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Clinical Education for UK GP Trainees

Minor Surgery in General Practice

From lipomas to toenails: your practical guide to safe, confident minor procedures (Because "minor" doesn't mean "simple" when it's your first time)

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Executive Summary

Minor surgery in UK general practice encompasses a range of procedures from simple excisions to joint injections. This guide covers patient assessment, common procedures, red flags, and practical tips for safe practice.

Common Procedures

Excisions, wound closure, joint injections, toenail surgery, and more

BNF Verified

Drug Doses

All local anaesthetic and medication doses checked against BNF/PCDS

4 Categories

Red Flags

Skin cancer, infection, vascular, and nerve injury warning signs

5 Types

Wound Dressings

Hydrocolloid, foam, alginate, hydrogel, and antimicrobial options

Quick Section Links

Patient Assessment Diagnostic Approach Differential Diagnosis Common Procedures Red Flags Do's & Don'ts

Downloads & Resources

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PCDS Skin Surgery Guidelines

Comprehensive UK guidance on minor skin surgery techniques, local anaesthetic dosing, and safety

Visit PCDS

BNF Online

British National Formulary - verify all drug doses, contraindications, and interactions

Visit BNF

NICE Skin Cancer Guidance

Referral criteria for suspected skin cancer, including melanoma and non-melanoma lesions

View Guidance

Patient.info Professional

Clinical articles on minor surgery procedures, complications, and patient information leaflets

Visit Patient.info

Brainy Bites

8 clinical pearls to make you look like a minor surgery wizard

1 Langer's Lines Mnemonic

Think 'Wrinkles': Incisions along natural skin tension lines (Langer's lines) heal with less scarring. On face: horizontal on forehead, around eyes/mouth. On trunk: horizontal. On limbs: longitudinal. If unsure, pinch skin - wrinkles show the lines.

2 3:1 Ellipse Rule

For elliptical excisions, length should be 3x the width. This creates 30° angles at the tips, allowing easy closure without 'dog ears'. Too short = puckering. Too long = unnecessary scar.

3 Lidocaine Dose Calculation

Quick calc: 1% lidocaine = 10mg/ml. Plain max = 3mg/kg (e.g., 70kg patient = 210mg = 21ml). With adrenaline max = 7mg/kg (70kg = 490mg = 49ml). Always aspirate before injecting to avoid intravascular injection.

4 Danger Zones to Avoid

Temporal branch of facial nerve (forehead - causes brow ptosis), Spinal accessory nerve (posterior triangle - causes shoulder drop), Digital nerves (fingers - run along sides), Facial artery (nasolabial fold). Know your anatomy!

5 Cyst Excision Trick

For epidermoid cysts: excise the entire cyst wall intact. If you rupture it, recurrence rate jumps from 5% to 40%. If inflamed/infected, incise & drain first, then excise 4-6 weeks later when inflammation settled.

6 Joint Injection Timing

Steroid injections take 3-7 days to work (not immediate). Warn patients about post-injection flare (10-20%, settles in 24-48h with ice/paracetamol). Effect lasts 6-12 weeks. Limit to 3-4 per year per joint to avoid cartilage damage.

7 Phenol Toenail Trick

After avulsing nail, DRY the nail bed thoroughly before applying phenol (moisture dilutes it). Apply 80% phenol for exactly 3 minutes to nail matrix. Neutralise with alcohol. Expect discharge for 2-6 weeks (normal, not infection).

8 Dressing Selection Mantra

Match dressing to exudate: Dry wound = hydrogel (adds moisture). Low exudate = hydrocolloid. Moderate = foam. Heavy = alginate. Infected = antimicrobial. Cavity = alginate rope. Simple!

Patient Assessment

Pre-Procedure Checklist

History

Indication for procedure (symptoms, cosmetic, diagnostic)
Duration and change in lesion/condition
Previous treatments attempted
Allergies (LA, antibiotics, dressings, latex)
Medications (anticoagulants, immunosuppressants, steroids)
Medical history (diabetes, bleeding disorders, keloid tendency, PVD)
Social history (occupation, hand dominance, smoking)

Examination

Lesion characteristics (size, shape, colour, texture, mobility)
Anatomical location (danger zones, cosmetically sensitive)
Surrounding skin (inflammation, infection, scarring)
Lymph nodes (if malignancy suspected)
Vascular status (pulses if limb procedure)
Nerve function (if near nerve)

Consent

Explain procedure in lay terms
Discuss risks: bleeding, infection, scarring, recurrence, nerve/vessel injury
Discuss benefits and alternatives
Document consent (written for excisions, verbal acceptable for minor procedures)
Ensure patient has capacity and understands

Anticoagulation Management

Risk stratification approach:

Low-risk procedures (continue anticoagulation):

Simple skin lesion excision
Skin biopsy
Joint injection (with caution)

Higher-risk procedures (consider stopping):

Large/deep excisions
Vascular areas (scalp, face)
Multiple procedures

Always weigh thrombotic risk vs bleeding risk. Discuss with patient and consider specialist advice if uncertain.

Diagnostic Approach

Clinical Assessment Framework

Systematic approach to evaluating skin lesions and surgical conditions

ABCDE for Melanoma Screening

Asymmetry

One half unlike the other

Border

Irregular, scalloped, or poorly defined

Colour

Varied shades of brown, black, red, white, blue

Diameter

>6mm (pencil eraser size)

Evolving

Changing in size, shape, or colour

7-Point Weighted Checklist (Score ≥3 = refer)

Major features (2 points each):

Change in size
Irregular shape
Irregular colour

Minor features (1 point each):

Largest diameter ≥7mm
Inflammation
Oozing
Change in sensation (itch/altered sensation)

Ugly Duckling Sign

A lesion that looks or feels different from the patient's other moles. This simple sign has high sensitivity for melanoma detection. If a lesion stands out as the "ugly duckling" among a patient's moles, consider referral even if other criteria not met.

When to Refer vs Manage in Primary Care

Urgent 2-Week Wait Referral

Suspected melanoma (ABCDE positive)
7-point checklist score ≥3
Ugly duckling lesion with concern
Non-healing lesion >4 weeks
Squamous cell carcinoma features

Safe for Primary Care

Lipomas (soft, mobile, slow-growing)
Epidermoid cysts (punctum present)
Skin tags
Dermatofibromas (dimple sign)
Seborrhoeic keratoses (stuck-on appearance)

Differential Diagnosis

Common benign lesions encountered in primary care minor surgery. Learn to distinguish them clinically.

Clinical Features:

Soft, doughy consistency
Mobile over underlying structures
Subcutaneous location
Slow-growing
Non-tender unless traumatised

Management:

Excision if symptomatic, cosmetically concerning, or diagnostic uncertainty. Use careful dissection with flat scissors held parallel to skin surface to avoid damage to surrounding structures.

