getting started - overview · 2018-05-28 · follow-up instructions •give written instructions...

Basil S. Cherpelis, M.D.

MINI-SYMPOSIUM

Skin Surgery

Fundamentals

•The ABC’s of Skin Surgery

•Managing Complications – Be Prepared!

• Objective

– Review important steps in the surgical process

– Become familiar with the tools of the trade

– Pass on pearls to minimize complications

Skin Surgery Fundamentals

The Surgical Process

• Review biopsy or assess clinically

• Decide treatment

• Pre-op the patient

• Schedule patient

• Obtain informed consent

• Proper positioning of the patient

• Sterilize the surgical field

• Anesthetize the area

• Excise the lesion and close the wound (pathology?)

• Dress the wound

• Document the procedure correctly

• Bill for services

• Follow-up and remove sutures

What Are We Excising?(Know The Treatment)

• Benign lesions

– Cysts (infundibular or

pilar)

– Benign Nevi

– Inflamed Seborrheic

Keratoses

– Lipomas

• Malignant lesions

– Squamous Cell

Carcinoma in Situ

– Squamous Cell

Carcinoma

– Basal Cell Carcinoma

– Dysplastic Nevi

– Melanoma in Situ

– Melanoma

Surgical Margins

• Basal and Squamous Cell Carcinoma

– Minimum of 4 to 5 millimeters

Surgical Margins

• Dysplastic Nevi

– Scallop-type removal

– Conservative excision

– (2 – 4 mm) margins

Surgical Margins

• Melanoma in Situ

– Minimum 5 millimeters

– Lentigo maligna melanoma

may require wider margins

or staged excision

MMIS Pearl

• Lentigo Maligna Melanoma

may exceed visible outline

• Use Wood’s light to help

define margins

MMIS Pearl

MMIS Pearl

Surgical Margins

• Malignant Melanoma

– Breslow depth < 1 mm - 1.0 cm margins

– Breslow depth 1 - 4 mm - 2.0 cm margins

– Breslow depth > 4 mm - 2.0-3.0 cm margins

• All excised down to fascia

– Consider SLN biopsy for lesions .8 mm

Biopsy Report Pearl

• “Go with your gut”

– Rely on your clinical expertise

– Question your pathologist if the report doesn’t

fit the clinical exam

Pearl - Case in Point

Pre-op

• “Hope for the best and plan for the worst”

– Purpose

• Identify conditions that could lead to a complication

• Intervene prior to complication

• Inform the patient of the potential risks

Scheduling Pearls

• Allow adequate time

• Schedule surgeries as groups– One afternoon a week

– First thing in morning

– Immediately after lunch

– At the end of the day

Accessing The Surgical Site

It Can Get Hairy

• Do not shave the surgical

site (increases risk of

infection)

• Use scissors to trim hair

• Use hair clips, hair gel,

Tape

Essential Tools of the Trade

• Surgical Tray– Blade handle and blade

– Needle holder

– Scissors - cutting, undermining and suture

– Forceps

– Skin Hooks (have two)

– Hemostat

– Gauze - 4 x 4’s

– Cotton Tip Applicators

Tray

Blades and Handles• No. 15, No. 10 and Beaver blades

• The sharpest edge is the belly

• No. 15 - face and extremity

• No. 10 - back

• Beaver - delicate face and Mohs

Anesthesia Pearl

• Mark the edges of the lesion

prior to anesthetizing

• Use anesthesia to “raise” the

lesion

• Technique

– Quick stick and slowly inject

– Create small Intradermal

wheal

– Inject into subQ through the

wheal

Elliptical (Fusiform) Excision

• 3 to 1 rule (length to width)

• Apical Angle ≈ 30°

• Angle of blade is perpendicular

to the skin

• Excise apical apexes at the

same depth

• Undermine in the subQ fat at

same depth as excision

• Use anesthesia in subQ to raise

the lesion and help facilitate

excision

Elliptical (Fusiform) Excision

Skin Tension Lines

• Use the “pinch test”

Excise the Lesion and Close the

Wound

Excise the Lesion and Close the

Wound

Excise the Lesion and Close the

Wound

Excise the Lesion and Close the

Wound - Video

Proper Suture

• Absorbable Suture

– Surgical Gut

– Vicryl (Polyglactin 910)

– Monocryl (Poliglecaprone 25)

• Non-Absorbable Suture

– Silk

– Nylon

– Polypropylene (Prolene)

