Minor Cutaneous Surgery

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Minor Cutaneous Surgery

• Dr Bill Porter

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Essentials

• A clean room
• Adjustable couch
• Good lighting
• Assistance- avoid operating alone if possible
• Good instruments
• Clean instruments
• A choice of sutures

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A clean room

• Easily cleaned surfaces
• Room to move around the couch
• Stool on wheels?
• Resus equipment?

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An Adjustable Couch

• A physiotherapy plinth is ideal
• If it tilts both ends even better
• On wheels so that you can move it
• BOTH patient and surgeon must be comfortable

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Good Lighting

• Adjustable lighting
• Ceiling mounted is best
• Quartz Halogen
• Avoid 240V Anglepoise
• Swan neck on wheels are a pain

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Assistance

• Never inject/incise without company
• Let them know why theyre there
• Avoid Oops! and Sorry
• Keep them keen, let them assist
• Avoid untrained enthusiasts

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Instruments

• The best you can afford
• Sterile packs best
• Autoclaved- under vacuum if hollow
• Scalpel No.15 blade
• Suture holder double the price you expect
• Blunt, curved strabismus scissors
• Fine Adson forceps

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A choice of sutures

• Ethilon 3/0 4/0 5/0 6/0
• PDS 4/0
• Vicryl 3/0
• Catgut?
• Glue? Dermabond
• Silk?

Cutting
Reverse Cutting
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Patient selection

• Will it bleed?
• Will it close?
• Will it heal?
• Will it stretch?
• Will it scar?

• Who wants it done, you, or the patient?
• Does it need to be done?
• If not, will the scar be better?
• Consent

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Other equipment

• Punch biopsy
• Curettes
• Electro-cautery
• Hyfrecator
• Haemostatics Driclor AgNO3
• Skin marker
• Diabetic syringe

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Getting started

• Skin marking cleansing
• Hibisol/Betadine or N.Saline near eyes
• Mark out before anaesthetic
• Anaesthetic
• Lignocaine 0.5-2 with adrenaline except digits
  and children?

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Mark the spot

• Identify skin tension lines
• Ensure adequate margins
• Mark before you inject

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Danger Areas

• Temporal artery
• Facial Artery Nerve
• Superficial branches Trigeminal nerve
• Spinal Accessory Nerve
• Axilla
• Wrist
• Femoral Triangle
• Knee Popliteal fossa head fibula (Lateral
  Popliteal Nerve)

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Basic Excisions

• Keep apex to 600
• Knife at 900 to skin

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Basic Excisions

• Mark skin with 2-5mm margin (/-)
• Length to width ratio 31
• Stabilise skin with thumb fingers
• Hold scalpel upright
• Cut boldly along lines, avoid numerous small cuts
  which cause jagged edges

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Basic Excisions

• Cut from apex not to apex
• Cut along outside edge

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Basic Excisions
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Basic Excisions

• Avoid fish tails and boat hulls

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Basic Excisions
Cut to the fat
Epidermis
Dermis
Subcutaneous fat
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Basic Excisions

• Undermine all edges

Blunt ended scissors
Including wound ends
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Basic Excisions

• Haemostasis
• Adrenaline in Anaesthetic
• Pressure
• Clamping (mosquito forcep)
• Vicryl
• Electro surgery/Diathermy
• Topical Driclor, AgNO3

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Basic Excisions

• Deep sutures where possible

Deep to skin, skin to deep
Buried knot Everted edge
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Basic Excisions

• In at 900, out at 900

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Skin Sutures

• Ethilon The easiest to use
• Prolene Difficult to knot
• Silk- avoid except for bx. of friable tumour
• Remove in
• Faces 5 days
• Upper body/arms 7-10 days
• Legs 10-14 days

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Deep Sutures

• Dissolvable

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Deep Sutures
Already closed Skin sutures or steri-strip?
Easy to close Strong
Easy to close But little strength
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Knife to skin
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Hands on

• Please make sure you each have
• Pig flesh /- nipple
• Scalpel
• Suture holder
• Forceps
• Insulin syringe /- skin hook
• Sutures 4/0 Ethilon 3/0 Vicryl/ 4/0 PDS
• Skin marker

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Hands on

• Gloves, aprons
• PLEASE DISPOSE
• of your sutures as you use them
• of all your sharps at the end of the day

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Take a 5-6mm punch biopsy
Punch a hole to be your Lesion!
Mark your excision
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Choose the suture

• Refresh your basic skills (4/0 Ethilon)
• Try using deep sutures (3/0 Vicryl)
• Try subcuticular /- deep sutures

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Crescentic Excision
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2
Undermine
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Proposed sutures
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The result
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Other suture techniques
Three point suture on triangular flap
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Other suture techniques
Three point suture on double triangle flap
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Other suture techniques
Vertical Mattress Suture
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Other suture techniques
Vertical Mattress Suture
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Other suture techniques
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Other suture techniques
Vertical Mattress Suture
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Sub-cuticular Sutures
With or without deep sutures
Tie ends Steristrip to support.
Ethilon or PDS II
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Sub-cuticular Sutures
Knotted suture
Wound
Steristrip
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Sub-cuticular Sutures
With or without deep sutures
If ethilon, and long take the middle onto the
surface
Ethilon
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Sub-cuticular Sutures
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Dog ears!
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Dog ears
Cut
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Dog ears
Cut
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Dog ears
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M-Plasty
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M-Plasty
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Rotation Flap
A
B
C
A
D
B
Suture points centre first
Extensive undermining
C
D
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Simple finger flap
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Island Flap
Or Double -Y Plasty