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

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

  1. 1. DermatologicDermatologic SurgerySurgery Kristy P. Gilbert, D.O.Kristy P. Gilbert, D.O. November 1, 2005November 1, 2005
  2. 2. IntroductionIntroduction  Derm surgery increasing in complexityDerm surgery increasing in complexity  Aesthetic and Laser proceduresAesthetic and Laser procedures  Plastic surgery – blepharoplasty, facelifts,Plastic surgery – blepharoplasty, facelifts, liposuctionliposuction  Mohs micrographic surgeryMohs micrographic surgery  Increasing emphasis on patient safety,Increasing emphasis on patient safety, documentation, and accreditation.documentation, and accreditation.
  3. 3. Basics: Pre-Op EvaluationBasics: Pre-Op Evaluation  Drug AllergiesDrug Allergies  Meds: Coumadin, Plavix, ASA.Meds: Coumadin, Plavix, ASA.  Pacemaker? Defibrillator?Pacemaker? Defibrillator?  MVP, Endocarditis, Prosthetics?MVP, Endocarditis, Prosthetics?  Informed Consent, photographic consent, risksInformed Consent, photographic consent, risks v. benefits and options must all be discussed &v. benefits and options must all be discussed & signedsigned  OTC and Herbals…..OTC and Herbals…..
  4. 4. Past Medical History….Past Medical History….
  5. 5. Past medical historyPast medical history  Factors that will affect wound healingFactors that will affect wound healing  Prophylactic antibioticsProphylactic antibiotics  Risks for scarringRisks for scarring  Risks for bleedingRisks for bleeding
  6. 6. Factors that will affect woundFactors that will affect wound healinghealing  Advanced ageAdvanced age  Nutritional statusNutritional status  DiabetesDiabetes  Immunosuppressive drugsImmunosuppressive drugs  SmokingSmoking  Critically ill patients, HIVCritically ill patients, HIV  Atherosclerosis, PVDAtherosclerosis, PVD
  7. 7. Prophylactic AntibioticsProphylactic Antibiotics  Contaminated or “dirty” wounds benefit, not cleanContaminated or “dirty” wounds benefit, not clean woundswounds  IndicationsIndications - ear, nose mouth, hand foot, axilla, genitalia (“dirty”ear, nose mouth, hand foot, axilla, genitalia (“dirty” areas)areas) -- Artificial Heart ValveArtificial Heart Valve -- Artificial Joint Replacement < 6 monthsArtificial Joint Replacement < 6 months -- Past history Endocarditis, Rheumatic FeverPast history Endocarditis, Rheumatic Fever - Mitral Valve Prolapse WITH holosystolic murmurMitral Valve Prolapse WITH holosystolic murmur - ImmunocompromisedImmunocompromised
  8. 8. Antibiotic Prophylaxis:Antibiotic Prophylaxis:  Standard: administer 1 hour pre-op and 6 hrsStandard: administer 1 hour pre-op and 6 hrs post-oppost-op  Keflex: 1gm po pre-op, 500mg po post-opKeflex: 1gm po pre-op, 500mg po post-op  Dicloxicillin: 1gm po pre, 500mg po postDicloxicillin: 1gm po pre, 500mg po post  Clindamycin 300mg po pre, 150mg po postClindamycin 300mg po pre, 150mg po post
  9. 9. Risks for scarringRisks for scarring  Location: upper chest, back, shoulders,Location: upper chest, back, shoulders, extremitiesextremities  Personal hx scarring: i.e. keloids, hypertrophicPersonal hx scarring: i.e. keloids, hypertrophic scarsscars  Medications: isotretinoin in past 12 mo. OrMedications: isotretinoin in past 12 mo. Or Vitamin A or E useVitamin A or E use
  10. 10. ASA/NSAID containing drugsASA/NSAID containing drugs  There are about 160 of themThere are about 160 of them  Most are OTCMost are OTC  Patients don’t think of these as drugsPatients don’t think of these as drugs because they are not prescriptions.because they are not prescriptions.
