32nd Annual Superficial Anatomy Cutaneous Surgery Course · 32nd Annual Superficial Anatomy &...
Transcript of 32nd Annual Superficial Anatomy Cutaneous Surgery Course · 32nd Annual Superficial Anatomy &...
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32nd Annual Superficial Anatomy & Cutaneous Surgery Course
July 6‐10, 2015 Del Mar Marriott Hotel, San Diego, California
32nd Annual Superficial Anatomy & Cutaneous Surgery Course
July 6‐10, 2015 Del Mar Marriott Hotel, San Diego, California
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Bi-level Anesthesia & Blunt DissectionBi-level Anesthesia & Blunt Dissection
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Blunt DissectionBlunt Dissection
BLUNT DISSECTION - Blunt - Edged and Blunt - Tipped Scissors, Cannulas, or fingers
Great separation strength
Sharp instruments are used only to facilitate entry into subcutaneous space
Should be on all surgical trays – not for cutting
Spares injury to fat layer
Reduces bleeding and scarring
Allows Palpation to feel depth and movement of instrument
Forward movement of the open “V” of your scissors’ fulcrum is used to shear the tissue layers from the flap underside.
Least injury to nerves, vessels or ducts results from this shearing movement - separates naturally at weakest point
BLUNT DISSECTION - Blunt - Edged and Blunt - Tipped Scissors, Cannulas, or fingers
Great separation strength
Sharp instruments are used only to facilitate entry into subcutaneous space
Should be on all surgical trays – not for cutting
Spares injury to fat layer
Reduces bleeding and scarring
Allows Palpation to feel depth and movement of instrument
Forward movement of the open “V” of your scissors’ fulcrum is used to shear the tissue layers from the flap underside.
Least injury to nerves, vessels or ducts results from this shearing movement - separates naturally at weakest point
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HILTON’S MANEUVER
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ANESTHESIA IN DERMATOLOGIC SURGERY
ANESTHESIA IN DERMATOLOGIC SURGERY
LOCAL
REGIONAL
TUMESCENT (liposuction and surgical)
BI-LEVEL
TECHNIQUES AND APPLICATIONS
LOCAL
REGIONAL
TUMESCENT (liposuction and surgical)
BI-LEVEL
TECHNIQUES AND APPLICATIONS
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TUMESCENT ANESTHESIATUMESCENT ANESTHESIA
1000 cc 0.9% Normal saline solution (NSS)
Lidocaine 0.01% is standard Klein’s formula (35 mgm/kg), but Lillis expanded to 50 mgm/kg, and Moy to 55 mgm/kg in healthy people.
Epinephrine HCl 1:500,000 (face, neck, and scalp) to 1:1,500,000 (body). 1.0 cc(1 mgm) of 1:1000 fresh epinephrine/liter gives a 1:1,000,000 dilution.
Sodium bicarbonate (8.4 meq/L) – use 12.5 cc to obtain 12.5 meq (8.4% NaH2CO3 solution). If you use Lactated Ringer’s solution, saves step of adding bicarbonate, which is another step
with potential error. More expensive.
Good to have pharmacists make up fresh. Then they have the responsibility.
If you are using surgical tumescent solution, you may prefer to add Triamcinolone 5 mgm/100 cc diluent for chemical peel,laser, dermabrasion, cryopeel, etc.
1000 cc 0.9% Normal saline solution (NSS)
Lidocaine 0.01% is standard Klein’s formula (35 mgm/kg), but Lillis expanded to 50 mgm/kg, and Moy to 55 mgm/kg in healthy people.
Epinephrine HCl 1:500,000 (face, neck, and scalp) to 1:1,500,000 (body). 1.0 cc(1 mgm) of 1:1000 fresh epinephrine/liter gives a 1:1,000,000 dilution.
Sodium bicarbonate (8.4 meq/L) – use 12.5 cc to obtain 12.5 meq (8.4% NaH2CO3 solution). If you use Lactated Ringer’s solution, saves step of adding bicarbonate, which is another step
with potential error. More expensive.
