Surg Flashcards
Mustarde rotation flap
Cheek rotation flap
Acute side effects of ray
Radiodermatitis: erythema dry desquamarion and moist desquamatoon
Mucositis
Chronic side effects from ray
Atrophy Loss of appendages: alopecia and anhidrosis Hyper or hypo pigmentation Telangiectasia Ulceration
Secondary malignancy 1/1000-2000 risk, average 24 years later: BCC SCC AFX MFH fibrosarcoma angiosarcoma
List all possible treatment of cutaneous tumors
Mohs Excision Cryotherapy Radiation therapy C&C Intralesional interferon, 5-fu, methotrexate PDT Ablative laser Topical 5FU and ingenol and imiquimod Vidmodegib
Normal bread loafing of histo examines what % of tumour margins
Less than 1%
5 year cure rate mohs vs excision
Mohs 99%
Conventional 93%
5 year cure rate for recurrent cancers Mohs vs excision
Mohs 95%
Excision 80%
Cancers on ear make up what % of cutaneous cancers
6% but high recurrences likely due to embryonic fusion planes
Post auricular tumors spread where
The ear
Pre auricular tumors spread where
Towards the tragus and medial and superior aspects of the helix. Once at tragus can spread down the external part of tragus between tragar cartilage and parotid gland to deeper like facial nerve
Which site most common recurrence for BCC
Nose
Indications for Mohs
Recurrent Positive margin High risk for recurrence or mets Sites that require tissue conservation Embryonic fusion planes: peri orbital (medial canthi), nasal, lips, ears, retroauricular sulcus, melolabial folds Poorly defined clinical margins PNI >2 cM Immunosuppressed Previous ray treatment Demonstrated biological aggressiveness
Sites where tissue conservation is important
Eyelids Ears Nose Lips Digits Hails Genitalia
Best site for cure rate for Mohs on penis
Glans or prepuce, <1 cm
Supplements that make you bleed
Vitamin E
Gingko biloba
Garlic
Ways to identify where the tumour is on the skin
Magnification Dermoscopt Woods light Curette lightly Ask patient
What angle do you have blade in Mohs
30-45 degrees
What kind of specimen is best in Mohs
Saucer shaped with 30 degree beveled edges so it can be flattened
What size specimen can fit on a microscope slide
0.5-1.5 cm
How do you number the edges of tissue specimens in Mohs
Clockwise, starting at one o clock
How is a Mohs specimen cut
Horizontal sections from the deep surface first
What do you freeze Mohs specimens with
Tetrafluorethylchloride
Liquid nitrogen
What intervals of sections are sliced in Mohs
4-8 um
What stains do you use in Mohs
After sliced, stain with H&E, sometimes toludine blue
After gone through slide drainer than rinse and use a clear mounting medium: Cytosdal-60 or similar
Other stains to help with diagnosis
MART1
Cytokerstin
CD34 for DFSP
What % of tissue shrinkage from frozen section processing
10-20
If tumour involved eyelid margin how should you protect the eye
Lubricated plastic eye shield after topical Anaesthetia of tetracain Ophthal drops
Which instruments are good for perinocular excisions
Castro Viejo needle driver
Westcott scissors
Patients with high risk of IE who need prophylactic abx
Prosthetic cardiac valve
Previous IE
Unrepaired CHD or repaired with prosthetic within 6 m of procedure
Repaired CHD with residual defects
Cardiac transplant recipients with valvulopathy
Patients at high risk of joint infection
Joint replacement within last 2 years Previous prosthetic joint infection Immunocompromised T1 DM HIV Malignancy Malnourishment Haemophilia
Sites of high risk of surgical infection
Wedge on lip or ear Genitalia Below knee Skin flap on nose Skin grafts Extensive inflammatory disease
Aldabra response rates for BCC
Superficial 87%
More invasive 65%
BCC most important predictor of sub clinical spread a part from agresiva histo
