From Clinic to Recovery · First Edition
Chapter 15 — Minor Outpatient Procedures under Local Anesthesia
Dr. Tamer Rushdy Elalfy · 13 min read
In this chapter
- 15.1 A minor procedure is not minor to the patient
- 15.2 Red flags: when a lump is not minor
- 15.3 Lipomas, cysts, and skin lesions
- 15.4 Ingrowing toenails
- 15.5 Skin abscesses
- 15.6 Local anesthesia safely
- 15.7 Preparation
- 15.8 Aftercare and stitch removal
- 15.9 Material risks
- 15.10 Consent checklist
- 15.11 Warning signs
- References
Removal of lumps and skin lesions, treatment of ingrowing toenails, and drainage of skin abscesses make up a large share of outpatient surgery. They are often delegated to the most junior member of the team and fitted into a busy list, yet for the patient they are real operations, performed while awake, on a visible part of the body, with a scar that may last for life. The principles of Part I apply in full: a proper consent discussion, attention to the scar and to the pathology result, and clear aftercare. This chapter also covers the red flags that mean a lump or lesion should not be treated as minor.
Learning objectives After reading this chapter you should be able to:
|
Table 15.1. Common minor procedures at a glance.
| Condition | Usual treatment | Key counseling points |
|---|---|---|
| Lipoma | Excision if symptomatic, growing, or for cosmetic reasons | Benign; check red flags; may recur |
| Epidermoid (sebaceous) cyst | Excision when not inflamed; drainage first if infected | Recurs if the wall is left behind |
| Skin lesion | Excision biopsy or referral, depending on suspicion | The laboratory result decides further treatment |
| Ingrowing toenail | Conservative care; partial nail removal with phenol | Phenol reduces recurrence |
| Skin abscess | Incision and drainage | Antibiotics only in selected cases |
STEP 1 Explaining the condition and the procedure
15.1 A minor procedure is not minor to the patient
The consent discussion for a minor procedure covers the same ground as for a larger operation (Chapter 1): what will be done, the alternatives (including leaving the lump alone), the scar, the chance of recurrence, infection and bleeding, and how the pathology result will be given. Many patients worry most about pain during the injection and about the scar on a visible area. Written consent, a chaperone for intimate areas, and a photograph where appropriate protect both patient and surgeon. Cosmetic requests are legitimate, but patients should understand that every excision leaves a scar, which may be more noticeable than the original lump.
15.2 Red flags: when a lump is not minor
Most subcutaneous lumps are lipomas or cysts, but a soft tissue sarcoma can look similar. An unexplained lump that is increasing in size should be imaged with urgent ultrasound, and features suggesting sarcoma need referral to a specialist service [1]. Lumps larger than 5 cm, deep to the muscle layer, growing, painful, or recurring after removal should not be shelled out in a minor procedures list (Figure 15.1). Pigmented lesions that are changing, irregular, bleeding, or new in an adult should be referred to dermatology or removed completely with a narrow margin; they should never be shaved or partly removed.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 15.1. Red flags for lumps and skin lesions before a minor procedure.
15.3 Lipomas, cysts, and skin lesions
A lipoma is a benign lump of fat that can be removed if it is uncomfortable, growing, or unwanted. An epidermoid cyst, often called a sebaceous cyst, is best removed when it is not inflamed; an infected cyst is drained first and excised once it has settled, because removal of the whole wall is needed to prevent recurrence. Every excised specimen should be sent to the laboratory, and the patient should know how and when the result will be given.
Script: explaining a minor procedure “We will numb the area with an injection. It stings for a few seconds, then the area goes numb. You will feel pushing and pulling, but not sharp pain. If you feel pain, tell me and I will give more numbing medicine.” “We remove the lump through a cut a little longer than the lump itself and close the skin with stitches. Every cut leaves a scar. It will be red at first and fades over months.” “We send what we remove to the laboratory. Almost all results are harmless, and I will tell you the result on [date] by [method].” |
15.4 Ingrowing toenails
Mild ingrowing toenails can be treated with warm soaks, lifting the nail edge, and cutting the nail straight across. When this fails, partial removal of the nail edge followed by phenol applied to the nail bed is more effective at preventing recurrence than surgical excision without phenol [2]. Check the circulation and sensation of the foot first: patients with diabetes or poor circulation need extra care and may need referral. Explain that the nail will be narrower afterward.
