Cutaneous surgery is the branch of surgery focused on diagnosing and treating conditions of the skin. It covers everything from removing a suspicious mole for biopsy to excising skin cancers and repairing the resulting wound. These procedures form a core part of dermatology practice and are used to address both benign growths (cysts, warts, scars) and malignant tumors like basal cell carcinoma, squamous cell carcinoma, and melanoma. Most cutaneous surgery is performed in an outpatient setting under local anesthesia, meaning you’re awake and go home the same day.
Biopsies: The Starting Point
A biopsy is often the first cutaneous procedure a patient encounters. The goal is to remove a small sample of skin so a pathologist can examine it under a microscope and determine what’s going on. The four main types are shave, punch, incisional, and excisional biopsies, and each one reaches a different depth of tissue.
A shave biopsy skims a thin layer from the skin’s surface and works well for raised lesions that sit in the upper layers. A punch biopsy uses a small circular blade (typically 2 to 6 mm wide) to cut through the full thickness of the skin into the fat layer beneath, giving the pathologist a complete cross-section. When a larger or deeper tissue sample is needed, an incisional biopsy removes a wedge of the lesion, while an excisional biopsy removes the entire growth with a margin of normal skin around it. For suspected melanoma, excisional biopsy is preferred whenever the size and location allow it. If that’s not feasible, a punch biopsy targeting the thickest part of the lesion is an acceptable alternative.
Standard Surgical Excision
When a skin cancer has been confirmed, standard excision is one of the most common treatments. The surgeon cuts out the tumor along with a surrounding border of healthy-looking skin, called the margin, to reduce the chance that cancer cells are left behind. How wide that margin needs to be depends on the type and size of the cancer.
For basal cell carcinomas smaller than 2 cm, a 4 mm margin achieves complete removal in about 95% of cases. Tumors larger than 2 cm call for margins wider than 4 mm. For squamous cell carcinomas, well-defined low-risk tumors under 2 cm also require 4 mm margins, while larger, higher-risk lesions (or those in sensitive areas like the ear, lip, eyelid, or scalp) need at least 6 mm margins. After the tissue is removed, it’s sent to a lab where sections are checked for cancer at the edges. If cancer is found at a margin, a second procedure may be needed.
Mohs Micrographic Surgery
Mohs surgery is a specialized technique that offers the highest cure rates of any skin cancer treatment: 99% for first-time basal cell carcinomas, about 94% for recurrent basal cell carcinomas, and over 94% for squamous cell carcinomas. It’s especially valuable for cancers on the face, where preserving as much healthy tissue as possible matters for both function and appearance.
The procedure starts with the surgeon outlining the visible tumor, numbing the area, and scraping away the bulk of the growth. Then a thin, saucer-shaped layer of tissue is removed at a 45-degree bevel around and beneath the wound. Small orientation marks are scored into the skin and tissue so the surgeon can map exactly where each piece came from. The removed tissue is divided into sections, color-coded with dyes, pressed flat, and frozen so it can be sliced horizontally. This horizontal sectioning is what makes Mohs unique: it allows virtually 100% of both the outer and deep margins to be examined under the microscope, compared with standard processing, which checks only a small fraction of the edge.
If the surgeon finds residual cancer in any section, the map shows precisely which spot on the patient still contains tumor. Only that specific area is removed in the next round. The cycle repeats until every margin is clear. This layer-by-layer approach means the smallest possible amount of healthy skin is sacrificed. Once the cancer is fully removed, the wound is closed using stitches, a skin flap, a skin graft, or sometimes left to heal on its own.
Destructive Techniques: Curettage, Electrosurgery, and Cryosurgery
Not every skin cancer or skin lesion requires a scalpel. For low-risk, superficial basal cell carcinomas and certain benign growths, destructive methods can be simpler and faster.
Curettage and electrodesiccation (commonly called ED&C) involves scraping the abnormal tissue with a sharp, spoon-shaped instrument called a curette, then using an electric current to destroy any remaining cells and stop bleeding. The scraping is done in multiple directions until a clean, evenly bleeding surface of normal skin is visible. This is typically repeated for two or three cycles in one session.
Cryosurgery destroys tissue by freezing it with liquid nitrogen. A spray nozzle directs the nitrogen onto the lesion, often through a cone that isolates the treatment area. The tissue is frozen until a frost halo extends about 4 mm into the surrounding healthy skin. The thaw time must reach at least 60 seconds to ensure the freeze was deep enough to kill the targeted cells. If the thaw is too fast, the freeze cycle is repeated. Both curettage and cryosurgery are quick, relatively inexpensive, and suitable for superficial cancers that haven’t invaded deeper tissue.
Closing the Wound
How a surgical wound is repaired depends on its size, depth, and location. The simplest option is primary closure: pulling the wound edges together with stitches. This works when there’s enough loose skin nearby and the tension won’t distort surrounding structures.
For intermediate-sized defects where direct closure isn’t possible, surgeons choose between skin flaps and skin grafts. A flap involves rotating or sliding a section of nearby skin (still attached to its blood supply) over the wound. A graft involves transplanting a piece of skin from another part of the body. On the nose, where both options may be technically feasible, flaps tend to produce better cosmetic results because the transplanted skin matches the surrounding area in color and texture. Some wounds, particularly in concave areas like the inner corner of the eye, are deliberately left open to heal on their own through a process called second intention healing.
Anesthesia and What to Expect
Nearly all cutaneous surgery uses local anesthesia, meaning only the treatment area is numbed. The standard agent is 1% lidocaine combined with a small amount of epinephrine. The epinephrine constricts blood vessels at the surgical site, which serves two purposes: it reduces bleeding during the procedure and slows the body’s absorption of the lidocaine, making the numbing effect last longer. You’ll feel a brief sting from the injection, but the surgical area itself should be pain-free within a minute or two.
If you take blood thinners, you generally don’t need to stop them before skin surgery. Current guidelines recommend continuing both aspirin and prescription anticoagulants for most dermatologic procedures, since the bleeding risk from skin surgery is low and the clotting risk from stopping these medications can be serious. For Mohs surgery specifically, blood-clotting levels (measured by INR) should be at or below 3.0 within 10 days before the procedure.
How Skin Heals After Surgery
Skin healing follows a predictable three-phase timeline. The first phase is inflammation, lasting roughly 2 to 5 days. During this time the wound may be red, swollen, and tender as the body sends immune cells to clean the area and prevent infection. Next comes the proliferative phase, spanning about 3 weeks, during which the body rebuilds blood vessels and fills the wound with new tissue. A scab forms and eventually falls off as fresh skin grows beneath it.
The final phase, remodeling, is the longest. The new scar tissue gradually strengthens and fades over months. A scar can continue to improve in appearance for up to 2 years. Factors like wound location, sun exposure, your age, and how well the wound was closed all influence the final cosmetic result. Keeping the area clean, moist, and protected from the sun during healing gives you the best outcome.