Proper Suture

• Surgical Gut• Processed collagen from bovine or sheep intestine

• Chromic - lasts 10 - 14 days

• Fast absorbing gut - lasts 3 - 5 days

• Dries quickly

• Good for grafts and when sutures not to be removed

Proper Suture

• Vicryl (Polyglactin 910)• Synthetic braided suture

• High tensile strength, easy to use, holds knots well

and low tissue reactivity

• Tensile strength - 75% at 2 wks and 50% at 3 weeks

• Completely absorbed at 90 days

• “spitting suture” common if not place in deep dermis

Proper Suture

• Monocryl (Poliglecaprone 25)• Synthetic Monofilament suture

• Tensile strength - 50-60 % at 7 days

• Completely absorbed at 90 days

• Best handling and knot security of the monofilaments

• Least tissue reactivity (decreases risk of keloids)

• More expensive (but can use one suture for “all”)

Proper Suture

• Silk

– Soft, pliable and easy to use

– Great for mucosa and intertriginous areas

– Low tensile strength, greater tissue reactivity and

greater risk of infection

Proper Suture

• Nylon

– Most common

– Monofilament

– High tensile strength, low tissue reactivity and

cheap

– Stiff with fair handling and knot security

Proper Suture

• Polypropylene (Prolene)• Monofilament

• Minimal tissue reactivity, slides through tissue easily

and “stretches”

• Best suture for running subcuticular and when facial

swelling anticipated

• Minimizes track marks

• Expensive

Suture Pearls

• Running subcuticular - think Prolene or Monocryl

• Mucosa - think silk

• “One for all?” - think Monocryl

• Grafts or not taking sutures out - consider gut

The Dog Days of Dog Ears

• Standing cones

• Excise along skin tension lines

• 3 to 1 rule (length to width)

• Apical Angle ≈ 30°

• Assure sides of the excision are equal length

• Eliminate excess subQ tissue at apical angles

• Undermine all edges, including apical angles

• “Lazy S” closure useful on convex surfaces (extremities)

The Dog Days of Dog Ears

Flaps

• Used to:

– Decrease tension

– Avoid important structures

– Place surgical scars at cosmetic subunit junctions or

relaxed skin tension lines

Flaps

• Burrows Triangle Displacement Flaps

– “sliding flaps”

– various advancement and rotation flaps

• Transposition and Interpolation Flaps

– “lifting flaps”

Rotation and Advancement Flaps“sliding flaps”

• Can place burrows triangle anywhere depending on cosmesis

• Utilize wide-base flaps

• Undermine at the same depth of excision (not too thin)

Advancement Flaps

Advancement Flaps

Advancement Flaps

Advancement Flaps

Rotation Flaps

Rotation Flaps

Transposition Flaps“lifting flap”

• Uses adjacent lax skin – often

parallel to lax skin tension

lines

• Careful planning is needed

• Very useful for nasal sidewall

defects

Transposition Flaps

Transposition Flaps

Island Pedicle (V-Y) Flaps

Grafts• Donor skin should cosmetically match graft site

• Avoid hairy areas for donor skin

• Pre or Post-auricular often good match

• Conchal bowl excellent for thin grafts

Grafts - Pearl• Allow defect on nose to granulate in for 10 days prior to

grafting

• Preventing tissue movement is the key to success!

“Don’t Fall Through That Trap Door”

Don’t Forget The Dressing

• A moist, occluded wound heals quicker with less

scarring and less pain

Don’t Forget The Dressing

• Components of the

Dressing (Three-

Layered)– Ointment (antibiotic or

petrolatum)

– Non-adherent, fluid

permeable layer (Telfa)

– Absorbent Layer (gauze)

– Outer layer or wrap (paper

tape or Coban)

• Pressure when and

where you need it

Follow-up Instructions

• Give written instructions (see handout)

• Limit strenuous activity, lifting, stretching or

working in “dirty” environment

• Change dressing in approximately 24 hours

– Remove bandage

– Cleanse with mild soap and water

– lightly remove any crusting or debri

– Apply ointment (petrolatum)

– Apply non-adherent pad or bandage

Proper Documentation

• Type and Site of Lesion

• Indication for Procedure

• Type of Procedure

• Size of Lesion including Margins

• Indications for type of closure

• Suture used

• Medications given

• Wound Instructions and follow-up

Proper Follow-up

• Face

– 5 to 7 days

• Trunk

– 12 to 14 days

• Extremities

– 10 to 14 days

Pearl Alert

• Call patient the night of their surgery

• Offer to see patient the next day

• Give them a phone number for any

emergencies

Avoiding Trouble

Avoiding Trouble

“Optimizing Outcomes”• A thorough preoperative assessment

• A well educated and informed patient

• Meticulous attention to detail and technique

• Proper management of unavoidable

complications

• Proper long-term monitoring of the patient

• Identify conditions that could lead to a

complication• Potential for bleeding

• Potential for poor wound healing or infection

• Potential problems with electrosurgery

• Potential allergies

• Potential social complications

Avoiding Trouble

Preoperative Assessment

• Potential bleeding disorders• Rare

• Identified in history

• Laboratory testing usually unnecessary

– CBC with Platelets

– Bleeding time (PFA-100)

