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Requisites in
ERRNVPHGLFRVRUJ
Dermatologic
Surgery
Edited by
Allison T Vidimos,
RPh, MD, FAAD, FACMS
Chair, Department of Dermatology
Cleveland Clinic Foundation
Cleveland, OH, USA
Christie T Ammirati,
MD, FAAD, FACMS
Associate Professor,
Department of Dermatology
Penn State Milton S. Hershey Medical Center
Hershey, PA, USA
Christine Poblete-Lopez,
MD, FAAD, FACMS
Associate Staff,
Department of Dermatology
Cleveland Clinic Foundation
Cleveland, OH, USA Series editor
DIRK M
ELSTON
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2009
An imprint of Elsevier Limited
ISBN: 978-0-7020-3049-9
Notice
Neither the Publisher nor the Editors assume any responsibility for
any loss or injury and/or damage to persons or property arising out
of or related to any use of the material contained in this book. It is
the responsibility of the treating practitioner, relying on independent
expertise and knowledge of the patient, to determine the best
treatment and method of application for the patient.
The Publisher
Printed in China
Acknowledgments
We would like to thank our mentors and teachers better physicians every day. Special thanks go
who have taught us the art and science of to the the art and photography departments at
dermatologic surgery, our residents, fellows and Cleveland Clinic, especially Joe Pangrace, Bill
medical students who have given us the privilege Garriott, Beth Halasz, and our dermatology
and pleasure of teaching them, and our patients department photographer, Flora Williams.
who put their trust in us and challenge us to be
T. Minsue Chen, md
Fellow, Mohs Research in Advanced
Dermatologic Surgery Education
Mohs and Dermasurgery Unit
Department of Dermatology
University of Texas, M. D. Anderson Cancer
Center
Houston, TX
viii Contributors
Justin G. Woodhouse, md
University Dermatologists, Inc.
South Euclid, OH
Also in the series
Requisites in
Dermatology
Series Editor: Dirk M Elston
Dermatopathology
Dirk M Elston and Tammie Ferringer
Cosmetic Dermatology
Murad Alam, Hayes B Gladstone,
and Rebecca C Tung
Pediatric Dermatology
Howard B Pride, Albert C Yan,
and Andrea L Zaenglein
Dermatologic Surgery
Allison T Vidimos, Christie T Ammirati,
and Christine Poblete-Lopez
General Dermatology
Kathryn Schwarzenberger, Andrew E Werchniak,
and Christine J Ko
Series foreword
The Requisites in Dermatology series of textbooks have contributed their time and energy to create
is designed around the principle that learning the sort of texts we wish we had had during our
and retention are best accomplished when own training and each of the texts in the series
the forest is clearly delineated from the trees. is accompanied by an innovative on-line module.
Topics are presented with an emphasis on the Each on-line module is designed to complement
key points essential for residents and practicing the text, providing lecture material not possible
clinicians. Each text is designed to stand alone as in print format, including video and lectures with
a reference or to be used as part of an integrated voice-over. These books have been a labor of love
teaching curriculum. Many gifted physicians for all involved. We hope you enjoy them.
Series dedication
This series of textbooks is dedicated to my wife
Kathy and my children, Carly and Nate. Thank
you for your love, support and inspiration. It is
also dedicated to the residents and fellows it has
been my privilege to teach and to the patients
who have taught me so much.
Dirk M Elston
Volume preface
This text is designed to cover the essentials of lecture. In this manner, the text acts as an over
dermatologic surgery in a style that is straight view for students learning the surgical aspects
forward and easily understood. Each topic is of dermatology, a focused study guide for
presented as a concise, yet thorough, review, dermatology residents, and a ready reference for
and each chapter is paired with an on-line those in practice.
Acknowledgments
We would like to thank our mentors and teachers better physicians every day. Special thanks go
who have taught us the art and science of to the the art and photography departments at
dermatologic surgery, our residents, fellows and Cleveland Clinic, especially Joe Pangrace, Bill
medical students who have given us the privilege Garriott, Beth Halasz, and our dermatology
and pleasure of teaching them, and our patients department photographer, Flora Williams.
who put their trust in us and challenge us to be
Chapter
Surgical anatomy of the
head and neck
Joseph F. Greco and Christopher B. Skvarka
The essentials of dermatologic surgery must be Table 1-1 The orbital rim
founded on a fundamental and thorough under
standing of the head and neck anatomy.This chapter Border Bones
begins with an outline of important topographic Superior Frontal bone
landmarks and cosmetic units before focusing on Lateral Frontal process of zygomatic bone
the musculature, nerve anatomy, vasculature, and
lymphatics of the head and neck. Special anato Inferior Zygomatic bone laterally and maxillary bone
medially
mic structures and regions such as the parotid
gland and scalp are addressed as well. Emphasis Medial Frontal bone superiorly and maxilla inferiorly
has been placed on the boundaries of anatomic
regions and danger zones as well as the spacial
relationships among clinically relevent structures. arch, mastoid process, and mental protuberance.
The orbital rim is formed by contributions from
Topographical landmarks the frontal, zygomatic, and maxillary bones (Table
1). Of note, the medial canthal ligaments are
1-�
Key Points easily palpated at the medial rim.
• The bony and muscular landmarks of the head Immediately above the superior orbital rim
and neck aid in locating underlying structures. lies the first of the three major foramina that can
• The supraorbital, infraorbital, and mental be found along a vertical, midpupillary line imag
foramina lie on the midpupillary line. ined approximately 2.5 cm lateral to the midline
• The masseter muscle aids in locating the facial (Fig. 1-1). The supraorbital, along with the
artery and Stenson’s duct (parotid duct). infraorbital and mental foramina will be discussed
• The sternocleidomastoid muscle divides the neck further in the sensory innervation of the head and
into anterior2 and posterior triangles.
neck section.
The prominence of the cheek or “cheekbone” is
The important topographical landmarks of the formed by the malar eminence of the zygomatic
head and neck are formed primarily by underlying bone. The buccal fat pad fills the area beneath
bones and musculature, but superficial accepted this eminence and gives fullness to the cheek. The
divisions are also made. These landmarks and zygomatic arch extends from the malar eminence
divisions are important cosmetically and are used towards the external acoustic meatus and is formed
in communication by the cutaneous surgeon. by the temporal process of the zygomatic bone
The scalp is divided into four areas – frontal, and the zygomatic process of the temporal bone.
parietal, temporal, and occipital. The frontal scalp The zygomatic arch also divides the temporal fossa
extends from the forehead to the vertex and is superiorly from the infratemporal fossa inferiorly.
bordered by the parietal and temporal regions. The temple is a well defined danger zone where
The occipital scalp is located at the inferior por the temporal branch of the facial nerve and the
tion of the scalp, and overlies the occipital bone. superficial temporal artery and vein lie vulnerable
The forehead meets the frontal scalp and extends to injury (Table 1-� 2). The danger zones and areas
down to the eyebrows and glabella. The glabella of susceptibility to injury are characterized later
lies between the eyebrows superior to the nasal in this chapter.
root. Vertical furrows (glabellar lines) are accen The auricle is the entire visible portion of the
tuated over this region when frowning. external ear with many named processes (Fig. 1-2).
The frontal, maxillary, zygomatic, temporal, The rim of the auricle is known as the helix, which
and mandibular bones all form prominent bony runs with a paired prominence, the antihelix. The
surface markers – the orbital rims, zygomatic antihelix runs anterior to the helix and divides
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Midpupillary line
Supraorbital foramen
2.5cm
Temporal bone
Nasal bone
Infraorbital foramen
Mastoid process
Zygomatic arch
Maxillary bone
Ramus of mandible
Angle of mandible
Body of mandible
Mental foramen
Figure 1-1 Bony landmarks of the skull and foramina
into two crura. Between these crura, the named Table 1-2 Borders of the temple
triangular fossa appears. The curved depression
between the helix and antihelix is referred to as Border
the scapha. Inferior to the antihelix lies a deep Inferior Zygomatic arch
cavity known as the concha. Anterior to the con Anterior Tail of the eyebrow
cha, the tragus arises as an eminence in front of
the external acoustic meatus. Opposite from the Superior Coronal suture line
tragus (separated by the intertragic notch) is a Posterior Temporal hairline
small tubercle called the antitragus.
Behind the ear lies the mastoid process of the
temporal bone. It is a bony prominence that, after are clenched. The facial artery may be found and
adolescence, protects the facial nerve as it exits palpated near the antero-inferior border of the
the stylomastoid foramen. Anterior to the ear lies masseter.
the condyle of the mandibular ramus, which can The nasal bones, alar cartilages, and anterior
be palpated as the mouth opens and closes. The nasal spine of the maxilla form the palpable bor
angle of the jaw and prominence of the chin are ders of the nose. The nasal bones form the supe
formed by the mandibular angle and mental pro rior root of the nose and the anterior nasal spine
tuberance, respectively. can be palpated at the root of the columella.
The masseter muscle attaches to the zygomatic The labial area is bordered by the nose, medial
arch and inserts on the ramus of the mandible. cheek, and mental chin. This area is separated from
It can be palpated most easily while the teeth the cheek by the melolabial crease. The upper lip
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Chapter
Surgical anatomy of the head and neck
Figure 1-2 Anatomy of the ear, superficial temporal artery, and auriculotemporal nerve
is divided in half by the philtrum. The philtrum is sternocleidomastoid muscle. This muscle divides
a central linear depression bordered by two verti the neck into anterior and posterior triangles (see
cal columns extending from the columella to the Table 1-�4 for information on the anterior triangle
vermillion border of the upper lip. At this inferior and Table 1-15 for the posterior triangle). The
border, the columns help to create a contoured anterior triangle can be subdivided into the muscu
double curve, resembling Cupid’s bow. lar, carotid, digastric, and submental triangles.
Continuing inferiorly, the most important Of note, the spinal accessory nerve is suscep
superficial landmark of the neck is the sternoclei tible to injury in the posterior triangle. Injury
domastoid muscle. When contracted, it is easily results in paralysis of the sternocleidomastoid and
palpated. See Table 1-� 3 for a discussion of the trapezius muscles.
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Table 1-3 The sternocleidomastoid muscle Table 1-4 The anterior triangle
Origin Two heads – medial head attaches to the Boundary
sternum; lateral head attaches to the medial
Anterior Median line of neck
third of the clavicle
Posterior Anterior border of sternocleidomastoid
Insertion Mastoid process of the temporal bone and
muscle
lateral portion of the superior nuchal line
Superior (base) Inferior border of mandible
Innervation Accessory nerve (cranial nerve XI)
Roof Skin, SMAS, platysma, and deep fascia
Action Acting alone, a single sternocleidomastoid
of neck
muscle turns the head towards the ipsilateral
shoulder in an upward glance; in tandem, both Floor Inferior and middle pharyngeal constric
sternocleidomastoid muscles draw the head tors; thyrohyoid and hyoglossus muscles
forward (carotid triangle); mylohyoid and
hyoglossus muscles (digastric triangle),
Comments The two originating heads of each
mylohyoid muscle (submental triangle)
sternocleidomastoid muscle form a depression
referred to as the lesser supraclavicular fossa;
torticollis is due to the permanent contracture during surgical procedures. Transection will result
of the sternocleidomastoid in extravasation of a clear watery fluid. If left
unrepaired, an external fistula may develop.
Thin watery saliva and thicker mucous of the
Parotid gland and duct parotid gland mediated by sympathetic and para
sympathetic fibers respectively. Cutaneous sen
Key Points sory innervation over the parotid gland is carried
• The parotid glands are the largest paired salivary by the auriculotemporal nerve. Vascular supply
glands. and lymphatic drainage of the parotid area are
• The facial nerve pierces the parotid gland soon described elsewhere in this chapter.
after leaving the stylomastoid foramen.
• The parotid duct may be palpated as it courses Contour lines and cosmetic
over the masseter muscle.
units
Key Points
The parotid gland is an anatomic landmark
deserving of special consideration. It is a triangular- • Contour lines separate the face into anatomic
subunits.
shaped salivary gland nestled anterior to the auri
• Regional variablility in skin structure impacts the
cle within the borders of the zygomatic arch and dermatologic surgeon’s choice of repair.
mandible (Fig. 1-� 3, Table 1-�
5). It is anchored into • Free margins are a type of contour line.
place by a fibrous fascial capsule contiguous with
the deep facia of the neck. The substance of the
gland houses and protects the facial nerve as it Contour lines are the natural lines of demarcation
branches into a superior temporofacial and infe that divide the face into several cosmetic units,
rior cervicofacial division. The five well known such as the forehead and nose (Table 1-� 7). Gen
branches of the facial nerve originate from these erally speaking, the skin texture and color is con
divisions prior to exiting the different poles of the sistent within each cosmetic unit and may vary
parotid gland (Table 1-� 6). considerably among them. This is due in part to
The parotid duct emerges from the gland at the differences in the density of sebaceous glands,
its upper anterior pole and courses over the mas terminal hair follicles, thickness and elasticity of
seter muscle and buccal fatpad (Fig. 1-� 4). Here the skin. The highly thick and sebaceous skin of
it turns medially to pierce the buccinator muscle the nose, for example, lies in stark contrast to the
and enters the oral mucosa opposite the second neighboring thin and highly lax skin of the eyelid.
upper molar (Fig. 1-� 5). The duct runs approxi Defects in one cosmetic unit are therefore best
mately one fingerbreadth inferior to the zygomatic repaired with skin of that same cosmetic unit. The
arch, between the transverse facial artery and dermatologic surgeon must consider this regional
buccal branch of the facial nerve. With the jaw variability during reconstructive surgery. Surgical
clenched, the parotid duct may be palpated as a incisions may be placed so that the final scar lies
firm cord along the middle third of a line drawn along or parallel to contour lines. Incisions that
from the earlobe to a point between the oral com violate this principle by crossing the demarca
missure and the nasal ala as it runs atop the mas tion lines may distort anatomic units and result in
seter. The duct is most vulnerable in this location highly perceptible scarring.
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Chapter
Surgical anatomy of the head and neck
Table 1-5 Borders of the parotid gland Table 1-6 Facial nerve branches and the parotid gland
Superior Posterior two thirds of zygomatic arch Exiting pole of the
Facial nerve branch parotid
Posterior Posterior border of mandibular ramus
Temporal (temporofacial division) Superior
Inferior Angle of mandible
Zygomatic (temporofacial division) Anterosuperior
Anterior Highly variable
Buccal (temporofacial division) Anterior
Floor Posterior half of masseter
Marginal mandibular Anteroinferior
Roof Integument, parotid fascia
(cervicofacial division)
Cervical (cervicofacial division) Inferior
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Chapter
Surgical anatomy of the head and neck
Table 1-7 Cosmetic units and contour lines at the SMAS–subcutaneous fat junction. All mo
of the face tor nerves course below the SMAS. A sub-SMAS
Contour line Cosmetic unit dissecting plane is attractive owing to its relatively
avascular nature. However, the risk to the motor
� Nasolabial fold � Forehead
nerves precludes use of the sub-SMAS plane in
� Nasofacial sulcus � Nose most locations. The subcutaneous fat superficial
� Mentolabial crease � Cheek to the SMAS is therefore the ideal dissecting
plane. An exception occurs over the pre-parotid
� Preauricular sulcus � Eye
cheek where the motor fibers of the facial nerve
� Eyelid margins � Lip lie protected within the substance of the parotid
� Philtral columns/crest � Chin gland.
Of note, the temporal branch of the facial
� Alar contours � Ear
nerve lies just deep to the thin superficial tem
� Vermillion border poral fascia on the medial temple. On the lateral
� Eyebrows temple, the auriculotemporal nerve and superficial
temporal vessels are located in the subcutaneous
� Hairline
fat above the superficial temporal fascia.
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Chapter
Surgical anatomy of the head and neck
Generally these wrinkles, termed skin tension may not be so noticeable. Furrows can be accen
lines (STLs), run perpendicular to the underlying tuated by asking patients to perform exaggerated
muscle fibers (Fig. 1-� 7). For example, the STLs of facial expressions, such as smiling, frowning,
the forehead are horizontal because the frontalis puckering lips, or whistling. Active manipulation
muscle contracts vertically. The skin tension lines of the skin by a gentle pinch or massage may also
of the lateral periocular skin (crow’s feet) radiate reproduce the natural folds and tension lines.
away from the lateral canthus, as the fibers of the STLs may be softened or eliminated by cos
orbicularis oculi circumferentially wrap from the metic injectable treatments. Injectable botulinum
superior to inferior eyelid. The horizontal wrinkles toxin targets the dynamic STLs and moderately
of the upper eyelid, which at first seem to contra fine relaxed STLs by blunting the actions of
dict this principle, lie perpendicular to the axis of the underlying musculature. However, deeper
the underlying levator palpebrae superioris. relaxed STLs, accentuated by the gravitational
Surgical planning must include a thorough pull of sun-damaged skin, are better treated by
knowledge of the STLs. The reconstruction of sur injectable fillers, which replace volume loss.
gical defects should be designed to minimize per
ceptible scarring. One such way is to align the long
axis of a repair within or parallel to the STLs. This
The facial nerve and muscles
places the scar under the least amount of tension, of facial expression
allowing the scar to fall within a natural wrinkle.
Wounds close more easily in this orientation, as
Key Points
the skin is approximately three times more disten • The muscles of facial expression develop from
sible perpendicular to the STLs than parallel. the second embryonic arch.
In elderly patients with severe sun damage, • They contribute to the relaxed skin tension lines
of the face.
the relaxed STLs will be obvious to any observer.
• They are innervated by the seventh cranial nerve –
However, certain techniques may be utilized to the facial nerve.
accentuate these lines where the static wrinkles
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10 Dermatologic Surgery
Facial artery
Masseter muscle
Cervical branch
The facial nerve, or cranial nerve VII, exits the the temporal, buccal, and marginal mandibular
skull at the stylomastoid foramen and proceeds branches have all been implicated in different
to innervate the muscles of facial expression series. Permanent injury to one of the branches
(Fig. 1-�
8). Immediately after exiting the foramen, of the facial nerve is reported as 0.4–2.6%, with
the posterior auricular branch breaks off the main equal rates for subcutaneous and sub-SMAS
trunk to innervate the occipitalis and postauricular procedures.
muscles. The remainder of the nerve pierces the The temporal branch is particularly vulnerable
parotid gland and departs as five branches – to damage on the lateral face after exiting the
temporal, zygomatic, buccal, marginal mandi superior pole of the parotid gland (Table 1-10, Fig.
bular, and cervical (Fig. 1-�
9). Each branch of the 1-10). This branch runs deep to the skin, subcu
nerve is discussed separately. Table 1-� 9 highlights taneous tissue and a thin layer of fascia along its
the muscles innervated by each branch. course to the frontails and orbicularis oculi mus
During surgical procedures injury to a single cles. To prevent damage to this nerve, the surgeon
branch of the facial nerve is more likely to occur should only dissect down to the superficial fat in
than injury to the main trunk. Conflicting reports this area. Table 1-10 highlights other areas where
exist on the most common branch injured, as the facial nerve is susceptible to injury.
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Chapter
Surgical anatomy of the head and neck 11
dotted line damaged nerves anterior to it likely result in full recovery while
damaged nerves posterior to it likely result in permanent paralysis
dotted circle danger zone for fa and mm
The zygomatic branch exits the anterosuperior The marginal mandibular branch exits the infe
border of the parotid gland and divides into upper rior pole of the parotid gland and travels along the
and lower rami (see Figs 1-4 & 1-9). Branches of lower angle of the mandible anterior to the facial
the lower ramus lie on the parotid duct. Injury artery (see Fig. 1-�
9). Ramification occurs distally,
to the zygomatic branch results in difficult clos near the muscles of the lower lip. This renders the
ing the ipsilateral lower eyelid and can affect the nerve vulnerable in its more proximal subplatys
nasal muscles and lip elevators. mal location near the anterior insertion point of
The buccal branch exits the anterior border of the masseter muscle on the mandible. With injury
the parotid gland before coursing anteriorly over to this nerve, the lower lip becomes impaired in
the masseter muscle and buccal fat pad. This its downward movement, which can lead to an
division runs parallel to the parotid duct prior to asymmetric smile.
delivering extensive rami to the mid-facial region The cervical branch of the facial nerve exits
(see Figs 1-4 & 1-9). Damage to this branch may the inferior pole of the parotid gland and descends
lead to the accumulation of food between the toward the submandibular triangle before ram
teeth and buccal mucosa while chewing, as well ifying extensively to innervate the platysma (see
as drooling, impaired lip pursing, and impaired Fig. 1-� 9). Injury to this branch rarely causes
smiling. Injury to the zygomatic or buccal branch noticeable damage.
es is often temporary because of the high degree The extensive anastomotic network of the
of anastamoses between the two branches. Some facial nerve, particularly via the zygomatic and
70–90% of patients have these anastomoses. buccal branches, may be predicted by dropping
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12 Dermatologic Surgery
Table 1-9 Muscles innervated by the facial nerve Table 1-10 Areas of the facial nerve susceptible to injury
Muscle innervated Branch of facial
Branch of facial nerve by branch nerve Danger zone description
Temporal Frontalis Facial nerve Behind the earlobe in children, the
Corrugator supercilii trunk as it exits facial nerve trunk is vulnerable to injury.
the stylomastoid In adults, the trunk is protected by the
Orbicularis oculi (upper foramen mastoid process
portion)
Facial nerve in Vulnerable to injury if the procedure
Auricular the parotid gland breaches the fascia of the parotid gland
Zygomatic Orbicularis oculi (lower Temporal branch Located between an imaginary line
portion) drawn between the earlobe and the
Nasalis (alar portion) lateral eyebrow and a second line drawn
between the earlobe and the most
Procerus superior forehead crease. It lies in its
Buccinator most superficial position as it crosses
the zygomatic arch. The facial nerve
Buccal Buccinator likely has multiple rami at this point
Depressor septi nasi Buccal branch Lying superficial to the masseter muscle,
Nasalis (transverse portion) but deep to SMAS, this section is
vulnerable at its branching points, 2 cm
Zygomaticus major and anterior to its exit of the parotid gland
minor and under the modiolus (see below)
Levator labii superioris Marginal This branch lies just below the fascia of
Levator anguli oris mandibular the SMAS anterior to the facial vein and
artery as it crosses the inferior edge of
Risorius the mandible near the insertion point of
Orbicularis oris (upper the masseter
portion)
Marginal mandibular Orbicularis oris (lower
portion) nerve (Fig. 1-15). See Boxes 1-1 through 1-3 for
Depressor anguli oris the other functions of the facial nerve.
Depressor labii inferioris
Mentalis
Sensory innervation of the
Cervical Platysma
head and neck
The trigeminal nerve
Key Points
an imaginary vertical line down from the lat • The trigeminal nerve, cranial nerve V, is the
eral canthus. Branches anterior to this line have largest of the 12 cranial nerves.
extensive anastomoses, and injured nerves in this • The three main branches are the ophthalmic (V1),
“safe zone” will likely recover. Damage posterior maxillary (V2), and mandibular (V3).
to this line, however, often results in permanent • The trigeminal nerve provides the primary
paralysis of the target musculature. sensory innervation to the face.
Table 1-11 discusses each muscle of facial • It also provides motor innervation to the muscles
expression separately. See Figures 1-11 through of mastication.
1-13 for the muscular anatomy of the face. With • Effective anesthesia via nerve blocks can be placed
by the cutaneous surgeon with an understanding
the exception of the buccinator, the muscles of the anatomy of the trigeminal nerve.
of facial expression receive motor innervation
from their deep surface and thus protect their
terminal branches (Fig. 1-14). Of note, the levator The trigeminal nerve, the largest of the cranial
palpebrae superioris muscle elevates the upper nerves, is the fundamental provider of sensory
eyelid under the direction of the oculomotor innervation to the face, supplying structures de
nerve (cranial nerve III) rather than the facial rived from the first branchial arch. Three branches
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Chapter
Surgical anatomy of the head and neck 13
The danger zone is predicted by drawing an imaginary line between the earlobe and the lateral
eyebrow and a second line drawn between the earlobe and the most superior forehead crease.
The temporal branch of the facial nerve is vulnerable to injury as it courses over the zygomatic
arch within this zone.
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14 Dermatologic Surgery
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Chapter
Surgical anatomy of the head and neck 15
Frontal belly of
occipitofrontalis
Orbicularis oculi
Corrugator supercilii
Procerus
Nasalis
Levator labii
superioris
alaeque nasi
Levator labii
superioris
Zygomaticus minor
Zygomaticus major Occipital
belly of
Modiolus occipitofrontalis
Orbicularis oris
Depressor labii
inferioris
Mentalis
Posterior auricular
Depressor anguli oris
Risorius
Buccinator
Platysma
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16 Dermatologic Surgery
of the trigeminal nerve, the ophthalmic (V1), (which innervates the tip of the nose) and the
maxillary (V2), and mandibular (V3), carry sensa ciliary nerve (which innervates the cornea). Her
tion from distinct regions of the face (Fig. 1-16). petic invasion of the ophthalmic division present
The regions are located anterior to an angled ing with blistering on the nasal tip (Hutchinson’s
coronal plane located at the vertex of the skull. sign) should alert the doctor to potential corneal
Each main branch divides into smaller cutaneous involvement. Zoster involvement of the external
branches either before or after emerging from the nasal nerve in one series indicated a 76% chance
skull via bony foramina (the significant branches of ocular involvement – double the chance if no
are listed in Table 1-12). lesions were present at the nasal tip.
The ophthalmic nerve (V1) is the smallest and The frontal branch of the ophthalmic nerve
uppermost division, and further subdivides into gives rise to the supratrochlear and supraorbital
the nasociliary, frontal, and lacrimal nerves. The nerves (Fig. 1-17). The supratrochlear nerve is
nasociliary nerve is the progenitor to the exter the smaller of the two branches and runs 1 cm
nal nasal branch of the anterior ethmoidal nerve lateral to the midline, lying in the supratrochlear
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Chapter
Surgical anatomy of the head and neck 17
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18 Dermatologic Surgery
Shows the undersurface of the orbicularis oculi receiving terminal nerve fibers of the
zygomatic branch of the facial nerve.
Figure 1-14 Orbicularis oculi muscle and the zygomatic branch of the facial nerve
The supraorbital and supratrochlear nerve Intraoral and percutaneous approaches can
block can be achieved with anesthetic placed be used for the infraorbital nerve block. For the
slightly superior to the superior orbital rim, intraoral route, the needle is inserted into the
0.5–2.5 cm lateral to the midline. Anesthetic superior labial sulcus with the surgeon’s thumb
should be infiltrated deeply as both of these and index finger grasping the upper lip. The
nerves lie underneath the frontalis and corruga needle is aimed toward the surgeon’s fourth
tor supercilii muscles at this location. Blocking finger overlying the infraorbital foramen (1 cm
the nerves will provide adequate anesthesia to below the infraorbital rim). Some 1.0–1.5 mL
the ipsilateral forehead and frontal scalp. Care of anesthetic can be injected in this location.
should be taken to avoid intraneural injection for The intraoral block offers less pain to the patient
all nerve blocks. Severe pain on injection reported than the percutaneous route, and allows the
by the patient may indicate an intraneural loca needle to enter the tissue in the same plane as
tion. This can be corrected by slightly retracting the infraorbital nerve. For the percutaneous
the needle. approach, the needle is aimed deeply toward
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Chapter
Surgical anatomy of the head and neck 19
B ox 1 - 1 B ox 1 - 2
Other muscles innervated by branches Areas innervated by sensory fibers
of the facial nerve of the facial nerve
• Submaxillary
• Submandibular
• Lacrimal
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20 Dermatologic Surgery
Branches from
From maxillary division cervical plexus
of trigeminal nerve [V2] Lesser occipital nerve
Infraorbital nerve (C2,3)
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Surgical anatomy of the head and neck 21
The cervical nerves and the angle of the jaw to the mastoid process, it may be
localized approximately 6 cm inferior to the mid
posterior triangle of the neck point of this line at the posterior border of the
Key Points sternocleidomastoid muscle (Figs 1-20 & 1-21).
This neural-rich zone sits approximately at the
• Peripheral nerves of the cervical plexus include level of the hyoid bone or the third cervical ver
the great auricular, lesser occipital, transverse
cervical, and supraclavicular nerve.
tebra. Alternatively, the region may be identified
• A superficial neural-rich zone may be identified roughly as an area near the junction of the upper
within the posterior triangle. Nerves lying within and middle thirds of the sternocleidomastoid
this zone are susceptible to injury during minor muscle along its posterior border.
surgical procedures. Interestingly, this neural-rich zone has often
• These nerves are responsible for the sensory and erroneously received distinction as “Erb’s
innervation of the neck, posterior scalp, a portion point.” Dr Wilhelm Heinrich Erb (1840–1921),
of the ear, and skin over the clavicle. a renowned German physician known widely
for his prolific contributions to the field of neuro
logy, described and illustrated an area on the side
The posterior triangle of the neck has definable of the neck “from a circumscribed point, about
boundaries and contains critical motor and sen two to three centimeters above the clavicle,
sory nerves (Table 1-15). Cutaneous branches of somewhat outside of the posterior border of the
the cervical plexus, along with the spinal acces sternomastoid and immediately in front of the
sory nerve, course through the posterior triangle transverse process of the sixth cervical vertebra.”
of the neck in a region worthy of anatomic dis He termed this point “Erb’s point” or the “supra
tinction. Using an imaginary line drawn from the clavicular point.” Erb noted that at this point,
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22 Dermatologic Surgery
Table 1-13 Nerves that innervate the nose through the posterior triangle of the neck. Lying
deep only to the skin and superficial cervical
Infraorbital nerve (V2) Mid-lower sidewall, ala
fascia, the nerve is vulnerable to injury during
External nasal branch Nasal tip routine surgical procedures such as the punch
of anterior ethmoidal biopsy.
nerve (V1) The cervical plexus lies deep to the sternoclei
Supratrochlear nerve (V1) Root, bridge, upper sidewall domastoid muscle. It is assembled from the ven
Infratrochlear nerve (V1) Bridge, upper sidewall tral rami of the first four cervical nerves. The most
prominent peripheral branches that arise from
this plexus are derived from the second through
“ simultaneous contraction may be produced in fourth (C2–C4) cervical nerves (Table 1-17).
the deltoid, biceps, brachialis anticus, and supi The lesser occipital nerve (C2) emerges from
nator longus muscles” through transcutaneous behind the sternocleidomastoid muscle and runs
electrical stimulation. The neural-rich zone of parallel to its posterior edge to innervate the neck,
the cervical plexus within the posterior triangle mastoid area, and scalp posterior to the ear. The
(approximately at the level of the third cervical great auricular nerves (C2 and C3) passes around
vertebra) thus lies superior to Erb’s point found the posterior border of the sternocleidomastoid
just above the clavicle (approximately at the level muscle and ascends vertically towards the parotid
of the sixth cervical vertebra). We shall refer to gland and earlobe (Fig. 1-22). The external
the former as “pseudo-Erb’s point.” One motor jugular vein runs in close approximation to the
and four sensory nerves of the cervical plexus great auricular nerves as they cross the superficial
emerge approximately 2 cm above or below border of the sternocleidomastoid.
pseudo-Erb’s point along their course in and out The transverse cervical nerves (C2 and C3)
of the posterior triangle. sharply curve anteromedially upon exiting the
The spinal accessory nerve (Table 1-16) is a posterior triangle, running between the external
cranial motor nerve that courses posteroinferiorly jugular vein and the sternocleidomastoid muscle.
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Surgical anatomy of the head and neck 23
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24 Dermatologic Surgery
Table 1-15 The posterior triangle The superficial arterial supply of the face encom
passes a vast network of vessels derived from both
Boundary
the external and internal carotid vascular systems
Anterior Posterior border of sternocleidomastoid (Fig. 1-23, Table 1-19). The dual contribution and
muscle intricate anastomoses among each system create
Posterior Anterior border of trapezius muscle a redundant blood supply that bathes the skin
Inferior (base) Middle third of clavicle and underlying structures richly with oxygen and
essential nutrients.
Roof Skin, SMAS, platysma (variable), deep The premiere facial branch of the external
fascia of neck (variable)
carotid system is the facial artery. This principal
Floor Splenius capitis, levator scapulae, and vessel carves a tortuous path throughout its course
scalene muscles over the superficial face, delivering multiple
Contents branches as described in Table 1-20. The facial
artery debuts on the superficial face at the anteroin
Motor nerves Spinal accessory (cranial nerve XI)
ferior angle of the masseter muscle over the body
Sensory nerves Lesser occipital (C2), great auricular of the mandible (see Fig. 1-� 9). Here the marginal
(C2,C3), transverse cervical (C2,C3), mandibular branch of the facial nerve may be
supraclavicular (C3,C4) found along with the facial artery. This potential
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Chapter
Surgical anatomy of the head and neck 25
Trapezius muscle
Sternocleidomastoid muscle
Clavicle
Supraclavicular nerves
Figure 1-20 Illustration of the posterior triangle of the neck
danger zone is protected by the overlying skin, unite superior to the medial canthal ligament
subcutaneous tissue, SMAS, and platysma. Along where the dorsal nasal and angular artery anas
its course, the facial artery runs deep to the riso tomose. Table 1-24 reviews the regional blood
rius and zygomaticus muscles, anterior to the supply of the face.
buccinator, and variably anterior or posterior to Peripheral pulses may be palpated over cer
the levator labii superioris. After the lateral nasal tain anatomical regions of the face (Table 1-25).
branch splits from the facial artery near the nasal The superficial location of the vessels in these
ala, the terminal facial artery is known as the areas renders them susceptible to trauma dur
angular artery (Fig. 1-24). ing surgical procedures. Physicians should always
After the facial artery branches off, the external recognize these “danger zones” prior to any surgi
carotid artery divides into two terminal branches – cal procedure in the area.
the maxillary artery and the superficial temporal
artery. The internal maxillary artery runs a deep Venous supply of the face
course within the head. It contains four pertinent
branches that supply blood to the superficial face Key Points
(Table 1-21). • Veins of the face run parallel to the arteries.
The superficial temporal artery (STA) arises • Superficial regions of the face drain to the internal
within the parotid gland and ascends superiorly jugular venous system.
over the posterior aspect of the zygomatic proc • Deep regions of the face drain to the external
jugular venous system.
ess. It terminates by bifurcating into two divisions,
both of which enter the temporal fossa (Table
1-22). The STA courses along with, and anterior Figure 1-23 and Table 1-26 review the veins
to, the auriculotemporal nerve (see Fig. 1-� 2). of the face. The supratrochlear and supraor
The internal carotid system contributes to the bital veins unite to form the facial vein near the
arterial supply of the superficial face through its medial canthus. The facial vein runs posteroinfe
ophthalmic arterial branches (see Fig. 1-17, Table riorly and merges with the anterior branch of the
1-23). The internal and external carotid systems retromandibular vein inferior to the mandible.
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26 Dermatologic Surgery
Figure 1-21 Anatomy of the posterior triangle of the neck (Erb’s point)
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Surgical anatomy of the head and neck 27
Table 1-17 Sensory nerves of the cervical plexus and superolateral arms respectively. The internal
jugular chain is the major collecting system of the
Spinal Cutaneous area head and neck. See Table 1-30 for the areas that
Nerve rami supplied
drain to each chain.
Great auricular C2 and C3 Lateral neck, angle of jaw,
skin over parotid gland,
anterior and posterior ear
The anatomy of the scalp
lobule, inferior cranial Key Points
surface of ear, and
posterior portion of lateral • The scalp is the soft tissue that covers the
surface of ear cranium and is made up of five layers.
• The forehead and temple are components of the
Lesser C2 Neck, mastoid area, and scalp, embryologically speaking.
occipital scalp posterior to the ear; • Regions of the scalp include: frontal, temporal,
superior portion of cranial parietal, occipital, vertex, and crown.
ear • The vertex lies at top of the scalp anterior to the
Transverse C2 and C3 Anterior neck crown.
cervical • The galea aponeurotica is a component of the
superficial musculoaponeurotic system (SMAS).
Supraclavicular C3 and C4 Lower neck, clavicle, and • Infection of the scalp can spread to the meninges
shoulder via emissary veins.
The lymphatic system The layers of the scalp are summarized in Box 1-� 5
and Figure 1-28 using the mnemonic SCALP. Its
of the head and neck borders are delineated in Table 1-31.
