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

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

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 - 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

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

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


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



• 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



• 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


Wound Healing and Infection

• Keloid or Hypertrophic Scarring Risk

– Shoulders, central chest, Upper Arms, Upper Back

– More common in certain skin types


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


• Consider prophylaxis to minimize infection– Long procedures

– Inflamed lesions

– Oronasal, genitourinary or axillary sites

– Distant skin infection


• 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


Reduce Complications• Tissue Injury and Necrosis

– Handle wound edges gently

– Use skin hooks or single-toothed forceps

– Resist urge to cauterize skin edges



• 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



• 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

• 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


• 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


• 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)


• 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


• 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


• Beware Infection

Imposters– Contact dermatitis to

topical antibiotic or

bandage adhesive

– “Itchy little red

bumps”


• 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


• 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


• Suture Granuloma– Most common

approximately 6

weeks post-op

– Lance with sterile

needle and remove

suture fragment


• 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


• 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


• 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!

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

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