  11. 11. ASA/NSAID containing drugsASA/NSAID containing drugs  AspirinAspirin - Irreversibly acetylates platelet COX reducing PGIrreversibly acetylates platelet COX reducing PG and thromboxane A2 synthesis thereforeand thromboxane A2 synthesis therefore platelets inhibited for their lifetime (7-10days)platelets inhibited for their lifetime (7-10days) - For this reason, must be D/Ced 7-10 d pre-opFor this reason, must be D/Ced 7-10 d pre-op  NSAIDsNSAIDs - Reversibly inhibit COX therefore less clinical- Reversibly inhibit COX therefore less clinical effecteffect
  12. 12. Other drugs affecting plateletsOther drugs affecting platelets  ProductionProduction - Myelosuppressive agents, ethanol, estrogens,Myelosuppressive agents, ethanol, estrogens, thiazidesthiazides  DestructionDestruction - Abx: sulfathiazole; quinine, ASA, dig,Abx: sulfathiazole; quinine, ASA, dig, methyldopamethyldopa  FunctionFunction - ASA, dipyridamole, ethanol, heparin, NSAIDS,- ASA, dipyridamole, ethanol, heparin, NSAIDS, plavix, ticlopidine, herbal supplementsplavix, ticlopidine, herbal supplements
  13. 13. Herbal Supplements thatHerbal Supplements that inhibit coagulation….inhibit coagulation….  MOST COMMON: Fish Oils, Garlic, Gingko,MOST COMMON: Fish Oils, Garlic, Gingko, Ginseng, Chinese Herbal/Green Teas, VitaminGinseng, Chinese Herbal/Green Teas, Vitamin EE  Alfalfa, Capsicum, Celery, Chamomile, DongAlfalfa, Capsicum, Celery, Chamomile, Dong quai, Fenugreek, Feverfew, Ginger, Horseradish,quai, Fenugreek, Feverfew, Ginger, Horseradish, Huang qui, Kava kava, Licorice, Passionflower,Huang qui, Kava kava, Licorice, Passionflower, Red Clover.Red Clover.  Dermatol Surg 28: June 2002, 449Dermatol Surg 28: June 2002, 449
  14. 14. Local AnesthesiaLocal Anesthesia
  15. 15. Local anesthesiaLocal anesthesia  Ideal propertiesIdeal properties - Rapid onsetRapid onset - Long duration of actionLong duration of action - Lack of toxicityLack of toxicity - Water solubilityWater solubility  Structure & functionStructure & function - Aromatic portion= lipophilic= potencyAromatic portion= lipophilic= potency - Amine= hydrophilic= solubilityAmine= hydrophilic= solubility - Intermediate chain- determines class: i.e. ester, amide AND mostIntermediate chain- determines class: i.e. ester, amide AND most importantly- this determines route of excretion and metabolismimportantly- this determines route of excretion and metabolism - MOA = blocks movement of Na+ influx across membraneMOA = blocks movement of Na+ influx across membrane thereby blocking depolarizationthereby blocking depolarization
  16. 16. Local Anesthesia CategoriesLocal Anesthesia Categories  Esthers:Esthers: - Procaine (novocaine)Procaine (novocaine) - Chloroprocaine (nesacaine)Chloroprocaine (nesacaine) - CocaineCocaine - TetracaineTetracaine - BenzocaineBenzocaine  AmidesAmides -Lidocaine (xylocaine)-Lidocaine (xylocaine) - Mepivacaine (carbocaine)Mepivacaine (carbocaine) - Prilocaine (citanest)Prilocaine (citanest) - Etidocaine(durantest)Etidocaine(durantest) - Bupivicaine (marcaine) = the LONGEST actingBupivicaine (marcaine) = the LONGEST acting - NupercaineNupercaine
  17. 17. ““I’m allergic to Novacaine”I’m allergic to Novacaine”  Pearl: It is OK to give Xylocaine to patientsPearl: It is OK to give Xylocaine to patients who had allergic reactions to Novocaine at thewho had allergic reactions to Novocaine at the dentist’s office, Lidocaine is an Amide anddentist’s office, Lidocaine is an Amide and Novocaine is an Ester.Novocaine is an Ester.  Pitfall: They may not know which medicationPitfall: They may not know which medication they reacted to: use Bacteriostatic NS orthey reacted to: use Bacteriostatic NS or diphenhydramine when in doubt.diphenhydramine when in doubt.  Esters>>>amidesEsters>>>amides
  18. 18. Local AnesthesiaLocal Anesthesia  Pearl: fears of epinephrine induced necrosis at distalPearl: fears of epinephrine induced necrosis at distal sites (nose, ears, penis, toes, fingertips) are largelysites (nose, ears, penis, toes, fingertips) are largely unfounded.unfounded.  Pitfalls: patients with severe peripheral vascular disease,Pitfalls: patients with severe peripheral vascular disease, diabetic angiopathy and Raynaud’s phenomenon maydiabetic angiopathy and Raynaud’s phenomenon may be exceptions to the rule.be exceptions to the rule.  Contraindications to epinephrine in anesthsia:Contraindications to epinephrine in anesthsia: -severe HTN, pheochromocytoma, HyperTH, severe-severe HTN, pheochromocytoma, HyperTH, severe vascular ds, bradycardia “ABSOLUTE”vascular ds, bradycardia “ABSOLUTE” -pregnancy, MAO inhibitors, narrow angle glaucoma-pregnancy, MAO inhibitors, narrow angle glaucoma “RELATIVE”“RELATIVE”
  19. 19. Local anesthesiaLocal anesthesia  Maximum dosageMaximum dosage - 1% lidocaine w/ epi 1:100,000 is 10mg of1% lidocaine w/ epi 1:100,000 is 10mg of lidocaine per 1cc of mixturelidocaine per 1cc of mixture Adult= 7mg/kg = 500mg/ 70kg (50cc)Adult= 7mg/kg = 500mg/ 70kg (50cc) Child = 3-4.5mg/kgChild = 3-4.5mg/kg - 1% lidocaine w/o epi1% lidocaine w/o epi Adult= 4.5mg/kg = 300mg/70kg (30cc)Adult= 4.5mg/kg = 300mg/70kg (30cc) Child= 1-2 mg/kgChild= 1-2 mg/kg
  20. 20.  Insert needle at a 30 degree angle and slowly retract the needle as youInsert 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.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,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 anesthetisedeach re-stick should be into an area that has already been anesthetised
  21. 21. Pain ControlPain Control  Local Anesthesia:Local Anesthesia:  INJECT SLOWLY: Decreases pain more thanINJECT SLOWLY: Decreases pain more than warming or adding bicarbonate.warming or adding bicarbonate.  Distraction techniques useful as well – pinchingDistraction techniques useful as well – pinching skin during injection, vibrating pen, etc.skin during injection, vibrating pen, etc.  For pediatric patients, let them sit in the lobbyFor pediatric patients, let them sit in the lobby with ELA-Max or EMLA under occlusion forwith ELA-Max or EMLA under occlusion for 30 min.- 1 hr. Your eardrums will thank you.30 min.- 1 hr. Your eardrums will thank you.
