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    Gilbert, DO - Medical Degree Programs Campus and Online Medical ... Gilbert, DO - Medical Degree Programs Campus and Online Medical ... Presentation Transcript

    • Dermatologic Surgery Kristy P. Gilbert, D.O. November 1, 2005
    • Introduction
      • Derm surgery increasing in complexity
      • Aesthetic and Laser procedures
      • Plastic surgery – blepharoplasty, facelifts, liposuction
      • Mohs micrographic surgery
      • Increasing emphasis on patient safety, documentation, and accreditation.
    • Basics: Pre-Op Evaluation
      • Drug Allergies
      • Meds: Coumadin, Plavix, ASA.
      • Pacemaker? Defibrillator?
      • MVP, Endocarditis, Prosthetics?
      • Informed Consent, photographic consent, risks v. benefits and options must all be discussed & signed
      • OTC and Herbals…..
    • Past Medical History….
    • Past medical history
      • Factors that will affect wound healing
      • Prophylactic antibiotics
      • Risks for scarring
      • Risks for bleeding
    • Factors that will affect wound healing
      • Advanced age
      • Nutritional status
      • Diabetes
      • Immunosuppressive drugs
      • Smoking
      • Critically ill patients, HIV
      • Atherosclerosis, PVD
    • Prophylactic Antibiotics
      • Contaminated or “dirty” wounds benefit, not clean wounds
      • Indications
      • ear, nose mouth, hand foot, axilla, genitalia (“dirty” areas)
      • - Artificial Heart Valve
      • - Artificial Joint Replacement < 6 months
      • - Past history Endocarditis, Rheumatic Fever
      • Mitral Valve Prolapse WITH holosystolic murmur
      • Immunocompromised
    • Antibiotic Prophylaxis:
      • Standard: administer 1 hour pre-op and 6 hrs post-op
      • Keflex: 1gm po pre-op, 500mg po post-op
      • Dicloxicillin: 1gm po pre, 500mg po post
      • Clindamycin 300mg po pre, 150mg po post
    • Risks for scarring
      • Location: upper chest, back, shoulders, extremities
      • Personal hx scarring: i.e. keloids, hypertrophic scars
      • Medications: isotretinoin in past 12 mo. Or Vitamin A or E use
    • ASA/NSAID containing drugs
      • There are about 160 of them
      • Most are OTC
      • Patients don’t think of these as drugs because they are not prescriptions.
    • ASA/NSAID containing drugs
      • Aspirin
      • Irreversibly acetylates platelet COX reducing PG and thromboxane A2 synthesis therefore platelets inhibited for their lifetime (7-10days)
      • For this reason, must be D/Ced 7-10 d pre-op
      • NSAIDs
      • - Reversibly inhibit COX therefore less clinical effect
    • Other drugs affecting platelets
      • Production
      • Myelosuppressive agents, ethanol, estrogens, thiazides
      • Destruction
      • Abx: sulfathiazole; quinine, ASA, dig, methyldopa
      • Function
      • - ASA, dipyridamole, ethanol, heparin, NSAIDS, plavix, ticlopidine, herbal supplements
    • Herbal Supplements that inhibit coagulation….
      • MOST COMMON: Fish Oils, Garlic, Gingko, Ginseng, Chinese Herbal/Green Teas, Vitamin E
      • Alfalfa, Capsicum, Celery, Chamomile, Dong quai, Fenugreek, Feverfew, Ginger, Horseradish, Huang qui, Kava kava, Licorice, Passionflower, Red Clover.
      • Dermatol Surg 28: June 2002, 449
    • Local Anesthesia
    • Local anesthesia
      • Ideal properties
      • Rapid onset
      • Long duration of action
      • Lack of toxicity
      • Water solubility
      • Structure & function
      • Aromatic portion= lipophilic= potency
      • Amine= hydrophilic= solubility
      • Intermediate chain- determines class: i.e. ester, amide AND most importantly- this determines route of excretion and metabolism
      • MOA = blocks movement of Na+ influx across membrane thereby blocking depolarization
    • Local Anesthesia Categories
      • Esthers:
      • Procaine (novocaine)
      • Chloroprocaine (nesacaine)
      • Cocaine
      • Tetracaine
      • Benzocaine
      • Amides
      • -Lidocaine (xylocaine)
      • Mepivacaine (carbocaine)
      • Prilocaine (citanest)
      • Etidocaine(durantest)
      • Bupivicaine (marcaine) = the LONGEST acting
      • Nupercaine
    • “ I’m allergic to Novacaine”
      • Pearl: It is OK to give Xylocaine to patients who had allergic reactions to Novocaine at the dentist’s office, Lidocaine is an Amide and Novocaine is an Ester.