– PT/PTT

Preoperative Assessment

Potential for Bleeding

• Medications (including OTC and herbs)• Aspirin - stop 10 days prior and several days after

• NSAIDS - 4 days prior

• Warfarin

– don’t stop if therapeutic (INR 2-3)

– stop 3 days prior and re-start the evening of the surgery

– consider checking INR the day before surgery

• Clopidogrel (Plavix) and ticlopidine (Ticlid)

– don’t stop or have patient check with his physician

Preoperative Assessment

Potential for Bleeding

• Medications

– Stop all 7 to 10 days prior

• Vitamin E - 200 - 400 IU/day

• Garlic - 900 mg/Day

• Gingko biloba

• Eicosapentaenoic acid (fish oil)

• Ginseng

• Feverfew

• ETOH - potent vasodilator

Preoperative Assessment

Potential for Bleeding

• The risk of a thromboembolic event is greater than

the risk of bleeding

• Don’t stop prescribed anticoagulants

• Be consistent and keep it simple

• Have patient check with his physician or check labs

(INR, PT/PTT)

Pearl Alert

• Chronic illness

– Any chronic illness can predispose

– Diabetes and CRF (i.e. renal dialysis)

• Medications

– Glucocorticoids and immunosuppressives

• Cigarette smoking

• Isotretinoin (Accutane)

– excessive granulation tissue formation

– postpone elective procedures (i.e. laser) for up to one year

Preoperative Assessment

Wound Healing and Infection

• Keloid or Hypertrophic Scarring Risk

– Shoulders, central chest, Upper Arms, Upper Back

– More common in certain skin types

Preoperative Assessment

Wound Healing and Infection

Prophylactic Antibiotics

• Reasons

– Prevent wound infection

– Prevent development of endocarditis

– Prevent infection of prosthetic device

Majority of dermatological surgery is clean or clean-

contaminated and does not require prophylaxis

Prophylactic Antibiotics

• Consider prophylaxis to minimize infection– Long procedures

– Inflamed lesions

– Oronasal, genitourinary or axillary sites

– Distant skin infection

Prophylactic Antibiotics

• Majority of infections caused by Staph– Ears - Pseudomonas

– Oromucosal - Streptococcus viridans

– Genitourinary - Escherichia coli

• First Generation cephalosporin is first line

Endocarditis Prophylaxis

• Dermatologic surgery is not considered in the

AHA guidelines

• Transient bacteremia with intact skin is low and is

generally not required for procedures of less than

20 minutes duration

• Consider for eroded or infected skin

Endocarditis Prophylaxis

• Consider for eroded or infected skin in high

risk cardiac patients– Prosthetic heart valves

– History of previous endocarditis

– Complex cyanotic congenital heart disease

– Surgically constructed systemic pulmonary shunts

• Others:– Orthopedic prosthesis or ventriculoatrial and peritoneal

shunts

Defibrillators and Pacemakers

• Safer to use battery operated cautery or

bipolar forceps

• If using conventional electrosurgery– Use on lowest possible setting

– Use short bursts only (< 5 seconds)

– Keep at least 15 cm away from device

– Obtain pre-operative cardiology consult and a

post-operative cardiac evaluation and perform

intra-operative cardiac monitoring

Allergies

• Anesthetics

• Antispeptics– Iodophor povidone-iodine (Betadine) - beware history

of IV dye or shell fish allergy

– Chlorhexidine gluconate

• Latex

• Tape

• Band-Aids

• Oral Antibiotics

Allergies

• Topical antibiotics– Neomycin most common

– Cross-reacts with bacitracin, gentamicin, kanamycin,

streptomycin and tobramycin

– Does not cross-react with mupiricin (Bactroban) or

erythromycin

Allergy Pearl

• No evidence that topical antibiotics prevent

infection

• Plain petrolatum (Vaseline) is just as good

Intraoperative Techniques to

Reduce Complications

• Hemostasis– Avoid indiscriminate and excessive electrodessication

– Precisely cauterize small vessels

– Tie-off larger bleeding vessels

– Eliminate dead space using layered closure

– Limit undermining if excessive oozing

– Consider Penrose drain for 24 hours

– Post-op pressure dressing for 24 hours

– QR Powder

Intraoperative Techniques to

Reduce Complications• Tissue Injury and Necrosis

– Handle wound edges gently

– Use skin hooks or single-toothed forceps

– Resist urge to cauterize skin edges

Intraoperative Techniques to

Reduce Complications

• Tension and Necrosis– Gain a good understanding of skin tension lines

– Perform adequate undermining in subQ fat layer

– Buried absorbable sutures should “bear the load”

