Core Principles of Cutaneous Surgery – Victoria Lazareth

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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

  1. Electrolysis
  2. Electrocautery

Hot tip, Direct current, Mono-terminal, Tissue touched, Degree of damage ++++

  1. 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