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 • Increasing emphasis on patient safety, documentation, and accreditation.
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…..
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
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….
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,
Antibiotic Prophylaxis: Absolute • Artificial Heart Valve • Artificial Joint Replacement < 6 months • Past history Endocarditis, Rheumatic Fever • Mitral Valve Prolapse with holosystolic murmur
Antibiotic Prophylaxis: • 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
Wound Healing Prognosis: • Diabetic? • Elderly? • Atherosclerosis? PVD Disease? • Thyroid dysfunction? • Nutritional status? • Smoker? • HIV, Immunosuppressive Medications?
Pacemakers • “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”
Coumadin • 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.
Anesthetics 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
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.
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.
“I’m allergic to Novacaine” • 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.
Pain Control • 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.
Pediatric Pain Management • 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.
Surgical Cleansers: • Clean Procedures: • Isopropyl alcohol • weak antimicrobial • most commonly used agent for shave biopsies • Hydrogen peroxide • no significant antiseptic properties • not suitable for sterile procedures
Surgical Cleansers: Sterile • 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
Common Procedures • Shave Biopsy • Punch Biopsy • Excisional Biopsy • Cryosurgery
Shave biopsy • 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 • Sterile #15 blade • 4x4’s • Drysol solution • Sterile Q-tips • Path container • Gillette Blue Blade Razor cut in half, bends to follow contour
Endpoint is “pinpoint bleeding”Indicates you are at the level of the papillary dermis, minimal scarring
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 • 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 • Sterile procedure! • Sterile gloves • 3 or 4 mm Punch • 4x4s, Drysol, Q-tips • Needle driver, forceps • Suture • Path specimen bottle
Punch Biopsy • 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 • 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 • 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.
Punch Biopsy • 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
Excisional Biopsy • Will cover this later under Excision…..
Hemostasis • Chemical • Electrical • Physical
Chemical Hemostasis • Drysol • Aluminum Chloride • Quick, easy, cheap. • Q-tip application. • No odor or discoloration. • Good for superficial biopsy - shave.
Chemical Hemostasis • Monsel’s solution. • 20% ferric subsulfate. • Cheap, easy to use. • Risk of tattooing. • Superficial only! • Caustic, may destroy connective tissue if sutured into wound.
High Frequency Electrosurgery • Monoterminal elecrodessication- low levels of current. • Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators. • Requires dry field.
THERMAL CAUTERY Heated metal results in tissue dessication, coagulation and necrosis.Safe to use in patients with pacemakers.Does not require a dry field.
Curettage • 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
Stabilize skin with non-dominant hand • Pencil method • Potatoe-peeler method • Normal dermis feels “gritty” • Cancer lesion + 2-3mm margin • 2-3 cycles