Dermatologic SurgeryDermatologic Surgery

KCOM/Texas Dermatology KCOM/Texas Dermatology ResidencyResidency

NE Regional Medical CenterNE Regional Medical Center

IntroductionIntroduction

• Derm surgery increasing in complexityDerm surgery increasing in complexity

• Aesthetic and Laser proceduresAesthetic and Laser procedures

• Plastic surgery – blepharoplasty, Plastic surgery – blepharoplasty, facelifts, liposuctionfacelifts, liposuction

• Mohs micrographic surgeryMohs micrographic surgery

• Increasing emphasis on patient safety, Increasing emphasis on patient safety, documentation, and accreditation.documentation, and accreditation.

Basics: Pre-Op EvaluationBasics: Pre-Op Evaluation• Drug AllergiesDrug Allergies

• Meds: Coumadin, Plavix, ASA.Meds: Coumadin, Plavix, ASA.

• Pacemaker? Defibrillator?Pacemaker? Defibrillator?

• MVP, Endocarditis, Prosthetics?MVP, Endocarditis, Prosthetics?

• Informed Consent, risks v. benefits Informed Consent, risks v. benefits and options must all be discussed & and options must all be discussed & signedsigned

• OTC and Herbals…..OTC and Herbals…..

Herbal Supplements that Herbal Supplements that inhibit coagulation….inhibit coagulation….

• MOST COMMON: Fish Oils, Garlic, MOST COMMON: Fish Oils, Garlic, Gingko, Ginseng, Chinese Gingko, Ginseng, Chinese Herbal/Green Teas, Vitamin EHerbal/Green Teas, Vitamin E

• Alfalfa, Capsicum, Celery, Chamomile, Alfalfa, Capsicum, Celery, Chamomile, Dong quai, Fenugreek, Feverfew, Dong quai, Fenugreek, Feverfew, Ginger, Horseradish, Huang qui, Kava Ginger, Horseradish, Huang qui, Kava kava, Licorice, Passionflower, Red kava, Licorice, Passionflower, Red Clover. Clover.

• Dermatol Surg 28: June 2002, 449Dermatol Surg 28: June 2002, 449

ASA/NSAID containing drugsASA/NSAID containing drugs

•There are about 160 of themThere are about 160 of them

•Most are OTCMost are OTC

•Patients don’t think of these as Patients don’t think of these as drugs because they are not drugs because they are not prescriptions.prescriptions.

•See next slide….See next slide….

• 4-Way Cold Tablets, Adprin B, A.S.A., Aches-N Pain, 4-Way Cold Tablets, Adprin B, A.S.A., Aches-N Pain, Advil, Alcohol, Aleve, Alka-Seltzer, Amigesic, Advil, Alcohol, Aleve, Alka-Seltzer, Amigesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Anacin, Anaprox, Anodynos, Ansaid, APC, Argesic, Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Arthra-G, Arthralgen, Arthritis Bayer, Arthritis Pain Formula, Arthritis-Strength Bufferin, Arthropan, Formula, Arthritis-Strength Bufferin, Arthropan, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Arthrotec, Ascodeen, Ascriptin, Asperbuf, Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Aspergum, Aspirin, Axdone, Axotal, Bayer, BC Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Powder, Brufen, Buf-Tabs, Buff-A Comp, Buffaprin, Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Bufferin, Buffets II, Buffex, Buffinol, Cama Arthritis Pain Reliever, Cataflam, Cephalgesic, Cheracol, Pain Reliever, Cataflam, Cephalgesic, Cheracol, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Clinoril, Congesprin, Cope, Coricidin, Coumadin, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Darvon, Dasin, Daypro, DiFlunisal, Disalcid, Doan’s, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Dolobid, Dristan, Duoprin-S, Duradyne, Easprin, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Ecotrin, Emagrin, Empirin, Emprazil, Endodan, Epromate, Equagesic, Equazine M, Etodolac, Epromate, Equagesic, Equazine M, Etodolac, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Excedrin, Feldene, Fenoprofen, Fiorgen PF, Fiorinal, Fluriprofen, Gelpirin, Gensan, Goody’s Headache Fluriprofen, Gelpirin, Gensan, Goody’s Headache Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Powder, Halfprin, Haltran, Ibu-Tab, Ibuprin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Ibuprohm, Indochron E-R, Indocin, Indomethacin, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Isollyl Improved, Ketorolac, Ketoprofen, Lanorinal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal, Lodine, Lortab, Magan, Magnaprin, Marnal, Magsal,

Past Medical History….Past Medical History….

