Skin lesion excision

# OPERATION NOTE — Skin lesion excision

Date: 19/05/2026Elective
Surgeon: Mateusz Gładysz, Consultant Plastic and Hand Surgeon
Assistant: [Registrar Dr ____]
Anaesthetic: Local infiltration
WHO Surgical Safety Checklist: Sign-in / Time-out / Sign-out — completed.

## Diagnosis / Indication

- BCC of right cheek, 8 mm.
- Plan: Excision with 3 mm clinical margin and direct primary closure.

## Consent

Risks discussed: bleeding, haematoma, infection, scar, recurrence, incomplete excision requiring re-excision, sensory change, dehiscence, asymmetry, suture reaction.

## Position / Prep / Drape

Supine; 0.5% chlorhexidine in alcohol (aqueous if facial / near eye); standard drape.

## Anaesthesia

Local infiltration of 1% lignocaine with 1:100,000 adrenaline, allowed 7 min for vasoconstriction.

## Procedure

1. Lesion marked with 3 mm clinical margin; ellipse oriented along RSTL with ~3:1 length-to-width ratio.
2. Skin incised with #15 blade; ellipse excised en bloc to deep subcutis.
3. Orientation suture placed: short = superior, long = lateral. Specimen sent in formalin for histology.
4. Haemostasis: bipolar diathermy; wound irrigated with normal saline.
5. Wide subdermal undermining as required to mobilise edges.
6. Closure: deep dermal 4-0 Monocryl interrupted; skin 5-0 nylon interrupted.

## Findings

- BCC 8 mm at right cheek; clinically clear margins; no deep invasion observed.

## Specimens

- "right cheek lesion — short = superior, long = lateral" → Histology.

## Estimated blood loss

<5 mL

## Complications

Nil intra-operative.

## Count

Swabs / needles / instruments — confirmed correct.

## Post-op plan

- Keep dressing dry 48 h; elevate where applicable.
- Analgesia: regular paracetamol; ibuprofen PRN.
- Sutures out: face 5–7 days; trunk/limb 10–14 days.
- Histology review at clinic.
- Follow-up: Plastics clinic 2 weeks (suture removal) and 6 weeks (with histology).
- GP letter to be sent.

## Signature

Mateusz Gładysz, Consultant Plastic and Hand Surgeon — 19/05/2026