Surgical Quiz Flashcards
1
Q
Recommended margins for:
1. AFX
2. Cutaneous undifferentiated pleomorphic sarcoma (cUPS)
A
AFX = 2cm margin
(If </=1cm AFX, then can be removed with 1cm WLE)
cUPS = 3cm margin
2
Q
What is at Erb’s point?
A
Greater auricular
Lesser occipital
Transverse cervical
Spinal accessory
Supraclavicular
3
Q
Which nerves supply which portions of the ear?
A
Auriculotemporal - upper ear
Lesser occipital - mid-lateral (and posterior ear)
Greater auricular - lobe/lower ear
Auricular branch of vagus nerve - conchal bowl
4
Q
Describe the course of the parotid duct
A
Exits anterior parotid
Superficial to masseter
Pierces through buccinator
Drains into mouth at 2nd molar
Chronic draining sinus if injured, required intervention, will NOT heal on its own (unlike parotid gland)
5
Q
What is the course of the temporal branch of facial nerve where it is vulnerable?
A
0.5cm below tragus, 1.5cm superior to lateral eyebrow, draw line
6
Q
What does the temporal branch of the facial nerve innervate?
A
Frontalis - raises eyebrows
Orbicularis oculi - closes eye
Corrugator supercilli - wrinkles brow
Ear
7
Q
External carotid artery course
A
Becomes facial artery after crosses mandibular rim
Facial a. then takes anterosuperior course in direction of oral commissure
Branches inferior and superior into labial arteries
Also courses along medial cheek to nose making angular artery - enters orbit to anastamose with ophthalmic artery branches
Superficial temporal artery behind parotid (psoteroinferior aspect), after zygomatic arch it enters subcutaneous fat
8
Q
Arteries danger zones
A
Labial artery at LIP
Angular artery as it courses near the NOSE
Facial artery as it crosses mandibular rim
Superficial temporal artery superior to ear
9
Q
Facial muscles, movements, innervation
A
Frontalis - raises eyebrows - temporal branch of facial nerve
Corrugator supercilii - brow medial and down - temporal branch of facial nerve
Procerus - forehead and brow inferiorly - temporal branch of facial nerve
Orbicularis oculi - closing eye - zygomatic and temporal branch facial nerve
Levator palpebrae superioris - opening eye - zygomatic branch facial nerve
Orbicularis oris - draws lips together, puckers mouth - buccal and marginal mandibular branches facial nerve
Buccinator - flattens cheeks against teeth - buccal branch facial nerve
Lip elevators - zygomatic branch facial nerve
Levator labii superioris
Levator labii superioris alaeque nasi
Zygomaticus major
Zygomaticus minor
Other lip elevators - buccal branch facial nerve
Levator anguli oris
Risorius
Lip depressors - marginal mandibular branch facial nerve
Depressor anguli oris
Depressor labii inferioris
Platysma (cervical branch of facial nerve)
Mentalis - lower lip elevation and protrusion - marginal mandibular
10
Q
Merkel cell carcinoma in situ management
A
WLE 5-10mm margin and no need for SLNBx
Active surveillance local recurrence for 5 years
11
Q
Peroneal nerve course and injury
A
Can be damaged at fibular head, easily palpable, injury leads to loss of dorsiflexion (foot drop)
12
Q
Chlorhexidine
A
Broad spectrum (but not so good for TB)
Long lasting (>6 hours)
Caution eyes and ears (ototoxicity, corneal ulceration)
13
Q
Povidone iodine
A
Works quickly (minutes)
Broad spectrum - gram +ve, -ve, enveloped virsues, mycobacteria, fungi
Must be left on skin (inactivated with blood, sputum)
Irritant
Chronic maternal use - hypothyroidism in newborns
Not for neonates or large surface area (potential systemic toxicity)
10% solution - too strong for eyes, but can dilute 1:1 or get 5% solution
14
Q
Alcohol as antiseptic
A
Fast onset
Flammable
Does not have sustained action
15
Q
Medications that interact with lidocaine
A
Lidocaine is metabolised by CYP450 3A4 (also 1A2 to lesser degree) - so that list of inhibitors and inducers will increase and decrease lidocaine levels respectively
Beta blockers (non-selective) - propranolol, sotalol
(note: combo of adrenaline and a non-selective beta blocker can cause malignant hypertension, although a selective beta 1 blocker like metoprolol is okay)
16
Q
Z plasty
A
A transposition flap
Lengthens scar (good for contracted scar - esp for free margins)
Makes scar less visible
The central diagonal is the scar
2 arms that are the same length as the common diagonal (also called the common limb) extend from the ends in opposite directions
Classic 60 degree angle results in a 90 degree change in scar direction, and a 75% gain in tissue length
(greater angle, greater lengthening)
As length of common diagonal and arms become longer, the tension placed across the transverse diagonal critically increases
17
Q
Preventing ectropion
A
Scars should be oriented perpendicular to lower lid margin (therefore not following relaxed skin tension lines)
Choice of repair to minimise any downward pull
e.g. Tenzel advancement flap from lateral or rhombi transposition flap from inferior
Oversize grafts up to double defect size
Size flaps generously in order to push up inferior lid
Periosteal tacking/suspencion suture to suspend flap to bony orbit/temple and prevent pull on lower lid
If lower lid laxity - full thickness triangular wedge
Canthoplasty/canthopexy - horizontal incision several mm lateral to the lateral canthus, exposing lateral canthal ligament, which is then tacked to superior orbital rim
Frost suture, taping, lower eyelid splinting
18
Q
Laser hair removal contraindications
A
Lupus erythematosus
Past or current gold treatment
Isotretinoin in last 6 months
Suntan (6 weeks)
Pregnancy
Keloids
Koebnerising conditions - psoriasis
Doxycycline
(ensure have been worked up for causes hirsutism)
19
Q
Hair follicle anatomy - describe
A
Infundibulum - orifice to sebaceous duct entrance
Isthmus - sebaceous duct to arrector pili
Inferior segment - from insertion arrector pili to base/bulb with dermal papilla at bottom
Hair bulb/bulge is laser target
Bulbar stem cells contain melanin, which is the target chromophore
20
Q
Rate of hair growth
A
Scalp 0.44mm/day
Beard 0.27mm/day
21
Q
Duration of anagen, telogen on scalp
A
Anagen 150 weeks
Telogen 12 weeks
22
Q
How do chemical depilatory creams work?
A
contain thioglycolates that dissolve hairs by disrupting disulfide bonds
eflornithine hydrochloride 13.9% cream, reduces unwanted facial hair in women by decreasing anagen phase of hair follicle leading to subsequent hair growth delay
23
Q
Electrolysis hair removal
A
Better on straight hair (in anagen) than curved
Galvanic electrolysis
- direct electrical current
(inserted into individual hair follicles)
- destroys the follicle by producing sodium hydroxide
- MORE EFFECTIVE (slower)
Thermolysis
- High frequency alternating current
- destroys hair follicle through heat production
- QUICKER BUT LESS EFFECTIVE
- Higher risk scar
Hair regrowth rates 15-50%
Multiple sessions
Can use EMLA
24
Q
Expected outcomes of laser hair removal
A
Perifollicular oedema (endpoint)
Hairs continuing to emerge for 1-2 weeks
25
List all of the hair removal lasers
694
755
800-810
1064
26
Risks laser hair removal
Blister, ulcer, scar
Folliculitis, acne flare
Hypo/hyperpigmentation
Increased hair growth
Poor to no response
Recurrence
27
What laser for brown hair, SPTI-II
694, 755, 800
28
What laser for brown/black hair, SPT III - V
Longer wavelength
Lower fluence
800, 1064
Note: 1064 is most painful
29
Laser hair removal technique points
Spot size?
TRT?
Larger spot size is better
pulse duration should be equal to or less than thermal relaxation time
pulse duration ideally 10-50ms
30
What laser for red/grey hair, SPTI-II
694, 755
31
What laser for blonde/white hair, SPTI-II
694
32
Diode laser hair removal
800-810nm
Less costly
Suitable for SPT3 and 4
Larger spot size, lower fluence
Vacuum assisted suction allows for lower effective fluence (and decreases pain)
Longer/larger pulse duration
100% clearance in 1/3rd patients in 1 year
33
What does LASER stand for
light amplification by the stimulated emission of radiation
34
IPL wavelength
Post treatment expectation
Safety tips
515 - 1200
Mild erythema
Do not use within orbital margin
Okay to overlap treatments
35
What tattoos respond well (and not so well) to laser?
