Practical Skin Cancer Surgery

Description

Practical Skin Cancer Surgery, written by Dr Mileham Hayes, offers primary care physicians a comprehensive practical go-to guide to detail and teach Skin Cancer Surgery operations which can be done in a doctor’s clinic under local anaesthetic. Perfect for: • Primary care physicians • Surgical trainees Benefits: • Surgery specific. • Clearly structured step-by-step instructions. • The book is divided into 8 sections covering all the requirements of the College examinations. • Evidence based diagnosis treatment and surgery. Progressing from equipment and set up, anatomy, basic, straight-line excisions to more complex flaps, Practical Skin Cancer Surgery outlines step-by-step, methodical instruction to proficiently excise skin cancer in a clinic, under local anaesthetic. Key Features • Clinical photo sequences • Stepped approach to procedures • Warning boxes • Hints and Tips • Notes Front cover PRACTICAL SKIN CANCER SURGERY Copyright page Table of Contents Preface Dedication Acknowledgements Reviewers Introduction 1 Equipment, sutures and design Setting up a skin clinic: essential equipment Examination room equipment Scrub room equipment Operating theatre/ room equipment Recovery area equipment Equipment required for skin surgery Cleaning equipment Ultrasound instrument-cleaning units Sink Steriliser Distilled water maker General surgery requirements Trolleys Tables and couches Operating chairs Lights Skin surgery equipment Hyfrecators Surgitron Smoke exhaust units Photodynamic therapy/intense pulsed light (PDT/IPL) laser machines Automated/computerised dermatoscopes Other equipment Sutures and needles Sutures Properties Classification of sutures Non-absorbable sutures Absorbable sutures Braided sutures Monofilaments Strength Choice of suture Mitigating factors Physical and biological suture characteristics Absorbable sutures for skin closure Cost-saving measures Biopsy sutures Thread length Winding in long sutures Needles Sharpness Metal quality Needle measurements Needle design Point Reverse cutting needles Cutting needles Taper needles Body of the needle Swage USP needle pull specifications Needle coating Suggested needle sizes Suggested needle circumference/circle Summary Surgical instruments Instrument set Scalpel handles and blades Forceps Toothed forceps Plain forceps Bipolar forceps Needle holders Needle holder selection Scissors Skin hooks and curved artery forceps Buying instruments Instrument care Stainless steel Instrument maintenance References 2 Essential anatomy for skin surgery Facial tissue layers The four danger zones Temporal danger zone Facial artery/mandibular danger zone Inner canthus danger zone Erb’s point danger zone Nerves – motor Facial nerve (CN VII) Zygomatic arch where the temporal branch of the facial nerve crosses Mandibular branch Accessory nerve (CN XI) Nerves – sensory Trigeminal nerve (CN V) Cervical plexus Nerve damage – altered sensation Arteries Superficial temporal artery Facial artery Inner canthus References 3 Local anaesthesia Classification Mode of effect Lignocaine (Xylocaine) Dose Interactions Toxicity At-risk patients Pregnancy Heart effects Technique Bupivacaine (Marcain) Prilocaine (Citanest) 0.5% Interactions Local complications Painless injections Redheads Sedation Additives Adrenaline (epinephrine) The adrenaline vasoconstrictive–necrosis myth Risks of vasoconstriction Systemic risks Symptoms and signs Maximum dose Interactions Sodium bicarbonate Hyaluronidase Head/neck nerve blocks Essential anatomy for anaesthesia Total facial anaesthesia Technique Supraorbital and supratrochlear nerve blocks Techniques Supratrochlear and infratrochlear nerve block Dorsal/external nasal branch block Technique Maxillary branch of the trigeminal nerve (the infraorbital nerve) blocks Technique Dose Complications Blocking the mental nerve Technique Zygomaticotemporal nerve block Technique Zygomaticofacial nerve block Technique Auriculotemporal nerve (mandibular nerve V3) block Technique Greater auricular and transverse cervical nerve (Erb’s point) block Technique Wrist blocks Median nerve block Technique Ulnar nerve block Technique Radial nerve block Technique Digital blocks Tourniquet for the finger Technique Ankle blocks Peroneal block Field blocks Technique Scalp blocks Topical blocks Precautions Indications Preparation Topical anaesthesia technique Analgesia Hydrodissection References 4 Haemostasis Surgical techniques to minimise bleeding Postoperative