Antibiotic Prophylaxis: Antibiotic Prophylaxis: AbsoluteAbsolute

• Artificial Heart ValveArtificial Heart Valve

• Artificial Joint Replacement < 6 monthsArtificial Joint Replacement < 6 months

• Past history Endocarditis, Rheumatic Past history Endocarditis, Rheumatic FeverFever

• Mitral Valve Prolapse with holosystolic Mitral Valve Prolapse with holosystolic murmurmurmur

Antibiotic Prophylaxis:Antibiotic Prophylaxis:

• DISCRETIONARY:DISCRETIONARY:• Mucous membrane surgeryMucous membrane surgery• Wound open > 24 hoursWound open > 24 hours• ImmunosuppressionImmunosuppression

• Regimen: Cephalexin or Erythromycin 1 Regimen: Cephalexin or Erythromycin 1 gram po 1 hour prior to procedure and gram po 1 hour prior to procedure and 500mg po 6 hours after the procedure500mg po 6 hours after the procedure

Wound Healing Prognosis:Wound Healing Prognosis:

• Diabetic? Diabetic?

• Elderly?Elderly?

• Atherosclerosis? PVD Disease?Atherosclerosis? PVD Disease?

• Thyroid dysfunction?Thyroid dysfunction?

• Nutritional status?Nutritional status?

• Smoker?Smoker?

• HIV, Immunosuppressive Medications?HIV, Immunosuppressive Medications?

PacemakersPacemakers• ““If a procedure is performed within a If a procedure is performed within a

few centimeters of a pacemaker, few centimeters of a pacemaker, electrosurgery should be executed electrosurgery should be executed with extreme care or possibly with extreme care or possibly replaced by (thermal) cautery” replaced by (thermal) cautery”

• ““Although modern devices are better Although modern devices are better shielded against external electrical shielded against external electrical interference, it is always prudent to interference, it is always prudent to consult a cardiologist and deliver consult a cardiologist and deliver short bursts < 5 seconds”short bursts < 5 seconds”

CoumadinCoumadin• The current thinking is to leave The current thinking is to leave

patients on Coumadin unless their patients on Coumadin unless their Cardiologist approves taking them off.Cardiologist approves taking them off.

• REMEMBER: Some people are not REMEMBER: Some people are not surgical candidates and might be surgical candidates and might be better served with radiation therapy better served with radiation therapy for their skin cancers. Radiation for their skin cancers. Radiation Oncologists love skin cancer because Oncologists love skin cancer because they can actually cure it.they can actually cure it.

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

Local AnesthesiaLocal Anesthesia

AnestheticsAnestheticsXylocaine – fast onset, lasts ¾ to 3 hoursXylocaine – fast onset, lasts ¾ to 3 hours

Marcaine – onset slow at 3-5 min, lasts 2-3 Marcaine – onset slow at 3-5 min, lasts 2-3 hourshours

cardiac side effectscardiac side effects

Allergic reactions are rare, but vasovagal Allergic reactions are rare, but vasovagal reactions are commonreactions are common

ELA-Max cream – 30 minutes prior to ELA-Max cream – 30 minutes prior to procedure reduces pain of injection. procedure reduces pain of injection. Avaliable OTC and expensive but patients Avaliable OTC and expensive but patients appreciate this extra measure of comfort.appreciate this extra measure of comfort.

EMLA - Rx only, methemoglobinemia side EMLA - Rx only, methemoglobinemia side effects due to prilocaine contenteffects due to prilocaine content

Local AnesthesiaLocal Anesthesia

• Pearl: fears of epinephrine induced Pearl: fears of epinephrine induced necrosis at distal sites (nose, ears, necrosis at distal sites (nose, ears, penis, toes, fingertips) are largely penis, toes, fingertips) are largely unfounded. unfounded.

• Pitfalls: patients with severe peripheral Pitfalls: patients with severe peripheral vascular disease, diabetic angiopathy vascular disease, diabetic angiopathy and Raynaud’s phenomenon may be and Raynaud’s phenomenon may be exceptions to the rule. exceptions to the rule.

• Insert needle at a 30 degree angle and slowly Insert needle at a 30 degree angle and slowly retract the needle as you inject the retract the needle as you inject the anesthetic. When the tissue blanches you are anesthetic. When the tissue blanches you are at the right level.at the right level.

““I’m allergic to Novacaine”I’m allergic to Novacaine”

• Pearl: It is OK to give Xylocaine to Pearl: It is OK to give Xylocaine to patients who had allergic reactions to patients who had allergic reactions to Novocaine at the dentist’s office, Novocaine at the dentist’s office, Lidocaine is an Amide and Novocaine Lidocaine is an Amide and Novocaine is an Ester.is an Ester.

