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Dermatologic Surgery. KCOM/Texas Dermatology Residency NE Regional Medical Center. Introduction. Derm surgery increasing in complexity Aesthetic and Laser procedures Plastic surgery – blepharoplasty, facelifts, liposuction Mohs micrographic surgery

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Dermatologic surgery l.jpg

Dermatologic Surgery

KCOM/Texas Dermatology Residency

NE Regional Medical Center


Introduction l.jpg
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.


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Basics: Pre-Op Evaluation

  • Drug Allergies

  • Meds: Coumadin, Plavix, ASA.

  • Pacemaker? Defibrillator?

  • MVP, Endocarditis, Prosthetics?

  • Informed Consent, risks v. benefits and options must all be discussed & signed

  • OTC and Herbals…..


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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


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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.

  • See next slide….


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  • 4-Way Cold Tablets, Adprin B, A.S.A., Aches-N Pain, Advil, Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,


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Past Medical History…. Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,


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Antibiotic Prophylaxis: Absolute Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

  • Artificial Heart Valve

  • Artificial Joint Replacement < 6 months

  • Past history Endocarditis, Rheumatic Fever

  • Mitral Valve Prolapse with holosystolic murmur


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Antibiotic Prophylaxis: Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

  • DISCRETIONARY:

  • Mucous membrane surgery

  • Wound open > 24 hours

  • Immunosuppression

  • Regimen: Cephalexin or Erythromycin 1 gram po 1 hour prior to procedure and 500mg po 6 hours after the procedure


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Wound Healing Prognosis: Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

  • Diabetic?

  • Elderly?

  • Atherosclerosis? PVD Disease?

  • Thyroid dysfunction?

  • Nutritional status?

  • Smoker?

  • HIV, Immunosuppressive Medications?


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Pacemakers Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

  • “If a procedure is performed within a few centimeters of a pacemaker, electrosurgery should be executed with extreme care or possibly replaced by (thermal) cautery”

  • “Although modern devices are better shielded against external electrical interference, it is always prudent to consult a cardiologist and deliver short bursts < 5 seconds”


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Coumadin Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

  • The current thinking is to leave patients on Coumadin unless their Cardiologist approves taking them off.

  • REMEMBER: Some people are not surgical candidates and might be better served with radiation therapy for their skin cancers. Radiation Oncologists love skin cancer because they can actually cure it.


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DR. LIN PERFORMS HIS 100TH SEBORRHEIC KERATOSIS-ECTOMY!!! Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,


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Local Anesthesia Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,


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Anesthetics Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

Xylocaine – fast onset, lasts ¾ to 3 hours

Marcaine – onset slow at 3-5 min, lasts 2-3 hours

cardiac side effects

Allergic reactions are rare, but vasovagal reactions are common

ELA-Max cream – 30 minutes prior to procedure reduces pain of injection. Avaliable OTC and expensive but patients appreciate this extra measure of comfort.

EMLA - Rx only, methemoglobinemia side effects due to prilocaine content


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Local Anesthesia Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

  • 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.


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“I’m allergic to Novacaine” needle as you inject the anesthetic. When the tissue blanches you are at the right level.

  • 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 when in doubt.


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Pain Control needle as you inject the anesthetic. When the tissue blanches you are at the right level.

  • Local Anesthesia:

  • Pearl: INJECT SLOWLY and your patients will love you forever. Decreases pain more than warming or adding bicarbonate.

  • Distraction techniques useful as well – pinching skin during injection etc.


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Pediatric Pain Management needle as you inject the anesthetic. When the tissue blanches you are at the right level.

  • Pearl: For pediatric patients, let them sit in the lobby with ELA-Max or EMLA covered with Saran Wrap for 30 minutes. Your eardrums will thank you.


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Surgical Cleansers: needle as you inject the anesthetic. When the tissue blanches you are at the right level.

  • Clean Procedures:

  • Isopropyl alcohol

    • weak antimicrobial

    • most commonly used agent for shave biopsies

  • Hydrogen peroxide

    • no significant antiseptic properties

    • not suitable for sterile procedures


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Surgical Cleansers: Sterile needle as you inject the anesthetic. When the tissue blanches you are at the right level.