Key Points The skin of the scalp contains many hair follicles
and sebaceous glands that slice into the subcutane
• Lymphatic drainage flows in an inferior and
ous fat. A rich network of nerves and blood vessels
diagonal direction away from the head towards
the deep lymph nodes in the neck. traverses the connective tissue layer. This second
• Flow is superficial to deep. layer also contains thick fibrous bands (retinacula)
• Lymphatic vessels contain valves. that connect the skin to the galea aponeurotica
• The superficial collecting nodes drain to the deep and form the support network for the blood ves
cervical nodes. sels. When these vessels are cut, the thick bands
hold the vessels open allowing the scalp to bleed
Knowledge of the lymphatic drainage of the profusely. Consequently, undermining in this
head and neck is essential for evaluation of plane is suboptimal due to decreased visualization
malignancy and infection of the skin (Fig. 1-27). from excessive bleeding and significant resistance
The lymphatic system begins with fine lymphatic to movement from retinacular attachments.
capillaries in the superficial dermis that con The third layer of the scalp, the galea aponeu
nect with larger lymphatic vessels deeper in the rotica, contains two layers of fascia that encase and
skin. Unidirectional flow into lymph nodes and unite the bellies of the occipitofrontalis muscle
lymphatic chains ultimately returns fluid to the through an intervening inelastic fascial membrane.
venous circulation at the junction of the internal The galea is the strongest layer of the scalp, and
jugular and subclavian veins via the thoracic and wounds superficial to it do not spread. Together
right lymphatic duct. The clinically important with the skin, it functions as a unit that can move
lymph nodes of the head and neck are listed in freely over the deeper layers. As the frontalis
Table 1-27. and occipitalis muscles pull the scalp in opposite
The lymphatic drainage of the scalp and face directions, incisions that interrupt the galea in a
follows a predictable pattern (Table 1-28), although coronal plane increase the mobility of this inelas
the drainage can be variable for each patient. tic membrane. Cutaneous surgeons may exploit
The above groups of superficial collecting this tendency by making a small coronal incision,
lymph nodes ultimately drain to the superficial or galeotomy, anterior or posterior to wound edges
and deep lateral cervical nodes. The superficial to relax tension forces and permit easier closures.
lateral cervical nodes lie above the sternocleido The loose areolar tissue of the scalp attaches
mastoid muscle and are associated with the the galea aponeurotica to the periosteum. This
external jugular vein. The deep lateral cervical relatively avascular layer provides the optimum
nodes run below the sternocleidomastoid muscle site for undermining in the scalp. Although the
with the internal jugular vein. The deep cervical looseness of this space permits mobility of the
nodes form a triangular pattern with the spinal skin and galea, it creates a potential space where
accessory, transverse cervical, and internal jugular large amounts of blood can collect after trauma
chains forming the superomedial, inferior base, or surgery. Posterior and posterolateral bony
ERRNVPHGLFRVRUJ
28 Dermatologic Surgery
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Chapter
Surgical anatomy of the head and neck 29
Table 1-18 Sensory innervation of the ear no bony insertions exist over the anterior bound
ary, infection or blood from the scalp may track
Nerve Anatomic location into the eyelids and root of the nose. Infection
Great auricular Majority of anterior and posterior in loose areolar tissue can also spread to the
auricle: helix, antihelix, antitragus, meninges via emissary veins that pass directly to
entire lobule the dura (see below).
Auriculotemporal Anterocranial auricle above external The final and deepest layer, the periosteum, is
auditory meatus: tragus, anterior adherent to the bones of the cranium by connec
crus and rim of helix, anterior half of tive tissue fibers known as Sharpey’s fibers.
external auditory canal The muscles of the scalp are summarized in
Lesser occipital Small segment of posterior auricle Table 1-33.
and pre-mastoid skin The sensory innervation of the scalp is provid
Facial, vagus Posterior half of external auditory
ed by six nerves, summarized in Table 1-34. When
(cranial canal, skin of concha, antihelix, anesthetizing the scalp, the anesthetic should be
nerve X), and tragus, and antitragus, posterior placed superficial to the galea aponeurotica, as
glossopharyngeal auricle–mastoid junction branches from these six nerves run in the connec
(cranial nerve IX) tive tissue layer.
nerves The arteries that supply the scalp navigate the
connective tissue layer. They are derived from
both the internal and external carotid arteries
insertions of the scalp prevent the spread of fluid (Table 1-35). Rich bilateral anastomoses, in
or infection to the neck (Table 1-32). Lateral addition to the aforementioned retinacular
spread is contained at the zygomatic arch, the attachments, explain why ligation of one end of a
insertion site for the temporal fascia. However, as transected artery is insufficient to stop bleeding.
Supratrochlear
artery and vein
Supraorbital
artery and vein
Angular artery
and vein
Lateral nasal
artery and vein
Posterior auricular
vein
Superficial temporal Posterior auricular
artery and vein artery
Occipital vein
Transverse facial
artery and vein
Occipital artery
Superior labial artery
Inferior labial artery
External jugular
Marginal mandibular vein
nerve
Facial artery and vein Internal jugular
vein
External carotid artery
Figure 1-23 Arterial and venous supply of the face
ERRNVPHGLFRVRUJ
30 Dermatologic Surgery
The veins of the scalp accompany the arter Skin cancer on the scalp can metastasize to
ies and are similarly named. They anastomose the lymph nodes of the head and neck. The scalp
with the diploic veins of the cranial bones and anterior to the ears drains to the parotid, sub
intracranial dural sinuses via emissary veins which mandibular, and deep cervical lymph nodes. The
lack valves. Subsequently, infection from the scalp posterior scalp is drained by the occipital and pos
can spread in a retrograde flow to the meninges terior auricular lymph nodes.
via these valveless veins.
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Chapter
Surgical anatomy of the head and neck 31
aa angular artery
fa facial artery
ln lateral nasal branch (facial artery)
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32 Dermatologic Surgery
Figure 1-25 Inferior labial artery and related structures of the lower lip and chin
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Chapter
Surgical anatomy of the head and neck 33
Figure 1-26 Superior labial artery and related structures of the upper lip and cheek
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34 Dermatologic Surgery
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Surgical anatomy of the head and neck 35
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36 Dermatologic Surgery
Direction of
Preauricular/ lymph flow
parotid nodes
Occipital nodes
Postauricular nodes
Jugulodigastric node
Submental nodes
Omohyoid muscle
Internal jugular vein
Jugulo-omohyoid node
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Chapter
Surgical anatomy of the head and neck 37
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38 Dermatologic Surgery
Table 1-31 Borders of the scalp Table 1-33 Muscles of the scalp
Anterior Supraorbital ridges Frontalis Occipitalis
Posterior Base of occipital bone Origin Galea Superior nuchal
Lateral Frontal process of zygomatic bone, aponeurotica line of occipital
zygomatic arch, external acoustic bone
meatus, mastoid process, and superior Insertion Skin and Galea
nuchal line of occipital bone muscular fascia of aponeurotica
upper eyelids
Innervation Temporal branch Posterior auricular
Table 1-32 Boundaries of the loose alveolar space
of facial nerve branch of facial
Posterior Superior nuchal line of occipital bone nerve
Posterolateral Mastoid process of temporal bone Action Raises eyebrows; Not under
allows skin to voluntary control;
Lateral Temporal fascia
slide over bones allows skin to
Anterior Frontalis muscle insertion points on skin of cranium slide over bones
and subcutaneous connective tissue of cranium
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Chapter
Surgical anatomy of the head and neck 39
Further reading Reich SG, Grill SE. Gustatory sweating: Frey syn
drome. Neurology 2005;65(11):E24.
Asarch RG. A review of the lymphatic drain Robinson JK, Anderson ER. Skin structure and surgi
age of the head and neck: use in evaluation of cal anatomy. In: Robinson JK, Hanke CW, Sen
potential metastases. J Dermatol Surg Oncol gelmann RD, Siegel DM, eds. Surgery of the Skin:
1982;8(10):869–872. Procedural Dermatology. Philadelphia: Elsevier
Mosby, 2005.
Baker DC, Conley J. Avoiding facial nerve injuries in
rhytidectomy. Anatomical variations and pitfalls. Robinson JK, Hanke W, Sengelmann RD, Siegel DM.
Plast Reconstr Surg 1979;64(6):781–795. Surgery of the Skin: Procedural Dermatology.
St Louis: Elsevier Mosby, 2005.
Bennett RG. Fundamentals of Cutaneous Surgery.
Washington, DC: CV Mosby, 1988. Salasche SJ, Berstein G, Senkarik M. Surgical Anato
my of the Skin. Norwalk: Appleton & Lange, 1988.
Breisch EA, Greenway HT. Cutaneous Surgical Anat
omy of the Head and Neck. New York: Churchill Scarborough D, Bisaccia E, Schuen W, Swensen R.
Livingstone, 1992. Anesthesia for the dermatologic surgeon. Int J
Dermatol 1989;28(10):629–637.
Carlson KC, Roenigk RK. Know your anatomy:
perineural involvement of basal and squamous cell Standring S, Healy J, Johnson D, Williams A. Gray’s
carcinoma on the face. J Dermatol Surg Oncol Anatomy: The Anatomical Basis of Clinical Prac
1990;16(9):827–833. tice. New York: Elsevier Churchill Livingstone,
2005.
Erb W. Handbook of Electro-Therapies (Translated by
Putzel L.) William Wood and Company. New York. Tart RP, Mukherji SK, Avino AJ, Stringer SP,
1883; 122-124. Accessed online at: http://books. Mancuso AA. Facial lymph nodes: normal
google.com/books?q=handbook+of+electro+ and abnormal CT appearance. Radiology
therapeutics 1993;188(3):695–700.
Gosain AK. Surgical anatomy of the facial nerve. Clin Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ.
Plast Surg 1995;22(2):241–251. The surgical anatomy of the scalp. Plast Reconstr
Surg 1991;87(4):603–614.
Harding SP, Lipton JR, Wells JC. Natural history of
herpes zoster ophthalmicus: predictors of post Tubbs RS, Loukas M, Salter EG, Oakes WJ. Wilhelm
herpetic neuralgia and ocular involvement. Br J Erb and Erb’s Point. Clin Anat. 2007;20:486–488.
Ophthalmol 1987;71(5):353–358.
Moore KL, ed. Clinically Oriented Anatomy, 3rd edn.
Baltimore: Williams & Wilkins, 1992.
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Chapter
Antisepsis
Gregory J. Fulchiero Jr, Christopher Riddell Jones,
and Christie T. Ammirati
ERRNVPHGLFRVRUJ
42 Dermatologic Surgery
likelihood of developing an infection for each at increased risk for Pseudomonas sp. coloniza-
procedure based on the status of the surgical site tion of the ear canal and may be predisposed
and the anatomic location (Fig. 2-1). Dermato- to infection after auricular surgery, particularly
logic surgery, in general, carries a low infection of the conchal bowl. Severe malnutrition and
rate but surgical wounds of the groin, axilla, chronic alcoholism are considered immunocom-
mouth, ear, and below the knee may be at a high- promised states and associated with increased
er risk of postoperative infection (exceeding 5%) risk of wound infection. Chronic corticosteroid
(Fig. 2-2). usage, chemotherapy, neutropenia (granulocyte
count <1000/mm3), and organ transplant pa-
Risk factors tients on chronic immunosuppressive medica-
tions have been associated with an increased
Certain patient risk factors and comorbidities risk of infection in general surgery but rarely in
are known to increase the risk of surgical site dermatologic surgery.
infection and may warrant the use of prophyl Most studies concerning immunosuppression
actic antibiotics (Box 2-4). A history of pre- and the risk for surgical site infection after derma-
vious wound infection may indicate that the tologic surgery have focused on organ transplant
patient has chronic bacterial colonization, most recipients. The vast majority of these reports do
frequently with S. aureus, and is at increased not support the use of prophylactic antibiotics
risk for subsequent wound infections. Reduced for uncomplicated dermatologic surgery in these
perfusion of the wound bed by either endoge patients. The effect of HIV-induced immuno-
nous vascular insufficiency or nicotine-induced suppression on surgical site infection remains to
vasoconstriction increases the risk of necro- be fully defined. Even when controlled for CD4
sis, dehiscence, and wound infection. Patients count, there are conflicting data and further
with poorly controlled diabetes mellitus are studies are needed.
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Chapter
Antisepsis 43
The differential diagnosis of wound infection var application of hydrogen peroxide, alcohol, or topi
ies, based on the length of time after surgery, clini cal antibiotics may cause an irritant or allergic
cal picture of the wound, and the complaints of contact dermatitis that can mimic a wound
the patient (Table 2-4). Normal postoperative se- infection (Fig. 2-4).
quelae that must be differentiated from infection
include incisional discomfort and swelling secon Antiseptic scrubs
dary to anesthesia or postoperative edema. A
suture abscess, which may suppurate but resolves There are several effective antiseptic agents that
with removal of the suture, is not considered to be can be used to cleanse the skin prior to surgery.
a wound infection (Fig. 2-3). Postoperative patient The most common are povidone–iodine and
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44 Dermatologic Surgery
B ox 2 - 4
Patient comorbid risk factors for surgical
site infection
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Chapter
Antisepsis 45
Another common antiseptic preparation is scrub is to remove transient flora and soil from
para-chlorometaxylenol (PCMX), or chloroxyle- the fingernails and skin. Its efficacy is dependent
nol. PCMX has effective Gram-positive bacterial on the duration, technique, and agent chosen. If
coverage but poor activity against Gram-negative done properly, a hand scrub can reduce the bacte-
organisms, such as P. aeruginosa. Some commercial rial load by 90–99%. The majority of hand flora
PCMX preparations have added a chelator, such are located under and around the fingernails, and
as ethylene diamine tetra-acetic acid (EDTA), these areas should receive close attention during
to markedly increase the formulation’s anti- the hand scrub. Most studies have found that,
Pseudomonas activity. Although PCMX has re- regardless of the agent used, the first scrub of the
sidual activity for several hours, it is somewhat day should be at least 2 min. The most common
less durable than chlorhexidine. The antiseptic agents are chlorhexidine, povidone–iodine, and
hexachlorophene (pHisoHex®) has been banned alcohol preparations. One limitation of alcohol
from use in newborns and pregnant women as it rubs is that they do not have detergent qualities
has been shown to be neurotoxic to neonates if and should be used only after the skin has been
absorbed through the skin. cleansed of all visible debris.
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46 Dermatologic Surgery
not been determined with certainty, but the ma- of the surgical atmosphere and have a moderate
jority of studies support a 1–2-min scrub. The role as personal protective gear. However, they can
most favored technique employs three succes- harbor pathogenic bacteria and fungi, which can
sive scrubs with a fresh sponge or gauze, starting survive on these materials for extended periods,
at the center of the surgical site and progressing particularly if allowed to become saturated. They
outward in concentric circles. A sufficient area should be changed immediately if visibly contam-
should be included in the scrub so that, once inated and, regardless of their state, laundered on
draped, a sterile field can be maintained. Common a daily basis. This is particularly true for white lab
antiseptics used for this purpose are chlorhexi- coats, which are frequently hung on hooks and
dine gluconate, povidone–iodine, and PCMX. On worn for several days without laundering.
the evening before surgery, a preoperative shower The role of facemasks with eye shields as
with chlorhexidine or benzoyl peroxide has been personal protective gear is undisputed, but their
shown to decrease surgical site infections with value in reducing surgical site infections remains
S. aureus and may be considered for large surgical debatable. It has been argued that facemasks may
fields such as liposuction. abrade the skin and increase the risk for contami-
nating the surgical field with desquamated skin
Sterile field cells. Alternatively, studies have shown a relation-
ship between bacterial contamination of the sur-
A sterile field limits contamination during surgery gical field and the volume at which the surgeon
and aims to maintain the low microbial counts of speaks. Speaking even briefly in a loud tone can
the surgical site achieved after antiseptic scrub- aerosolize significantly more bacteria (up to 1 m
bing. Disposable, impermeable sterile drapes and away) than speaking in a normal tone for up to
reusable, tightly woven cotton drapes are the types 30 min. In this respect, a properly fitted mask may
most commonly used in dermatologic surgery. play a role in decreasing wound contamination,
Disposable impermeable drapes are inexpensive, especially when coughing or sneezing (which can
but they may allow blood and fluids to pool on propel bacteria up to 3 m away). When worn,
them, and their stiffness can cause them to shift facemasks should be discarded and replaced after
easily during surgery. Cotton surgical drapes every surgical procedure as they rapidly become
are more pliable, and this allows them to be saturated with the surgeon’s expired flora. Bouf-
shaped to fit the surgical site. They are arguably fant hair covers that enclose all of the scalp hair,
more comfortable for the patient, but may wick as opposed to small surgical caps that cover only
bacteria into the surgical field if saturated. the top of the head, may decrease the incidence
of surgical site infections. Outbreaks of infection
Breaks in sterile field have been traced to S. aureus and group A Strep-
tococcus bacteria from the scalp and hair of both
A break in the sterile field can include any surgical personnel and the patient. There is no evi-
number of scenarios (i.e. patient touches surgi- dence supporting a correlation between disposable
cal site, nonsterile instrument placed onto field, shoe covers and surgical site infection. However,
or suture-tail touching nonsterile surface). When in procedures known to be associated with fluid
a break in the sterile field occurs, the surgical transfer (i.e. liposuction), they may serve to limit
wound is likely to be upgraded (see Table 2-3), contamination of the surgeon’s shoes.
corresponding to a higher risk of postoperative
infection. This may influence the decision to re-
scrub the sterile field, replace the drapes, change Patient preparation and hair
gloves, or replace contaminated suture. Depend- removal
ing on the degree of contamination, the surgeon
may also decide to place the patient on prophyl Several studies have shown a clear correlation
actic antibiotics. between wound infection and hair remo
val by shaving (incidence 2.3–7.1%). This is
Surgical attire particularly true when the surgical site is shaved
more than 24 h before the procedure (incidence
The image of the surgeon in scrub suit, surgical up to 20%). This increased risk is attributed to
cap, and facemask is well known to us all. Al- microabrasions in the skin caused by shaving, as
though this attire is familiar and at times expected abrasions encourage higher levels of resident and
by patients, it has not been proven to affect the transient flora. If hair must be removed from the
incidence of surgical site infection. In fact, there surgical field, it is best to clip it with scissors or
are no scientific data that prove wearing scrub electric shears prior to establishing a sterile field,
suits, rather than street clothes, affects the inci- as this is associated with only a modest increase
dence of surgical site infection. Polyester/cotton in risk for wound infection (1.7% versus a con-
scrub suits serve to maintain the overall hygiene trol of 0.9% in one study). When possible, the
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Chapter
Antisepsis 47
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48 Dermatologic Surgery
Further reading Mangram AJ, Horan TC, Pearson ML, et al. Guide-
line for prevention of surgical site infection, 1999.
Dixon AJ, Dixon MP, Askew DA, et al. Prospective Hospital Infection Control Practices Advisory
study of wound infections in dermatologic surgery Committee. Infect Control Hosp Epidemiol
in the absence of prophylactic antibiotics. Derm 1999;20:250–278.
Surg 2006;32(6):819–827. Patton LL, Shugars DA, Bonito AJ. A systematic
Edwards PS, Lipp A, Holmes A. Preoperative skin review of complication risks for HIV-positive
antiseptics for preventing surgical wound infec- patients undergoing invasive dental procedures.
tions after clean surgery. Cochrane Database Syst J Am Dent Assoc 2002;133:195–203.
Rev 2004;3: CD003949. Seal LA, Paul-Cheadle D. A systems approach to
Futoryan T, Grande D. Postoperative wound infec- preoperative surgical patient skin preparation. Am
tion rates in dermatologic surgery. Dermatol Surg J Infect Control 2004;32(2):57–62.
1995;21:509–514.
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3
Chapter
Local anesthetics
Jon G. Meine
Key Points s odium channel, the local anesthetic must first pass
• Local anesthetics are commonly used in skin through the lipophilic (phospholipid bilayer) nerve
surgery, avoiding the risks associated with cell membrane. Local anesthetics are supplied in an
general anesthesia. acidic solution, in which most of the drug is present
• Anesthetics may be delivered through topical in its ionized state (H+), which is hydrophilic and
application, local infiltration, or regional nerve
lipophobic. The drug must convert to its un-ionized
blocks.
• The choice of anesthetic agent and method of (base) state to pass through the nerve cell mem-
delivery depends on the type of surgery planned, brane (Fig. 3-1). The proportion of drug available
anatomic location of surgery, and patient in its base form is determined by the pKa of the
characteristics. drug (Table 3-1) and the pH of the tissue/inter-
stitial fluid. Once the drug enters the intracellular
History space, the lower pH converts the drug back to its
ionized/cationic (active) form, which can block the
Modern local anesthesia was revolutionized in internal portion of the sodium channel.
1905 with the synthesis of procaine by Einhorn. For an anesthetic to function, it must:
Procaine use was limited, however, owing to the
potential for severe allergic reaction to one of • Reach the target nerve in sufficient
its metabolites, para-aminobenzoic acid (PABA). concentration
Tetracaine, a more potent ester anesthetic, was • Diffuse through the cell membrane’s lipid
introduced in 1930, but its use was also limited bilayer
because of similar allergic reactions. • Convert to an active (cationic, NH+) form.
In 1943, lidocaine was developed by Lofgren.
It is an amino amide that does not metabolize to Pain and temperature sensation are carried by
PABA. Lidocaine replaced procaine as the local small unmyelinated type C fibers and myelinated
anesthetic of choice because of its low allergic type A delta fibers (Table 3-�2). Local anesthetics
potential. have the greatest effect on these smaller fibers, so
that pain is the primary sensation blocked, while
Mechanism of action touch, pressure, and motor function are minimally
affected.
Local anesthetics produce their effect by prevent-
ing depolarization of the nerve cell membrane. Structure
Stimulation of a nerve causes an influx of sodium
ions into the cell from the extracellular space. Local anesthetics have a similar basic chemical
The rapid influx of sodium ions starts the proc- structure (backbone) (Fig. 3-2). They consist of
ess of depolarization and produces an action po- three portions: an aromatic portion, and inter-
tential. Local anesthetics prevent the rapid influx mediate chain, and a terminal amine group. The
of sodium ions through the voltage-gated sodium aromatic component is typically a benzene ring,
channels (as well as interfering with potassium which is lipophilic.
channels), thereby preventing depolarization and The terminal amine portion is hydrophilic, or
the production of an action potential. water soluble. The amine portion is a weak base
It is believed that local anesthetics reversibly that accepts hydrogen ions (H+) and converts
block the internal portion of the sodium chan- the anesthetic into an active (cationic) form. The
nels. To reach this intracellular portion of the intermediate chain is composed of either an ester
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50 Dermatologic Surgery
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Chapter
Local anesthetics 51
Ester anesthetics are metabolized via hydrolysis r educe blood flow to the liver and therefore slow
by pseudocholinesterase, a widely available plasma the metabolism of amide local anesthetics.
enzyme, and excreted in urine. One of the me-
tabolites of ester anesthetics is PABA, which is a Adverse effects
well documented allergen. Patients with defects in
pseudocholinesterase have a decreased ability to Local anesthetics are very safe when administered
metabolize ester anesthetics; this could potentially properly and within the recommended dosage
lead to high serum drug levels. Ester anesthetics (Table 3-�4). Allergic reactions, local toxicity, and
should be avoided in patients with such conditions systemic toxicity are rare but potential complica-
and in those with a documented allergy to PABA. tions of local anesthetics.
Amide anesthetics are metabolized in the liver
via microsomal enzymes, specifically cytochrome Local effects
P-4503A4. Patients with liver disease and patients
taking medications that interfere with the metab- Pain is a common local effect with injection of
olism of the anesthetic may be at increased risk local anesthetics, but can be minimized with
for adverse effects due to high serum drug levels good technique (Box 3-2). Less common adverse
(Box 3-1). Antihypertensive medications, such effects at the site of injection include ecchymosis,
as beta-blockers, and congestive heart failure can hematoma, infection, nerve laceration, and tissue
necrosis. Nerve laceration can result in temporary
R1 or longer-lasting pain or paresthesias.
Amide or
Ester linkage
N Systemic effects
R2 Systemic adverse effects occur due to raised plas-
ma concentrations of local anesthetics. Inadvertent
Lipophilic aromatic ring Hydrophilic amine
intravascular injection or excessive doses of local
Figure 3-2 Generic structure of local anesthetic agents anesthetic are usually responsible for systemic
ERRNVPHGLFRVRUJ
52 Dermatologic Surgery
Aminoesters
Table 3-4 Maximum recommended dose of lidocaine
O CH2 CH3 Maximum dose (mg/kg)
H2N C C CH3 CH2 N Adults Children
CH2 CH3 With epinephrine 7.0 3.0–4.5
Without 5.0 1.5–2.0
Aminoamides epinephrine
CH3
O CH2 CH3 B ox 3 - 2
NH C CH3 N
Tips for reducing the pain of injection
CH2 CH3
CH3 Do not leave fluid on the needle when entering the skin.
Figure 3-3 Amino esters and amino amides Pinch the area before injecting.
Use the smallest (diameter) and longest needle possible.
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Chapter
Local anesthetics 53
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54 Dermatologic Surgery
• Severe hypertension
B ox 3 - 3
• Severe cardiovascular disease
Treatment of CNS toxicity • Severe peripheral vascular disease
Need to reduce hypoxia and acidosis • Hyperthyroidism
Oxygen • Pheochromocytoma
Leg elevation
Increase respiratory rate to produce a respiratory alkalosis
Convulsions:
• Valium 5–10 mg IV B ox 3 - 7
B ox 3 - 4
Alternatives to local anesthetics of epinephrine in a healthy patient is 1 mg, or
• Benzyl alcohol
100 mL of a 1:100 000 concentration. Special
caution should be taken in patients with cardio-
• Diphenhydramine vascular disease. See Boxes 3-6 through 3-8 for
• Saline contraindications and relative contraindications
• Ice
to epinephrine.
• Dichlorotetrafluoroethane or ethyl chloride
Pregnancy and lactation
Local anesthetics can cross the placental membrane
by (passive) diffusion. Used conservatively, they
increased absorption of the drug. Vasoconstrictors, are considered to be safe in pregnancy. Although
namely epinephrine, are commonly added to elective or large procedures are best delayed until
local anesthetics to counteract this effect (Box after delivery, simple procedures such as biopsy
3-5). Epinephrine is typically found in a 1:100 000 of a changing and/or atypical pigmented lesion
concentration, but is an effective vasoconstrictor has little risk to the fetus with the use of a small
at dilutions of up to 1:1 000 000 (Klein’s tumes- amount of local anesthetic. Some obstetricians
cent formula). The maximal vasoconstrictive recommend avoiding local anesthetics in the first
effect of epinephrine takes up to 10–15 min and trimester when organogenesis occurs. Lidocaine,
is evident by blanching of the affected skin. etidocaine, levobupivacaine, prilocaine, and pro-
Adverse effects of epinephrine can occur caine are considered pregnancy category B, while
with low doses. The most common side effect bupivacaine, mepivacaine, articaine, tetracaine,
is tachycardia. Higher doses (as with inadvert- and chloroprocaine are category C. Epinephrine
ent intravenous injection) can cause palpitations, is considered pregnancy category C and should
diaphoresis, pallor, angina, tremors, nervousness, be used conservatively, as large doses can cause
headache, and hypertension. The maximum dose decreased placental perfusion.
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Chapter
Local anesthetics 55
B ox 3 - 8 B ox 3 - 9
Drug reactions with epinephrine Anesthesia techniques
Methods of administration
Severe, prolonged hypotension or hypertension may be
produced if given to patients taking: • Local infiltration
• Monoamine oxidase inhibitors • Field block
• Tricyclic antidepressants • Nerve block
• Butyrophenones • Ring (digital) block
• Phenothiazines
• Vasopressors
• Oxytocin may be considered. Another option is to have
the patient pump her breast milk several hours
Non-selective beta-blockers can lead to unopposed after the procedure and discard the expressed
α-adrenergic stimulation:
milk.
• propranolol (Inderal)
• carvedilol (Coreg) Topical anesthesia
• labetalol (Normodyne, Trandate)
A number of agents are available for anesthe-
• nadolol (Corgard) tizing the skin and mucosal membranes (Table
• penbutolol (Levatol) 3-�7). The stratum corneum is a major barrier to
absorption of topical anesthetics through intact
• pindolol (Visken)
skin; therefore application times are generally
• sotalol (Betapace) longer than for mucosal sites, and occlusion is
• timolol (Blocarden) frequently used to enhance absorption. Products
containing benzocaine and prilocaine should be
Treatment for epinephrine toxicity:
avoided in infants due to the risk of methemo-
• Hydralazine 20 mg in 250 mL normal saline globinemia.
• Pentolamine 5 mg over 1 min
Anesthesia techniques
There are several methods of anesthesia ad-
Local anesthetics and epinephrine are excreted ministration in dermatologic surgery (Box 3-9).
in breast milk and should be used with caution The most common method is local infiltration,
in women who are nursing. Ester anesthetics where the anesthetic is injected directly into or
are preferred during lactation because they are below the lesion into the subcutaneous tissue.
significantly metabolized in plasma before reach- This is most useful for small or limited surgical
ing breast tissue. Alternatives to “caine” anesthetics areas.
Table 3-7 Topical anesthetics for mucous membrane and intact skin anesthesia
Generic name Brand name Concentration (%) Type Primary use
Benzocaine Americaine otic 20 Ester Tympanic membrane
Benzocaine Hurricane 20 Ester Mucous membranes
Benzocaine/tetracaine Cetacaine 14/2 Ester Mucous membranes
Cocaine 2–10 Ester Nasal mucosa
Dibucaine (cinchocaine) Nupercainal 1 Amide Mucous membranes
Lidocaine LMX 4–5 Amide Intact skin
Lidocaine Topicaine 4 Amide Intact skin
Lidocaine Xylocaine 2–5 Amide Mucous membranes
Lidocaine in acid mantle cream 30–40 Amide Intact skin
Prilocaine/lidocaine EMLA 2.5/2.5 Amide Intact skin
Proparacaine (proxymetacaine) Alcaine 0.5 Ester Conjunctiva
Tetracaine Pontocaine 0.5 Ester Conjunctiva
Prilocaine–lidocaine mix Betacaine LA Proprietary Amide Intact skin
ERRNVPHGLFRVRUJ
56 Dermatologic Surgery
B ox 3 - 1 0 B ox 3 - 1 2
Nerve blocks Infraorbital block (V2)
Advantages
Provides sensation to lower eyelid, medial cheek, nose, and
• Anesthetizes the nerve before it reaches the operative site upper lip
• Affects a large area with small amount of anesthetic Indications
• No distortion of operative site • Fillers
Disadvantages: • Laser resurfacing
• No vasoconstriction • Large surgical defects
• Longer onset Location
• Shorter duration • Foramen is 1 cm inferior to the infraorbital ridge along the
mid-pupillary line
• Risk of nerve laceration
Approach through the oral cavity
Technique – general principles
The nerve is 0.5–1 cm above superior labial sulcus
• Lidocaine and/or longer-acting anesthetic
Anesthetize oral mucosa with topical benzocaine first
• 5-mL syringe
Enter at apex of first bicuspid and direct needle towards
• 27- or 30-gauge 1⁄2-inch needle
estimated location of foramen
• Inject slowly into subcutaneous plane in vicinity of nerve
Inject 1–2 mL with a 1⁄2-inch needle (27 or 30 g)
• Avoid directly hitting the nerve (back off if sharp pain when
inserting needle)
• Don’t inject directly into the foramen
B ox 3 - 1 3
• Pull back on the plunger before infiltrating
• Wait 10–15 min for the full effect Mental nerve block (V3)
Indications Location
• Hair transplantation • Midway between upper and lower edge of mandible below
second bicuspid (mid-pupillary line)
• Laser resurfacing
Approach through the oral cavity
• Large surgical defects
Anesthetize oral mucosa with topical benzocaine first
Location
27- or 30-G 1⁄2-inch needle
• Supraorbital nerve – mid-pupillary line along superior
bony orbit Enter inferior labial sulcus between first and second bicuspids
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Chapter
Local anesthetics 57
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4
Chapter
Surgical instruments
Ashish C. Bhatia and Aashish Taneja
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60 Dermatologic Surgery
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Chapter
Surgical instruments 61
Figure 4-5 No. 15 blade Figure 4-6 No. 10 blade Figure 4-7 No. 11 blade
ERRNVPHGLFRVRUJ
62 Dermatologic Surgery
size refers to the width of the opening. The width Figure 4-15 Scissors consist of tips, blades and handles
ranges from 1 to 10 mm. In general, smaller sizes
are utilized for finer procedures. Scissors are a common instrument in the derma-
Some dermatologists prefer the reusable tologist’s office. They come in a variety of shapes
curettes because of their physical weight and and sizes suited to different tasks (Fig. 4-14).
“dullness.” This combination allows the physician Common types of scissors include Gradle scissors,
to get a better feel of the difference in consistency tissue scissors, undermining scissors, suture-
between various tissue types, such as tumor, der- cutting scissors, and bandage-cutting scissors.
mis, and subcutaneous tissues. These practitioners Dozens of specialty varieties of scissors are also
find disposable curettes too sharp and light, essen- available for special purposes.
tially cutting through any tissue almost equally The basic anatomy of scissors consists of three
well, and providing minimal sensory feedback parts: the handle, the blade and the tip (Fig. 4-15).
regarding the tissue being curettaged. The handle may be short or long. Generally, short
To obtain optimal sensory feedback from a handles provide better control but less leverage,
curette, it should be held like a pencil with the and are utilized for fine work such as delicate sur-
sharp side of the tip angled downward. The scrap- geries on thinner tissues of the face. Long han-
ing motion is towards the operator, and can be dles not only provide greater leverage, but are
performed in a linear or curvilinear method. also optimal for surgeries requiring a long reach.
A longer reach may be necessary when operating
Scissors in cavities or undermining deeply under tissues.
Scissor handles are available in straight, curved,
Key Points or bent contours for increased visibility and
• A variety of scissors are available for the many hand/wrist comfort for the surgeon. The blades
tasks involving cutting in a dermatology practice. of scissors can also be straight or curved, for the
• There are a host of specialty scissors available same reasons (Fig. 4-16). Straight blades allow for
for very specific tasks in a dermatology office. straight cuts such as for gross trimming of flaps
• Common uses for scissors in dermatology and grafts, and are commonly used for cutting
include cutting or trimming tissue or grafts and
sutures. Curved blades are often utilized for dis-
flaps, trimming bandages, cutting sutures, and
undermining tissues prior to closure. section, allowing easy movement around tumors
or cysts. They increase the surgeon’s visibility and
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Chapter
Surgical instruments 63
Figure 4-16 Scissors with a straight blade (top) Figure 4-18 Scissors reinforced with tungsten carbide
and a curved blade (bottom) (note the gold handle)
ERRNVPHGLFRVRUJ
64 Dermatologic Surgery
Figure 4-21 Iris scissors Figure 4-22 Westcott and Castroviejo Figure 4-23 O’ Brien suture-cutting
scissors scissors
Figure 4-24 Mayo scissors Figure 4-25 Metzenbaum scissors Figure 4-26 Standard operating
scissors
can be smooth or serrated, and the tip can be tissues that are more difficult to cut or dissect.
sharp or blunt. They are commonly used for larger excisions
Westcott and Castroviejo scissors are one of the and undermining in areas such as the trunk and
most delicate and complicated scissors used in scalp.
dermatologic surgery (Fig. 4-22). Unlike other Like the Metzenbaum scissors, the Lagrange
scissors, they are held like forceps and gently scissors also have a high handle to blade ratio. Its
squeezed to cut (Fig. 4-23). They are also unique strongly curved tip with a reverse curve on the
because of their spring action, which is used to handle shank makes this instrument useful to
open the blades as pressure is released on the harvest hair transplant donor grafts. It can also be
handles. They generally have very fine, pointed useful for freeing punch biopsy specimens with a
tips and are good for delicate dissections such as deep base.
in periorbital surgery. Tissue scissors, such as most of the scissors
Mayo scissors are generally heavier scissors with mentioned above, should generally be reserved
nearly a one to one handle to blade ratio (Fig. 4-24). for cutting tissue. Surgical kits should contain
They are useful as general-use scissors. They are dedicated suture scissors for trimming and cut-
not usually used for fine or delicate work, but ting sutures. Using the same scissors to cut tissue
rather for coarse dissection. and sutures may result in premature dulling of
Metzenbaum scissors are heavier, with a high the tissue scissors. These scissors generally have
handle to blade ratio for maximal leverage and large, heavy-duty blades. Examples of good suture
length (Fig. 4-25). These long-handled scissors scissors include standard operating scissors (Fig.
are available in varying lengths. The blade can 4-26) and Northbent scissors, which are specifi-
be straight or curved, and the tip can be sharp cally designed with a half-moon hook on the low-
or blunt. These qualities make this instrument er blade to remove sutures (Fig. 4-27). O’Brien
ideal in areas that require long reach and for scissors have a short-angled blade that allows the
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Chapter
Surgical instruments 65
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66 Dermatologic Surgery
Figure 4-30 Straight- and curved-tip Figure 4-31 Pointed smooth forceps Figure 4-32 Forceps with serrated tip
Semken forceps
Figure 4-33 Forcep with 1 × 2 teeth Figure 4-34 Brown–Adson forceps Figure 4-35 Forceps with needle
with multiple 8 × 9 teeth platform
ERRNVPHGLFRVRUJ
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Chapter
Surgical instruments 67
instruments are available in fine, extra fine, or being removed, such as the wall of a cyst, or the
super fine varieties. These instruments are ideal nail plate during an avulsion. They can also be
for grasping very small vessels, retrieving su- utilized as towel clamps for securing towels or to
ture fragments, or removing splinters. Jeweler’s secure the electrosurgical handle within the sur-
forceps with angled or curved tips are often gical field or on the surgical tray.
utilized in hair transplantation when placing the The tremendous variety and subtypes of forceps
delicate micrografts in the small recipient sites available make it a difficult choice when purchas-
on the scalp. ing forceps. It is best to purchase a few sets with
Iris forceps come in several varieties for various the type of forceps that one knows to be best
uses. They have a narrower handle like that of the suited for the appropriate task. Once the basic kits
Bishop–Harmon forceps, but of varying lengths have been assembled, different varieties and sizes
(Fig. 4-39). They have a high tip to handle ratio, of forceps can be tried to see whether they are well
allowing less gripping force, which minimizes suited for the task and for the surgeon’s hands. Not
trauma to the tissues being handled. They of- all forceps work best for every surgeon, so finding
ten have a guiding pin, which extends from one the right fit for the surgeon and task is essential to
handle and is received by a hole in the opposing help perform procedures efficiently and safely.
handle. This helps prevent misalignment of the
tips when applying grasping force. The tips can be
smooth, serrated, or toothed. Iris forceps tend to Needle holders (needle
be utilized for more delicate tissues, with longer drivers)
Iris forceps used for working in deeper cavities.