Good to have pharmacists make up fresh. Then they have the responsibility.
If you are using surgical tumescent solution, you may prefer to add Triamcinolone 5 mgm/100 cc diluent for chemical peel,laser, dermabrasion, cryopeel, etc.
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Blunt multi-port infiltratorVarying lengths
2.1 mm face & ant, lat neck3.5 mm nuchal area, body & extremities
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Field, Lawrence (1989)
Surgical Tumescent Solution(Modified for non-liposuction applications):
Field, Lawrence (1989)
Surgical Tumescent Solution(Modified for non-liposuction applications):
Lactated Ringer’s Solution (500 cc)
50 – 100 cc 1% Lidocaine (0.1 – 0.2%)
May use 2% for face and neck ( to 0.3% ) Safe to 55 mg / kg
1 cc 1:1,000 fresh Epinephrine HCL (1:500,000) (LSS is 1:1,000,000-1:1,500,000)
Warm to 38 – 40 degrees Centigrade
+ / - Triamcinalone acetonide (5 mg)
Lactated Ringer’s Solution (500 cc)
50 – 100 cc 1% Lidocaine (0.1 – 0.2%)
May use 2% for face and neck ( to 0.3% ) Safe to 55 mg / kg
1 cc 1:1,000 fresh Epinephrine HCL (1:500,000) (LSS is 1:1,000,000-1:1,500,000)
Warm to 38 – 40 degrees Centigrade
+ / - Triamcinalone acetonide (5 mg)
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Simplified Surgical Tumescent Anesthesia - 2008Simplified Surgical Tumescent Anesthesia - 2008
Use Klein’s formula (based on 1000 cc) , cut to 1/4 the volume (250 cc)
of Ringers Lactate if available (or NSS if not)
For vascular areas , use ¼ diluent (250 cc), and add Epinephrine 0.5 mgm
Non-vascular areas, 0.25 mgm Epinephrine w/ Lidocaine 250 mgm
(25 cc of 1% lidocaine solution). Put in the same quantities of additives as in the original formula
(except use 1/4 the sodium bicarbonate if using NSS)
It is rare to use more than this quantity for a single case,
but even double this quantity (500 cc) will not be in toxic levels for almost anyone
If inflammation / edema expected, add small quantity of steroid (5-10 mgm triamcinolone)
In this circumstance worry more about too much epinephrine than too much lidocaine
No known / reported allergic reactions (to my knowledge)
Use Klein’s formula (based on 1000 cc) , cut to 1/4 the volume (250 cc)
of Ringers Lactate if available (or NSS if not)
For vascular areas , use ¼ diluent (250 cc), and add Epinephrine 0.5 mgm
Non-vascular areas, 0.25 mgm Epinephrine w/ Lidocaine 250 mgm
(25 cc of 1% lidocaine solution). Put in the same quantities of additives as in the original formula
(except use 1/4 the sodium bicarbonate if using NSS)
It is rare to use more than this quantity for a single case,
but even double this quantity (500 cc) will not be in toxic levels for almost anyone
If inflammation / edema expected, add small quantity of steroid (5-10 mgm triamcinolone)
In this circumstance worry more about too much epinephrine than too much lidocaine
No known / reported allergic reactions (to my knowledge)
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Field, L, Leventer, M.
Delineation of Tumor Extension and Depth Utilizing
Superficial and Deep Tumescence
XXIII Congress of the ISDS and the National Meeting of the Portuguese Group of Dermatologic Surgery,
Porto, Portugal September 2002
And the European Academy of Dermatology, (Surgical Section), Prague, Czechoslovakia
November 2002
Field, L, Leventer, M.