      • Pitfall: They may not know which medication they reacted to: use Bacteriostatic NS or diphenhydramine when in doubt.
      • Esters>>>amides
    • Local Anesthesia
      • Pearl: fears of epinephrine induced necrosis at distal sites (nose, ears, penis, toes, fingertips) are largely unfounded.
      • Pitfalls: patients with severe peripheral vascular disease, diabetic angiopathy and Raynaud’s phenomenon may be exceptions to the rule.
      • Contraindications to epinephrine in anesthsia:
      • -severe HTN, pheochromocytoma, HyperTH, severe vascular ds, bradycardia “ABSOLUTE”
      • -pregnancy, MAO inhibitors, narrow angle glaucoma “RELATIVE”
    • Local anesthesia
      • Maximum dosage
      • 1% lidocaine w/ epi 1:100,000 is 10mg of lidocaine per 1cc of mixture
      • Adult= 7mg/kg = 500mg/ 70kg (50cc)
      • Child = 3-4.5mg/kg
      • 1% lidocaine w/o epi
      • Adult= 4.5mg/kg = 300mg/70kg (30cc)
      • Child= 1-2 mg/kg
      • Insert needle at a 30 degree angle and slowly retract the needle as you inject the anesthetic. When the tissue blanches you are at the right level.
      • Always best to try to avoid too many sticks, if your doing a larger area, each re-stick should be into an area that has already been anesthetised
    • Pain Control
      • Local Anesthesia:
      • INJECT SLOWLY: Decreases pain more than warming or adding bicarbonate.
      • Distraction techniques useful as well – pinching skin during injection, vibrating pen, etc.
      • For pediatric patients, let them sit in the lobby with ELA-Max or EMLA under occlusion for 30 min.- 1 hr. Your eardrums will thank you.
    • Surgical Cleansers
      • Clean Procedures:
      • Isopropyl alcohol
        • weak antimicrobial
        • most commonly used agent for shave biopsies
      • Hydrogen peroxide
        • no significant antiseptic properties
        • not suitable for sterile procedures
    • Surgical Cleansers: Sterile
      • Betadine
        • irritating to skin, residual color
        • must dry completely to be antimicrobial
        • absorbed by premature infants
      • Chlorhexidine (Hibiclens)
        • keratitis if it gets in the eyes
      • Hexachlorophene (pHisoHex)
        • not on women or children due to neurotoxicity and teratogenicity
    •  
    • Common Procedures
      • Shave Biopsy
      • Punch Biopsy
      • Excisional Biopsy
      • Cryosurgery
    • Shave biopsy
      • Best suited to pedunculated, papular or otherwise elevated lesions but may be used for macular lesions.
      • Simple
      • Quick
      • Satisfactory cosmetic result
      • Adequate biopsy tissue for diagnosis
    • Shave Biopsy
      • Sterile #15 blade
      • 4x4’s
      • Drysol solution
      • Sterile Q-tips
      • Path container
      • Gillette Blue Blade Razor cut in half, bends to follow contour
    • Shave Biopsy - skin tension
    • Shave Biopsy - flush w/ surface
    • Endpoint is “pinpoint bleeding” Indicates you are at the level of the papillary dermis, minimal scarring
      • Stay superficial for minimal scarring.
      • Pink atrophic area has a full year to heal.
      • Upper chest and back scars no matter what you do.
    • Punch Biopsy
      • Most common use is for skin biopsy
      • Can excise small lesions
      • Treats acne scars
      • Hair transplantation
      • May stretch skin perpendicular to skin tension lines to create elliptical defect and avoid “dog ears”
    • Punch Biopsy
      • Sterile OR clean procedure
      • 3 or 4 mm punch is standard
      • 4x4s, Drysol, Q-tips
      • Needle driver, forceps
      • Suture
      • Path specimen bottle
    • Punch Biopsy
      • Twist punch tool until buried to the hub*
      • *Caveat: Have a firm grasp of anatomy and skin thickness in the area you are punching before you punch it.
      • Finger tendons, facial and neck structures.
    • Punch biopsy
      • KEY: do not crush tissue when removing it from the biopsy site.
      • Crush artifact makes pathologic interpretation difficult to impossible.
      • Some pull it out using the suture needle as this method is atraumatic.
    • Punch Biopsy
      • Use 5-0 or 6-0 nylon/Prolene on the face.
      • 4-0 nylon/Prolene most other areas.
      • Silk or vicryl usu. best for mucosal areas.
      • 2 simple interrupted sutures.