• Pitfall: They may not know which Pitfall: They may not know which medication they reacted to: use medication they reacted to: use Bacteriostatic NS when in doubt.Bacteriostatic NS when in doubt.

Pain ControlPain Control

• Local Anesthesia:Local Anesthesia:

• Pearl: INJECT SLOWLY and your Pearl: INJECT SLOWLY and your patients will love you forever. patients will love you forever. Decreases pain more than warming Decreases pain more than warming or adding bicarbonate. or adding bicarbonate.

• Distraction techniques useful as well Distraction techniques useful as well – pinching skin during injection etc.– pinching skin during injection etc.

Pediatric Pain ManagementPediatric Pain Management

• Pearl: For pediatric patients, let Pearl: For pediatric patients, let them sit in the lobby with ELA-Max or them sit in the lobby with ELA-Max or EMLA covered with Saran Wrap for EMLA covered with Saran Wrap for 30 minutes. Your eardrums will 30 minutes. Your eardrums will thank you.thank you.

Surgical Cleansers: Surgical Cleansers:

• Clean Procedures:Clean Procedures:

• Isopropyl alcohol Isopropyl alcohol – weak antimicrobialweak antimicrobial– most commonly used agent for shave most commonly used agent for shave

biopsiesbiopsies

• Hydrogen peroxideHydrogen peroxide– no significant antiseptic propertiesno significant antiseptic properties– not suitable for sterile proceduresnot suitable for sterile procedures

Surgical Cleansers: SterileSurgical Cleansers: Sterile• Betadine Betadine

– irritating to skin, residual colorirritating to skin, residual color– must dry completely to be antimicrobialmust dry completely to be antimicrobial– absorbed by premature infantsabsorbed by premature infants

• Chlorhexidine (Hibiclens) Chlorhexidine (Hibiclens) – keratitis if it gets in the eyeskeratitis if it gets in the eyes

• Hexachlorophene (pHisoHex) Hexachlorophene (pHisoHex) – not on women or children due to not on women or children due to

neurotoxicity and teratogenicityneurotoxicity and teratogenicity

RICK UTILIZES VALUABLE INTERNET RESOURCES DURING HIS RESIDENCY…

Common ProceduresCommon Procedures

• Shave BiopsyShave Biopsy

• Punch BiopsyPunch Biopsy

• Excisional BiopsyExcisional Biopsy

• CryosurgeryCryosurgery

Shave biopsyShave biopsy

• Best suited to pedunculated, papular Best suited to pedunculated, papular or otherwise elevated lesions but or otherwise elevated lesions but may be used for macular lesions.may be used for macular lesions.

• SimpleSimple

• QuickQuick

• Satisfactory cosmetic resultSatisfactory cosmetic result

• Adequate biopsy tissue for diagnosisAdequate biopsy tissue for diagnosis

Shave BiopsyShave Biopsy• Sterile #15 bladeSterile #15 blade

• 4x4’s4x4’s

• Drysol solutionDrysol solution

• Sterile Q-tipsSterile Q-tips

• Path containerPath container

• Gillette Blue Gillette Blue Blade Razor cut in Blade Razor cut in half, bends to half, bends to follow contourfollow contour

Shave Biopsy - skin tensionShave Biopsy - skin tension

Shave Biopsy - flush w/ Shave Biopsy - flush w/ surfacesurface

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

• Stay superficial for minimal scarring.Stay superficial for minimal scarring.

• Pink atrophic area has a full year to heal.Pink atrophic area has a full year to heal.

• Upper chest and back scars no matter Upper chest and back scars no matter what you do.what you do.

Punch BiopsyPunch Biopsy

• Most common use is for skin biopsyMost common use is for skin biopsy

• Can excise small lesionsCan excise small lesions

• Treats acne scarsTreats acne scars

• Hair transplantationHair transplantation

• May stretch skin perpendicular to May stretch skin perpendicular to skin tension lines to create elliptical skin tension lines to create elliptical defect and avoid “dog ears”defect and avoid “dog ears”

Punch BiopsyPunch Biopsy

• Sterile procedure!Sterile procedure!