> 2.5 cm
BCC margins excision versus Mohs
<2 cm 4 mm margin clears 95% in excision
Mohs <1 cm 99.9%, 1-2 cm 99.3%, 2-3 98 and >3 84.3
Recurrent BCC excision versus Mohs
Excision 12.1% recurrent at 5 years
Mohs 2.4%
Facial BCC excision versus Mohs
Mohs 2.5
Excision 4.1
Basosquamous recurrent Mohs versus excision
Mohs 4.1
Excision 12-45
What % of BCC become metastatic
<0.5%
Biologically aggressive SCCs
Cystic
Clear cell carcinoma
Adenoid SCC
Spindle cell SCC
Risk of PNI in SCC
<2.5 cm 11 %
>2.5 cm 64%
Margins for SCC excision
4-6 mm depending on risk
Recurrent SCC Mohs clearance rates
94%
Verrucous carcinoma rates Mohs versus excision
Excision 80
Mohs 98
Merkel CC recurrence, nodes and Mets rates
Recurrence 30%
Regional LN 50%
Mets 40%
Merkel cell carcinoma clinical margins
1-2 cm
Treatment of choice for DFSP
Mohs - no recurrence
Imatinib - tyrosine kinase inhibitor for Mets
AFX margins
1 cm
MAC recurrent rates
Excision 50%
Mohs 10%
Eccrine porocarcinona - appropriate for Mohs?
Well it has skip areas
Also it’s radio resistant
Is sebaceous carcinoma appropriate for Mohs
CAn have skip lesions and recognizing pagetoid spread may be tricky
DFSP margins
<2 cm 1.5 cm
Larger 2.5 cm
When is adjuvant radiation usually performed
Witihin 4-8 weeks post operatively
What is the usual total dose of radiation over how many fractions
50-55 gy over 20 daily fractions
What is the preferred treatment of choice for rad onc treating keratinocyte cancers
Electron beam radiotherapy
What is the radiation threshold dose that predisposes eyes to cataracts
5-10 gray
Acute reactions from radiation
Erythema Dry and then moist desquamation Dyspigmentation Ulceration, haemorrhage Pruritos Temporary alopecia Temporary loss of fingernails or toenails Temporary hypohidrosis Mucositis
Suspect infection if not healing
Late reactions from radiation
Telangiectasias Fibrosis Necrosis of soft tissue, cartilage, bone Dyspigmentation Permanent alopecia Hypohidrosis, sweat gland atrophy Xerostomia Delayed wound healing NMSC ~20 yrs later
Success % with radiation usually
~90%
Ideal tumour size for TEBR
< 5 cm diameter, <0.5 cm depth
Ideal tumour size for Brachytherapy (both surface and interstitial) radionuclide
<2 cm diameter and <0.5 cm depth
Ideal tumour size for superficial ray
<5 cm diameter and <0.5 cm depth
Contraindications for radiation
Absolute: genoderm Gorlins, XP
Relative: AICTD - lupus, scleroderma (Bolognia says this is absolute) Poorly vasculairsed Chronic ulceration Trauma Thermal burns Prior radiation Deeply invading into the cartilage Extremities: foot, anterior lower leg, dorsum of hand <50-60
When to do adjuvant radiation for BCC
Substantial perineural involvement: >0.1 mm in caliber or >3 nerves, or positive margins
When to do adjuvant radiation for SCC if clear margins
What margins
if substantial peri neural involvement, larger than 0.1 mm or invasion of nerve below the dermis
Also for nodal mets to the head and neck, unless the patient has 1 small node with no extracapsular extension
Most treated with 1-1.5 cm margin
What is the first and second line treatment for DFSP now
WLE first
Imatinib second
Radiation is third now and you do a wide field 3-5 cm
Can you use radiation treatment for MCC
Yes - its recommended as adjuvant regardless of positive or negative margins
Recommend doing within 4 weeks after surgery
The excision site, in transit tissue and draining nodal basins are irradiated to account for subclinical disease UNLESS the primary tumour is <1 cm, negative post operative margins are obtained, no lymphovascular invasion, and SLNB is negative
What sort of radiation field for MCC
5 cm
Common cx post radiation for Kaposi
Lymphoedema
When to do radiation for melanoma