Electro-haemostasis Monoterminal (‘monopolar’) Biterminal (‘bipolar’) Identification and location of bleeding points Technique: roll, don’t dab; visualise, then cauterise Nose tips Lips Tying off – suture ligation The stick tie Figure-of-eight The mattress and square or U suture Running lock stitch Technique Anticoagulation therapy Maintain anticoagulants Warfarin (Coumadin) Aspirin Primary prevention Secondary prevention Clopidogrel (Plavix/Clovix) New anticoagulants Dabigatran (Pradaxa) Apixaban (Eliquis) and Rivaroxaban (Xarelto) Discontinuation Medications, ALTERNATIVE medications, supplements and foods Medications Foods, herbs and supplements Postoperative Rest Elevation Pressure dressings Hydrostatic pressure Secondary bleeding Alcohol Trauma Haematomas Haematoma stages References 5 The basics Margins Excisional biopsy Dysplastic naevus/atypical mole Melanoma Basal cell carcinoma (BCC) Lateral margins Deep margins Squamous cell carcinoma (SCC) Recurrence/clearance rates Mohs or en face pathology Specimen shrinkage Margins and quality control Shave and snip excisions Optimising excision technique Incision technique Types of excisions Punch Simple fusiform ellipses or diamonds and rhomboids Preoperative planning Pre-op preparations Marking skin for excisions Hairy areas Catchers Drapes/undersheets Incision lines Surface anatomy – Langer’s and other lines and orientating incision lines Face Cosmetic units Free margins Loose skin – harvest areas Nasolabial groove Back Scar spread Limbs Nerve blocks Undermining Benefits Complications Technique Planes of dissection/undermining Take care Orientation location Dog-ears Causes and prevention Dog-ear treatment and repair Observation Suturing techniques Repair Healing Follow-up References 6 Suturing, knots and closures Suturing techniques First the margins Closure Anyone can do it Fundamentals and essentials for skin surgery and wound repair Careful matching of layers Eversion of sutured wound edges Lack of tension Good blood supply Simplest procedure Different sutures and their uses Interrupted sutures Simple interrupted sutures Flask or pear sutures Mattress sutures Vertical mattress suture Horizontal mattress suture Horizontal locking mattress suture Gilles, tip, corner or half-buried horizontal mattress suture Running or continuous sutures Simple running suture Locked or blanket suture Subcuticular running suture Buried sutures Normal buried suture Vertical mattress buried suture Buried butterfly suture Purse string suture Running subdermal suture Wide wounds – high tension sutures Suspension periosteum (plexing/tacking) sutures Considerations to repair and close a defect Closure options Secondary intention healing Deep suture sites Suture lines Wound closure The rule of halves versus ‘creeping Charlie’ Match-up lines ‘X’ sutures: closing small circular excisions S-plasty Closing wounds with unequal edge lengths Closure of serial excisions Knots Surgeon’s knot The instrument tie It’s a cinch Suture orientation Handling long lengths of sutures Problems with knots Themes, variations and tricks Other closures Tape skin closures Staples and glue References 7 Operating Preoperative preparation Diagnosis Skin cancer priorities Informing the patient Costs and fees Patient assessment Fast pre-op screen Complete the pre-op exam Examination Pre-planning the operation Type of operation Sketches Suture selection Duration estimate and optimal timing Operation planning Informed consent Scheduling Lists The operation Calm, peace and quiet, time to gather one’s wits On patient arrival Preliminaries Patient clothing and cleanliness Site exposure Site identification and assessment Time-out protocols Preventing wrong-site surgery Suggested procedure for dubious/healed sites Marking out the site Local anaesthetic Positioning the patient The face Scalp hair Music Sterile surfaces Tray set-up Photo documentation Scrubbing up: preoperative hand washing Surgical scrubs Chlorhexidine allergy Preoperative hand washing technique Other hygiene measures Gloves Perforations Double-gloving Gloving technique: gloving up Face masks Drapes Smoke plume Hygiene, sterility and below the table Wound infection prevention – surgical site infection (SSI) Clean vs sterile Preventing SSIs in nasal carriers of Staphylococcus aureus Behaviour and rituals in the operating theatre Sources of SSI Infected cases Clean cases Skin preparation Selection of prepping agent Application of prepping agent Body wash Hand washing Safety