• Sterile glovesSterile gloves

• 3 or 4 mm Punch3 or 4 mm Punch

• 4x4s, Drysol, Q-tips4x4s, Drysol, Q-tips

• Needle driver, Needle driver, forcepsforceps

• SutureSuture

• Path specimen Path specimen bottlebottle

Punch BiopsyPunch Biopsy

• Twist punch tool until Twist punch tool until buried to the hub*buried to the hub*

• *Caveat: Have a firm *Caveat: Have a firm grasp of anatomy grasp of anatomy and skin thickness in and skin thickness in the area you are the area you are punching before you punching before you punch it. punch it.

• Finger tendons, facial Finger tendons, facial and neck structures.and neck structures.

Punch biopsyPunch biopsy

• KEY: do not crush tissue when KEY: do not crush tissue when removing it from the biopsy site. removing it from the biopsy site.

• Crush artifact makes pathologic Crush artifact makes pathologic interpretation difficult to impossible.interpretation difficult to impossible.

• Some pull it out using the suture Some pull it out using the suture needle as this method is atraumatic.needle as this method is atraumatic.

Punch BiopsyPunch Biopsy

• Hemostasis works Hemostasis works best in 2 steps.best in 2 steps.

• First use the Q-tip to First use the Q-tip to buy time to grab buy time to grab needle driver and needle driver and suture.suture.

• Suture so that Suture so that closure is low closure is low tension - simple tension - simple palpation reveals.palpation reveals.

Punch BiopsyPunch Biopsy

• Use 6-0 Prolene on Use 6-0 Prolene on the face.the face.

• 4-0 Prolene most 4-0 Prolene most other areas.other areas.

• Silk for mucosal Silk for mucosal areas.areas.

• 2 simple interrupted 2 simple interrupted sutures.sutures.

• Out 7d face, 10d otwOut 7d face, 10d otw

Narrow hole extrusion of lipoma

Narrow hole extrusion of lipoma

Narrow hole extrusion of lipoma

Narrow hole extrusion of lipoma

Excisional Biopsy Excisional Biopsy

• Will cover this later under Will cover this later under Excision…..Excision…..

HemostasisHemostasis

• Chemical Chemical

• ElectricalElectrical

• Physical Physical

Chemical HemostasisChemical Hemostasis

• DrysolDrysol

• Aluminum ChlorideAluminum Chloride

• Quick, easy, cheap.Quick, easy, cheap.

• Q-tip application.Q-tip application.

• No odor or No odor or discoloration.discoloration.

• Good for superficial Good for superficial biopsy - shave.biopsy - shave.

Chemical HemostasisChemical Hemostasis

• Monsel’s solution.Monsel’s solution.

• 20% ferric 20% ferric subsulfate.subsulfate.

• Cheap, easy to use.Cheap, easy to use.

• Risk of tattooing.Risk of tattooing.

• Superficial only!Superficial only!

• Caustic, may destroy Caustic, may destroy connective tissue if connective tissue if sutured into wound.sutured into wound.

High Frequency High Frequency ElectrosurgeryElectrosurgery• Monoterminal Monoterminal

elecrodessicatielecrodessication- low levels on- low levels of current.of current.

• Risk of Risk of Bradycardia or Bradycardia or Asystole in Asystole in patients with patients with Pacemakers or Pacemakers or Defibrillators.Defibrillators.

• Requires dry Requires dry field. field.

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

THERMAL CAUTERY

CurettageCurettage

• Round semi-sharp knife 0.5 to 10mmRound semi-sharp knife 0.5 to 10mm

• Does not easily cut through normal Does not easily cut through normal dermis and will not enter the dermisdermis and will not enter the dermis

• Best for soft friable lesions.Best for soft friable lesions.

• Learning Curve: BCC recurrence rate for Learning Curve: BCC recurrence rate for residents far higher than that of residents far higher than that of attending physicians – Kopf et al, 1977attending physicians – Kopf et al, 1977

• Stabilize skin Stabilize skin with non-with non-dominant handdominant hand

• Pencil methodPencil method

• Potatoe-peeler Potatoe-peeler methodmethod

• Normal dermis Normal dermis feels “gritty”feels “gritty”

• Cancer lesion + Cancer lesion + 2-3mm margin2-3mm margin

• 2-3 cycles2-3 cycles

CryosurgeryCryosurgery

• Easy, heals quickly, minimal complicationsEasy, heals quickly, minimal complications

• Liquid nitrogen -195.6 degrees CLiquid nitrogen -195.6 degrees C

• Rapid freezing, slow thaw increases Rapid freezing, slow thaw increases cellular damagecellular damage

• Melanocytes are more sensitive to Melanocytes are more sensitive to freezing than keratinocytes, may cause freezing than keratinocytes, may cause long lasting hyperpigmentation in darker long lasting hyperpigmentation in darker complexionscomplexions

Classic atrophic Classic atrophic hypopigmented cryosurgery hypopigmented cryosurgery scars……scars……

SUPERFICIAL BCC TREATED WITH CRYOSURGERY USING 3-4mm MARGINS

ElectrosurgeryElectrosurgery

• DestructionDestruction

• Hemostasis for simple or complex Hemostasis for simple or complex excisional surgeryexcisional surgery

• Mechanism – heat destroys tissueMechanism – heat destroys tissue

• Electrocautery – no current passes Electrocautery – no current passes through the patient.through the patient.