15.5 Skin abscesses
Incision and drainage is the main treatment for a skin abscess. Antibiotics are added for surrounding cellulitis, signs of systemic infection, reduced immunity, or abscesses in difficult sites; in a large trial, an antibiotic after drainage modestly improved cure rates, so local resistance patterns and patient factors guide the decision [3]. Recurrent abscesses raise the possibility of diabetes or other underlying conditions. Abscesses in the perianal and pilonidal areas are covered in Chapters 7 and 8.
STEP 2 Local anesthesia, preparation, and aftercare
15.6 Local anesthesia safely
Caution: local anesthetic safety
|
15.7 Preparation
- Blood thinners. Most minor skin procedures can be done without stopping anticoagulants or antiplatelet medicines; follow the plan in Chapter 22.
-
Fasting and driving. No fasting is needed for local anesthesia. Patients can usually drive home after small procedures, but not after toenail surgery on the right foot or procedures that limit movement.
-
Ramadan. Some fasting patients ask whether the injection affects their fast. Offer an appointment after iftar or outside Ramadan if they prefer, and refer religious questions to their adviser.
-
Wound site. Agree the incision line with the patient before marking, especially on the face, neck, chest, and shoulders.
15.8 Aftercare and stitch removal
Most wounds can be kept dry for 24 to 48 hours and then washed normally. Stitch removal depends on the site (Table 15.2). Scars are red and may be raised for some months before fading (Figure 15.2). Silicone gel or sheeting is recommended to help prevent abnormal scarring in patients at risk [5]. Keloids, raised scars that grow beyond the wound, are more common on the chest, shoulders, and earlobes and in people with darker skin; ask about previous keloids before operating on these sites.
Table 15.2. Typical stitch removal times by site.
| Site | Stitches usually removed after | Notes |
|---|---|---|
| Face | 5 to 7 days | Fine stitches; protect from the sun |
| Scalp and neck | 7 to 10 days | |
| Chest, back, and shoulders | 10 to 14 days | Highest risk of wide or keloid scars |
| Arms and legs | 10 to 14 days | Longer over joints |
| Hands and feet | 10 to 14 days | Elevate to reduce swelling |
| Toenail after phenol | No stitches | Daily soaks and dressings for 2 to 4 weeks while it heals |
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 15.2. How a scar heals and how to look after it, for use with patients.
STEP 3 Questions patients ask
“Will it hurt?”
The numbing injection stings for a few seconds. After that you should feel only pushing and pulling. Tell me if you feel pain, and I will give more.
“Will it leave a scar?”
Yes. Every cut leaves a scar, usually a thin line that fades over months. Some areas, such as the chest and shoulders, scar more.
“Is it cancer?”
Most lumps like this are harmless. We send every specimen to the laboratory to be sure, and I will tell you the result.
“Will it come back?”
A lipoma or cyst removed completely rarely comes back. A cyst that is removed while inflamed is more likely to recur.
“Can I drive home?”
Usually yes after small procedures. Not after an operation on your right foot or one that limits your movement.
“When can I wash and do ablution?”
Keep the wound dry for 1 to 2 days, then wash normally. Use a waterproof dressing for ablution in the first days.
“When can I go back to work?”
Usually the same or next day, unless the wound is on a part of the body you use heavily at work.
“Will my toenail grow back normally?”
The nail will be a little narrower, which is what stops it growing in again.
“I have had a raised scar before. Will it happen again?”
It might, especially on the chest, shoulders, or earlobes. Tell us before the procedure, so that we can plan the cut and start scar treatment early.