Better response
- Amateur
- Dark
- Uniformly coloured
- Red colour
Worse response
- Professional
- Older tattoo (>36 months)
- Location on feet or legs
- Green and yellow colours/ colours other than black and red
- Dense pigment
- Smoker
- Immediate pigment darkening
- Larger tattoos (>30cm)
- Interval of treatment sessions <8 weeks
36
What laser for red pigment?
Pigment: cinnabar, caadmium red
Laser: QS 510nm pulsed dye
Or KTP 532
*Use with caution laser that destroys cadmium salt pigment in those who have cadmium allergy
37
What laser for red/brown pigment?
Pigment: iron oxide
Laser: QS KTP
38
What laser for yellow pigment?
Pigment: cadmium sulfide
Laser: QS KTP
*Use with caution laser that destroys cadmium salt pigment in those who have cadmium allergy
39
What laser for green pigment?
Pigment: chromium salts
Laser: QS ruby, QS alexandrite, picosecond alexandrite
40
What laser for dark blue pigment?
Pigment: cobalt salts
Laser: QS ruby, QS alexandrite, picosecond alexandrite, QS ndYAG
41
What laser for black pigment?
Pigment: carbon
Laser: QS ruby, QS alexandrite, picosecond alexandrite, QS ndYAG
42
What laser for white pigment?
Pigment: titanium dioxide
Laser: any QS laser
43
What is QS laser?
Allows emission of nano-second (shorter) pulses
Shorter pulse allows heat to be more targeted to the chromophore
44
Laser for lentigines?
QS KTP (532)
QS Ruby (694)
Superficial pigment, shorter wavelength
QS 755 (alexandrite) for superficial and deep pigment
+ (not commonly used):
510
IPL
45
How to treat cosmetic tattoo e.g. lip liner?
Single pass ablative laser
(beware paradoxical hyperpigmentation with QS laser)
46
755nm alexandrite laser
Indications
Tattoo - green, blue or black
- Greater than 75% improvement in blue or green pigment after 1 or 2 picosecond alexandrite laser treatments
Ephelides, lentigines
Melanocytic lesion?
47
Laser for naevus of Ota
Fluence?
Endpoint?
Regime?
Responds well
Uniform whitening is the desired end point
Generally want higher fluences for dermal pigment compared with epidermal
If fluence is too low, can cause paradoxical hyperpigmentation
Treat 6-8 weekly, gradual rather than immediate response
48
Laser for melasma
What lasers can you use?
QS ndYAG or picosecond
Fraxel
IPL - mixed results
49
List ablative lasers
CO2 (10,600 nm)
Er:YAG (2940 nm)
Er:YSSG (2790 nm)
50
Laser for CALM
Can achieve complete or partial/spotty clearance with multiple treatments
Recurs commonly
QS or erbium YAG
51
Pigment laser endpoint
Immediate ash-white colour
52
Hydroquinone pregnancy category
C
53
Ablative laser
Target
Absolute contraindications
Pre-treatment
Post-treatment
Expectations, downtime
Aims to ablate papillary dermis
Double pass gets deeper tissue penetration
Absolute CI
Active infections or inflammation
Hx keloid scarring
Lupus erythematosus
Isotretinoin within last 6-12 months
Pre-treatment
Need to be off isotretinoin 6-12 months
Pre-treatment with tretinoin reduces PIH
Antiviral prophylaxis (by day of surgery and 7-10 days post op, 10% risk)
(Note OCP increases risk PIH)
Post-treatment
Post treatment tretinoin reduces PIH
Expectations
Ooze 1-2 days
Erythema, oedema, crusting (resolves within 7 days, 5-7 days for fractional)
Erythema up to 3 months
(can use ascorbic acid for erythema but not until 4 weeks after)
Results/peak response seen at 3-6 months
54
Non-ablative fractional laser
Indications
Striae distensae
Deep rhytides (not dynamic)
Facial photoaging (need 4-5 treatments)
Can be used on non-facial sites
55
Ablative laser resurfacing risks
Scarring
Hyperpigmentation
Allergic and irritant contact dermatitis
Acneiform eruptions, milia formation
Hypertrophic scarring
Ectropion
56
Laser for port wine stain
Prognostic factors
Good prognostic factors:
Infancy > older
Trunk > extremities
Lateral > central face
Smaller > larger
Dilated superficial vessels in superficial horizontal plexus
Red lesion > pink
V3/1 > V2
V2 dermatome is SLOW
Can use IPL if PDL unsuccessful
KTP 532nm
Alex, diode, ndYAG 1064
57
Port wine stain prognosis
70% will achieve > 50% clearance
<20% complete lightening
20% poor response
Depends on lesion size:
67% decrease in size for lesions < 20cm^2;
23% decrease in size for lesions >40cm^2
58
Phenol - cardiac arrhythmias
Likelihood and risk factors
6.6%
Depression, diabetes, HTN
(not age, sex or previous cardiac hx)
59
What is Jessners solution
What is the endpoint
Resorcinol 14g
Sal acid 14g
Lactic acid 14g
Ethanol 95% 100ml
Endpoint is erythema and speckling, not frosting
60
Blue TCA peel
What is the advantage?
What is the conc of TCA?
15-20% TCA
Depth-controlled, more standardisation in acid absorption
Base increases surface tension of solution, results in slower absorption of TCA
Frosting occurs more slowly
Can apply several coats
61
TCA cross
Chemical reconstruction of skin scars
For atrophic acne scars
TCA 65-100%
Sharpened wooden applicator (or paint brush)
Best to treat rest of face with superficial peel (e.g. TCA 10-15%)
2-6 treatments
62
Sal acid peels
Beta hydroxy acid
20-30%
Good for acne
Immediate white precipitation
Self-limiting, no need for timing or neutralisation
Very little discomfort, due to anaesthetic properties of sal acid
Polyethelene glycol is good base - less stinging/burning/redness than ethanol
63
Phenol croton oil peel
Deep chemical peel
(meaning mid reticular dermis is level peel goes to)
Indications: wrinkles, AKs
Cannot use extrafacially
Full cardiopulmonary monitoring and IV hydration
Degreasing skin prior
General or deep sedation/ regional blocks
Endpoint - ivory white/grey colour skin
Wait 15 mins between cosmetic units (so takes 60-90 mins)
Burning sensation that lasts for 15–20 seconds, subsides for 20 minutes, and then returns for the next 6 to 8 hours
Waterproof zinc oxide tape for 1 day
Sunprotection
Risks:
Cardiac arrhythmias 6.6%
Pigmentary change (expect hypopigmentation)
Infection (antiviral prophylaxis)
Milia
Acneiform dermatitis
Scarring (delayed healing and persistent redness are warning signs)
Will penetrate nitrile gloves (can use neoprene)
64
Modified Jessners
Removes resorcinol
65
Glycolic acid peel
Time dependent
Leave on for 15s - 3min
Build up - up to max 7min
Need to monitor time
Can neutralise - wash off face, sodium bicarbonate 5% solution, multiple rinses
66
List superficial peels
"Just START"
Jessners
Sal acid
TCA (10-25%, 30% if one coat)
AHAs, e.g. GA (20-30%)
Resorcinol (modified Unna's resorcinol paste)
Tretinoin solution
(+solid CO2 slush)
67
List medium depth peels
TCA 50%
TCA 35% + Jessners
70% GA + 35% TCA
88% phenol
Pyruvic acid
Solid CO2 + 35% TCA
68
Expected side effects superficial peels
Erythema, stinging, burning, light peeling
69
Deep peels example
Baker's phenol/
Phenol croton oil
70
Superficial peels depth of penetration
Indications
partial epidermis or full epidermis to papillary dermis
Solar lentigines, PIH, acne
71
Salicylism
Tinnitus, dizziness, headache
Self resolving
Increase water intake/hydration
72
Variables that can affect depth of superficial peels
Peel itself
- agent
- conc
- number of coats
- technique of application (cotton tips, gauze)
- pressure exerted
- duration of contact
Patient factors
- pre-treatment preparation/priming
- skin type - sebaceous, anatomic location
73
Jessners + TCA 35%
Endpoint, precaution
Frosting appears after 1-2 minutes
Give antivirals
74
Peel option for melasma
Jessners + ascorbic acid 5% + TCA 20%
75
Pre-treatment preparation for a chemical peel
Sunscreen - 3 months prior, indefinitely afterwards
Tretinoin - pre and post - 6 weeks prior, minimum, restart post re-epithelialisation
AHAs (GA or LA)
Hydroquinone
+/- antiviral
76
Describe basic technique of performing chemical peel
Facial cleansing, degreasing - acetone rubbing alcohol, chlorhexidine
Apply peeling agent
- saturated cotton balls with GA
- rung out gauze for TCA or Jessners
- cotton tip applicator for intraorbital region
Careful to wipe any tears so no wicking
Forehead, lateral face, nose, cheeks, periorbital and then infraorbital
Feather application at edges
Look for frosting endpoint (unless Jessners)
GA - neutralise after time or if discomfort, erythema
Analgesia - fan/cold air
Expectations:
Medium depth
- erythema sunburn within 30 minutes
- oedema within 24 hours
- light brown appearance
- day 3-7 desquamation
Keep skin greasy post op, avoid scrubbing/peeling
Careful sunprotection
Erythema should fade after 2-4 weeks
77
Pre-peel screening
Hx
Isotretinoin 6-12 months
HSV
Radiation
Facial surgery
Smoking
Minocycline
Keloid
Immunosuppression
PIH
Realistic expectations
Skin PT
78
PLLA
Poly-L-lactic acid
Non-animal-derived
Synthetic
(therefore no pre-test required)