• SK, DPN, SGH, SKIN TAGS, VVSK, DPN, SGH, SKIN TAGS, VV

Electro-epilationElectro-epilation

• Follicular destructionFollicular destruction

• AKA ElectrolysisAKA Electrolysis

• Chemical reaction at electrode tip Chemical reaction at electrode tip causes production of sodium hydroxide causes production of sodium hydroxide (lye) at the hair root – works without (lye) at the hair root – works without scarring.scarring.

• Takes 1 minute per follicle, very slow.Takes 1 minute per follicle, very slow.

• Largely replaced by laser hair removal.Largely replaced by laser hair removal.

Electrodessication/Electrodessication/ElectrofulgurationElectrofulguration

• Electrodessication – tip touches tissueElectrodessication – tip touches tissue

• Electrofulguration – 1-2mm separation Electrofulguration – 1-2mm separation between tip and tissuebetween tip and tissue

• High voltage and low amperage limits High voltage and low amperage limits depth of destructiondepth of destruction

• Monoterminal current – no grounding Monoterminal current – no grounding requiredrequired

ElectrodessicationElectrodessication

• LOW POWER: LOW POWER:

• Facial telangiectasiasFacial telangiectasias

• SyringomasSyringomas

• HIGH POWER:HIGH POWER:

• SK, Skin Tags, VVSK, Skin Tags, VV

• EDC: BCC & SCC under 2 cm, 2-3 cyclesEDC: BCC & SCC under 2 cm, 2-3 cycles

• Hemostasis during excisional surgery.Hemostasis during excisional surgery.

ElectrosectionElectrosection• ““Cutting Current”, Radio-Frequency Cutting Current”, Radio-Frequency

Ablat.Ablat.• Biterminal current produced by vacuum Biterminal current produced by vacuum

tube is similar in form to radiowavestube is similar in form to radiowaves• Active electrode is coolActive electrode is cool• Tissue disruption occurs in response to Tissue disruption occurs in response to

the wave at the point of contact.the wave at the point of contact.• Minimal trauma, excellent hemostasis.Minimal trauma, excellent hemostasis.• ““Custom” attachments: wire loops, Custom” attachments: wire loops,

balls, needles, scalpels.balls, needles, scalpels.

Excision: InstrumentsExcision: Instruments

• Needle HoldersNeedle Holders

• ForcepsForceps

• Skin hooksSkin hooks

• ScissorsScissors

WEBSTER NEEDLE HOLDER

GILLIES

BROWN ADSON FORCEPS – HEAVY TISSUES

CASTROVIEJO FORCEPS – DELICATE TISSUES

SMALL TISSUE FLAPS

LARGER FLAPS

IDEAL FOR DELICATE TISSUE FLAPS WHERE SKIN IS THIN

IDEAL FOR FLAPS, CUTTING THICK, LESS DELICATE TISSUE

USEFUL IN ACCURATE TAILORING OF FINER STRUCTURES, ALSO STEVENS TENOTOMY, FINE IRIS AND GRADLE

A word on excisional biopsyA word on excisional biopsy• If you suspect thin melanoma a shave If you suspect thin melanoma a shave

“saucerization” of entire lesion is OK“saucerization” of entire lesion is OK

• If you have residual pigment at the If you have residual pigment at the base you can always punch that.base you can always punch that.

• If you suspect a nodular melanoma If you suspect a nodular melanoma excisional biopsy to SQ.excisional biopsy to SQ.

• Punch bx, while deep enough, is NOT Punch bx, while deep enough, is NOT representative of the entire lesion. representative of the entire lesion.

• Using felt tip Using felt tip pen mark a pen mark a circle around circle around lesion with lesion with recommenderecommendedmargins.dmargins.

• Ellipse Ellipse should be 3 should be 3 times longer times longer than circle than circle around around lesion.lesion.

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

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

BRANCHES OF FACIAL NERVE:

TO ZANZIBAR BY MOTOR CAR….