  22. 22. Surgical CleansersSurgical Cleansers  Clean Procedures:Clean Procedures:  Isopropyl alcoholIsopropyl alcohol  weak antimicrobialweak antimicrobial  most commonly used agent for shave biopsiesmost commonly used agent for shave biopsies  Hydrogen peroxideHydrogen peroxide  no significant antiseptic propertiesno significant antiseptic properties  not suitable for sterile proceduresnot suitable for sterile procedures
  23. 23. Surgical Cleansers: SterileSurgical Cleansers: Sterile  BetadineBetadine  irritating to skin, residual colorirritating to skin, residual color  must dry completely to be antimicrobialmust dry completely to be antimicrobial  absorbed by premature infantsabsorbed by premature infants  Chlorhexidine (Hibiclens)Chlorhexidine (Hibiclens)  keratitis if it gets in the eyeskeratitis if it gets in the eyes  Hexachlorophene (pHisoHex)Hexachlorophene (pHisoHex)  not on women or children due to neurotoxicity andnot on women or children due to neurotoxicity and teratogenicityteratogenicity
  24. 24. Common ProceduresCommon Procedures  Shave BiopsyShave Biopsy  Punch BiopsyPunch Biopsy  Excisional BiopsyExcisional Biopsy  CryosurgeryCryosurgery
  25. 25. Shave biopsyShave biopsy  Best suited to pedunculated, papular orBest suited to pedunculated, papular or otherwise elevated lesions but may be used forotherwise elevated lesions but may be used for macular lesions.macular lesions.  SimpleSimple  QuickQuick  Satisfactory cosmetic resultSatisfactory cosmetic result  Adequate biopsy tissue for diagnosisAdequate biopsy tissue for diagnosis
  26. 26. Shave BiopsyShave Biopsy  Sterile #15 bladeSterile #15 blade  4x4’s4x4’s  Drysol solutionDrysol solution  Sterile Q-tipsSterile Q-tips  Path containerPath container  Gillette Blue BladeGillette Blue Blade Razor cut in half, bendsRazor cut in half, bends to follow contourto follow contour
  27. 27. Shave Biopsy - skin tensionShave Biopsy - skin tension
  28. 28. Shave Biopsy - flush w/ surfaceShave Biopsy - flush w/ surface
  29. 29. Endpoint is “pinpoint bleeding”Endpoint is “pinpoint bleeding” Indicates you are at the level of theIndicates you are at the level of the papillary dermis, minimal scarringpapillary dermis, minimal scarring
  30. 30.  Stay superficial for minimal scarring.Stay superficial for minimal scarring.  Pink atrophic area has a full year to heal.Pink atrophic area has a full year to heal.  Upper chest and back scars no matter what youUpper chest and back scars no matter what you do.do.
  31. 31. Punch BiopsyPunch Biopsy  Most common use is for skin biopsyMost common use is for skin biopsy  Can excise small lesionsCan excise small lesions  Treats acne scarsTreats acne scars  Hair transplantationHair transplantation  May stretch skin perpendicular to skin tensionMay stretch skin perpendicular to skin tension lines to create elliptical defect and avoid “doglines to create elliptical defect and avoid “dog ears”ears”
  32. 32. Punch BiopsyPunch Biopsy  Sterile OR cleanSterile OR clean procedureprocedure  3 or 4 mm punch is3 or 4 mm punch is standardstandard  4x4s, Drysol, Q-tips4x4s, Drysol, Q-tips  Needle driver, forcepsNeedle driver, forceps  SutureSuture  Path specimen bottlePath specimen bottle
  33. 33. Punch BiopsyPunch Biopsy  Twist punch tool untilTwist punch tool until buried to the hub*buried to the hub*  *Caveat: Have a firm*Caveat: Have a firm grasp of anatomy andgrasp of anatomy and skin thickness in the areaskin thickness in the area you are punching beforeyou are punching before you punch it.you punch it.  Finger tendons, facialFinger tendons, facial and neck structures.and neck structures.