Need to reconstitute/dilute
Subcutaneous fat/supraperiosteal plane
3-6 treatments
Difference noticed around 2nd-3rd
Effects last up to 2-3 years, breaks down to lactic acid
Indication:
Lipoatrophy
Recontour face, 3D augmentation, lifting face, stretching rhytides,
not intended for direct injection into rhytides
Not used in the lip
Can get delayed subcutaneous papules
79
Hyaluronic acid filler
Effects last for 6-24 months
Store at room temperature
No test patch needed
Inject below dermis
(If injected too superficial or overly lrge volume, can cause blue discolouration, Tyndall)
Tower technique for Marionette lines
80
What to do for inadvertent intra-arterial filler injection (skin + eyes)
Assess for skin necrosis - pain, blanching, dusky, cool
Stop treatment
Massage
Warm compresses
Inject hyaluronidase -
If vision loss - 1500 units in 2 mL xylocaine 1%
Otherwise - 1000 unit pulse, repeat hourly until resolution, up to 3 pulses
Nitroglycerine paste topically
300mg aspirin stat, then 75mg daily (not good evidence for eyes)
Oral abx
Photos, document timing
If eyes -
examine each eye separately (read text, number of fingers holding up, detect movement of hand)
pupillary reactions, eye movements
Ophthalm emergency - call in advance, urgent transfer, do not delay transfer with assessments
Hx of migraines
Neuro exam
associated cutaneous signs of impending skin necrosis
eye massage
eye patch
warm compress
sublingual GTN
Timolol 0.5% drops (1-2 drops each eye)
Apology
MDO
close follow up
81
Nodules post HA filler
Immediate - superficial or excessive injection
Delayed - inflammatory or granulomatous foreign body reactions
Can reassure, massage, time or TOP tacro, ILCS and I+D
82
Retinal artery occlusion from filler - highest risk areas
Glabella, nose and forehead are the 3 highest risk spots for injection
83
Minimising risk arterial occlusion with filler injection
Know anatomy (avoid danger zones), depth of injection (periosteum)
Inject very slowly, low pressure
Cannulae safer than needles in most areas (brow, cheeks, not nose)
Micro-boluses, small aliquots
LA with adrenaline to constrict local vessels
Regular movements
Direction of injection away from eye
Inject perpendicular to vessels
Use of HA (because can dissolve)
No evidence to support aspiration
84
List different types of fillers for soft tissue augmentation
Hyaluronic acid
Poly L lactic acid
Calcium hydroxylapatite (CaHA)
Polymethylmethacrylate (bovine collage, requires skin test)
85
Contraindications to soft tissue augmentation
BDD
Unrealistic expectations
Known hypersensitivity to filler component
Infection at or near site of injection
Pregnancy or breast feeding
Relative
Anticoagulation, bleeding disorders, keloid scarring
86
Filler side effects and complications
Discomfort
Redness, bruising, swelling immediately post
(Redness lasts 1-2 days)
(Bruising lasts 5-10 days)
Incomplete, uneven, asymmetry
Beading and nodule formation
Bluish discolouration (Tyndall)
Hypersensitivity reaction (red bumps)
Atypical infection
Neuropraxia
Haematoma
Scarring
Skin necrosis (intra-arterial injection)
Vision loss
87
Total skin electron beam
Prognosis
Regime
SEs
Effective for skin-limited MF
- MF stage IA–B disease - complete response rates of >80%
- Tumour stage MF response rates ~40%
total dose is 36 Gy administered in fractions of 1.5–2 Gy over 8–10 weeks
can do lower doses 10-22 Gy, allowing for re-treatment
perineum, plantar surfaces
& scalp receive supplemental “boosts” as not
adequately treated in standing position
Side effects mild, including:
erythema, scaling, and temporary
loss of hair, nails and sweat gland function (hypohidrosis)
NO other systemic side effects,
NO nausea/vomiting
Can do adjunct PUVA
88
Hair transplant indications/ selection criteria
Age >/= 25
Inadequate response to medications after 12 months
Norwood class 3 or more
Ruled out diffuse unpatterned alopecia
Ruled out non-androgenetic causes of hair loss
No medical contraindications (keloid, CTD)
Reasonable patient expectations
Donor hair density >70 follicular units/cm2
89
Follicular unit transplant (FUT)
Harvest strip 30-35cm from occiput/overlying the occipital prominence (+ superior nuchal line)
Linear scars
89
Follicular unit extraction (FUE)
Advantages over FUT
Donor heals by secondary intention
Disadvantages:
FUE takes longer
Increased risk of transecting hairs
Requires larger donor area
Can be more difficult for subsequent sessions (fibrosis from secondary intention healing)
Advantages:
FUE better than FUT if concerned about scarring (can wear hair shorter)
FUE is better than FUT if it is a very loose or very tight scalp.
- Although can be difficult in a loose scalp - follicular units may shed during extraction
- Tight scalps will have a more limited donor supply
90
Consent for hair transplant
Expectations
Risks
Alternatives
Expectations:
Transplanted hair sheds around 2-6 weeks after the procedure
First signs of new growth at around 10 weeks, can take longer
Second session would usually be 12 months later
This procedure moves rather than creates hair
It is the patient's own hair from the sides and back of head that will be transplanted
Therefore the resulting transplanted density will be significantly less than the person's non-balding density
Results are not guaranteed
Risks:
Allergy
Sterile folliculitis
Infection
Cyst formation at graft site
Scarring in donor area
Hair loss related to procedure
Hair texture changes
Failure of transplanted hair to grow
Numbness, paraesthesia
Temporary swelling or bruising
Alternatives:
Doing nothing
Changing hairstyles (lightening, shortening)
Medical therapy
Wearing a hair piece
91
Tumescent anaesthesia
What is in it
Max dose lignocaine
Where do you use higher sensitivities
Max volumes
Rate
What do you do if tachy from adrenaline
Lignocaine 10ml
Sodium bicarbonate 8.4% 1.25mL
1:1000 adrenaline 0.1ml
In 100ml normal saline
(base normal saline)
Max lignocaine 30-55mg/kg
Higher concentrations for fibrous areas (back, abdo, breasts)
Higher concentrations for sensitive areas (inner thigh)
Max volume head and neck 250-400ml/ 300-500ml
Rate <100ml/min for comfort
Can give clonidine if tachy so long as BP >100/70
Hyaluronidase not used (does not augment degree of anaesthesia; increases rate of absorption and risk of toxicity)
92
Two categories of anaesthetics
Esters and amides
Esters
- tetracaine; benzocaine
- get converted to PABA
- higher allergenicity
- cross-reactions: PPD, sulfonylureas, thiazides
Amides
- lignocaine (most rapid acting); prilocaine; bupivacaine
- can use prilocaine if patients have lignocaine allergy (if not type 1)
- prilocaine more likely to cause methaemaglobinaemia
- higher toxicity than esters
93
Lignocaine metabolism
CYP450 3A4
94
Lignocaine toxicity
Light headednesss
Euphoria
Paraesthesia tongue and perioral
Tinnitus
Blurred vision
Flushing, malaise
THEN vomiting, tremors, muscular fasciculations
THEN seizures, cardiopulmonry depression
THEN coma respiratory and cardiac arrest
Signs of CNS toxicity precede cardiopulmonary
HR goes up, BP goes up
95
Bupivacaine
Amide
Slower onset, longer acting, more cardiotoxic (+ risk of fetal bradycardia)
96
Lignocaine onset and duration
Max dose
With and without adrenaline
Preservative added
<1min
30-120 mins (1-6.5hrs with adrenaline)
Max:
5mg/kg without adrenaline
7mg/kg with adrenaline
Kids:
1.5-2 mg/kg without adrenaline
3-4.5mg/kg with adrenaline
Lignocaine has acidic preservatives
97
Steatocystoma
Staetocystoma multiplex - AD, KT17
Thin wall
Punctum
Most often on chest, can also occur on abdomen, arms, face
98
EMLA max doses
0-3 months or <5kg
Max 1g, 1hr, 10cm^2
3-12 months and >5kg
Max 2g, 4hr, 20cm^2
1-6 years and >10kg
Max 10g, 4hr, 100cm^2
7-12 years and >20kg
Max 20g, 4hr, 200cm^2
99
Adrenaline interactions
MAO
TCA
Non selective beta blockers
100
Mental nerve block
inferior labial sulcus between lower first and second premolars
percutaneous - 2.5cm lateral to midline, just medial to midpupillary line and midway along vertical height of mandibular bone
foramen lies closer to upper margin of mandible in older patients, but does not lower with age
onset of anaesthesia 5-10 mins
101
Wrist block/anatomy
From medial:
Flexor carpi ulnaris, palmaris longus, median nerve, flexor carpi radialis
Put 5th finger and thumb together to bring out palmaris longus
For ulnar nerve - inject just radial to flexor carpi ulnaris at the ulnar styloid process
Ulnar nerve supplies palmar 5th + half 4th
Median supplies most rest of palmar
Radial nerve lateral and dorsal thumb
102
Ankle nerve block
List the nerves in order
Where do you inject to block each one?
