1 / 34

Skin Surgical Techniques

Skin Surgical Techniques. Biopsy – Shave vs Punch. Shave a lot faster Haemostasis less of a problem (Driclor) Useful for tumours, papules, pedunculated lesions, ID naevi, Macular PSL

phong
Download Presentation

Skin Surgical Techniques

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Skin Surgical Techniques

  2. Biopsy – Shave vs Punch • Shave a lot faster • Haemostasis less of a problem (Driclor) • Useful for tumours, papules, pedunculated lesions, ID naevi, Macular PSL • Punch is appropriate for inflammatory skin diseases and tumours where sample of tissue depth necessary (usually more indurated lesions)

  3. Excisional Biopsy

  4. Shave Biopsy

  5. Punch Biopsy

  6. Excision – Shave vs Punch • Depends on type of tumour • Shave - epidermal lesions (achrocordon, some intradermal naevi, KAs) • Punch – ID naevi face, vascular tumours eg capillary haemangioma, seb hyperplasia • NB melanocytic naevi with hairs will only stop growing hair if dermis/subcutis excised

  7. Excisional Biopsies • Avoid danger areas such as pre-auricular, angle of mandible and posterior cervical triangle • plan excision along relaxed skin tension lines • use 3:1 ratio and mark site with gentian violet marker • use appropriate anesthesia (I.e. no epinephrine on finger tips, nose tip, tip of penis)

  8. Ellipse

  9. Tense closures • Sites eg scalp, lower leg • Undermine • Assistant • Stronger suture material • Vertical Pulley, Butterfly (double butterfly), Traction sutures

  10. Weak, thin skin • Eg Scleroderma, Solar damage, Corticosteroid use – partic lower legs • Deep sutures • Assistant, Steri-strips, Crepe bandage • Secondary intention healing • SSG, FTSG • Avoid, Refer

  11. Suture removal – general guide • Face – 7 days • Neck – 10 days • Trunk, Limbs – 12-14 days, (7-10 days if deep sutures in place)

  12. Moh’s Surgery

  13. MOHS’ SURGERY What is it? • Form of skin cancer surgery for SCC, BCC, KA, +/- Melanoma • Highest cure rate for primary and secondary cancers • Dermatologist - surgery, pathology and repair

  14. MOHS’ SURGERY How is it done ? Principles • Remove tumour • Repair to suit function • Cosmesis

  15. METHOD CONT’D • Any remaining tumour is located on the slide and further surgery is done to this area • Above steps are repeated until all tumour is removed • Defect is repaired

  16. MOHS’ SURGERY Indications • BCC/ SCC/ Other tumours • Located on the central face or periorifical areas (eyes, mouth, nose, ears, etc) • Recurrent tumours • Incompletely excised tumours • High risk histological types eg morphoeic BCC • Large or ill-defined lesions • Young patients with skin cancers

  17. MOHS’ SURGERY Advantages • Tissue conservation • Highest cure rate • Local anaesthetic procedure • Cost to patient is no different to standard surgery

  18. MOHS’ SURGERY Disadvantages • Time consuming for doctor and patient • Expensive equipment • Expertise required

  19. Mohs Micrographic Surgery • Recurrent tumors • Tumors >2 cm • Aggressive Histology • Ill-defined margins • Incompletely excised tumors • Local cure rates >99%

  20. Needle Selection • Cutting-most skin surgery. • FS- for skin • P, PS, PRE for cosmetic areas • Taper-fascia and bowel • Blunt-liver and kidney • Higher number=smaller needle • Use larger needles for deep tissue, smaller needle to close the skin.

  21. Needle Types

  22. Skin Grafts • Split Thickness Skin Grafts -include part of the dermis and all of epidermis -donor site regenerated from hair follicles and skin edges on the graft • Full Thickness Grafts -less wound contracture -usually used for palms and back of hands

  23. Evolution of Skin Grafts

  24. Flaps • Free Flaps -predisposed to venous thrombosis TRAM flaps • Rely on superior epigastric vessels for blood supplu • Periumbilical perforators are the most important determinant of TRAM viability

  25. Squamous Cell Carcinoma • Risk Factors – actinic keratoses, zeroderma pigmentosum, bowen’s disease, atrophic epidermitis, arsenic, coal tar, nitrates, HPV, fair skin, XRT exposure • Tx: .5-1.0cm margins for low risk • Reginal adenectomy for positive nodes • Mohs Surgery – margin mapping using conservative slicles, never used for melanoma, best for facial lesions

  26. Melanoma Staging

  27. Management

  28. Sentinel Lymph Node • No more elective node dissection • Nodal status is a strong prognostic factor • Indicated for melanomas >1 mm • Lymphazurin blue and 99Tc- sulfur colloid

  29. Melanoma Adjuvants • Chemotherapy usually not too effective • Dacarbazine: 20% response • Interferon alpha: 20% response • Isolated limb perfusion – Melphalan: 80 % • Immunotherapy: 15% response • Melanoma vaccines?

  30. Squamous Cell Carcinoma • 250,000 cases/year, 2nd most common skin CA, 2500 deaths/yr • Bowen’s Disease: early stage or intraepidermal form of SCC • Poor prognostic factors: >2 cm deep, poorly differentiated, rapid growth, originating in scar, perineural involvement • Only 50% 5-year survival if nodes involved

  31. Treatment Options • Wide local excision: >4-7 mm margins to deep subcutaneous tissue • Radiation for poor surgical candidates • Mohs micrographic surgery • Cryosurgery • Currettage and Electrodessication • Laser ablation • Topical 5-FU

  32. Basal Cell Cancer • 900,000 cases/year, lifetime risk for Caucasians 30%, rarely metastasize • Local destruction, 30% develop non-melanoma skin CA recurrence within a year • Excise with negative margins (4-7 mm) • Lymphadenectomy only for basosquamous variant with clinically (+) nodes • Moh’s is best for high risk lesions

More Related