Referral Criteria:

Rapid growth, hard consistency, fixed to deep structures, >5cm diameter. Subfrontalis lipomas (lie under frontalis muscle, less obvious when eyebrow raised) require specialist referral due to risk of temporal nerve damage.

Clinical Features:

Central punctum (pathognomonic)
Fixed to skin, mobile over deeper structures
Cheesy discharge if ruptured
May become inflamed/infected
Common on face, neck, trunk

Management:

Excise entire cyst wall intact to prevent recurrence (5% vs 40% if ruptured). If inflamed/infected, incise & drain first, then excise 4-6 weeks later. Score skin with scalpel only, then use small flat dissecting scissors at angle almost parallel to skin surface to carefully dissect each layer until sac visible.

Referral Criteria:

Recurrent infection, diagnostic uncertainty, cosmetically sensitive area

Clinical Features:

Firm, tethered to skin
Dimple sign positive (dimples when pinched)
Brown/pink colour
Usually <1cm
Common on legs

Management:

Usually conservative. Excision if symptomatic or diagnostic doubt

Referral Criteria:

Rapid change, bleeding, ulceration, >1cm diameter

Clinical Pearl: The Punctum Test

When examining a subcutaneous lump, look for a central punctum (tiny opening). If present, it's almost certainly an epidermoid cyst. If absent and the lump is soft/mobile, think lipoma. If absent and firm/tethered, consider dermatofibroma or other diagnosis. This simple sign has excellent diagnostic accuracy.

Common Procedures

Excision of Skin Lesions

Elliptical excision is the gold standard for removing benign and suspicious skin lesions. Proper technique ensures complete removal, good cosmetic outcome, and adequate tissue for histology.

Indications

Diagnostic uncertainty (rule out malignancy)
Symptomatic lesions (bleeding, catching on clothing, painful)
Cosmetic concerns
Patient preference

Contraindications

Suspected melanoma (refer for specialist excision with appropriate margins)
Active infection at site
Bleeding disorder (relative - may need specialist setting)
Keloid tendency in cosmetically sensitive area

Equipment Required

Sterile gloves, drapes, gauze
Local anaesthetic (lidocaine 1% or 2%, with/without adrenaline)
Scalpel (size 15 blade for most lesions, size 11 for small/precise work)
Toothed forceps (Adson's)
Non-toothed forceps
Scissors (sharp and blunt dissecting)
Needle holder
Sutures (absorbable for deep layers, non-absorbable for skin)
Specimen pot with formalin

Step-by-Step Technique

1Mark the lesion: Draw ellipse around lesion with 3:1 length-to-width ratio. Orient along Langer's lines (natural skin tension lines). Include 2-4mm margin for benign lesions.
2Infiltrate LA: Inject lidocaine around and under lesion. Wait 5-10 minutes for full effect. Aspirate before injecting to avoid intravascular injection.
3Initial incision: Hold scalpel like a pen at 90° to skin. Cut through full thickness of dermis in one smooth motion along marked line.
4Undermine: Angle blade at 45° to undercut lesion. Dissect in subcutaneous fat plane to include lesion base. Use toothed forceps to lift lesion gently (avoid crushing if histology needed).
5Achieve haemostasis: Use pressure, diathermy, or ligatures for bleeding vessels. Ensure dry field before closure.
6Close wound: Deep dermal sutures (absorbable, e.g., Vicryl 4-0) to reduce tension. Skin sutures (non-absorbable, e.g., Prolene 5-0 face, 4-0 body, 3-0 limbs) with edges everted.
7Dress wound: Apply non-adherent dressing. Advise keep dry for 48 hours.
8Send for histology: Place specimen in formalin pot. Label clearly with patient details and site.

Local Anaesthetic Dosing (BNF/PCDS Verified)

Lidocaine 1% Plain

Max dose: 3 mg/kg (max 200mg total)

Example: 70kg patient = 210mg = 21ml of 1%

Duration: 30-60 minutes

Lidocaine 1% with Adrenaline 1:200,000

Max dose: 7 mg/kg (max 500mg total)

Example: 70kg patient = 490mg = 49ml of 1%

Duration: 2-6 hours

Avoid: Digits, penis, nose tip, ear lobes (end-arteries)

Lidocaine 2% Plain

Max dose: 3 mg/kg (max 200mg total)

Example: 70kg patient = 210mg = 10.5ml of 2%

Use: When smaller volume needed

Bupivacaine 0.25% Plain

Max dose: 2 mg/kg (max 150mg total)

Example: 70kg patient = 140mg = 56ml of 0.25%

Duration: 4-8 hours (longer than lidocaine)

LA Toxicity Warning

Early signs: Perioral tingling, metallic taste, tinnitus, dizziness

Severe signs: Seizures, arrhythmias, cardiovascular collapse

Prevention: Always aspirate before injecting. Never exceed maximum dose. Inject slowly.

Suture Selection Guide

Location	Deep Layer (Absorbable)	Skin (Non-absorbable)	Removal Time
Face	Vicryl 5-0	Prolene 6-0 or 5-0	5-7 days
Scalp	Vicryl 4-0	Prolene 4-0 or 3-0	7-10 days
Trunk	Vicryl 4-0	Prolene 4-0	10-14 days
Arms/Legs	Vicryl 4-0	Prolene 4-0 or 3-0	10-14 days
Hands/Feet	Vicryl 5-0	Prolene 5-0 or 4-0	10-14 days
Back (high tension)	Vicryl 3-0	Prolene 3-0	14 days

Post-Procedure Care

Keep wound dry for 48 hours
Avoid strenuous activity for 2 weeks (longer for back/high-tension areas)
Watch for signs of infection (increasing pain, redness, discharge, fever)
Suture removal as per table above
Advise scar massage with moisturiser after 2 weeks
Sun protection for 6-12 months

GP Script: Post-Excision Advice

What to expect:

Mild discomfort for 2-3 days (paracetamol usually sufficient)
Bruising and swelling normal for 1-2 weeks
Scar will be red/raised initially, fades over 6-12 months

When to seek help:

Increasing pain, redness, or swelling after 48 hours
Pus or foul-smelling discharge
Fever or feeling unwell
Wound edges separating
Excessive bleeding

Complications & Management

Bleeding: Usually settles with pressure. If persistent, may need cautery or suture ligation
Infection (1-5%): Treat with flucloxacillin 500mg QDS for 7 days. Consider swab if not improving
Wound dehiscence: If early (<7 days), can re-suture. If late, allow to heal by secondary intention
Hypertrophic scar/keloid: Refer to dermatology for steroid injection or silicone gel
Nerve injury: Usually temporary neuropraxia. Refer if persistent >3 months
Dog ears: Can revise at 3-6 months if cosmetically concerning

Curettage & Cautery

Curettage involves scraping away superficial skin lesions with a curette. Often combined with cautery (heat/chemical) for haemostasis and to destroy residual tissue. Suitable for benign superficial lesions only.