      • Out 7d face, 10d otw
    • Hemostasis
      • Chemical
      • Electrical
      • Physical
    • Chemical Hemostasis
      • Drysol
      • Aluminum Chloride
      • Quick, easy, cheap.
      • Q-tip application.
      • No odor or discoloration.
      • Good for superficial biopsy - shave.
    • Chemical Hemostasis
      • Monsel’s solution.
      • 20% ferric subsulfate.
      • Cheap, easy to use.
      • Risk of tattooing.
      • Superficial only!
      • Caustic, may destroy connective tissue if sutured into wound.
    • Electrosurgery
    • Electrosurgery- definitions
      • Electrosurgery- passing high frequency alternating current (AC) thru the tissue
      • Electrocautery- electrically heated metal element applied to tissue; transfers heat but does not transfer current thru tissue
      • Electrolysis- low direct current (DC) passed thru tissue b/w 2 electrodes; chemical reaction occurs @ one electrode
      • Diathermy- the process of heat production and tissue necrosis due to electrosurgery
      • Monoterminal= one connection b/w device and pt. (i.e. electrodessication, electrofulgration, epilation, hyfercation)
      • Biterminal= 2 contacts b/w device and pt. such as a ground plate (i.e. electrocoagulation, electrosection)
    • Electrodessication/Electrofulguration
      • Electrodessication – tip touches tissue
      • Electrofulguration – 1-2mm separation between tip and tissue
      • High voltage and low amperage limits depth of destruction
      • Monoterminal current – no grounding required
    • Electro-epilation
      • Follicular destruction
      • AKA Electrolysis
      • Chemical reaction at electrode tip causes production of sodium hydroxide (lye) at the hair root – works without scarring.
      • Takes 1 minute per follicle, very slow.
      • Largely replaced by laser hair removal.
    • Electrodessication
      • LOW POWER:
      • Facial telangiectasias
      • Syringomas
      • HIGH POWER:
      • SK, Skin Tags, VV
      • ED&C: BCC & SCC under 2 cm, 2-3 cycles
      • Hemostasis during excisional surgery.
    • Electrosection
      • “ Cutting Current”, Radio-Frequency Ablation
      • Biterminal current produced by vacuum tube is similar in form to radiowaves
      • Active electrode is cool
      • Tissue disruption occurs in response to the wave at the point of contact.
      • Minimal trauma, excellent hemostasis.
      • “ Custom” attachments: wire loops, balls, needles, scalpels.
      • i.e. tx of rhynophyma
    • Heated metal results in tissue dessication, coagulation and necrosis. Safe to use in patients with pacemakers. Does not require a dry field. THERMAL CAUTERY
    • Electrosurgery and pacemakers
      • Published debate
      • Standard of care tends to be use of only electrocautery
      • Most modern pacemakers operate in a demand mode, requiring sensing and output circuits which can be interupted by high frequency electrosurgery
    • Curettage
      • Round semi-sharp knife 0.5 to 10mm
      • Does not easily cut through normal dermis and will not enter the dermis
      • Best for soft friable lesions. Normal dermis feels gritty
      • Cancer lesion + 2-3mm margin
      • 2-3 cycles of ED&C
    • ED&C
    • Cryosurgery
      • Easy, heals quickly, minimal complications
      • Liquid nitrogen -195.6 degrees C
      • Rapid freezing, slow thaw increases cellular damage
      • Melanocytes are more sensitive to freezing than keratinocytes, may cause long lasting hyperpigmentation in darker complexions.
      • Very commonly used in treatment of AKs, verruca, acrochordons, SKs, etc. Occasionally for superficial skin CAs
    • Cryosurgery delivery systems
      • Cotton swabs
      • Cryospray
      • Cryoprobe (allows deeper freeze w/o lateral damage)
      • Cones
      • Thermacouples
    • Cryosurgery complications
      • Pain
      • HA
      • Syncope
      • Bleeding (2-3 wks p tx)
      • Edema
      • Abnormal scarring
      • Nerve damage (digital neuropathy)
      • Cartilage necrosis (ear)
      • Abnormal pigmantation
      • Alopecia
      • Notching (eyelid, nasal tip, ear rim, VB of lip)
      • Traumatic exfoliation ( if probe is not pre- chilled)
    • Classic atrophic hypopigmented cryosurgery scars……
    • Excisions- margins
      • BCC surgical margins
      • Less than 2cm diameter- 4mm margins
      • Greater than 2cm- MOHS
      • SCC surgical margins
      • 4mm margin
      • diameter <2cm in low risk anatomical areas
      • diameter <1cm in high risk area
      • 6mm margin
      • diameter >2cm in low risk areas
      • diameter > 1cm in high risk areas
    • Excisions- margins (cont’d)
      • Melanoma surgical margins
      • In situ
      • 0.5 cm border of clinically normal skin
      • <2mm
      • 1cm border of clinically normal skin
      • >2mm
      • 2-3cm margin
    • Mask Area of Face
      • Using felt tip pen mark a circle around lesion with recommended margins.
