Excisional Surgery • Incising/cutting – Hold at 90 degree angle to skin surface and cut toward yourself – Need only cut lightly at first, then press more firmly – Cut with the belly of the blade, not the tip – Penetrate as appropriate for wound to achieve necessary depth – Be uniform to minimize repeat cutting
Excisional Surgery • Incising/cutting – Ensure shortest incision through tissue and you will obtain minimal distortion of wound edges – Tendency is to slant blade toward the lesion, rather that hold perpendicular to skin – This causes beveling and poor approximation of the skin edges
Excisional Surgery • Incising/cutting – When beginning or ending incision, avoid carless extension of incisions “fish-tailing” and avoid nicking lateral edges
Excisional Surgery • Excision of tissue – After proper incision made, pick up is used, or skin hook to grasp the lesion – Scissor or scalpel may be used to remove the specimen – Tissue draped over the blade will yield shallow depth, tissue pulled back will be deeper – Once removed, even the fat or dermis at base
Excisional Surgery • Undermining – Generally good to undermine – Takes tension off of wound edges laterally and vertically – Removes fibrous bands – Mobilizes the area – Reveals tension lines – Creates scar at regions of undermining, which contracts and holds wound margin more securely – If little or not tension, no need to undermine
Excisional Surgery • Disadvantages to undermining – Tissue relationship changes, no longer lined up for repair – Changes plane if malignancy, which might need re-excision-lose orientation – Increased dead space, bleeding risk
Excisional Surgery • Suggested level of undermining – Difficult to make universal – Follow least resistance – Try for more superficial when possible – Most of the time, plane is somewhere in the superficial fat – Thin areas like eyelid are more superficial – Scalp is typically quite deep, even to subgalea – Differing opinions about apices
Suggest Levels of Undermining Scalp Below hair follicles or below galea Forehead Low subcutaneous tissue Temple, cheeks, chin High subcutaneous tissue Lips Beneath mucosa Nose Mild or low subcutaneous tissue Neck Mid or high subcutaneous tissue Trunk, extremities Any level above muscle fascia Hands, feet Below dermis
Excisional Surgery • Hemostasis – Spot coagulation with electrocautery – Must be dry field for electrocautery – Wipe tip, as needed – Avoid wound edges – Ground patient with certain units, no metal contact – Cotton tip applicators make more precise
Excisional Surgery • Ligation for hemostasis – Tie vessels only when profusely bleeding – High pressure vessels have potential to bleed despite ligation, if only the vessel alone is tied – Insert needle into small amount of supporting structure to anchor and tie vessel – Pressure bandages are very effective, no need to char wound bed or tie all vessels – Suturing wound edges may tamponade – Cellulose/ Oxycel when needed
Excisional Surgery: Technique for Wound Closure – Holding needle • Placement of needle is most commonly midway between tip and the swage • Some recommend 3/4 th from tip • Halfway point may have less tendency to bend and one may need to pronate less to achieve 90 degree angle • Thumb near spring , index finger near jaw • Don’t necessarily need to have fingers in the loops of the needle holder
Needle Anatomy
Placement of Needle
Holding the Needle Holder
Holding Needle Holder
Holding Needle Holder
Holding Needle Holder
Excisional Surgery • Simple interrupted sutures – For wounds extending only to dermal-subdermal junction – Little to no tension – No dead space – No significant tissue loss
Excisional Surgery • Placement of interrupted sutures – Insert needle at 90 degree angle – Slight hyperpronation of wrist is necessary – Bring through opposite side and grasp with forceps – Minimize use of needle holder to grasp needle point, can injure needle – May need to pick up skin edge to ensure proper placement of suture (thin skin, curling edge)
Excisional Surgery • Simple interrupted suture – Skin hook can be useful , as toothed forceps and crimp or tear wound edges, enhancing infection risk – Should produce slight eversion of wound edges – Eversion counteracts the tendency of wound edges to contract and invert – Proper path of suture: perpendicular 90 degrees, then laterally as it descends