Definitive: large facial lentigo maligna not amenable to surgery - 1-1.5 cm margin
Adjuvant:
Post operatively desmoplastic
LN mets
Stereotactic: CNS mets
Palliative for cutaneous mets, in transit disease etc
When to do radiation for UPS
Always - post operaatively whether negative or positive margins
What is the concern of radiation with systemic therapies for melanoma
BRAF and MEK inhibitors may lead to increased toxicity when used with RT - so hold at least 3 days before and after fractionated RT
Risk of BCCs and SCCs from radiation (according to bolognia)
2% and 1.5% respectively
How to deal with a haematoma post op
<48 hours large bore needle 16-18 gauge aspiration
>48 hours irrigation
If liquefied (7-10 days) then can needle aspirate
When does a haematoma liquefy
7-10 days post op
Most common timeframe for surgical site infections
4–10 days
Risk of transformation of individual AK to invasive SCC is what at 5 years
2.88%
Action spectrum of 8 mop
330-335
Maximum EMLA dosage
0-3 m: 10 cm2 for 1 hour
3-12 m: 20 for 4 hrs
1-6 yes: 100 for 4 hrs
7-12: 200 for 4 hrs
Nasal tip side to side closure can do for defects less than what
8 mm
Max size for dorsal nasal rotation
2-2.5 cm
with myocutaneous flap incise down to where
lateral to subcut fat
medial to periosteum
where should you put the peng flap
supra tip best site
width of paramedian flap
1.2-1.5 cm
blood supply for nasolabial interpolation
random
size for composite graft
<1 cm
principles of the transposed island pedicle
draw and ellipse lateral to the defect
undermine distal 3/4 in fat, then swing deeper into muscle to create fat/mm island pedicle
undermine widely
swing around 45-90 degrees
good for deep defects
shark island pedicle sutures
1st: back of shark to nasofacial sulcus - this should make head and snout drape down into defect
second: snout down to inf border of defect
with second intention healing how much contraction occurs/decrease in size
30%
second intention how long will have open wound
4-6 weeks
three best closures for nasal dorsum defect
peri alar unilateral single sided advancement flap
SCIP
back cut rotation (dorsal nasal rotation essentially)
Nasolabial advancement flap - design and where to put sutures
Design: inferomedial aspect of defect around alar crease and down nasolabial fold
Sutures:
- Pex middle of flap at NF sulcus, pull superomedially
- 1/2 cm behind advancing corner of flap to periosteum under superior edge of defect
Nasolabial advancement flap negatives
Can lower eyelid
Blunting of nasofacial sulcus
Elevation of alar rim
Webbing of medial canthus
Rules for back cut rotation flap
Surface area of flap needs to be twice the size of the defect
Angle of inverse V should be 30-45 degrees
Undermine above procerus and corrugator supercilli
Close glabella defect first, then close the primary defect
If do side to side on lateral forehead, what is the size of the defect
<1 cm to ensure no lateral eyebrow elevation
Rotation flap general principle regarding area of flap within the arc compared to defect
2-3 times the size of defect
how long does it take for eyebrow hairs to re grow
4 months
when in the eyebrow, what considerations for surgery
undermine beneath the hair bulb
medial eyebrow hairs grow vertically
lateral eyebrows grow horizontally
make sure to incise parallel to the hair shafts
Best closure for the eyebrow
O to U or O to H or SCIP
Do O to U if medial or lateral
O to H if in centre of eyebrow
DCP initial
2%
4X4 cm area
Photoprotect
What is the trigeminocardiac reflex
Operating in trigeminal nerve - ophthalmic and maxillary branch, trigeminal nerve connects with trigeminal nucleus - links with motor nuclehys of vagus nerve
Results in bradycardia, hypotension, asystole, apnoea, death