Other varieties of forceps are the DeJardin Key Points
forceps (Fig. 4-40) and the Graefe and Harmon • Needle holders come in a variety of shapes,
Fixation forceps. These all have wide, horizontally sizes, and compositions.
oriented, tips with eight or more horizontal teeth. • Choosing needle holders for a practice is based
They are used in dermatologic surgery to prima- upon the type of procedures being done in the
rily handle cartilage. practice.
• Generally, two or more sizes of needle holders
Another style of forceps with a horizontally
are required in most dermatology practices to
oriented tip is the Allis forceps or clamp (Fig. accommodate various suture needle types.
4-41). Unlike many other forceps, these have
ringed finger loops in the handle as well as a
mechanism to click the jaws closed with various Although needle holders or drivers (Fig. 4-42) are
jaw pressure, much like towel clamps and needle available in a variety of sizes and configurations,
drivers. These are generally used to grasp tissues one basic premise holds true: small needle holders
Figure 4-39 Iris forceps Figure 4-40 DeJardin forceps Figure 4-41 Allis forceps or clamp
ERRNVPHGLFRVRUJ
68 Dermatologic Surgery
Figure 4-42 Large (top) and small Figure 4-43 Smooth surfaced needle Figure 4-44 Serrated-surface needle
(bottom) needle holder holder holder
Figure 4-45 Crile–Wood needle holder Figure 4-46 Baumgartner needle Figure 4-47 Webster (Halsey) needle
holder holders
should be used for small needles and large needle Webster (Halsey) needle holders are shorter dri
holders for large needles.The options available with vers with narrow jaws and tapered tips (Fig. 4-47).
needle holders include their size, the texture of The surface of the jaws can be smooth or serrated.
the jaws, the metal of the jaws, and the shape These drivers are suitable for finer needles.
of the jaws. The jaws of needle holders can be Castroviejo needle holders are delicate instru-
smooth or fine toothed. A smooth surface ments that have a spring lock handle (Fig. 4-48).
minimizes damage to finer needles (Fig. 4-43). They do not have finger loops in the handles. In-
One drawback, however, is that on a smooth sur- stead, they are held like forceps. As the handles
face the small needles may tend to slip. As a re- are partially brought together, with a click, the
sult, small needle holders are available with fine mechanism locks the jaws firmly to clamp the
serrations that will not damage the needle. Nee- needle in the needle holder. To release the needle,
dle holders that have fine serrations prevent the the handles are compressed further until they
twisting of needles during suturing (Fig. 4-44). click. At that point, the spring action separates
TC inserts are also available for increased durabil- the jaws as the surgeon releases the handles. The
ity of the jaws. These inserts increase the strength jaws of these instruments are very fine, making
and hardness of the instruments, and also allow them suitable for extremely delicate procedures
for secure gripping of needles. around the eyes and ears.
Crile–Wood needle holders are large instru- Another type of needle driver used by derma-
ments with blunt tips that are best utilized when tologists is the Olsen–Hegar needle holder (Fig.
working on the trunk or extremities where larger 4-49). These, too, are available in several different
suture materials and needles are needed (Fig. sizes. They differ from other needle holders be-
4-45). Similarly, Baumgartner and Mayo Hegar cause they serve a dual purpose. Just proximal to
needle holders are strong, durable drivers with ser- the jaws, there is a suture-cutting scissor surface,
rated jaws, making them suitable for procedures allowing the surgeon to suture and cut suture
on the trunk or extremities (Fig. 4-46). with the same instrument. Care must be taken
ERRNVPHGLFRVRUJ
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Chapter
Surgical instruments 69
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70 Dermatologic Surgery
Figure 4-52 Curved, serrated Figure 4-53 Jacobsen hemostat Figure 4-54 Halstead mosquito
hemostat hemostats
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Chapter
Surgical instruments 71
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5
Preoperative evaluation
Chapter
of the dermatologic
surgery patient
Lisa M. Grandinetti and Susan Teri McGillis
The preoperative consultation and examination is c onsultation, there should be minimal distraction
an integral component of the physician–patient from incoming phone calls, pagers or office staff.
relationship. This interaction allows the surgeon
carefully to assess the problem, evaluate the Preoperative assessment
patient’s health status, identify risk factors, (Box 5-1)
educate the patient and discuss the surgery
in detail. The patient should gain a realistic
understanding of the proposed surgery, be
General medical history
informed of treatment options and know what to A preoperative questionnaire completed by the
expect in the postoperative period. The additional patient or with the aid of the medical staff (nur
time to perform a preoperative evaluation is ses, medical assistants, and physician assistants)
well compensated for by a reduction in surgical facilitates the consult and provides useful infor-
complications and an improved interaction mation. Preprinted forms may be used or, as is the
between patient and physician. case in the authors’ practice, an electronic medi-
cal record template assures that key components
of the preoperative assessment are addressed. The
The consultation area patient’s response to these key questions helps to
Key Points identify potential problems and avert subsequent
complications. Additionally, forms can be tailored
• Should be clean and private with natural lighting to the anticipated procedure.
• Should include a place for patient to disrobe and
leave garments and a sink, with clean towels, for
patient to wash face and remove makeup
B ox 5 - 1
• Should have several mirrors on hand to help
patient point out their concerns or follow along Basic components of preoperative
with the surgeon’s explanations. assessment
ERRNVPHGLFRVRUJ
74 Dermatologic Surgery
In evaluating a patient’s past and current medi- Three main areas for evaluation
cal issues, the surgeon should be acutely aware
Angina and ischemic heart disease
of possible complications and interactions that
may negatively impact the safety of the patient • Sublingual nitroglycerin readily available
or the outcome of the procedure. The more com- • Caution when using α-adrenergic agonists such as
monly encountered conditions are individually epinephrine
addressed below. • Be prepared for possible cardiac related emergencies
—“crash cart” on site.
Diabetes mellitus
Valvular heart disease and prosthetic valves
Key Points
• Higher risk of bacterial endocarditis and prosthesis infection
• Diabetes should be relatively well controlled prior
to procedure. • Risks and benefits of prophylactic antibiotics must be
• Diabetics have compromised microvasculature. weighed
• Diabetics have an increased risk of delayed —prudent use of antibiotics is indicated in high-risk
wound healing.
patients, certain anatomic locations, and the presence of
• Delaying procedure until diabetes control is overt infection.
optimized may be necessary.
• Be aware of signs and symptoms of —updated guidelines (Tables 5-1 & 5-2)
hypoglycemia. —antibiotic regimens (Table 5-3)
• Sweetened juices or glucose tablets should be
readily available. Implantable electronic devices (pacemakers/defibrillators)
ERRNVPHGLFRVRUJ
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Chapter
Preoperative evaluation of the dermatologic surgery patient 75
Table 5-3 Antibiotic regimens (1-h preoperative dose) Patients with pacemakers and implanted
Non-oral sites Oral and nasal mucosa defibrillators
Cephalexin 2 g PO Amoxicillin 2 g PO Key Points
Dicloxacillin 2 g PO Cephalexin 2 g PO • Consider an alternative procedure that allows
Clindamycin 600 mg PO Clindamycin 600 mg PO chemical cautery.
(PCN allergy) (PCN allergy) • Tie vessels when possible.
• Consider biterminal forceps, thermal cautery, or
Azithromycin or Azithromycin or carbon dioxide laser for hemostasis.
clarithromycin 500 mg PO clarithromycin 500 mg PO • Simple electrodessication of small lesions
(PCN allergy) (PCN allergy) located distant to the pacemaker poses
PCN, penicillin. Adapted from Maragh SL, Otley CC, Roenigk RK, Phillips negligible risk.
PK. Antibiotic prophylaxis in dermatologic surgery: updated guidelines.
Dermatol Surg 2005;31(1):83–91.
Patients with implantable electronic devices, such
as cardiac pacemakers, internal cardiac defibril-
disease or angina. The use of epinephrine, an lators (ICDs), or deep brain stimulators (DBSs),
α-adrenergic agonist, in local anesthetics in such should also be identified. Potential pacemaker,
patients may be cause for concern due to its ICD or DBS interference is a risk if using electro-
vasoconstrictive and cardiostimulatory effects. surgery during the procedure.
Although the rate of bacteremia during skin Although most modern pacemakers and ICDs
surgery is very low, patients with valvular disease have technology that helps to shield external
or prosthetic valves are at higher risk of develop- electromagnetic currents, caution must be taken
ing bacterial endocarditis and thus may require to prevent adverse events, such as accidental fir-
antibiotic prophylaxis. ing of the ICD or the triggering of skipped beats.
Consideration may be given to changing pace-
Antibiotic prophylaxis (Table 5-3) makers to fixed-rate mode or to magnetically de-
Key Points activating the ICD during electrosurgery.
Devices that limit the area of the electromag-
• Endocarditis prophylaxis involves a single large netic current, such as biterminal forceps, or elimi-
preoperative dose of antibiotic.
nate the flow of current at all, such as in the case
• Wound infection prophylaxis can be
accomplished with a single dose of antibiotic or of electrocautery, are safer alternatives. Carbon
with antibiotic added to the local anesthetic. dioxide lasers provide an additional alternative
• Few skin surgery patients need prophylaxis. for hemostasis. Simple electrodessication of small
lesions located distant to the pacemaker poses
negligible risk.
Additionally, procedures that involve oronasal If appropriate safety precautions are taken
mucosa, genital, genitourinary and axillary tissues during the procedure, the vast majority of
may warrant prophylactic antibiotic coverage. patients will not need to undergo preoperative
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76 Dermatologic Surgery
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Chapter
Preoperative evaluation of the dermatologic surgery patient 77
The presence or absence of allergies to medica- A vital part of any medical history is a list of
tions must be clearly indicated and easily vis- current medications, both prescription and
ible on the patient’s medical record. This helps nonprescription. Such information can alert
to minimize the patient’s risk of accidental the physician to undisclosed medical problems,
exposure. Allergies of particular concern to the potential drug interactions, and possible peri
dermatologic surgeon are addressed below. operative concerns.
Medications Isotretinoin
Key Points Patients on oral isotretinoin, currently or within
the past year, may have an increased risk of ad-
• Take a careful history.
verse healing and scar formation. Elective proce-
• Anticoagulants can usually be continued
(see below). dures should be deferred for 6 months to 1 year in
these instances.
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78 Dermatologic Surgery
Table 5-5 Guidelines for anticoagulation therapy Transportation is another issue that is often
overlooked. If a patient is to receive conscious
Aspirin and sedation or will have vision-obstructing dressings,
NSAIDs Warfarin
they may need to have someone accompany them
On anticoagulation by Continue Continue on the day of the procedure. Likewise, if the pa-
physician order medication medication tient has a disability and requires special accom-
(INR should modations, the physician’s office can made aware
be within
of these needs in advance of the procedure.
therapeutic
range 2–3.5)
Alcohol
On anticoagulation Continue Continue Patients who drink socially should discontinue
due to history of medication medication consumption at least 48 h prior to surgery. If the
heart attack, angina, (INR should
patient is known to have an alcohol addiction, it is
transient ischemic be within
attack, or stroke therapeutic not advisable to stop alcohol consumption “cold
range 2–3.5) turkey,” as this may precipitate serious and life-
threatening alcohol withdrawal symptoms.
Prophylaxis for Discontinue ASA NA
stroke or heart attack 7 days prior
Smoking
prevention (no history Discontinue
of prior stroke or heart NSAIDs 3 days Cigarette smoking also affects the viability of
attack) prior (may be cutaneous tissue following surgical procedures.
resumed 3 days There is a risk of delayed wound healing, wound
postoperatively) dehiscence, and wound necrosis, particularly if
Used only for pain Discontinue ASA NA flaps or grafts were performed. Ideally, patients
control 7 days prior should cease smoking entirely. If the patient is
Discontinue unwilling to stop smoking completely, they should
NSAIDs 3 days be strongly encouraged to decrease consumption
prior(may be to less than one pack per day for 1week before
resumed 3 days surgery and for 3–4 weeks afterwards.
postoperatively)
The physical examination
INR, international normalized ratio; ASA, aminosalicylic acid (aspirin).
Modified from Otley CC. Continuation of medically necessary aspirin and A thorough examination of the lesion(s) in question
warfarin during cutaneous surgery. Mayo Clin Proc 2003;78:1392–1396. and any associated areas is essential. An assessment
of overall health status should also be performed.
Findings may mandate further evaluation. Appro-
priate laboratory tests and diagnostic studies can be
Response to prior procedures ordered in advance of the procedure and will allevi-
The purpose of eliciting the patient’s response ate any surprises on the day of the operation.
to prior procedures is to gain better understand- The lesion should be evaluated for size loca-
ing into the patient’s perception of their scars, tion, proximity to old scars, and relationship to
their pain tolerance and the need for postop- potential danger areas or natural skin lines. Any
erative analgesia, and difficulties they may have unusual feature or preexisting abnormalities such
had with postoperative care. If the patient has as eyelid ptosis or nasal alae asymmetry should
a history of hypertrophic scarring or keloid for- be photographed and recorded. This is especially
mation, steps can be taking postoperatively (in- important if it occurs in close proximity to the
tralesional steroid injection, silicone sheets/gel) proposed surgery site. Lesion location should be
to reduce the probability of a recurrence. Dis- carefully assessed for proper planning prior to the
cussing these issues with the patient enables the procedure. It is best documented by using several
physician better to address these issues prior to different methods concurrently. One option is to
the procedure. measure from two distinct anatomic landmarks.
Another possibility is to use standardized num-
Social and family history bering systems such as the New York University
Social and family issues often provide valu- numbers consistently to identify different ana-
able information about a patient and should not tomic sites. Perhaps the most important method
be overlooked. For example, it is wise to have the of documenting location is with photographs.
patient provide a “contact person,” should the Digital photography has become commonplace
physician need to provide information to some- among dermatologic surgeons. It provides an ex-
one other than the patient. If the patient is unable cellent means of documentation and allows for
to provide wound care to the operative site, an the easy storage and retrieval of patient photos.
assessment of the support available to help the Awareness of anatomic structures residing
patient is critical. close to the intended surgical field is essential.
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Preoperative evaluation of the dermatologic surgery patient 79
A thorough understanding of the vascular networks, a vailable through the American Academy of
neural innervations, and structural anatomy is Dermatology and the American Society of Der-
needed. A detailed description of surgical anatomy matologic Surgery. Additionally, private printing
is discussed in Chapter 1 on Cutaneous anatomy. companies can individualize patient information
brochures that are tailored to your practice. These
Laboratory evaluations pamphlets provide accurate information and will
At a minimum, each patient should have blood often direct the patient to trustworthy websites
pressure and pulse recorded during the examina- for additional information.
tion. Further workup and laboratory testing (such Although basic guidelines exist for the pre
as magnetic resonance imaging, Doppler evalua- operative assessment of the dermatologic sur-
tions, or blood work) will be at the discretion of the gery patient, they are just that – guidelines. Each
surgeon, and directed by the history and physical patient must be evaluated on a case by case basis.
examination. Simple excisions and cosmetic pro- The previously discussed guidelines are designed
cedures will require less evaluation than a patient to eliminate avoidable risk and provide a posi-
undergoing extensive skin cancer removal. tive outcome. The preoperative assessment helps
identify potential problems so that they can be
addressed prior to surgery. It provides an avenue
Explanation of procedure for patient education and, most importantly, it
and informed consent builds trust and strengthens the physician–patient
relationship.
Key Points
• Outline the risks, benefits, options, and
alternatives.
• Have a documented policy of how you obtain Further reading
consent (verbal or written).
Beeson WH, Rachel JD. Valacyclovir prophylaxis for
herpes simplex virus infection or infection recur-
At the completion of the history and physical ex- rence following laser skin resurfacing. Dermatol
amination, the physician should take the time to Surg 2002;28(4):331–336.
discuss the nature of the problem with the patient. Fein H, Vidimos AT. Patient evaluation, informed
Outline the risks, benefits, options, and alternatives consent, preoperative evaluation and care. In:
of a procedure. Make it clear to the patient that Robinson JK, Hanke CW, Sengelmann RD,
the ultimate decision to undergo the procedure is Siegel DM, eds. Surgery of the Skin: Procedural
theirs, and that not going ahead with the planned Dermatology. Philadelphia: Elsevier Mosby, 2005:
procedure is an option. In obtaining informed 67–76.
consent, tell the patient or their legal guardians as Kanzler MH, Gorsulowsky DC. Patients’ attitudes
much as possible, including alternative forms of regarding physical characteristics of medical care
therapy. Leave time for the patient to ask ques- providers in dermatologic practices. Arch Derma-
tions and try to answer all questions as fully as pos- tol 2002;138:463–466.
sible. It is important to stress to the patient that McGillis ST, Stanton-Hicks U. The preoperative
unexpected complications may occur despite best evaluation: preparing for surgery. Dermatol Clin
efforts, but as their physician you will help to sup- 1998;16(1):1–15.
port them and assist in any way possible. Maragh SL, Otley CC, Roenigk RK, Phillips PK. Anti
Unfortunately, physicians practice in a litigious biotic prophylaxis in dermatologic surgery: updated
guidelines. Dermatol Surg 2005;31(1):83–91.
era in which malpractice lawsuits are common.
Messingham MJ, Arpey CJ. Update on the use of
Most are filed for reasons of unexpected compli-
antibiotics in cutaneous surgery. Dermatol Surg
cations or poor results, both of which reflect back
2005;31(8 Pt 2):1068–1078.
to the issue of informed consent. Accordingly,
Otley CC. Continuation of medically necessary
it is integral to document completely what has
aspirin and warfarin during cutaneous surgery.
transpired during the discussion. Many physicians Mayo Clin Proc 2003;78:1392–1396.
have patients sign that they have received and un-
Otley CC. Perioperative evaluation and management
derstand the information that was discussed dur- in dermatologic surgery. J Am Acad Dermatol
ing the informed consent. 2006;54(1):119–127.
Go over all preoperative details such as which Smack DP, Harrington AC, Dunn C, et al. Infection
medications should be discontinued, and what and allergy incidence in ambulatory surgery
will be expected with regard to wound care and patients using white petrolatum vs. bacitracin
follow-up. Prescriptions for prophylactic medica- ointment. JAMA 1996;276:972–977.
tions should be given to the patient or called into Stasko T, Clayton AS. Surgical complications and
the pharmacy. optimizing outcomes, In: Bolognia JL, Jorizzo JL,
Provide your patient with reading materi- Rapini RP, eds. Dermatology, 1st edn. New York:
als. Numerous patient education pamphlets are Mosby, 2003:2341–2353.
ERRNVPHGLFRVRUJ
6
Chapter
Cutaneous wound healing
John A. Ebner and Edward V. Maytin
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82 Dermatologic Surgery
Inflammation
Proliferation
Tissue remodeling
Hemostasis:
Platelets
Epithelial proliferation
Fibroblast proliferation
Fibroblast migration
Collagen synthesis
Angiogenesis
Myofibroblasts,
wound contraction
01 2 3 12 1 2 3 4 5 6 1 2 3 4 1 2 3 4 5
– sticky molecules that assist platelet aggregation in The inflammatory phase begins within hours of
the wound. Clotting factors released from the vas- wounding and lasts for up to 2 weeks in normal
culature produce a fibrin clot, forming a provisional wounds (but much longer in chronic wounds).
matrix. Proteases bind to the surface of platelets The first cells to arrive are the neutrophils, repre-
trapped within this fibrin web, further activating senting 50% of all cells in the wound at 24 h post-
and accelerating the clotting cascade (Fig. 6-2). wounding. Neutrophils clear the wound of debris
This fibrin clot serves as a scaffolding for in- and bacteria by releasing proteolytic enzymes
vading cells. Certain growth factors released from (metalloproteinases and elastases) that digest
platelets (platelet-derived growth factor [PDGF] bacteria, and degrade old ECM and nonviable tis-
and transforming growth factor β [TGFβ]), C5a sue. Neutrophils also release free radicals via the
complement, and bacterial proteins help to initi- myeloperoxidase system. These highly reactive
ate the later states of wound healing by recruiting molecules help to sterilize the wound.
cells to the wound (neutrophils and monocytes The process by which the neutrophil arrives
first, then fibroblasts and endothelial cells later). at the wound site is governed by the interaction
Vascular endothelial growth factor (VEGF), of leukocyte adhesion molecules (integrins) and
TGFα and fibroblast growth factor (FGF) (all vascular endothelial receptors (selectins, cad-
platelet-derived growth factors) help to initiate herins, and the intercellular and vascular cell
angiogenesis, whereas fibroblasts initiate the syn- adhesion molecules, ICAM and VCAM). These
thesis of collagen and glycosaminoglycans (e.g. interactions control the processes of adhesion,
hyaluronan) that will form the more permanent rolling, and diapedesis, allowing the neutrophils
ECM. All of these actions are initiated in the wan- to squeeze through the vascular endothelium
ing moments of the hemostasis phase. and home toward the wound site along a gra-
dient of cytokines, growth factors, and soluble
Phase 2: Inflammation ECM fragments. After 2–3 days, the neutrophils
undergo apoptosis and are cleared by the in-
Key Points coming monocyte/macrophages. As circulating
• Neutrophils and macrophages cleanse the monocytes invade the wound, they are converted
wound of bacteria, debris, and damaged tissue, into activated tissue macrophages, and after 48 h
and are a secondary source of cytokines and represent the majority of inflammatory cells in
growth factors.
the area. Macrophages produce numerous inflam
• Prolonged inflammation can interfere with healing
and increase scar tissue formation, as increased
matory cytokines and growth factors, making
protease activity destroys essential factors. them the central players in the inflammatory
phase of wound healing. Macrophages continue
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Cutaneous wound healing 83
Table 6-1 Different cell types in the skin and their roles in wound healing
Cell type Functions/comments
Platelets Wound hemostasis: neutrophil, monocyte, and lymphocyte chemotaxis
Release of hemostatic effectors: fibrin, factor XIII, complement, fibronectin, PAF, thromboxane A2
Cytokines/growth factors: PDGF, TGFβ, FGF, EGF, histamine, serotonin, prostaglandins, prostacyclin
Neutrophils First cell to arrive at wound; peak number at 24 h postwounding
Attracted by platelet-derived chemotactic signals: C5a complement, IL -1, TNFα, TGFβ, and bacteria
Adhere to endothelial cells via selectins, followed by rolling, margination, and diapedesis between endothelial
cells
Migrate through the ECM via integrin–receptor interactions
Provide wound debridement via phagocytosis and release of proteases and oxygen free radicals
Macrophages Migrate into wound at 48–96 h
Arrive as circulating monocytes, then transform into activated tissue macrophages
Orchestrator of wound healing. Release of cytokines and growth factors (paracrine signaling)
Help in wound debridement via phagocytosis and matrix metalloproteinases (MMPs)
Provide antimicrobial action (oxygen free radical: H2O2, O2, OH)
Recruit other cells (via growth factors: PDGF, TGFβ, TGFα, FGF; cytokines: TNFα, IL -1, IL -6, IL -8, fibronectin)
ECM synthesis (via growth factors: TGFβ, EGF, PDGF; cytokines: TNFα, IL -1, IFNγ; collagenases)
Angiogenesis (via growth factors: VEGF, TGFβ, FGF; cytokines: TNFα)
Keratinocytes Migration over wound surface in the first 24 h (over type I collagen and fibronectin)
Proliferation and differentiation into stratified layers occur later
Stimulated by fibroblasts secreting KGF-1, KGF-2, and IL -6 (paracrine signaling)
Wound edge keratinocytes secrete VEGF and promote neovascularization
Fibroblasts Primary cell type that rebuilds dermis in the proliferative phase
Induced by cytokines and growth factors from platelets and activated macrophages (primarily PDGF)
Synthesize collagen. Some are transformed into myofibroblasts (via TGFβ), which facilitate wound contraction
Endothelial Vasoconstriction after injury. Activation of coagulation cascade to achieve hemostasis
cells
Produce a host of mediators to stimulate chemotaxis and initiate the inflammatory stage
Selectins on cell surface bind circulating inflammatory cells, which then roll, adhere, and diapedese out of
vasculature
Release IL -1, TNFα, PDGF, VEGF, FGF
Activated by VEGF to sustain angiogenesis
Release nitric oxide, which assists in vasodilatation and perfusion of healing tissues
PAF, platelet activating factor; PDGF, platelet-derived growth factor; TGFβ, transforming growth factor β; EGF, epidermal growth factor; IL -1, interleukin 1;
TNFα, tumour necrosis factor α; ECM, extracellular matrix; IFNγ, interferon γ; MMPs, matrix metalloproteinases; KGF, keratinocyte growth factor;
VEGF, vascular endothelial growth factor.
the local cleansing process by generating large and growth factors (PDGF, FGF, and TFGα and
amounts of nitric oxide (NO) and other oxygen TFGβ). These growth factors stimulate the fibro
free radicals. Mast cells are another important blasts to synthesize ECM molecules and endothelial
source of mediators, including histamine, and are cells to begin sprouting new vessels. Recently, “stop
predominantly responsible for the classic signs signals” of inflammation have been elucidated. The
of rubor (redness), calor (warmth), dolor (pain), responsible molecules are called lipoxins (LXA4,
and tumor (edema) seen during the inflamma- LXB4). Lipoxins are synthesized by lipoxygenase
tory phase. enzymes, a pathway that produces the inflamma-
While neutrophils and monocytes /macrophages tory mediators in the prostaglandin family (e.g.
serve to cleanse the wound of infection and debris, prostacyclins, thromboxanes, and leukotrienes).
an equally important function is to initiate recruit- Lipoxins have been shown to inhibit neutrophil
ment of fibroblasts and epithelial cells via the release chemotaxis, degranulation and adhesion, and the
of cytokines (interleukin (IL)-6, IL-8, and TNFα) generation of superoxide free radicals.
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84 Dermatologic Surgery
Intrinsic pathway
Damaged endothelial
surface
X Xa X
Va
Prothrombin Thrombin
(II) (IIa)
Fibrinogen Fibrin
(I) (Ia)
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Cutaneous wound healing 85
The defining feature of this phase is the deposi- chemical mediators, growth factors, and ECM
tion and reorganization of collagen. Early on, the (Table 6-2). The ECM, no longer viewed as just
matrix is loose, pliable, and thin, allowing inflam- inert scaffolding, is a dynamic structure com-
matory cells as well as fibroblasts and endothe- posed of collagen and proteoglycans that plays
lial cell precursors to move freely. However, as important roles in cell adhesion, migration, dif-
the matrix is remodeled and becomes denser ferentiation, and proliferation. The ECM of the
with thick, mature, collagen fibrils, it becomes fetal wound is less compact than that in the
less compliant. As the matrix (scar) matures, adult, partly due to higher levels of HA and
some fibroblasts in the wound differentiate into other glycosaminoglycans. Although type I col-
myofibroblasts with contractile properties, initi- lagen is the most abundant collagen in both fetal
ating a process of wound contraction. In rodents, and adult skin, the ratio of type III to type I col-
myofibroblast-mediated contraction is a power- lagen is higher in fetal skin. During fetal develop-
ful component of wound closure, but this is less ment, this ratio slowly approaches that of adults
true in human skin. During the maturation and in the postnatal period. The high levels of HA
remodeling phase, granulation tissue matures in fetal skin contribute to scarless healing. HA in-
into scar as capillaries are replaced by larger ves- creases water content of the ECM, perhaps allow-
sels, cellularity decreases, and type III collagen ing easier cellular movement, but probably more
is replaced by type I collagen (the dominant importantly it facilitates the adhesion, migration,
collagen found in normal skin). Collagen synthe- and differentiation of cells. In addition, high
sis occurs for at least 4–5 weeks; by the end, the HA levels in fetal skin are related to a lower
relative content of type III collagen has decreased influx of inflammatory cells and to the produc-
from 30% to 10%. Remodeling is assisted by tion of fewer proinflammatory cytokines, seen in
MMPs, which remove the early unorganized ma- fetal wounds.
trix components (granulation tissue and collagen Therefore, scarless fetal wounds exhibit a
type III). relative lack of inflammation – a distinct differ-
Remodeling occurs over several months and is ence from the robust inflammatory response in
regulated by a constantly changing mileu of cy- the postnatal wound phenotype. This is further
tokines and growth factors. The dermis of healed clarified by studies showing that the introduction
skin is usually thinner than that of unwounded of inflammation into normally scarless wounds
skin, and the collagen fibrils are oriented in par- induces increased wound neutrophils, macro-
allel bundles rather than the basket-woven struc- phages, collagen deposition, and scarring. There-
ture seen in normal skin. The tensile strength of fore, it appears that inflammation plays a critical
the tissue continues to increase during the re- role in scar formation.
modeling phase, but will never exceed 75–80% MMPs and tissue-derived inhibitors of metal-
of normal. The wound strength is generally loproteinases (TIMPs) function in opposition of
7–10% of baseline by 1 week, 40% by 1 month, one another, regulating ECM turnover. A higher
and 75–80% by 3 months. Unfortunately, ap- ratio of MMPs to TIMPs is observed in scarless
proximately 80% is the maximum ever attained: fetal wounds than in adult wounds, indicating
a scar will never be as strong as the original a shift toward remodeling rather than toward
uninjured skin. the accumulation of dense collagen fibrils (fi-
brosis). Another important aspect that favors
Biology of fetal wound healing scarless wound healing in the fetus is the rela-
Key Points tive proportion of different isoforms of TGFβ.
TGFβ1 and β2 are profibrotic, whereas TGFβ3
• Fetal wounds heal without a scar until roughly
is antifibrotic. The ratio of β1 to β3 appears to
24 weeks’ gestation; after that, wounds heal with
scarring. be an important factor in determining wound
• Unlocking the secret of fetal scarless healing is phenotype.
the “holy grail” for wound healing biology. Other growth factors and cytokines are also
involved in determining scarless versus scarring
In adults, scarring and fibrosis are the usual end- repair, but ultimately the differences between
result of full-thickness wounding. This is not the these two phenotypes are controlled at the level
case for fetal wound healing. Up to 24 weeks’ of gene expression. Certain transcription factors
gestation, fetal skin wounds heal with complete (proteins that regulate gene expression) that
restoration of epidermal and dermal architec- are implicated in many aspects of fetal develop
ture, and the absence of scarring. This finding ment, including skin embryogenesis, are also
has triggered intense investigation and significant differentially expressed during wound healing.
advances, yet the mechanisms remain largely For example, decreased expression of HOXB13
unknown. is seen in scarless healing, and adult HOXB13
Fetal and postnatal (adult) wounds differ knockout mice exhibit a nearly complete scarless
in their inflammatory responses, cellular and healing phenotype.
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86 Dermatologic Surgery
Table 6-2 Comparison of fetal (scarless) and adult (scarring) wound healing
Mediator Function Fetal Postnatal
Type III collagen ECM component ↑ ↓
HA ECM component ↑ ↓
IL-1 Proinflammatory cytokine ↓ ↑
TNFα Proinflammatory cytokine ↓ ↑
IL-6 Monocyte chemotaxis, macrophage activation ↓ ↑
IL-8 Neutrophil chemoattractant, neovascularization ↓ ↑
IL-10 Anti-inflammatory, inhibits IL -6 and IL -8 production ↑ ↓
MMPs Wound remodeling ↑ ↓
TIMPs MMP inhibitors ↓ ↑
Platelets Hemostasis, secretion of growth factors, cytokines ↓ ↑
Neutrophils Phagocytosis of bacteria, damaged ECM ↓ ↑
Macrophages Debris removal, wound cleansing, cellular trafficking ↓ ↑
Fibroblasts Synthesis of ECM ↓ ↑
TGFβ1 Profibrotic cytokine ↓ ↑
TGFβ2 Profibrotic cytokine ↓ ↑
TGFβ3 Antifibrotic cytokine ↑ ↓
PDGF Profibrotic cytokine ↓ ↑
FGF Profibrotic cytokine ↓ ↑
VEGF Angiogenesis ↑ ↑
HoxB13 Homeobox gene (transcription factor) ↓ ↑
HA, hyaluronic acid; IL -1, interleukin-1, TNFα, tumor necrosis factor α; IL, interleukin; MMPs, matrix metalloproteinases; TIMPs, tissue inhibitors of
metalloproteinases; TGF, transforming growth factor; PDGF, platelet-derived growth factor; FGF, fibroblast growth factor; VEGF, vascular endothelial growth
factor; HoxB13, homeobox transcription factor B13.
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Cutaneous wound healing 87
hypoxia, supply the correct mixture of MMP in- Table 6-3 lists some of the many possible etiologies
hibitors (TIMPs), add appropriate growth factors, for chronic wounds that can be seen in practice.
eliminate inflammation, and reduce protease Many are not obvious upon initial evaluation, and
activity in order to shift the microenvironment require detailed investigation.
toward a more acute wound setting.
