Removal of fibroids - laser or scalpel? Comparison of methods

The most common question in the office is: remove fibroma with a laser or a scalpel? In my practice, the answer depends primarily on one thing - whether the lesion needs to be examined histopathologically. The laser vaporizes the tissue and usually leaves no material for examination, while excision with a scalpel provides the entire fragment for evaluation under a microscope. Below I explain when which method makes sense.

What is fibroma

A fibroma is a benign skin lesion composed of connective tissue and epidermis. Most often we encounter the so-called soft fibroma (acrochordon) - a soft, pedunculated formation appearing in places of friction: on the neck, nape of the neck, under the arms, in the groin or on the eyelids. These changes are painless and usually harmless, and their frequency increases with age, overweight and metabolic disorders [1].

I write more about the formation of these changes in the entry: Soft fibroma - where does it come from and does it need to be removed?

Two removal routes - how each method works

CO2 laser and ablation methods

The laser beam evaporates and at the same time coagulates the tissue, thanks to which the lesion is removed pointwise and the small vessels are closed. The procedure is precise, usually does not require stitches, and the morning after treatment is superficial. However, it must be remembered that heat also affects the edge of the tissue - it leaves a zone of thermal damage [2].

Surgical excision with a scalpel

The scalpel allows the lesion to be removed along with a margin of healthy tissue, and the wound is closed with a suture. The greatest advantage of this method is that the entire removed fragment remains intact and can be submitted for histopathological examination. Cold cutting causes the least damage to the edges of the specimen among the compared techniques [2].

Key difference: histopathological examination

This is the crux of the selection. The laser vaporizes the tissue - after the procedure, there is usually nothing to send to the laboratory, and if the material is successfully collected, its edges may be affected by the heat, making it difficult to evaluate under a microscope. In a study comparing the methods, the thermal damage zone with a cold scalpel was on average approximately 2 µm, while with a CO2 laser it reached approximately 538 µm [2]. Excision with a scalpel provides a complete, well-preserved specimen.

Why does this matter if skin tags are benign? Because some lesions that look harmless clinically turn out to be something else when examined. In an analysis of 1815 clinically benign lesions removed surgically, 0.33% proved malignant [3]. In addition, the differential diagnosis of a soft fibroma includes nodular (polypoid) melanoma and basal cell carcinoma, among others [1]. That is why the rule in my practice is simple: if there is any doubt about the nature of a lesion, we choose excision with histopathological examination rather than laser vaporisation.

When to use a laser and when to use a scalpel - indications

• CO2 laser: clinically certain, benign soft fibromas - especially small and multiple ones, and in areas where we care about a good aesthetic effect.
• Scalpel excision: lesions that are ambiguous, changing, pigmented, ulcerated, larger or where we want histopathological certainty.
• A suspicious lesion is always excised with histopathological examination - it cannot be evaporated.

The method is always determined by the assessment of the lesion during the consultation, including a dermatoscopic examination. Qualification for laser removal of skin tags in Wrocław is done individually.

What does the procedure look like - course

The treatment begins with a consultation and assessment of the lesion. After qualification, local anaesthesia is used, and the procedure itself - regardless of the method - usually lasts from several to several minutes for a single lesion. Finally, a small dressing is applied and care recommendations are provided.

Effects, healing and scar

After laser, the wound is small and usually heals quickly; Redness or discolouration may occur temporarily. After excision with a scalpel, a linear scar remains, and its appearance depends on the size of the lesion, location and individual predisposition to healing. The cosmetic effect is an individual matter and cannot be guaranteed in advance.

Safety and contraindications

Both procedures are considered safe when performed by a prepared person after prior assessment of the lesion. We discuss contraindications (e.g. active skin infections at the treatment site, tendency to develop keloid scars, certain general conditions) during the consultation. skin tags should not be removed at home - this may cause bleeding, infection and, importantly, prevents examination of the lesion.

Aftercare instructions

• Keep the wound clean and follow office care recommendations.
• Don't scratch the scab - new skin is healing underneath.
• Protect the area after treatment from the sun to reduce the risk of discolouration.
• Seek evaluation if increasing redness, pain or discharge occurs.

Summary

Laser and scalpel are not competitors, but tools for different situations. The laser works well for certain, benign and small skin tags when we want quick healing and a discreet mark. We choose the scalpel when the lesion is ambiguous and we need the certainty provided by histopathological examination. The method is always determined by the assessment of a specific change.

Sources

1. Pandey A, Saleh HM. Skin Tag (Acrochordon). StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated 13/12/2025. ncbi.nlm.nih.gov/books/NBK547724
2. Monteiro L, Delgado ML, Garcês F, et al. A histological evaluation of the surgical margins from human oral fibrous-epithelial lesions excised with CO2 laser, Diode laser, Er:YAG laser, Nd:YAG laser, electrosurgical scalpel and cold scalpel. Med Oral Patol Oral Cir Bucal. 2019. pubmed.ncbi.nlm.nih.gov/30818322
3. Milton CJ, Ganesamoorthy K, Dharanya GS, et al. Is it Necessary to Send Clinically Diagnosed Benign Skin and Subcutaneous Lesions Excised Under Local anaesthesia for Routine Histopathological Examination? Cureus. 2021;13(8):e17194. doi:10.7759/cureus.17194. pmc.ncbi.nlm.nih.gov/articles/PMC8439399