Indications

Seborrhoeic keratoses (warts)
Viral warts (verrucae)
Molluscum contagiosum
Pyogenic granuloma
Skin tags (can also use cryotherapy or snip excision)

Contraindications

Suspected malignancy (curettage destroys tissue architecture - no histology possible)
Deep lesions
Pigmented lesions (unless certain diagnosis of seborrhoeic keratosis)

Technique

1Infiltrate LA: Inject lidocaine 1% around lesion
2Curette: Hold curette like a pen. Scrape lesion with firm pressure until reach normal skin (feels gritty). Curette in multiple directions.
3Cautery: Apply electrocautery, cryocautery, or chemical cautery (silver nitrate) to base for haemostasis
4Dress: Apply non-adherent dressing. Advise may ooze for few days

Cryocautery vs Electrocautery vs Chemical Cautery

Cryocautery (Liquid Nitrogen):

Freeze lesion for 10-30 seconds (depends on lesion type and depth)
Causes blister formation and tissue destruction
Suitable for viral warts, seborrhoeic keratoses, actinic keratoses
Warn patient: blistering, pain, temporary pigment change
Avoid over-treatment (can cause scarring)

Electrocautery:

Uses heat to coagulate tissue
Haemostatic (stops bleeding)
NOT suitable for viral warts (releases viral particles in smoke)
Avoid spirit-based skin cleaners (fire risk)
Do not allow cautery tip to contact dressings (fire risk)

Chemical Cautery (Silver Nitrate):

75% or 95% silver nitrate sticks
Suitable for nasal cautery (epistaxis), granulation tissue, small warts
Apply to moist area (dip in water first)
Causes black staining (warn patient)
Protect surrounding skin with petroleum jelly

Important: Histology Limitation

Curettage destroys tissue architecture. You CANNOT send curettings for histology (cytology only, which is not diagnostic). Only use curettage when you are certain of the diagnosis. If any doubt about malignancy, perform excision biopsy instead.

Post-Procedure Care

Keep area clean and dry
Expect oozing/crusting for 1-2 weeks
Healing by secondary intention (no sutures)
Scar usually flat and pale (better cosmetic outcome than excision for some lesions)
Hypopigmentation common (warn patient, especially darker skin)

Wound Closure Techniques

Primary closure of traumatic wounds in primary care. Assess wound carefully before attempting closure - some wounds are better left to heal by secondary intention or require specialist referral.

Assessment: Can I Close This Wound?

✅ Suitable for Primary Closure

Clean wound <6 hours old (face <24h)
Minimal tissue loss
No signs of infection
Edges can be approximated without tension
No foreign body
Adequate blood supply

❌ Unsuitable - Refer or Secondary Intention

Heavily contaminated/infected
Significant tissue loss
Bite wounds (except face - discuss with specialist)
Wounds >12 hours old (>24h face)
Underlying structure damage (tendon, nerve, bone)
Compromised blood supply

Wound Cleaning & Preparation

1Analgesia: Infiltrate LA (lidocaine 1% with adrenaline if not contraindicated)
2Irrigate: Use copious normal saline (at least 200ml). High-pressure irrigation (syringe with 19G needle) removes debris effectively
3Debride: Remove devitalised tissue and foreign material. Trim ragged edges if necessary (minimal tissue removal)
4Explore: Check for foreign bodies, assess depth, check for tendon/nerve injury
5Haemostasis: Achieve before closure (pressure, cautery, or ligature)

Closure Methods

Simple Interrupted Sutures

Best for: Most wounds, especially irregular or under tension

Technique:

Enter skin 3-5mm from wound edge at 90°
Pass needle through dermis, exit at same distance on opposite side
Tie with instrument tie (3 throws for synthetic, 4 for silk)
Evert wound edges slightly (prevents depressed scar)
Space sutures 5-10mm apart

Continuous (Running) Suture

Best for: Long linear wounds under minimal tension

Advantages: Faster, more haemostatic

Disadvantages: If one suture breaks, entire closure fails. Harder to adjust tension

Mattress Sutures (Vertical or Horizontal)

Best for: Wounds under tension, everting wound edges

Vertical mattress: Excellent eversion, good for thick skin (back, palms, soles)

Horizontal mattress: Good for fragile skin (elderly), distributes tension

Steri-Strips (Adhesive Skin Closures)

Best for: Superficial wounds, low-tension areas, children (avoid LA/needles)

Technique:

Ensure skin completely dry (use alcohol wipe, allow to dry)
Apply tincture of benzoin to improve adhesion (optional)
Apply strips perpendicular to wound, starting at middle
Space 2-3mm apart
Leave in place 5-10 days (will fall off naturally)

Limitations: Not suitable for hairy areas, high-tension areas, or wounds >2cm

Tissue Adhesive (Dermabond, Histoacryl)

Best for: Small (<5cm), low-tension wounds, especially in children

Technique:

Ensure wound edges dry and approximated (use forceps or assistant)
Apply thin layer of glue over wound (not in wound)
Hold edges together for 30 seconds
Apply 2-3 layers
Sloughs off naturally in 5-10 days

Advantages: No removal needed, waterproof, painless

Disadvantages: Expensive, not suitable for high-tension areas, hands, or over joints

Tetanus Prophylaxis

Vaccination History	Clean Wound	Tetanus-Prone Wound*
Fully immunised (5 doses) and last dose <10 years ago	No vaccine needed	No vaccine needed
Fully immunised but last dose >10 years ago	No vaccine needed	Give booster dose
Incomplete or uncertain history	Give vaccine (complete course)	Give vaccine + immunoglobulin

*Tetanus-prone wounds: puncture wounds, wounds with soil/manure contamination, wounds with devitalised tissue, compound fractures, wounds/burns requiring surgical intervention delayed >6 hours

Antibiotic Prophylaxis

Not routinely required for clean wounds. Consider for:

Bite wounds (human or animal) - Co-amoxiclav 625mg TDS for 5-7 days
Heavily contaminated wounds
Immunocompromised patients
Diabetic foot wounds
Wounds with delayed presentation

GP Script: Wound Care Advice

First 48 hours:

Keep wound dry and covered
Elevate if possible (reduces swelling)
Paracetamol for pain (avoid NSAIDs first 48h - may increase bleeding)

After 48 hours:

Can shower (pat dry gently, don't rub)
Change dressing if wet or soiled
Watch for signs of infection

Suture removal: Face 5-7 days, scalp 7-10 days, trunk/arms/legs 10-14 days

Intra-Articular & Peri-Articular Injections

Joint injections are used for both diagnostic and therapeutic purposes. Corticosteroid injections provide temporary relief of inflammation in joints, bursae, and tendon sheaths.