– Superficial sutures only to approximate wound edges

– Consider:

• Consider flap closure

• Consider partial secondary intention healing

Tension and Necrosis Pearl

• Secondary intention healing

– Medial canthus

– Conchal bowl

– Partial closure on leg

Intraoperative Techniques to

Reduce Complications

• Nerve Deficits– Document preoperative nerve function

– Inform patient of the risks

– Sensation almost always impaired, especially digits,

forehead and scalp

– Sensation usually improves, but may take months

Danger Zones

Danger Zones

Danger Zones

• Temporal Branch– Superficial over zygomatic arch

– Impairment leads to inability to raise eyebrow and

forehead

– Usually only cosmetic unless pre-existing brow ptosis

Danger Zones

• Marginal Mandibular Branch– Superficial as it crosses mandible just anterior to the

angle of the mandible

– Covered only by skin and thin platysma muscle

– May be 1 or 2 cm below mandible in elderly

– Innervates lip depressors and impairment leads to facial

asymmetry and (“crooked smile”) and mouth

dysfunction (i.e. drooling)

Management of Complications

• Post-operative Bleeding– Highest risk within 24 hours

– Properly inform patient of expectations and wound care

– Patient to reinforce dressing and hold pressure for 20

minutes

– If not controlled, evaluate the patient

Management of Complications

• Post-operative Expanding Hematoma– A surgical emergency

– acute throbbing pain and Swelling

– Remove sutures, evacuate hematoma, eliminate bleeding

source, irrigate with normal saline and re-suture

– Consider penrose drain and antibiotic prophylaxis

Management of Complications

Management of Complications

• Post-operative Small Hematoma– If noticed early - may evacuate, irrigate and re-suture

– If noticed late or organized - use warm compresses

intermittently applied for 30 to 60 minutes to speed

resolution

– If fluctuant liquefaction present at around 1 to 2 weeks,

may aspirate with large bore needle (16 to 18 gauge)

Management of Complications

Management of Complications

• Post-operative Infections– Rare - < 5% (most likely 1 to 2 %)

– Presents POD 4 to 8

– Increasing pain, drainage, swelling and redness

– Properly inform patient on wound care

• Wash hands prior to dressing changes

• Don’t allow blood to accumulate

Management of Complications

• Treatment of Post-operative Infections– If fluctuant, open a few sutures and allow to drain

– Culture (usually S. aureus)

– Begin antibiotics prior to culture results

– 1st generation cephalosporin

– For ear, consider a fluoroquinolone to cover

Pseudomonas

Management of Complications

• Beware Infection

Imposters– Contact dermatitis to

topical antibiotic or

bandage adhesive

– “Itchy little red

bumps”

Management of Complications

Management of Complications

• Necrosis– Reduce edema and tension with elevation

– Reduce tension by removing or replacing suture

– Avoid temptation to aggressively debride the area

– Allow full extent of necrosis to present before

debridement

Management of Complications

Management of Complications

• Wound Dehiscence– Caused by tension, infection or necrosis

– Usually occurs at suture removal

– 2 weeks post-op - tensile strength only 10% of normal

– Consider removing sutures in stages or using Sterri-Strips

– If tension alone the cause, may re-suture

Management of Complications

• Suture Granuloma– Most common

approximately 6

weeks post-op

– Lance with sterile

needle and remove

suture fragment

Management of Complications

• Suture Tracks– Caused by sutures too tight and left in too long – not size of

suture

– Minimize with good buried sutures and removing

superficial sutures early

Management of Complications

Management of Complications

• Hypertrophic Scar and Keloid– Common on back, chest, shoulders, Earlobes and Neck

– Genetic Predisposition

– Potent topical or intralesional steroids

– Silicone gel sheeting or Mederma (onion extract)

– Occlusion, hydration and massage may be as effective

Hypertrophic Scar and Keloid Pearl

Jet Injector

Management of Complications

• Vasovagal Syncope– No loss of bladder or bowel control, heart rate low and

blood pressure and respiratory rate normal

– Always properly position patient prior to any procedure

– Place patient in Trendelenburg position, wet paper towel to

forehead and keep patient calm

Vasovagal Syncope – Pearl

Universal Precautions Always

Final Pearls• Allow adequate time for surgery (especially when getting

started)

• Inform and prepare the patient well

• Plan ahead for complications and anticipate problems

• Properly position the patient

• Mark the lesion prior to administering anesthesia

• Place good subcuticular sutures and HANDLE TISSUE GENTLY

• Apply pressure dressing (careful with flaps)

• Have systems in place and “be a creature of habit”• Document everything

• Universal precautions always!