      • Ellipse should be 3 times longer than circle around lesion.
      • Try to position the final suture line within existing wrinkle lines/least tension.
    • Always consider the anatomy! Branches of the facial nerve
    • Facial Nerve Damage
      • Temporal branch -
      • Vulnerable as crosses mid zygoma lateral to eyebrow (don’t go below superficial fat)
      • forehead and eyebrow ptosis, may obstruct vision.
      • Zygomatic branch –
      • Vulnerable as crosses buccal fat pad
      • impaired blinking, eyes cannot close tightly
      • Buccal branch –
      • - drooping corner of mouth, difficulty chewing
      • Marginal Mandibular –
      • - Vulnerable @ angle of mandible, inf to parotid
      • - lower lip function, drooling
    • Anatomy a lecture in itself- nerves, arteries, veins, glandular structures
    • Excision: Instruments
      • Needle Holders
      • Forceps
      • Skin hooks
      • Scissors
    • Webster Gillies
    • BROWN ADSON FORCEPS – HEAVY TISSUES
    • CASTROVIEJO FORCEPS – DELICATE TISSUES
    •  
    • IDEAL FOR FLAPS, CUTTING THICK, LESS DELICATE TISSUE
    • Absorbable Suture
      • Gut (Chromic)
        • fast absorbing for surface closure as tensile strength is lost in days (FTSG)
        • Plain
      • Polyglycolic acid (Dexon)
      • Polyglactin 910 (Vicryl)
      • Polydiaxone (PDS)
      • Polytrimethylene carbonate (Maxon)
      • Poliglecaprone 25 (Monocryl)
    • Non Absorbable Suture
      • Silk (good for oral mucosa)
      • Nylon (Dermalon, Ethilon, Surgilon)
      • Polypropylene (Prolene, Surgilene)
      • Polyester (Dacron, Ethibond, Mersilene)
      • Polybutester (Novafil)
    • SIMPLE INTERRUPTED PRO: Good approximation of superficial tissues. CON: RR track scarring/time
    • VERTICAL MATTRESS PRO: Enhances wound eversion and decreases scarring CON: Time consuming
    • CORNER STITCH Helps avoid tip strangulation KEY: Be sure this is the last suture, not the first. Should be low tension.
    • HORIZONTAL MATTRESS PRO: Good for high tension wounds CON: Tends to cut into/strangulate tissues and higher risk dehiscence or scarring.
    • RUNNING
    • RUNNING, LOCKED
    • RUNNING HORIZONTAL MATTRESS
    • DEEP SUTURES
    • RUNNING SUBCUTANEOUS
    • RUNNING SUBCUTICULAR
    • Mohs Surgery
      • Frederick Mohs 1930 Fixed Tissue
      • Tromovitch 1970’s Frozen Tissue
      • Pros:
      • Cost effective outpatient surgery
      • Precise control of tumor margins
      • Allows smaller margins to be taken
      • Cosmetically sensitive areas- H zone
      • Not just for recurrent tumors anymore
      • 95-99% cure rates for recurrent and previously untreated tumors
      • Cons:
      • Labor intensive and time consuming
      • More expensive
    • Mohs
      • Excision of tumor in successive layers
      • Rapid frozen sections of tissues made
      • Microscopic evaluation of entire undersurface & margins of each layer
      • Results recorded on diagram
    • Mohs- indications
      • Recurrent or persistent tumor
      • Anatomic location
      • Embryonic fusion planes
      • Nasolabial folds
      • Columella of nose
      • Pre- auricular, post-auricular sulcus
      • Conservation of tissue impt.