From 12 oclock anterior tibial surface - clockwise according to diagram with fibula on the left; anticlockwise if looking down at my own right foot:
Deep peroneal nerve
Sapenous nerve (post to saphenous vein)
Posterior tibial nerve (behind post tibial artery)
Sural nerve
Superficial peroneal nerve
Saphenous nerve - inject medial to saphenous vein and anterior to medial malleolus
Sural nerve - prone - inject distal to tip of lateral malleolus
Superficial peroneal nerve - supplies most of dorsal foot - inject halfway between anterior tibial surface and lateral malleolus
Posterior tibial nerve - inject upper half medial malleolus, posterior to posterior tibial artery and anterior to calcaneal tendon
103
Methaemoglobinaemia
Which LAs especially
Time to onset
Treatment
Benzocaine and prilocaine most commonly associated
Children more at risk, haemoglobin F more susceptible to oxidation
Occurs 1-3 hours following treatment
treatment is methylene blue 1-2mg/kg as a 1% solution, although contraindicated in G6PD deficiency in which case you us ascorbic acid
104
Speed of onset topical anaesthetics
30-60 mins for LMX - quickest
tetracaine 60-90
EMLA 60-120
However, mucosally lignocaine (1-2min) is slower than tetracaine and proparacaine (20s)
105
What happens to HR and BP in:
vasovagal
adrenaline toxicity
anaphylaxis
vasovagal
- HR and BP low
adrenaline
- HR and BP high
anaphylaxis
- HR high, BP low
106
LMX vs EMLA
LMX more effective than EMLA, even if unoccluded vs occluded
LMX = lidocaine 5%
EMLA = prilocaine 2.5%, lidocaine 2.5%
LMX quicker, EMLA slower
LMX longer duration
EMLA should not be used near the eyes - caustic/alkaline injury to cornea
107
Ocular anaesthesia
Proparacaine 0.5%
Tetracaine 0.5%
(Benoxinate 0.25%)
Works in 30secs
Lasts 15mins
Tetracaine more painful than proparacaine
Proparacaine longer duration
For longer procedures
Can use proparacaine every 10 mins for 5-7 doses
Risk of corneal abrasion - wear eye patch until resolved
108
Hyaluronidase in anaesthesia
150 units in 20-30mL of anaesthetic
Facilitates diffusion through tissue planes
Increases area of anaesthesia
Minimises tissue distortion
Facilitates undermining in subcutaneous plane by hydrodissection
Decreases duration of anaesthesia
Not used in tumescent liposuction
Increases rate of systemic absorption of lignocaine and increases toxicity risk
Contains thimerosal (contact allergen)
109
Clonidine
α2A-adrenergic agonist
Lowers HR, BP
Anxiolytic
Reduces analgesia requirement after surgery
Takes 60 minutes to work
oral midazolam is quicker (20mins)
BP needs to be >100/60-70
110
Foam vs liquid sclerotherapy
Foam
- more migraine
- more pigmentation
- more induration
- more effective
- no leg movement for 5 minutes
111
Pre- foam sclerotherapy screening/
contraindicatons
No need to perform lab tests for thrombophlia
No need to specifically investigate for patent foramen ovale
(Although PFO is a CI)
CIs:
PFO (known) - symptomatic right to left shunt
Bed bound/ non ambulatory patient
Pregnancy
Acute DVT or PE
Breastfeeding (interrupt 2-3 days)
Allergy
Infection
Note history of DVT, obesity, saphenofemoral reflux are not absolute CIs (although may be relative)
Thrombophilia, high risk of thromboembolism and neuro symptoms post previous treatments are things that can be discussed/worked around
112
Polidocanol sclerotherapy
Can be liquid or foam
Detergent-type sclerosant
Generally painless
Concentration range (liquid):
Telangiectasias 0.25-0.5%
Large varicose veins 3%
Volume range:
Telangiectasias 0.2ml
Reticular varicose veins 0.5ml
Large varicose veins 2.0ml
Max foam volume per leg 10ml
113
Sodium tetradecyl sulfate (STS) sclerotherapy
Can be liquid or foam
Detergent-type sclerosant
Concentration range (liquid):
Telangiectasias 0.1-0.2%
Large varicose veins 3%
Volume range:
Telangiectasias 0.2ml
Reticular varicose veins 0.5ml
Large varicose veins 2.0ml
Max foam volume per leg 10ml
114
Sclerotherapy risks/complications
Rare but significant:
Anaphylaxis, large tissue necrosis, stroke and TIA, DVT, PE, motor nerver injury
Other:
Matting (5-15%)
Hyperpigmentation (0.3-10%)
- lasts 6-12 months
Visual disturbance <1%
Headaches and migraines <1%
Sensory nerve injury <0.1%
Skin necrosis (minimal) <0.1%
Chest tightness, dry cough <0.01%
Local allergic reactions <0.01%
115
endovenous ablation for the saphenofemoral junction
Better than vein stripping
Technique:
Finish at vein insertion point
Advance tip to 1-2 cm distal to SFJ junction
116
SIlicone sheets for keloids
- Silicone sheets and gel as effective as each other
- Improves all of the vancouver scores except for pain
- 3-7% get dermatitis from use
- Polyurethane dressings are better than silicone
- silicone gel dressings should be left on for 24/24 for 2 months
117
ILCS for keloid
- causes lateral spread
- symptoms settle within 1 week (takes longer to soften)
- commonest cause of treatment failure is using too dilute
- hypopigmentation can last 6-12 months
- mixing with 5FU makes the treatment more effective (and less painful than straight 5FU)
118
5FU for keloid
- hyperpigmentation, pain, ulcers
- do not exceed 100mg per week
119
Radiotherapy for keloid
- dose range 12–16 Gy in 3–4 fractions to 20 Gy in 5 fractions
- not as monotherapy (ineffective)
- begin within 24–48 hours following surgery, or at least 2 weeks
- recurrence rate 10%
- avoid neck
- side effects: atrophy, pigmentation, dermatitis, alopecia
- not in children
120
Bleomycin for keloid
topical is not as effective as IL but still great response rate
dose 1.5IU/mL
Applied to surface of skin and then punctured repeatedly with 25G needle
Hyperpigmentation is very common
121
Ear keloid management
Ear has lower recurrence rate than other sites
Pressure earring to be worn post op ~6-18 months
Compression must be worn >18hrs per day
Surgery and radiotherapy combined have recurrence rate 0-8.6%
Can do wedge excision if small lobular or wraparound keloid
122
PDL for keloid
PDL associated with decreased collagen fibrosis
123
Compression therapy for keloid
At least 4-6 months, up to 2 years
20-30mmHg which is above capillary pressure (not SBP)
18-24 hours per day
Local hypoxia is the goal
124
Cryotherapy for keloids
Direct cell damage and vascular damage
Can be used as monotherapy
8-10 visits, 3 weekly, 2-3 freeze thaw cycles of 15-30secs
125
List 5 types of ear keloids
Dumbell
Anterior button
Posterior button
Wrap around
Lobular
126
Keloid
list treatment options (and doses where relevant)
Topicals:
- TCS
- Retinoids
- Imiquimod BD 8 weeks (post op)
IL:
- Triamcinolone
- 5-FU (50mg/ml 0.05ml per 1cm interval weekly, max 100mg)
- Bleomycin
- Interferon alpha 2b (post op, day of and then 1 week later, 1 million units/cm, max 5 million units)
Physical:
- laser - CO2, PDL
- compression 20-30mmHg at least 4-6 months
- silicone sheets
- cryotherapy
- radiotherapy
Prevention:
- remove sutures at appropriate time
- ILCS
- wounds moist, clean, covered
127
PDT contraindications
Pregnancy, lactation
Peanut allergy (MAL)
Hypersensitivity
Photosensitising medication
Photosensitive disease e.g SLE
Epilepsy triggered by light
128
PDT indications
AKs
Bowens
sBCC (contraindicated for morphoeic and pigmented)
Photoging
Leishmaniasis
EMPD
Acne (blue light)
129
PDT for acne
ALA and MAL have similar efficacy
Works for 60-70% of inflammatory acne
Blue light alone leads to clinical improvement in 2/3rd of inflammatory acne lesions after 8 treatments
Extended duration of ALA and higher fluence of red light leads to more pain and burning but also longer remission
130
Daylight PDT
Can do all year round in Aus (just not on a rainy day)
Indication: grade 1 and 2 AKs
Procedure:
Consent, photos, clean skin
Chemical sunscreen (not physical) to whole face
Curette scale and crust
ML 16% 1mm thick
Incubation 30 mins
2 hours outside, shaded sun
Return, wash face
Apply chemical and physical sunscreen
Post op:
Strict sunprotection (48hrs)
Skin care
Reaction peaks 1-2 days, lasts 1 week
FU 3 months check response
Advantages:
Can treat larger surface area
Less pain
Fewer AEs
Same efficacy as regular PDT
131
Systemic PDT
Can use in Gorlins
Give IV
Photosensitive for 4 weeks
132
Actinic cheilitis
CO2 is the most effective non surgical technique (recurrence rate 6%)
5FU is more effective than PDT
Ingenol mebutate ~40% clearance
133
What chemicals can you use in PDT and their percentages?