Indications

Inflammatory arthritis (RA, psoriatic, crystal arthropathy)
Osteoarthritis (symptomatic relief)
Bursitis (subacromial, trochanteric, olecranon, prepatellar)
Tendinitis (tennis elbow, golfer's elbow, De Quervain's)
Plantar fasciitis
Trigger finger

Contraindications

Absolute Contraindications

Infection at injection site or systemic infection
Septic arthritis (suspected or confirmed)
Bacteraemia
Joint prosthesis (refer to orthopaedics)
Fracture through joint

Relative Contraindications

Bleeding disorder or anticoagulation (weigh risk vs benefit)
Uncontrolled diabetes (steroid will raise glucose)
Previous injection <3 months ago (limit 3-4 per year per joint)
Tendon rupture risk (Achilles, patellar - avoid direct tendon injection)

Corticosteroid Preparations (BNF Verified)

Preparation	Strength	Use	Typical Dose
Methylprednisolone acetate (Depo-Medrone)	40mg/ml	Most common, intermediate duration	20-80mg depending on joint size
Triamcinolone acetonide (Kenalog)	40mg/ml	Longer duration, less soluble	10-40mg depending on joint size
Hydrocortisone acetate	25mg/ml	Shorter duration, less potent	25-50mg for soft tissue

Dose by Joint/Site (PCDS Guidelines)

Joint/Site	Methylprednisolone (Depo-Medrone)	Triamcinolone (Kenalog)	Lidocaine 1%
Knee	40-80mg (1-2ml)	20-40mg (0.5-1ml)	2-5ml
Shoulder	40mg (1ml)	20-40mg (0.5-1ml)	2-4ml
Elbow	20-40mg (0.5-1ml)	10-20mg (0.25-0.5ml)	1-2ml
Wrist	20-40mg (0.5-1ml)	10-20mg (0.25-0.5ml)	1-2ml
Ankle	20-40mg (0.5-1ml)	10-20mg (0.25-0.5ml)	1-2ml
Small joints (MCP, PIP)	10-20mg (0.25-0.5ml)	5-10mg (0.125-0.25ml)	0.5-1ml
Plantar fascia	20-40mg (0.5-1ml)	10-20mg (0.25-0.5ml)	1-2ml
Carpal tunnel	20-40mg (0.5-1ml)	10-20mg (0.25-0.5ml)	1ml
Trigger finger	10-20mg (0.25-0.5ml)	5-10mg (0.125-0.25ml)	0.5ml

General Technique Principles

1Consent: Explain procedure, risks (infection <1%, post-injection flare 10-20%, skin depigmentation, fat atrophy, tendon rupture rare), benefits, alternatives
2Aseptic technique: Clean skin with chlorhexidine or alcohol. Use sterile gloves. No-touch technique.
3Prepare syringe: Draw up steroid + lidocaine in same syringe (mix well). Use 21-23G needle for most joints.
4Identify landmarks: Mark entry point. Avoid neurovascular structures.
5Insert needle: Advance until in joint space (loss of resistance, can aspirate synovial fluid if effusion present)
6Aspirate: Check not in blood vessel (if blood, withdraw and reposition)
7Inject: Should be easy with minimal resistance. If high resistance, may be in tendon (withdraw slightly)
8Withdraw: Apply pressure with gauze. Apply dressing.

Specific Joint Techniques

Knee (Lateral Approach)

Position: Supine, knee extended or slightly flexed

Landmarks: Midpoint of patella, 1cm lateral to border

Needle: 21G, 1.5 inch (blue)

Direction: Aim posteriorly and slightly medially, under patella

Depth: 2-4cm (until loss of resistance)

Shoulder (Posterior Approach)

Position: Sitting, arm relaxed at side

Landmarks: 2cm below and 2cm medial to posterolateral corner of acromion

Needle: 21G, 1.5 inch (blue)

Direction: Aim anteriorly towards coracoid process

Depth: 2.5-4cm

Elbow (Lateral Approach)

Position: Elbow flexed 90°, forearm pronated

Landmarks: Centre of triangle formed by lateral epicondyle, radial head, olecranon

Needle: 23G, 1 inch (blue)

Direction: Perpendicular to skin

Depth: 1-2cm

Ankle (Anteromedial Approach)

Position: Supine, foot plantarflexed

Landmarks: Medial to tibialis anterior tendon, level with tip of medial malleolus

Needle: 23G, 1 inch (blue)

Direction: Aim laterally and posteriorly

Depth: 1-2cm

Plantar Fascia (Medial Approach)

Position: Lateral decubitus, affected foot uppermost

Landmarks: Medial aspect of heel, point of maximal tenderness

Needle: 23G, 1 inch (blue)

Direction: Perpendicular to skin, into fascia (not fat pad)

Depth: 1-1.5cm

Warning: Risk of fat pad atrophy - inject into fascia, not fat pad

Carpal Tunnel

Position: Supine, wrist extended 30°

Landmarks: 1cm proximal to distal wrist crease, ulnar side of palmaris longus tendon (or radial side of FCU if palmaris absent)

Needle: 25G, 1 inch (orange)

Direction: 45° angle, aim distally under flexor retinaculum

Depth: 0.5-1cm

Warning: If paraesthesia, withdraw immediately (median nerve)

Anatomical Danger Zones

Avoid these structures:

Shoulder: Axillary nerve (posterior approach safer than anterior)
Elbow: Ulnar nerve (medial), radial nerve (lateral)
Wrist: Median nerve (carpal tunnel), radial artery (lateral)
Knee: Popliteal vessels (posterior approach risky - use lateral)
Ankle: Dorsalis pedis artery (anterior), tibial nerve (medial)

Post-Injection Advice

GP Script: Post-Injection Care

What to expect:

Steroid takes 3-7 days to work (not immediate)
10-20% get post-injection flare (increased pain for 24-48h) - treat with ice and paracetamol
Effect lasts 6-12 weeks on average
May need repeat injection (max 3-4 per year per joint)

Activity advice:

Rest joint for 48 hours (avoid strenuous activity)
Can use joint for light activities
Gradually increase activity after 48 hours

When to seek help:

Increasing pain, redness, swelling, warmth (infection)
Fever or feeling unwell
Severe pain not settling with paracetamol

Complications

Infection (<1%): Septic arthritis is rare but serious. If suspected (increasing pain, fever, hot swollen joint), refer urgently for joint aspiration and IV antibiotics
Post-injection flare (10-20%): Temporary increase in pain for 24-48h. Treat with ice, rest, paracetamol. Settles spontaneously
Skin depigmentation: More common in darker skin. Warn patient. Usually temporary but can be permanent
Fat atrophy: Subcutaneous injection causes visible dimple. Avoid by ensuring deep injection
Tendon rupture: Rare. Risk increased with repeated injections, fluoroquinolone use, direct tendon injection. Avoid Achilles and patellar tendons
Nerve damage: Temporary paraesthesia common if nerve touched. Permanent damage rare if withdraw immediately
Systemic effects: Facial flushing (common, settles in days), hyperglycaemia (diabetics), menstrual irregularity

Toenail Avulsion with Phenol Ablation

Partial or total nail avulsion with phenolisation of the nail matrix is the definitive treatment for recurrent ingrowing toenails. Success rate >95% with proper technique.