      • eyelids, nose, lips, ears, genitalia
      • Size
      • >1cm on head
      • >2cm on trunk & extremities
      • Special considerations
      • Very young/ old
      • Immunocompromised
      • Unusual tumors
      • Pt or family anxiety
      • Poorly defined borders
      • Scar carcinoma
      • Major histo indications
      • BCC subtypes
      • Morpheaform
      • Adenoid
      • Superficial multifocal
      • Perineural
      • SCC subtypes
      • Poorly differentiated
      • Acantholytic
      • Perineural
      • Basosquamous
      • Microcystic Adenexal
      • DFSP
      • Merkel cell
      • Malignant fibrous histiocytoma
      • Lentigo maligna
    • Mohs
      • Rowe et al reviewed literature since 1947
      • 5 year recurrence rates primary BCC
      • Mohs 1%
      • Excision 10.1%
      • C&D 7.7%
      • XRT 8.7%
    • Mohs
      • Rowe et al cont’d
      • Primary SCC 5 year recurrence rates
      • Mohs 3.1%
      • Excision 8.1%
      • C&D 3.7%
      • XRT 10%
    • General Surgical Complications
      • Hematoma –
      • usu 24-48 hrs post-op
      • no evidence that ASA, NSAID or COUMADIN increases risk of hematoma
      • Open and evacuate clot if necessary
      • Gentle heat may facilitate reabsorption
      • Bleeding
      • Intraoperative control imperative
      • Post-op: dressings, minimize post-op movement/activities
      • ? d/c anticoagulants
      • Infection –
      • Main contamination period is peri-operative
      • Pain, warmth, erythema, swelling, D/C, fever, chills, malaise
      • Can culture, Irrigate, daily wound care, abx 7-10 days
      • Dehiscence – from infection, trauma, poor surgical technique, excessive movement
      • Necrosis – high tension in sutures or wound edges, poor flap design.
    • Avoiding Surgical Complications
      • Aseptic technique
      • Meticulous hemostasis
      • Wide undermining
      • Good surgical planning
    • A bit about flaps…
    • Advancement flaps
      • Primary movement is straight across the primary defect
      • Essentially a large ellipse/ fusiform closure
      • Types: O-H, O-T, V-Y, island pedicle
      • Locations:
      • -Unilateral- anywhere
      • -Bilateral- forehead, eyebrow, upper lip, upper nose, chin
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    • Rotation flaps
      • Primary movement is arc-like or rotary
      • Tension distributed away from primary defect to secondary defect
      • Tension decreased by increasing length
      • Recommended locations:
      • Scalp, forehead, chin, cheek
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    • Transposition flaps
      • Movement of flap results in crossing intervening skin to reach defect
      • Tension completely redirected from primary to secondary defect
      • Creates larger secondary defect than other flaps
      • Good for defects near free margin
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    • Cutaneous Laser Surgery
      • L ight A mplification by S timulated E mission of R adiation
      • Light limited to one WAVELENGTH
      • CHROMOPHORES are substances that preferentially absorb one WAVELENGTH
      • Examples: water, Hgb, melanin
      • HEAT created = “Selective Thermolysis”
    • Argon Laser
      • Vascular and pigmented lesions
      • 488 to 514 nm wavelength
      • These are NOT the wavelengths specific to Hgb and melanin, therefore damage to surrounding tissue significant, possibly leading to scarring and hypopigmentation.
      • Has fallen out of favor
    • Flashlamp Pumped Pulsed Dye
      • Port wine stains, telangiectasias
      • 585 nm wavelength
      • Low risk of scarring and pigment change
      • Black/gray discoloration due to intravascular coagulation.
    • Q switched Ruby
      • Melanin and darkly pigmented tattoo pigments (black, blue, green) targets
      • 694 nm wavelength
      • Q-switching allows delivery of extremely high energy at pulses that last only nanoseconds
      • Good for deep pigment, ie. Nevus of Ota
      • Minimal scarring, transient hypopigmentation
    • Neodynium:Yttrium-Aluminum-Garnet (Nd:YAG)
      • 1064 wavelength
      • Continuous mode – PWS, venous malformations
      • Q-switched mode – black, blue tattoos
      • Frequency doubled 532 - red tattoo, vascular, superficial pigmented
    • KTP: Potassium Titanyl Phosphate
      • 532 nm wavelength
      • Vascular and superficial pigmented.
      • Significant Hgb and melanin absorption
    • Q-Switched Alexandrite
      • 755 nm wavelength
      • Absorbed by deep dark pigment ie., blue, black and green tatoo pigment
    • IPL: Intense Pulsed Light
      • Continuous spectrum 515 - 1200nm
      • Extremely versatile
      • Rosacea
      • Telangiectasias
      • Spotty discoloration
    • Carbon Dioxide
      • 10,600 nm wavelength, H2O chromophore
      • Super-pulsed allows destruction of epidermis and papillary dermis while limiting deeper damage.
      • Can actually see it tighten the collagen
      • Excellent for photodamage, rhytids
      • Lots of down time, side effects.
    • Erbium:Yttrium-Al-Garnet Er:YAG
      • 2940 nm wavelength
      • Ablative, but with less thermal damage than the CO2 laser
      • Ideal for treating very early photodamage (superficial), but will never tighten collagen as well as the CO2