ALA 20%
aminolevulinic acid
410nm (blue light)
Hydrophilic - not for NMSCs
16 mins 40 seconds light
MAL 16%
methyl aminolevulinate
630nm (red light)
Lipophilic
8 minutes light
134
Procedure for standard PDT
Include expected effects and side effects
2 sessions, 1 week apart
in clinic/hospital
cost cream $300
remove scale curette
apply MAL
5mm margin, 1mm thick
opaque dressing
leave on 3 hours, keep sunprotected
Return
Remove excess cream
Protective eyewear
Red light (630nm) 8 minutes, 8cm away
Pain
Post op
Vaseline
Opaque dressing 48 hours
Analgesia
Expected effect:
Photosensitive 48 hours
Pain, red, swelling, crusting, scale - 1 week to heal
Side effects:
severe pin, redness, swelling
blistering, burns
infection
hypo/hyperpigmentation
scar
incomplete treatment/recurrence
hypersensitivity
macular degeneration with light
135
PDT pain management
Preop (60 mins) - paracetamol 1g, ibuprofen 400mg
Lignocaine without adrenaline
Nerve blocks
Intra-op
Distract - talking, stress ball
Cold air, zimmer cooler, water mist
Lower fluence
Pause
Opt for daylight
Post-op
Sun avoidance
analgesia
Cool compresses, ice packs
136
Acne scars - grade 1
Erythematous
- skin care, retinoids, vascular laser, fractionated non-ablative 1550nm
Hyperpigmented
- sunprotection, bleaching agents (hydroquinone), light peels, microdermabrasion, pigment laser, IPL
Hypopigmented
- sunprotection, pigment transfer, bleaching to limit contrast, fractionated non-ablative 1550nm
137
Acne scars - grade 2
Mild rolling
- skin needling, rolling, microdermabrasion, laser resurfacing (fractionated non ablative), dermal filler
Small papular
- fine wire diathermy
138
Acne scars - grade 3
Significant rolling
Superficial box car
- fractionated resurfacing
- ablative lasers
- dermabrasion
- chemical peels
- dermal filler
- botox
- subscision
Mild-mod hypertrophic
- intralesionals, PDL
139
Acne scars - grade 4
Ice pick
- TCA CROSS
- punch techniques - float, elevation, excision, grafting
Deep box car
- above
Marked atrophy
- fat transfer and dermal filler
Significant hypertrophy or keloid
Bridges, tunnels, dystrophic scars
- excisions
(botox if movement related)
140
Acne scar - punch elevation
Scar needs to be <3-4mm
No sutures (punch excision needs sutures, not punch elevation)
Punch bx should be larger than defect
141
Acne scar - punch grafting
Scar needs to be <3-4mm
Best for sharp walled or deep ice pick scars with dystrophic or white bases
Skin graft usually taken from post auricular area
142
Filler for acne scars
Injected intradermal
Grade 2 - 4 acne scares
Can be used for nose dorsum indentations
143
Octyl cyanoacrylate (dermabond)
Can be used for: superficial lacs, grafts, low tension incisions
Apply 3 layers
First layer takes 2.5min to polymerise
Polymerisation causes heat
Apply to edges of wound, not in wound itself (may slow healing)
Strength equivalent to 5.0 nylon
144
Sutures
What used most commonly
What are the parts of a suture and their features
Types of tips
3/8 circle is most common
1/2 circle can be used for small flaps
Shank (weakest, and largest part)
Body (strongest, part to grip)
Tip
Reverse cutting needles (most commonly used) result in less tissue tear;
rounded needles cause even less tear and are good for delicate areas and fascia
145
Blades
10 blade
- good for back
- convex belly
- not good for delicate/ sharp angles (too big)
15 blade
- sharpest aspect is apex of curve at belly (used for the incision)
146
Other surgical instruments and what they are used for:
Castroviejo needle holder
Harmon Bishop forceps
Metzenbaum, Gradle, Mayo scissors
Adson Brown forceps
Castroviejo needle holder
- spring handle
- not for large bore needles, but rather for 5.0 to 8.0
Harmon Bishop forceps
- used for delicate surgery
Metzenbaum scissors
- used for undermining (large flaps)
Gradle scissors
- micro dissections
Mayo scissors
- cut dense and hard tissues
Adson Brown forceps
- teeth
- flat/wide handle
- tapered tip
147
Scissor handle colour meaning
Gold
- have Tungsten Carbide inserts
Black (supercut)
- one serrated blade to minimise slippage and one super sharp blade
148
Absorbable sutures and their characteristics
Gut
- weakest
- most reactive
- multifilament
- twisted
- plain, fast absorbing and chromic types
- heat treated --> fast absorbing
- fast absorbing loses tensile strength by 7 days, absorbed by 21-42 days
- plain gut loses tensile strength in 7-10 days, absorbed by 70 days
- chromic gut loses tensile strength after 10-21 days, absorbed by 90 days
- absorption rate unpredictable
Vicryl
- braided multifilament
- good knot strength
- dissolves in 56-70 days
- vicryl rapide dissolves in 42 days
Monocryl
- very good knot strength
- least reactive
- increased pliability
- has higher initial tensile strength than PDS II and Maxon, but does not last as long
- absorption 90-120 days
PDS and PDS II
- PDS II has improved handling
Maxon
Biosyn
149
Non-absorbable sutures and their characteristics
Silk
- most reactive
- very slowly absorbed (1-2 years)
- very soft and good for sensitive areas like mucosa
Novafil
- compared with prolene - better handling, better knot strength, flexibility and elasticity and tensile strength
(lower memory)
Prolene
- not used much (see novafil above)
Nylon
- multifilament
- good handling
- high tensile strength
150
Butterfly sutures
Achieves great wound eversion, even greater than buried vertical mattress suture
Need to undermine
Suture from subcut to reticular dermis
Expect dimple, although does not persist
151
Purse string stitch
Variation of buried dermal suture
Can reduce size of defect by 50-70%
Good for closing dead space
Sutures at level of mid to deep dermis
Multiple horizontal bites 5-10mm apart
Remaining defect can then be left to heal by secondary intention or with a graft
152
Buried vertical mattress suture
For prolonged wound eversion
Needle in subcut and exit through mid dermis
153
Vertical and horizontal mattress sutures
Good for eversion, decreasing wound tension, closing dead space
Half buried horizontal mattress tip stitch is good for flap tip - allows increased blood flow
154
Locked running suture
good for haemostasis
155
What are properties of a less reactive vs more reactive suture
More immunogenic:
Natural
Multifilament
Absorbable
Large
Less:
Synthetic
Monofilament
Non-absorbable
Small
156
Suture removal times based on location
Eyelid 2-4 days
Face 4-6
Neck 5-7
Scalp 5-7
Trunk 7-12
Extremities 10-14
157
What are synthetic and natural sutures degraded by?