  34. 34. Punch biopsyPunch biopsy  KEY: do not crush tissue when removing itKEY: do not crush tissue when removing it from the biopsy site.from the biopsy site.  Crush artifact makes pathologic interpretationCrush artifact makes pathologic interpretation difficult to impossible.difficult to impossible.  Some pull it out using the suture needle as thisSome pull it out using the suture needle as this method is atraumatic.method is atraumatic.
  35. 35. Punch BiopsyPunch Biopsy  Use 5-0 or 6-0Use 5-0 or 6-0 nylon/Prolene on thenylon/Prolene on the face.face.  4-0 nylon/Prolene most4-0 nylon/Prolene most other areas.other areas.  Silk or vicryl usu. bestSilk or vicryl usu. best for mucosal areas.for mucosal areas.  2 simple interrupted2 simple interrupted sutures.sutures.  Out 7d face, 10d otwOut 7d face, 10d otw
  36. 36. HemostasisHemostasis  ChemicalChemical  ElectricalElectrical  PhysicalPhysical
  37. 37. Chemical HemostasisChemical Hemostasis  DrysolDrysol  Aluminum ChlorideAluminum Chloride  Quick, easy, cheap.Quick, easy, cheap.  Q-tip application.Q-tip application.  No odor orNo odor or discoloration.discoloration.  Good for superficialGood for superficial biopsy - shave.biopsy - shave.
  38. 38. Chemical HemostasisChemical Hemostasis  Monsel’s solution.Monsel’s solution.  20% ferric subsulfate.20% ferric subsulfate.  Cheap, easy to use.Cheap, easy to use.  Risk of tattooing.Risk of tattooing.  Superficial only!Superficial only!  Caustic, may destroyCaustic, may destroy connective tissue ifconnective tissue if sutured into wound.sutured into wound.
  39. 39. ElectrosurgeryElectrosurgery
  40. 40. Electrosurgery- definitionsElectrosurgery- definitions  Electrosurgery- passing high frequency alternating current (AC)Electrosurgery- passing high frequency alternating current (AC) thru the tissuethru the tissue  Electrocautery- electrically heated metal element applied toElectrocautery- electrically heated metal element applied to tissue; transfers heat but does not transfer current thru tissuetissue; transfers heat but does not transfer current thru tissue  Electrolysis- low direct current (DC) passed thru tissue b/w 2Electrolysis- low direct current (DC) passed thru tissue b/w 2 electrodes; chemical reaction occurs @ one electrodeelectrodes; chemical reaction occurs @ one electrode  Diathermy- the process of heat production and tissue necrosisDiathermy- the process of heat production and tissue necrosis due to electrosurgerydue to electrosurgery  Monoterminal= one connection b/w device and pt. (i.e.Monoterminal= one connection b/w device and pt. (i.e. electrodessication, electrofulgration, epilation, hyfercation)electrodessication, electrofulgration, epilation, hyfercation)  Biterminal= 2 contacts b/w device and pt. such as a ground plateBiterminal= 2 contacts b/w device and pt. such as a ground plate (i.e. electrocoagulation, electrosection)(i.e. electrocoagulation, electrosection)
  41. 41. Electrodessication/ElectrofulgurationElectrodessication/Electrofulguration  Electrodessication – tip touches tissueElectrodessication – tip touches tissue  Electrofulguration – 1-2mm separation betweenElectrofulguration – 1-2mm separation between tip and tissuetip and tissue  High voltage and low amperage limits depth ofHigh voltage and low amperage limits depth of destructiondestruction  Monoterminal current – no grounding requiredMonoterminal current – no grounding required
  42. 42. Electro-epilationElectro-epilation  Follicular destructionFollicular destruction  AKA ElectrolysisAKA Electrolysis  Chemical reaction at electrode tip causesChemical reaction at electrode tip causes production of sodium hydroxide (lye) at the hairproduction of sodium hydroxide (lye) at the hair root – works without scarring.root – works without scarring.  Takes 1 minute per follicle, very slow.Takes 1 minute per follicle, very slow.  Largely replaced by laser hair removal.Largely replaced by laser hair removal.
  43. 43. ElectrodessicationElectrodessication  LOW POWER:LOW POWER:  Facial telangiectasiasFacial telangiectasias  SyringomasSyringomas  HIGH POWER:HIGH POWER:  SK, Skin Tags, VVSK, Skin Tags, VV  ED&C: BCC & SCC under 2 cm, 2-3 cyclesED&C: BCC & SCC under 2 cm, 2-3 cycles  Hemostasis during excisional surgery.Hemostasis during excisional surgery.