Facial Nerve DamageFacial Nerve Damage

• Temporal branch - forehead and Temporal branch - forehead and eyebrow ptosis, may obstruct vision.eyebrow ptosis, may obstruct vision.

• Zygomatic branch - impaired blinking, Zygomatic branch - impaired blinking, eye dries out, clarity of vision is eye dries out, clarity of vision is affected.affected.

• Buccal branch - drooping corner of Buccal branch - drooping corner of mouth, mouth,

• Marginal Mandibular - lower lip function.Marginal Mandibular - lower lip function.

TO ZANZIBAR BY MOTOR CAR & TO ZANZIBAR BY MOTOR CAR & VARIATIONS ON A THEME…..INFORMED VARIATIONS ON A THEME…..INFORMED CONSENT!!!!!CONSENT!!!!!

Excisional SurgeryExcisional Surgery

• Indicated for LOW RISK SCC and BCC:Indicated for LOW RISK SCC and BCC:• Trunk, Neck or Extremitiy <20mmTrunk, Neck or Extremitiy <20mm• Cheeks, Forehead, Scalp <10mmCheeks, Forehead, Scalp <10mm• ““Mask Areas”, Genitalia, Hands, Feet Mask Areas”, Genitalia, Hands, Feet

<6mm<6mm• Age > 40Age > 40• No history of immunosuppresion, rapidly No history of immunosuppresion, rapidly

growing tumor, prior X-ray tx, palpable growing tumor, prior X-ray tx, palpable LAD, pain, paresthesais, paralysis.LAD, pain, paresthesais, paralysis.

• Path without: poor differentiation, Path without: poor differentiation, morpheaform, micronodular, infiltrationmorpheaform, micronodular, infiltration

Mask Area of FaceMask Area of Face

Absorbable SutureAbsorbable Suture

• Gut (Chromic)Gut (Chromic)– fast absorbing for surface closure as fast absorbing for surface closure as

tensile strength is lost in days (FTSG)tensile strength is lost in days (FTSG)– PlainPlain

• Polyglycolic acid (Dexon)Polyglycolic acid (Dexon)• Polyglactin 910 (Vicryl)Polyglactin 910 (Vicryl)• Polydiaxone (PDS)Polydiaxone (PDS)• Polytrimethylene carbonate (Maxon)Polytrimethylene carbonate (Maxon)• Poliglecaprone 25 (Monocryl)Poliglecaprone 25 (Monocryl)

Non Absorbable SutureNon Absorbable Suture

• Silk (good for oral mucosa)Silk (good for oral mucosa)

• Nylon (Dermalon, Ethilon, Surgilon)Nylon (Dermalon, Ethilon, Surgilon)

• Polypropylene (Prolene, Surgilene)Polypropylene (Prolene, Surgilene)

• Polyester (Dacron, Ethibond, Polyester (Dacron, Ethibond, Mersilene)Mersilene)

• Polybutester (Novafil)Polybutester (Novafil)

SIMPLE INTERRUPTEDSIMPLE INTERRUPTEDPRO: Good approximation of PRO: Good approximation of superficial tissues. superficial tissues. CON: RR track scarring/timeCON: RR track scarring/time

VERTICAL MATTRESSVERTICAL MATTRESSPRO: Enhances wound eversion PRO: Enhances wound eversion and decreases scarringand decreases scarringCON: Time consumingCON: Time consuming

CORNER STITCHCORNER STITCHHelps avoid tip strangulationHelps avoid tip strangulationKEY: Be sure this is the last KEY: Be sure this is the last suture, not the first. Should be suture, not the first. Should be low tension.low tension.

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

RUNNINGRUNNING

RUNNING, LOCKEDRUNNING, LOCKED

RUNNING HORIZONTAL RUNNING HORIZONTAL MATTRESSMATTRESS

DEEP SUTURESDEEP SUTURES

RUNNING SUBCUTANEOUSRUNNING SUBCUTANEOUS

RUNNING SUBCUTICULARRUNNING SUBCUTICULAR

Mohs SurgeryMohs Surgery

Frederick Mohs 1930 Fixed TissueFrederick Mohs 1930 Fixed Tissue

Tromovitch 1970’s Frozen TissueTromovitch 1970’s Frozen Tissue

Control of 100% of surgical marginsControl of 100% of surgical margins

Allows smaller margins to be takenAllows smaller margins to be taken

Cosmetically sensitive areasCosmetically sensitive areas

H zoneH zone

Not just for recurrent tumors anymoreNot just for recurrent tumors anymore

MohsMohs

• Rowe et al reviewed literature since Rowe et al reviewed literature since 19471947