STEP 4 Risks, warning signs, and consent
15.9 Material risks
Table 15.3. Material risks of minor procedures. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | A scar, sometimes wider or more visible than expected | All patients | “Every cut leaves a scar.” |
| Common | Bruising and swelling | Many patients | “Bruising is common and fades in 1 to 2 weeks.” |
| Less common | Wound infection | [unit data] | “A few wounds become infected and need antibiotics.” |
| Less common | Recurrence of a cyst, lipoma, or ingrowing nail | [unit data] | “Sometimes the problem comes back.” |
| Less common | Keloid or thick scar | More common in darker skin and on the chest and shoulders [unit data] | “Some people form thick, raised scars.” |
| Rare but serious | Bleeding needing return; numbness from injury to a skin nerve; allergic or toxic reaction to local anesthetic | [unit data] | “Rarely, bleeding or a reaction to the numbing medicine needs treatment.” |
15.10 Consent checklist
Before the procedure ☐ Red flags checked; imaging or referral arranged where needed. ☐ Procedure, alternatives (including no treatment), scar, and recurrence explained. ☐ Incision line agreed; previous keloids asked about. ☐ Blood thinners and allergies recorded; maximum local anesthetic dose calculated. ☐ Chaperone offered for intimate areas; photograph taken with consent where appropriate. ☐ Who will perform the procedure, including trainees under supervision. ☐ How and when the pathology result will be given. ☐ Aftercare, stitch removal date, and warning signs explained; patient guide given. |
15.11 Warning signs
Table 15.4. Green, amber, and red warning signs after a minor procedure.
| Level | Signs after a minor procedure | What to do |
|---|---|---|
| Green | Mild soreness and bruising A little blood on the dressing in the first hours Redness only along the edge of the wound | Expected. Follow the guide. |
| Amber | Spreading redness, warmth, or pus Temperature of 38 °C or more Wound edges opening A scar that becomes thick, itchy, and keeps growing | Call the clinic the same day. |
| Red | Bleeding that does not stop after 15 minutes of firm pressure Rapidly spreading redness with fever and feeling unwell A toe or finger that turns pale, blue, or cold | Go to the emergency department now. |
Key points
|
STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the procedure, fill in the stitch removal date, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE After Your Minor Procedure For you and your family. Keep it until your wound has healed. |
The procedure you had
☐ Removal of a lump (lipoma)
☐ Removal of a cyst
☐ Removal of a skin lesion
☐ Ingrowing toenail treatment
☐ Drainage of an abscess
1. Pain
-
The numbing medicine wears off after a few hours. Take simple pain medicine, such as paracetamol, as advised.
-
Raise a hand or foot on pillows for the first day to reduce swelling and pain.
2. Your wound
-
Keep the dressing dry for 1 to 2 days, then shower normally and pat dry.
-
Use a waterproof dressing for ablution in the first days.
-
Stitches out on: ______________________ at: ______________________
-
Toenail: soak the foot in warm salty water once or twice a day and change the dressing until healed, usually 2 to 4 weeks.
3. Your scar
-
The scar will be red at first and fade over months.
-
After the stitches are out, massage gently with a plain cream. Use silicone gel if we advised it.
-
Protect it from the sun for 12 months.
-
Tell us if the scar becomes thick, itchy, and keeps growing.
4. Getting back to normal
| Activity | Usually from |
|---|---|
| Work or school | The same or next day |
| Driving | The same day after small procedures; later after foot surgery |
| Exercise and swimming | When the wound has healed, usually 1 to 2 weeks |
| Prayer | As usual |
5. Results
- We will tell you the laboratory result by: ☐ clinic visit ☐ phone call, on: ______________________
6. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Mild soreness; bruising; a little redness at the edge of the wound | This is normal. Keep following this guide. |
| AMBER | Spreading redness, warmth, or pus; temperature of 38 °C or more; wound opening; thick, growing scar | Call us today. |
| RED | Bleeding that does not stop after 15 minutes of firm pressure; spreading redness with fever; a toe or finger that turns pale, blue, or cold | Go to the emergency department now. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral (NG12). London: NICE; 2015, updated.
2. Eekhof JAH, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;(4):CD001541.
3. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med. 2016;374(9):823-832.
4. Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30(5):1061-1067.
5. Gold MH, McGuire M, Mustoe TA, et al. Updated international clinical recommendations on scar management: part 2, algorithms for scar prevention and treatment. Dermatol Surg. 2014;40(8):825-831.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.