Cutaneous microbiology
Normal resident skin flora varies by anatomic
Clinical approaches site. These organisms are generally nonpatho-
to wounds: evaluation and genic, and include Staphylococcus epidermidis,
preparation of the wound bed Micrococcus species, Corynebacterium, Propioni-
bacterium, Acinetobacter species, and Pityrospo-
Classification of cutaneous wounds rum species. Staphylococcus aureus, normally not
part of the resident flora, can be isolated from
Erosions are wounds that involve only the epi- the intertriginous (20%) and nasal (20–40%)
dermis and can result from mild abrasive trauma, passages of normal adults and is the most
microdermabrasion, and superficial chemical peels. common pathogen isolated from infected surgical
Erosions heal quickly, with minimal risk of scarring wounds. Group A β-hemolytic Streptococcus pyo-
or postinflammatory pigmentary alteration. genes is also a common wound pathogen, while
Partial-thickness wounds extend through the Streptococcus viridans, resident flora of the upper
epidermis and into some portion of the dermis. respiratory tract, is the principal agent causing
These wounds do not affect dermal adnexal struc- infective endocarditis. Enterococci (Streptococcus
tures (hair follicles, sebaceous, eccrine or apocrine faecalis, S. faecium) represent an increasing cause
glands), but some scarring is likely, depending on of infective endocarditis and are becoming
the depth of dermal injury. Common dermatologic more antibiotic-resistant (vancomycin-resistant
procedures including shave biopsies/excisions, enterococci [VRE]), but are still uncommon in
electrodessication and curettage, dermabrasion, cutaneous wound infections. Escherichia coli, res-
medium-depth chemical peels, and some abla- ident skin flora in the gastrointestinal and genito
tive laser therapies (carbon dioxide laser, erbium urinary regions, can cause wound infections in
YAG) create partial-thickness wounds. Healing those areas.
of these wounds occurs relatively quickly, with
keratinocytes migrating out from nearby wound Surgical wounds: planning
edges and adnexal structures.
the approach to optimize healing
Full-thickness wounds extend through the full
depth of the dermis, exposing the underlying As a whole, the field of dermatology creates more
subcutaneous adipose tissue. Damage to adnexal cutaneous wounds, via a greater variety of meth-
structures and clinically obvious scarring are com- ods, than does any other specialty in medicine.
mon. Examples are wedge excisions and deep Whether performing skin biopsies, excisions,
punch biopsies. Full-thickness wounds, whether chemical peels, laser ablation, photochemother-
made by surgical instrumentation, trauma, or apy, Mohs surgery, or hair transplants, the derma-
other means, may be closed by approximating the tologist must be knowledgeable about maximizing
wound edges or instead left to heal by secondary healing and cosmetic outcome while minimizing
intention. Either way, full-thickness wounds will complications. Necessary steps must be taken
heal but those with well approximated wounds prior to, during, and after surgery to optimize the
will experience fewer adverse effects from scar- results. These steps may include prophylactic an-
ring and wound contraction. tibiotics, proper selection of preoperative antisep-
With proper wound care, most wounds heal tics, appropriate intraoperative sterile technique,
over a period of several weeks. Some wounds, and postoperative wound care with or without
however, lapse into a state of chronicity that can systemic antibiotics.
become exceedingly difficult to correct the longer
the wound remains unhealed. Chronic wounds Antiseptics
(ulcers) have a multitude of possible etiologies. Most antiseptics are applied to the intact skin
Identification of the underlying cause is essential prior to surgery in order to decrease bacterial
to provide patient-specific treatments. Therefore, counts and reduce the risk of postoperative in-
it is imperative that dermatologists understand fection. The ideal topical antiseptic should have a
how to evaluate chronic wounds and what ad- wide antimicrobial spectrum, a persistent antibac-
ditional diagnostic testing and consultations may terial effect, and minimal adverse or toxic effects.
be required. A multidisciplinary approach involv- Examples include:
ing dermatology, vascular medicine, and plastic
surgery is frequently required to arrive at the • Povidone–iodine (Betadine) 10%
correct diagnosis and an adequate treatment plan. • Chlorhexidine gluconate (Hibiclens) 0.4%
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88 Dermatologic Surgery
• Dakin’s solution – sodium hypochlorite 0.5% cell damage, retardation of wound contraction,
and boric acid 4% and overall delayed wound healing.
• Sodium hypochlorite (bleach) in various
concentrations – 0.025%, 0.25%, 0.5%. Antibiotic ointments
Topical antibiotic ointments are designed to be
Povidone–iodine and chlorhexidine have become applied directly to wounds. They serve functions
the agents of choice in recent years. Of the two, over and above their antibacterial nature, includ-
chlorhexidine exhibits superior antiseptic activ- ing keeping the wound bed moist and prevent-
ity. Benzoyl peroxide 10% is also an effective anti- ing tissue adherence to dressings. The three most
septic with sustained broad-spectrum germicidal common topical antibiotics used in topical prepa-
activity and high liposolubility, making it a good rations are bacitracin zinc, polymyxin B sulfate,
choice for the sebum-rich areas of the central and neomycin sulfate (either alone, or in any
face. However, all of these agents are deleterious combination of the three).
to open wounds, causing neutrophil and fibroblast Bacitracin is effective against S. aureus, strep-
cytotoxicity, increased inflammation, endothelial tococci, and Gram-positive bacilli. Bacitracin
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Chapter
Cutaneous wound healing 89
is also popular because of its activity against Clean wounds generally do not require prophy-
more resistant staphylococcal species, notably lactic antibiotics, but contaminated and infected
methicillin-resistant S. aureus (MRSA). S. aureus wounds will required the use of antibiotics (con-
is the most commonly isolated pathogen in sidered therapeutic rather than prophylactic).
surgical wounds, but Gram-negative bacteria The clean-contaminated wound may require
also represent a major share of pathogens found prophylactic antibiotics in select cases. Deci-
in postsurgical wounds. Therefore, bacitracin is sion criteria include the surgical site, nature and
often combined with neomycin for additional length of the procedure, level of contamination,
coverage against most Gram-negative bacilli, and the overall health status of the patient (e.g.
except Pseudomonas aeruginosa. immune status). In general, incisions through
Polymyxin B provides additional coverage for contaminated areas (oronasal mucosa, axilla,
P. aeruginosa as well as for other Gram-negatives. and genitourinary) or in patients with implanted
Today, the most favored topical combination prosthetic devices should be given prophylactic
is bacitracin and polymyxin B. Neomycin is ex- antibiotics. A single preoperative dose is given
cluded because roughly 10% of the US popula- 1 h prior to incision, and a postoperative dose is
tion experiences an allergic contact dermatitis to sometimes given 6 h afterwards, depending on
neomycin. Other agents include mupirocin (Bac- the length of the procedure. For contaminated
troban) and silver sulfadiazine (Silvadene). or infected wounds, therapeutic antibiotic ad-
Despite their popularity, the use of antibacte- ministration requires a full 7–10-day course at
rial ointments for postsurgical wounds has been bactericidal doses.
debated in recent years. A study by Smack and
colleagues in 1996 compared the effects of white Medical and surgical approach
petrolatum versus bacitracin ointment in post-
to the pre-existing wound
operative wound infections, and found no differ-
ences in the rates of wound infection nor time to The correct diagnosis of a wound’s etiology is
healing. This suggests that the addition of anti- essential to reaching resolution and closure. It
bacterial ointments to uncontaminated postsurgi- is often necessary to incorporate a multidis-
cal wounds may be unnecessary. ciplinary approach in difficult cases (chronic
wounds), which may include vascular medicine
Hemostatic agents and plastic surgery input along with dermatology.
Twenty per cent ferric subsulfate (Monsel’s solu- Determination of wound etiology, local blood
tion) and 20–60% aluminum chloride solution are flow (arterial and venous), medical problems,
two hemostatic agents used frequently in derma- and nutritional status are all critical elements.
tologic surgery. Both agents act by causing protein An underlying principle is that a chronic wound
denaturation and vascular thrombosis, which has must be “converted” to an acute wound in order
been shown to delay wound healing by 2–6 days to allow appropriate progression through the
and may result in larger scars by 0.5–2 mm. There- normal phases of wound healing and achieve
fore, it is now recommended to use pinpoint closure.
electrocoagulation, pressure, and/or sutures rather
than the chemical agents wherever possible, to re- Approach to the acute wound
duce toxicity to the local wound environment. Wounds of recent origin can be either surgical
or traumatic in origin. Patients with traumatic
Antibiotic prophylaxis acute wounds should be assessed for their
When considering antibiotic prophylaxis, surgical tetanus status; if unknown, or not up to date
wounds are generally classified in four categories: (>5 years) the patient should receive a booster
immunization. Wound irrigation with normal
1 Clean wounds – noncontaminated skin with saline and debridement of dead tissues should
sterile surgical technique; infection rate <5%. be carried out. Deep wound cultures should
2 Clean-contaminated wounds – incisions be taken and empiric broad-spectrum antibiot-
created in areas considered contaminated (oral ics initiated in suspected contaminated wounds,
cavity, respiratory tract, axillae, perineum) including human or animal bites. Antibiotics
or with minor breaks in sterile technique. can be fine-tuned later, following the results
These represent the majority of dermatologic of the initial cultures. Traumatic acute wounds
surgery procedures; infection rate <10%. should be reassessed daily and additional deb-
3 Contaminated wounds – created by trauma ridements performed as needed, every 24–48 h.
or with major breaks in sterile technique; Normal wounds should show closure rates of
infection rate 20–30%. roughly 15% per day as a marker of normalized
4 Infected wounds – grossly contaminated with wound healing. Wounds healing slower than this
foreign bodies and necrotic tissue; infection should be continually reassessed to optimize
rate 30–40%. wound care.
ERRNVPHGLFRVRUJ
90 Dermatologic Surgery
B ox 6 - 1
Approach to the infected wound
If infection is suspected, the edge of erythema Assessment of chronic wounds
surrounding the wound should be identified,
Wound history
traced with a pen, and the date and time recorded
to help identify progression/regression of the Timing of occurrence of ulcer/wound
infective process. In some cases, obtaining radio- Location
graphic evidence to rule out bony involvement
Prior ulcer/wound history
or gas within the tissues is critical. Gas within a
wound (a byproduct of the anaerobic bacterium Current and past treatment
Clostridium perfringens) is a surgical emergency. Complications of ulcer/wound
When quantitative bacterial counts reach greater Prior procedures
than 105 bacteria per gram of tissue, the wound’s
inflammatory response can overwhelm the local Drainage (quantified)
healing process, lead to failure of granulation and Pain
neovascularization, and thereby perpetuate the
infection. Deep tissue wound cultures should Complete medical history
be collected, to aid in guiding appropriate anti- Past medical history
biotic therapy after empiric coverage has been
Family history
implemented. Aggressive removal of all necrotic,
infected, and nonviable tissue prevents the devel- Surgical history
opment of an environment that fosters bacterial Social history
overgrowth. Wound debridement, along with ap-
propriate antibiotics, represents a critical element Physical exam
of proper wound care. Blood pressure (calculate ABI)
Approach to the chronic wound Wound exam
One difficulty in treating chronic wounds lies in ac- Location
curately determining the correct etiology. In these Wound measurements (length × width × depth)
cases, debridement may not be the proper first step, Drainage (quality/quantity)
as with vasculitic ulcers or pyoderma gangreno-
sum. These ulcers require medical treatment of the Surrounding skin appearance (cellulitis)
underlying illness before any debridement should Wound bed evaluation (granulation tissue, fibrinous debris,
take place. For example, an underlying coagulopa- eschar)
thy may be contributing to the patient’s wound Pain
persistence. A biopsy of the wound edge, including
Odor
normal skin, may be necessary to establish a diag-
nosis and guide further treatment. Additionally, Wound edge (undermining, active)
vascular studies (Doppler ultrasonography) can Wound details
help to assess arterial patency and venous valvular Tissue perfusion/oxygenation
competence. Chronic ulcers of long duration must
also be followed for signs of malignant degenera- • Palpation of peripheral pulses (macrocirculation)
tion, also known as a Marjolin’s ulcer. • Capillary refills (microcirculation)
Additional factors that can contribute to Wound contamination (bioburden ± infection)
chronic wound states include diabetes, smoking,
Wound bed (excess protease activity, inflammatory cytokines,
malnutrition, and hematologic abnormalities in-
altered growth factors)
cluding clotting abnormalities, cryoglobulinemias,
and antiphospholipid antibody syndrome. Only Nutrition and immune status
after the cause of the wound has been established Psychosocial details (depression, pain)
and medically treated should the wound be de Neuropathy
brided. Box 6-� 1 outlines the important questions
to ask in the evaluation of chronic wounds to help Weekly follow-up
in establishing a diagnosis.
Consider re-evaluation after 4 weeks
Debridement of wounds Consider biopsy if wound present for more than 3–4 months
Surgical debridement
In order to achieve complete removal of all non-
viable, necrotic, and infected material from the
wound bed, nontraumatic surgical methods are
ERRNVPHGLFRVRUJ
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Chapter
Cutaneous wound healing 91
a b
Figure 6-3 (a) Adult and larval forms of the green bottle fly. The larvae can be obtained in a standardized and sterilized
form (b) and may be helpful for chronic wound debridement. (Photo from R. A. Sherman, © Monarch Labs, LLC, used
with permission)
recommended. Sharp dissection is most com- can be purchased only from Monarch Labs,
monly employed to selectively remove nonviable Irvine, California (www.monarchlabs.com). The
tissues, leaving only healthy, well vascularized tis- technique is completely painless, and useful for
sues in the new wound bed. Any damage to the a wide variety of wounds in patients not suitable
underlying healthy tissue (burning, crushing) cre- for surgical debridement.
ates a nidus for infection and prolongs the heal- Additional nonsurgical methods of wound de-
ing process. One should debride until there is bridement include chemical debridement. These
pinpoint bleeding, which identifies healthy viable chemicals are enzymes that function to degrade
tissues. For most chronic wounds and for selected the necrotic nonviable tissues, yet they have no
acute wounds, debrided tissues may be sent for action against bacterial wound contamination or
pathologic analysis to assess for infection, vascu- infection (Fig. 6-3).
litis, and malignancy. After surgical debridement,
the wound must be irrigated well with normal sa- Wound dressings
line (without added antibiotics, as these have been
proven to add no additional benefit), to remove Key Points
any remaining loose debris, tissue, or bacteria. • Numerous wound dressings are available, each
with certain characteristics designed to treat
Medical debridement specific wound types: exudative, dry/necrotic,
For patients unable to receive standard surgical wet/necrotic, macerated, infected.
debridement, medical alternatives can be quite • The ideal dressing should provide adequate
effective under the right circumstances. Biologic moisture levels in the wound bed, through a
agents include the use of medical maggots, Phae- combination of good absorption of excess wound
fluids and an adequate permeability barrier.
nicia sericata (the green bottle fly). These maggots
• Supportive dressings (compression stockings)
are sterilized with radiation and do not progress can reduce wound edema.
past the larval stage. Bottle fly maggots secrete
tissue-degrading enzymes that affect only devi-
talized tissues, dissolving them along with any While the previous sections dealt with optimiz-
biofilms produced by invading bacteria into a ing the wound bed for healing, this section de-
nutrient-rich fluid that the maggots ingest. Thirty scribes the use of wound coverings (dressings)
larvae can consume 1 g of tissue per day. Another to maintain a moist, clean wound environment
major advantage is that the maggots consume all that allows the wound to progress through the
bacteria within the wound regardless of antibiotic natural phases of healing. A revolution in wound
resistance, including MRSA and VRE. Obtaining healing that began a few decades ago can be at-
these maggots requires a prescription and they tributed to the discovery that wound dressings
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92 Dermatologic Surgery
Table 6-4 Functions of wound dressings Cadexomer iodine, an iodophore with mul-
tiple properties, is a three-dimensional starch
Actions Benefits lattice structure with iodine-containing micro-
Maintains Enhances epithelial migration. Reduces spheres embedded within a gel dressing. This
moisture at pain in chronic wounds. Increases allows the slow release of antimicrobial iodine
wound/dressing autodebridement via retention of into the wound as the starch lattice structure
interface enzymes and growth factors exercises a tremendous absorptive capacity. One
Absorbs Avoids maceration while keeping wound gram of cadexomer iodine can absorb up to 7 g
exudates moist of fluid, making this dressing an ideal choice for
Provides Guards against contamination (microbes/ highly exudative wounds with concurrently high
permeability foreign material) and trauma. Minimizes microbial bioburden. Of note, cadexomer iodine
barrier fluid loss. Increases angiogenesis is active against S. aureus, specifically MRSA.
(hypoxic stimulation) In addition to these antimicrobial dressings, there
Compression Assists in hemostasis. Minimizes is a multitude of other dressings available to fit vir-
edema. Prevents wound dehiscence tually all wound characteristics. Table 6-5 includes
many of the available dressings with their general
use and the manufacturer listed for reference.
can dramatically hasten closure and healing. Prior
to 1958, it was believed that wounds healed best Skin substitutes (“biologic” or “living”
when left dry and open to the air, but Odland’s
observation that blisters heal faster when left un-
dressings)
broken challenged that assumption. In addition, Key Points
in 1962 it was shown that superficial wounds • In recent years, several different skin substitutes
covered with a moist film dressing healed twice have emerged that contain epidermal, dermal, or
as fast as wounds exposed to the air. Later stud- combined epidermal and dermal components.
ies in humans found similar superior healing • These substitutes are gaining acceptance as
with moist dressings. a valuable resource to aid in healing chronic
While the benefits of occlusion is well estab- recalcitrant wounds.
lished for acute wounds, the same cannot be said • Improvements in wound healing therapy must
for chronic wounds in which exudative fluids can come from research. Stem cells derived from a
multipotent population found in the hair follicle
be very abundant. Despite this concern, most evi-
bulge are known to be involved in epidermal
dence still advocates the use of occlusive dressings, repair postwounding. These cells, or patient-
but choosing the correct dressing type/function derived (autologous) bone marrow stem cells,
becomes of paramount importance. No single may eventually prove to be important as wound
dressing is suitable for all wound types, and many healing adjuvants for the healing of chronic
wounds require adjustment of the dressing type intractable wounds.
as the wound progresses to healing and closure. In
general, though, all wound dressings should em- Prompt wound coverage is the foundation of wound
ploy the strategies outlined in Table 6-4. management. Most wounds can be covered imme-
Table 6-5 lists some of the most common diately after cleansing, debridement, and appropri-
wound dressings available today, and their char- ate wound bed preparation. However, sometimes
acteristics. Dressings are classified by their com- wound closure must be delayed and the wound
position and appearance, but the most important allowed to heal by secondary intention. For rela-
consideration is their function. Proper choice of tively simple or small wounds, coverage can often
the appropriate dressing depends upon first defin- be provided by the synthetic and natural dressings
ing the wound bed characteristics: described in Table 6-5. However, for more exten-
sive or recalcitrant wounds, autologous skin grafts
• Dry/dessicated wounds need moisture. used to be one of the few options. Now, however,
• Draining wounds need absorptive dressings. a number of artificial skin substitutes have evolved
• Necrotic wounds need debridement. that can be used instead of autologous skin grafts,
• Infected wounds need antimicrobial thereby avoiding the additional pain and scarring
treatment. at donor sites. Three general categories of skin sub-
stitutes are listed in Table 6-6, as follows:
A newer advance involves dressings that contain
nanoparticles of silver, a broad-spectrum anti 1 Cultured epidermal cells, devoid of dermal
biotic agent. Silver-containing dressings should components
be used only in infected wounds; although not 2 Dermal components without the epidermal
highly toxic to human cells, the silver particles do overlay
affect keratinocytes in culture and therefore may 3 A bilayer containing both the dermal and
inhibit epithelialization of wounds. epidermal components.
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Chapter
Cutaneous wound healing 93
ERRNVPHGLFRVRUJ
94 Dermatologic Surgery
In general, these skin substitutes are gradually re- advance: a patient’s own skin keratinocytes could
placed by the host epidermal and dermal compo- now be expanded in culture and used to cover
nents, but while present are a primary stimulus for large burns and other kinds of wounds, providing
the host to produce the variety of cytokines and permanent coverage of large areas. Although
growth factors needed for timely wound healing. scarring and wound contraction still occurred,
In turn, these soluble mediators promote the se- the technique was life saving. Unfortunately,
quential steps of wound healing while at the same keratinocyte autografts are still quite expensive
time promoting appropriate inflammation and and considerable time (2–4 weeks) is required to
wound granulation, and preventing dessication. culture the epidermal sheets.
To avoid the long wait times needed for au-
Epidermal skin substitutes tologous grafting, cultured allografts have been
The science of epidermal tissue culture emerged developed. Keratinocytes for allografts come from
in 1975 when scientists discovered how to grow cadavers or unrelated adult donors. Entire sheets
sheets of human keratinocytes. This was a major of decellularized human dermis (Alloderm) are
ERRNVPHGLFRVRUJ
6
Chapter
Cutaneous wound healing 95
also available. These products are quite effective drawback of these composite grafts is their high
in treating burns, skin-graft donor sites, chronic cost, limiting their use to relatively small recalci-
pressure sores, and venous stasis ulcers. As they trant wounds.
are temporary, they are unsuitable for permanent
closure of full-thickness wounds.
Dermal skin substitutes
Optimizing outcomes: wound
The primary advantage of using a dermal com-
care guidelines
ponent is to minimize wound contraction and
provide more stability. Dermal allografts from
Guidelines for patients
human cadavers must be chemically modified to After a wound has been dressed appropriately in
remove their antigenic components to avoid graft the office or postoperative setting, the patient or
rejection. These dermal grafts are often overlaid their caregiver will be responsible for the con-
with autologous epidermal grafts to enhance the tinued care of the wound at home. Therefore, he
overall wound healing effect. Currently available or she must be provided detailed information on
products are listed in Table 6-6. how to care for their specific wound. Written in-
structions are most effective. Instructions should
Composite skin substitutes be formatted in a stepwise manner to avoid con-
These grafts have a collagen-based dermal com- fusion about the proper order of cleansing and
ponent with incorporated living fibroblasts and dressing applications. Patients should keep the
keratinocytes on top, to provide as natural a sub- wound dressing dry and untouched for 24 h,
stitute as possible. Although effective, the main unless the bandage becomes soiled and soaked
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96 Dermatologic Surgery
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Cutaneous wound healing 97
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Cutaneous wound healing 99
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100 Dermatologic Surgery
Falabella A, Kirsner R. Wound Healing (Basic and Singer AJ, Clark RA. Cutaneous wound healing.
Clinical Dermatology). Boca Raton, Florida: Taylor N Engl J Med 1999;341(10):738–746.
and Francis, 2005. Steed DL, Attinger C, Colaizzi T. Guidelines for the
Leveriza-Oh M, Phillips TJ. Dressings and postopera- treatment of diabetic ulcers. Wound Repair Regen
tive care. In: Robinson JK, Hanke CW, Sengel- 2006;14(6):680–692.
mann RD, Siegel DM, eds. Surgery of the Skin: Whitby DJ, Ferguson MW. The extracellular matrix
Procedural Dermatology. Philadelphia, Elsevier of lip wounds in fetal, neonatal and adult mice.
Mosby, 2005:117–135. Development 1991;112(2):651–668.
Robson MC, Barbul A. Guidelines for the best Whitney J, Phillips L, Aslam R. Guidelines for the
care of chronic wounds. Wound Repair Regen treatment of pressure ulcers. Wound Repair Regen
2006;14(6):647–648. 2006;14(6):663–679.
Robson MC, Cooper DM, Aslam R. Guidelines for
the treatment of venous ulcers. Wound Repair
Regen 2006;14(6):649–662.
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7
Chapter
Electrosurgery
Oliver J. Wisco and Paula S. Vogel
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102 Dermatologic Surgery
Tissue effect
Table 7-2 Waveform factors Continuous, undamped
Discontinuous, damped
Surgical approach (Box 7-2)
Key Points Desiccation and
coagulation
• Multiple conditions can be treated with
electrosurgery. The most common are those with
a superficial process.
• Electrodessication and curettage is an effective Figure 7-1 Types of waveform. Adapted from Robinson
option for superficial cutaneous malignancies. et al (2005) with permission from Mosby Publishing
ERRNVPHGLFRVRUJ
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Chapter
Electrosurgery 103
Epidermis Epidermis
Dermis Dermis
Adapted from Robinson et al (2005) with permission from Mosby Publishing Company.
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104 Dermatologic Surgery
Epidermis Epidermis
Dermis Dermis
Adapted from Robinson et al (2005) with permission from Mosby Publishing Company.
B ox 7 - 1
Burns • The surgeon should not make or break contact with the
patient during current delivery.
• Use a nonflammable cleanser such as chlorhexidine or
povidone–iodine.
Transmission of infection
• Avoid alcohol cleanser, ethyl chloride anesthesia, and flowing
oxygen. • Use a smoke evacuator with the intake nozzle 2 cm from the
operative site.
• Ensure that the indifferent electrode has broad contact with
skin and is not placed over a bony prominence, scar tissue, or • Wear a surgical mask and eye protection when working with
implanted metal. human papillomavirus-related lesions.
• Ensure the patient is not touching grounded metal objects. Eye injuries
• Place the indifferent electrode away from vital structures to • Avoid using treatment electrode close to the eye, if
decrease the risk of current channeling into a substance that is possible.
more conductive than skin (e.g. nerve or vessel), especially if
it leads to an isolated region such as the penis or finger. • Use plastic corneal shields if working close to the eye.
• Use a three-pronged receptacle that is not overloaded. • See discussion in the Controversies section.
Adapted from Robinson et al (2005) with permission from Mosby Publishing Company.
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Chapter
Electrosurgery 105
B ox 7 - 2 B ox 7 - 3
Dermatologic electrosurgery
interference with pacemakers
and defibrillators
The use of electrosurgery in dermatologic sur-
gery may cause interference with pacemakers
or defibrillators (Box 7-3). It is recommended to
discuss with the patient’s cardiologist the need
for preoperative/postoperative evaluation and/or
intraoperative monitoring.
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Chapter
Cryosurgery
Leonid Benjamin Trost and Philip L. Bailin
Key Points
• Cryosurgery is a versatile and cost-effective directly or indirectly to the skin. This causes local
method of treating many benign, premalignant, tissue destruction, and healing occurs by second
and malignant lesions. intention. Today, cryosurgery is commonly used
• The most commonly used cryogen is liquid by most dermatologists.
nitrogen.
• The most common cryosurgical technique is the History
open spray technique. In 1845, James Arnott, an English physician,
• To kill all malignant cells, a final temperature used salt solutions containing crushed ice (−8
of −20 to −30°C must be achieved.
to −12°C) to treat advanced cancers in sites that
• For malignant lesions, the depth of freeze should
be roughly equal to the radius of the surface were easily accessible, such as breast and cervi-
frozen area. A thermocouple can be inserted at cal cancer. The goal was reduction in tumor
the base of the lesion for greater accuracy. size and pain control. Olszenski was the first to
• If an intermittent spray technique is used, the liquefy air in 1885. In 1899, A. Campbell White
resultant ice ball will have a greater depth and used liquefied air to treat nevi, warts, boils, and
more limited lateral spread. If a continuous spray herpes zoster. Over the next several decades, car-
technique is used, the resultant ice ball will be bon dioxide snow (−78.5°C) and liquid oxygen
more shallow and will have a greater lateral (−182.9°C) were used. In 1950, Allington was
spread.
the first to use liquid nitrogen (−195.6°C) to
• The greatest possible depth of the ice ball is
about 10 mm.
treat skin diseases such as warts, keratoses,
• Benign lesions usually require only one freeze– hemangiomas, and keloids.
thaw cycle. Initially, cotton-tipped applicators and solid
• Premalignant lesions usually require one copper cylinder disks chilled in the cryogen
freeze–thaw cycle, although two may be used. were used. For the next several years, cryosur-
• For cryosurgery of malignant lesions, the goal of gery was limited by the depth of tissue dam-
therapy is to destroy the same mass of malignant age that could be achieved (maximum 7 mm).
tissue by freezing as would be removed by In 1961, Cooper and Lee developed a closed
excision. Therefore, an adequate margin around system with a vacuum-insulated probe that was
the tumor must be frozen. Malignant lesions
used in neurosurgery to treat conditions such
usually require two freeze–thaw cycles, although
three may be used in some cases. as Parkinsonism. In 1965, two American der-
• For malignant lesions, the halo thaw time, or the matologists, Douglas Torre and Setrag Zacarian,
duration of surface thawing of marginal tissue helped to develop a nitrogen spray device that
beyond the target site, should be greater than could be used with different cryoprobe tips.
60 s. The total thaw time of the entire lesion These developments allowed deeper tissue in-
should be more than 90 s. jury. In 1968, a handheld spray device was first
• A large lesion may first be debulked surgically to developed at Brooke Army Medical Center, us-
create a thinner lesion that freezes more rapidly. ing a rubber bulb to create pressure and force
• The combination of rapid freezing and slow thaw the liquid nitrogen through the aperture. Later
produces maximal tissue damage.
versions were high-pressure systems that har-
nessed the pressure created by the evaporating
Introduction nitrogen.
The most common method of cryosurgery uses
Cryosurgery is a versatile and cost-effective a handheld device that contains liquid nitrogen.
method of treating many benign, premalignant, A direct spray is used most commonly, but a cryo-
and malignant lesions. A cryogenic agent is applied probe is sometimes used as well.
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108 Dermatologic Surgery
Table 8-1 Cryogens and their boiling points Table 8-2 Factors that affect the freezing of tissue
Cryogen Boiling point (°C) Factor Key principles
Chlorodifluoromethane −40.8 Rate of tissue freezing Rapid freezing (<60 s)
Solidified carbon dioxide −78.5 causes more cell death
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Chapter
Cryosurgery 109
Figure 8-2 Relationship between depth of freeze to Figure 8-3 Relationship between the Therapeutically
spraying factors. (a) The depth of the ice ball is equal to Lethal Isotherm (TLI) (–30°C) and the edge of the ice ball
the surface radius of the ice ball. This tends to occur when (0°C isotherm). In both A and B, the sizes and shapes of
the spray is intermittent and when the spray tip is close the ice balls (0°C isotherm) are the same. In A, the TLI is
to the skin. (b) The depth of the ice ball is less than the close to the edge of the ice ball. This tends to occur when
surface radius of the ice ball (R΄ < R). This tends to occur the spray is intermittent and when the spray tip is close to
when the spray is continuous and when the spray tip is the skin. In B, TLI is farther from the edge of the ice ball
further from the skin. It can also occur when the liquid (Y > X). Note that if the location of the TLI is too far from
nitrogen is “painted on’’ and/or the rate of intermittent the edge of the ice ball, the entire tumor may not be
spray is too slow. Note that if the depth of the ice ball is destroyed even though the frozen surface margins appear
too shallow, then entire tumor may not be destroyed even to be adequate
though the frozen surface margins appear to be adequate
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110 Dermatologic Surgery
B ox 8 - 1 B ox 8 - 2
Benign lesions that can be treated Premalignant lesions and in situ cancers
with cryosurgery that can be treated with cryosurgery
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8
Chapter
Cryosurgery 111
b
Table 8-4 Cryosurgery techniques and the lesions
that can be treated with each technique Figure 8-6 Instruments used in the dipstick technique:
(a) a cotton-tipped applicator and (b) a metal cryoprobe
Lesion type applicator
Technique Benign Premalignant Malignant
Dipstick Yes No No
Open spray Yes Yes Yes
Closed Yes Yes Yes
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112 Dermatologic Surgery
Figure 8-8 Spray tips. (A) has the largest diameter, (D) the
smallest Figure 8-10 Cryoprobe attached to a handheld liquid
nitrogen unit
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Chapter
Cryosurgery 113
Benign lesions
Benign lesions usually require only one freeze–
thaw cycle. See Table 8-� 5 for treatment param-
eters. Some of the most common benign lesions
treated are warts, molluscum contagiosum, sebor-
rheic keratoses, and lentigines. Each lesion on a
patient may require a slightly different technique.
The open spray technique is used most frequent-
ly. If the cryoprobe is used, the time for which
the tissue remains adequately frozen may be two
to three times longer. The lateral spread of freeze
is usually to the edge of the lesion or 2–3 mm
Figure 8-11 Pyrometer–thermocouple needle device beyond its border.
Benign neoplasms such as seborrheic kera-
spread. Using liquid nitrogen, the greatest possible toses and senile lentigos should be frozen
depth of the ice ball is roughly 10 mm. Larger superficially, as they are epidermal. Vascular le-
lesions should be debulked surgically (e.g. curet- sions such as venous lakes and spider nevi can
ted) before cryosurgery is performed. be frozen with one freeze–thaw cycle with or
For malignant lesions, tissue temperature and without a 2–3-mm margin. For other benign
depth of freezing may be monitored by a py- neoplasms such as warts, dermatofibromas, and
rometer–thermocouple device (Fig. 8-11) using myxoid cysts, the lateral spread of freeze may
implanted 25–30-guage needles. The tip of the be 2–3 mm.
needle should lie beneath or lateral to the lesion.
For malignant lesions, the final tissue temperature
should be −20 to −30°C. This pyrometer–
Premalignant lesions
thermocouple technique is rarely used today, and Premalignant lesions usually require one freeze–
then only in specialized circumstances. thaw cycle, although two may be used. See Table
5 for treatment parameters. For actinic kera-
8-�
Applications toses, the lateral spread of the freeze may go just
to the edge of the lesion or slightly beyond. For
Cryosurgery technique depends on the type of le- squamous cell carcinoma in situ, the optimal lat-
sion being treated. Table 8-�
5 shows the general eral spread depends on the lesion and location.
treatment guidelines for benign, premalignant, The lateral spread of the freeze is usually 3–5 mm,
and malignant lesions. but may be less.
Premalignant
Actinic 1 <60 Variable Variable −10 98.8 1
keratosis
Leukoplakia 1–2 <60 >90 >60 −20 to −30 96.2 2–3
Squamous 2 <60 >90 >60 −20 to −30 2–3
cell carcinoma
in situ
Malignant
Basal cell 2–3 <60 >90 >60 −20 to −30 >98.6 5
carcinoma
Squamous cell 2–3 <60 >90 >60 −20 to −30 >98.6 5
carcinoma,
invasive
Times are for open spray technique. NA, not applicable.
ERRNVPHGLFRVRUJ
114 Dermatologic Surgery
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Cryosurgery 115
• Some storage tanks have a metal hose. This Graham GF. Cryosurgery. Clin Plast Surg
should never be grasped by hand, as the hand 1993;20:131–147.
may freeze to the hose while the unit fills. James WD, Berger TG, Elston DM. Dermatologic
surgery. In: Andrews’ Diseases of the Skin: Clinical
Dermatology, 10th edn. Canada: Saunders Elsevier,
Further reading 2006: 869–887.
Kokoszka A, Scheinfeld N. Evidence-based review
Alam M, Ratner D. Cutaneous squamous-cell carci- of the use of cryosurgery in treatment of basal cell
noma. N Engl J Med 2001;344:975–983. carcinoma. Dermatol Surg 2003;29:566–571.
Arlette JP, Trotter MJ, Trotter T, Temple CLF. Man- Kuflik EG. Cryosurgery updated. J Am Acad Derma-
agement of lentigo maligna and lentigo maligna tol 1994;31:925–944.
melanoma: seminars in surgical oncology. J Surg
Kuflik EG. Cryosurgery for cutaneous malignancy.
Oncol 2004;86:179–186.
Dermatol Surg 1997;23:1081–1087.
Castro-Ron G, Pasquali P. Cryosurgery. In: Robinson JK,
Kuflik EG, Gage AA, Lubritz RR, Graham GF. His-
Hanke CW, Sengelmann RD, Siegel DM, eds. Surgery
tory of dermatologic cryosurgery. Dermatol Surg
of the Skin. Philadelphia: Elsevier Mosby, 2005:
2000;26:715–722.
191–202.
Lubritz RR, Smolewski SA. Cryosurgery cure
Dachow-Siwiec E. Treatment of cryosurgery in
rate of actinic keratoses. J Am Acad Dermatol
premalignant and benign lesions of the skin. Clin
1982;7:631–632.
Dermatol 1990;8:69–79.
Mallon E, Dawber R. Cryosurgery in the treatment
Drake LA, Ceilley RI, Cornelison RL, et al. Guide-
of basal cell carcinoma: assessment of one and
lines of care for cryosurgery. J Am Acad Dermatol
two freeze–thaw cycle schedules. Dermatol Surg
1994;31:648–653.
1996;22:854–858.
Elton RF. Complications of cutaneous cryosurgery.
Sterling JC, Handfield-Jones S, Hudson PM. Guide-
J Am Acad Dermatol 1983;8:518–519.
lines for the management of cutaneous warts. Br J
Gage AA. History of cryosurgery. Surg Oncol Dermatol 2000;144:4–11.
1998;14:99–109.
Zouboulis CC. Principles of cutaneous cryosurgery:
Gage AA, Caruana JA, Garamy G. A comparison an update. Dermatology 1999;198:111–117.
of instrument methods of monitoring freezing
in cryosurgery. J Dermatol Surg Oncol
1983;9:209–214.
ERRNVPHGLFRVRUJ
9
Chapter
Biopsy techniques
Lisa B. Campbell and Victor J. Marks
Biopsies are vital in dermatology and dermatologic • Underlying medical conditions. Atrial
surgery, allowing for dermatopathologic assess- fibrillation, hypertension, pregnancy,
ment with resulting diagnostic information. Cli- prosthetic heart valve or joint surgery,
nicians choose from several biopsy techniques, prior vasovagal response, and other medical
although the ultimate goal is to provide adequate conditions may alter your preoperative
tissue for microscopic examination. In doing a management of a patient.
biopsy, the clinician may wish to sample part of • Photography. Digital photography is now
or a whole lesion or inflammatory process. Also easily accessed in many dermatology clinics.
taken into consideration are the size and location, Consider utilizing this technology as it can be
cosmetic concerns, and depth of the pathologic useful in clinicopathologic correlation, assist
process. in confirming location of biopsy at a later
time, and serve as visual history in a medical
Overview chart.
