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Soft Tissue Surgery. Scott M. Strayer, MD, MPH Assistant Professor University of Virginia Health System Department of Family Medicine. Case Study. - PowerPoint PPT Presentation
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Soft Tissue Surgery
Scott M. Strayer, MD, MPH
Assistant Professor
University of Virginia Health System
Department of Family Medicine
Case Study A 50 year old white male presents to your
office with a large, dark mole on his back that has been there for several years. He reports that he often fishes on the Chesapeake Bay without his shirt on and has been doing this for years. He reports that the mole has been enlarging. On physical exam you find a very dark mole, approximately 7mm in diameter with an irregular border. How would you approach this lesion?
Significance of Skin Cancer in Primary Care
Expect to encounter 6-7 cases of basal cell cancer annually
1-2 cases of squamous cell cancer 1 case of melanoma
Introduction Soft tissue surgery is an important
skill for family practitioners to learn and practice
Identifying lesions for removal and using the proper techniques is critical
Knowing when to refer is very important
Topics of Discussion
identifying worrisome lesions removal options (cryotherapy,
punch biopsy,shave biopsy, incisional biopsy, and excisional biopsy)
excisional techniques (3:1 ratio) suture types
Informed Consent
Get it. Complications, Indications and
Alternatives. Need pre-printed form, plus need a
note describing the above.
Suture Selection
Absorbable (vicryl, dexon, pds) and Non-absorbable types (skin, vascular, orthopedics).
Number of “0s” (the more “Os” the smaller the suture.
Common Suture Use
Skin (interr.) Skin (subq) Buried Removal
Location
Face 5-0, 6-0 4-0 or 5-0 4-0 or 5-0 4-7 days nylon prolene synthetic absorbable
Extremities,trunk 4-0 or 5-0 3-0 or 4-0 3-0 or 4-0 7-14 days nylon synth. Abs. Synth. Abs.
Needle Selection
Cutting-most skin surgery. FS- for skin P, PS, PRE for cosmetic areas Taper-fascia and bowel Blunt-liver and kidney Higher number=smaller needle Use larger needles for deep tissue,
smaller needle to close the skin.
Needle Types
Cosmetic Needles
Anesthesia
Lidocaine Epinephrine Location Toxic doses
Worrisome Lesions the A, B, C’s of worrisome lesions Asymmetry Border irregularity Color variegation Diameter (>6mm) Elevation any lesion which the patient reports is
growing, changing, irritating, bleeding, etc. Skin surveys should be done at least yearly on
asymptomatic patients, more frequently on patients with histories of skin cancer
Removing the Lesion Options include punch biopsy, shave
biopsy, cryotherapy, incisional biopsy, and excisional biopsy
punch biopsies should be reserved for lesions with a low index of suspicion for malignancy
cryotherapy should be used on lesions such as seborrheic keratoses, actinic keratoses, and other non-malignant lesions such as plantar warts, molluscum contagiosum, etc.
If in doubt use an excisional biopsy
Choice of Biopsy Technique
Punch Biopsy Technique
Punch Biopsy Technique
Complications
Scarring Wound infection Bleeding
Main Suture Techniques
Buried suture Interrupted suture Vertical mattress suture Subcuticular suture
Suturing Techniques
Excisional Biopsies Avoid danger areas such as pre-auricular,
angle of mandible and posterior cervical triangle
plan excision along relaxed skin tension lines
use 3:1 ratio and mark site with gentian violet marker
use appropriate anesthesia (I.e. no epinephrine on finger tips, nose tip, tip of penis)
Skin Tension Lines
Excisional Biopsy
Buried Suture
Interrupted Suture
Vertical Mattress Suture
Uses
Wound eversion Evenly distributes tension Dead space closure Good for holding tension (e.g. back)
Use on: Posterior neck, concave surfaces
Avoid on: Cosmetically sensitive areas
Horizontal Mattress
Uses
Wound eversion Anchoring stitch Fragile skin (e.g. elderly, steroid
use)
Warnings: Tend to cause scarring and can cause necrosis if too tight, remove after 3-5 days.
Subcuticular Suture