Definition (What it is) of serial excision
serial excision is a staged surgical technique that removes a skin lesion or scar in multiple planned operations.
Instead of taking the entire area at once, the surgeon excises a portion and closes the wound, then repeats later.
It is used in plastic and reconstructive surgery and may also be used for cosmetic concerns.
The goal is typically to achieve closure with the patient’s own nearby skin while limiting distortion and extensive grafting.
Why serial excision used (Purpose / benefits)
serial excision is used when a lesion, scar, or area of abnormal skin is too large to remove and close comfortably in a single procedure without creating excessive tension, widening the scar, or distorting nearby structures (such as an eyelid, lip, nostril, or hairline). By dividing removal into stages, the surrounding skin has time to relax and stretch between procedures, which can make subsequent closures more manageable.
From a reconstructive perspective, the approach can help preserve local anatomy and function by avoiding closures that pull on nearby free margins or joints. From a cosmetic perspective, it may help reduce the need for more conspicuous reconstructions, such as skin grafts with color/texture mismatch, or larger flap procedures. It can also be chosen when a patient and clinician prefer a stepwise plan, accepting multiple smaller procedures rather than one larger operation.
Benefits are case-dependent, but commonly include a more controlled approach to wound tension, a potentially more favorable scar position/orientation, and the ability to reassess healing and aesthetics between stages. The trade-off is that it requires time, follow-up, and more than one procedure.
Indications (When clinicians use it)
Common situations where clinicians may consider serial excision include:
- Large benign pigmented lesions (for example, certain congenital or acquired nevi) where staged removal may help with closure
- Broad scars (including some traumatic or surgical scars) when single-stage excision could cause excessive tension or distortion
- Lesions in cosmetically sensitive areas (face, eyelids, lips, nasal subunits, ear margins) where tissue preservation is prioritized
- Lesions near functional landmarks or joints, where tight closure could limit movement or alter position
- Selected benign soft-tissue lesions of the skin where removing the full footprint at once would likely require a graft or complex flap
- Situations where the patient and surgeon agree on a staged plan to balance scar burden, contour, and reconstruction complexity
Contraindications / when it’s NOT ideal
serial excision may be less suitable, or another approach may be preferred, in situations such as:
- Suspicion of skin cancer or a lesion requiring definitive margins and prompt, complete excision (oncologic priorities may differ)
- Active skin infection, uncontrolled inflammation, or poor local skin quality that could impair healing
- Limited ability to attend multiple visits and procedures (because serial excision is inherently staged)
- Medical conditions or medications that significantly increase surgical risk or impair wound healing (risk assessment varies by clinician and case)
- Areas with very limited surrounding skin laxity where staged closure still cannot be achieved without distortion
- History of problematic scarring (hypertrophic scarring or keloids) where repeated incisions may raise aesthetic concerns
- Situations where an alternative reconstructive method (local flap, graft, or tissue expansion) is more appropriate for the defect size, location, or goals
How serial excision works (Technique / mechanism)
serial excision is a surgical approach, not a minimally invasive or non-surgical treatment. Its primary mechanism is progressive removal and reshaping: the surgeon excises part of the lesion/scar and closes the wound in a way that encourages surrounding skin to accommodate the reduced area over time. With healing and scar maturation, the adjacent skin may become more permissive to further excision at a later stage.
The technique typically relies on:
- Incisions and excision: removing a portion of the lesion in an elliptical or otherwise planned shape
- Undermining and tissue mobilization: gently freeing nearby skin to reduce closure tension (extent varies by clinician and case)
- Layered suturing: deeper sutures to support the closure and superficial sutures to align skin edges
- Strategic planning of scar direction: often aligning with natural skin tension lines or aesthetic units when feasible
Energy-based devices (lasers, radiofrequency) and injectables are not the core mechanism of serial excision. They may be used in some practices for scar management or adjunctive aesthetic refinement, but that is separate from the staged excision strategy itself.
serial excision Procedure overview (How it’s performed)
A typical serial excision workflow is staged and planned, but the exact steps vary by clinician and case:
- Consultation: discussion of goals (cosmetic and/or reconstructive), medical history, prior scars, and expectations about staging.