  44. 44. ElectrosectionElectrosection  ““Cutting Current”, Radio-Frequency AblationCutting Current”, Radio-Frequency Ablation  Biterminal current produced by vacuum tube is similarBiterminal current produced by vacuum tube is similar in form to radiowavesin form to radiowaves  Active electrode is coolActive electrode is cool  Tissue disruption occurs in response to the wave at theTissue disruption occurs in response to the wave at the point of contact.point of contact.  Minimal trauma, excellent hemostasis.Minimal trauma, excellent hemostasis.  ““Custom” attachments: wire loops, balls, needles,Custom” attachments: wire loops, balls, needles, scalpels.scalpels.  i.e. tx of rhynophymai.e. tx of rhynophyma
  45. 45. Heated metal resultsHeated metal results in tissue dessication,in tissue dessication, coagulation and necrosis.coagulation and necrosis. Safe to use in patients withSafe to use in patients with pacemakers.pacemakers. Does not require a dry field.Does not require a dry field. THERMAL CAUTERY
  46. 46. Electrosurgery and pacemakersElectrosurgery and pacemakers  Published debatePublished debate  Standard of care tends to be use of onlyStandard of care tends to be use of only electrocauteryelectrocautery  Most modern pacemakers operate in a demandMost modern pacemakers operate in a demand mode, requiring sensing and output circuitsmode, requiring sensing and output circuits which can be interupted by high frequencywhich can be interupted by high frequency electrosurgeryelectrosurgery
  47. 47. CurettageCurettage  Round semi-sharp knife 0.5 to 10mmRound semi-sharp knife 0.5 to 10mm  Does not easily cut through normal dermis andDoes not easily cut through normal dermis and will not enter the dermiswill not enter the dermis  Best for soft friable lesions. Normal dermisBest for soft friable lesions. Normal dermis feels grittyfeels gritty  Cancer lesion + 2-3mm marginCancer lesion + 2-3mm margin  2-3 cycles of ED&C2-3 cycles of ED&C
  48. 48. ED&CED&C
  49. 49. CryosurgeryCryosurgery  Easy, heals quickly, minimal complicationsEasy, heals quickly, minimal complications  Liquid nitrogen -195.6 degrees CLiquid nitrogen -195.6 degrees C  Rapid freezing, slow thaw increases cellularRapid freezing, slow thaw increases cellular damagedamage  Melanocytes are more sensitive to freezing thanMelanocytes are more sensitive to freezing than keratinocytes, may cause long lastingkeratinocytes, may cause long lasting hyperpigmentation in darker complexions.hyperpigmentation in darker complexions.  Very commonly used in treatment of AKs,Very commonly used in treatment of AKs, verruca, acrochordons, SKs, etc. Occasionallyverruca, acrochordons, SKs, etc. Occasionally for superficial skin CAsfor superficial skin CAs
  50. 50. Cryosurgery delivery systemsCryosurgery delivery systems  Cotton swabsCotton swabs  CryosprayCryospray  Cryoprobe (allowsCryoprobe (allows deeper freeze w/o lateraldeeper freeze w/o lateral damage)damage)  ConesCones  ThermacouplesThermacouples
  51. 51. Cryosurgery complicationsCryosurgery complications  PainPain  HAHA  SyncopeSyncope  Bleeding (2-3 wks p tx)Bleeding (2-3 wks p tx)  EdemaEdema  Abnormal scarringAbnormal scarring  Nerve damage (digitalNerve damage (digital neuropathy)neuropathy)  Cartilage necrosis (ear)Cartilage necrosis (ear)  Abnormal pigmantationAbnormal pigmantation  AlopeciaAlopecia  Notching (eyelid, nasalNotching (eyelid, nasal tip, ear rim, VB of lip)tip, ear rim, VB of lip)  Traumatic exfoliation ( ifTraumatic exfoliation ( if probe is not pre- chilled)probe is not pre- chilled)
  52. 52. Classic atrophic hypopigmentedClassic atrophic hypopigmented cryosurgery scars……cryosurgery scars……
  53. 53. Excisions- marginsExcisions- margins  BCC surgical marginsBCC surgical margins - Less than 2cm diameter- 4mm marginsLess than 2cm diameter- 4mm margins - Greater than 2cm- MOHSGreater than 2cm- MOHS  SCC surgical marginsSCC surgical margins - 4mm margin4mm margin diameter <2cm in low risk anatomical areasdiameter <2cm in low risk anatomical areas diameter <1cm in high risk areadiameter <1cm in high risk area - 6mm margin6mm margin diameter >2cm in low risk areasdiameter >2cm in low risk areas diameter > 1cm in high risk areasdiameter > 1cm in high risk areas
  54. 54. Excisions- margins (cont’d)Excisions- margins (cont’d)  Melanoma surgical marginsMelanoma surgical margins - In situIn situ 0.5 cm border of clinically normal skin0.5 cm border of clinically normal skin - <2mm<2mm 1cm border of clinically normal skin1cm border of clinically normal skin - >2mm>2mm 2-3cm margin2-3cm margin
  55. 55. Mask Area of FaceMask Area of Face
  56. 56.  Using felt tip penUsing felt tip pen mark a circlemark a circle around lesionaround lesion withwith recommendedrecommended margins.margins.  Ellipse should beEllipse should be 3 times longer3 times longer than circlethan circle around lesion.around lesion.
  57. 57.  Try to position the final suture line withinTry to position the final suture line within existing wrinkle lines/least tension.existing wrinkle lines/least tension.