Excisional Surgery • Simple interrupted suture – Good technique to exit at wound center – Re-enter the skin at opposite site – Ensures the loop is broad enough and aids in approximation of wound edges – Avoid ‘one turn’ of the needle to prevent overlapping of the wound edges
Suture Placement
Excisional Surgery • Suture tying – Loop, knot, and tail – Tying with needle holder is preferred – First loop is teased town to coapt with wound edges – Second loop sets the knot – Generally 4 throws to secure for percutaneous suture – Do not tie so tight as to strangulate
Excisional Surgery • Suture tying – Attempting to remove lateral tension with just simple interrupted suture to make up for buried suture, will result in spread scar and/or hypertrophy – Additional throws should alternate opposite directions to increase security of “square” knot – Our tendency is to tie in the same direction, so must use conscious effort
Excisional Surgery • Steps to tie square knot – Loop suture over needle holder or circle needle holder tip around suture material – Grasp free end of suture with needle holder and pull through the created loop – Ease knot down to skin edge – Loop suture on opposite side of wound – Grasp free end of suture with needle holder, and pull through created loop – Repeat 3-4 total created loops, alternating direction
Excisional Surgery • Suture tying – May let needle dangle – Some grasp at swage/suture junction – Double loop for first throw may temporarily hold wound together, though may not allow for adjustments after second throw – Allow room for swelling – Silk, 2-3 throws, nylon, 4 throws recommended
Excisional Surgery • Size of loop – Smallest bit for the job (depth, width) – One that doesn’t cause crimping or tearing – ~1-3 mm of wound edge – Thin tissue, closer to wound – Thicker tissue, may require wider bit – Larger bites, one tends to tie tighter-necrosis – Increased bite does not equal increased strength
Excisional Surgery • Suture tying – In general, the greater the wound tension, the farther the suture should be placed from the edges – Typically the suture loop is slight larger in horizontal directions, compared to vertical/deep direction
Excisional Surgery • Suture spacing – Wound strength is partially determined by number of sutures – Use the minimum needed to hold wound edges exactly without crimping – In general, greater tension requires sutures to be placed closer together – However, very closely spaced sutures can impede blood flow, be prudent
Excisional Surgery • Suture spacing – Uniformity isn’t always necessary – Higher tension areas may require more closely spaced, such as center of wound. Fewer sutures may be needed at apices, where there might be less tension
Excisional Surgery • Sequence of placing sutures • Some recommend best to start in center and place by rule of halves • Minimize dog ear potential • Evenly distributes length of the sides • Tension reduced if sutures are place at ends first, thereby reducing tension in center-may be better in some instances
Excisional Surgery • Buried interrupted – Can include dermal, dermal-subdermal, and subcutaneous – Purpose • Realign deep tissues to normal position • Help coapt the overlying epidermis • Fewer percutaneous suture needed • Finer more inconspicuous scar • Closes dead space
Excisional Surgery • Buried interrupted – Stitch begins deep in wound and passes to the superficial aspect of one side – The needle is remounted, then enters at superficial aspect of opposite side and exits in the deep portion of wound – The suture does not pierce the epidermis – When tied, the knot is buried deep in the deep dermis or subdermis – Does not get in way of percutaneous sutures
Buried Suture
Suture materials • http://emedicine.medscape.com/article/884838 -overview
Suture Materials • Lack of agreement among those performing surgery about which material or method of suturing is best • No one suture material is best under all circumstances for all patients at all times by all providers • Based often on subjectivity or prejudices of the teacher or institutional offerings
Suture Materials • Limitations of suture choices – Cost – Availability of different needles, material type, colors – Too many choices and nomenclature varies
Suture Materials: Structure • Absorbable – Natural (plain gut, chromic gut) – Synthetic (vicryl, Polysorb, PDS, Caprosyn) • Nonabsorbable – Natural (silk, cotton, steel) – Synthetic (nylon -Ethilon or Monosof , polyester- Ethibond , polybutester- Novafil , polypropylene - Prolene ) • Monofilament: single strand • Multifilament: twisted or braided