Synthetic - hydrolysis
Natural - proteolysis
158
Suspension sutures
First pass through reticular dermis
Second throw through deep subcutis
Goes through fascia
Substantial bite of periosteum
159
What is:
Electrodessication
Electrocoagulation
Electrofulguration
Electrosection
Electrocautery
Electrodessication
- tip in contact with skin
- superficial tissue dehydryation through water vaporisation
- monoterminal
- alternating current
- voltage high
- amperage low
- waveform damped
- good for superficial, not very vascular
- slightly higher risk dermal damage c/w electrofulguration
Electrofulguration
- tip not in contact with skin (spark)
- superficial tissue carbonisation or charring
- monoterminal
- alternating current
- voltage high
- amperage low
- waveform damped
- good for superficial, not very vascular
Electrocoagulation
- tip in contact with skin
- deeper tissue, through thermal denaturation
- biterminal
- alternating current
- voltage low
- amperage high
- waveform moderatley damped
Electrosection
- cuts through tissue by causing tissue vaporisation
- alternating current
- voltage low
- amperage high
- undamped or slightly damped
- superior speed and haemostasis
Electrocautery
- hot tip
- safe with PM and defib
- tissue charring
- voltage low
- amperage high
- pinpoint haemostasis (otherwise not great)
160
Coagulation vs cutting current
Coagulation - high voltage current, flows ~6% of cycle
Cutting - lower voltage, flows 100% of cycle
161
Biterminal, monoterminal, bipolar and monopolar definitions
Biterminal - 2 points for current to enter and exit (can be monopolar or bipolar)
Monoterminal - like electrocautery hot tip, not as effective for haemostasis
162
PPM and defib and electrosurgery
Electrocautery - completely safe
Electrocoagulation otherwise safest
With forceps (bipolar, small current path)
If needing to do electrofulguration or electrodessication with a plate, need power setting as low as possible and short bursts <5 seconds, cardiac rate monitoring
>15cm (16 inches) from PM/defib
pathway not to pass through heart
163
BDD DSM V criteria
1. Worries about appearance/flaw not visible or minor for >1hr day
2. Repetitive behaviours in response to appearance
3. Distress/interference with functioning
4. Not better explained by gender dysphoria/eating disorder
164
Electrosurgical interference on pacemaker function, if:
Fixed rate
Demand: ventricular inhibited
Ventricular triggered
Fixed rate
No effect
Demand: ventricular inhibited
Bradycardia
Asystole
Ventricular triggered
Extrasystole
Tachyarrhythmia
VF
165
Pilar cysts
More common in females
AD if multiple
No central punctum
Can be painful if inflamed
Alopecia if large
Cyst wall is thick and not prone to rupture
Histology: granular layer is absent
Origin is outer root sheath
More difficult I+D as compared with epidermoid
166
Lipomas
Usually encapsulated
Rarely inflamed
Aim incision length 1/2 to 1/3 of the lipoma diameter
Forehead lipomas - within or beneath frontalis, take care to avoid damage to supratrochlear and supraorbital neurovascular bundles
Frontalis muscle should be dissected VERTICALLY
Suture the submuscular fascia and then then the frontalis
Infiltrating lipoma of upper extremities
Intermuscular > intramuscular
Usually asymptomatic
167
Epidermal cysts
Stratified squamous epithelium lining with granular layer
Options: no.15 blade incision, or no.11 blade stab incision
If stab incision, include punctum/epidermal pore
Can decompress the cyst if large, so it can be delivered through incision
168
Infected cysts
What to do
LA may be less effective
Protective clothing (eyewear, mask)
Incision over area of greatest fluctuance
Collect material for culture
Irrigate
Place pack (iodoform, algisite Ag) or drain
Packing material withdrawn a small amount each day
Broad spectrum abx
169
Radiation side effects
Red, warm
Peeling, moist
Ulcer
Radiation dermatitis
Recurrence, progression outside of field radiated (e.g. for KS)
Atrophy
Telangiectasias
Pigmentation
Alopecia
SCC
Angiosarcoma
170
Explanation of radiotherapy to a patient
Energy is administered to the skin, absorbed by DNA and preferentially causes cell death of abnormally dividing cells
171
Gummy smiles
Due to what muscle
Different types and technique
Mainly levator labii superioris
Defined as >3mm gum exposure with smile
Anterior gummy smile
- Most common
- Treated with one injection each side of nasolabial fold, 0.5-1cm lateral and below ala nasi
Posterior gummy smile
- Treated at 2 points in malar region - nasolabial fold at point of greatest lateral contraction during smile, and 2cm lateral to that
Mixed type
Asymmetric
No more than 2.5U ABO for each spot
172
Botox and hyperhidrosis
Where to use higher dose/concentration
Dose for palms and soles is higher than for axilla
Feet/soles have least response
Higher concentration does not cause greater diffusion
173
Botox around the eyes
Risks if inject lower eyelid
If inject lower eyelid:
Can cause dilated pupil/Adie's pupil/ectropion/entropion/ skin laxity/ bulging
(not pupil miosis)
174
Corrugator supercili and procerus
What is the direction of wrinkles they create
Procerus - horizontal (nasal root)
Corrugator - vertical (glabellar)
175
Upper eyelid ptosis (palpebral ptosis)
How does it happen
What injections
What muscle
What treatment
May occur following treatment for glabellar wrinkles (diffusion through orbital septum, or if very close to orbital rim, or if massage post)
Paralyis of levator palpebrae superioris (not orbicularis oculi)
Aim to keep 0.5-1cm above the brow (and prevent massage)
Apraclonidine 0.5% eye drops
176
Diplopia from botox
How does it happen
injection close to globe or diffusion into orbit
lateral rectus muscle
177
Orbicularis oculi 2 parts
voluntary vs involuntary
Palpebral part voluntary, part involuntary
Orbital all voluntary
178
Botox for nasal droop
base of columella
179
Botox for bunny lines
high lateral nasal wall/ transversal areas of nasalis
depressor nasae septae
need to avoid levator labii superioris (avoid nasofacial groove)
180
Botox for platysma/face lift
lateral mandibular border 2-4 points
181
Post botox instructions
No sauna 1 day
No exercise 4 hours
No lying down for 4 hours
No massage
182
Botox for nasal flare
In lower nasalis muscle above alae nasi
183
Botox storage/reconstitution
Store at 2-8 degrees
After reconstitution, can use for 2-6 weeks
Cannot freeze after reconstitution/dilution
184
Botox side effects
Effects appear after 24-72 hours, peak at 2 weeks, last 3-6 months
Pain
Bruising
Allergy
Asymmetry
Eyebrow ptosis
Eyelid ptosis
Diplopia
Ectropion, entropion, skin laxity and eye bulging
Dilated/adie's pupil
Mouth functional incompetence
Exacerbated bunny lines
Dysphagia (neck)
Muscle atrophy with repeated treatments
185
Botox for Crow's feet
Keep distance 1cm from orbital rim
Inject when not smiling
Can cause upper lip ptosis (zygomaticus major and levator labii superioris)
Target is orbicularis oculi
186
Regarding botox types:
ABO; Inco
Which is more potent?
Which diffuses more?
Which can be stored at room temp?
