Transcript Dermatologic Surgery Kristy P. Gilbert, D.O. November 1, 2005

Dermatologic
Surgery
Kristy P. Gilbert, D.O.
November 1, 2005
Introduction
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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
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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
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Factors that will affect wound healing
Prophylactic antibiotics
Risks for scarring
Risks for bleeding
Factors that will affect wound
healing
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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
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Antibiotic Prophylaxis:
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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
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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.
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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
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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
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Herbal Supplements that
inhibit coagulation….
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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.
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Dermatol Surg 28: June 2002, 449
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Local Anesthesia
Local anesthesia
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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
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“I’m allergic to Novacaine”
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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”
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Local anesthesia
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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
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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
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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
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Clean Procedures:
Isopropyl alcohol
weak antimicrobial
 most commonly used agent for shave biopsies
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Hydrogen peroxide
no significant antiseptic properties
 not suitable for sterile procedures
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Surgical Cleansers: Sterile
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Betadine
irritating to skin, residual color
 must dry completely to be antimicrobial
 absorbed by premature infants
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Chlorhexidine (Hibiclens)
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keratitis if it gets in the eyes
Hexachlorophene (pHisoHex)
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not on women or children due to neurotoxicity and
teratogenicity
Common Procedures
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Shave Biopsy
Punch Biopsy
Excisional Biopsy
Cryosurgery
Shave biopsy
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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
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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
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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
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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
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Sterile OR clean
procedure
3 or 4 mm punch is
standard
4x4s, Drysol, Q-tips
Needle driver, forceps
Suture
Path specimen bottle
Punch Biopsy
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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
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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
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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
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Drysol
Aluminum Chloride
Quick, easy, cheap.
Q-tip application.
No odor or
discoloration.
Good for superficial
biopsy - shave.
Chemical Hemostasis
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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
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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
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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
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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
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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
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“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
THERMAL CAUTERY
Heated metal results
in tissue dessication,
coagulation and necrosis.
Safe to use in patients with
pacemakers.
Does not require a dry field.
Electrosurgery and pacemakers
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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
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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
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ED&C
Cryosurgery
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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
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Cotton swabs
Cryospray
Cryoprobe (allows
deeper freeze w/o lateral
damage)
Cones
Thermacouples
Cryosurgery complications
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Pain
HA
Syncope
Bleeding (2-3 wks p tx)
Edema
Abnormal scarring
Nerve damage (digital
neuropathy)
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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
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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)
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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
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Using felt tip pen
mark a circle
around lesion
with
recommended
margins.
Ellipse should be
3 times longer
than circle
around lesion.
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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
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Anatomy
a lecture in itself- nerves, arteries, veins, glandular structures
Excision: Instruments
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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
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Gut (Chromic)
fast absorbing for surface closure as tensile strength
is lost in days (FTSG)
 Plain
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Polyglycolic acid (Dexon)
Polyglactin 910 (Vicryl)
Polydiaxone (PDS)
Polytrimethylene carbonate (Maxon)
Poliglecaprone 25 (Monocryl)
Non Absorbable Suture
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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
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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
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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
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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
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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
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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
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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
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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
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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
Transposition flaps
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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
Cutaneous Laser Surgery
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Light Amplification by Stimulated Emission of
Radiation
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Light limited to one WAVELENGTH
CHROMOPHORES are substances that
preferentially absorb one WAVELENGTH
Examples: water, Hgb, melanin
HEAT created = “Selective Thermolysis”
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Argon Laser
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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
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Port wine stains, telangiectasias
585 nm wavelength
Low risk of scarring and pigment change
Black/gray discoloration due to intravascular
coagulation.
Q switched Ruby
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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-AluminumGarnet (Nd:YAG)
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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
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532 nm wavelength
Vascular and superficial pigmented.
Significant Hgb and melanin absorption
Q-Switched Alexandrite
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755 nm wavelength
Absorbed by deep dark pigment ie., blue, black
and green tatoo pigment
IPL: Intense Pulsed Light
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Continuous spectrum 515 - 1200nm
Extremely versatile
Rosacea
Telangiectasias
Spotty discoloration
Carbon Dioxide
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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
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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