- Assessment and planning: evaluation of lesion size, skin laxity, location relative to nearby landmarks, and likely number of stages. Photographs and measurements may be taken for documentation and planning.
- Preparation and anesthesia: the skin is cleansed and marked; anesthesia is selected (often local anesthesia for smaller areas, with sedation or general anesthesia in selected cases).
- Procedure: the surgeon removes a planned portion of the lesion/scar, mobilizes surrounding skin as needed, and closes the wound with sutures to achieve a controlled-tension closure.
- Closure and dressing: layered closure may be used; a dressing is applied, and wound care instructions are provided by the treating team.
- Recovery and follow-up: healing is monitored, sutures may be removed depending on location and technique, and the next stage (if needed) is timed based on healing, scar behavior, and patient scheduling. The interval between stages varies by clinician and case.
Types / variations
serial excision is not one single standardized “device-based” procedure; it is a surgical strategy that can be adapted. Common variations include:
- Partial (staged) elliptical excision: removing a segment of the lesion in an ellipse, closing primarily, then repeating later.
- Staged excision with changing vectors: adjusting the direction/shape of the excision at subsequent stages to optimize scar placement and minimize distortion.
- Short-axis vs long-axis staging: selecting which dimension to reduce first based on anatomy, laxity, and nearby structures.
- Primary closure-focused serial excision: emphasizing a plan that avoids grafting by using multiple smaller closures.
- Combination with local tissue rearrangement: in some cases, limited flap techniques may be incorporated to refine contour or reduce tension (approach varies by clinician and case).
Anesthesia choices may include:
- Local anesthesia: commonly used, especially for smaller lesions or straightforward stages.
- Local anesthesia with sedation: may be considered for patient comfort or longer stages.
- General anesthesia: more common when the area is large, the patient is a child, or the plan includes more extensive reconstruction (varies by clinician and case).
serial excision does not inherently involve implants, fillers, or energy-based devices.
Pros and cons of serial excision
Pros:
- Can allow staged removal of large lesions that are difficult to close in one operation
- Often supports primary closure with adjacent skin, potentially avoiding a graft in selected cases
- May help limit distortion of nearby cosmetic/functional landmarks by controlling closure tension
- Provides checkpoints between stages to evaluate healing and refine the plan
- May yield a more predictable wound closure compared with forcing a single high-tension closure
- Can be adapted to different body sites and clinical goals (cosmetic and reconstructive)
Cons:
- Requires multiple procedures and multiple recovery periods
- Total treatment timeline can be months to longer, depending on staging intervals
- Produces more than one episode of scarring and healing, even if the final scar is consolidated over time
- Any surgery carries risks such as bleeding, infection, wound separation, and unfavorable scarring (risk level varies)
- Not ideal when a lesion needs single-stage definitive removal for diagnostic or oncologic reasons
- Final appearance depends on individual healing, skin type, location, and technique, so predictability is limited
Aftercare & longevity
Aftercare following serial excision generally focuses on supporting uncomplicated wound healing and scar maturation. Clinicians typically provide individualized instructions based on the body area, closure tension, and suture technique. Across plastic surgery, common themes include keeping the incision protected, monitoring for signs of irritation or infection, attending scheduled follow-ups, and using scar-care strategies when the incision has healed sufficiently (the timing and products vary by clinician and case).
Longevity depends on what is being treated. If serial excision is used to remove a benign lesion or a portion of abnormal skin, the removal itself is typically permanent for the tissue that was excised, while the scar continues to mature over time. For scar revision goals, durability can be influenced by factors such as skin elasticity, ongoing tension across the scar, genetics of scarring, sun exposure, smoking status, and whether the original cause of scarring (such as repeated trauma or inflammation) persists.
Because serial excision is staged, the appearance may evolve after each step. Many clinicians consider both the short-term healing response and longer-term scar behavior when deciding the timing and design of subsequent stages.