Inco is more potent
ABO diffuses more (therefore need higher concentrations)
Inco can be stored at room temp
Both contain human albumin
187
Wart treatments
Podophyllotoxin - more systemic side effects
188
Electron beam radiotherapy
Ideal treatment for cutaneous malignancies <5mm thick
Energy source is electron delivered through a linear accelerator
Uses megaelectron volt (MeV)
Requires margin of 1-2cm
Needs a bolus (of gelatin like material) to deliver 100% of designated dose at skin surface (thus minimising tissue damage including to bone and cartilage)
189
Radiotherapy contraindications
Absolute:
Gorlin's
XP
Relative:
CTDs (scleroderma, LE)
Chronic ulceration
Poorly vascularised, oedematous tissues
Trauma, thermal burns
Prior field of radiation
190
Superficial radiation therapy
Uses low energy photons produced by 10-30 kilovolt Xray machine
Radiation is absorbed within first 2mm of tissue
Bolus not required
191
Electrons vs photons
Electrons have lower relative biological effectiveness (RBE) in comparison to photons
192
Radiotherapy for keloids
Max 20Gy
1-4 fractions
Immediately after surgery or within 2 weeks
Recurrence rate ~10%
193
Diseases induced by radiotherapy:
Limited to irradiation sites
Not confined to sites of irradiation
Spare irradiation
Limited to irradiation sites
- AIBD
- Comedonal acne, folliculitis
- EM
- GVHD
- Digitate keratosis
- Grovers
- LP
- LS
- Morphoea
- Sclerosing post-irradiation panniculitis
- Recall
- UP
- Vitiligo
Not confined to sites of irradiation
- Herpes zoster
- EM
- AIBD
- Eosinophilic polymorphic and pruritic erruption associated with radiotherapy syndrome
Spare irradiation
- Exanthematous drug eruption
194
Boiling point of different chemicals
LN2 (liquid nitrogen)
CO2
LN2 -196
CO2 -78
Nitrogen gas -88
195
Lethal temp for different cells (freezing)
Melanocytes -4
Keratinocyte cancer cells -50
Sarcoma -60
Vascular endotheilum -15 to -40
In general would aim to achieve -50 at edge of tumour/ice ball
196
What happens during freezing and thawing
Freezing
- water moves out of cell, with internal dehydration
- internal crystal formation
- cell bursting
Thawing
- ice crystals reorganise inside the cell
- forming larger crystals
- cell destruction
- reversed water movement from outside to inside (due to melting outside cells)
Compensatory vasodilation after thawing (and prolonged vasoconstriction while thawing)
197
LN2 for capillary malformation/haemangioma
Timing:
Haemangioma - best used as soon as it appears
PWS - for bulky nodules that develop over time
Technique:
Haemangioma - contact technique with probe fitted over whole lesion
For deep and superficial combined haemangiomas - combination Rx with ILKA
Vascular tissue v susceptible, usually 10-20s sufficient time for frozen probe contact
PWS - grasp protruding portion with froozen tweezer, or door-knob probe
198
Freeze tip sizes, which are bigger/smaller?
A (largest), B, C, D (smallest)
199
Local anaesthetic and cryo pain
Alleviates freeze pain but not thaw pain
200
Cryosurgery uses/indications
Acne in pregnancy
KS
LM
AK, Bowens, SCC
BCC
Venous lake
Angiokeratoma
Sebaceous hyperplasia
Pearly penile papule
Seb K
Warts, molluscum
Haemangiomas
Resistant cutaneous larva migrans
Hypertrophic scars and keloids
201
Cryotherapy
Occasional temporary
Occasional permanent
Occasional temporary
- milia
Occasional permanent
- hypopigmentation
- retraction
- notching (ear, nose)
- alopecia
- nail dystrophy
- atrophic or depressed scar
202
Cryotherapy for KS
Not first line
Can use open or closed technique
If open spray technique - double freeze thaw cycle
Aim for margin a few mm
203
Cryosurgery healing time based on body site
Dorsal hand >3 weeks
Legs 1-2 months
Arms trunk 2-3 weeks
Head/neck 7-10 days
204
Supplements which can impact haemostasis
Garlic
Evening primrose oil >3g/day
Gingko
Licorice
Policosanol
Sweet clover/coumarin
Vit E
Tocopherol
Glucosamine/chondroitin
Magnesium, tamarind if on aspirin
If on warfarin: Danshen, Devil'ss claw, Dong quai, Ginseng, Papaya, selenium
Also, these are actual anticoagulants:
Dipyradimole
Ticlopidine
205
Instructions on cessation of the following to reduce bleeding:
Alcohol
Ginseng
Aspirin
NSAIDs
Stop ginseng 10 days prior to surg (discontinue any supplement 10-14 days)
Stop alcohol 2 days prior
Stop aspirin 5-7 days (or 10-14) prior, resume 1 week post surg
Stop NSAIDs 5-7 days (or 10-14)
206
Haemostatic/caustic agents
And risk of leaving pigment
Ferric sulfate (Monsels) - pigment risk
Silver nitrate - pigment risk
Aluminium chloride
35% TCA
207
Haematoma management
If early, return to operating room, re-open, evacuate haematoma, locate and ligate bleeding source
Haematoma solidifies within several days, then after 7-10 days liquifies
Liquified clot can be aspirated with 16-18G needle
Resorption takes months
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Drains
Should be removed within 24hrs, up to 48hrs
Penrose drain, a passive drain, can be used if minimal draining, sutured to place
Jckson-Pratt is a suction drain, negative pressure
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When to avoid surgery on warfarin
INR >3 (need it to be at or below 3)
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Gelatin foams/sponges
Non antigenic
Absorbed within 4-6 weeks
Can cause significant swelling
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Chemical phenolisation of nail
Alternative to phenol
Time to heal
Healing takes between 2-4 weeks
An alternative to phenol is sodium hydroxide 10% (rubbed in for 2 mins)
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Matricectomy vs nail ablation
What happens with the proximal nail fold?
Matricectomy = complete removal of germinal matrix
Ablation = definitive extirpation of entire nail organ
Matricectomy - de-epithelialise proximal nail fold and place back
Ablation - remove proximal nail fold entirely
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Second intention healing
- Time taken
- Contraction
4-6 weeks
Contraction 30% head and neck
Inner canthus <10mm
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Aluminium chloride
Caustic
Works by activation of extrinsic coagulation pathway and vasoconstriction
Can be used in nail surgery
215
Silver impregnated dressings
Bactericidal (as opposed to bacteriostatic)
Broad spectrum including MRSA, VRE, fungi and yeast
Release antibacterial levels of silver for 3-7 days
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Hydrocolloids
e.g. duoderm
Bacterial and physical barrier
Enhance angiogenesis
Absorbant (but nit highly, mild-mod exudate)
Autolytic debridement (can initially increase size of wound)
Opaque
Waterproof
Unpleasant odour and yellow gel
Also available as powders and pastes
Not for 3rd degree burns or actively infected ulcers
217
Hydrogels
Soothing, do not adhere to wounds, hydrating
Painful wounds, post laser/peel/dermabrasion
Best for dry wounds (or low/mild exudate)
218
Alginates
Haemostatic
Do not adhere
Unpleasant smell
Partial or full thickness (even subcutis, muscle, bone)
Can use to pack cavities
Can be difficult to remove
219
Films (dressings)
Bacterial barrier/ not permeable to bacteria (or fluid)
Permeable to oxygen
Can cause fluid collection
Best for no to minimal exudate
Very adhesive and not good for fragile skin
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Cartilaginous/composite grafts
Where to place at nasal ala rim
How much to oversize
Max graft diameter
Where to harvest
Distal nasal cartilaginous struts should be placed 2-3mm superior to free ala rim (to avoid ridged appearance)
Oversize 5-15%
Max diameter 1-2cm
Crus of helix is most common harvest site
For sebaceous nose, free cartilage grafts from ear (without attached skin) are preferred (then better skin match from local flap e.g. bilobe, or mesolabial skin graft)
221
Delayed grafts
When are they recommended
Max size
Time to let granulate
When are they recommended
When >25% periosteum or perichondrium is lacking
1-3 weeks
222
Skin graft physiology
Imbibition - 1st stage - ischaemic period - 24-48hrs - fibrin attaches graft to bed - graft sustained by plasma exudate from wound bed, passive diffusion of nutrients
Inosculation - 2nd stage - revascularisation - linking graft dermal vessels with those in recipient bed - lasts 7-10 days
Neovascularisation - final stage - often occurs in conjunction with inosculation - capillary ingrowth to graft from recipient base and sidewalls
Lymphatics usually restored within 1 week
223
Supratrochlear and suprorbital neurovascular bundles
Both are in deep subcutaneous fate overlying muscle
224
Karapandzic flap
Perioral crescent advancement flap
225
Hunt variant of bipedicle myocutaneous flap
Useful repair for defects with a long vertical axis on the nasal tip
226
Myocutaneous island pedicle
Technique