• Location. Legs heal poorly in many individuals
• Preoperative planning and upper trunk procedures may result in
• Choosing the appropriate biopsy technique hypertrophic scarring.
based on diagnosis • Antibiotics. Preoperative antibiotics are not
• Incisional vs excisional biopsy necessary for biopsy (considered a clean
• Shave biopsy technique surgical procedure) according to American
• Punch biopsy technique Heart Association guidelines, when the
• Full-thickness/elliptical biopsy technique biopsy is performed through clinically
• Biopsy specimen handling uninfected skin. (See Chapter 5: Preoperative
evaluation.)
Preoperative planning • Antisepsis. Generally, an alcohol swab for
10 s is adequate antisepsis for small biopsies.
Key Points Other surgical scrubs can be employed for
• Obtain informed consent, verbal or written. larger procedures or for patients at higher risk
• Be aware of underlying medical conditions and for infection. (See Chapter 2: Antisepsis.)
adjust procedure accordingly. • Anesthesia. Most dermatologists use lidocaine
• Take photographs where appropriate. (0.5–1%) with or without 1:100,000 or
• Consider biopsy location for healing 1:200,00 epinephrine. (See Chapter 3: Local
characteristics. anesthetics.)
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118 Dermatologic Surgery
Pigmented lesions
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Chapter
Biopsy techniques 119
Inflammatory lesions
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120 Dermatologic Surgery
b
a
c d
Figure 9-6 Scalpel shave technique. After anesthetizing the skin, hold the blade parallel to the skin surface, entering with
the curve of the blade (a). Using a short sawing motion, draw the blade across the base, elevating slightly to exit the skin (b).
A thin defect results (c) and aluminum chloride can be used for hemostasis (d)
a b c
Figure 9-7 Razor shave technique. After anesthesia, hold curved edge of blade parallel to skin surface (a). Using a short
sawing motion, push the blade across the base, elevating to exit the skin (b). The resulting specimen and defect can be
seen in (c)
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Chapter
Biopsy techniques 121
Biopsy specimens
Each laboratory will have specific handling instruc
tions for biopsy. As a minimum, specimens must
be labeled with the patient’s name and, if there
are multiple specimens, an appropriate number
or letter. They should be placed in an appropriate
medium: formalin is used for routine light micro-
scopy. Alternatively, specimens sent for direct im-
munofluorescence should be placed in Michel’s
solution or taken directly to the laboratory in
normal saline. Any special requests should first be
discussed with the pathologist to ensure optimal
Figure 9-8 Curette technique. Begin with curette nearly
perpendicular to the skin
specimen processing. Clinical history and lesion
a b c d
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122 Dermatologic Surgery
a b
Cut
Cut
Figure 9-10 Deeper placement of anesthesia minimizes the depth of the defect. (a) Shallow placement which displaces
skin upward, obscuring the edge of a raised lesion. (b) Deeper placement, preserving the elevation of the lesion and
allowing a more shallow biopsy defect
a b c
Figure 9-11 Punch biopsy technique. After anesthesia, place the punch perpendicular to the skin. While applying
downward pressure, rotate the punch until desired depth is achieved (a). Elevate the specimen and snip the base (b).
Hemostasis can be achieved with a suture or gel foam (c)
a b c
Figure 9-12 Oval defect from a punch. To make an oval shape, apply tension outward on the skin perpendicular
to relaxed skin tension lines (a–c)
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10
Chapter
Basic excisional surgery
Christine Poblete-Lopez
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124 Dermatologic Surgery
Table 10-1 General rules for margins of excision Preparing for the excision
Type of lesion Margin (mm) Planning the excision should be done with the
Benign lesions 0–2 patient upright, to minimize apparent distortion
Atypical nevi 3–4 of the relaxed skin tension lines. Marking of the
planned excision should be done prior to infiltrat-
Nonmelanoma skin cancer 4–6 ing the anesthetic. This minimizes distortion of
(not an indication for Mohs
the skin tension lines and avoids obscuring the
surgery)
lesion margins.
Melanoma (Breslow level 10 Prior to marking, the area should be cleansed
≤ 1 mm) with 70% isopropyl alcohol. Any hair in and
Melanoma (Breslow level 20–30 around the operative site that will interfere with
>1 mm) the surgical procedure should be secured away
from the operative field or clipped with scissors.
Preoperative shaving creates microabrasions in
in general, many variations exist. Therefore, one the skin and should be avoided due to increased
should consider each patient individually. In risk of wound infection.
elderly patients, the lines are quite evident. In Lines of planned excision may now be drawn
younger individuals, asking them to make an ex- using a skin marking pen, fine-tipped perma-
aggerated facial expression or pinching the skin nent marker, or a wooden applicator dipped in
and identifying the natural skin lines will aid in gentian violet. The surgical site is then anesthe-
determining the axis of orientation. If there is tized, including a sufficient margin to allow for
question as to optimal suture line orientation, wide undermining (Fig. 10-� 4). The area is then
the lesion should first be removed in a circular prepped with an appropriate surgical scrub (e.g.
fashion, and undermined. This maneuver allows povidone–iodine, chlorhexidine) (see Chapter 2:
the skin’s inherent elasticity to determine along Antisepsis). Chlorhexidine should be used with
which axis it will form an oval. The surgeon can caution around the eye, as it can cause corneal
then extend the incision along this axis to form ulceration, and avoided completely around the
an ellipse. ear if there is chance of a tympanic membrane
Cosmetic subunit junction lines are formed at perforation. Povidone–iodine should be avoided
the borders of fixed structures on the face, and in patients with known allergy to iodine. Univer-
divide the face into cosmetic units that have simi- sal precautions should be employed at this point,
lar skin color, texture, sebaceous gland quantity including the use of sterile gloves, masks, and eye
and quality, and hair content (see Fig. 10-�
2). Exci- protection for surgical personnel. The surgical
sions should be designed and contained within a field is then draped with sterile towels, or dispos-
single cosmetic unit and resultant scars planned able sheets, and the excision carried out under
so that they lie within cosmetic subunit junction aseptic conditions.
lines. This best maintains the normal anatomy of
the face, in particular, as well as making the scar
Performing the excision
less conspicuous than one that crosses multiple
cosmetic units. Some surgeons even enlarge their For the majority of basic excisional surgery, a
excisions so that the resultant scar will lie along no. 15 scalpel blade attached to a Bard Parker han-
a subunit junction line, emphasizing the impor- dle, is appropriate (see Chapter 4: Surgical instru-
tance of these boundary lines over relaxed skin ments). For small, delicate excisions, the scalpel
tension lines. should be held vertically like a pen. For larger ex-
As a general rule, the length of the ellipse cisions, it may be preferable to hold it horizontally,
should be three to four times the width, and the like a steak knife. Prior to starting the incision,
tips drawn at an angle ranging from 30° to 75° traction should be placed on the wound edges by
(Fig. 10-�3). This ensures that the wound edges the surgeon’s nondominant hand or by a surgical
will come together without “dog ears” or redun- assistant. Next, the skin is incised at a 90° angle,
dancies at the apices of the ellipse, and that the starting at the distal tip of the ellipse. The incision
scar will lay down flat against the skin. If pos- should be carried out toward the surgeon, ideally
sible, the length of the ellipse should be drawn with enough pressure to incise the skin up to the
along the length of the lesion, to minimize the subcutaneous fat. The angle of the scalpel is de-
length of the scar. However, there are times creased to about 45° when incising along the cur-
when a longer, well placed scar, such as one that vature of the ellipse, with the belly of the blade in
is oriented within a contour line or along skin contact with the skin. This is the sharpest part of
tension lines, will result in a more cosmetically the blade (Fig. 10-�5). Again, the angle of the blade
acceptable scar than a shorter, more conspicu- is held at 90° when approaching the other apex
ous, one. of the ellipse (Fig. 10-�6). The incision is repeated
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Chapter
Basic excisional surgery 125
Figure 10-1 Relaxed skin tension lines. (a) face; (b) trunk; (c) extremities
ERRNVPHGLFRVRUJ
126 Dermatologic Surgery
Lateral ridge
of nose
Infraorbital
crease
Nasofacial Nasoalar
sulcus crease
Nasal ala Melolabial
Nasal tip crease
Philtral Vermillion
crest border
Labiomental
crease
a
1 cm 30º
3 cm
b
Figure 10-3 Dimensions of the ellipse
Figure 10-5 With the nondominant hand providing tension
opposite the side of incision, the tip of the blade is used
to incise the apex of the ellipse (a) and the belly of the
blade incises the curvature of the ellipse (b)
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128 Dermatologic Surgery
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Chapter
Basic excisional surgery 129
a b
a b
Figure 10-14 Blunt undermining of the wound edges using the closed–open technique. Note the use of a skin hook to
minimize trauma to the skin edge
ERRNVPHGLFRVRUJ
130 Dermatologic Surgery
Table 10-2 Planes of undermining 1 cm would necessitate undermining 1–2 cm later-
ally. Ultimately, undermining is done to the extent
Location Plane of undermining that is necessary to facilitate placement of subcuta-
Face Superficial fat neous/intradermal sutures with minimal tension.
Scalp Subgaleal
Neck Superficial fat Obtaining hemostasis
Trunk and extremities Mid to deep subcutaneous fat Complete hemostasis should be achieved to min-
above muscular fascia imize the risk of hematoma formation after sur-
Hands and feet Immediately subdermal gery. One should be very meticulous, taking into
consideration the effects of epinephrine during
the procedure and its expected vasodilatation
inserted with its tips closed, and then opened to postoperatively. This can be achieved using elec-
separate fibrous attachments aside, as well as cut- trodessication and electrocoagulation techniques.
ting the intervening fibers. For small bleeding vessels, a direct touch to the
The extent of undermining depends on the lax- vessels using the handheld electrode is sufficient.
ity of the surrounding skin. In general, the width of When larger vessels are transected, use of a tissue
undermining is the distance equal to, or up to dou- forceps to elevate and isolate the vessel is help-
ble the length of, the short axis of the ellipse. For ful. The electrode is then touched to the distal
example, excision of a lesion with a diameter of aspect of the forceps, which transmits the energy
a b
Figure 10-15 (a) Direct touch to smaller vessels; (b) isolation of larger vessels with tissue forceps; (c) transmission of
energy by touching the electrode tip to the tissue forceps.
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Chapter
Basic excisional surgery 131
a b
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132 Dermatologic Surgery
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Chapter
Basic excisional surgery 133
the redundant tissue excised. Undermining this thin lax skin, for example the periorbit, is also more
newly formed apex will minimize pseudo-dog prone to edema. As such, elevation of the limb or
ear formation. The wound is then closed accord- head is often recommended. Excisions around and
ingly (Fig. 10-18). Dog ear deformity may also be over joints often require special immobilization
repaired using the M-plasty technique described to give the wound the time to strengthen, and to
above (see Fig. 10-11). minimize the risk of wound dehiscence.
Patient education is the key to avoiding post-
Postoperative course and care operative complications (see Chapter 17: Surgical
complications). The patient should understand
Patients should receive written and verbal post- that some edema, ecchymosis, erythema, and ten-
operative instructions relating to the excisional derness is normal and should be expected. These
surgery just performed. When the patients are expected sequelae of surgery may be alarming if
properly educated about postoperative expec- the patient has not been forewarned. Patients who
tations, instructions for care and potential com- are anticoagulated should be cautioned regarding
plications, their anxieties are tempered and the difference between exaggerated bruising ver-
the risks for complications are minimized. Al- sus an expanding hematoma. All patients should
though considered a relatively minor procedure, be provided with a 24-h contact telephone
patients should be prepared to experience some number and instructed to contact their surgeon
limitations in their daily activities, at least for with any concerns. All information should be
the first 24–48 h. This is especially stressed with explained verbally to the patient and any family
regard to strenuous activities, including heavy member who may be accompanying them. These
lifting and vigorous exercise. Further restric- same instructions should be provided in written
tions on physical activity are individually tailored form for ready reference at home.
according to the patient’s age, preoperative level
of activity, and extent, location, and depth of the
wound.
Wound care
Certain situations warrant special attention dur- Most excisions require a simple pressure dressing
ing the postoperative period. Surgery performed that should remain intact for 24 h. Basically, this
on dependent areas, such as the hand, wrist, or leg, is prepared as follows: a thin layer of ointment
are more likely to result in edema. Surgery around (petrolatum ointment, Aquaphor®, or antibiotic
ERRNVPHGLFRVRUJ
134 Dermatologic Surgery
a b
c d
ointment), a nonadherent gauze (such as Telfa®, Table 10-3 Suture removal recommendations
cut to fit the dimensions of the suture line), an ab-
sorbent layer of gauze, and secured with an outer Location No. of days
layer of surgical tape (e.g. Mefix®, Micropore™). Eyelid 2–4
Oftentimes a liquid adhesive (tincture of benzoin
Face 4–7
or Mastisol®) is used to secure the surgical tape in
place (Fig. 10-19). Neck 5–7
Patients are instructed to remove the pres- Scalp 7–10
sure dressing in 24–48 h. The wound surface is
Trunk 7–12
cleansed with soap and water. Hydrogen perox-
ide may be used sparingly to remove any dried Extremities 10–14
blood or crust. Occlusive ointment is reapplied,
and, depending on location and level of activity,
a light dressing or strip bandage may be required. provide further support to the wound edges after
This wound care is repeated two to three times the percutaneous sutures have been removed.
daily until the sutures are removed. These typically stay on for about 5–7 days. Pa-
tients are instructed to leave these alone, and
allow them to fall out on their own. Table 10-�3
Suture removal outlines general recommendations on suture
The timing of removal of the percutane- removal.
ous sutures is of utmost importance. Sutures
should be left long enough to permit complete Complications
epithelialization across the wound margins, but
early enough to avoid suture tracking. Obviously, Although relatively infrequent, patients need to
there is individual variability in wound healing. be informed about the potential complications of
For example, sutures may be removed a little skin surgery at the time of informed consent, and
earlier for young, healthy, nonsmoking individu- be educated about how these may be manifested
als, compared to older, smoking, diabetic patients, immediately after surgery. When they do occur, the
because of problem with delayed wound healing. surgeon should be able to recognize and manage
Occasionally, wound closure tapes are used to them appropriately. The four most frequently
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Chapter
Basic excisional surgery 135
encountered complications (see Chapter 17: leave permanent scars (Fig. 10-20). When the
Surgical complications) are: middle finger is placed between the tongs of the
forceps about half way down, the forceps are
• Hematoma formation held open and one side can be used in place of
• Infection a skin hook.
• Wound dehiscence • When placing sutures, both intradermally and
• Necrosis. percutaneously, the square knot can be secured
by drawing one end of the suture toward you,
while keeping steady tension on the other end
PEARLS
of the suture. This will avoid slippage of the
• Handle the skin with great care. This will be knot and separation of the wound edges
evident in the final scar that results. To minimize (Fig. 10-21).
trauma to the wound edges, use of a skin • As much as possible, try to use your
hook is quite helpful. If not, with the toothed instruments to help you perform the procedure
forceps, grasp the relatively acellular dermis or in an efficient manner. When performing a
fascia, rather than the epidermis, which may running percutaneous suture, try to minimize
Figure 10-20 Grasp the dermis, rather than the epidermis, to minimize trauma to the surface that might potentially leave
a permanent scar
ERRNVPHGLFRVRUJ
136 Dermatologic Surgery
a
d
Figure 10-22 Use instruments to aid closure of the wound in an efficient manner. (a) Secure the exit point on the skin with
a skin hook. (b) Grasp the needle while maintaining tension on the needle’s exit point. (c) Grab the needle at the body,
ready to place the next bite. (d) Pick up the suture and provide sufficient tension to help placement of the next bites
ERRNVPHGLFRVRUJ
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Chapter
Basic excisional surgery 137
Further reading
Bennett RG. Fundamentals of Cutaneous Surgery.
St Louis: CV Mosby, 1988:353–444.
Dunlavey E, Leshin B. The simple excision. In:
McGillis ST, ed. Dermatologic Clinics, Excision
and Repair. Philadelphia: WB Saunders, 1998:
49–64.
Figure 10-23 Closure using strip suture method for thin
atrophic skin Leshin B. Proper planning and execution of surgical
excisions. In: Wheeland R, ed. Cutaneous Surgery.
Philadelphia: WB Saunders, 1994:171–177.
Jackson IT. Local Flaps in Head and Neck
your movements by using your forceps to Reconstruction. St Louis: CV Mosby, 1985.
stabilize your exit point, and push the needle Olbricht S. Biopsy techniques and basic excisions. In:
through with your needle-holder. This movement Bolognia J, Jorizzo J, Rapini R, eds. Dermatology.
will allow you to grasp and lock the needle at London: Mosby, 2003:2269–2286.
the intended body of the needle, ready to take
Paolo B, Stefania R, Massimiliano C, et al. Modified
the next bite. You or your assistant can also hold S-plasty: an alternative to the elliptical excision
onto the suture, providing just enough tension to reduce the length of suture. Dermatol Surg
along the already sutured wound edge; this 2003;29:394–398.
provides tension along the wound edge
Perry AW, McShane RH. Fine tuning of the skin
that you are about to place the needle in
edges in the closure of surgical wounds. J Dermatol
(Fig. 10-22).
Surg Oncol 1981;7:471–476.
• Management of cysts: For noninflamed cysts, Robinson JK, Hanke CW, Sengelmann RD, Siegel
mark the margin of the cyst, but perform a DM, eds. Surgery of the Skin: Procedural
punch biopsy or elliptical excision within the Dermatology. Philadelphia: Elsevier Mosby, 2005.
margins, carefully dissect around the well Sadick N, D’Amelio DL, Weinstein C. The modified
demarcated cyst, and perform a layered closure. buried vertical mattress suture. J Dermatol Surg
This minimizes the resulting scar. Oncol 1994;20:735–739.
• Management of lipomas: Similarly, carefully Salasche SJ, Bernstein G, Senkarik M. Surgical
palpate the lesion to assess the depth and size Anatomy of the Skin. Norwalk: Appleton & Lange,
of the lipoma, and mark the presumed size. 1988:13–35.
Plan for an incision well within the margins of Zalla MJ, Padilla RS. Excision. In: Roenigk RK, Ratz
the lesion, or a punch biopsy. A lipoma can be JL, Roenigk HH, eds. Roenigk’s Dermatologic
delivered through a very small opening when Surgery: Current Techniques in Procedural
pressure is placed on both sides. Carefully Dermatology, 3rd edn. New York: Informa
dissect the lesion out. When involving the Healthcare, 2007:131–139.
forehead, attempt to dissect the frontalis muscle Zitelli JA. Tips for a better ellipse. J Am Acad
bundles in a vertical orientation, and repair the Dermatol 1990;22:101–103.
muscle and fascial planes if necessary.
A layered closure will minimize the risk of
seroma or hematoma formation.
ERRNVPHGLFRVRUJ
11
Chapter
Suture techniques
Brittany Wilson, Andrea Willey,
and Ken K. Lee
Key Points
• Suturing is one of the mainstays of cutaneous General guidelines for suture
surgery. placement
• Closing a wound by first intention helps achieve
hemostasis, decreases the risk of infection, and Typically, the needle should penetrate the skin at
closes dead space. a 90° or greater angle. This helps facilitate wound
• The primary goals of suturing include eversion and minimizes trauma to tissue. Simi-
achieving wound eversion, decreasing tension larly, the needle should exit perpendicular to the
on the wound, and approximating wound
skin surface. It may be helpful to use forceps to
edges.
• Wound eversion helps to decrease the risk of a grasp the needle as it exits the tissue. This can help
spreading or depressed scar. stabilize the needle and minimize the chance of
• Various suture techniques can be selected loosing the needle in the soft tissue. Needle safety
based upon anatomical location, tension on the is paramount when suturing. The following steps
wound, tissue quality, and wound depth. are important in preventing needle sticks:
Tissue stabilization
Tissue stabilization aids in proper suture place-
ment. Depending on the setting, tissue may be
stabilized using the hands, forceps, or skin hooks.
Tissue should always be handled delicately to
avoid excessive trauma.
ERRNVPHGLFRVRUJ
140 Dermatologic Surgery
3. Use your third, fourth, and fifth fingers 3. Open the needle holder and grasp the short
to shorten any extra slack in the suture. (cut) end of the suture.
One technique is to “figure 8” the 4. Gently pull the loops off the needle holder
slack between the third and fifth fingers and reverse your hands. This knot should be
(Fig. 11-�
2). slightly looser than the final desired tension
of the wound (the second knot will tighten
Instrument tie the tie).
5. Bring the needle holder across the wound
The square knot is the basic surgical knot and is again and make a single loop (in the opposite
the primary knot used in cutaneous surgery. direction of the first knot) with the long
(needle) end of the suture.
Tying a square knot (Fig. 11-�
3) 6. Open the needle holder and grasp the short
1. Place the suture using the desired technique (cut) end of the suture.
and leave approximately 4–5 cm of suture 7. Gently pull the loops off the needle holder,
on the short (cut) end. Grasp the base of the reverse your hands and tighten.
needle between the index finger and thumb of 8. Repeat steps 5–7 again. The important point
your nondominant hand (as described above). is to reverse the direction of the loop and
2. Bring the needle holder across the wound the direction in which the needle holder is
and loop the suture twice around the tip of pulled across the wound.
the holder.
Simple interrupted suture
The simple interrupted suture (Box 11-1) is the
fundamental suture in cutaneous surgery:
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Chapter
Suture techniques 141
Pull gently
Pull gently
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142 Dermatologic Surgery
Pull gently
Pull gently
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11
Chapter
Suture techniques 143
B ox 1 1 - 1
Simple interrupted sutures
B ox 1 1 - 2
Disadvantages of simple interrupted sutures
2. Place the second, shallower, bite by entering Advantages and disadvantages of vertical mattress
and exiting in the opposite direction from sutures are shown in Boxes 11-�
3 & 11-4.
the first pass, approximately 1–3 mm from
the wound edge.
Half-buried vertical mattress suture
3. The distance of the sutures from the wound A vertical mattress suture in which one side of
edge will vary depending on tension on the the suture remains subcuticular is called a half-
wound and the amount of dead space to be buried vertical mattress suture (Fig. 11-�8). This
closed. suture can be useful to close dead space without
ERRNVPHGLFRVRUJ
144 Dermatologic Surgery
B ox 1 1 - 3 bite that exits far from the wound (Fig. 11-� 9).
This suture is useful in elevating the deep tissue
Advantages of vertical mattress sutures in which it is placed, for example when closing
the orbicularis oris muscle in a lip wedge.
• Excellent wound eversion
• Decreased wound tension
Pulley suture
• Provide added support to defects under stress
The pulley suture can be very helpful when closing
• Useful for closing dead space
wounds under tension. The critical feature of the
pulley suture is multiple passes through the tissue,
creating significant resistance and making the suture
B ox 1 1 - 4 unlikely to slip. Although variations exist, the suture
is typically initiated by entering the epidermis dis-
Disadvantages of vertical mattress sutures tant to the defect, traveling across the defect and
exiting nearby. The needle is then redirected to en-
• Potential for railroad tracking
ter the epidermis near the wound, traveling across
• More time consuming than some other methods the defect and finally exiting far from the wound
• Tissue strangulation may occur if tied too tight (Fig. 11-10). The suture may be left in place after
wound closure, or used to decrease tension while
placing additional sutures and then removed.
ERRNVPHGLFRVRUJ
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Chapter
Suture techniques 145
wound to evert the underlying mucosal surface of closed (Fig. 11-13). An overly tight or improperly
full-thickness mucosal defects. placed corner suture can lead to tissue necrosis.
Three-point corner (tip) suture Four-point corner (tip) suture
This important variation on the horizontal mat- Another variation on the horizontal mattress su-
tress suture can be employed when closing acute ture can be employed when closing two acute tis-
tissue angles. This suture involves passing the sue angles. This suture involves passing the needle
needle subcuticularly through the “tip” to be subcuticularly through the two “tips” to be closed
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Suture techniques 147
Advantages and pitfalls on buried sutures are flap repair. The modified version is performed
shown in Boxes 11-�
9 & 11-10. by entering the wound edge deep and exiting
through the epidermis lateral to the wound. The
needle is then redirected to enter back through
Buried vertical mattress suture the same hole and to exit within the mid dermis.
This is a modification of the simple buried suture The suture is repeated on the opposite side by
that further optimizes wound eversion. To initi- entering the contralateral mid dermis and exiting
ate the suture, place a deep suture by entering through the epidermis. Again the needle re-enters
the undersurface of the dermis and traveling with the same hole, but exits deep (Fig. 11-21). The
the needle in a superficial direction almost to the modified heart-shaped suture path yields superior
level of the epidermis. Then travel back down to eversion. Care must be taken to ensure that the
exit at the level of the mid dermis. On the oppos- suture is placed sufficiently in the mid dermis to
ing side of the wound, again enter at mid dermis, prevent “pull through.”
travel superficially, then dive down and exit deep.
Running subcuticular suture
The path of the suture creates a heart shape when
complete (Fig. 11-20). When used properly, the running subcuticular
suture can yield superior cosmetic results because
Modified buried vertical it leaves no suture exit and entrance marks along
the edge of the suture line (Fig. 11-22). This suture
mattress suture should be used only when the wound is well
The buried vertical mattress suture can be modi- approximated, the edges are everted, and wound
fied to produce similar wound eversion in areas tension is minimal. If a deep space is present, it
too small to perform a standard buried mattress should be closed with a separate buried suture.
suture, such as a small punch biopsy defect or If using a nonabsorbable suture that will need
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Chapter
Suture techniques 149
B ox 1 1 - 8
B ox 1 1 - 7
Disadvantages of the running
Advantages of the running subcuticular suture
subcuticular suture
• Cannot be used on wound under tension due to tissue
• Efficient use of time strangulation
• Applies equal tension to wound edges • Does not close dead space
• Can allow for excellent wound eversion • Can leave “track lines”
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150 Dermatologic Surgery
Purse-string suture
The purse-string suture is a variation on the
buried dermal or simple continuous suture that
is useful for fully or partially reducing wound
diameter or closing dead space. Circumferentially
placed intradermal or epidermal sutures can be
applied to redistribute tension equally around the
wound. In some cases the purse-string suture is
used to close a defect entirely. Alternatively, it can
be used to decrease the defect size and optimize
secondary intention. Multiple bites are oriented
horizontally around the wound edge and pulled
taught (Fig. 11-23).
Suture removal
Proper suture removal technique is often under-
appreciated. The suture should be cut and the
freed knot should be pulled across the suture line.
This allows the suture to be pulled out in the di-
rection in which it was placed and avoids placing
tension opposite the axis of closure. Improper
Figure 11-16 Running locked stitch suture removal can place tension on the suture
line and put the wound at risk of dehiscence.
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Suture techniques 153
B ox 1 1 - 9
Advantages of the buried suture
B ox 1 1 - 1 0
Pitfalls of the buried suture
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156 Dermatologic Surgery
Further reading Moody BR, McCarthy JE, Linder J, Hruza GJ. En-
hanced cosmetic outcome with running horizontal
Adams B, Anwar J, Wrone DA, Alam M. Techniques for mattress sutures. Dermatol Surg 2005;31:1313–
cutaneous sutured closures: variants and indications. 1316.
Semin Cutan Med Surg 2003;22(4):306–316. Odland PB, Murakami CS. Simple suturing tech-
Adams B, Levy R, Rademaker AE, Goldberg LH, niques and knot tying. In: Wheeland RG, ed.
Alam M. Frequency of use of suturing and repair Cutaneous Surgery. Philadelphia: WB Saunders,
techniques preferred by dermatologic surgeons. 1994:178–188.
Dermatol Surg 2006;32(5):682–689. Olbricht S. Biopsy techniques and basic excisions. In:
Alam M, Goldberg LH. Utility of fully buried Bolognia J, Jorizzo J, Rapini R, et al, eds. Derma-
horizontal mattress sutures. J Am Acad Dermatol tology. Philadelphia: Mosby, 2003:2269–2286.
2004;50(1):73–76. Starr J. Surgical pearl: the vertical mattress tip stitch.
Collins SC, Whalen JD. Surgical pearl: percutaneous J Am Acad Dermatol 2001;44(3):523–524.
buried vertical mattress for the closure of narrow Stasko T. Advanced suturing techniques and layered
wounds. J Am Acad Dermatol 1999;41(6): closures. In: Wheeland RG, ed. Cutaneous Surgery.
1025–1026. Philadelphia: WB Saunders, 1994:304–317.
Harrington AC, Montemarano A, Welch M, Farley M. Swanson NA. Atlas of Cutaneous Surgery. Boston:
Variations of the pursestring suture in skin cancer Little, Brown, 1987.
reconstruction. Dermatol Surg 1999;25(4): Vistnes L. Basic principles of cutaneous surgery. In:
277–281. Epstein E, Epstein E Jr, eds. Skin Surgery, 6th edn.
Krunic Al, Weitzul S, Taylor RS. Running combined Philadelphia: WB Saunders, 1987:44–55.
simple and vertical mattress suture: a rapid skin- Zelac D, Swanson N, Simpson M, Greenway H. The
everting stitch. Dermatol Surg 2005;31: history of dermatologic surgical reconstruction.
1325–1329. Dermatol Surg 2000;26(11):983–990.
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Chapter
Suture materials
Oliver J. Wisco and Matthew R. Ricks
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158 Dermatologic Surgery
Options
Body Key Points
Figure 12-1 Curved needle. Adapted from Robinson et al • All sutures are absorbed to some degree if left in
(2005) with permission from Mosby Publishing Company long enough (except stainless steel).
• Sutures are defined as absorbable or
Conventional Reverse Round nonabsorbable according to whether the suture
loses its tensile strength by 60 days (Tables 12-3
& 12-4).
• The rate of absorption is dependent on the
suture type, the location, and the presence of
infection.
Surgical approach
Key Points
• Choose the smallest suture that can provide
adequate strength for the closure but still
minimize tissue trauma.
• For subcutaneous suturing in areas of high
tension, use sutures with longer absorption rates.
• Use sutures with minimal tissue reactivity in areas
of high cosmetic importance.
Comparative outcomes
Figure 12-2 Different needle types. Adapted from
Key Points
Robinson et al (2005) with permission from Mosby • While suturing is typically the preferred method
Publishing Company of wound closure, staples, tissue adhesives,
and skin closure tapes can be good alternatives
P-1 PS-1 (Table 12-6).
Controversies
P-3
PS-2 Key Points
• Data on the risk of infection with braided sutures
P-4 has historically been controversial.
• It has been theorized that the braids in braided
sutures harbor microorganisms, thus increasing
PS-4 the risk of infection.
PC-1 • However, a study published in 2001 by
Gabrielli et al showed that age, sex, wound
site and length, and surgeon experience were
more important in predicting complications
PC-3 PS-6 than the choice of suture materials and suturing
techniques.
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Chapter
Flaps
T. Minsue Chen,
Rungsima Wanitphakdeedecha, and Tri H. Nguyen
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164 Dermatologic Surgery
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Chapter
Flaps 165
No: FTSGd
Vascular
base poor?
Yes: STSGe or
allograft/xenograft
Superficial
Second intentc
Figure 13-1 Algorithm for defect closure. The algorithm is not all inclusive. Repair depends greatly on the location of
the defect; for instance, a 1-cm defect on the nose demands greater consideration and complexity than a wound of the
same size on the cheek. aSmall (<1 cm), medium (1–3 cm), large (>3 cm). Location is critical. bDefects greater than
3 mm in depth will likely heal with a contour depression (unless in concave area), especially if overlying convex surfaces
or sebaceous skin. cSmall, superficial defects in concave areas are ideal for second intention healing. Avoid second
intention if bare bone, tendon, or neurovascular structures are exposed. Large defects will also heal well if superficial.
However, anticipate significant wound contraction and its impact, if any, on free margins or function. dA full-thickness skin
graft (FTSG) may be applied to any defect that is well vascularized. Superficial defects with FTSGs will maintain contour. If
deep defects are repaired with FTSGs, contour depressions may result unless delayed (partial granulation to fill the depth)
skin grafting is performed. eSplit-thickness skin grafts (STSGs) have less metabolic demand and survive better in poorly
vascularized defects. However, significant graft contraction (with potential effect on free margins) is assured compared
with FTSGs. fCombination closures (flap + flap, flap + graft, flap + second intention) should be considered for wounds
involving multiple subunits. gComposite grafts work best for small deep wounds at free margins. Owing to their bulk and
high metabolic demand, composite grafts survive poorly if sized above 1.5 cm
e.g. supratrochlear artery in a paramedian fore- outcomes, such as inadequate flap length, tissue
head flap, labial artery in a lip-switch flap) (Table ischemia, edema, and/or inability to close the sec-
13-2). All axial flaps are multistaged flaps. Not all ondary defect. The best flap designs must account
staged flaps, however, are axial in vascular supply. for and overcome a variety of tissue restraints. All
The cheek to nose staged flap, for example, is a ran- flap movement is limited by inherent, vertical,
dom pattern flap (incorporates arterial perforators and lateral restraints.
from the angular artery but the angular itself is Inherent restraint refers to the intrinsic laxity of
not in the flap pedicle), despite being a two-stage the flap tissue. For example, scalp tissue is more re-
repair. Due to a more robust and reliable vascular strained than cheek skin due to the inherent rigidi
supply, axial designs permit flaps to reach farther ty of the galeal fascia. Similarly, the sebaceous nasal
and close more complex defects. Axial flaps can tip is more restrained than the nasal sidewall. Flap
even become free flaps if the vessels are divided, design must compensate for inherent tissue re-
and the flap is moved and reanastomosed with straint. A rotation flap on the scalp must be greater
microsurgical techniques at the recipient site. than the 3–4 : 1 ratio (flap diameter = 3–4 × defect
diameter) because of the scalp’s reduced mobility.
Flap biomechanics and design Vertical restraint refers to the fibrous fibers that
tether the flap to its base. Vertical restraints are
The physics mantra “for every action, there is an released by appropriate undermining. A form of
equal and opposite reaction” is applicable to flap restraint that combines both inherent and vertical
design. Poor flap design may have deleterious restraint is pivotal restraint, which is a term that
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166 Dermatologic Surgery
a b
c d
Figure 13-2 Flap lexicon. (a) A = primary defect; B = pedicle, attached portion of flap; C = primary standing cone
(excises redundancy at primary defect). (b) Flap is rotated superiorly to close the defect. Note how the tension from the
primary defect is reduced, redirected, and redistributed to the secondary defect (D). (c) Length discrepancy at secondary
defect will be excised in the secondary standing cone (E), which is strategically placed at the submentum; (C) is the
primary standing cone that has been excised at the temple. (d) Outcome at 6 months
is specific to rotation flaps. It refers to the point for flap movement. Once these restraint concepts
(usually between the pedicle and the primary are understood, flap design may begin.
standing cone) on which the flap rotates into the Next to flap restraints, the secondary defect
defect. If a door is the flap, then the door hinge is closure is the most important factor to consider.
the area of pivotal restraint. Pivotal restraint teth- When designed accurately, closure of the second-
ers the flap during rotation so that the flap’s supe- ary defect can facilitate flap movement. Improp-
rior leading edge falls short of the superior border erly designed, however, untoward tension may
of the defect. Wide undermining and elongating result with subsequent complications. Closing the
the rotation flap height is required to overcome secondary defect usually involves lines of unequal
pivotal restraint (Fig. 13-5). lengths, which may be resolved by a number of
Lateral restraints are the attachments of the techniques (see below in Operative technique).
flap to its periphery (see Fig. 13-5). A cheek flap, An advancement flap is simply a method of dis-
for instance, is laterally restrained by its attach- placing a standing tissue cone from the primary
ments to the temporal and preauricular fascia. defect. The best example is the Burow’s wedge
Lateral restraints can be overcome only by prop- advancement flap (BWAF), in which one stand-
erly placed incisions. These “relaxing or releasing” ing cone is displaced laterally in a linear fashion
incisions separate peripheral anchors and allow (Fig. 13-6). Rarely used advancement flaps are
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Chapter
Flaps 167
Flap classification
schemes
Local Regional Distant Advancement Rotation Random Axial Single stage Multi-staged
pattern
Donor Donor tissue Distant Linear Pivotal Named artery Additional Additional
tissue is nearby donor site movement movement Dermal, nourishes flap (e.g. procedures procedures
is adjacent but not (e.g. tubed subdermal septocutaneous, not required required (e.g.
and directly pedicle plexus musculocutaneous) flap delay,
contiguous contiguous flap, radial nourishes flap inset,
with defect with defect forearm flap pedicle
(e.g. free flap, division, flap
paramedian rectus debulking,
forehead abdominis scar
flap) free flap, Transposition Microvascular revision)
latissimus
Flap tissue Division of flap and
dorsi flap)
transferred over an axial blood supply,
area of unaffected followed by
skin to reach defect reanastmosis by
microvascular
techniques
the U-plasty or H-plasty, as they result in long A rotation flap is more complex, in that the
narrow pedicles and unnatural box-like incisions surface area of the defect itself (and its tension)
(Fig. 13-7). Other variations of advancement is redirected and redistributed laterally in a cur-
flaps, such as A to T or crescenteric designs, are vilinear fashion into the secondary defect. The
more useful and aesthetic (Figs 13-8–13-10). length, height, and arc of the curvilinear exten-
Island pedicle flaps (IPFs) are especially flexible sion determine where the secondary defect is lo-
advancement designs. Also known as a Kite or cated and how well it closes (Figs 13-12–13-15).