Alternatives / comparisons
The best comparison depends on the problem being addressed (large lesion, scar, contour irregularity, or reconstruction near a landmark). Common alternatives include:
- Single-stage excision with primary closure: appropriate when the lesion is small enough and surrounding skin laxity is sufficient. This avoids multiple procedures but may not be feasible for larger areas without high tension.
- Excision with skin grafting: can cover larger defects in one operation. Grafts may differ in color and texture from surrounding skin, and the final appearance varies by donor site and healing.
- Local or regional flap reconstruction: moves nearby tissue to cover a defect with similar skin characteristics. Flaps can be highly effective but may involve more complex planning and additional scars.
- Tissue expansion: places an expander under nearby skin over time to create extra tissue, then removes the lesion and advances the expanded skin. This can be useful for large areas but involves an implantable device and a multistep process.
- Non-surgical scar management (when the concern is scar texture or color rather than removing tissue): silicone-based therapies, laser treatments, microneedling, or injections may be used in some practices. These do not remove a lesion in the same way and are not substitutes when tissue removal is required.
- Laser or energy-based treatments for pigmented lesions: may be used for selected cosmetic pigment concerns, but they do not provide the same histologic confirmation as excision, and suitability varies widely by lesion type and clinical context.
serial excision sits between “one-and-done” excision and more complex reconstruction: it is still surgery, but uses staging to make closure and contour more manageable in selected cases.
Common questions (FAQ) of serial excision
Q: Is serial excision the same as scar revision?
serial excision can be used as a form of scar revision when a scar is large and staged removal is chosen. However, scar revision is a broader category that also includes techniques like Z-plasty, W-plasty, dermabrasion, lasers, and injections. The terms overlap, but they are not identical.
Q: How many stages are usually needed?
The number of stages varies by lesion size, location, skin laxity, and the clinician’s approach. Some cases may need only two stages, while others require more. Planning is typically individualized and may be adjusted based on healing between procedures.
Q: Is serial excision painful?
Discomfort is usually managed with anesthesia during the procedure and with clinician-directed pain control afterward. Sensations often include soreness, tightness, or tenderness around the incision. The intensity and duration vary by body area, closure tension, and individual pain sensitivity.
Q: What kind of anesthesia is used?
Many serial excision stages are performed under local anesthesia, especially for smaller areas. Sedation or general anesthesia may be used for larger areas, pediatric patients, or when the stage is expected to be more involved. The choice varies by clinician and case.
Q: Will there be a scar?
Yes. serial excision is a surgical excision technique, so scarring is expected. Surgeons often plan incisions to place scars in less conspicuous locations or along natural lines when feasible, but scar appearance ultimately depends on anatomy, healing biology, and aftercare.
Q: How long is the downtime?
Downtime varies based on the size and location of the excision and the type of work or activities a person does. Some people resume many routine activities relatively soon, while others need more time due to swelling, dressing needs, or tension at the incision. Your clinician’s protocol and the treated area are major factors.
Q: How long do results last?
For removed tissue, the change is lasting in the sense that excised skin does not return. What continues to evolve is scar maturation and how the area blends over time. If the procedure is performed for scar improvement, long-term appearance can be influenced by tension, sun exposure, and individual scarring tendencies.
Q: Is serial excision considered safe?
When performed by qualified clinicians in appropriate candidates, serial excision is a commonly used surgical concept in plastic and reconstructive practice. Like all surgery, it has risks such as bleeding, infection, wound healing problems, and unfavorable scarring. Overall risk varies by clinician and case.
Q: How much does serial excision cost?
Costs vary widely based on geographic region, facility setting, clinician fees, anesthesia type, number of stages, and whether pathology evaluation is performed. Because it often requires multiple procedures, total cost is usually cumulative rather than a single fee. An individualized estimate typically follows an in-person evaluation.
Q: Can serial excision be combined with other procedures?
In some cases, clinicians may combine serial excision with other surgical steps (such as limited local tissue rearrangement) or later scar treatments. Combination planning depends on anatomy, timing, and healing considerations. Whether combination is appropriate varies by clinician and case.