Delineation of Tumor Extension and Depth Utilizing
Superficial and Deep Tumescence
XXIII Congress of the ISDS and the National Meeting of the Portuguese Group of Dermatologic Surgery,
Porto, Portugal September 2002
And the European Academy of Dermatology, (Surgical Section), Prague, Czechoslovakia
November 2002
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M. Leventer, MDROMANIA - 2010
Founder and first president -Romanian Society Dermatologic Surgery
First Mohs unit in Romania
Invited Speaker ASDS Honorary Lectureship 2014
MENTOR / HOST
Romania, USA, Austria,Germany, Indonesia, Korea, Thailand,
China, Indonesia
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SubQ TsunamiWave of
Surgical Tumescentsolution
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The Bi-Level AnesthesiaTechnique (Field, L.)
The Bi-Level AnesthesiaTechnique (Field, L.)
First Infiltrate Surgical Tumescent Solution
into subcutaneous space by creating angled puncture wound
Multiport infiltrator inserted to far limit of area to be anesthetized
Inject on withdrawal unless invasive tumor suspected
Tamponades deeper vessels
Facilitates space and eases blunt undermining
First Infiltrate Surgical Tumescent Solution
into subcutaneous space by creating angled puncture wound
Multiport infiltrator inserted to far limit of area to be anesthetized
Inject on withdrawal unless invasive tumor suspected
Tamponades deeper vessels
Facilitates space and eases blunt undermining
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“Pocar" - Pierre FournierSpreads elastin, collagen
w/o scar
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o Tumor ? Observe hydrodissection planeSecondly,
Superficial cutaneous anestheticis then injected
Now instillation less painful
Vital structures protected by expanded subQ space
Decreases bleeding at incision lines to virtually nothing!!!!!!
o Tumor ? Observe hydrodissection planeSecondly,
Superficial cutaneous anestheticis then injected
Now instillation less painful
Vital structures protected by expanded subQ space
Decreases bleeding at incision lines to virtually nothing!!!!!!
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Field, L..,
Blunt Liposuction Cannula Dissection and Flap Elevation - Origins and Applications,
American Society for Dermatologic Surgery, Monterey, California April l988
Field, L..,
Blunt Liposuction Cannula Dissection and Flap Elevation - Origins and Applications,
American Society for Dermatologic Surgery, Monterey, California April l988
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University of Porto, Porto, Portugal, October 2002
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I. Juhász, MDHUNGARY - 2011
MENTOR / HOST
U. of Debrecen, Hungary
President, Hungarian Society of Dermatologic Surgery
Chair , EADV dermsurg training
Negative Pressure Wound Therapy
Hungary, Germany, Austria, Portugal, Indonesia
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Field, L., Istvan Juhasz, MD,PhD.Andras Tamas, MD, (Section of Dermatologic Surgery)
Paldeak, L., MD (Section of Dermatologic Surgery and Plastic Surgery)University Medical School, Debrecen, Hungary
Dermatofibrosarcoma Protruberans:A Case Presentation and Review of the Literature
10 yr. Survival ReportDublin 2005
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Surgical tumescent infiltration
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Blunt LSS dissecting cannula
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Ready for STG
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5858
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5959
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Change of Ex direction
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Delineating incision line
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Surgical tumescent into Sub Q space w/ infiltrator
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Standard anesthetic to depth of #27 needle at oblique angle -
@mini-Tbn skin test
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Precise controlled incision only to fat layer
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Blunt undermining in hydro-dissected plane
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Field, L., Lestari, S., et al, .
The “Open Scissors Fulcrum Dissection” Technique,
ISDS Book of Abstracts, P. 56, ISDS XXII Annual Congress and Congreso de la Sociedad
Mexicana de Cirugia Dermatologica y Oncologica, Guadalajara, Jalisco, Mexico Nov. 2001.