  58. 58. Always consider the anatomy!Always consider the anatomy! Branches of the facial nerve
  59. 59. Facial Nerve DamageFacial Nerve Damage  Temporal branch -Temporal branch - - Vulnerable as crosses mid zygoma lateral to eyebrow (don’t goVulnerable as crosses mid zygoma lateral to eyebrow (don’t go below superficial fat)below superficial fat) - forehead and eyebrow ptosis, may obstruct vision.forehead and eyebrow ptosis, may obstruct vision.  Zygomatic branch –Zygomatic branch – - Vulnerable as crosses buccal fat padVulnerable as crosses buccal fat pad - impaired blinking, eyes cannot close tightlyimpaired blinking, eyes cannot close tightly  Buccal branch –Buccal branch – -- drooping corner of mouth, difficulty chewingdrooping corner of mouth, difficulty chewing  Marginal Mandibular –Marginal Mandibular – -- Vulnerable @ angle of mandible, inf to parotidVulnerable @ angle of mandible, inf to parotid -- lower lip function, droolinglower lip function, drooling
  60. 60. AnatomyAnatomy a lecture in itself- nerves, arteries, veins, glandular structuresa lecture in itself- nerves, arteries, veins, glandular structures
  61. 61. Excision: InstrumentsExcision: Instruments  Needle HoldersNeedle Holders  ForcepsForceps  Skin hooksSkin hooks  ScissorsScissors
  62. 62. WebsterWebster GilliesGillies
  63. 63. BROWN ADSON FORCEPS – HEAVY TISSUES
  64. 64. CASTROVIEJO FORCEPS – DELICATE TISSUES
  65. 65. IDEAL FOR FLAPS, CUTTING THICK, LESS DELICATE TISSUE
  66. 66. Absorbable SutureAbsorbable Suture  Gut (Chromic)Gut (Chromic)  fast absorbing for surface closure as tensile strengthfast absorbing for surface closure as tensile strength is lost in days (FTSG)is lost in days (FTSG)  PlainPlain  Polyglycolic acid (Dexon)Polyglycolic acid (Dexon)  Polyglactin 910 (Vicryl)Polyglactin 910 (Vicryl)  Polydiaxone (PDS)Polydiaxone (PDS)  Polytrimethylene carbonate (Maxon)Polytrimethylene carbonate (Maxon)  Poliglecaprone 25 (Monocryl)Poliglecaprone 25 (Monocryl)
  67. 67. Non Absorbable SutureNon Absorbable Suture  Silk (good for oral mucosa)Silk (good for oral mucosa)  Nylon (Dermalon, Ethilon, Surgilon)Nylon (Dermalon, Ethilon, Surgilon)  Polypropylene (Prolene, Surgilene)Polypropylene (Prolene, Surgilene)  Polyester (Dacron, Ethibond, Mersilene)Polyester (Dacron, Ethibond, Mersilene)  Polybutester (Novafil)Polybutester (Novafil)
  68. 68. SIMPLE INTERRUPTEDSIMPLE INTERRUPTED PRO: Good approximation of superficial tissues.PRO: Good approximation of superficial tissues. CON: RR track scarring/timeCON: RR track scarring/time
  69. 69. VERTICAL MATTRESSVERTICAL MATTRESS PRO: Enhances wound eversion and decreases scarringPRO: Enhances wound eversion and decreases scarring CON: Time consumingCON: Time consuming
  70. 70. CORNER STITCHCORNER STITCH Helps avoid tip strangulationHelps avoid tip strangulation KEY: Be sure this is the last suture, not the first. ShouldKEY: Be sure this is the last suture, not the first. Should be low tension.be low tension.
  71. 71. HORIZONTAL MATTRESSHORIZONTAL MATTRESS PRO: Good for high tension woundsPRO: Good for high tension wounds CON: Tends to cut into/strangulate tissues andCON: Tends to cut into/strangulate tissues and higher risk dehiscence or scarring.higher risk dehiscence or scarring.
