateral plantar artery angiosome include proximally, the anterolateral
edge of the plantar heel; the medial border proximally is the central
midline of the plantar foot and distally, the medial border is the gla­
brous junction between the medial plantar forefoot and the medial
distal dorsal forefoot. The lateral border is the glabrous junction
between the lateral dorsum of the foot and the plantar surface of the
foot. The anterior border includes the entire plantar forefoot including
the hallux. The hallux can also be part of the medial plantar artery or
the dorsalis pedis angiosome. The lateral plantar artery and the dor­
salis pedis artery together form the deep plantar transverse arch with
the dorsalis pedis the predominant contributor to the arch.
Figure 14.5  The angiosomes of the anterior tibial artery and its
branches. The anterior tibial artery’s angiosome supplies the anterior part
of the leg overlying the anterior compartment with the fibula as the
lateral boundary of the anterior tibial angiosome and the anterior tibia as
the medial boundary.
(Reproduced with permission from: Attinger, C., Cooper, P., Blume, P., et al., 2001.
The safest surgical incisions and amputations applying the angiosome principles and
using Doppler to assess the arterial–arterial connections of the foot and ankle. Foot
Ankle Clin 6, 745–799.)
A
B
Figure 14.6  The angiosomes of the peroneal artery and its branches.
The angiosome extends from the midline of the posterior calf to the
anterior edge of the lateral compartment. It extends inferiorly to the
anterolateral ankle and lateral heel.
(Reproduced with permission from: Attinger, C., Cooper, P., Blume, P., et al., 2001.
The safest surgical incisions and amputations applying the angiosome principles and
using Doppler to assess the arterial–arterial connections of the foot and ankle. Foot
Ankle Clin 6, 745–799.)
A
B