Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
CPT4 code
Name of the Procedure:
Excision of a Benign Lesion (excluding skin tag), Scalp, Neck, Hands, Feet, Genitalia; Excised Diameter 2.1 to 3.0 cm
Summary
This procedure involves surgically removing a non-cancerous lesion from specific areas of the body, including the scalp, neck, hands, feet, or genitalia. The excised lesion, along with a margin of healthy tissue around it, is removed to ensure complete extraction.
Purpose
The procedure addresses benign (non-cancerous) lesions that may cause cosmetic concerns, discomfort, or potential complications if left untreated. The primary goal is to remove the lesion entirely to prevent any recurrence or development of symptoms.
Indications
The procedure is indicated for:
- Visible and palpable benign lesions that are of cosmetic concern.
- Lesions causing discomfort, pain, or irritation.
- Any benign growths that have changed in size, shape, or color, warranting removal for biopsies to rule out malignancy.
Preparation
- Patients may need to refrain from eating or drinking for a specific period before the procedure.
- Certain medications, especially blood thinners, may need to be adjusted or paused as per medical advice.
- A physical examination and possibly imaging or biopsy may be required to assess the lesion.
Procedure Description
- The affected area is sterilized, and local anesthesia is administered to numb the site.
- An incision is made around the lesion, including a surrounding margin of healthy tissue to ensure complete removal.
- The lesion and margins are excised carefully.
- The wound is then closed using sutures, and a bandage is applied.
- Sterilized surgical tools like scalpels and forceps are used, along with possible assistance from medical imaging for precision.
- Local anesthesia is typically used; general anesthesia is rare for this procedure unless otherwise indicated.
Duration
The procedure generally takes about 30 to 60 minutes, depending on the lesion's size and location.
Setting
The excision is performed in various settings, including hospital surgical units, outpatient clinics, or specialized surgical centers.
Personnel
The procedure involves a team comprising:
- A surgeon or dermatologic surgeon.
- A nurse or surgical assistant.
- An anesthesiologist or nurse anesthetist, if sedation or anesthesia is required.
Risks and Complications
Common risks include:
- Infection at the surgical site.
- Bleeding or hematoma formation.
- Scarring. Rare complications might involve:
- Nerve damage leading to numbness or altered sensation.
- Poor wound healing.
Benefits
- Effective and complete removal of the benign lesion.
- Reduction in symptoms or discomfort associated with the lesion.
- Improved aesthetic outcome and peace of mind if the lesion's nature is uncertain. Benefits are usually realized immediately post-procedure, with cosmetic improvements more noticeable after healing.
Recovery
- Patients may need to keep the surgical site clean and dry, following specific wound care instructions.
- Stitches might need to be removed in a follow-up visit, typically 1-2 weeks post-procedure.
- Avoid strenuous activities or stretching the area until it has healed adequately, usually within 2-4 weeks.
Alternatives
Options include:
- Monitoring the lesion without intervention if asymptomatic.
- Cryotherapy, laser therapy, or topical treatments may be suitable for some cases.
- Each alternative has its pros and cons regarding effectiveness, risks, and recovery time, and should be discussed with the healthcare provider.
Patient Experience
- Patients will feel numbness at the site due to local anesthesia during the procedure.
- Post-procedure, mild discomfort or pain can be managed with over-the-counter pain relievers.
- Patients might experience slight swelling, bruising, or tenderness around the excision site, which resolves within a few days. Pain and discomfort are generally minimal and manageable with routine care.