MRSA Wound irrigation Hair removal Wound closure Healing by primary intention Healing by secondary intention Postoperative infection rates Antibiotic prophylaxis Systemic antibiotics Regimen if systemic antibiotics warranted Topical antibiotics Contamination-prone regions Nostril antibiotic ointment Clinic efficiency Assistance Working alone Hand stabilisation Ergonomics Surgeons’ symptoms The ‘arc’ Many surgeons suffer injuries from minimally invasive techniques Operation notes The checklist In theatre References 8 Flaps Classification, principles and blood supply Classification Scar shapes Principles Details of the procedure Guidelines Fundamentals of flap survival Common mistakes Blood supply Flap and graft necrosis Cutaneous vascular patterns Perfusion pressure/blood flow in flaps Undermining Flap tension Tension vectors (TV) Other factors affecting flap survival Oedema Revascularisation/angiogenesis Inflammation Reperfusion injury Capillary obstruction Infection Smoking Conclusions Tissue bank: harvest areas Monitoring of skin flaps and follow-up Advancement flaps Single advancement flap Technique Double advancement flap or h-plasty Technique Burow’s triangle flaps Burow’s triangle Technique Burow’s triangle advancement flap (AA or O-Z flap) A-T flap (bilateral T-plasty) L-Plasty, hatchet or 7 flap Mercedes flap M flap V-Y island flap Island flaps Technique V-Y plasty Technique V-Y flap for helical repair Technique Rotation or pivotal flaps Tension Sites Pros Cons Plan Pivot point Undermining S-plasty Classic or conventional rotation flap Technique Medial cheek Technique O-S or O-Z flap Sites Technique Where to place incisions Closure O-Z or O-S? Transposition flaps Pivot point Rhomboid flap Sites Lobed flaps Single lobe flap Banner flap Technique Bilobed flap Trilobed flap Pinwheel or multiple rhomboid flap Z-plasty References 9 Ear, nose, lip, scalp and digits Ear Surgical locations Operations/techniques Surgical site preparation Simple ellipse Wedge resection Technique Flaps Helical rim repairs Advancement flaps Standard advancement flap A-T flap V-Y island flap Transposition flaps Banner flap Bilobed flap Grafts Secondary intention – healing over bare cartilage Chondrodermatitis nodularis helices chronicus (CNH/CNC) Technique Nose Essential anatomy Nerves and arteries Flaps vs grafts Possible operations Undermining Nostril antibiotic ointment Two surgical areas Upper nose Simple transposition flap Rhomboid flap Nasal banner flap A-T flap Lower nose Asymmetrical ellipse Note flap Melo (naso)-labial banner flap Advancement flap Bilobed flap Technique Suture placement Resume bilobed flap Improvements Angle of lobe rotation Flap blood supply Haemostasis Postoperative details Follow-up Complications and prevention Good cosmesis Trilobed flap Dorsal and nasal sidewall nasal flaps – DNF (Reiger) and NAR Grafts Secondary intention healing Technique Lip Anatomy Musculature Vasculature Nerves Principles of lip surgery Scalp Subgaleal area Complications of scalp surgery Closure techniques Digits References 10 Cysts and lipoma Cysts Epidermoid cysts Other epithelial cysts Treatment Slit incision Normal incision Removal of the whole cyst intact Towel clamp retractor Traditional wide excision Minimal incision and punch biopsy excision Recurrence Minimal incision technique Punch biopsy excision technique Technique Punch external extrusion excision (PEEE) Technique Resume incision with expression of the contents Comparison of techniques ‘Infected’ (inflamed) cysts Recommendations Equipment Anaesthesia Sterile tray for the procedure Non-sterile technique Complications and difficulties Pathology Lipoma References 11 Grafts Types Donor origin Graft survival Delayed grafting/slow mohs Pros and cons Special considerations Site preparation Full thickness skin graft (FTSG) Technique Complications Recipient sites Harvest/donor sites Limitations Pre-op technique Procedure Dressings Haematoma stages Post-op ROS Grafts not taking Repair Special sites Split skin graft (STSG) Contractions Types Indications Instruments Harvesting hand-held knives Technique Selection of skin thickness Donor sites Tensioning and stretching the skin Lubricating the harvest area Harvesting the STSG skin Transferring the graft Applying the graft to the recipient site Dressings Grafts on digits References 12 Postoperative care Dressings The ideal dressing Optimum healing The basic dressing Non-adherent dressings Adherent dressings Other dressings Interactive dressings