Indications

Recurrent ingrowing toenail (onychocryptosis)
Failed conservative management (cotton wool packing, nail cutting technique)
Chronic paronychia
Involuted/pincer nail

Contraindications

Active infection (treat first with antibiotics, then operate 2-4 weeks later)
Peripheral vascular disease (check pulses - if absent, refer to vascular)
Diabetes with neuropathy/PVD (relative - higher infection risk, refer if severe)
Bleeding disorder

Equipment Required

Sterile gloves, drapes, gauze
Lidocaine 1% or 2% plain (NO adrenaline - digit is end-artery)
5ml syringe with 25G needle
Tourniquet (Penrose drain or finger tourniquet)
Nail elevator (Thwaites or MacDonald)
Nail splitter (English anvil pattern)
Artery forceps (straight)
80% phenol solution
Surgical spirit or isopropyl alcohol (to neutralise phenol)
Cotton-tipped applicators
Non-adherent dressing (e.g., Jelonet)

Step-by-Step Technique

1Digital ring block: Inject 2-4ml lidocaine 1% plain at base of toe, both sides of extensor tendon. Wait 5-10 minutes. Test anaesthesia before proceeding. DO NOT use adrenaline (risk of digital ischaemia).
2Apply tourniquet: Wrap Penrose drain around base of toe, secure with artery forceps. Provides bloodless field.
3Free nail: Insert nail elevator under nail plate, sweep side to side to free nail from nail bed. Work from distal to proximal.
4Split nail: For partial avulsion, use nail splitter to cut nail longitudinally (usually lateral 1/4 to 1/3). For total avulsion, skip this step.
5Avulse nail: Grasp nail (or nail portion) with artery forceps. Rotate forceps towards centre of toe while pulling distally. Nail should come away cleanly.
6DRY nail bed: CRITICAL STEP. Use gauze to dry nail bed and matrix thoroughly. Moisture dilutes phenol and reduces efficacy.
7Apply phenol: Dip cotton-tipped applicator in 80% phenol. Apply to nail matrix (under proximal nail fold) for EXACTLY 3 minutes. Use gentle pressure. Repeat with fresh applicator if needed to ensure full coverage.
8Neutralise phenol: Wipe area with surgical spirit or isopropyl alcohol-soaked gauze. This neutralises phenol and prevents burns.
9Release tourniquet: Remove tourniquet. Check for bleeding (usually minimal).
10Dress wound: Apply non-adherent dressing (Jelonet) and gauze. Bandage loosely (not too tight - risk of ischaemia).

Phenol Safety

Storage: Phenol and lidocaine must be stored separately (phenol can contaminate lidocaine). Keep phenol in locked cupboard (controlled drug in some areas).
Handling: Wear gloves. Phenol causes chemical burns. If spills on skin, wash immediately with copious water.
Disposal: Dispose of phenol-soaked applicators in clinical waste (not sharps bin).
Timing: 3 minutes is optimal. <2 minutes = higher recurrence. >4 minutes = increased tissue damage and delayed healing.

Post-Procedure Care

GP Script: Toenail Surgery Aftercare

What to expect:

Discharge from toe for 2-6 weeks (normal, not infection)
Mild discomfort for 2-3 days (paracetamol usually sufficient)
Healing takes 4-6 weeks
Nail will not regrow in treated area (that's the point!)

Dressing changes:

Keep original dressing on for 48 hours
After 48h, remove dressing and soak toe in warm salty water for 10 minutes daily
Pat dry gently, apply non-adherent dressing (Jelonet) and gauze
Continue daily soaks and dressing changes until healed

Activity:

Elevate foot for first 48 hours (reduces swelling)
Wear open-toed shoes or loose trainers for 2 weeks
Avoid sports for 2 weeks
Can return to work after 2-3 days (desk job) or 1-2 weeks (manual work)

When to seek help:

Increasing pain, redness, or swelling after 48 hours
Foul-smelling discharge or pus
Fever or feeling unwell
Toe becomes cold, blue, or numb (vascular compromise - urgent)

Complications

Infection (2-5%): More common in diabetics. Treat with flucloxacillin 500mg QDS. If cellulitis spreading, consider admission for IV antibiotics
Prolonged discharge: Normal for 2-6 weeks. If >6 weeks, check for retained nail spicule or infection
Recurrence (3-5%): Usually due to inadequate phenolisation. Can repeat procedure
Regrowth of nail spike: If small spike regrows, can trim or repeat phenol to that area
Post-operative pain: Usually mild. If severe, check for haematoma or infection
Delayed healing: More common in diabetics, smokers, PVD. May take 8-12 weeks

Partial vs Total Nail Avulsion

Partial Nail Avulsion (Wedge Resection)

Indications: Ingrowing toenail affecting one side only

Advantages: Preserves most of nail, better cosmetic result

Technique: Remove lateral 1/4 to 1/3 of nail. Phenolise corresponding portion of matrix

Result: Narrower nail, no regrowth on treated side

Total Nail Avulsion

Indications: Bilateral ingrowing, involuted nail, chronic paronychia, fungal nail (if failed medical treatment)

Advantages: Definitive treatment, no recurrence

Disadvantages: No nail (cosmetic concern for some patients)

Technique: Remove entire nail. Phenolise entire matrix

Result: No nail regrowth

Wound Dressing Selection

Choosing the right dressing depends on wound type, exudate level, infection status, and healing stage. Modern dressings promote moist wound healing, which is faster and less painful than dry healing.

Principles of Wound Dressing

Moist wound healing: Maintains optimal moisture balance (not too wet, not too dry)
Match exudate level: Dressing should absorb exudate without drying wound
Protect from infection: Barrier to bacteria while allowing gas exchange
Minimise trauma: Non-adherent dressings reduce pain on removal
Cost-effective: Use simplest dressing that meets needs

Dressing Selection by Exudate Level

Exudate Level	Dressing Type	Examples
Dry/Minimal	Hydrogel, Hydrocolloid (thin)	Intrasite Gel, Granuflex (thin)
Low	Hydrocolloid, Foam (thin)	DuoDERM, Allevyn Thin
Moderate	Foam, Hydrocolloid (standard)	Allevyn, Biatain, Granuflex
High	Alginate, Foam (extra absorbent)	Kaltostat, Sorbsan, Allevyn Plus
Very High	Alginate + secondary dressing	Kaltostat + gauze pad

Dressing Types - Detailed Guide

Description:

Occlusive dressing containing gel-forming agents (carboxymethylcellulose). Forms gel on contact with wound exudate.

