Surgical Dermatology

Dr. Skinner is Cullman’s only Mohs surgeon and only Fellow of the American Society for Dermatologic Surgery.  Below is a list of surgical procedures we provide at Cullman Dermatology Clinic, P.C. 

Cryosurgery This is the destruction of a lesion by the controlled application of liquid nitrogen. The nitrogen is sprayed on the lesion for a few seconds, which results in the destruction of cells in the epidermis. Usually, the lesion will begin to swell and then form a blister (water or blood blister). Complete healing usually occurs between 3-6 weeks. This is primarily used for actinic keratoses (precancers), warts, and skin tags. 

Biopsy This is the removal of a skin lesion, either partially or entirely, so that the tissue may be examined microscopically to aid in the diagnosis of the lesion or disorder. First, the appropriate lesion and site are identified by the provider. It is photographed and then cleaned with an antibacterial agent. Next, it is anesthetized with a dilute mixture containing lidocaine using a very small (30g) needle. The lesion is then biopsied with either a flexible razor blade leaving a circular scab or with a tubular punch (like a cookie cutter) and may be closed with stitches. 

Electrodesiccation and Curettage (ED&C) This is used to treat small basal and squamous cell carcinomas, and occasionally warts. The lesion is cleaned with an antibacterial agent and then anesthetized with a dilute mixture of lidocaine using a very small (30g) needle. A sharp circular instrument called a curette is then used to scrape the lesion until healthy tissue is identified. The base of the defect is then treated with an electric needle (electrodesiccation) to kill any remaining cancerous or precancerous cells, and to stop bleeding. This cycle is often repeated 1-2 more times. The wound resembles a “skinned knee” and takes 3-6 weeks to heal. The scar is often slick and lighter-colored than the surrounding skin. 

Excision This is the removal of a lesion in its entirety, often with an extra safety margin of normal tissue. The excision is carried down at least to the level of the subcutaneous fat. This may be performed on cancerous, precancerous, or benign lesions. The tissue that is removed is submitted for pathology to confirm the diagnosis and that all of the lesion has been removed. 

Mohs Micrographic Surgery Mohs surgery offers the highest cure rate for the treatment of basal cell and squamous cell carcinomas (~99%). Because the physician performing the procedure must function as both the surgeon and the pathologist, the accuracy of the cancer mapping is greatly enhanced. It is particularly helpful for large tumors, recurrent tumors, tumors near important structures such as the eye or lip, and aggressive tumors (such as those occurring in young patients or those growing rapidly). Mohs surgery allows viewing of 100% of the margin, whereas the standard permanent sectioning only allows viewing of <1% of the margin.
*For a more detailed description of this procedure, please click here - Mohs Micrographic Surgery

Reconstruction – The first goal of cutaneous oncology is to remove the cancer in its entirety. The second goal is to preserve function (e.g., the nostril should not collapse when you breathe, the eyelid should open and close properly, etc…). The third goal is to restore the surgery site as close as possible to its original state. EVERY procedure that involves the dermis or deeper tissue ALWAYS results in a scar. Our goal is to control and minimize scarring as much as possible. There are several options for repairing defects after these first two goals are achieved. Reconstructions are individualized to each patient. Variables considered include things such as smoking (this ALWAYS worsens scars), can the patient or their family perform wound care, do they prefer absorbable cutaneous sutures so they don’t have to return for stitch removal even though they may get a less acceptable scar, are there other surrounding scars or lesions that limit options, etc...

The reconstruction options that we offer are as follows:

  • Granulation – This means the lesion heals on its own. This usually takes ~6 weeks and requires twice daily topical care. It is best for concave areas and often results in reasonably nice scars.
  • Linear Closure – This means the lesion is sewn together using one or more layers of suture. Often, the lesion is first undermined (i.e., the deep layers are cut free form the superficial ones), then absorbable sutures close the deep layer(s). The top layer is closed with very small sutures placed close together to evenly distribute tension and ensure the edges are everted (curled-up). Absorbable sutures (convenient, but have more potential to scar) or non-absorbable sutures that are removed in ~1 week may be used.
  • Grafts – Once the appropriate site is determined to best match the skin surrounding the defect, a graft is harvested by excising enough skin (epidermis and dermis) to fill the defect. It is usually harvested free hand using a scalpel. Any fat that is included is trimmed off and discarded. It may be soaked in saline while the recipient site is being prepared. It may be sutured into place using absorbable or non-absorbable stitches. The donor site is generally sewn as a linear closure. A pressure dressing is applied to the graft and left in place for 2 or more days. It is extremely important not to rub or manipulate the graft, as new blood vessels must grow into it within 48 hours for it to survive. If part or all of the graft fails to survive, debridement by your provider may be necessary, but healing is generally still quite acceptable. It is not unusual for a graft to change colors and eventually end up with a lighter color than the surrounding skin. Smoking is extremely detrimental to grafts.
  • Flaps – This involves freeing the surrounding tissue on 3 sides, loosening the flap from the deeper tissues, and moving it into the recipient site while maintaining blood flow through the attached side. Since it carries its blood supply with it, it usually heals faster and better than a graft. The stitch lines generally are more extensive than with any other closure, but often result in less visible scarring and superior healing.

For more information, please visit the following websites: