Download Soft Tissue Surgery - University of Virginia

Soft Tissue
Surgery
Scott M. Strayer, MD, MPH
Assistant Professor
University of Virginia Health
System
Department of Family Medicine
Case Study
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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
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Expect to encounter 6-7 cases of
basal cell cancer annually
1-2 cases of squamous cell cancer
1 case of melanoma
Introduction
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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
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identifying worrisome lesions
removal options (cryotherapy,
punch biopsy,shave biopsy,
incisional biopsy, and excisional
biopsy)
excisional techniques (3:1 ratio)
suture types
Informed Consent
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Get it.
Complications, Indications and
Alternatives.
Need pre-printed form, plus need a
note describing the above.
Suture Selection
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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
Extremities,trunk
5-0, 6-0
nylon
4-0 or 5-0
prolene
4-0 or 5-0
synthetic
absorbable
4-7 days
4-0 or 5-0
nylon
3-0 or 4-0
synth. Abs.
3-0 or 4-0
Synth. Abs.
7-14 days
Needle Selection
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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
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Lidocaine
Epinephrine
Location
Toxic doses
Worrisome Lesions
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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
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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
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Scarring
Wound infection
Bleeding
Main Suture Techniques
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Buried suture
Interrupted suture
Vertical mattress suture
Subcuticular suture
Suturing Techniques
Excisional Biopsies
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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
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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
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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