Indications:

Low to moderate exudate wounds
Pressure ulcers (stage 2-3)
Leg ulcers
Minor burns
Donor sites

Advantages:

Maintains moist environment
Autolytic debridement (removes slough)
Waterproof (can shower)
Stays in place 3-7 days
Cushions wound

Disadvantages:

Not suitable for infected wounds
Not suitable for high exudate
Can produce odour (normal, not infection)
May cause maceration if too occlusive

Application:

Clean wound with saline
Dry surrounding skin
Apply dressing with 2-3cm overlap onto healthy skin
Warm dressing with hands to improve adhesion
Change when gel leaks from edges or after 7 days

Description:

Polyurethane foam with high absorbency. Available in adhesive and non-adhesive versions.

Indications:

Moderate to high exudate wounds
Leg ulcers
Pressure ulcers
Post-operative wounds
Traumatic wounds

Advantages:

Highly absorbent
Maintains moist environment
Cushions wound
Non-adherent (won't stick to wound bed)
Can stay in place 3-7 days
Breathable (reduces maceration)

Disadvantages:

More expensive than simple dressings
Not suitable for dry wounds
May require secondary dressing if non-adhesive

Application:

Clean wound with saline
Dry surrounding skin
Apply foam with absorbent side towards wound
Ensure 2-3cm overlap onto healthy skin
Change when saturated or after 7 days

Description:

Derived from seaweed (calcium/sodium alginate). Forms gel on contact with exudate. Available as flat sheets or rope for cavities.

Indications:

High exudate wounds
Cavity wounds (use rope)
Bleeding wounds (haemostatic properties)
Infected wounds (can use with antimicrobials)
Leg ulcers
Pressure ulcers (stage 3-4)

Advantages:

Highly absorbent (can absorb 20x its weight)
Haemostatic (promotes clotting)
Conforms to wound shape
Easy to remove (irrigate with saline)
Can pack cavities

Disadvantages:

Requires secondary dressing
Not suitable for dry wounds
Can dry out and adhere if insufficient exudate
More expensive

Application:

Clean wound with saline
Apply alginate to wound (loosely pack cavities - don't overfill)
Cover with secondary dressing (foam or gauze pad)
Change daily initially, then every 2-3 days as exudate reduces
Remove by irrigating with saline (gel will wash away)

Description:

Water-based gel (80-90% water). Donates moisture to dry wounds. Available as amorphous gel or sheet.

Indications:

Dry/sloughy wounds
Necrotic wounds (autolytic debridement)
Minor burns
Painful wounds (cooling effect)
Granulating wounds

Advantages:

Rehydrates dry wounds
Promotes autolytic debridement
Cooling/soothing (reduces pain)
Non-adherent
Maintains moist environment

Disadvantages:

Not suitable for high exudate
Requires secondary dressing
Can cause maceration if overused
Needs frequent changes (daily to every 3 days)

Application:

Clean wound with saline
Apply generous layer of gel to wound bed
Cover with secondary dressing (non-adherent pad + gauze)
Change daily or when gel dries out

Description:

Dressings containing antimicrobial agents (silver, iodine, PHMB, honey). Reduce bacterial load in wounds.

Types:

Silver: Acticoat, Aquacel Ag, Allevyn Ag (broad-spectrum, sustained release)
Iodine: Iodosorb, Inadine (broad-spectrum, rapid action)
Honey: Medihoney, Activon (antibacterial, debriding)
PHMB: Kendall AMD (broad-spectrum, non-toxic)

Indications:

Infected wounds
Critically colonised wounds (high bacterial load but not clinically infected)
Wounds at high risk of infection
Malodorous wounds

Advantages:

Reduces bacterial load
Broad-spectrum activity
Can use with systemic antibiotics
Reduces odour

Disadvantages:

Expensive
Not a substitute for systemic antibiotics if cellulitis/sepsis
Silver can cause grey discolouration (temporary)
Iodine contraindicated in thyroid disease, pregnancy
Should not be used long-term (max 2 weeks)

Application:

Clean wound with saline
Apply antimicrobial dressing as per manufacturer instructions
Cover with secondary dressing if needed
Change frequency depends on product (daily to every 3 days)
Review after 2 weeks - stop if infection resolved

Description:

Simple dressings that don't stick to wound bed. Include paraffin gauze (Jelonet), silicone dressings (Mepitel), and film dressings (Tegaderm).

Types:

Paraffin gauze (Jelonet): Gauze impregnated with soft paraffin
Silicone (Mepitel): Silicone-coated mesh
Film (Tegaderm): Transparent polyurethane film
Low-adherent pad (Melolin): Absorbent pad with non-stick surface

Indications:

Sutured wounds
Skin grafts/donor sites
Minor burns
Abrasions
Wounds healing by secondary intention
Fragile skin (elderly)

Advantages:

Painless removal
Inexpensive
Easy to apply
Allows wound inspection (if transparent)
Protects wound from trauma

Disadvantages:

Minimal absorbency (requires secondary dressing)
Frequent changes needed
Paraffin gauze can dry out and stick
Film dressings not suitable for exuding wounds

Application:

Clean wound with saline
Apply non-adherent layer directly to wound
Cover with absorbent pad and secure with tape or bandage
Change daily or when strike-through occurs

Quick Dressing Selection Guide

Dry wound: Hydrogel → adds moisture

Low exudate: Hydrocolloid → maintains moisture

Moderate exudate: Foam → absorbs excess

High exudate: Alginate → highly absorbent

Infected: Antimicrobial (silver/iodine) + systemic antibiotics if cellulitis

Cavity: Alginate rope → packs cavity

Sutured wound: Non-adherent (Jelonet) → protects sutures

Sloughy/necrotic: Hydrogel → autolytic debridement

Red Flags

Skin Cancer Warning Signs

Melanoma (Urgent 2-Week Wait Referral)

ABCDE positive (Asymmetry, Border irregular, Colour varied, Diameter >6mm, Evolving)
7-point checklist score ≥3
Ugly duckling sign (lesion looks different from patient's other moles)
New pigmented lesion in patient >50 years
Change in size, shape, or colour of existing mole
Bleeding, crusting, or itching of pigmented lesion
Satellite lesions around pigmented lesion

Squamous Cell Carcinoma (Urgent 2-Week Wait)

Non-healing ulcer or nodule >4 weeks
Indurated (hard) base
Rolled edges
Rapid growth
Bleeding or crusting
Sun-exposed areas (face, ears, scalp, hands)

Basal Cell Carcinoma (Routine Referral, Urgent if Functional/Cosmetic Risk)

Pearly, translucent nodule with telangiectasia
Central ulceration ("rodent ulcer")
Slow-growing
Rarely metastasises but locally invasive
Urgent if near eye, nose, ear (functional risk)

Action: Do NOT excise suspected melanoma or SCC in primary care. Refer urgently (2-week wait) for specialist assessment and excision with appropriate margins.

