Dermatologic Surgery Powerpoint Presentation

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Dermatologic Surgery

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Dermatologic Surgery KCOM/Texas Dermatology Residency NE Regional Medical Center

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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….

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Antibiotic Prophylaxis: Absolute 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: 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: Diabetic? Elderly? Atherosclerosis? PVD Disease? Thyroid dysfunction? Nutritional status? Smoker? HIV, Immunosuppressive Medications?

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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”

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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.

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DR. LIN PERFORMS HIS 100TH SEBORRHEIC KERATOSIS-ECTOMY!!!

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Local Anesthesia

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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

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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.

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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.

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“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.

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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.

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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.

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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

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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

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RICK UTILIZES VALUABLE INTERNET RESOURCES DURING HIS RESIDENCY…

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Common Procedures Shave Biopsy Punch Biopsy Excisional Biopsy Cryosurgery

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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

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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

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Shave Biopsy - skin tension

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Shave Biopsy - flush w/ surface

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

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Stay superficial for minimal scarring. Pink atrophic area has a full year to heal. Upper chest and back scars no matter what you do.

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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”

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Punch Biopsy 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 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 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 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 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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Narrow hole extrusion of lipoma

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Narrow hole extrusion of lipoma

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Narrow hole extrusion of lipoma

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Narrow hole extrusion of lipoma

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Excisional Biopsy Will cover this later under Excision…..

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Hemostasis Chemical Electrical Physical

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Chemical Hemostasis Drysol Aluminum Chloride Quick, easy, cheap. Q-tip application. No odor or discoloration. Good for superficial biopsy - shave.

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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.

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High Frequency Electrosurgery Monoterminal elecrodessication- low levels of current. Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators. Requires dry field.

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

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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

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Stabilize skin with non-dominant hand Pencil method Potatoe-peeler method Normal dermis feels “gritty” Cancer lesion + 2-3mm margin 2-3 cycles

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Cryosurgery 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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Classic atrophic hypopigmented cryosurgery scars……

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SUPERFICIAL BCC TREATED WITH CRYOSURGERY USING 3-4mm MARGINS

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Electrosurgery 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 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 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 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 “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 Needle Holders Forceps Skin hooks Scissors

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WEBSTER NEEDLE HOLDER

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GILLIES

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BROWN ADSON FORCEPS – HEAVY TISSUES

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CASTROVIEJO FORCEPS – DELICATE TISSUES

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SMALL TISSUE FLAPS LARGER FLAPS

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IDEAL FOR DELICATE TISSUE FLAPS WHERE SKIN IS THIN

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IDEAL FOR FLAPS, CUTTING THICK, LESS DELICATE TISSUE

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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 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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Using felt tip pen mark a circle around lesion with recommendedmargins. Ellipse should be 3 times longer than circle around lesion.

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Try to postion the final suture line within existing wrinkle lines/least tension.

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Sterile procedure requires Betadine application, but have nurses use GENTLY, if you get too aggressive ink will rinse away, now you’re lost!

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BRANCHES OF FACIAL NERVE: TO ZANZIBAR BY MOTOR CAR….

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Facial Nerve Damage 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 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

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Absorbable Suture 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 Silk (good for oral mucosa) Nylon (Dermalon, Ethilon, Surgilon) Polypropylene (Prolene, Surgilene) Polyester (Dacron, Ethibond, Mersilene) Polybutester (Novafil)

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SIMPLE INTERRUPTED PRO: Good approximation of superficial tissues. CON: RR track scarring/time

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VERTICAL MATTRESS PRO: Enhances wound eversion and decreases scarring CON: Time consuming

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CORNER STITCH Helps avoid tip strangulation KEY: Be sure this is the last suture, not the first. Should be low tension.

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HORIZONTAL MATTRESS PRO: Good for high tension wounds CON: Tends to cut into/strangulate tissues and higher risk dehiscence or scarring.

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RUNNING

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RUNNING, LOCKED

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RUNNING HORIZONTAL MATTRESS

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DEEP SUTURES

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RUNNING SUBCUTANEOUS

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RUNNING SUBCUTICULAR

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Mohs Surgery 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 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 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 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 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 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 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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National Comprehensive Cancer Network SKIN CANCER MGMT 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

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National Comprehensive Cancer Network SKIN CANCER MGMT 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

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Rick working on his home-made LASER

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Cutaneous Laser Surgery 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 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 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 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) 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 532 nm wavelength Vascular and superficial pigmented. Significant Hgb and melanin absorption

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Q-Switched Alexandrite 755 nm wavelength Absorbed by deep dark pigment ie., blue, black and green tatoo pigment

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IPL: Intense Pulsed Light Continuous spectrum 515 - 1200nm Extremely versatile Rosacea Telangiectasias Spotty discoloration

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Carbon Dioxide 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 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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RICK SOMETIMES GETS CARRIED AWAY WITH THE PUNCH BIOPSY TECHNIQUE ON THE SCALP…