Equipment. You need a pair of (non)sterile gloves (13), marker pen, chlorhexidine, sterile gauzes, a syringe (5 ml), two cannulas (blue/orange), Xylocaine 0.5–1 % with adrenaline, sterile instruments (scalpel handle, scalpel blade no. 15, needle holder, forceps, blunt/sharp dissection scissors, suture scissors and possibly skin hook), absorbable polyfilament suture, non-absorbable monofilament suture, sterile saline in sterile container, brown skin tape, self-adhesive bandage, specimen jar with formalin and histology submission form.
Markup. Determine the tension direction and do a fusiform markup (Figure 2). Aim for a macroscopic free margin of about 2 mm. The markup can be done with a non-sterile marker pen.
Sterility. Wash your hands. Put on (non)sterile gloves. Damp a gauze with chlorhexidine and swab the whole area. Chlorhexidine/alcohol must air-dry. Lay out all the equipment on a sterile cloth/ changing set. Drape if possible.
Local anaesthetic. Draw up local anaesthetic and then switch the cannula (one for drawing up and one for injection). Inject the local anaesthetic in the upper layer of the dermis so that the skin rises and forms a weal. As a rule, aspiration is not necessary, but should be carried out in the proximity of major arteries and veins (for example on the hand, in the elbow and on the neck). The maximum adrenaline effect is attained after 6–8 minutes.
Excision. Excise the skin lesion as described above. Bleeding can be compressed for 15–20 seconds (or diathermised). Suture marking of the specimen is not necessary.
Undermining Undermine the wound edges as described above. Try not to vary the level of the undermining.
Suturing. The dermal sutures are applied first. The sutures should be inverted (see video) so that the knots are as deep as possible. Start from one of the sides. After the dermal sutures have been applied, the interrupted skin sutures are applied in the epidermis. Normally, fewer sutures are placed in the dermis than in the epidermis (for example, two at depth and three at the surface), and the different sutures are preferably applied alternately. The dermal sutures reduce the tension, while the epidermal sutures provide precision at the surface.
Dressing. Swab with sterile saline and dry carefully. Apply brown paper tape over the linear closure. Then cover with self-adhesive dressing.
Histology All excised skin lesions must be sent for histological examination.