  72. 72. RUNNINGRUNNING
  73. 73. RUNNING, LOCKEDRUNNING, LOCKED
  74. 74. RUNNING HORIZONTALRUNNING HORIZONTAL MATTRESSMATTRESS
  75. 75. DEEP SUTURESDEEP SUTURES
  76. 76. RUNNING SUBCUTANEOUSRUNNING SUBCUTANEOUS
  77. 77. RUNNING SUBCUTICULARRUNNING SUBCUTICULAR
  78. 78. Mohs SurgeryMohs Surgery Frederick Mohs 1930 Fixed TissueFrederick Mohs 1930 Fixed Tissue Tromovitch 1970’s Frozen TissueTromovitch 1970’s Frozen Tissue  Pros:Pros: Cost effective outpatient surgeryCost effective outpatient surgery Precise control of tumor marginsPrecise control of tumor margins Allows smaller margins to be takenAllows smaller margins to be taken Cosmetically sensitive areas- H zoneCosmetically sensitive areas- H zone Not just for recurrent tumors anymoreNot just for recurrent tumors anymore 95-99% cure rates for recurrent and previously untreated tumors95-99% cure rates for recurrent and previously untreated tumors  Cons:Cons: Labor intensive and time consumingLabor intensive and time consuming More expensiveMore expensive
  79. 79. MohsMohs  Excision of tumor in successive layersExcision of tumor in successive layers  Rapid frozen sections of tissues madeRapid frozen sections of tissues made  Microscopic evaluation of entire undersurface &Microscopic evaluation of entire undersurface & margins of each layermargins of each layer  Results recorded on diagramResults recorded on diagram
  80. 80. Mohs- indicationsMohs- indications  Recurrent or persistent tumorRecurrent or persistent tumor  Anatomic locationAnatomic location - Embryonic fusion planesEmbryonic fusion planes - Nasolabial foldsNasolabial folds - Columella of noseColumella of nose - Pre- auricular, post-auricular sulcusPre- auricular, post-auricular sulcus  Conservation of tissue impt.Conservation of tissue impt. - eyelids, nose, lips, ears, genitaliaeyelids, nose, lips, ears, genitalia  SizeSize - >1cm on head>1cm on head - >2cm on trunk & extremities>2cm on trunk & extremities  Special considerationsSpecial considerations - Very young/ oldVery young/ old - ImmunocompromisedImmunocompromised - Unusual tumorsUnusual tumors - Pt or family anxietyPt or family anxiety - Poorly defined bordersPoorly defined borders - Scar carcinomaScar carcinoma  Major histo indicationsMajor histo indications  BCC subtypesBCC subtypes - MorpheaformMorpheaform - AdenoidAdenoid - Superficial multifocalSuperficial multifocal - PerineuralPerineural  SCC subtypesSCC subtypes - Poorly differentiatedPoorly differentiated - AcantholyticAcantholytic - PerineuralPerineural  BasosquamousBasosquamous  Microcystic AdenexalMicrocystic Adenexal  DFSPDFSP  Merkel cellMerkel cell  Malignant fibrous histiocytomaMalignant fibrous histiocytoma  Lentigo malignaLentigo maligna
  81. 81. MohsMohs  Rowe et al reviewed literature since 1947Rowe et al reviewed literature since 1947  5 year recurrence rates primary BCC5 year recurrence rates primary BCC  MohsMohs 1%1%  ExcisionExcision 10.1%10.1%  C&DC&D 7.7%7.7%  XRTXRT 8.7%8.7%
  82. 82. MohsMohs  Rowe et al cont’dRowe et al cont’d  Primary SCC 5 year recurrence ratesPrimary SCC 5 year recurrence rates  MohsMohs 3.1%3.1%  ExcisionExcision 8.1%8.1%  C&DC&D 3.7%3.7%  XRTXRT 10%10%
  83. 83. General Surgical ComplicationsGeneral Surgical Complications  Hematoma –Hematoma – - usu 24-48 hrs post-opusu 24-48 hrs post-op - no evidence that ASA, NSAID or COUMADIN increases risk of hematomano evidence that ASA, NSAID or COUMADIN increases risk of hematoma - Open and evacuate clot if necessaryOpen and evacuate clot if necessary - Gentle heat may facilitate reabsorptionGentle heat may facilitate reabsorption  BleedingBleeding - Intraoperative control imperativeIntraoperative control imperative - Post-op: dressings, minimize post-op movement/activitiesPost-op: dressings, minimize post-op movement/activities - ? d/c anticoagulants? d/c anticoagulants  Infection –Infection – - Main contamination period is peri-operativeMain contamination period is peri-operative - Pain, warmth, erythema, swelling, D/C, fever, chills, malaisePain, warmth, erythema, swelling, D/C, fever, chills, malaise - Can culture, Irrigate, daily wound care, abx 7-10 daysCan culture, Irrigate, daily wound care, abx 7-10 days  Dehiscence – from infection, trauma, poor surgical technique, excessiveDehiscence – from infection, trauma, poor surgical technique, excessive movementmovement  Necrosis – high tension in sutures or wound edges, poor flap design.Necrosis – high tension in sutures or wound edges, poor flap design.