Infection Warning Signs

Cellulitis/Spreading Infection

Spreading erythema beyond wound margins
Increasing pain, warmth, swelling
Red streaks (lymphangitis)
Fever, rigors, malaise
Lymphadenopathy

Action: Oral antibiotics (flucloxacillin 500mg QDS). If systemically unwell, spreading rapidly, or immunocompromised, consider admission for IV antibiotics.

Necrotising Fasciitis (Surgical Emergency)

Severe pain out of proportion to clinical signs
Rapidly spreading erythema
Skin discolouration (purple, black)
Bullae, crepitus, anaesthesia
Systemic toxicity (fever, tachycardia, hypotension)

Action: Emergency admission. Call ahead. Requires urgent surgical debridement + IV antibiotics. Mortality 20-30% even with treatment.

Septic Arthritis (Post-Joint Injection)

Severe joint pain (worse than pre-injection)
Hot, swollen, red joint
Fever, rigors
Unable to move joint
Onset usually 24-72 hours post-injection (but can be delayed)

Action: Urgent orthopaedic referral same day. Requires joint aspiration (culture, WCC, crystals), IV antibiotics, possible washout. Delay = cartilage destruction.

Vascular Compromise

Arterial Insufficiency (Pre-Procedure)

Absent pulses (dorsalis pedis, posterior tibial, radial)
Cold, pale limb
Prolonged capillary refill (>2 seconds)
History of PVD, claudication, rest pain
Ulcers with punched-out appearance

Action: Do NOT proceed with procedure. Refer to vascular surgery for assessment. High risk of non-healing, infection, amputation.

Compartment Syndrome (Post-Procedure)

Severe pain (out of proportion, not relieved by analgesia)
Pain on passive stretch
Tense, swollen limb
Paraesthesia, numbness
Pallor, pulselessness (late signs - don't wait for these)

Action: Surgical emergency. Remove all dressings/bandages immediately. Elevate limb. Emergency referral to orthopaedics. Requires fasciotomy within 6 hours to prevent permanent damage.

Digital Ischaemia (Post-Ring Block/Tourniquet)

White, cold digit
Severe pain or numbness
Prolonged capillary refill
Occurred after ring block with adrenaline or prolonged tourniquet

Action: Remove tourniquet immediately. Warm digit. If adrenaline used, consider phentolamine injection (alpha-blocker reverses vasoconstriction). Urgent referral if not improving within 30 minutes.

Nerve Injury

Immediate Nerve Injury (During Procedure)

Patient reports shooting pain, electric shock sensation during injection/incision
Immediate numbness or weakness in distribution of nerve
Loss of function (e.g., unable to oppose thumb after carpal tunnel injection = median nerve injury)

Action: Stop procedure immediately. Document carefully. Most are neuropraxia (temporary) and recover in weeks to months. Refer to hand surgery/neurology if no improvement at 3 months or complete loss of function.

Delayed Nerve Injury (Post-Procedure)

Progressive numbness or weakness developing hours to days post-procedure
May indicate haematoma compressing nerve
Carpal tunnel syndrome worsening after injection

Action: Urgent referral if acute onset with complete loss of function (may need surgical decompression). Routine referral if gradual onset or partial deficit.

High-Risk Anatomical Areas

Temporal branch of facial nerve: Forehead procedures (causes brow ptosis)
Spinal accessory nerve: Posterior triangle neck (causes shoulder drop)
Digital nerves: Finger procedures (run along sides of fingers)
Median nerve: Carpal tunnel injections
Ulnar nerve: Medial elbow procedures
Radial nerve: Lateral elbow procedures

Prevention: Know your anatomy. Use landmarks. Avoid injecting if patient reports paraesthesia. Withdraw and reposition needle.

Do's & Don'ts

DO

Check patient's anticoagulation status before any procedure
Obtain informed consent (written for excisions, verbal acceptable for minor procedures)
Use aseptic technique for all procedures (sterile gloves, clean skin, no-touch technique)
Aspirate before injecting local anaesthetic (avoid intravascular injection)
Mark incision lines along Langer's lines (natural skin tension lines)
Send all excised tissue for histology (except curettings)
Document procedure thoroughly (indication, consent, technique, complications, histology sent)
Provide written post-procedure instructions to patient
Arrange follow-up for suture removal and histology results
Know your limits - refer if uncertain or beyond your competence

DON'T

Excise suspected melanoma in primary care (refer urgently for specialist excision)
Use adrenaline-containing LA on digits, penis, nose tip, ear lobes (end-arteries)
Exceed maximum LA dose (calculate based on patient weight)
Inject directly into tendon (risk of rupture)
Perform procedures on infected sites (treat infection first, operate later)
Use curettage if any doubt about malignancy (destroys tissue architecture)
Inject joints more than 3-4 times per year (cartilage damage risk)
Apply phenol to wet nail bed (moisture dilutes it - dry thoroughly first)
Store phenol and lidocaine together (phenol can contaminate lidocaine)
Proceed if patient reports paraesthesia during injection (nerve injury risk)

The Golden Rule of Minor Surgery

"If in doubt, don't cut it out."

When faced with diagnostic uncertainty, always err on the side of caution. It's better to refer a benign lesion than to inadequately excise a malignant one. Your patient's safety and your medicolegal protection depend on knowing when to refer.

Remember: Competence is not just about what you can do, but knowing when NOT to do it.

Minimising the Risk of Litigation in Minor Surgery

Medicolegal considerations and risk reduction strategies for safe minor surgery practice in UK general practice.

Core Medicolegal Principles

Competence: Only perform procedures you are trained and competent to do. Maintain skills through regular practice and CPD.
Consent: Obtain informed consent. Explain procedure, risks, benefits, alternatives. Document consent clearly.
Documentation: Contemporaneous, legible, comprehensive records. "If it's not written down, it didn't happen."
Communication: Clear communication with patient before, during, and after procedure. Written post-op instructions.
Follow-up: Arrange appropriate follow-up. Chase histology results. Act on abnormal results promptly.
Referral: Know when to refer. Don't exceed your competence. Document referrals and ensure patient attends.
Indemnity: Ensure adequate medical indemnity insurance covers minor surgery procedures.