  • 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



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Common Procedures RESIDENCY…

  • Shave Biopsy

  • Punch Biopsy

  • Excisional Biopsy

  • Cryosurgery


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Shave biopsy RESIDENCY…

  • 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


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Shave Biopsy RESIDENCY…

  • Sterile #15 blade

  • 4x4’s

  • Drysol solution

  • Sterile Q-tips

  • Path container

  • Gillette Blue Blade Razor cut in half, bends to follow contour




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Endpoint is “pinpoint bleeding” RESIDENCY…Indicates you are at the level of the papillary dermis, minimal scarring


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Punch Biopsy RESIDENCY…

  • 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”


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Punch Biopsy RESIDENCY…

  • Sterile procedure!

  • Sterile gloves

  • 3 or 4 mm Punch

  • 4x4s, Drysol, Q-tips

  • Needle driver, forceps

  • Suture

  • Path specimen bottle


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Punch Biopsy RESIDENCY…

  • 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.


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Punch biopsy RESIDENCY…

  • 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.


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Punch Biopsy RESIDENCY…

  • Hemostasis works best in 2 steps.

  • First use the Q-tip to buy time to grab needle driver and suture.

  • Suture so that closure is low tension - simple palpation reveals.


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Punch Biopsy RESIDENCY…

  • Use 6-0 Prolene on the face.

  • 4-0 Prolene most other areas.

  • Silk for mucosal areas.

  • 2 simple interrupted sutures.

  • Out 7d face, 10d otw






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Excisional Biopsy RESIDENCY…

  • Will cover this later under Excision…..


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Hemostasis RESIDENCY…

  • Chemical

  • Electrical

  • Physical


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Chemical Hemostasis RESIDENCY…

  • Drysol

  • Aluminum Chloride

  • Quick, easy, cheap.

  • Q-tip application.

  • No odor or discoloration.

  • Good for superficial biopsy - shave.


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Chemical Hemostasis RESIDENCY…

  • Monsel’s solution.

  • 20% ferric subsulfate.

  • Cheap, easy to use.

  • Risk of tattooing.

  • Superficial only!

  • Caustic, may destroy connective tissue if sutured into wound.


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High Frequency Electrosurgery RESIDENCY…

  • Monoterminal elecrodessication- low levels of current.

  • Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators.

  • Requires dry field.


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THERMAL CAUTERY RESIDENCY…

Heated metal results in tissue dessication, coagulation and necrosis.Safe to use in patients with pacemakers.Does not require a dry field.


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Curettage RESIDENCY…

  • 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.

  • Learning Curve: BCC recurrence rate for residents far higher than that of attending physicians – Kopf et al, 1977


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Cryosurgery RESIDENCY…

  • 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




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Electrosurgery RESIDENCY…

  • Destruction

  • Hemostasis for simple or complex excisional surgery

  • Mechanism – heat destroys tissue

  • Electrocautery – no current passes through the patient.

  • SK, DPN, SGH, SKIN TAGS, VV


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Electro-epilation RESIDENCY…

  • 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.


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Electrodessication/Electrofulguration RESIDENCY…

  • 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


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Electrodessication RESIDENCY…

  • LOW POWER:

  • Facial telangiectasias

  • Syringomas

  • HIGH POWER:

  • SK, Skin Tags, VV

  • EDC: BCC & SCC under 2 cm, 2-3 cycles

  • Hemostasis during excisional surgery.


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Electrosection RESIDENCY…

  • “Cutting Current”, Radio-Frequency Ablat.

  • 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.


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Excision: Instruments RESIDENCY…

  • Needle Holders

  • Forceps

  • Skin hooks

  • Scissors



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GILLIES RESIDENCY…




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LARGER FLAPS RESIDENCY…

SMALL TISSUE FLAPS




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USEFUL IN ACCURATE TAILORING OF FINER STRUCTURES, ALSO STEVENS TENOTOMY, FINE IRIS AND GRADLE


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A word on excisional biopsy STEVENS TENOTOMY, FINE IRIS AND GRADLE

  • If you suspect thin melanoma a shave “saucerization” of entire lesion is OK

  • If you have residual pigment at the base you can always punch that.

