Core Principles of Cutaneous Surgery – Victoria Lazareth
Victoria Lazareth MA, MSN, NP-C, DCNP
Increased Risk for Bleeding
High Risk Sites (acral)
Scalp, Face (ears, nose, eyes, lips), Digits, genitals
Danger zones
temple (temporal artery), base of ala (angular artery), mandible (mental artery)
Increased Risk for Nerve damage
Facial nerve (temporal branch of CN VII)
over zygomatic arch through temporal fossa
Innervates the frontalis & orbicularis oculi & anterio-superior muscles of the ear
Damage: eyebrow ptosis (impaired eyelid elevation & closure)
Spinal accessory nerve (Cranial Nerve XI)
emerges near Erb’s point
posterior triangle of neck behind the sternocleidomastoid ~2cm above clavicle
Innervates the trapezius muscle
Damage: shoulder droop & winged scapula
Trigeminal nerve (Cranial Nerve V)
Opthalmic V1 division (scalp, forehead, nose)
Maxillary V2 division (lateral forehead, medial cheek, upper cutaneous lip)
Mandibular V3 division (lateral temple, lateral cheek, upper ear, cutaneous lower lip)
Damage: sensory innervation of face, motor innervation of mastication muscles
Increased Risk for Tumor Recurrence
NMSC at High-Risk for recurrence
Location
Scalp, eyes, ears, nose, lips, genitalia, hands, feet
Size
> 6 mm at scalp, eyes, ears, nose, lips, genitalia, hands, feet
>10 mm at the head, forehead, cheeks, neck
>20 mm at all other areas
History
Recurrent tumor, Older age, male gender, Immunocompromised pt
History of XRT, PUVA at site, arsenic ingestion
Histology
Recurrent BCC
clinical extension
Micronodular, Morpheaform, Sclerosing, Infiltrative, Basosquamous
Metastatic BCC
very large tumor (>10cm sq)
peri-neural invasion. Basosquamous or Morpheaform sub-types
Recurrent / Metastatic SCC
peri-neural invasion, perivascular invasion
moderately differentiated, poorly differentiated, single cell sub-types
Performing the Eliptical Excision
Excise the ellipse through full-thickness skin to appropriate depth
Hold scalpel perpendicular to skin surface to avoid beveling the wound margins
Common mistake leaving more fat & dermal tissue at the tip & tail of the ellipse than at the center
à leads to redundancies & elevations at the ends of the ellipse
Anatomic Level of Undermining
SCALP
subgaleal space: virtually avascular plane
Large vertically-oriented FOREHEAD wounds
beneath frontalis muscle
Sebaceous areas of the NOSE
subdermal
Dorsum of the NOSE, FOREHEAD, EYELIDS, LIPS, LIMBS
fat-fascia interface ! Temporal branch of Facial n. (CN VII) @ zygomatic arch
CHEEK, NECK
beneath deep plexus in high subcutis ! Spinal accessory nerve (CN XI) @ Erb’s point
BEARD, SIDEBURN
deep subcutis beneath follicles ! Facial nerve (CN VII) @ marginal mandibular
Electrosurgery
Includes 3 types of procedures
- Electrolysis
- Electrocautery
Hot tip, Direct current, Mono-terminal, Tissue touched, Degree of damage ++++
- High Frequency Electrosurgery
Electrocutting (Bi / damage ++++)
Electrocoagulation
Cold tip, Alternating high frequency current, Bi terminal, Degree of damage +++
Electrodesiccation (Mono / damage +) Electrofulguration (Mono / damage +)
Planning the Closure
Ensure complete extirpation of malignant lesion
Malignant cells left behind can grow
along undermining plane, in scar tissue, along nerves, long before becoming visible!
May not be able to identify original lesion site to clear persistent tumor cells if tissue is moved with a flap for closure
Know the Anatomy, Have a Back-up Closure Plan, Assure meticulous Hemostasis
Use Surgical Techniques to avoid dead space, avoid blunt trauma, avoid flap elevation
Closure Techniques
Advancement Flaps: Epidermis plus full thickness of dermis
Full Thickness Skin Graft: Best choice when clearance of malignancy is uncertain
Ways to Speed Healing
Stiches / Adhesive bandage strips establish apposition of wound edges; minimizing distance cells need to migrate
Aseptic technique minimizes bacterial contamination
Proper hemostasis prevents hematoma formation
Close dead space prevents seroma formation
Avoid suture strangulation prevents tissue necrosis