V to Y advancement flap, an IPF is separated An O to Z flap is a bilateral rotation design that
from its peripheral skin (hence its label as an is useful for larger defects, especially on the scalp
island). Its only attachment is a subcutaneous or (see Fig. 13-15).
myocutaneous pedicle that is either underneath Transposition flaps are most demanding in geo-
the flap or to its side. Rather than displacing a cone metric accuracy. Several eponym versions exist,
laterally, an elongated standing cone is developed such as DuFourmental, Limberg, and Webster.
as a flap and advanced directly into the defect. IPFs The most commonly applied designs in derma-
are the most tissue sparing of all flaps as there is tologic surgery are the 30° transposition flap
no secondary or primary standing cone resection (Webster), the bilobe, and the trilobe transposi-
(Fig. 13-11). IPFs are categorically a local, single- tion flaps (Figs 13-16–13-19). Z-plasties are a
stage advancement flap. However, they may also form of transposition flaps used in scar revision.
rotate and or be transposed into the defect. Transposition flaps recruit donor laxity that is
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Chapter
Flaps 169
a b c
Figure 13-4 Rhombic transposition flap. (a) A = primary defect; B = flap; C = intervening area of skin. (b) Transposition
flap (B) crosses over an intervening area of unaffected skin (C) to close the primary defect. (c) Closure
Table 13-2 Flap vascular supply: random versus axial pattern flap
Random pattern flap Axial flap
Illustration Rotation flap – random pattern Paramedian forehead flap – axial pedicle (in this
example the left supratrochlear artery at the left
medial eyebrow is contained within pedicle)
• Flap debulking – to improve contour and the pedicle may be divided, most commonly
aesthetic outcome, flaps may require incision in 3 weeks’ time.
and removal of excess tissue. • Scar revision – procedures to optimize surgical
• Pedicle division – once a flap has established scars may include scar excision, Z-plasty, laser,
vascular connection with the recipient site, and dermabrasion.
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170 Dermatologic Surgery
a b
Figure 13-5 Pivotal and lateral restraints. (a) Arrows represent lateral restraints that prevent donor tissue mobility. Black
arrows are in areas where tissue movement should be avoided to prevent an eclabium. Blue arrows are preferred donor
flap tissue. Note how rotation incision (gentian violet) cuts through lateral restraints, thereby releasing their tethers on the
flap. Pivotal restraint (PR) is the area on which the flap will rotate into the defect. (b) Pivotal restraint (PR) prevents flap
from fully covering the defect and tethers the flap downward. Proper design and wide undermining in this area helps to
minimize the anchoring effect of pivotal restraint
a b c
Figure 13-6 Burow’s wedge advancement flap closure. (a) The BWAF displaces one standing cone laterally: (B) is
the displaced standing cone that extends laterally and linearly to the looser donor cheek and is the same size as (A) or
slightly wider; (C) is the linear vector of closure for this advancement flap. (b) Closure lines are camouflaged along natural
creases: (A) hides along the nasal dorsum; (B) hides at the melolabial fold, and linear extension hides at the superior alar
sulcus. (c) Long-term results demonstrating functional and cosmetic restoration
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Flaps 171
a b
Figure 13-7 U-plasty advancement flap design and anticipated final suture line conformation if this closure was chosen.
(a) U-plasty design displaces two standing cones (A) and (B) laterally compared with the BWAF. These are the same
cones that would be excised if the defect were closed primarily. Two parallel linear incisions extend laterally to form the
flap; (P) is the long narrow pedicle. (b) Rectangular box shape incision lines are less camouflaged than with a BWAF
a b c
Figure 13-8 Crescenteric advancement flap. (a) The crescenteric advancement flap is similar to the BWAF in that one
standing cone is displaced laterally (A); however, the displaced standing cone is crescentic in shape (A) rather than
triangular, thus conforming better to areas such as the lateral alar curve (shown here) or lateral eyebrow. (b) Suture lines
show how the crescenteric cone blends into the lateral alar sulcus. (c) Appearance 1 week after surgery
a b
Figure 13-9 A to T advancement flap. (a) A to T design: flap incisions camouflaged at mental crease, primary standing
cone placed inferiorly. (b) “T” closure as flaps advance bilaterally. Eversion is needed only at the center, where tension is
greatest
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172 Dermatologic Surgery
a b c
Figure 13-10 Bilateral advancement flap. (a) A bilateral crescenteric advancement flap is ideal for larger midline lower
lip defects. Two crescenteric standing cones are removed along mental crease. The bilateral movement maintains lip
symmetry and minimizes tension on any one side. (b) A wedge of lip (skin, muscle, mucosa) has been removed centrally
and crescenteric cones have been resected and advanced medially. Note how crescenteric cones are concealed along
mental crease. (c) Final closure. (d) Long-term results
a b c
Figure 13-11 Island pedicle flap (V to Y, or kite advancement flap). (a) Length : width ratio of island flap is 2–3 : 1
relative to defect. Smaller white outline is the final flap dimension. (b) Flap incised and pedicle (myocutaneous) created
underneath. Circular defect is angulated to enhance aesthetic closure. (c) Closure
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Chapter
Flaps 173
a b
c d
Figure 13-12 Cervicofacial rotation flap. (a) Lateral restraints are circumferential to defect. Dark blue arrows represent
best laxity and donor skin, and are released by flap curvilinear incision (white curve). There is also some movement from
the medial cheek (light blue arrows); movement from black arrows is undesirable. (b) Flap incised and undermined. Note
incision onto upper neck, which serves as a back-cut and releases additional restraint. (c) Flap rotated to close defect;
note displacement of defect and tension vectors onto secondary defect (zygoma, preauricular, upper neck). Primary
standing cone at medial cheek. (d) Closure – secondary standing cone revised behind ear at postauricular sulcus
a b
Figure 13-13 Cheek rotation flap. (a) Classic rotation design, which begins rotation curve level with superior edge
of defect. Pivotal restraint (P) tethers flap inferiorly and brings its leading edge A down to A′; this leaves a secondary
defect below the eyelid (may lead to ectropion once closed). (b) Modified rotation height, which is above the level of the
defect’s superior edge. The elevated rotation height compensates for pivotal restraint and minimizes the risk of ectropion.
Secondary standing cone excised posteriorly at sideburn.
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174 Dermatologic Surgery
c d
Figure 13-13, cont’d (c) Elevated height of flap allows suspension of flap to lateral orbital rim, thus minimizing the
gravitational pull on lower eyelid that inevitably occurs with time and wound contraction. (d) Six-month follow-up: there is
no ectropion and ipsilateral eyelid is properly supported
a b
c d
Figure 13-14 Dorsal nasal rotation flap (Rieger). (a) Rotation flap extended to superior glabella, with back-cut to optimize
movement. (b) Flap is broadly undermined – above perichondrium on the nose. (c) Flap rotates inferiorly. (d) Long-term
results. Note flap thickness relative to thinner nasal root area
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Chapter
Flaps 175
a b c
Figure 13-15 O to Z bilateral rotation on scalp. (a) Bilateral rotation design recruits donor laxity from parietal scalp
bilaterally. White arrow is tension vector of primary defect. (b) Flap elevated subgaleally and rotated to close defect. Note
that tension vectors are redirected and redistributed to smaller secondary defects. (c) Final closure. Length discrepancies
resolved by using rule of halves suturing
a b
c d
Figure 13-16 Melolabial transposition flap. (a) Flap width B and D must equal defect diameter at points A and C
respectively. Flap length is extended to lower melolabial fold to form a 30° angle (*), which prevents standing cone
formation. (b) Flap transposes across lateral ala to close the defect. The distal edge of the flap at D will be trimmed.
(c) Closure. (d) Long-term results. Note blunting of superior alar sulcus, which is typical of the melolabial transposition flap
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176 Dermatologic Surgery
a b c
Figure 13-17 Laterally based bilobe transposition flap. (a) The pedicle is laterally based (vascular supply from cheek
laterally). The length of the primary cone (P) is intentionally longer in order to optimize flap movement, and is placed at
the alar sulcus for camouflage. The entire arc of movement from C to A is less than 90°. The diameter of the first lobe (B)
equals that of the defect (A). The diameter of second lobe (C) may be equal to or no less than 75% that of the primary
lobe. The two arcs radiating from the defect (A) emanate from the mid and superior edges of the defect. These arcs
ensure that the first and second lobes are properly positioned and proportioned when rotating towards the defect. (b) The
flap is rotated inferiorly and the defect is closed. The primary lobe (B) closes the defect (A), the second lobe (C) moves
into where (B) was, and the donor site at (C) is closed linearly along the upper nasal dorsum. (c) Long-term results
a b
Figure 13-18 Medially based bilobe transposition flap. (a) Pedicle is medially based (vascular supply from medial nose).
Note intentional elongation of primary cone, now positioned at lateral nasal tip. (b) Closure. (c) Long-term results
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Chapter
Flaps 177
a b c
Figure 13-19 Trilobe transposition flap. (a) Three lobes may be used for larger defects under tension. The first lobe (A)
equals the defect diameter; the second and third lobes (B) and (C) may be equal to or less than (A), depending on the
laxity of donor skin. Angles of movement from (B) to (A) and from (C) to (B) are 90° of rotation. (b) Closure. (c) Short-term
results
a b
c d
Figure 13-20 Staged axial flaps. (a) Stage I: a paramedian forehead flap, based on the left supratrochlear artery is
being developed to repair complex defect on the left nasal tip (a cartilage batten graft has been inserted across the alar
rim defect for infrastructure support). (b) Stage I: the forehead flap has been rotated, transposed, and interpolated 180°
inferiorly to close the nasal defect. The supratrochlear artery is within the pedicle tube attached at the left medial eyebrow.
(c) Healthy appearance of paramedian forehead flap 3 weeks later, before stage II. (d) Stage II: the flap is partially elevated
and excess subcutaneous tissue is debulked for better sculpting of the nasal tip. The vascular pedicle is still attached at
the medial eyebrow.
Continued
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178 Dermatologic Surgery
e f g
Figure 13-20, cont’d (e) Stage III: the pedicle is divided and donor site closed primarily. (f) Stage III: pedicle tube is
discarded; flap is sculpted and inset into nose. (g) Outcome 6 months after surgery: note restoration of contour, alar rim
stability, and symmetry of eyebrows
a b
c d
Figure 13-21 Cheek to nose staged random pattern flap. (a) Flap based on melolabial fold; defect has cartilage batten
graft inserted for support of alar rim. (b) Pedicle is random pattern, based on arterial myocutaneous perforators of nasalis
muscles. (c) Cheek flap inset onto nasal alar defect. (d) Long-term results after pedicle division in stage II
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Chapter
Flaps 179
a b c
Figure 13-22 Lengthening shorter line. (a) Burow’s wedge advancement flap: note curved upper line (A) that eliminates
need for standing cone revision inferiorly (line B) by equalizing line A with line B. (b) Closure without standing cone
inferiorly. (c) Final long-term results
and the plane of flap elevation and undermining surgical team, especially in patients with complex
should match the wound depth closely. This dressings and/or intricate reconstructions.
should be performed cautiously to minimize in- Patients and their caretakers should be encour-
jury to vital structures and to maximize the flap’s aged to view the wound prior to bandage place-
vascular supply. ment to avoid any surprises with the first dressing
Flap insetting requires at least two layers of su- change at home. They also should be educated on
tures. Subcutaneous–dermal sutures approximate the anticipated postoperative wound appearance,
skin edges and minimize wound closure tension phases of healing, and potential complications.
on epidermal edges. Suspension or tacking sutures Written instructions should include recommen-
may be necessary to anchor a portion of the flap, dations to enhance flap survival, as well as when
in order to shift tension off the leading edge of to seek medical attention.
the flap, reorient tension, and/or reduce potential
wound dead space. Fascial plication sutures may Summary
also be placed to reduce wound tension and
defect size. Aesthetic flap reconstruction requires careful as-
Borders of unequal length will result from the sessment of patient and wound characteristics,
discrepancy between the primary and secondary an expansive knowledge of surgical anatomy,
defects. To equalize this discrepancy, a standing meticulous flap design and execution, an artistic
tissue cone (dog ear, Burow’s triangle) may need sense of function and form, and an understand-
to be removed from the longer side, or the shorter ing of flap biomechanics and tissue movement.
sides may need to be lengthened (Fig. 13-22). A systematic approach to design considerations
Alternatively, if the incision lines are long enough will optimize an outcome that is both functional
(rotation flap with length : width ratio of 4 : 1), the and beautiful.
discrepancy may be sewn out either by closing
the wound by the “rule of halves.”
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180 Dermatologic Surgery
Cook J, Zitelli JA. Axial pattern flaps. In: Robinson Nguyen TH. The nose. In: Roenigk RK, Ratz JL,
JK, Hanke WC, Sengelmann R, Siegel D, eds. Roenigk HH, eds. Roenigk’s Dermatologic Surgery:
Surgery of the Skin: Procedural Dermatology. Current Techniques in Procedural Dermatology3rd
St Louis: Mosby, 2005: 345–365. edn, New York: Informa Healthcare, 2007: 219–230.
Dzubow LM. Facial flaps: biomechanics and Stotland MA, Kerrigan CL. Principles of skin flap
regional application. Norwalk: Appleton & Lange; surgery. In: Weinzweig J, ed. Plastic Surgery Secrets.
1990. Philadelphia: Hanley & Belfus, 1999: 414–416.
Fazio MJ, Zitelli JA. Flaps. In: Ratz JL, Geronemus Tromovitch TA, Stegman SJ, Glogau RG. Flaps and
RG, Goldman MP, Maloney ME, Padilla RS, eds. Grafts in Dermatologic Surgery. St Louis: Mosby,
Textbook of Dermatologic Surgery. Philadelphia: 1989.
Lippincott-Raven, 1998: 223–245. Verheyden CN, Losee J, Miller MJ, Rockwell WB,
Nguyen TH. Staged cheek-to-nose and auricular Slezak S, eds. Essentials for Students: Plastic Sur-
interpolation flaps. Dermatol Surg 2005;31(8 Pt gery, 6th edn. Arlington Heights, IL: Plastic Surgery
2):1034–1045. Educational Foundation, 1979.
ERRNVPHGLFRVRUJ
14
Chapter
Skin grafts
Daihung Vu Do and Christine M. Hayes
ERRNVPHGLFRVRUJ
182 Dermatologic Surgery
ERRNVPHGLFRVRUJ
14
Chapter
Skin grafts 183
a b c
d e f
g h i
j k l
Figure 14-1 Full-thickness skin graft. (a) Biopsy-proven basal cell carcinoma of the left ala prior to Mohs surgery.
(b) Defect on the left nasal ala following Mohs micrographic surgery for a basal cell carcinoma. (c) A Gentian violet marker
is used to mark the perimeter of the defect. (d) The reverse side of the suture cardboard label is pressed against the defect
to create an imprint of the defect to serve as a template. Scissors are used to cut the template out. (e) The cardboard
template is placed on the donor site and used to draw an appropriately sized ellipse. (f) A no. 15 Bard–Parker scalpel is
used to excise the donor tissue. The deep surgical margin is shown to illustrate the yellow color of the adipose tissue, which
must be removed. (g) Curved iris scissors are used to defat the graft. The graft is placed with the epidermis facing down.
Curved scissors are used to remove the fat. Fat is relatively soft and easily removed by the scissors. The dermis is relatively
tough and not easily cut by the scissors. (h) After the graft has been defatted, the white appearance of the dermis can be
appreciated. (i) The donor tissue is laid onto the recipient site and positioned correctly. ( j ) Two simple interrupted sutures are
placed at opposite ends of the graft to secure it in place. Curved scissors are then used to trim the graft to fit the recipient site
exactly. (k) Simple interrupted sutures are placed to secure the graft in place. (l) Donor site repair with simple running suture
Pearls
Hyper/hypopigmentation • For grafts on the nose, place basting sutures oriented
along the alar groove to help recreate it (see Fig. 14-������
2�����
).
Color mismatch may occur if the donor and
• If pleats develop along the circumference of
recipient tissue have different degrees of actinic
the graft, the graft is oversized and needs to be
damage. Superficial dermabrasion, dermasanding, trimmed down to size.
Erbium or carbon dioxide resurfacing can result
in a better color match when performed as early • Some surgeons prefer to harvest the graft using a
45° bevel, to match the bevel of the recipient site
as 6–8 weeks postgraft. However, these proce-
following Mohs micrographic surgery.
dures require additional wound care.
ERRNVPHGLFRVRUJ
184 Dermatologic Surgery
a b
c d
Figure 14-3 Bolsters. (a) Full-thickness skin graft after placement. (b) Simple interrupted sutures are placed around
the perimeter of the graft. One end of the suture is cut short and the other end is left long. (c) Gauze impregnated with
petroleum jelly is placed over the graft to keep it moist. (d) The long ends of the suture are tied to one another to secure
the bolster
ERRNVPHGLFRVRUJ
14
Chapter
Skin grafts 185
a b
Figure 14-4 Necrosis. (a) Necrosis is characterized by a black, thick, tightly adherent crust or eschar. (b) It is best
to leave the necrotic graft intact to act as a biological dressing. With conservative wound care, the eschar will fall off,
revealing pink viable tissue underneath
Complications
Split-thickness grafts are subject to many of the
same complications that may occur with full-
thickness grafts. Hematoma and seroma forma
tion can be avoided by meshing the graft in
addition to tacking sutures or bolster dressings.
Owing to the decreased nutritional requirements,
split-thickness grafts are less likely to undergo
necrosis than full-thickness grafts. Split-thickness
grafts are not as durable and tend to develop ul-
cers in areas of mechanical trauma. Pain at the
donor site is common and may be ameliorated
with occlusive dressings.
Figure 14-5 Persistent elevation of the graft may be due Composite grafts
to the development of a hypertrophic scar or pincushioning
Composite grafts are used to replace defects that
are missing both cartilage and skin, such as full-
thickness loss of the alar rim. These grafts require
revascularization from the graft’s edge and thus
Technique (Fig. 14-�
6) are usually small in size (less than 1 cm).
Free-hand grafts Donor site selection
A no. 10 or 15 blade can be used to harvest small The cartilage and skin of the ear is most often
split-thickness grafts by hand. Alternatively, a used to repair nasal defects. Donor sites are se-
Weck blade, which is a long straight blade, may be lected so that the harvested graft matches the
used to obtain larger split-thickness grafts by hand. missing nasal tissue as closely as possible. The
Free-hand grafts can be performed quickly and do crus or the helical rim is most commonly used
not require the use of specialized equipment. to reconstruct the ala. The conchal cartilage is
most commonly used to repair the nasal sidewall
Dermatome grafts or columella.
Powered dermatomes (driven electrically or pneu-
matically) can be used to harvest larger split-
Technique (Fig. 14-7)
thickness grafts and allow the harvesting of grafts First, the recipient site must be made smooth so
with consistent thickness. Graft thickness can be that the planned graft may fit in precisely. Be-
selected by means of a lever on the dermatome. cause revascularization from the sides is manda-
Most grafts of the head and neck are 0.012– tory for graft survival, it is critical that a template
0.016 inches thick. For recipient sites on the trunk of the wound be drawn and then transferred to
and extremities, grafts of 0.020–0.024 inches the selected donor site. The template should be
are used. slightly oversized to account for postoperative
ERRNVPHGLFRVRUJ
186 Dermatologic Surgery
a b c
d e
g h i
Figure 14-6 Split-thickness skin graft. (a) This patient presented with a large morpheaform basal cell carcinoma on
the right cheek. (b) There is a large defect on the cheek following Mohs surgery. (c) A template on the right thigh is
drawn for the split-thickness skin graft. The graft taken may be smaller than the recipient site if meshing will be
performed. Hair within the template is shaved and a drop of mineral oil is applied to the donor site to facilitate the
harvest. (d) An electrically powered dermatome is used to harvest the graft using firm, steady, downward pressure on
the device. (e) Donor site after harvesting of the graft. Note the pinpoint bleeding. The donor site is allowed to heal by
secondary intention. (f) The split-thickness graft is put in a Petri dish with normal saline to keep it moist. (g) The graft has
been put through a mesher to increase its size and placed over the wound bed. Absorbable sutures may be placed to
secure the graft to the recipient bed. (h) The graft 4 days after placement. (i) Some 2.5 months later, the graft has fully
healed
contraction. The graft may be designed with wings aligns the graft at the recipient site. The cartilaginous
or struts that extend beyond the cutaneous por- struts are placed into the pockets created previ-
tion and fit into grooves at the recipient site for ously. Sutures are placed around the perimeter to
additional mechanical security. If cartilaginous secure the graft. Intranasal packing is placed fol-
wings are used, then a scalpel should be used to lowed by petroleum jelly and gauze externally.
incise a groove or pocket in the tissue adjacent to
the recipient site into which the struts of the com-
Complications
posite graft may be placed. Composite grafts are subject to necrosis due to
Sutures are placed to secure the graft to the inadequate revascularization. This is a particular
mucosal surface of the nose first. This secures and problem in smokers.
ERRNVPHGLFRVRUJ
14
Chapter
Skin grafts 187
a b
c d
Figure 14–7 Composite graft. (a) Nasal ala defect following Mohs surgery for basal cell carcinoma. (b) Donor site of
composite graft at crus of helix drawn approximately 10% larger than the defect. (c) Donor site following excision of
composite graft. (d) Underside of helical composite graft illustrating cartilage on left side of graft, which will provide support
to the alar rim. (e) Composite graft sutured into place with petrolatum-coated dental roll in nostril
ERRNVPHGLFRVRUJ
188 Dermatologic Surgery
Geyer AS, Pasternack F, Adams C, Ratner D. Use of Shook BA, Peterson J, Wells MJ, Butler DF. The
a skin–fat composite graft to prevent alar notch- beveled edge technique for harvesting of full-
ing: an alternative to delayed postoperative repair. thickness skin grafts. Dermatol Surg 2005;31(9 Pt
Dermatol Surg 2005;31(5):602–607. 1):1128–1130.
Gloster HM Jr. The use of full-thickness skin grafts Silapunt S, Peterson SR, Alam M, Goldberg LH.
to repair nonperforating nasal defects. J Am Acad Clinical appearance of full-thickness skin grafts of
Dermatol 2000;42(6):1041–1050. the nose. Dermatol Surg 2005;31(2):177–183.
Gurunluoglu R, Shafighi M, Gardetto A, Piza-Katzer H. Stephenson AJ, Griffiths RW, La Hausse-Brown TP.
Composite skin grafts for basal cell carcinoma de- Patterns of contraction in human full thickness
fects of the nose. Aesthetic Plast Surg 2003;27(4): skin grafts. Br J Plast Surg 2000;53(5):397–402.
286–292.
Meads SB, Greenway HT, Eaton JS. Surgical pearl:
thermoplastic bolster dressing for full-thickness
skin grafts. J Am Acad Dermatol 2006;54(1):
152–153.
ERRNVPHGLFRVRUJ
15
Chapter
Nail surgery
Elizabeth Magill Billingsley
Key Points the proximal nail plate, is called the lunula. The
• Nail surgery can be relatively painless when proximal matrix forms the dorsal surface of the
performed properly. nail plate, and the distal matrix is responsible for
• Patient relaxation is important for nail surgery to the ventral portion, or underside, of the plate. This
run smoothly. anatomic concept is important when performing
• It is important to discuss the risk of permanent nail unit surgery because damage to the proxi-
nail dystrophy and obtain informed consent prior mal matrix is likely to produce a visible perma-
to the procedure. nent nail dystrophy. This is in contrast to surgery
• Avoid unnecessary trauma to the proximal nail of the distal matrix, which may produce a nail
matrix to minimize the chance of permanent nail
dystrophy.
deformity that is not visible because it is on the
• Perform biopsies no larger than 3 mm if possible. undersurface of the nail plate. The nail bed, some-
• Orient excisions in the nail matrix transversely, times called the sterile matrix, extends from the
and excisions in the nail bed longitudinally for lunula to the hyponychium. The hyponychium is
optimal results. the end of the nail bed and the beginning of the
• The distal matrix produces the undersurface normal volar epidermis. The proximal and lateral
of the nail plate. Small wounds in this area are nail folds surround and support the nail plate. The
unlikely to produce a visible nail defect. cuticle is the distal extension of the proximal nail
• The proximal matrix produces the dorsal surface fold, and serves to seal and protect the proximal
of the nail plate. Large wounds in this area have
the greatest potential to produce a visible nail
nail fold from external pathogens and irritants.
defect. The vascular supply to the nail unit and distal
• Explain postoperative instructions clearly. digit is derived from the paired proper palmar and
plantar arteries. These arteries travel along the lat-
eral aspects of the digit, and form a series of arcades
Introduction supplying blood to the proximal nail fold, matrix,
nail bed, and end of the digit. The paired palmar
Surgical procedures involving the nail unit may and plantar nerves run in close apposition to the
be necessary to diagnose inflammatory disorders blood vessels, along the lateral aspects of the digit.
or neoplasms. They may also be therapeutic, as The extensor tendon of the digit is an impor-
when removing a growth or relieving the discom- tant anatomic structure. This tendon attaches in
fort of an ingrown nail. Many nail procedures, a broad distribution approximately 12 mm proxi-
such as avulsions, matrixectomy, and biopsies, can mal to the proximal nail fold. Extensive damage
be simple to perform in an office setting. With to this tendon attachment, either with a surgical
experience, they can be performed quickly, and
planned so as to minimize the risk of permanent
B ox 1 5 - 1
nail dystrophy (Box 15-� 1).
Keys to successful nail surgery
Anatomy • Patient relaxation – calm atmosphere, positioning
Before undertaking any nail procedure, it is • Communication – expectations of the procedure and post
important to have a thorough understanding of operative period
nail unit anatomy (Fig. 15-�
1). • Painless anesthesia (relatively!) and painless procedure
The most important structure in the nail unit
• Proper instruments
is the nail matrix. The matrix is the germinative
epithelium from which the nail plate is gener- • Appropriate knowledge of nail anatomy and surgical technique
ated. The distal nail matrix, often visible through
ERRNVPHGLFRVRUJ
190 Dermatologic Surgery
Nail plate
Hyponychium
instrument or through excessive heat with cautery a ddressing these concerns prior to undergoing
or laser, could result in difficulty with full exten- the procedure is extremely beneficial (Box 15-�
2).
sion of the tip of the digit.
Anesthesia
Preoperative considerations
Perhaps the most anxiety-provoking aspect of nail
As with any surgical procedure, a thorough surgery is the patient’s fear of pain from adminis-
medical history should be obtained prior to tration of the local anesthetic. Nail surgery can be
performing nail surgery. Although not absolute performed with significantly less anxiety when at-
contraindications to surgery, a history of pe- tention is focused on minimizing the discomfort
ripheral vascular disease, collagen vascular dis- of this part of the procedure. Patient relaxation is
ease, diabetes, or a bleeding disorder should be very important to lessen the real and perceived
noted. Prophylactic antibiotics may be indicated discomfort of the injection. Placing the patient in
in patients who have artificial heart valves or a supine position and creating a relaxed atmos-
other risk factors for endocarditis. The patient’s phere in the surgical room, through a reassuring
medications should be reviewed, with specific and confident staff, can help to calm an anxious
attention to anticoagulants. Patients on aspirin, patient. Music can also be helpful.
warfarin, clopidogrel, and certain supplements A digital nerve block is an excellent means
may have increased operative and postoperative of decreasing the pain of achieving anesthesia in
bleeding, and will need extra attention paid to the distal nail unit. This is far less painful than
hemostasis. Allergies to medications should be injecting directly into the nail unit. As small vol-
recorded. umes of anesthetic are needed for this procedure,
Photographs should be taken preoperatively, 2% plain lidocaine is an excellent choice of an-
especially for pigmented streaks, neoplasms, and esthetic. If prolonged anesthesia is required, sup-
where there is significant risk of permanent nail plemental 0.25% bupivacaine can be also be used.
dystrophy. These photos could be helpful in a Recent literature has suggested the use of epine-
medicolegal situation to document the location phrine in digital blocks is generally safe, and may
of the lesion and the need for the procedure to be helpful for minimizing operative bleeding, but
be performed. Photos are also very helpful for should be avoided in patients with peripheral vas-
teaching purposes. When there is suspicion that cular disease.
there may be an underlying bony process, such To perform the digital nerve block, a 30-
as a subungual exostosis, or invasive malignancy, gauge needle is placed at the midline of the
radiographs are helpful to delineate the extent of medial and lateral aspects of the base of the
the neoplasm. digit. An initial small bleb of anesthetic is in-
Prior to the procedure, it is extremely impor- jected very superficially (Fig. 15-� 2). Addi-
tant to spend time in consultation with the patient tional anesthetic is administered slowly, while
explaining the procedure, expectations of pain, advancing the needle deep in the skin toward
and postoperative limitations. Risk of permanent the bone. The needle is then withdrawn slightly
nail dystrophy should also be explained fully and and advanced toward the dorsal and then vol-
informed consent should be obtained. Patients ar aspects of the digit. It is important that the
generally have many questions, and time spent needle is advanced in a linear fashion and that
ERRNVPHGLFRVRUJ
15
Chapter
Nail surgery 191
B ox 1 5 - 2
Preoperative considerations
• Medications: anticoagulants
• Allergies
• Medical history: peripheral vascular disease, diabetes, bleed
ing diathesis, prosthetic valves, collagen vascular disease
• Photos or digital images
• X-rays: subungual exostosis, enchondroma, tumor with bony
invasion
• Counseling: expectations of discomfort, time for nail regrowth,
postoperative footwear, possible difficulty with work
• Consent: risk of permanent nail dystrophy
Figure 15-2 Digital block at base of thumb Figure 15-4 Wing block of thumb
ERRNVPHGLFRVRUJ
192 Dermatologic Surgery
B ox 1 5 - 4
Hemostasis
• Cautery
• Penrose drain
• Gel foam
• Aluminum chloride
• Pressure, lateral compression
B ox 1 5 - 3
Surgical instruments
ERRNVPHGLFRVRUJ
15
Chapter
Nail surgery 193
a b
Figure 15-7 Nail avulsion performed by (a) direct pulling motion or (b) rolling the nail plate, assuring removal of lateral
aspects of nail
B ox 1 5 - 5
Nail avulsion Nail matrixectomy
Matrixectomy is performed when the goal is perma-
• Clean procedure
nently to remove all or part of the nail, and prohibit
• Digital block further nail growth. The most common indication
• Insert nail spatula or Freer septum elevator under distal free for this is recalcitrant ingrown nails (onychocrypto-
edge of nail sis), but this procedure may also be performed for
• Gently push instrument proximally, avoiding damage to the
other reasons, such as deformed nails or fungal dis-
nail bed and matrix ease. Matrixectomy may be achieved by excision or
ablation. Excisional techniques include cold steel,
• Remove and reinsert several times until plate is free from bed electrosurgery, or laser. More commonly, ablative
and nail folds
techniques that achieve chemical destruction of the
• Remove nail plate in rolling or pulling motion matrix are performed. The most common chemical
used for this purpose is phenol (88% carbolic acid),
ERRNVPHGLFRVRUJ
194 Dermatologic Surgery
which must be kept in a dark bottle, and must not phenol solution. It is inserted underneath the nail
have exceeded its expiration date (Box 15-�
6). fold and advanced onto the lateral corner of the
matrix. It is important that the swab reaches the
Partial matrixectomy most proximal and lateral horns of the matrix to
Partial matrixectomy destroys the lateral aspect of prevent regrowth of nail spicules. Urethral swabs,
the nail matrix, and allows the central portion which are smaller than most cotton-tipped appli-
of the nail to remain for cosmetic and functional cators, can be more effective in reaching under-
importance. Phenol matrixectomy is performed neath the nail fold and limiting any inadvertent
as a clean, but not sterile, procedure. After a dig- contact with the nail fold (Fig. 15-11). Petrolatum
ital block is performed, an English nail splitter is may be placed along the nail folds to prevent dam-
used to make an incision approximately 2–4 mm age to the surrounding skin. The phenol is left in
from the lateral edge of the nail. The incision is place for 30–60 s and rinsed with alcohol or saline.
advanced proximally, by gently inserting the blunt This procedure is then repeated. A curette may
end of the splitter underneath the proximal nail be helpful to remove any granulation tissue along
fold until the proximal aspect of the nail plate is the nail folds or any residual necrotic tissue in
cut (Fig. 15-10). Next, the Freer septum elevator the treated area. Corticosteroid injected into the
is used gently to separate the nail plate from the proximal and lateral nail fold helps to minimize
nail bed in this area, and this portion of the nail postoperative discomfort. Triamcinolone, 5 mg/mL
plate is then removed. Care should be taken to is often used. Phenol is an effective coagulant, and
ensure that the most proximal and lateral aspects has antiseptic as well as local anesthetic properties.
of nail in the proximal groove are included. Chemical matrixectomy can also be performed
The next step is the destruction of the matrix. using 10% sodium hydroxide, applied for 1 min,
A bloodless field is necessary as blood minimizes and then neutralized with 10% acetic acid.
the effectiveness of phenol. Once this is achieved,
a cotton-tipped applicator is then saturated with Complete matrixectomy
Complete matrixectomy is performed when the
goal is permanent removal of the entire nail plate.
B ox 1 5 - 6 A complete nail avulsion is performed, followed
by application of phenol to the entire nail matrix.
Nail matrixectomy using phenol
Electrodessication and curettage, electrosurgery,
• Clean procedure laser, and surgical excision are other approaches
for complete matrixectomy.
• Partial or complete nail avulsion
• Obtain a bloodless field
Nail unit biopsy
• Apply phenol with small cotton swab or urethral swab to Biopsy of the nail unit may be necessary to diag-
proximal matrix nose a dermatosis, such as psoriasis, a tumor such
as squamous cell carcinoma, or to determine the
• Apply to deep corners for partial matrixectomy, to entire
matrix for complete matrixectomy
cause of a pigmented streak. The biopsy may be
done via a punch through the nail plate, or after
• Rinse with alcohol or saline after 30–60 s nail avulsion. Nail matrix and nail bed lie in close
• Repeat phenol application and rinse again proximity to periosteum, and these procedures
should be performed using sterile technique to
Figure 15-10 English nail splitter being used to incise Figure 15-11 Urethral swab saturated in phenol, prior to
lateral portion of nail plate placing underneath nail fold
ERRNVPHGLFRVRUJ
15
Chapter
Nail surgery 195
prevent osteomyelitis. Also, great care should be location may become difficult to identify once
taken to handle the biopsy specimen carefully, as the nail plate is removed. To visualize the entire
crushing the tissue can produce artifact making matrix after nail avulsion, it may be necessary to
histologic interpretation much more difficult. reflect back the proximal nail fold, as described
above (Fig. 15-13). A shave or saucerization can
Biopsy of pigmented streak be used to remove the lesion in question.