Non-absorbing, waterproof, transparent island films – no-to-low exudate wounds Hydrocolloids – low-to-moderate exudate wounds Superficial surgical wounds Foams/polyurethane pads – medium-to-high exudate Calcium alginates – medium-to-high exudate Hydroactive – medium-to-high exudate Hydrogels – dry or sloughing wounds Hypertonic dressings for hypergranulation – ‘proud flesh’ Adhesive silicon gel sheets for scar treatment Resorbing matrices Barrier films Antimicrobials Dressings for special sites Nose Ears Fingers Retention tapes: strapping Better strip adherence Fixomull strips Retention conforming bandages When to take a dressing down Wound infection risk Adhesive dressing removal Healing and postoperative care Wound classification Thickness Age Morphology Multiple structure involvement Classification of healing Primary intention Secondary intention Tertiary intention Phases of healing Haemostasis Inflammatory phase Proliferative phase Remodelling phase Nerve injury and repair Three degrees of nerve injury Response and repair Four phases of regeneration Optimising healing Wound strength Removal of sutures (ROS) Traditional recommendations ROS after skin cancer surgery Infected wounds Who should remove sutures Scar minimisation Impairment to wound healing Influence of preoperative skin appearance Recommendations Assessment of the patient Surgical technique Aftercare Pain relief Rest Elevation No stretching of the wound Bleeding Numbness Alcohol Infection Dressings Secondary intention healing Complications Complications of skin surgery Patient factors Personality/anxiety Free arms Cough/sneeze Anticoagulants Epilepsy Needle phobia (belonephobia, trypanophobia) Intervention Technique Infection Clean surgery Systemic and topical antibiotic prophylaxis Regimen: Prevention of infection Increased risk of infection Poor technique Diagnosis Treatment Bleeding Operative Severe bleeding complications Postoperative Rest Elevation Pressure dressings Hydrostatic pressure Secondary bleeding Alcohol Trauma Bruising or ecchymosis Haematomas Seromas Wound burst, dehiscence and epidermolysis Preventive technique Re-suturing Refreshing Clinical studies Necrosis Treatment Reaction to sutures Suture tracks – ‘tension and time’ Suture spitting Signs Treatment Poor cosmesis – trapdooring, pin-cushioning Wound assessment Hypergranulation – ‘proud flesh’ Scars – spread, contraction Scar care Scar spread Scar contraction Keloid/hypertrophic scars Aetiology Prevention Treatment Topical Intralesional Other methods Pigmentation Nerve damage Ongoing pain or pruritus Incomplete excision Treatment Recurrent tumours Margin clearance and recurrence Risk of local recurrence Delayed healing or closure Contact dermatitis and hypersensitivity Treatment Life-threatening complications Complications of flaps Late complications References 13 What operation where Margins Scar shape Aids to better scars and what operation where Possible operations for a primary skin cancer Tissue wastage Closures and techniques Flaps and their uses Rotation flaps Transposition flaps Bilobed flaps O-S (Z) flaps Some suggested operations Head Bilobed and trilobed flaps Bilobed flaps in skin cancer of the face Limbs Joints Hands References 14 Hints, tips, tricks and reminders AK to SCC Local anaesthetic Anatomy Bell ringers Biopsy Bleeding Bluey face down pre-cut Cable identification Catchers Cautery Hyfrecator – insulated tip Clopidogrel Chloramphenicol for nares Complaints Cryosurgery pain Curettes Dermabrasion Design and equipment Drapes and hair Dressings Dropped needles Dysplastic naevi Ears Examinations Grafts Haemostasis Hair Hand stabilisation Healing Keratoacanthoma Leg ulcers Lights Measuring lesions Needle sticks Nose Opening sealed packs – sutures and syringes Photodamage Skin markers Skin prep Spitz naevi Statistics Sterilisation Sunscreens Sunglasses Surgery Mohs Lentigo maligna melanoma MIS Incision markers Orientate Alar groove Face Umbilical lesions Incise outwards Dog-ear minimisation Skin stretches Compress wide wound edges Sutures Withdrawing sutures to needle holder Use 75 cm Sutures on the same side Suture length to cut Deep sutures Cutting deep sutures Suture memory erasure Four throws for 6/0 slippery Tightening arrested knots Knots Mixed sutures Short end and one more suture needed Blue sutures for hair Mouth sutures Tape strips Tidying up – gloves Toes Towel clamp Tourniquets Warts FINGER WEB dressings References Index A B C D E F G H I J K L M N O P R S T U V W X Z