• 5 year recurrence rates primary BCC5 year recurrence rates primary BCC

• MohsMohs 1%1%

• ExcisionExcision 10.1%10.1%

• C&DC&D 7.7%7.7%

• XRTXRT 8.7%8.7%

MohsMohs

• Rowe et al cont’dRowe et al cont’d

• Primary SCC 5 year recurrence ratesPrimary SCC 5 year recurrence rates

• MohsMohs 3.1%3.1%

• ExcisionExcision 8.1%8.1%

• C&DC&D 3.7%3.7%

• XRTXRT 10%10%

Surgical ComplicationsSurgical Complications

• Hematoma – no evidence that ASA, Hematoma – no evidence that ASA, NSAID or COUMADIN increases risk of NSAID or COUMADIN increases risk of hematomahematoma

• Infection – high risk on earInfection – high risk on ear

• Dehiscence – from infection, traumaDehiscence – from infection, trauma

• Necrosis – high tension in sutures or Necrosis – high tension in sutures or wound edges, poor flap design.wound edges, poor flap design.

Avoiding Surgical Avoiding Surgical ComplicationsComplications

• Aseptic techniqueAseptic technique

• Meticulous hemostasisMeticulous hemostasis

• Wide undermining Wide undermining

• Good surgical planningGood surgical planning

• Controversy: DC ASA 2 weeks, Controversy: DC ASA 2 weeks, Coumadin 2 days, NSAIDS 1 weekCoumadin 2 days, NSAIDS 1 week

X-ray therapy for NMSCX-ray therapy for NMSC• Similar recurrence rates as standard Similar recurrence rates as standard

excision, C&D, Cryo but less invasive.excision, C&D, Cryo but less invasive.

• Ideal for patients that are not Ideal for patients that are not surgical candidates due to multiple surgical candidates due to multiple co-morbiditiesco-morbidities

• Once Mohs determines tumor has Once Mohs determines tumor has bone or perineural involvement.bone or perineural involvement.

• Downfall: Tumors that recur after Downfall: Tumors that recur after XRT tend to be aggressive with wider XRT tend to be aggressive with wider subclinical tumor extensionsubclinical tumor extension

Photodynamic TherapyPhotodynamic Therapy

• Light + Photosensitizer = O2 free Light + Photosensitizer = O2 free radicalsradicals

• Aminolevulenic Acid (5-ALA) + Blue lightAminolevulenic Acid (5-ALA) + Blue light

• ExpensiveExpensive

• PainfulPainful

• Not widely acceptedNot widely accepted

• NMSC cure rates vary from 50% to 100%NMSC cure rates vary from 50% to 100%

National Comprehensive Cancer National Comprehensive Cancer NetworkNetwork

SKIN CANCER MGMTSKIN CANCER MGMT

• LOCAL DISEASE:LOCAL DISEASE:

• C&D FOR LOW RISK BCC ONLY – F/UC&D FOR LOW RISK BCC ONLY – F/U

• EXCISION WITH POMA – CLEAR? –F/UEXCISION WITH POMA – CLEAR? –F/U

• IF RECURRENT OR HIGH RISK, MOHSIF RECURRENT OR HIGH RISK, MOHS

• IF MOHS CANNOT CLEAR OR IF MOHS CANNOT CLEAR OR INVOLVES BONE OR NEURAL, XRT, INVOLVES BONE OR NEURAL, XRT, MULTIDISCIPLINARY APPROACHMULTIDISCIPLINARY APPROACH

National Comprehensive Cancer National Comprehensive Cancer NetworkNetwork

SKIN CANCER MGMTSKIN CANCER MGMT• PALPABLE LYMPHADENOPATHY SHOULD PALPABLE LYMPHADENOPATHY SHOULD

PROMP FNA, BUT EVEN IF FNA IS NEGATIVE PROMP FNA, BUT EVEN IF FNA IS NEGATIVE OPEN BIOPSY WITH FROZEN SECTIONS AND OPEN BIOPSY WITH FROZEN SECTIONS AND POSSIBLE REGIONAL DISSECTION FOLLOWSPOSSIBLE REGIONAL DISSECTION FOLLOWS

• ADJUVANT XRT ESPECIALLY IF > 1 LYMPH ADJUVANT XRT ESPECIALLY IF > 1 LYMPH NODE INVOLVEDNODE INVOLVED

• PALPABLE PAROTID MASS = PAROTIDECTOMYPALPABLE PAROTID MASS = PAROTIDECTOMY

Rick working on his home-Rick working on his home-made LASERmade LASER

Cutaneous Laser SurgeryCutaneous Laser Surgery

• LLight ight AAmplification by mplification by SStimulated timulated EEmission of mission of RRadiationadiation