Facial Lesions

Consider referral to plastic surgery for cosmetically sensitive areas (face, neck, hands)
Warn about scarring risk (even with perfect technique, scars are inevitable)
Document discussion about scar appearance and patient's acceptance
Avoid excising lesions near danger zones (temporal nerve, facial artery) unless confident in anatomy

Keloid Scarring Risk

Ask about previous keloid/hypertrophic scars
Higher risk in darker skin, chest, shoulders, earlobes
Warn patient of risk and document discussion
Consider referral if high-risk patient in high-risk area

Practice Nurse Consultation

If practice nurse performs minor surgery, ensure they are trained, competent, and indemnified
GP remains responsible for patient selection, consent, and follow-up
Clear protocols for nurse-led procedures
Regular audit and supervision

Post-Operative Protocols

Written post-op instructions (wound care, activity restrictions, when to seek help)
Clear plan for suture removal (who, when, where)
System to track histology results (don't rely on patient to chase)
Action plan for abnormal histology (who contacts patient, how, when)

Documentation

Pre-op: indication, consent discussion, risks explained, patient questions answered
Intra-op: procedure performed, LA dose, complications, specimen sent for histology
Post-op: instructions given, follow-up arranged, histology tracking system
Consider using a minor surgery record book (separate from main notes for easy audit)

Patient Information

Provide written information leaflet (procedure, risks, aftercare)
Document that leaflet given
Allow time for questions
Cooling-off period for non-urgent procedures (patient can change mind)

Aseptic Precautions

Strict aseptic technique (sterile gloves, clean skin with chlorhexidine/alcohol)
No-touch technique (don't touch needle after removing from packet)
Single-use vials only (never re-use multi-dose vials between patients)
Document aseptic technique used

Avoiding Infected Areas

Never inject through infected skin or into infected joint
If cellulitis present, treat with antibiotics first, inject later (4-6 weeks)
Document that injection site examined and no infection present

Suspected Septic Arthritis

If patient presents with hot, swollen, painful joint post-injection, assume septic arthritis until proven otherwise
Urgent same-day referral to orthopaedics (don't wait for blood results)
Document time of referral, who spoke to, advice given
Safety-net: if can't get through to orthopaedics, send to A&E with referral letter

Avoiding Neural/Vascular Damage

Know your anatomy (use landmarks, avoid danger zones)
If patient reports paraesthesia during injection, STOP immediately, withdraw needle, reposition
Document that patient warned about nerve injury risk (rare but possible)
If nerve injury occurs, document fully, refer to specialist, apologise (apology is not admission of liability)

Phenol/Lignocaine Separation

Store phenol and lidocaine in separate locked cupboards
Phenol can contaminate lidocaine if stored together (risk of chemical burn)
Label clearly
Check expiry dates regularly

Locked Storage for Phenol

Phenol is a controlled drug in some areas (check local policy)
Store in locked cupboard (CD cupboard if required locally)
Keep register of phenol use (date, patient, amount used)
Dispose of expired phenol safely (pharmacy collection)

Silver Nitrate Precautions

Protect surrounding skin with petroleum jelly (silver nitrate causes black staining)
Warn patient about staining (temporary but can last weeks)
Use on moist area only (dip stick in water first)
Don't overuse (excessive application causes tissue damage)
Document warnings given to patient

Blistering/Scarring Warnings

Warn patient that blistering is normal (not a complication)
Warn about temporary pigment change (hypopigmentation common, especially darker skin)
Warn about scarring risk (rare but possible, especially if over-treated)
Document warnings given

Recording Warnings

Document in notes: "Patient warned about blistering, pigment change, scarring risk. Patient consents to proceed."
Consider using a cryotherapy consent form (especially for cosmetic treatments)
Provide written aftercare instructions

Avoiding Over-Treatment

Follow recommended freeze times (10-30 seconds depending on lesion)
Don't over-treat (longer freeze = higher risk of scarring, not better efficacy)
If lesion doesn't respond after 2-3 treatments, consider alternative diagnosis or referral

Avoiding Spirit-Based Cleaners

Do NOT use alcohol-based skin cleaners immediately before electrocautery (fire risk)
If alcohol used, allow to dry completely (at least 2 minutes)
Use aqueous chlorhexidine instead (no fire risk)
Document skin prep used

Contact with Dressings

Do NOT allow hot cautery tip to contact dressings, drapes, or gauze (fire risk)
Place cautery in holder when not in use (don't leave on drape)
Have water/saline available in case of fire
Ensure smoke evacuator or good ventilation (cautery smoke is toxic)

High-Risk Anatomical Sites

The following areas have higher complication rates and should be approached with caution or referred:

Face: Cosmetically sensitive. Risk of nerve injury (temporal, facial). Consider plastic surgery referral.
Neck: Risk of spinal accessory nerve injury (posterior triangle). Vascular structures. Refer if uncertain.
Axilla: Risk of brachial plexus injury. Vascular structures. Difficult haemostasis. Consider referral.
Thigh (medial): Risk of femoral vessels/nerve injury. Refer if deep lesion.
Popliteal fossa: Risk of popliteal vessels/nerve injury. Refer all lesions in this area.
Shin: Poor blood supply. High infection risk. Slow healing. Avoid if possible or use minimal tension closure.

When to Refer

Lesion in danger zone and you're not confident in anatomy
Lesion >2cm in cosmetically sensitive area
Lesion overlying major vessel or nerve
Patient has keloid tendency and lesion in high-risk area
Suspected malignancy (always refer, never excise in primary care)
Patient requests specialist opinion

General Risk Reduction Strategies

Training: Attend minor surgery courses. Observe experienced practitioners. Practice on models before patients.
Competence: Start with simple procedures. Build experience gradually. Know your limits.
Protocols: Develop practice protocols for common procedures. Include consent, technique, follow-up, histology tracking.
Audit: Regular audit of outcomes (infection rates, histology results, patient satisfaction, complications).
Peer review: Discuss difficult cases with colleagues. Learn from complications (yours and others').
Patient selection: Choose appropriate patients. Avoid high-risk patients (PVD, immunosuppressed, bleeding disorders) unless experienced.
Equipment: Use appropriate equipment. Maintain and replace regularly. Don't improvise.
Indemnity: Ensure adequate medical indemnity insurance. Inform insurer of procedures performed.
Apology: If complication occurs, apologise (not admission of liability). Explain what happened. Offer support. Document fully.
Reflection: Reflect on every procedure. What went well? What could be improved? Learn continuously.

You've Got This!

Minor surgery is a valuable skill that improves patient care and job satisfaction. Start with simple procedures, build your confidence gradually, and always prioritise patient safety. Remember: competence comes with practice, but wisdom comes from knowing your limits.

Every expert was once a beginner. Keep learning, keep practicing, and don't be afraid to ask for help.