Skin Surgical Techniques

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Skin Surgical Techniques
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Biopsy Shave vs Punch

• Shave a lot faster
• Haemostasis less of a problem (Driclor)
• Useful for tumours, papules, pedunculated
  lesions, ID naevi, Macular PSL
• Punch is appropriate for inflammatory skin
  diseases and tumours where sample of tissue depth
  necessary (usually more indurated lesions)

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Excisional Biopsy
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Shave Biopsy
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Punch Biopsy
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Excision Shave vs Punch

• Depends on type of tumour
• Shave - epidermal lesions (achrocordon, some
  intradermal naevi, KAs)
• Punch ID naevi face, vascular tumours eg
  capillary haemangioma, seb hyperplasia
• NB melanocytic naevi with hairs will only stop
  growing hair if dermis/subcutis excised

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Excisional Biopsies

• Avoid danger areas such as pre-auricular, angle
  of mandible and posterior cervical triangle
• plan excision along relaxed skin tension lines
• use 31 ratio and mark site with gentian violet
  marker
• use appropriate anesthesia (I.e. no epinephrine
  on finger tips, nose tip, tip of penis)

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Ellipse
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Tense closures

• Sites eg scalp, lower leg
• Undermine
• Assistant
• Stronger suture material
• Vertical Pulley, Butterfly (double butterfly),
  Traction sutures

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Weak, thin skin

• Eg Scleroderma, Solar damage, Corticosteroid use
  partic lower legs
• Deep sutures
• Assistant, Steri-strips, Crepe bandage
• Secondary intention healing
• SSG, FTSG
• Avoid, Refer

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Suture removal general guide

• Face 7 days
• Neck 10 days
• Trunk, Limbs 12-14 days, (7-10 days if deep
  sutures in place)

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Mohs Surgery
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MOHS SURGERY

• What is it?
• Form of skin cancer surgery for SCC, BCC, KA, /-
  Melanoma
• Highest cure rate for primary and secondary
  cancers
• Dermatologist - surgery, pathology and repair

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MOHS SURGERY

• How is it done ?
• Principles
• Remove tumour
• Repair to suit function
• Cosmesis

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METHOD CONTD

• Any remaining tumour is located on the slide and
  further surgery is done to this area
• Above steps are repeated until all tumour is
  removed
• Defect is repaired

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MOHS SURGERY

• Indications
• BCC/ SCC/ Other tumours
• Located on the central face or periorifical areas
  (eyes, mouth, nose, ears, etc)
• Recurrent tumours
• Incompletely excised tumours
• High risk histological types eg morphoeic BCC
• Large or ill-defined lesions
• Young patients with skin cancers

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MOHS SURGERY

• Advantages
• Tissue conservation
• Highest cure rate
• Local anaesthetic procedure
• Cost to patient is no different to standard
  surgery

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MOHS SURGERY

• Disadvantages
• Time consuming for doctor and patient
• Expensive equipment
• Expertise required

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Mohs Micrographic Surgery

• Recurrent tumors
• Tumors gt2 cm
• Aggressive Histology
• Ill-defined margins
• Incompletely excised tumors
• Local cure rates gt99

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Needle Selection

• Cutting-most skin surgery.
• FS- for skin
• P, PS, PRE for cosmetic areas
• Taper-fascia and bowel
• Blunt-liver and kidney
• Higher numbersmaller needle
• Use larger needles for deep tissue, smaller
  needle to close the skin.

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Needle Types
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Skin Grafts

• Split Thickness Skin Grafts
• -include part of the dermis and all of epidermis
• -donor site regenerated from hair follicles and
  skin edges on the graft
• Full Thickness Grafts
• -less wound contracture
• -usually used for palms and back of hands

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Evolution of Skin Grafts
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Flaps

• Free Flaps
• -predisposed to venous thrombosis
• TRAM flaps
• Rely on superior epigastric vessels for blood
  supplu
• Periumbilical perforators are the most important
  determinant of TRAM viability

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Squamous Cell Carcinoma

• Risk Factors actinic keratoses, zeroderma
  pigmentosum, bowens disease, atrophic
  epidermitis, arsenic, coal tar, nitrates, HPV,
  fair skin, XRT exposure
• Tx .5-1.0cm margins for low risk
• Reginal adenectomy for positive nodes
• Mohs Surgery margin mapping using conservative
  slicles, never used for melanoma, best for facial
  lesions

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Melanoma Staging
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Management
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Sentinel Lymph Node

• No more elective node dissection
• Nodal status is a strong prognostic factor
• Indicated for melanomas gt1 mm
• Lymphazurin blue and 99Tc- sulfur colloid

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Melanoma Adjuvants

• Chemotherapy usually not too effective
• Dacarbazine 20 response
• Interferon alpha 20 response
• Isolated limb perfusion Melphalan 80
• Immunotherapy 15 response
• Melanoma vaccines?

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Squamous Cell Carcinoma

• 250,000 cases/year, 2nd most common skin CA,
  2500 deaths/yr
• Bowens Disease early stage or intraepidermal
  form of SCC
• Poor prognostic factors gt2 cm deep, poorly
  differentiated, rapid growth, originating in
  scar, perineural involvement
• Only 50 5-year survival if nodes involved

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Treatment Options

• Wide local excision gt4-7 mm margins to deep
  subcutaneous tissue
• Radiation for poor surgical candidates
• Mohs micrographic surgery
• Cryosurgery
• Currettage and Electrodessication
• Laser ablation
• Topical 5-FU

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Basal Cell Cancer

• 900,000 cases/year, lifetime risk for Caucasians
  30, rarely metastasize
• Local destruction, 30 develop non-melanoma skin
  CA recurrence within a year
• Excise with negative margins (4-7 mm)
• Lymphadenectomy only for basosquamous variant
  with clinically () nodes
• Mohs is best for high risk lesions