I am writing with concerns over an article by Dr Tim Cantor on surgical techniques (MIMS Dermatology 2008; 4(2): 56). Other GPs share my concerns who have seen this article in that perhaps surgical excision was inappropriate in these cases. I have been a GP and performed networked minor surgery for other practices in my area for 20 years. I am alarmed at several points in this article. In my view, none of the lesions shown should have been excised on initial presentation, given the extreme age of the patients in general, the anatomical site and the likely clinical diagnoses stated. A 'watch and see' policy should have been adopted, or even a simple punch biopsy in case three if a squamous cell carcinoma was suspected.
Also of concern is the shallow and angulated scalpel technique shown for excision, raising the possibility of incomplete excisions.
I do not think these are good examples of safe practice. There is a lack of awareness of serious risk of infection/sinus thrombosis, web space infection/ascending fasciitis and poor surgical technique shown in these examples.
Dr T Lock, GP, Merthyr Tydfil, South Wales
Dr Tim Cantor replies
All of these operations were performed in the context of an enhanced minor surgery service serving patients referred from other local practices as well as our own. There were sound clinical reasons for removing these lesions, some of which were omitted from the article during the editing process.
The epidermal cyst on the nose was interfering with the positioning of the patient's spectacles. The haemangioma on the chest wall was growing and causing discomfort. Although it had not bled, it seemed likely that it would eventually do so. The keratoacanthoma on the dorsum of the hand was causing discomfort when it came into contact with hard objects. There was also an outside chance that this lesion might have been malignant and so it seemed wise to excise it.
I cannot accept that a policy of 'watch and see' was appropriate in the case of the dysplastic naevus. Occasionally, apparently dysplastic naevi turn out on histology to be early malignant melanomas. I think they should always be excised promptly.
In my view, of the four cases described, only the keratoacanthoma carried a significant risk of serious complications. In fact, that procedure was complicated by a wound infection, which resolved satisfactorily with antibiotics.
Finally, it is worth mentioning that all of these patients chose to have their operations because of discomfort, practical problems with everyday living and concerns about the risk of malignancy. I do not think patients should be denied the benefits of minor surgery purely because of their age.
Dr Tim Cantor, sessional GP with an interest in minor surgery, west Kent
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