• Light limited to one WAVELENGTHLight limited to one WAVELENGTH

• CHROMOPHORES are substances that CHROMOPHORES are substances that preferentially absorb one WAVELENGTHpreferentially absorb one WAVELENGTH

• Examples: water, Hgb, melaninExamples: water, Hgb, melanin

• HEAT created = “Selective Thermolysis”HEAT created = “Selective Thermolysis”

Argon LaserArgon Laser

• Vascular and pigmented lesionsVascular and pigmented lesions

• 488 to 514 nm wavelength488 to 514 nm wavelength

• These are NOT the wavelengths These are NOT the wavelengths specific to Hgb and melanin, therefore specific to Hgb and melanin, therefore damage to surrounding tissue damage to surrounding tissue significant, possibly leading to significant, possibly leading to scarring and hypopigmentation.scarring and hypopigmentation.

• Has fallen out of favorHas fallen out of favor

Flashlamp Pumped Pulsed Flashlamp Pumped Pulsed DyeDye

• Port wine stains, telangiectasiasPort wine stains, telangiectasias

• 585 nm wavelength585 nm wavelength

• Low risk of scarring and pigment Low risk of scarring and pigment changechange

• Black/gray discoloration due to Black/gray discoloration due to intravascular coagulation.intravascular coagulation.

Q switched RubyQ switched Ruby

• Melanin and darkly pigmented tattoo Melanin and darkly pigmented tattoo pigments (black, blue, green) targetspigments (black, blue, green) targets

• 694 nm wavelength694 nm wavelength

• Q-switching allows delivery of extremely Q-switching allows delivery of extremely high energy at pulses that last only high energy at pulses that last only nanosecondsnanoseconds

• Good for deep pigment, ie. Nevus of OtaGood for deep pigment, ie. Nevus of Ota

• Minimal scarring, transient Minimal scarring, transient hypopigment.hypopigment.

Neodynium:Yttrium-Aluminum-Neodynium:Yttrium-Aluminum-Garnet (Nd:YAG)Garnet (Nd:YAG)

• 1064 wavelength1064 wavelength

• Continuous mode – PWS, venous Continuous mode – PWS, venous malform.malform.

• Q-switched mode – black, blue Q-switched mode – black, blue tattoostattoos

• Frequency doubled 532 - red tattoo, Frequency doubled 532 - red tattoo, vascular, superficial pigmentedvascular, superficial pigmented

KTP: Potassium Titanyl KTP: Potassium Titanyl PhosphatePhosphate

• 532 nm wavelength532 nm wavelength

• Vascular and superficial pigmented.Vascular and superficial pigmented.

• Significant Hgb and melanin Significant Hgb and melanin absorptionabsorption

Q-Switched AlexandriteQ-Switched Alexandrite

• 755 nm wavelength755 nm wavelength

• Absorbed by deep dark pigment ie., Absorbed by deep dark pigment ie., blue, black and green tatoo pigmentblue, black and green tatoo pigment

IPL: Intense Pulsed LightIPL: Intense Pulsed Light

• Continuous spectrum 515 - 1200nmContinuous spectrum 515 - 1200nm

• Extremely versatileExtremely versatile

• RosaceaRosacea

• TelangiectasiasTelangiectasias

• Spotty discolorationSpotty discoloration

Carbon Dioxide Carbon Dioxide

• 10,600 nm wavelength, H2O 10,600 nm wavelength, H2O chromophorechromophore

• Super-pulsed allows destruction of Super-pulsed allows destruction of epidermis and papillary dermis while epidermis and papillary dermis while limiting deeper damage.limiting deeper damage.

• Can actually see it tighted the collagenCan actually see it tighted the collagen

• Excellent for photodamage, rhytidsExcellent for photodamage, rhytids

• Lots of down time, side effects.Lots of down time, side effects.

Erbium:Yttrium-Al-GarnetErbium:Yttrium-Al-GarnetEr:YAGEr:YAG

• 2940 nm wavelength2940 nm wavelength

• Ablative, but with less thermal Ablative, but with less thermal damage than the CO2 laserdamage than the CO2 laser

• Ideal for treating very early Ideal for treating very early photodamage (superficial), but will photodamage (superficial), but will never tighten collagen as well as the never tighten collagen as well as the CO2CO2

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