17 - Derm Surgery

Question 1

Incisional vs excisional removal?

Answer 1

Incisional - only a portion of the tumor is removed

Excisional - entire tumor is removed

Pic on slide 7

Question 2

Biopsy techniques?

Answer 2

Shave biopsy
Punch biopsy
Excisional biopsy

Question 3

Local anesthesia agents?

Answer 3

Lidocaine

• rapid onset 2 min
• duration 60-120 min

Bipivicane (marcaine)

• slow onset 5 min
• duration 4-8 hrs

Epinephrine

• vasoconstriction
• prolongs anesthesia
• dont use on anything with a tip

Question 4

Surgical instruiments

Answer 4

Scalpels
Needle drivers
Skin hooks
Sutures

Slid 11-15 has pics

Question 5

Purpose of shave biopsy?

Answer 5

• Obtain tissue for diagnostic purposes
• Remove benign surface neoplasms

Use for raised lesions when full thickness tissue specimen is not necissary

Question 6

Shave techniques?

Answer 6

Mark lesion prior to anesthesia

Inject/infiltrate anesthetic

Hold traction and shave

Pics 23-24

Question 7

Contraindications for shaving?

Answer 7

Suspicion of melanoma

• doesnt do full thickness
• need to determine thickness of tumor (breslow) and degree of invasiveness (clark level)

Question 8

Advantages of shave biopsy?

Answer 8

• Rapid
• no sutures
• no assistant needed
• clean procedure (not sterile)
• easy
• simple wound care (RTD)

Question 9

Disadvantages of shave biopsy?

Answer 9

Hypopigmentation +/- scar
Depressed scar may result
Not full thickness (diagnosis)

Question 10

Complications of shave biopsy?

Answer 10

• Scar (indented/hypertrophic)
• Hypopigmentation
• Erythema
• Regrowth of incompletely removed lesion
• Infection (rare)

Question 11

Uses for punch biopsy?

Answer 11

For full thickness specimen

Superficial inflammatory and bullous diseases
Tumors: Benign and malignant

Question 12

Dont use punch biopsy for?

Answer 12

MM

Question 13

Size range of punch biopsy?

Answer 13

2-8mm

2-3mm for face and small lesions

Larger usually require 1+ stitch

Question 14

Punch technique?

Answer 14

Anesthestic
- wait 10 min

Pull tension on skin

Penetrate completely -> dermis exposing subQ fat

Pics 29-31

Question 15

Punch contraindications?

Answer 15

Certain anatomical locations

• arteries and nerves esp
• hand dorsum
• face
• volar wrist

Question 16

Advantages of punch biopsy

Answer 16

Full thickness specimen
Better cosmesis
Faster healing
Easy to use, convenient
Cheap

Question 17

Disadvantages of punch biopsy

Answer 17

Hyptertrophic scar

Suture removal

Question 18

Complications of punch biopsy?

Answer 18

Induration
Erythema
Hypertrophic scar
Excessive protruding at skin edges (dog ears)
Bleeding (rare)
Infection (rare)

Question 19

Indications for excisional biopsy?

Answer 19

Deep inflammatory disease
- erythema nodosum
MM
Deep or nodular lesions
- BCC, SCC

Question 20

Preoperative evaluation for excisional biopsy

Answer 20

Allergies to meds
Screen for bleeding tendencies 
ETOH/Tobacco
HIV/hepatitis
Abnormal scarring

Question 21

When planning biopsy you should look at?

Answer 21

Skin tension lines
Natural wrinkle lines
- incision parallel or w/in the lines

Biopsy should include 2mm of margin of normal skin

Question 22

Size/shape of biopsy technique?

Answer 22

Draw ellipse
Length = 3x width

Pics on 43-45

Question 23

How to avoid “dog ears”?

Answer 23

Ends of ellipse 30%

Question 24

Depth of excisional biopsy

Answer 24

Cut to depth of subQ fat

Then elevate it and snip w scissors/blade

Question 25

Suture technique for excisional biopsy?

Answer 25

Get sub Q to decrease tension

1nd layer is cuticular sutures

Question 26

Postoperative wound care

Answer 26

53-56 seems pretty intuitive

Question 27

Suture choice and removal chart?

Answer 27

Slide 57

Question 28

I went to a turtle’s party last night

Answer 28

I had a shell of a time

Question 29

Guess what…

Answer 29

You know enough now to pass PA school