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A Huge Asymmetric Pigmented Nevus of Distal Nose - Excision and Repair
by Two Supra-alar Hemi-Perinasal Crescentic Flaps (one
transposition, 1 advancement) and Anastomosis - 1 year follow-up with Laserabrasion + Silicone
A Huge Asymmetric Pigmented Nevus of Distal Nose - Excision and Repair
by Two Supra-alar Hemi-Perinasal Crescentic Flaps (one
transposition, 1 advancement) and Anastomosis - 1 year follow-up with Laserabrasion + Silicone
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“Tulip” multi-port infiltrator with surgicaltumescent anesthetic solution
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And from below superiorly to hydro-dissect cheek flaps
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undermining in hydrodissectedto lift nevus, preserve nasal tip
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Asymmetric central anastomosis, as majority of tissue came from left to right,
w/ sacrifice of cone on the right
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1 year follow-up Isabella de Santiago
4-port microinjection of pure Silicone&
“Sharplan” laser on previous scars
Plan to re-inject q 2 months.
1 year follow-up Isabella de Santiago
4-port microinjection of pure Silicone&
“Sharplan” laser on previous scars
Plan to re-inject q 2 months.
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M. Roscher, MD,SOUTH AFRICA -
2010
Founding President, South African Soc Derm
Surgery
Founding EditorSouth African Jrl of
Dermatologic Surgery
MENTOR / HOST
South Africa,India, Austria,
UK, Kuwait, Israel
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Triangular excision of Szymanowski to remove excess tissue along course of incision line, but not at the end
(von Burow)
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Excision of Szymanowski
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Field, L.
Hairline Reconstruction Utilizing Modified Winged V-plastic Hair-bearing Flaps and Anastomotic
Line Focal Excisions - A Case Report
Dermatologic Surgery, Vol. 22, No. 11, Pp. 937 - 940 November 1996
Field, L.
Hairline Reconstruction Utilizing Modified Winged V-plastic Hair-bearing Flaps and Anastomotic
Line Focal Excisions - A Case Report
Dermatologic Surgery, Vol. 22, No. 11, Pp. 937 - 940 November 1996
111111
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Makassar, Sulawesi, Indonesia
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Anesthetic entrance points
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EXCISIONEXCISIONAfter bi-level anesthesia, blunt “open fulcrum” scissors
and forceps were used to remove the hypertrophic keloid
After bi-level anesthesia, blunt “open fulcrum” scissors and forceps were used to remove
the hypertrophic keloid
Open fulcrum
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TUMESCENT EXCISION:FOLLOW UP POST OPERATIVELY
TUMESCENT EXCISION:FOLLOW UP POST OPERATIVELY
1 MONTH 3 MONTHS
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Conclusions:Advantages of Combining Blunt Undermining, Surgical Tumescent Anesthesia, and Bi-level
anesthesia (Field)
Conclusions:Advantages of Combining Blunt Undermining, Surgical Tumescent Anesthesia, and Bi-level
anesthesia (Field) Maximal Safety of any known system Rapid delivery of large volume Hydrodissection (via elevation) Spares all vital structures Aids in determining plane of tumor involvement / fixation
Sharp instruments only penetrate epidermis Blunt instruments for subQ tissues & below Surgery can be completed in the least time
Maximal Safety of any known system Rapid delivery of large volume Hydrodissection (via elevation) Spares all vital structures Aids in determining plane of tumor involvement / fixation
Sharp instruments only penetrate epidermis Blunt instruments for subQ tissues & below Surgery can be completed in the least time
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Field, L., Bilevel Anesthesia and Blunt Dissection:
Rapid and Safe SurgeryDermatologic Surgery, 2001 27: 989-991 November
Bi-level Anesthesia and Blunt Dissection
Innovative Techniques in Skin Surgery ,
Harahap, M., Editor, Marcel Dekker, Part V (Anesthesia), Chapter 32,
Pp. 185-189 May 2002
Field, L., Bilevel Anesthesia and Blunt Dissection:
Rapid and Safe SurgeryDermatologic Surgery, 2001 27: 989-991 November
Bi-level Anesthesia and Blunt Dissection
Innovative Techniques in Skin Surgery ,
Harahap, M., Editor, Marcel Dekker, Part V (Anesthesia), Chapter 32,
Pp. 185-189 May 2002
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