If inadequate mobility, can make conservative horizontal cuts through muscle to release pedicle from inferior attachments
Evert the leading edge (tendency to trough)
First incision lateral - incise to subcut (ensuring muscle stays intact)
Can further mobilise flap by carefully by making horizontal incisions to narrow muscle pedicle
Medial incision down to muscle
227
Mucosal advancement flap
Undermining generally extended to the area where the mucosa reflects on the mandible
228
Rotation flaps
Types
Impact of arc length
Limberg
Tenzel
Mustarde
Bilobed
Rieger
Shorter arc length means larger width of secondary defect (narrower and easier to close if longer)
229
Chin rotation flaps
For medium to large defects
Require extensive undermining
Surface area flap should be 2x surface area of defect
230
Dorsal nasal rotation/Rieger flap
Can repair defects up to 2cm
Secondary defect is along nasoFACIAL sulcus
231
Banner flap
Transposition
Long and narrow with length to width ~4:1
Transposed 90 degrees
Can do post- or pre-auricular banner flap for superior helical rim
232
Tenzel flap
Rotation flap from temple and lateral canthus for lower eyelid defect
Extends superior to lateral canthus
Lateral cantholysis and tackig suture lateral canthal rim periosteum
233
Mustarde flap
Rotation of cheek and temple for lower eyelid defect
234
Paramedian forehead flap
Dissection of pedicle deep to corrugator
Pedicle portion is dissected in submuscular plane
Flap is turned down and sutured into place with interrupted buried absorbable sutures and cutaneous sutures to at least 50% of defect circumference
Superior aspect of nasal defect is not sutured (initially)
235
Bilobe flap
When is modified Zitelli used
When do you use medially based vs laterally based
Zitelli - suitable for smaller defects <1.5cm
Medially based - defects on lateral aspects of ala
Laterally based - defects on alar rim and anterior to alar crease
Closer to alar rim the primary lobe should be vertically oriented (perpendicular to rim), therefore pushing rim down
236
Rhombic transposition flap on neck
For medium to large defects
Skin laxity on neck is horizontal, therefore draw rhombus so that secondary defect utilises horizontal skin movement
237
Nasolabial transposition flap
Repair option for full thickness rim defect
To subcutaneous
60 degrees transposition
238
Pull through flap
At least 1/3rd of pedicle needs to remain intact
Suture the flap into place using superficial sutures
239
Mucosal bilateral rotation flap
Defect must be in middle third of lip
And <50% lip
Burrow's on mucosal lip
240
Keystone island pedicle flap
Orient long axis of ellipse parallel to direction of vessels and nerves
Incise down to fascia
At least 1:1 flap width:defect width
Angle adjacent to ellipse is 90 degrees
241
Biopsy techniques
Glans
Vulva
Stretch and skin tension lines
Generally avoid ellipse at genitals
Shave for glans
Snip for vulva
For punch biopsy, stretch at right angle to RSTL
242
Biopsy medium
DIF
Flow
PCR
EM
DIF - Michel's, or snap frozen in liquid nitrogen
Flow - fresh or RPMI
EM - glutaraldehyde
PCR - frozen or formalin fixed
243
Ectropion repair
V to Y good for mild (not severe) ectropion
Z plasty
244
Margins for DFSP
Recurrence rates with Mohs
If <2cm, then 1.5cm
If larger, then 2.5cm
1.3-2.3% recurrence rates with Mohs
Whereas with wide excision they may range 20-60%
DFSP
245
Mohs interpretation
DFSP - characteristic SPINDLE cell morphology
Sebaceous carcinoma - lobules of atypical sebaceous glands and LARGE cells with mitoses
Merkel - MONOmorphous sheets of basaloid cells
AFX - bizarre histology, fibrohistiocytic
Micorcystic adnexal carcinoma - can resemble BCC and adnexal neoplasms like desmoplastic trichoepithelioma and syringoma. Ductal and glandular structures, keratin cysts, follicular structures, DESMOPLASTIC stroma
246
Nerves of the feet
List 5
Where does each come from
What part of foot do they ssupply
From sciatic nerve:
Tibial/post tibial - plantar foot
Superficial peroneal/fibular - most of dorsum foot
Deep peroneal/fibular - first web space
Sural - lateral foot
From femoral nerve:
Saphenous nerve - medial foot
247
Multiple non syndromic BCC
(>9 BCCs within 3 years)/ high frequency BCCs
4x increased risk colorectal, breast cancer and haem malignancy
risk factors: male, hx melanoma, hx SCC
prevalence:
Of those with non-syndromic BCC monitored for 5-10 years, 3% developed >9 BCCs
Estimated prevalence in population of high frequency BCC is ~0.05% (51 per 100,000 persons)
248
Sterilisation facts
- Key point to chemical immersion
- What temp is reached with dry heat
- What can autoclave be used for
- Which are okay / not okay for sharp instruments
Chemical immersion
- need to use straight away, cannot store
Autoclave (steaming under pressure)
- efficient, economical
- can dull sharp instruments (high humidity)
- 121°C 15-30mins
- useful for: liquids, glass, metal instruments, paper, cotton
- should NOT be used for heat sensitive plastics or oils
Dry heat
- glass, oils, instruments (does not dull or rust)
- temp 121–204°C
Gas
- for heat sensitive and moisture sensitive instruments
Heated chemical vapour
- Low-humidity method that can be used on sharp instruments, with less concern for dulling
249
Punch mini grafting for vitiligo
Punched out chambers should be spaced 5-10mm apart
Same sized punches are used for donor and recipient
Recipient chambers should be slightly deeper than the graft so that it fits snuggly and doesn't pop out
Donor area is either upper lateral thigh or gluteal area
Grafts are placed directly from donor to recipient area
Perigraft repigmentation expected in 3-4 weeks
Complete repigmentation 3-6 months
Phototherapy can be commenced 1 week post op
250
Vitiligo procedural options
Mini punch grafting
Suction blister grafting
Cultured melanocyte grafting
Thin STSG
Tattooing or micropigmentation
251
Ageing face - where do you get hypertrophy vs atrophy
Hypertrophy
- Nasolabial fold
- Cheek bones
- Under chin/neck
Atrophy
- Forehead
- Temples
- Upper and lower eyelids
- Lateral cheeks
- Upper cutaneous lip
- Marionette area
252
BJD phototherapy guidelines
What to do if miss sessions
1 week - hold (except for burns)
2 weeks - reduce dose by 25%
3 weeks - reduce dose by 50%
4 weeks - review by doctor, start over
253
Phototherapy for CTCL
Response rate depends on stage, not on extent of skin involvement
254
Minimal erythema dose
With UVB, you start at 70% MED
MED testing is done on sunprotected skin
You read MED at 24/24
255
Bath PUVA
Lower starting dose (30% MPD) - photosensitivity is up to 10 times higher than with oral PUVA
Phototoxic threshold declines during early treatment phase (4th MPD is ~50% of 1st MPD)
TMP more phototoxic than MOP
Bath for 15-20 mins
Immediate exposure to UV
Photosensitive for 2 hours
No GI or ocular effects
peak erythema is delayed as compared to the oral route (96-120hrs)
256
Indications for UVA1
Sclerosing dermatoses
GVHD
UP
MF?
Eczema
257
5MOP vs 8MOP
5MOP less erythrogenic and no GIT issues
258
UVA for morphea
At least 60% respond/markedly improve
Linear and pansclerotic may also improve (less experiece)
259
BJD/AJD phototherapy guidelines
Which drugs CAN and CANNOT be used with phototherapy
CAN
Corticosteroids
MTX
Retinoids
Biologics
CANNOT
CsA
AZA
MMF
260
BJD phototherapy guidelines
Absolute vs relative contraindications
Absolute:
Photogenoderms - XP, Cockayne, Bloom, Rothmund Thomson, PIBIDs
Disorders with genetic predisposition to skin cancer (Gorlin syndrome, albinism)
Concomitant immunosuppression - CsA, AZA, MMF, tacro
Medically unfit and unable to safely stand in cubicle
Relative:
Lupus erythematosus
Prev arsenic or ionising radiation
Hereditary dysplastic naevus syndrome
Past excessive exposure to natural sunlight, sunbeds, phototherapy
Prev significant use of oral immunosuppression
Current premalignant skin lesions
Current and past history of melanoma and NMSC
Strong family hx skin cancer young age
261
BJD phototherapy guidelines no benefit of nbUVB in which conditions
Palmoplantar pustulosis
GA
Acquired perforating
Keratosis lichenoides chronica
Lichen nitidus
Notalgia paraesthetica
Seb derm
Subcorneal pustular dermatosis
Pruritic papular eruption HIV
Pregnancy induced dermatoses
262
PUVA and skin cancer risk
Increase in SCC not BCC
263
UVB erythema timing
Erythema develops within 3-5hrs following exposure
Peaks between 12 and 24 hrs
Resolves by 72hrs
264
Phototherapy and CTCL
Response is related to MF stage (patch better than plaque), not extent
265
PUVA for eczema and psoriasis
Eczema is harder to treat with PUVA than PsO
Need more sessions
Recurrence rates are high and rapid
266
How many nm for different types of UV?
broadband UVB (290–320 nm)
narrowband UVB (311–313 nm)
308 nm excimer laser
UVA1 (340–400 nm)
UVA (320–400 nm) plus psoralens (PUVA) or alone
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