Transcript Completely excise Large – Selective sampling

Basic Suturing Techniques
Daniel Stulberg, M.D.
Prof. of Family and Community Medicine
University of New Mexico
Suspicious Lesion - Options
• Shave biopsy
• Punch biopsy
• Punch excision
• Elliptical excision
• Electrosurgery
• ? Cryosurgery
Approach to Suspicious Lesions
Suspicious
Raised
Shave
Possible
Melanoma
Flat
Small
completely
excise
Large –
Selective
sampling
Small –
Completely
excise
Large –
Selective
sampling
Procedures
• Clean for most
• Sterile for excisions with suturing
• Consent
• Time out
• Follow up instructions
Shave Excision – Cancer or cosmesis
• Scalpel 15 or 10 blade
• Personna
• Gillette
• Dermablade
Suspicious Lesion
Daniel Stulberg, MD
Possible BCC
Daniel Stulberg, MD
Local Anesthesia
• 1% lidocaine with epinephrine
• local anesthesia not needed for:
• telangiectasias
• small cherry angiomas
• small skin tags
Daniel Stulberg, MD
Epinephrine Effect
Daniel Stulberg, MD
Shave Set Up
Daniel Stulberg, MD
Shave – Scalpel or Flexible Blade
Daniel Stulberg, MD
Flip Over’s
Daniel Stulberg, MD
Stabilize Lesion
Daniel Stulberg, MD
Complete Transection
Daniel Stulberg, MD
Daniel Stulberg, MD
Dab and Fulgurate/Cauterize
Daniel Stulberg, MD
Metal is Not Hot – Sparks at the Gap – Light
touch for Fulguration
Daniel Stulberg, MD
Courtesy Richard Usatine, MD
© Dr Richard Usatine
Courtesy Richard Usatine, MD
Punch Biopsy
• Diagnosis of:
• inflammatory skin disease
• Psoriasis
• Vasculitis
• lupus
• Infiltrative diseases
• Sarcoid
• mycosis fungoides
• Skin cancers – unless EDC
Courtesy Richard Usatine, MD
Suturing Set Up
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Figure 8 and Inverted
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Courtesy Richard Usatine, MD
Courtesy Richard Usatine, MD
Courtesy Richard Usatine, MD
Courtesy Richard Usatine, MD
Evert skin edges
Daniel Stulberg, MD
Daniel Stulberg, MD
Cutting an ellipse -Three to one ratio
Courtesy of Dermatologic and Cosmetic Procedures in Office Practice
Placement of the Incision Line
• Relaxed skin tension
lines
• Stretch/pinch the skin
• Circle and observe
elongation
Courtesy of Dermatologic and Cosmetic Procedures in Office Practice.
Adapted from Richard Usatine, MD
Facial Skin Tension Lines
Courtesy of Dermatologic and Cosmetic Procedures in Office Practice.
Courtesy Richard Usatine, MD
Closing Ellipses
• Deep suture w inverted knots
• Running simple
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Pull across then turn
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Skin tension and fragile skin
• Vertical mattress
• Horizontal mattress
• Adhesive tapes
Far - far - near - near
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Daniel Stulberg, MD
Vertical Mattress + Adhesive Strips
Daniel Stulberg, MD
Avoiding dog ears
• Rule of halves
• Unequal sides
Rule of halves
Unequal sides
Undermining
Courtesy of Dermatologic and Cosmetic Procedures in Office Practice
Resources
• Usatine R, Pfenninger J, Stulberg D, Small R. Dermatologic and
Cosmetic Procedures in Office Practice. 2012. With DVD.
• App available at: www.usatinemedia.com
• Robinson, et al. Surgery of the Skin. 2010.
• Mayeaux EJ, The Essential Guide to Primary Care Procedures. 2009.