  • If you suspect a nodular melanoma excisional biopsy to SQ.

  • Punch bx, while deep enough, is NOT representative of the entire lesion.


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BRANCHES OF FACIAL NERVE: nurses use GENTLY, if you get too aggressive ink will rinse away, now you’re lost!

TO ZANZIBAR BY MOTOR CAR….


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Facial Nerve Damage nurses use GENTLY, if you get too aggressive ink will rinse away, now you’re lost!

  • Temporal branch - forehead and eyebrow ptosis, may obstruct vision.

  • Zygomatic branch - impaired blinking, eye dries out, clarity of vision is affected.

  • Buccal branch - drooping corner of mouth,

  • Marginal Mandibular - lower lip function.


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TO ZANZIBAR BY MOTOR CAR & VARIATIONS ON A THEME…..INFORMED CONSENT!!!!!


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Excisional Surgery THEME…..INFORMED CONSENT!!!!!

  • Indicated for LOW RISK SCC and BCC:

  • Trunk, Neck or Extremitiy <20mm

  • Cheeks, Forehead, Scalp <10mm

  • “Mask Areas”, Genitalia, Hands, Feet <6mm

  • Age > 40

  • No history of immunosuppresion, rapidly growing tumor, prior X-ray tx, palpable LAD, pain, paresthesais, paralysis.

  • Path without: poor differentiation, morpheaform, micronodular, infiltration


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Mask Area of Face THEME…..INFORMED CONSENT!!!!!


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Absorbable Suture THEME…..INFORMED CONSENT!!!!!

  • 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)


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Non Absorbable Suture THEME…..INFORMED CONSENT!!!!!

  • Silk (good for oral mucosa)

  • Nylon (Dermalon, Ethilon, Surgilon)

  • Polypropylene (Prolene, Surgilene)

  • Polyester (Dacron, Ethibond, Mersilene)

  • Polybutester (Novafil)


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SIMPLE INTERRUPTED THEME…..INFORMED CONSENT!!!!!PRO: Good approximation of superficial tissues. CON: RR track scarring/time


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VERTICAL MATTRESS THEME…..INFORMED CONSENT!!!!!PRO: Enhances wound eversion and decreases scarringCON: Time consuming


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CORNER STITCH THEME…..INFORMED CONSENT!!!!!Helps avoid tip strangulationKEY: Be sure this is the last suture, not the first. Should be low tension.


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HORIZONTAL MATTRESS THEME…..INFORMED CONSENT!!!!!PRO: Good for high tension woundsCON: Tends to cut into/strangulate tissues and higher risk dehiscence or scarring.


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RUNNING THEME…..INFORMED CONSENT!!!!!


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RUNNING, LOCKED THEME…..INFORMED CONSENT!!!!!


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RUNNING HORIZONTAL MATTRESS THEME…..INFORMED CONSENT!!!!!


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DEEP SUTURES THEME…..INFORMED CONSENT!!!!!


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RUNNING SUBCUTANEOUS THEME…..INFORMED CONSENT!!!!!


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RUNNING SUBCUTICULAR THEME…..INFORMED CONSENT!!!!!


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Mohs Surgery THEME…..INFORMED CONSENT!!!!!

Frederick Mohs 1930 Fixed Tissue

Tromovitch 1970’s Frozen Tissue

Control of 100% of surgical margins

Allows smaller margins to be taken

Cosmetically sensitive areas

H zone

Not just for recurrent tumors anymore


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Mohs THEME…..INFORMED CONSENT!!!!!

  • 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%


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Mohs THEME…..INFORMED CONSENT!!!!!

  • Rowe et al cont’d

  • Primary SCC 5 year recurrence rates

  • Mohs 3.1%

  • Excision 8.1%

  • C&D 3.7%

  • XRT 10%


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Surgical Complications THEME…..INFORMED CONSENT!!!!!

  • Hematoma – no evidence that ASA, NSAID or COUMADIN increases risk of hematoma

  • Infection – high risk on ear

  • Dehiscence – from infection, trauma

  • Necrosis – high tension in sutures or wound edges, poor flap design.


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Avoiding Surgical Complications THEME…..INFORMED CONSENT!!!!!