Pigmented streaks should be biopsied at the
most proximal aspect of the streak. If the origin Nail matrix biopsy
of the streak is visible through the nail plate, a When possible, biopsies of the nail matrix should
punch biopsy may be adequate for diagnosis. This be performed in the distal matrix to minimize
is most easily done with a larger punch, such as visible permanent nail dystrophy. Ideally, punch
a 4 or 5 mm, to remove the overlying nail plate, biopsies should be 3 mm or less, and these small
followed by a 3-mm punch to remove the desig- biopsies do not need to be sutured in the mid and
nated nail bed or matrix. Ink placed on the super- distal matrix. Biopsies 3 mm or larger in the proxi-
ficial surface of the biopsy can aid in specimen mal matrix should be sutured to minimize the po-
orientation for proper embedding. If the origin of tential for nail dystrophy. Another technique for
the pigmented streak is proximal to the lunula, sampling matrix tissue is the shave biopsy. Shave
the proximal nail fold may need to be reflected. biopsies can be performed for larger lesions and
This is accomplished by making two 5-mm re- for lesions in the proximal matrix. This method
leasing incisions at the junction of the proximal has less risk for causing permanent nail dystrophy.
and lateral nail folds. These should extend at an Elliptical excisions of the nail matrix should be ori-
angle towards the lateral aspects of the digit. The ented transversely, and with careful undermining
proximal nail fold is then reflected back, and held of the matrix, may be sutured with an absorbable
in place with retaining sutures that can be secured or nylon suture. This would result in a uniformly
with a hemostat, or by using a skin hook. The thinner nail rather than a longitudinal split. It is
proximal matrix should then be visible. A single important not to interfere with the curvilinear dis-
punch may be used for both the thin proximal tal border of the lunula in order to prevent distal
nail plate and the underlying tissue (Fig. 15-12). onycholysis and abnormal curvature of the distal
Complete nail avulsion may be performed to free nail edge (Box 15-� 7).
facilitate a biopsy and allows the entire nail unit
to be examined. Avulsion is also often necessary Nail bed biopsy
for complete removal of tumors, or to obtain a Punch biopsies of the nail bed that are 3 mm or
shave biopsy of the nail unit. It is very helpful to less do not need to be sutured. Elliptical excisions
ink the proximal nail fold in line with the area to of lesions, such as a glomus tumor, should be ori-
be biopsied prior to avulsing the nail, as biopsy ented longitudinally, and with careful undermin-
ing above the periosteum they may be sutured to
minimize the risk of onycholysis.
ERRNVPHGLFRVRUJ
196 Dermatologic Surgery
En bloc excision
Postoperative management
Longitudinal resection or wedge resection in-
volves the removal en bloc of nail folds, nail Immediately after the procedure, the area should
plate, nail bed, matrix, and hyponychium. This be cleansed and dried. It is helpful to hold direct
may be necessary to help with diagnosis of lateral compression for a few minutes to ensure hemos-
longitudinal pigmented bands and for some in- tasis. The bandage should be absorbent, nonad-
flammatory conditions that involve many parts of herent, bulky, and nonconstrictive. An initial layer
the nail unit. It is performed by making an exci- of petroleum jelly should be used to protect the
sion through the proximal nail fold, matrix, nail wound bed. Vaseline-impregnated gauze is also
plate and nail bed, and through the lateral nail useful. The next layer consists of nonadherent
fold on the other side (Fig. 15-14). The specimen gauze, followed by an additional layer of gauze
is removed en bloc, and the wound is sutured or for absorption and protection. The securing layer
allowed to granulate (Fig. 15-15). must hold the bandage in place but not be con-
Lesions arising in or underneath the proximal strictive, and can be a metal frame or tape. For
nail fold, such as mucous cysts, can produce sig- toe-nail surgery, an open-toed shoe may improve
nificant nail dystrophy due to pressure on the un- comfort.
derlying matrix. These lesions can be excised by Patients need to be educated about their
reflecting back the proximal nail fold and remov- expectations of postoperative pain and possible
ing the lesion, or by an en bloc excision of the limitations in activities. Nail surgical patients may
proximal nail fold. These en bloc excisions should or may not experience significant pain. Postop-
be symmetric across the width of the digit to al- erative pain management should consist initially
low for aesthetic healing, and are allowed to heal of elevation of the affected area and adminis-
by second intention. Significant care must be tak- tration of acetaminophen or nonsteroidal anti-
en not to damage the underlying matrix. A Freer inflammatory agents (NSAIDs). If pain is not
septum elevator placed underneath the proximal adequately managed with these interventions,
nail fold can protect the matrix from inadvertent a prescription pain medication may be needed.
damage (Fig. 15-16). A prescription sent home with the patient with
instructions to fill only if needed can be helpful.
B ox 1 5 - 7 Also, taking acetaminophen or NSAIDs before
the local anesthetic has worn off, and on a regular
Nail matrix biopsy schedule in the first 24–48 h, may minimize any
postoperative pain.
• Sterile procedure
After 24 h, the initial bandage may be re-
• May be performed through the nail plate or after nail avulsion moved. The wound should be cleansed once or
• 3 mm or smaller punch if possible twice daily with soapy water, gently loosening
any debris. Soaking may be helpful to loosen an
• Distal matrix rather than proximal matrix if possible
adherent bandage or debris, or if there is much
• Elliptical biopsies should be oriented transversely, under swelling. The new bandage should be nonadher-
mined, and sutured ent, absorbent, protective, and secure. Petroleum
Figure 15-14 En bloc excision Figure 15-15 Sutured wound after Figure 15-16 En bloc removal of
of lateral nail fold, including en bloc excision of lateral nail fold proximal nail fold mucous cyst. Note
hyponychium, nail plate, nail bed, lesion Freer septum elevator being used to
matrix, and proximal nail fold protect underlying matrix
ERRNVPHGLFRVRUJ
15
Chapter
Nail surgery 197
ERRNVPHGLFRVRUJ
16
Chapter
Mohs micrographic
surgery
Justin G. Woodhouse and Allison T. Vidimos
ERRNVPHGLFRVRUJ
200 Dermatologic Surgery
ERRNVPHGLFRVRUJ
16
Chapter
Mohs micrographic surgery 201
Figure 16-1 The tumor is removed in a saucer-shaped section and divided into pieces for processing. Evaluation of all
excised margins reveals skin cancer present at one of the dermal edges of excision. This area is subsequently excised to
remove the rest of the tumor
B ox 1 6 - 2
Indications for Mohs surgery
• Facial tumors, particularly in H zone, lips, eyelids, ears
• Recurrent tumors
• Tumors 1 cm or greater on the neck or face
• Aggressive pathology on hands, feet, genitals
• Tumors 2 cm or greater in areas other than face
• Positive margins on recent excision Highest Intermediate Lowest
• Poorly defined borders obviating margin control
Figure 16-2 “H zone” of the face indicating areas of
• Radiation-induced tumors particular recurrence risk
• Tumors with perineural invasion on biopsy
• Deeply infiltrating tumors exhibiting difficulty in estimating
tumor depth patient to be treated at a center with more expe-
• Tumor occurring in an old scar or wound (Marjolin’s ulcer) rience of treating that particular type of cancer.
• Tumor in a patient with basal cell nevus syndrome
• Tumor in a patient with xeroderma pigmentosa Mohs preoperative evaluation
• Tumor in patients with proven difficulty with skin cancer – Prior to surgery, several factors are important to
immunocompromised or organ transplant patients address for optimal outcomes. Once Mohs surgery
has been deemed appropriate for the given tumor
ERRNVPHGLFRVRUJ
202 Dermatologic Surgery
B ox 1 6 - 3 B ox 1 6 - 4
Tumors potentially treated with Mohs Preoperative evaluation
surgery
• Medications and allergies – anticoagulants, anesthetics, and
• Basal cell carcinoma (BCC) surgical scrubs may need to be adjusted
• Squamous cell carcinoma (SCC) • Propensity for infection at surgical site or elsewhere –
indications for preoperative and postoperative antibiotics
• Lentigo maligna (LM)
• Alcohol and tobacco history
• Dermatofibrosarcoma protuberans (DFSP)
• Presence of implants such as defibrillators, pacemakers, or
• Atypical fibroxanthoma (AFX)
deep brain stimulators that affect choice of hemostatic device
• Microcystic adnexal carcinoma (MAC)
• Necessity of preoperative imaging based on tumor character-
• Desmoplastic trichoepithelioma (DTE) istics and symptoms
• Verrucous carcinoma • Preoperative consultations (plastics, oculoplastics, head and
• Keratoacanthoma (KA) neck surgeons)
and patient, various medical and psychologic issues Figure 16-3 The estimated tumor margins are marked
are taken into consideration during evaluation and with ink and the area is surgically scrubbed and
preparation of the patient for surgery. Important anesthetized
questions to address are included in Box 16-�4.
The procedure
that can occur with infiltration. Furthermore,
The area is cleansed with a surgical scrub, typi- pinching the adjacent skin while inserting the
cally Betadine® or chlorhexidine. The perceived needle through a pore can decrease the pain of
tumor margins are carefully marked along with needle insertion. Ideally, the anesthetic is allowed
important cosmetic lines and units using a surgi- to penetrate the larger nerves in the area for
cal pen or gentian violet (Fig. 16-�3). 5–10 min, and this will also allow time for the
The area is infiltrated with local anesthetic, typ- vasoconstrictive action of epinephrine to set in.
ically 1% lidocaine with epinephrine 1 : 100 000. Typically, a debulking procedure is performed
Lidocaine is the most commonly used anesthetic prior to excision of the first Mohs layer (Fig. 16-�
4).
but the surgeon may choose to use another an- The tissue of most interest is the border of nor-
esthetic based on its duration of action, cost, or mal tissue surrounding the tumor. Accordingly,
allergenic potential. Some individuals have an gross pathologic tissue is usually removed and
intolerance to epinephrine, and plain lidocaine discarded, although many exceptions to this oc-
can be used in these circumstances. To minimize cur. If the tumor is particularly large or exophytic,
the stinging sensation that occurs from injec- tissue scissors or a scalpel may be used to remove
tion of unbuffered acidic lidocaine, the lidocaine obvious tumor mass. More commonly, curettage
can be buffered with sodium bicarbonate in a is employed to remove gross tumor and delineate
ratio of one part bicarbonate to nine parts lido- gross tumor margins. Skin cancer is usually very
caine. Slow injection of the anesthetic will also friable and easily parts with normal tissue when
decrease the uncomfortable burning sensation using a curette. A rough estimate of tumor width
ERRNVPHGLFRVRUJ
16
Chapter
Mohs micrographic surgery 203
Figure 16-4 Tumor is often debulked with a curette to aid Figure 16-6 Hash marks are placed in the skin and tumor
in determination of initial incisions for orientation purposes
Figure 16-5 Tumor is excised with a 1–2-mm margin of Figure 16-7 The tissue is excised, keeping the deep
normal appearing skin. The scalpel is kept at an angle to margin in the same plane parallel with the surface of the skin
bevel the skin edge and facilitate processing in the lab
ERRNVPHGLFRVRUJ
204 Dermatologic Surgery
B C D E
A F
ERRNVPHGLFRVRUJ
16
Chapter
Mohs micrographic surgery 205
The sections give the pathologist a relative “sam- the surface of the skin (Fig. 16-12). In this manner,
pling” of the surgical margin. This method leads to sections contain both the skin edge margin and
a handful of sections which are of the order of sev- the deeper subcuticular margins all within the
eral microns, although the actual specimen may same section. The Mohs map is used to orient the
be several centimeters in multiple dimensions. specimen, and the location of persistent tumor is
In fact, it is estimated that standard processing indicated on the map to guide further tissue re-
presents less than 1% of the true surgical margin moval. A true section, as would be obtained based
for evaluation by the pathologist. Based on this on Figure 16-12, is seen in Figure 16-13.
fact, it is not surprising that the cure rates for ex-
cision listed in Box16-1 are lower than with Mohs
surgery and are based on recommended standard Management of postoperative
margins rather than histologic control. defects and postoperative
In contrast, Mohs processing involves section- course
ing the tissue in a horizontal rather than vertical
plane. The skin edge is bent into the same plane Repair of postoperative defects is usually per-
as the deeper subcutaneous tissue margin, and formed by the Mohs surgeon, although consul-
sections are taken in a horizontal plane parallel to tation with other surgical specialties is often
Slice
Slice section
Figure 16-12 Schematic portraying tissue removal and manipulation of the skin edge such that the entire skin edge is in
the same plane as the deeper tissue margin. Horizontal sections are taken in a bottom-up approach so that the first few
sections are a representation of the true surgical margin comprising both skin edge and deeper tissues
ERRNVPHGLFRVRUJ
206 Dermatologic Surgery
Further reading
Cook J, Zitelli JA. Mohs micrographic surgery: a cost
analysis. J Am Acad Dermatol 1998;39:698–703.
Martinez JC, Otley CC. The management of
melanoma and nonmelanoma skin cancer: a review
for the primary care physician. Mayo Clinic Proc
2001;76:1253–1265.
Messingham MJ, Arpey CJ. Update on the use of
antibiotics in cutaneous surgery. Dermatol Surg
2005;31:1068–1078.
Figure 16-13 Hematoxylin and eosin stain of a frozen Rowe DE, Carroll RJ, Day CL. Long-term recurrence
section depicting half of the excised surgical margin. The rates in previously untreated (primary) basal cell
inks used (blue and red) are clearly visible at the deep carcinoma: Implications for patient follow-up.
margin of the tissue, and the epidermis, dermis, and
J Dermatol Surg Oncol 1989;15(3):315–328.
subcutaneous fat are all seen and evaluated in the section.
In this case, the section is clear of tumor Rowe DE, Carroll RJ, Day CL. Prognostic factors for
local recurrence, metastasis, and survival rates in
squamous cell carcinoma of the skin, ear, and
lip: implications for treatment modality selection.
J Am Acad Dermatol 1992;26:976–990.
appropriate. Some wounds are allowed to heal by
Thissen MR, Neumann MH, Schouten LJ. A
second intention. Repair options include primary systematic review of treatment modalities for
closure, flaps, grafts or delayed closure. Utiliza- primary basal cell carcinomas. Arch Dermatol
tion of various wound care principles and closure 1999;135:1177–1183.
techniques is addressed in other chapters. Tromovitch TA, Stegman SJ. Microscopically
Complications with Mohs surgery are rare. Ex- controlled excision of skin tumors: chemosurgery
pected postoperative events include at least some (Mohs): fresh tissue technique. Arch Dermatol
degree of scarring, bruising, swelling, and post 1974;110:231–232.
operative tenderness. Infection occurs in 1–2%
of cases, and excessive bleeding or hematoma
formation increases the likelihood of infection.
ERRNVPHGLFRVRUJ
17
Chapter
Surgical complications
Erin J. Allen and Summer R. Youker
ERRNVPHGLFRVRUJ
208 Dermatologic Surgery
a b c
Figure 17-2 (a) A stitch is removed from the bulging wound to reveal a hematoma. (b) Insertion of an instrument breaks
up the clot and aids evacuation. (c ) Firm pressure expels the clot from the wound bed. (Photos courtesy of John Skougee
MD)
ERRNVPHGLFRVRUJ
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Chapter
Surgical complications 209
a b c
d e
Figure 17-3 (a,b) The patient, on warfarin, underwent two stages of Mohs surgery to clear a basal cell carcinoma on
the lower back. Despite instructions to rest, the patient did yardwork and presented on postoperative day 1 with a rapidly
expanding hematoma. (c) The flaps were taken down. The bleeding vessels were identified and tied off. (d) Drains were
placed with the openings to the dependent portion and the flaps resutured into place. (e) There is necrosis of the left flap
tip as a result of a relatively long length : width ratio, hematoma, and tension
at least 7 days. There should be no lifting greater of hematoma as the nutrient-rich collection is a
than 10–15 pounds. breeding ground for infection. A first-generation
When a hematoma occurs, there is often con- cephalosporin such as cefalexin is an appropriate
tinued oozing from the site and pronounced first-line treatment option.
swelling. Patients often complain of worsening
pain, especially if the hematoma is expanding.
Ecchymosis (Fig. 17-4)
Hematomas should be evacuated whenever Although often alarming to patients, ecchymosis
possible, as they delay wound healing, facili- alone rarely causes problems other than the tem-
tate epidermal necrosis, and serve as a nidus of porary cosmetic appearance. Make certain that
infection. the ecchymosis is not masking a hematoma that
If a patient presents with a hematoma, evacu- should be addressed. Ecchymosis is more preva-
ation should be attempted if the hematoma is lent around the eyes, in the setting of blood thin-
large enough to palpate. The wound often does ners or coagulopathies, and in elderly skin. Surgery
not need to be anesthetized, as epidermal reinner- close to the eye, even when not on the eyelids, can
vation of the wound edges is not yet complete. If
anesthesia is needed, then avoid epinephrine as it
causes temporary vasoconstriction and can mask
the culprit vessel(s). The incision site should be
opened by removing the sutures; often, some of
the sutures can be left in place. A no. 11-blade
or large-bore needle on a syringe is then inserted
into the wound at the incision line. Direct pres-
sure or suction with the syringe is applied in
all directions to aid hematoma evacuation. Any
actively bleeding vessels should be cauterized
or tied off.
Once the hematoma is evacuated, the wound
is flushed with copious amounts of sterile saline.
The wound can be packed with iodiform gauze
if a large space is present. Loose Steri-Strips can
also be applied to reapproximate the wound
edges and facilitate further drainage. Most authors Figure 17-4 Ecchymosis. Note the extension well beyond
recommend empiric antibiotics in the setting the surgical site
ERRNVPHGLFRVRUJ
210 Dermatologic Surgery
ERRNVPHGLFRVRUJ
17
Chapter
Surgical complications 211
Necrosis (Box 17-5, Fig. 17-6) crush tissue will prevent tissue crush injury. Su-
tures placed in a layered closure help eliminate
Key Points tension. Suture knots should be secure but not
• Necrosis is caused by compression of blood so tight that they compromise blood supply to
vessels from sources such as tension on the the wound edges. Planning a flap or graft may
wound, crush injury, infection, hematoma, and be necessary when a complex closure will not
smoking. suffice.
• The best treatment is continued observance, Flap and graft necrosis rates range from
moist dressings, and antibiotics if there are signs 1.9% to 10.4%. The tip of the flap is the most
of infection. vulnerable region as it is the most distal from
• Extensive debridement is not recommended. the blood supply. Undersizing flaps is a rela-
tively common mistake that demands too much
of the flap, causes tension, and compromises
Necrosis occurs when vascular perfusion is com- blood supply. Back-cuts into the flap pedicle
promised. Reiterating the relationship between or improper length : pedicle ratio (3 : 1 is usu-
adverse surgical outcomes, necrosis is usually the ally appropriate) will also cause flap-tip necro-
result of another complication. The superficial sis. Lastly, the surgeon should not cut into the
dermal plexus provides the main supply to the pedicle when taking the standing cone, as it will
skin. Any of the previously mentioned compli- reduce the flap’s blood supply.
cations can threaten this vascular plexus. Poor Grafts derive their blood and nutrient supply
closure design places tension on the wound that from the wound bed. Cartilage and exposed bone
is often evident after closure as pale and poorly are not suitable for grafts owing to the relative
perfused tissue. Extensive undermining in an lack of blood supply. Areas of exposed cartilage
excessively superficial plane will interrupt the on the auricle greater than 1 cm2 can be fenes-
feeding arterioles. Using the correct instrument trated with a 2-mm punch to facilitate graft per-
such as hooks instead of forceps to lift rather than fusion from the underlying dermis. Exposed bone
should be allowed to granulate, and a delayed graft
placed when the wound bed is ready to accept a
B ox 1 7 - 5 graft. Alternatively, the outer table of bone may
be burred to stimulate bleeding before a graft is
Causes of epidermal necrosis placed. A hematoma in the wound bed will inter-
fere with graft survival. A bolster dressing and/or
Interference of blood supply
basting sutures aid adequate contact between the
• Inadequate closure design graft and wound base.
• Wound tension Smoking contributes to numerous adverse
• Crush injury from poor tissue handling
surgical outcomes by directly and indirectly de-
creasing blood flow. Smoking more than one pack
• Extensive superficial undermining per day increases the risk of flap or graft necro-
Infection sis threefold. All patients should be instructed to
Hematoma decrease, or if possible stop, smoking for 1 week
before and 2 weeks after surgery.
Smoking Necrosis is typically partial thickness. When
wound necrosis is encountered, extensive
a b
Figure 17-6 (A) Necrosis of a full-thickness skin graft. (B) Allowed to heal by secondary intent. (Photos courtesy of Mary
Maloney MD)
ERRNVPHGLFRVRUJ
212 Dermatologic Surgery
ERRNVPHGLFRVRUJ
17
Chapter
Surgical complications 213
Site of infection
Routine skin
Skin folds
surface
Gram
Most likely causative agent S. aureus Pseudomonas
negatives
ERRNVPHGLFRVRUJ
214 Dermatologic Surgery
Figure 17-11 Alar notching. (Photo courtesy of Figure 17-14 Ectropion. (Photo courtesy of Scott W.
Scott W. Fosko MD) Fosko MD)
Figure 17-12 Hypertrophic scar. (Photo courtesy of Mary Figure 17-15 Hypertrophic scarring. (Photo courtesy
Maloney MD) of Scott W Fosko MD)
Figure 17-13 Scar spread or “fish mouth scar” Figure 17-16 Suture granuloma that resolved after
3 months. (Photo courtesy of Scott W. Fosko MD)
ERRNVPHGLFRVRUJ
17
Chapter
Surgical complications 215
Figure 17-17 Trap-dooring of a flap. (Photo courtesy Although sensory nerve deficits are more com-
of Scott W. Fosko MD) mon, motor nerve deficits are of more concern.
Almost all patients can expect some sensory
specific to flaps and grafts. When a wound is nerve loss, which is more pronounced in flaps,
healing with an unacceptable scar, interven- grafts, and areas of wide undermining. The loss
tion may be appropriate (see Table 17-2). How- is usually temporary but may be permanent –
ever, patience and conservative therapy can also more so in grafts. Patients should be warned that,
ERRNVPHGLFRVRUJ
216 Dermatologic Surgery
a b
Figure 17-18 (a) The patient lost function of the temporal branch of the facial nerve after Mohs surgery on the right
temple. (b) Partial movement was recovered when local anesthesia resolved on postoperative day 1
as sensation recovers, some parasthesias or neu- surgical procedure to determine whether this
ropathic pain could occur along with the normal temporary phenomenon has occurred. Most mo-
healing process. Temporary motor nerve loss is tor nerves of the face are protected by the fascia.
not uncommonly caused by the effect of local There are three areas at particular risk during cu-
anesthesia or nerve blocks. It is important to as- taneous surgery of the head and neck that place
sess the patient’s motor function prior to each the temporal, marginal mandibular, and accessory
ERRNVPHGLFRVRUJ
17
Chapter
Surgical complications 217
(cranial nerve XI) nerves at risk. Chapter 1 pro- Futoryan T, Grande D. Postoperative wound infec-
vides detailed information of their anatomy and tion rates in dermatologic surgery. Dermatol Surg
deficits that occur when transected. 1995;21:509–514.
If transection of a major motor nerve is con- Gette MT, Marks JG Jr. Maloney ME. Frequency
firmed, early intervention offers the best results. of postoperative allergic contact dermatitis to
When no intervention occurs, recovery is possi- topical antibiotics. Arch Dermatol 1992;128:
ble but is unlikely and unpredictable. Colleagues 365–367.
in Head and Neck Surgery or Neurosurgery can Goldminz G, Bennett RG. Cigarette smoking and
sometimes reanastomose or patch the defect flap and full-thickness graft necrosis. Arch Derma-
tol 1991;127:1012–1015.
if the transection is relatively proximal and the
nerve is not significantly arborized. Haas AF, Grekin RC. Antibiotic prophylaxis in
dermatologic surgery. J Am Acad Dermatol
1995;32:155–176.
Life-threatening complications Helfman T, Ovington L, Falanga V. Occlusive
(Table 17-3) dressings and wound healing. Clin Dermatol
1994;12:121–127.
Key Points Kargi E, Babuccu O, Hosnuter M, Babuccu B,
• Relatively rare in cutaneous surgery. Altinyazar C. Complications of minor cutaneous
• A vasovagal syncopal episode can initially mimic surgery in patients under anticoagulant treatment.
an emergency. Aesthetic Plast Surg 2002;26(6):483–485.
• Complications include anaphylaxis or type 1 Khalifeh MR, Redett RJ. The management of
allergic reactions, lidocaine toxicity, seizures, patients on anticoagulants prior to cutaneous
myocardial infarction, and arrhythmias. surgery: case report of a thromboembolic com-
plication, review of the literature, and evidence-
Life-threatening complications are fortunately based recommendations. Plast Reconstr Surg
rare in dermatologic surgery. All surgical staff 2006;118(5):110e–117e.
should have emergency training such as Basic Life Kirsner RS, Eaglestein WH. The wound healing
Support (BLS) or Advanced Cardiac Life Sup- process. Dermatol Clin 1993;11:629–640.
port (ACLS) certification. Surgeons should main- Lawrence C, Sakuntabhai A, Tiling-Grosse S. Effect
tain up-to-date ACLS certification. Some offices of aspirin and nonsteroidal antiinflammatory drug
choose to keep an automated external cardiac therapy on bleeding complications in derma-
defibrillator on site. Emergency plans should be tologic surgical patients. J Am Acad Dermatol
in place and all office staff knowledgeable as time 1994;31(6):988–992.
is limited in emergencies. McGrath M, Simon R. Wound geometry and the
kinetics of wound contraction. Plast Reconstr Surg
1983;72:66–72.
Further reading Otley CC, Fewkes JL, Frank W, Olbricht SM. Com-
plications of cutaneous surgery in patients who are
Aasi SZ, Leffell DJ. Complications is dermatologic
taking warfarin, aspirin, or nonsteroidal anti-
surgery: how safe is safe? Arch Dermatol
inflammatory drugs. Arch Dermatol 1996;132:
2003;139:213–214.
161–166.
Arpey CJ, Whitaker DC. Postsurgical wound man-
Salasche SJ. Acute surgical complications: cause,
agement. Dermatol Clin 2001;19(4):787–797.
prevention, and treatment. J Am Acad Dermatol
Billingsley EM, Maloney ME. Intraoperative and 1986;15:1163–1185.
postoperative bleeding problems in patients taking
Singer AJ, Clark RAF. Cutaneous wound healing.
warfarin, aspirin, and nonsteroidal antiinflamma-
N Engl J Med 1999;341:738–746.
tory agents. A prospective study. Dermatol Surg
1997;23(5):381–385. Smith AG. A prospective study of 134 consecutive
patients requiring diagnosis, excision and repair of
Bolton L, Fattu AJ. Topical agents and wound heal-
a facial cutaneous lesion. Br J Oral Maxillofac Surg
ing. Clin Dermatol 1994;12:95–120.
1992;30:157–160.
Classen DC, Evans RS, Pestotnik SL, Horn SD,
Whitaker DC, Grande DJ, Johnson SS. Wound infec-
Menlove RL, Burke JP. The timing of prophylactic
tion rates in dermatologic surgery. J Dermatol Surg
administration of antibiotics and the risk of surgi-
Oncol 1988;14:525–528.
cal-wound infection. N Engl J Med 1992;326:
281–286. Witte M, Barbul A. General principles of wound
healing. Surg Clin North Am 1997;77:509–528.
Cook JL, Perone JB. A prospective evaluation of
the incidence of complications associated with
Mohs micrographic surgery. Arch Dermatol
2003;139(2):143–152.
ERRNVPHGLFRVRUJ
18
Chapter
Sclerotherapy of varicose
and telangiectatic leg veins
Allison Jo Moosally and Allison T. Vidimos
Key Points system. The deep veins lie within the muscular sys-
• Varicose veins are a common problem affecting tem and the fascia, transporting the majority of the
one third of all Western adult populations; the deoxygenated blood returned from the legs to the
incidence increases with age. heart. The superficial veins, which transport only
• They can be a cosmetic problem due to their about 10% of the blood, lie outside the muscles
appearance, or affect the quality of life of the and drain the venules from the skin. Perforator
patient due to their symptoms. veins connect the two systems and contain one-way
• They typically involve the deep and superficial
check valves (Fig. 18-�
2). These one-way valves pre-
venous systems of the legs.
• The prevalence is 25–33% in women and 10–20% vent backflow of blood. The blood is transported
in men. from the superficial veins to the deep veins by the
• Patients commonly complain of aching and perforator veins during muscle relaxation, when
cramping in the affected areas. pressure in the deep veins is less than the pressure
of the superficial veins. Conversely, contraction of
the leg muscles causes constriction of the veins,
moving blood upward through the vessels. This
Clinical overview mechanism of venous blood flow has been referred
to as the muscle pump or peripheral heart.
Varicose veins are a common problem in many Varicose veins result from chronic venous insuf-
Western populations today, with a prevalence of ficiency (valvular incompetence) with a number
25–33% in women and 10–20% in men. They ap- of known causes (Box 18-� 1). They develop
pear to be more common in Western or industrial- most commonly at the communication point
ized societies, increase in frequency with age, and (perforator veins) between the two systems, for
vary among ethnic backgrounds. Varicose veins example at the saphenofemoral or saphenopop-
are rare in childhood, but, when present, are more liteal junction. They are the result of structural
commonly associated with a vascular malforma- and functional defects in the venous system.
tion as in Klippel–Trenaunay syndrome. They not After a prolonged period of time, these defects
only affect the patient by their cosmetic appear- cause ambulatory venous hypertension, weak-
ance, but also cause symptoms that affect the pa- ening of the vein walls, abnormal distensibility
tient’s quality of life. They are typically found on of surrounding connective tissue and seperation
the lower extremities but also can appear on the of the valve cusps within the vein. The result is
spermatic cords (varicoceles), vulva, rectum (he- valvular incompetence or reflux, and permanent
morrhoids), esophagus (esophageal varices), and venous dilatation. Valvular incompetence can
even other less common sites such as the neck fol- occur anywhere within the deep or superficial
lowing administration of certain drugs or surgical venous system. Incompetence of the perforat-
procedures that affect the vascular supply. ing veins leads to reflux between the deep and
superficial veins. Prolonged dilatation of the
Pathophysiology venules, the most distal branches, results in te-
langiectases clinically.
The venous system of the legs is divided into deep Varicose veins are classified as either a primary
and superficial vessels (Fig. 18-�
1). The superficial or a secondary disorder. Primary varicosities are
venous system runs parallel to the deep venous more common in women and patients with a
ERRNVPHGLFRVRUJ
220 Dermatologic Surgery
Superficial circumflex
Superficial
ilium v.
epigastric v.
Saphenofemoral
junction
Femoral v.
Anterolateral v. Superior external
pudendal v.
Posteromedial v.
Long saphenous v.
Saphenopopliteal
Femoral v. junction
Popliteal v. Hunterian perforator Intrasaphenous v.
Boyd’s perforator Long saphenous v.
Posterior tibial v.
Short saphenous v.
Anterior saphenous v. Paraperoneal perforator
Posterior arch v.
Crockett’s perforating v.
Anterior tibial v. Peroneal v.
a b c B ox 1 8 - 1
Etiologies of chronic venous dilatation
that can result in valvular incompetence
and resultant varicosities
ERRNVPHGLFRVRUJ
18
Chapter
Sclerotherapy of varicose and telangiectatic leg veins 221
• Throbbing
Clinical presentation • Aching
A majority of patients who present with vari- • Burning
cose or spider veins do so for cosmetic concerns.
• Cramps
However, frequent complaints including pain,
cramping, swelling, throbbing, burning, and the • Fatigue
sensation of heaviness in the legs prompt patients • Heaviness
to seek medical attention (Box 18-� 2). Symptoms
• Pruritus
are exacerbated by prolonged standing, sitting,
and weight-bearing, whereas they improve with • Restless legs
leg elevation and walking. Varicose veins com- • Tingling
monly present during pregnancy. • Swelling
To date, studies have failed to show that the
size or number of varicosities directly correlates • Hyperpigmentation
with symptom severity. One patient with small • Dermatitis
telangiectases or reticular veins may complain of • Superficial thrombophlebitis
severe throbbing and burning, whereas another
patient with few but very large veins may be • Ulceration
asymptomatic and concerned only about the cos-
metic appearance.
Prolonged chronic venous insufficiency, if left
untreated, commonly leads to more severe signs
and symptoms including hemorrhage, dermatitis, Diagnosis
and ulceration. The ulcerations are commonly
present on the medial malleolus of the ankle.
History
The hyperpigmentation is due to hemorrhage
with extravasation of the red blood cells into the The diagnosis of varicose veins starts with a
skin and ulceration is from prolonged insufficient thorough history and physical exam. Onset of
blood supply to the affected area. symptoms, aggravating factors, job description,
Severe complications of chronic venous insuf- and a patient’s activity level are all valuable
ficiency are superficial thrombophlebitis, stasis der- pieces of information, not only for diagnosis
matitis, lipodermatosclerosis, and atrophie blanche. but for overall management. Determination of
These complications are frequently seen in individ- events surrounding the onset of the varicosities
uals with varicosities. Atrophie blanche is a condi- could lead to relevant information regarding
tion characterized by star-shaped ulcerations that a possible preceding deep venous thrombosis
heal classically with white star-shaped scars around (DVT) that may have been overlooked. A his-
the medial ankles. Lipodermatosclerosis is charac- tory of recent travel, pregnancy, chronic consti-
terized by edematous, hyperpigmented, firm, thick- pation, change in medications, immobilization,
ened, painful legs with the classically described surgery, previous DVT, or clotting disorder pro-
“inverted champagne bottle” appearance. Stasis vides valuable pieces of information that must
dermatitis, a condition frequently seen by derma- be elicited during the evaluation. A review of
tologists, is characterized by edema, hyperpigmen- the patient’s current medical problems, past
tation due to hemorrhage, poor wound healing, medical history, past surgical history, medica-
and pruritus with or without dermatitis. Superficial tions, and family history is all essential for di-
thrombophlebitis is less common in patients with agnosis and management of varicose veins. It is
varicose veins. It can be caused by trauma, a hyper- important to know how many hours per day the
coagulable state, or may occur spontaneously. The patient is on their feet, if they wear high-heeled
greater saphenous vein is most commonly affected. shoes, and whether they cross their legs often.
This condition manifests with warmth, tender- Taking oral contraceptive pills or hormone re-
ness, erythema, and swelling at the affected site. It placement therapy, a recent pregnancy, or even
must be treated to prevent extension into the deep a change of occupation can all help to explain
venous system leading to a possible deep venous the onset, worsening, or even improvement of
thrombosis or pulmonary embolus. the varicosities (Box 18-� 3).
ERRNVPHGLFRVRUJ
222 Dermatologic Surgery
a b
Figure 18-3 (a) Large tortuous, bulging blue varicosities. (b) Resolution of varicosites after sclerotherapy with sotradecol.
ERRNVPHGLFRVRUJ
18
Chapter
Sclerotherapy of varicose and telangiectatic leg veins 223
Treatment
Treatment options for varicose veins vary from
conservative to invasive. Each patient is different,
presenting with a different type of varicosity, dif-
ferent contributing medical issues, and different
desired outcomes. Some patients present with
asymptomatic varicose veins and telangiectases
that are cosmetically displeasing and would like
Figure 18-5 Telangiectases are the smallest vessels (less treatment for cosmetic reasons only. Other pa-
than 1 mm in diameter) and may be blue, red, or purple in tients are very symptomatic and seek treatment
color. for the relief of symptoms. After a careful his-
tory, physical, and laboratory testing, one should
be able to choose a treatment based on the
reliable results. Examination occurs in the stand- outcome of the work-up and the patient’s needs
ing or, more commonly, the reverse Trendelen- (Box 18-�4).
burg position. The Valsalva maneuver or coughing
helps to elicit reflux.
Compression therapy
Controversy still exists on whether the above Compression therapy remains the standard of
testing should be done universally on all patients care for most varicose veins and, if employed early
presenting with varicosities or telangiectases, or enough in life, may prevent or delay the onset of
whether only those with significant clinical dis- symptoms. Compression hose can be used as mon-
ease and predisposing history should be tested. otherapy or in conjunction with other therapies.
Other diagnostic tests available to evaluate the They can be ordered as socks, knee highs, thigh
venous system include venography, air phlethys- highs or full pantyhose. Compression therapy is a
mography, photophlethysmography, ambulatory conservative and inexpensive approach, but many
ERRNVPHGLFRVRUJ
224 Dermatologic Surgery
B ox 1 8 - 4
Treatment options for varicose veins and
telangiectases
• Weight loss
• Leg elevation
• Compression stockings
• Sclerotherapy
• Laser or light therapy
• Endovenous obliteration
• Ambulatory phlebectomy, stab avulsion phlebectomy,
transilluminated power phlebectomy Figure 18-6 A 3-mL syringe with a 30-gauge needle bent
to 145° in feeder vein of a telangiectatic cluster
• Vein stripping
• Vein ligation
B ox 1 8 - 5
Contraindications to compression therapy
ERRNVPHGLFRVRUJ
18
Chapter
Sclerotherapy of varicose and telangiectatic leg veins 225
See Tables 18-2 & 18-3 for sclerosing agents and alcohol. Shadow-free lighting of the affected ar-
concentrations. Polidocanol (Aethoxysklerol)® eas allows for adequate visualization; additional
is not approved by the Food and Drug Admin- magnifying loupes/glasses may be necessary.
istration. Box 18-�
6 lists the contraindications to Sclerotherapy should start proximally with the
sclerotherapy. feeder vessels and proceed distally down the legs.