Suture Materials: Interaction with Skin • Adverse reaction to suture materials – Allergy (rare, chromic, cat gut) – Hypertrophic scar (improper placement) – Spitting (improper placement, usually at 14-34 days) – Nodules (usually resolve, vicryl -due to coating) – Fire (alcohol in packaging) – Tissue reactions (occurs routinely) – Milia (suture in place too long) – Infection (avenue of infection from surface)
Suture Materials: Interaction with Skin • Tissue reaction to suture material – All are foreign bodies – Evoke reaction to differing degrees – Want to select best material for particular task – Select least amount of material – Least number of knots should be thrown
Preoperative Evaluation
Preoperative Evaluation • Minimize complications • Health history • Psychosocial history • Consultation • Risks • Alternatives • Consent • Anxiety • Antibiotic prophylaxis
Preoperative Evaluation • Many complications can be avoided in the preoperative setting • Consultation whenever possible • Health history, current and past • Psychosocial History • Patient able to provide informed consent
Consultation: Talk with the Patient • Are the patient’s expectations appropriate? • Do they understand the entire procedure and possible defects or risks? • Is the patient asking appropriate questions?
Understanding of risks of procedure • Bleeding, infection • Scar • Incomplete treatment • Recurrence • Nerve damage • Pain • Bruising, swelling • Ectropion, lid droop
Risks, cont. • Pigment changes • Temporary improvement • Suture reaction
Anxiety • Affects patient comfort and progress of surgery • Anti-anxiety medication • External distracters
Antibiotic Prophylaxis in Dermatologic Surgery • Prosthetic joint – 1 year post surgery; previous joint infection? Ortho organizations do not all agree; immuno-compromised, IDDM, HIV infection; malignancy; malnourishment; hemophilia • Cardiac – High risk cardiac conditions: prosthetic cardiac valve, previous infective endocarditis; CHD including those with unrepaired cyanotic CHD, including palliative shunts and conduits; completely repaired congenital heart defects with prosthetic material or device, during the first 6 month after procedure; repaired CHD with residual defects at site or adjacent to site of prosthetic patch or prosthetic device; or cardiac transplantation recipients who develop cardiac valvulopathy (adapted from American Heart Assoc guidelines)
Antibiotic Prophylaxis in Dermatologic Surgery • “Increased risk for surgical site infection”* – lower extremity – groin – wedge section of lip – skin flap on nose – skin graft – extensive inflammatory disease (*”The data underlying these factors are suboptimal; therefore decisions should be individualized”, Wright, et al., 2008)
Postoperative Wound Care
Pressure Bandage • Always apply after any excision • An effective pressure dressing mimics the function of normal skin
When Applying a Pressure Dressing, Remember To: • Cover the entire surgical area, including areas that have been undermined • Keep it as small as possible to get the job done • It should be a aesthetically pleasing as possible • How a dressing is applied can greatly influence the surgical results
Sutured Wounds • Remove pressure bandage in 24 hours • Leaving sutured wounds uncovered after the post- op pressure bandage is removed, reduces the amount of drainage present against normal skin and can often allow for a better cosmetic result long-term • The wound must always be moist with antibiotic ointment or petrolatum • When the sutured area is covered with clothing, a non-stick bandage over the ointment will be necessary to keep from rubbing the ointment off
Surgical Complications
Postoperative Complications • Defined as: “Any negative outcome after surgery, whether perceived by the surgeon or patient”
Preventing Complications • Prevention is key • Complications must be anticipated • Action must be taken in every surgical case • Early recognition with prompt intervention is the best way to avert progression of a complication
Positive Postoperative Outcome • Thorough preoperative evaluation • Proper surgical technique • Appropriate choice of suture materials • Appropriate postoperative care • Detailed patient education • Close follow-up
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