  • Aseptic technique

  • Meticulous hemostasis

  • Wide undermining

  • Good surgical planning

  • Controversy: DC ASA 2 weeks, Coumadin 2 days, NSAIDS 1 week


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X-ray therapy for NMSC THEME…..INFORMED CONSENT!!!!!

  • Similar recurrence rates as standard excision, C&D, Cryo but less invasive.

  • Ideal for patients that are not surgical candidates due to multiple co-morbidities

  • Once Mohs determines tumor has bone or perineural involvement.

  • Downfall: Tumors that recur after XRT tend to be aggressive with wider subclinical tumor extension


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Photodynamic Therapy THEME…..INFORMED CONSENT!!!!!

  • Light + Photosensitizer = O2 free radicals

  • Aminolevulenic Acid (5-ALA) + Blue light

  • Expensive

  • Painful

  • Not widely accepted

  • NMSC cure rates vary from 50% to 100%


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SKIN CANCER MGMT THEME…..INFORMED CONSENT!!!!!

  • LOCAL DISEASE:

  • C&D FOR LOW RISK BCC ONLY – F/U

  • EXCISION WITH POMA – CLEAR? –F/U

  • IF RECURRENT OR HIGH RISK, MOHS

  • IF MOHS CANNOT CLEAR OR INVOLVES BONE OR NEURAL, XRT, MULTIDISCIPLINARY APPROACH

National Comprehensive Cancer Network


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SKIN CANCER MGMT THEME…..INFORMED CONSENT!!!!!

  • PALPABLE LYMPHADENOPATHY SHOULD PROMP FNA, BUT EVEN IF FNA IS NEGATIVE OPEN BIOPSY WITH FROZEN SECTIONS AND POSSIBLE REGIONAL DISSECTION FOLLOWS

  • ADJUVANT XRT ESPECIALLY IF > 1 LYMPH NODE INVOLVED

  • PALPABLE PAROTID MASS = PAROTIDECTOMY

National Comprehensive Cancer Network


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Rick working on his home-made LASER THEME…..INFORMED CONSENT!!!!!


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Cutaneous Laser Surgery THEME…..INFORMED CONSENT!!!!!

  • Light Amplification by Stimulated Emission of Radiation

  • 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 THEME…..INFORMED CONSENT!!!!!

  • 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


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Flashlamp Pumped Pulsed Dye THEME…..INFORMED CONSENT!!!!!

  • Port wine stains, telangiectasias

  • 585 nm wavelength

  • Low risk of scarring and pigment change

  • Black/gray discoloration due to intravascular coagulation.


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Q switched Ruby THEME…..INFORMED CONSENT!!!!!

  • 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 hypopigment.


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Neodynium:Yttrium-Aluminum-Garnet (Nd:YAG) THEME…..INFORMED CONSENT!!!!!

  • 1064 wavelength

  • Continuous mode – PWS, venous malform.

  • Q-switched mode – black, blue tattoos

  • Frequency doubled 532 - red tattoo, vascular, superficial pigmented


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KTP: Potassium Titanyl Phosphate THEME…..INFORMED CONSENT!!!!!

  • 532 nm wavelength

  • Vascular and superficial pigmented.

  • Significant Hgb and melanin absorption


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Q-Switched Alexandrite THEME…..INFORMED CONSENT!!!!!

  • 755 nm wavelength

  • Absorbed by deep dark pigment ie., blue, black and green tatoo pigment


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IPL: Intense Pulsed Light THEME…..INFORMED CONSENT!!!!!

  • Continuous spectrum 515 - 1200nm

  • Extremely versatile

  • Rosacea

  • Telangiectasias

  • Spotty discoloration


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Carbon Dioxide THEME…..INFORMED CONSENT!!!!!

  • 10,600 nm wavelength, H2O chromophore

  • Super-pulsed allows destruction of epidermis and papillary dermis while limiting deeper damage.

  • Can actually see it tighted the collagen

  • Excellent for photodamage, rhytids

  • Lots of down time, side effects.


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Erbium:Yttrium-Al-Garnet THEME…..INFORMED CONSENT!!!!!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



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