advanced derm procedures

Question 1

steps of derm procedures

Answer 1

1. evaluation of the wound or the area of the procedure
2. cleansing of the area
3. anesthetizing the area
4. complete the procedure or biopsy
5. follow up care and suture removal

Question 2

wound evaluation include

Answer 2

evaluating for damage to underlying structures and presence of foreign bodies or body cavity penetration

Question 3

wound evaluation - nerve injury

Answer 3

neuro exam: light touch and motor function; 2-point discrimination for hand and finger injuries

compare findings to uninjured side

Question 4

wound evaluation - tendon injury

Answer 4

complete tendon laceration causes resting deformity (foot drop when Achilles tendon laceration); partial tendon laceration does not cause resting deformity

exam: full ROM

Question 5

wound evaluation - vascular injury

Answer 5

suggested by signs of ischemia, rapidly expanding or pulsatile mass or bruit

Question 6

wound evaluation - bone injury

Answer 6

plain X-ray to rule out fracture

Question 7

wound evaluation - foreign bodies

Answer 7

1. wounds involving glass usually have foreign bodies, lacerations from sharp metal rarely do
2. localized pain or tenderness, esp if pain worsens with motion
3. imaging studies for all wounds involving glass and other suspected foreign bodies
4. x-ray for glass, metallic; other modalities for organic materials (ex: wood splinters or plastic)

Question 8

contraindications for primary wound closure

Answer 8

concern about wound infection. circumstances assoc with high risk of infection:

1. acute wound > 6hrs
2. foreign debris that can’t be completely removed
3. active oozing of blood
4. dead space under the skin closure
5. too much tension on the wound

Question 9

delayed primary closure definition

Answer 9

compromise between primary repair and allowing an acute wound to heal secondarily

Question 10

delayed primary closure considered for which type of wound?

Answer 10

wound >6hrs even though primary closure is preferable such as a large wound or a wound near a skin crease

Question 11

delayed primary closure procedure

Answer 11

1. treat the wound with wet-to-dry dressing changes for a few days
2. suture the wound closed within 3-4 days

Question 12

when to seek surgical consultation for laceration repair

Answer 12

1. deep wounds of hand or foot
2. full-thickness lacerations of the eyelid, lip, or near ear
3. lacerations involving nerves, arteries, bones, or joints
4. penetrating wounds of unknown depth
5. severe crush injuries
6. severely contaminated wounds requiring placement of a drain
7. wounds leading to a strong concern about cosmetic outcome

Question 13

cleanse with what? what should be avoid?

Answer 13

cleanse with saline or tap water

avoid povidone/iodine, detergents and hydrogen peroxide

Question 14

where to anesthesize to minimize pain when cleansing wound?

Answer 14

anesthesize around the wound, not in the wound

Question 15

anesthetize with what? and how long does it last?

Answer 15

lidocaine (last 1hr)

bupivacaine (last 2-4hrs)

Question 16

where can you use anesthetic agent + epinephrine? where can you not use it?

Answer 16

can add epinephrine for wounds of face or scalp

can’t add epinephrine for wounds of digits, nose, penis, and earlobes

Question 17

administration of anesthetic

Answer 17

1. inject with a needle as small as possible
2. inject slowly and in skin surrounding wound
3. do a nerve block isntead of anesthetic if possible
4. sting from anesthetic can be decreased with slow administration and buffering solution

Question 18

non-absorbable suture

Answer 18

1. silk - lowest tensile strength
2. nylon - high tensile strength, but requires a number of knots
3. polypropylene (prolene) - low tissue reactivity and high tensile strength, but requires extra knots, can stretch to accommodate wound swelling
4. cotton
5. stainless steel

Question 19

absorbable suture

Answer 19

1. catgut - retain tensile strength for 5-7 days
2. chromic gut - retains tensile strength for 10-14 days, used to close oral mucosa laceration because rapidly absorbed
3. fast-absorbing gut - epidermal suturing especially for facial lacerations, retain strength for 5-7 days, low tensile strength
4. polyglactin (vicryl) - ideal for subcutaneous sutures
5. monocryl - for facial lacerations closed with subcuticular running sutures
6. polyglycolic acid (dexon)

Question 20

interrupted suture:
used for which wounds?
advantage?

Answer 20

used for wounds that are jagged or irregular

advan: allows for removal of some sutures in cause of infection, suture breaks still have remaining sutures in place

Question 21

continuous suture
advantage?
disadvantage?

Answer 21

advantage:

1. closes wound quickly
2. gives better cosmetic result since tension spread uniformly

disadvantage:
1. suture breaks, entire wound opens

Question 22

subcuticular running suture

used for which wounds?

Answer 22

1. for low-tension, cosmetically important wounds

Question 23

vertical mattress suture used for which wounds?

Answer 23

everting wound edges in locations that tend to invert

Question 24

horizontal mattress suture used for which wounds?

Answer 24

high-tension wounds or wounds with fragile skin

Question 25

layered closure:
when to do it
how to do it
what happens if not done

Answer 25

1. when wound is widely separated or closure will be under some tension
2. use dermal sutures by placing absorbable suture under epidermis
3. not done -> seroma in open space

Question 26

tissue adhesives advantage

Answer 26

applied quickly
no anesthesia required
eliminate need for follow-up

Question 27

tissue adhesive contraindicated in which patients

Answer 27

immunosuppressed patients

diabetics

Question 28

tissue adhesive not used in which wounds?

Answer 28

1. high-tension areas such as over joints
2. mucosal surfaces
3. wound that are contaminated, complex, jagged

Question 29

biopsy types

Answer 29

1. incisional
   shave - superficial portion of suspected area is removed
   punch - small cylinder of tissue is removed
2. excisional - entire area of abnormal tissue is removed (ellipitcal shape)

Question 30

at how many weeks do the wounds look the worst? when does it shrink down?

Answer 30

1. looks angriest at 1mo - 6wks

2. shrink down in 1yr

Question 31

aftercare

Answer 31

1. After suturing the wound closed, apply a small amount of antibiotic ointment over the suture line and cover the area with a dry gauze.
2. After 24 hours, remove the original dressing.
3. The patient can wash the area with gentle soap and water the day after the repair. A shower is fine, but if the patient wants to take a bath, the injured area should not be allowed to soak in the water for more than a few minutes.
4. A small amount of antibiotic ointment can be applied daily for the first few days; then leave the area open to air.
5. If the injured area is on the hand, foot, or calf, have the patient elevate the affected extremity. Elevation decreases swelling in the injured area and thereby improves healing.
6. Applying white petrolatum to a sterile wound to promote wound healing is as effective as applying an antibiotic ointment although neither is necessary and may delay wound healing.

Question 32

when can suture be removed

Answer 32

face - 3-5 days
scalp - 7-10 days
arms - 7-10 days
trunk - 10-14 days
legs - 10-14 days
hands or feet - 10-14 days
palms or soles - 14-21 days

Question 33

how to decreased scarring

Answer 33

skin sutures are removed while the scar tissue is still relatively weak compared with the final scar strength (which is not attained for several months).

Question 34

how to maintain wound closure after sutures are removed

Answer 34

it is useful to place Steri Strips (if available) across the scar once the sutures have been removed. These strips fall off on their own, and the patient can wash the area, even with the strips in place