  84. 84. Avoiding Surgical ComplicationsAvoiding Surgical Complications  Aseptic techniqueAseptic technique  Meticulous hemostasisMeticulous hemostasis  Wide underminingWide undermining  Good surgical planningGood surgical planning
  85. 85. A bit about flaps…A bit about flaps…
  86. 86. Advancement flapsAdvancement flaps  Primary movement is straight across the primaryPrimary movement is straight across the primary defectdefect  Essentially a large ellipse/ fusiform closureEssentially a large ellipse/ fusiform closure  Types: O-H, O-T, V-Y, island pedicleTypes: O-H, O-T, V-Y, island pedicle  Locations:Locations: -Unilateral- anywhere-Unilateral- anywhere -Bilateral- forehead, eyebrow, upper lip, upper-Bilateral- forehead, eyebrow, upper lip, upper nose, chinnose, chin
  87. 87. Rotation flapsRotation flaps  Primary movement is arc-like or rotaryPrimary movement is arc-like or rotary  Tension distributed away from primary defect toTension distributed away from primary defect to secondary defectsecondary defect  Tension decreased by increasing lengthTension decreased by increasing length  Recommended locations:Recommended locations:  Scalp, forehead, chin, cheekScalp, forehead, chin, cheek
  88. 88. Transposition flapsTransposition flaps  Movement of flap results in crossing interveningMovement of flap results in crossing intervening skin to reach defectskin to reach defect  Tension completely redirected from primary toTension completely redirected from primary to secondary defectsecondary defect  Creates larger secondary defect than other flapsCreates larger secondary defect than other flaps  Good for defects near free marginGood for defects near free margin
  89. 89. Cutaneous Laser SurgeryCutaneous Laser Surgery  LLightight AAmplification bymplification by SStimulatedtimulated EEmission ofmission of RRadiationadiation  Light limited to one WAVELENGTHLight limited to one WAVELENGTH  CHROMOPHORES are substances thatCHROMOPHORES are substances that preferentially absorb one WAVELENGTHpreferentially absorb one WAVELENGTH  Examples: water, Hgb, melaninExamples: water, Hgb, melanin  HEAT created = “Selective Thermolysis”HEAT created = “Selective Thermolysis”
  90. 90. Argon LaserArgon Laser  Vascular and pigmented lesionsVascular and pigmented lesions  488 to 514 nm wavelength488 to 514 nm wavelength  These are NOT the wavelengths specific to HgbThese are NOT the wavelengths specific to Hgb and melanin, therefore damage to surroundingand melanin, therefore damage to surrounding tissue significant, possibly leading to scarringtissue significant, possibly leading to scarring and hypopigmentation.and hypopigmentation.  Has fallen out of favorHas fallen out of favor
  91. 91. Flashlamp Pumped Pulsed DyeFlashlamp Pumped Pulsed Dye  Port wine stains, telangiectasiasPort wine stains, telangiectasias  585 nm wavelength585 nm wavelength  Low risk of scarring and pigment changeLow risk of scarring and pigment change  Black/gray discoloration due to intravascularBlack/gray discoloration due to intravascular coagulation.coagulation.
  92. 92. Q switched RubyQ switched Ruby  Melanin and darkly pigmented tattoo pigmentsMelanin and darkly pigmented tattoo pigments (black, blue, green) targets(black, blue, green) targets  694 nm wavelength694 nm wavelength  Q-switching allows delivery of extremely highQ-switching allows delivery of extremely high energy at pulses that last only nanosecondsenergy at pulses that last only nanoseconds  Good for deep pigment, ie. Nevus of OtaGood for deep pigment, ie. Nevus of Ota  Minimal scarring, transient hypopigmentationMinimal scarring, transient hypopigmentation
  93. 93. Neodynium:Yttrium-Aluminum-Neodynium:Yttrium-Aluminum- Garnet (Nd:YAG)Garnet (Nd:YAG)  1064 wavelength1064 wavelength  Continuous mode – PWS, venousContinuous mode – PWS, venous malformationsmalformations  Q-switched mode – black, blue tattoosQ-switched mode – black, blue tattoos  Frequency doubled 532 - red tattoo, vascular,Frequency doubled 532 - red tattoo, vascular, superficial pigmentedsuperficial pigmented
  94. 94. KTP: Potassium Titanyl PhosphateKTP: Potassium Titanyl Phosphate  532 nm wavelength532 nm wavelength  Vascular and superficial pigmented.Vascular and superficial pigmented.  Significant Hgb and melanin absorptionSignificant Hgb and melanin absorption
  95. 95. Q-Switched AlexandriteQ-Switched Alexandrite  755 nm wavelength755 nm wavelength  Absorbed by deep dark pigment ie., blue, blackAbsorbed by deep dark pigment ie., blue, black and green tatoo pigmentand green tatoo pigment
  96. 96. IPL: Intense Pulsed LightIPL: Intense Pulsed Light  Continuous spectrum 515 - 1200nmContinuous spectrum 515 - 1200nm  Extremely versatileExtremely versatile  RosaceaRosacea  TelangiectasiasTelangiectasias  Spotty discolorationSpotty discoloration
  97. 97. Carbon DioxideCarbon Dioxide  10,600 nm wavelength, H2O chromophore10,600 nm wavelength, H2O chromophore  Super-pulsed allows destruction of epidermisSuper-pulsed allows destruction of epidermis and papillary dermis while limiting deeperand papillary dermis while limiting deeper damage.damage.  Can actually see it tighten the collagenCan actually see it tighten the collagen  Excellent for photodamage, rhytidsExcellent for photodamage, rhytids  Lots of down time, side effects.Lots of down time, side effects.
  98. 98. Erbium:Yttrium-Al-GarnetErbium:Yttrium-Al-Garnet Er:YAGEr:YAG  2940 nm wavelength2940 nm wavelength  Ablative, but with less thermal damage than theAblative, but with less thermal damage than the CO2 laserCO2 laser  Ideal for treating very early photodamageIdeal for treating very early photodamage (superficial), but will never tighten collagen as(superficial), but will never tighten collagen as well as the CO2well as the CO2

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