Repairing The Ellipse: An Alternative Approach

By Navid Malakouti, MD and Pavan Nootheti, MD, FAAD, FACMS

The fusiform (elliptical) excision is a common surgical technique employed by dermatologists for the removal of benign and malignant lesions. Methods of approach and proper form are well documented.1,2,3 Many dermatologists will approach closure of these wounds by placing the key dermal suture at the center of the ellipse, as this is the area of highest tension. This has been described in textbooks as the “Rule of Halves,” where one places the first suture at the center of the wound, then proceeds to halve the wound into smaller segments (Figure 1).4

We propose a supplementary technique in repairing the fusiform lesion by initiating closure at the apices and working toward the center of the defect. This method allows easier closure of wounds under high tension and mitigates the need for extensive undermining as typically experienced when working on the scalp or back. Additionally, ideal scar length can be secured by virtually eliminating apical standing cones, a consideration when working between sensitive cosmetic subunits such as the lip or the eye.

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The first suture will be placed at either apex of the ellipse using standard techniques of interrupted buried dermal sutures (Figure 2). Sutures are then placed in an alternating pattern approaching the center of the defect. With each subsequent suture placement, the surgeon will be able to appreciate reduction of tension at the center of the wound and can therefore minimize the amount of undermining that is necessary for approximation.

One important consideration when utilizing this method is that standing apical cones are not likely to occur, since the apices are closed first. A standing cone at the center of the lesion is still possible, and if that cone needs to be corrected, a small perpendicular scar will be created upon repair. The formation of a perpendicular scar may be preferable in some situations when working around cosmetically sensitive areas where anatomic function would otherwise be compromised, such as the formation of an eclabium or ectropion.

Although it may not be suitable for all situations, this supplemental technique may prove useful for repairing defects under high tension or when scar length must be preserved.

Drs. Navid Malakouti and Pavan Nootheti have no relevant disclosures or conflicts of interest.

Special thanks to Mr. Gary Strange, Visual Information Specialist at Washington, D.C. VAMC, for assisting with the creation of Figure 2.

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Navid Malakouti, MD is Chief Resident at Howard University Hospital, Department of Dermatology in Washington, DC.

Pavan Nootheti, MD, FAAD, FACMS is Chief of Dermatologic Surgery and a Mohs surgeon at the Veterans Affairs Medical Center, an Associate Professor at Howard University Hospital, Department of Dermatology, and Clinical Associate Professor at George Washington University, Department of Dermatology in Washington, DC.

1. Olbricht S. Biopsy Techniques and Basic Excisions. In: Bolognia JL, Jorizzo JL, Schaffer JV, editors. Dermatology 3rd ed. Philadelphia, PA: Saunders Elsevier; 2012. p. 2381-2397

2. Poblete-Lopez C. Basic Excisional Surgery. In: Vidimos AT, Ammirati CT, Poblete-Lopez C, editors. Requisites in Dermatology: Dermatologic Surgery. Philadelphia, PA: Saunders Elsevier; 2009. p. 123-137

3. Book SE, Aasi SZ, Leffell DJ. Ellipse, Ellipse Variations, and Dog-ear Repairs. In: Robinson JK, Hanke CW, Siegel DM, Fratila A. Surgery of the Skin: Procedural Dermatology 2nd ed. St. Louis, MO: Mosby Elsevier; 2010. P 239-250

4. Berg D. Primary Closure. In: Rohrer TE, Cook JL, Nguyen TH, Mellette Jr, JR. Flaps and Grafts in Dermatologic Surgery. Philadelphia, PA: Saunders Elsevier; 2007 p. 31-39