At the time of consultation the preoperative A 3-mL syringe with either a 30- or 33-gauge
and postoperative instructions are discussed with needle bent to a 145° angle is inserted into the
the patient. Some practical guidelines are included feeder vein and the sclerosant is injected slowly
in Box 18-� 7. with a 5–15-s vein filling time (Fig. 18-� 6). This
The appropriate technique for sclerotherapy allows for a slow low-pressure injection of the
starts with appropriate positioning of the pa- sclerosant which optimizes results and allows for
tient. The patient is placed in a supine position maximum patient comfort during the procedure.
and the areas to be treated are cleansed with The injected telangiectases blanch as they fill
ERRNVPHGLFRVRUJ
226 Dermatologic Surgery
ERRNVPHGLFRVRUJ
18
Chapter
Sclerotherapy of varicose and telangiectatic leg veins 227
B ox 1 8 - 7 B ox 1 8 - 8
Preoperative and postoperative guidelines Complications of sclerotherapy
for sclerotherapy
• Pain during and following injections (mainly with hypertonic
Preoperative instructions saline and glycerin solutions)
Avoid shaving legs for 2 days prior to the scheduled procedure. • Urticaria directly following injections but typically resolves
within 30 min
Avoid blood-thinning drugs (such as aspirin, ibuprofen, vitamin E,
etc.) for 7–10 days prior to the scheduled procedure. • Hyperpigmentation
Bring loose-fitting shorts to wear during the procedure. • Telangiectatic matting
Bring the medical-grade support pantyhose recommended by • Superficial thrombophlebitis
the physician.
• Edema
A light breakfast or lunch is recommended 1 h prior to the
• Necrosis or ulceration (typically due to extravasation or high
procedure.
concentrations of sclerosant)
Postoperative instructions • Deep venous thrombosis
Normal activity may be resumed, but avoid strenuous physical • Anaphylaxis (rare)
activity (such as aerobics, jogging, heavy lifting) for the first • Blistering
2–3 days after the procedure.
• Recurrence of treated vessels
Avoid hot baths or showers for 24 h after the procedure.
Avoid prolonged standing in one position. If necessary, move
your feet or toes frequently, or support one foot on a small
stool or box. B ox 1 8 - 9
Wear the medical-grade support pantyhose for the first 24 h
Indications for laser therapy
and during the day for 7 days.
Do not apply creams or lotions to the legs for the first 24 h after • Small-caliber isolated telangiectases without varicosities
the procedure.
• Adjunctive treatment
If swelling occurs over an injection site, elevate and apply ice
• Matted telangiectases
to the affected extremity.
• Fine telangiectases
Small dark clots may develop in the treated veins. If so, let the
physician know when the area becomes painful or red. This • Allergy to sclerosant
area may be removed by making a small incision over the top • Patients with needle phobia
of the clot.
• Patients who have failed sclerotherapy or had unacceptable
A small, superficial ulceration of the skin may occur over
side-effects
an injected vein. Contact the physician should this happen.
Meticulous wound care with hydrogen peroxide and a healing
ointment will help expedite its healing and prevent a scar from
forming.
Irritation of the injected vein (superficial thrombophlebitis) small-caliber telangiectases without underlying
rarely occurs. This can be treated with compression stockings varicosities or as an adjunctive treatment for
and anti-inflammatory medications, such as aspirin and telangiectases after using another method to treat
ibuprofen. the varicosities (Box 18-� 9). Typically more than
Repeat treatments may be performed after 6–8 weeks, as one session is needed, at 6–12-week intervals.
needed. Patients must be advised strongly against tanning
prior to and following the procedure to avoid the
risk of dyschromia. Side-effects of laser therapy
include pain, bruising, blistering, dyschromia,
If the underlying cause of the varicosities/ transient hemosiderin staining, and rarely scarring.
telangiectases is addressed and proper technique See Chapter 19 for an in-depth discussion of laser
with adequate postsclerotherapy compression is treatments of spider veins.
maintained, the risk of recanalization will de-
crease due to permanent vessel fibrosis. A number of surgical approaches for varicose veins
are available including saphenous vein stripping,
Laser treatment of spider veins ligation of the saphenofemoral or sapheno-
The development of new lasers over the past popliteal junction, short stripping of the greater
20 years has led to increased efficacy and safety saphenous vein in the thigh, ambulatory phlebec-
when using laser technology to treat telangiecta tomy, endovenous laser or radiofrequency abla-
ses. Laser or light therapy is used primarily to treat tion, and transilluminated power phlebectomy.
ERRNVPHGLFRVRUJ
228 Dermatologic Surgery
Sclerotherapy may be performed after the larger Goldman MP. Complications and adverse sequelae of
varicosities have been addressed with one or more sclerotherapy. In: Goldman MP, ed. Sclerotherapy:
of these approaches. Treatment of Varicose and Telangiectatic Leg Veins.
St Louis: Mosby Year Book, 1991: 219–2618.
Goldman MP, Bennett RG. Treatment of telangiecta-
Further reading sia: a review. J Am Acad Dermatol 1987;17:
167–182.
Bergan J. Surgical management of primary and
recurrent varicose veins. In: Gloviczki P, Yao J, Goldman MP, Kaplan RP, Oki LN, Cavender PA,
eds. Handbook of Venous Disorders: Guidelines Strick RA, Bennett RG. Sclerosing agents in the
of the American Venous Forum, 2nd edn. London: treatment of telangiectasia: comparison of the
Arnold Press, 2001:287–302. clinical and histological effects of intravascular
polidocanol, sodium tetradecyl sulfate, and hyper-
Bergan JJ, Sparks SR, Owens EL, et al. Growing the
tonic saline in the dorsal rabbit ear vein model.
vascular surgical practice: venous disorders. Cardio-
Arch Dermatol 1987;123:1196–1201.
vasc Surg 2001;9:431–4318.
Goldman MP, Weiss R, Bergen J. Diagnosis and
Bradbury A, Evans C, Allan P, et al. What are the
treatment of varicose veins: a review. J Am Acad
symptoms of varicose veins? Edinburgh vein
Dermatol 1994;31:393–413.
study cross sectional population survey. BMJ
1999;318:353–356. London NJM, Nash R. Varicose veins. BMJ
2000;320:1391–1394.
Coon WW, Willis PW, Keller JB. Venous thrombo
embolism and other venous disease in the Neumann HAM. Compression therapy with medical
Tecumseh Community Health Study. Circulation elastic stockings for venous diseases. Dermatol
1973;48:839–846. Surg 1998;24:765–770.
Dover JS, Sadick NS, Goldman MP. The role of Nicolaides AN. Investigation of chronic venous
lasers and light sources in the treatment of leg insufficiency: a consensus statement. Circulation
veins. Dermatol Surg 1999;25:328–336. 2000;102(20):e126–e163.
Fedor L, Kistner RL, Eklof B. Surgical manage- Sadick NS. Treatment of varicose and telangiectatic
ment of deep venous reflux. Semin Vasc Surg leg veins with hypertonic saline: a comparative
2002;15:50–56. study of heparin and saline. J Dermatol Surg Oncol
1990;16:24–28.
Fowkes FGR, Evans CJ, Lee AJ. Prevalence and risk
factors of chronic venous insufficiency. Angiology Sadick NS. Sclerotherapy of varicose and telangiec-
2001;52(Suppl):S5–S118. tatic leg veins: minimal sclerosant concentrations
of hypertonic saline and its relationship to vessel
Fronek HS. Noninvasive examination of the venous
diameter. J Dermatol Surg Oncol 1991;17:65–70.
system in the leg: presclerotherapy evaluation.
J Dermatol Surg Oncol 1989;15:170–173. Somjen GM, Ziegenbein R, Johnston AH, Royle JP.
Anatomical examination of leg telangiectases
Fronek HS. Noninvasive examination of the patient
with duplex scanning. J Dermatol Surg Oncol
before sclerotherapy. In: Goldman MP, ed. Sclero-
1993;19:940–9418.
therapy: Treatment of Varicose and Telangiectatic
Leg Veins. St Louis: Mosby Year Book, 1991: Thibault P, Bray A, Wlodarczyk J, Lewis W. Cosmetic
108–157. leg veins: evaluation using duplex venous imaging.
J Dermatol Surg Oncol 1990;16:612–618.
Goldman MP. Polidocanol (Aethoxyskerol) for sclero
therapy of superficial venules and telangiectases. J Weiss RA, Weiss MA. Resolution of pain associ-
Dermatol Surg Oncol 1989;15:204–209. ated with varicose and telangiectatic veins after
compression sclerotherapy. J Dermatol Surg Oncol
Goldman MP. Anatomy and histology of the venous
1990;16:333–336.
system of the leg. In: Goldman MP, ed. Sclerother-
apy: Treatment of Varicose and Telangiectatic Leg Weiss RA, Weiss MA. Doppler ultrasound findings
Veins. St Louis: Mosby Year Book, 1991:7–31. in reticular veins of the thigh subdermic lateral
venous system and implications for sclerotherapy.
Goldman MP. Pathophysiology of varicose veins. In:
J Dermatol Surg Oncol 1993;19:947–951.
Goldman MP, ed. Sclerotherapy: Treatment of
Varicose and Telangiectatic Leg Veins. St Louis: Weiss RA, Weiss MA, Goldman MP. How minor
Mosby Year Book, 1991:61–818. varicosities cause leg pain. Contemp Ob Gyn
1991;36(8):113–1218.
Goldman MP. Mechanism of action of sclerotherapy.
In: Goldman MP, ed. Sclerotherapy: Treatment of Weiss RA, Weiss MA. Sclerotherapeutic agents used
Varicose and Telangiectatic Leg Veins. St Louis: for treatment of spider and varicose veins: update
Mosby Year Book, 1991:183–218. 2002. J Drugs Dermatol 2002;1(1):53–59.
ERRNVPHGLFRVRUJ
19
Chapter
Lasers: physics
and medical indications
Theresa Dressler Conologue
ERRNVPHGLFRVRUJ
230 Dermatologic Surgery
adjacent pulses, reducing the potential for t issue. For this to be effective, the laser must
thermal damage. Pulsed lasers emit a high-energy first be able to produce an appropriate wave-
laser light with ultrashort pulse durations and a length that is absorbed by the key chromophore
long intervening time (0.1–1 s) between pulses. in the particular lesion being treated. Second,
Laser systems can be long pulsed (LP), with pulse the exposure time or the pulse duration of the
duration ranging from 450 ms to 40 ms, or qual- laser beam must be shorter than the time it
ity switched (QS), creating a very short pulse takes for a chromophore to cool to one half of
of 5–100 ns. QS lasers use shutters to build up its peak temperature, defined as the thermal re-
laser energy maximally, permitting the release laxation time. This allows heating of the target
of ultrashort high-energy bursts that cause ex- chromophore while preventing heat diffusion to
tremely rapid heating of the target. The resulting the surrounding tissue (Table 19-2). Finally, the
shockwaves cause a photomechanical disruption energy density or fluence must be strong enough
of the target. to destroy the target within the allotted pulse
There are key measurements that determine duration. Putting it all together allows one to
the laser output. Energy, the amount of work of tailor a specific wavelength, pulse duration, and
a laser, is measured in joules. Power, or rate at fluence to target cutaneous lesions selectively
which the laser expends energy, is measured in without nonselective damage to surrounding
joules per second. Fluence, the energy density, is tissues (Table 19-3).
measured in joules per square centimeter. Spot
size is determined by the cross-sectional area of
the laser beam and directly affects the fluence
and irradiance. Irradiance, the power divided by Table 19-2 Target chromophores and thermal
the spot size, is expressed in watts per square relaxation times for vascular and pigment lasers
centimeter. The ability to manipulate the differ- Target Size Thermal relaxation time
ent measurements – fluence, irradiance, spot size,
Melanosome 1 mm 1 ms
exposure time, power, and energy – allows differ-
ent parameters to be adjusted for specific clinical Erythrocyte 7 mm 20 ms
applications. Blood vessel 50 mm 1 ms
Selective photothermolysis is the principle of
a laser’s ability selectively to target a particu- Ectatic blood 100 mm 15 ms
lar chromophore while sparing the surrounding vessel
ERRNVPHGLFRVRUJ
19
Chapter
Lasers: physics and medical indications 231
Table 19-3 Side-effects of lasers and light sources (blue–green light), argon-pumped tunable dye, kryp-
ton 568 nm, copper vapor/bromide 578 nm, potas-
Pulsed-dye laser Purpura, swelling, sium–titanyl-phosphate (KTP) 532 nm, pulsed-dye
hypopigmentation (tanned
laser (PDL) 577–600 nm, neodymium:yttrium–alu-
and darker skin types more
at risk), postinflammatory minum–garnet (Nd:YAG) 532 nm and Nd:YAG
hyperpigmentation, crusting, 1064 nm.
urticaria papules The introduction of the flashlamp-pumped
PDL changed the way we treat vascular lesions.
KTP lasers Erythema, urticaria edema
lasting up to 36 h, crusting,
Some of the early PDL systems used a wave-
scarring length of 577 nm, which was later increased to
585 nm to allow for deeper tissue penetration.
LP Nd:YAG lasers Scarring, crusting, Second-generation PDLs have been developed
erythema, urticarial edema,
with longer wavelengths (595 and 600 nm) and
swelling, postinflammatory
hyperpigmentation, blisters pulse durations ranging from 0.45 to 40 ms. This
longer pulse duration allows for reduced inten-
IPL Sunburn-like erythema, sity and duration of purpura, as well as the use
edema, burning, scarring
of higher fluence for treating larger vessels. In ad-
Tattoo/pigment lasers Hypopigmentation, scarring, dition, dynamic cooling devices have been incor-
pinpoint bleeding, crusting, porated into the laser system to increase patient
blisters, paradoxical comfort while protecting the epidermis from
darkening of flesh-colored thermal injury.
tattoos, chrysiasis, allergic
The Nd:YAG laser uses a KTP crystal to halve
reaction to tattoo pigment
the 1064-nm wavelength (frequency doubling) so
that it emits a 532-nm wavelength in the green
Medical treatment options: spectrum. The light is absorbed by hemoglobin
about the same as the 585-nm light, with a slightly
vascular laser systems shorter depth of penetration. An advantage of the
Key Points KTP system is that pulse durations are extended
to the 1–200-nm range, providing slow heating
• Vascular laser systems target intravascular of the vessels and thereby avoiding purpura. The
oxyhemoglobin.
disadvantage is the increased risk in dark-skinned
• Oxyhemoglobin has three primary peaks at 418,
518, and 577 nm.
individuals as a result of increased absorption of
• There is a broad oxyhemoglobin absorption band melanin at the lower wavelength.
in the 800–1000-nm range Near-infrared lasers are useful in treatment
• Absorption of melanin decreases as wavelength of vascular lesions owing to their greater depth
increases. of penetration and the broad oxyhemoglobin
• Longer wavelengths have greater depth of absorption band in the 800–1000-nm range.
penetration and can be used to target deep Intense pulsed-light (IPL) systems, although
vascular lesions. not a laser, use a high-intensity flashlamp to emit a
• Intense pulsed-light systems, although not a broad spectrum of noncoherent light ranging from
laser, use a high-intensity flashlamp to emit a
500 to 1200 nm. This includes green, yellow, red,
broad spectrum of light ranging from 500 to
1200 nm. and infrared light, thereby delivering hundreds or
thousands of colors of light at a time. Pulsed-light
machines use “cut off” filters selectively to deliver
The key element in all vascular laser systems is the desired wavelengths. These wavelengths can
the ability to target intravascular oxyhemoglobin. be customized to reach the specific target chromo-
This relies on the absorption peaks of oxyhemo- phore, or skin component, being treated, and can
globin, which lie in the visible light range, with be modified with each pulse. As longer wave-
three primary peaks at 418, 518, and 577 nm. In lengths penetrate deeper into the target, filters can
the infrared region there is a broad oxyhemo- be used to block out shorter visible wavelengths,
globin band, beyond 900 nm. As the absorption of resulting in the ability to target deeper or larger-
melanin decreases over the range of wavelength diameter blood vessels while avoiding superficial
from 200 to 2000 nm, lasers in the infrared region parts of the skin. IPL sources have multiple pulse
have an advantage of targeting hemoglobin with modes, fluences ranging from 3 to 90 J/cm2, and a
minimal interference of melanin. In addition, the large rectangular footprint. Prior to treatment, a
longer wavelength has a greater depth of penetra- thick layer (1–2 mm) of water-based gel is applied
tion and can be used to target deep vascular le- to protect the skin. It is recommended to perform
sions. In the past few decades a number of laser multiple test spots carefully with increasing en-
systems have been developed to target specific ergy until a faint erythema is achieved. The pulses
vascular lesions, including the argon 488–514 nm should be applied with minimal overlap. A major
ERRNVPHGLFRVRUJ
232 Dermatologic Surgery
B ox 1 9 - 1
Intense pulsed light sources: clinical
applications
• Hair removal
• Rosacea
• Facial erythema
• Port-wine stain
• Hemangioma Figure 19-1 Port-wine stain
• Ephelids
• Photorejuvenation
• Rhytids
• Scars
• Acne
• Tattoo
Comparative outcomes
Port-wine stains
Key Points
• Port-wine stain (PWS) is a progressive vascular Figure 19-2 Treated port-wine stain
malformations that occurs in 0.03% of newborns.
• They begin as pink macules, becoming patients require a series of treatments, ranging
thickened and even nodular by adulthood. from 5 to 12, with gradual clearing at each suc-
• Treatment should begin as early as possible. cessive treatment. Average treatment intervals
• Pulsed-dye lasers remain the “gold standard” of range from 4 to 6 weeks. Approximately 80% fad-
laser treatment. ing is usually seen after 10 treatments. Clearance
• Most patients require a series of treatments, rates depend on a number of factors, including
ranging from 5 to 12, with average treatment
anatomic location and size of the lesion. In one
intervals of 4–6 weeks.
• Approximately 80% fading is usually seen after 10 study, PWS of the centrofacial regions (medial as-
treatments. pect of the cheek, upper cutaneous lip, and nose)
• PWS of the centrofacial regions (medial aspect responded less favorably than other grouped re-
of the cheek, upper cutaneous lip, and nose) and gions (periorbital, forehead/temple, lateral aspect
V2 dermatome responds less favorably. of the cheek, neck, and chin). In addition, evalu-
ation by dermatomal distribution revealed that
dermatome V2 showed a good response (mean
Port-wine stains (PWSs) are progressive vascular lightening 73.8%), combined dermatomes V1,
malformations (Fig. 19-1). They occur in 0.03% V3, and C2/C3 showed an excellent response
of newborns and are a congenital malformation of (mean lightening 82.4%), and midline lesions had
small-caliber vessels. They can occur anywhere on an excellent response rate in adults and children,
the body, but nearly two-thirds are found on the with mean lightening of 92.4%.
face. The natural progression of the lesions is to The most common side-effect is purpura,
begin as a pink macule, becoming thickened and which may occur during the procedure and can
even nodular by adulthood. Given the natural persist for up to 2 weeks (Fig. 19-2). Hyperpig-
history of these lesions, it is recommended to start mentation has been reported in darker-skinned
treatment as early as possible. Children whose patients, but is not permanent. Vascular blanch-
treatments begin at less than 1 year of age show a ing and atrophic scaring is a rare but a significant
marked reduction in the lesion. PDLs remain the complication, especially in younger patients.
“gold standard” of laser treatment of PWS. Most Although not considered a side-effect, patients
ERRNVPHGLFRVRUJ
19
Chapter
Lasers: physics and medical indications 233
ERRNVPHGLFRVRUJ
234 Dermatologic Surgery
The treatment of hemangiomas remains contro- Most studies have used PDL lasers at a wave-
versial owing to the self-resolving nature of these length of 585–595 nm with a pulse duration of
lesions. One study of 121 patients showed that 0.45–1.5 ms. Currently we use the long pulsed
the percentage of completely cleared hemangi- tunable dye laser (LPTDL) with cryogen cooling
omas at 1-year follow-up was significantly higher at a 7.0-mm spot size with a 0.45–1.5-ms pulse
in the group treated with PDL. However, when duration and 3–7 J/cm2. In some cases intralesional
looked at in terms of complete clearance or mini- triamcinolone (Kenalog) at doses of 10–20 mg/mL
mal residual signs, there was no significant differ- is used directly after the laser treatment.
ence between the treated and untreated group. Laser treatment of postinvolution residua is
The authors concluded that PDL should not be generally accepted. The debate remains on how
used to treat uncomplicated hemangiomas. It long to wait to treat. Not only PDL but other la-
is important to recognize the laser used in this sers such as KTP and Nd:YAG can have benefit
study was an older model with no cooling device. in treating residual vascular lesions. Fatty atrophic
A more recent study looked at 52 Asian infants, residual and scars can be improved with the car-
aged 1–3 months, with early hemangiomas. These bon dioxide laser or Er:YAG. IPL may play a role
infants were assigned to PDL (585 nm) treatment in treatment of posthemangioma residua, but it is
at 0.45 ms and 7 J/cm2 without epidermal cool- still too early to tell.
ing or LPD laser (595 nm) treatment at 10–20 ms
and fluence of 9–15 J/cm2 with cryogen sprayed Facial telangiectases
cooling. At 1 year of age, outcome measures such
as clearance rate, time period of maximum pro- Key Points
liferation, and complications were assessed. A • Lasers are an excellent treatment choice for facial
higher clearance was found with the LPD laser: telangiectases.
65% compared with 54% in the PDL group. • Longer pulse durations can be used at
subpurpuric doses with little or no down time.
Compared with the LPD laser, PDL-treated
• An effective endpoint is observed vessel spasm.
children had more hypopigmentation (3 [12%] • Evaluate the vessel size and depth; many larger-
versus 8 [31%]; P = 0.001), more hyperpigmen- caliber or deeper vessels require purpuric dosing
tation (2 [8%] versus 4 [15%]; P = 0.005), and or deeper penetrating lasers.
more textural changes (1 [4%] versus 6 [23%];
P = 0.001). It is important to keep in mind that Lasers are an excellent treatment choice for facial
the PDL was not designed to treat hemangiomas telangiectases. Newer, tunable systems can give
and, given the shallow depth of penetration dramatic results with little or no down time. In
(1.2 mm), has little effect on thick tumors. The the past, PDL treatments with short pulse dura-
fluences used for PWS treatment may become tions resulted in significant purpura which lasted
treacherous because there is so little dermis be- for up to 2 weeks. Technologic advances allow
tween the target vessels. One author has recom- for longer pulse durations which can be used at
mended low fluence at 3–6 J/cm2 and a short subpurpuric doses. Effective treatment requires
pulse duration, with the aim of triggering an ac- pulse stacking or multiple pulses to an endpoint
tive process of regression, rather than ablation of of observed vessel spasm. Flash darkening of the
some abnormal vessels. vessel is seen with each pulse; the goal endpoint is
On the other hand, PDL treatment of ulcerated an observed transient oxidation and in some cases
hemangiomas has been shown to be effective. blanching of the vessel.
Reports vary, but several have shown increased In a study that compared pulse stacking with
healing, decreased pain, and an acceleration of lower fluence to a single pulse of higher fluence,
involution. In one study 71 of 78 patients re- mean vessel clearing 1 week after treatment was
sponded to laser therapy alone, with a mean of 2.0 74.3% for the pulse stacked side and 58.5% for the
treatments. Six patients with very large heman- single pulsed side. Mean vessel clearing 6 weeks
giomas required oral steroids (2–3 mg/kg daily) after treatment was 87.6% for the pulse stacked
in combination with the PDL. After failing to side and 67.4% for the single pulsed side. Another
improve on steroid therapy, two patients required study compared a single purpuric pass with four
the addition of interferon to their treatment pro- subpurpuric passes, and showed that purpuric
tocol. At a mean follow-up of 15 months there fluences produced a greater reduction in ves-
was no sign of recurrence. sel diameter and arborization, whereas the sub-
Before starting laser therapy it is important purpuric doses were more effective in reducing
to rule out other vascular lesions, such as venous background erythema. Of note, purpuric fluence
malformation, which can look similar to a hem produced more significant edema and transient
angioma. Further, deep lesions will not respond hyperpigmentation in one patient.
to PDL treatment. Magnetic resonance imaging Most patients prefer the subpurpuric approach,
with gadolinium can be helpful in the diagnosis and the use of pulse stacking enables treatment
of difficult cases. with PDL that is cosmetically acceptable and
ERRNVPHGLFRVRUJ
19
Chapter
Lasers: physics and medical indications 235
e ffective. It important to evaluate the vessel size t elangiectatic matting. In the author’s experi-
and depth; many larger-caliber or deeper vessels ence, most patients present with a wide variety of
require purpuric dosing or deeper penetrating la- vascular ectasias and achieve the best results us-
sers. Typical settings with a 10-mm spot size range ing a combination of techniques. It is important to
from 6.5 to 7.5 J/cm2 with a pulse duration of consider vessel size, depth, and patient skin type
6–10 ms, and those for a 7-mm spot size range from in order to select the best modality for treatment.
8.0 to 14 J/cm2 with pulse duration of 6–10 ms. Superficial reddish telangiectases have more
KTP lasers are also an effective and safe treat- oxygenated blood flow and are better target-
ment for facial telangiectases. The treated vessels ed with shorter wavelength visible light lasers
are drawn out with pulses applied directly over (500–600 nm). The drawback is the limited depth
the vessel to the endpoint of visible vessel blanch- of penetration and risk of hypopigmentation due
ing. It is important to have epidermal cooling, and to the considerable melanin absorption. A study
newer KTP systems are equipped with a cooled comparing the 532-nm Nd:YAG with the 595-nm
sapphire tip, used with cold gel applied to the skin. pulsed dye laser showed that both were effective
Typical fluence ranges from 9 to 14 J/cm2 at 2– in minimizing the appearance of leg telangiecta-
4-mm spot sizes. Limitations with KTP lasers are sias smaller than 1.0 mm.
in treating tanned or pigmented skin, due to com- Vessels that are deep blue, owing to their depth
petitive melanin absorption. A recent split-faced and size, require longer wavelengths (800–1100 nm)
comparison of the 532-nm KTP and 595-nm to penetrate deeply and selectively destroy the tar-
PDL demonstrated more effective treatment get chromophore. In particular, the 1064-nm Nd:
using the KTP, but more swelling and erythema. YAG laser has been shown to be effective in treat-
Long-pulsed Nd:YAG is useful in treating ing leg veins. With regard to skin type, the 1064-nm
deeper reticulated facial veins, prominent vessels wavelength has been shown to be safe for type V
around the nose, and facial telangiectases. Caution skin, the 810-nm wavelength at super-long pulse
must be taken to assure proper epidermal cooling widths of 400–1000 ms is safe for type IV and mar-
using both before and after cooling, and avoid- ginal for type V skin, and the 755-nm wavelength
ance of pulse stacking. Given the lower absorp- is limited to nontanned type I–III skin.
tion spectrum of the wavelength, high fluences More recently, IPL has been used in the treat-
are needed for effective absorption by the vessel. ment of leg veins. In one study patients with tel-
Typical parameters range from 100 to 150 J/cm2, angiectases, cherry angiomas, or leg veins smaller
with spot sizes of 2–6 mm and pulse widths of than 1 mm were more satisfied after IPL, whereas
25–100 ms depending on the size of the vessel. patients with leg veins greater than 1 mm were
more satisfied after Nd:YAG therapy. Overall, sat-
Leg veins isfaction with treatment of vascular lesions was
greater with Nd:YAG, although this method was
Key Points more painful.
• Sclerotherapy remains the “gold standard.” Of the two primary clearance mechanisms, ves-
• Treat the deep incompetent feeder vessels first. sel contraction and thrombosis, vessel contraction is
• Lasers are an effective tool for patients who favored. Most side-effects occur with vessel throm-
are needle phobic, have contraindications
bosis. To achieve constriction of the vessel, the use
to sclerotherapy, small vessels, or have
telangiectatic matting following sclerotherapy. of parameters that induce “slow” vessel heating
• Consider vessel size, depth, and patient skin type (longer pulses with long wavelengths) has been
in order to select the best modality for treatment. suggested to decrease side-effects when using lasers
• Shorter wavelengths work well for superficial to treat leg veins of 0.2–2 mm in diameter, with the
reddish telangiectases but are limited because of exception of very small vessels (0.1–0.6 mm) in fair
melanin absorption. skin, where an equal response to green and yellow
• Longer wavelengths penetrate deeply and can light short-wavelength lasers can be achieved with
be used in darker skin tones with proper cooling much less pain and lower side-effect potential. This
techniques.
is consistent with the extended theory of selective
• In general, pulse duration should increase as the
target size increases.
photothermolysis where nonuniformly absorbing
structures, such as blood vessels, require longer
pulse durations for selective destruction. For vessel
Laser therapy for leg veins has made significant closure to occur, the vessel wall, with resultant col-
advancements over the past decade. Sclerother- lagen shrinkage, must be heated by diffusion from
apy remains the “gold standard,” but lasers can the blood; this requires a significantly longer pulse
be used in patients who are needle phobic, have duration (see Table 19-4).
contraindications to sclerotherapy, or have vessels When using the 1064-nm Nd:YAG laser,
that are too small for effective treatment. Even high fluences (350–600 J/cm2), small spot sizes
after successful sclerotherapy of leg veins, some (<2 mm), and short pulse durations (15–30 ms)
patients will require laser treatment for residual are most effective for small red vessels (<1 mm),
ERRNVPHGLFRVRUJ
236 Dermatologic Surgery
which are usually superficial, red, and have a high green light changes the chemical constituents of
oxyhemoglobin saturation. For larger blue vessels blood to met-hemoglobin and results in enhanced
(1–4 mm) that are deeper and have a lower oxy- infrared absorption. Another approach to leg vein
genated hemoglobin content, larger spot sizes treatment is the use of a bimodal approach in
(2–8 mm), moderate fluences (100–350 J/cm2), which shorter wavelengths (500–600 nm) are uti-
and extended pulse durations (30–50 ms) are lized to treat oxygenated red telangiectasias, and
most efficacious. In general, pulse duration longer wavelengths (800–1100 nm) to treat de-
should increase as the target size increases (Table oxygenated blue venulectasias and reticular veins.
19-5). In a study that investigated the optimal However, this approach requires the utilization of
treatment parameters for vessel ablation in vivo two lasers, or a laser plus an intense pulsed light
using the 1064-nm Nd:YAG laser and a 6.0-mm source, in order to achieve the desired effects
spot size, for a vessel diameter of 0.2–1.0 mm (Table 19-6).
the ideal pulse width range was found to be 15– The endovenous laser is fast approaching the
60 ms with an optimal fluence of 80–110 J/cm2. mainstream for the treatment of incompetent
Improved cooling technologies in laser therapy veins. One of the first published studies in 2001
have not only improved results in the treatment showed short-term safe results using fiberoptic
of leg veins while minimizing side-effects, but also insertion and photocoagulation of the greater
provides greater patient comfort. This is particu- saphenous vein with a diode 810-nm laser. Vari-
larly important when using higher wavelengths, ous wavelengths, including 810, 940, 980 nm
which have an increased risk of epidermal damage (all target hemoglobin) and 1320 nm (targets
and are generally more painful. The use of proper water), have been used to produce intravascular
cooling allows the delivery of higher energies destruction of varicose veins. In 2002, the US
while maintaining epidermal protection. Several Food and Drug Administration (FDA) approved
types of cooling device have been incorporated endovenous laser treatment as a minimally inva-
to provide direct cooling: copper-cooled plates or sive method for ablating incompetent saphenous
water-cooled sapphire tips applied directly to the veins. The procedure is performed in the office
skin, cooling gels, air-blowing cooling devices, and under local anesthesia using a form of directed
cryogen-cooled spray devices. laser energy from the inside to shrink and seal the
There are some interesting but still limited targeted vein. Tumescent anesthesia is used, not
data on the use of two-pulsed visible and near- only as a safe alternative to general anesthesia, but
infrared lasers to treat leg veins. The theory is because it protects perivascular tissues from the
based on a phenomenon called green light - thermal effects of the intravascular energy. It also
induced infrared absorption, whereby a pulse of provides greater efficacy by collapsing the treated
vein, allowing for better absorption of energy by
Table 19-5 Laser treatment of deep vascular lesions
the target chromophore. The 1320-nm water-
using constant wavelength of 1064 nm targeting device appears to be associated with
less pain and bruising than 810-, 940-, or 980-nm
Increase with Decrease with
hemoglobin-targeting endovenous devices.
Pulse duration Large-diameter Small-diameter Treatment of varicose veins should follow a
vessels vessels logical and algorithmic approach:
Higher vascular Lower vascular
volume volume 1 Diagnose and treat the deep incompetent
feeder vessels.
Spot size Deep vessels Superficial
vessels 2 Perform sclerotherapy, proceeding from the
largest to the smallest vessels – 80–90% of
Large-diameter Small-diameter vessels respond to a single treatment.
vessels vessels
Fluence Pink or red Purple or blue able 19-6 Recommended light and laser systems
T
vessels vessels based on vessel size
Small-diameter Large-diameter Size of vessel (mm) Recommended system
vessels vessels
0.1–0.4 585/595-nm PDL, 532-nm
Deep vessels Superficial KTP, 500–1200-nm
vessels (noncoherent) IPL
Small spot sizes Large spot sizes 0.4–1.0 585/595-nm long pulse
High-pressure Flaccid vessels PDL, intense pulsed light,
vessels 755-nm pulsed alexandrite,
800–940-nm diode, 1064-nm
Adapted from Groot D, Rao J, Johnston P, Nakatsui T. Algorithm for using long pulsed Nd:YAG
a long-pulsed Nd:YAG laser in the treatment of deep cutaneous vascular
lesions. Dermatol Surg 2003;20(1):35–42. 1.0–3.0 Diode, Nd:YAG
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Lasers: physics and medical indications 237
3 Employ lasers and IPL sources for residual Table 19-7 Selective and nonselective pigment lasers
vessels that do not respond to sclerotherapy,
are too small to be injected, or remain after Nonselective pigment CO2, Erb:YAG, fractional
lasers
feeding vessels have been treated.
Selective: epidermal QS 532-nm frequency-
Pearls doubled Nd:YAG
QS 694-nm ruby
Leg vein treatment
QS 755-nm alexandrite
Treat incompetent feeder vessels first.
Selective: dermal QS 800-nm diode
Sclerotherapy remains the first-line treatment.
QS 1064-nm Nd:YAG
Assess the residual vessel for size and depth to
guide treatment. Other IPL 500–1200 nm
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238 Dermatologic Surgery
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Chapter
Lasers: physics and medical indications 239
lasers found that both had a similar short-term • Early treatment has been argued, based on the
morbidity, but patients felt the QS alexandrite smaller size of early lesions, better tolerance, and
was more tolerable. Hypopigmentation can occur cosmetic benefit prior to school years.
with any of the QS laser treatments, but appears • Benefit of early treatment with regard to
decreasing recurrence or malignant potential has
to be more common with combined treatments,
yet to be proven.
such as in patients who receive alternating treat-
ments with QS alexandrite and QS Nd:YAG.
Alternatively, when comparing efficacy, the Nd: Laser treatment for congenital nevi should be
YAG has been shown to be more effective in reserved for lesions that are disfiguring and can-
lightening nevi of Ota, with no differences in not be excised surgically. For such patients, lasers
complications. that have been used successfully include pigment-
Recommendations of treatment intervals vary. specific lasers, resurfacing lasers, or a combina-
One study found that clinical response in the tion of both. Many congenital nevi are resistant
20–27-week treatment interval group was signifi- to laser treatment; even successfully removed
cantly better than that in the 12–19-week interval lesions have a high rate of repigmentation. One
group, but showed no significant difference when of the key issues of removal is that lesions con-
compared to both the 28–35- and the ≥36-week sist of both superficial and deeper components,
interval group. This study also indicated that and can extend deep into the dermis and adnexal
zygomatic, buccal, and frontal areas had a better structures. There have been reports of extension
response than ocular and temporal areas. Light- into the fat and muscle. The most likely cause of
ening of the lesion can take months due to re- repigmentation is remnant deep dermal melano-
sidual melanin in the dermis long after the nevus cytes that, over time, lead to repigmentation.
cells have been removed, leading many to suggest The QS ruby laser has been reported to light-
treatment intervals of 3–6 months. In one study, en small and medium congenital nevi effectively
three treatments were applied at 1-month inter- without scarring. The initial lightening was not
vals, with follow-up at 6–8 months; the lesion permanent, leading the authors to conclude that
had usually disappeared by the follow-up. It is the QS ruby laser is a viable alternative for cos-
unclear what is the best age to start treatment. metic improvement of irresectable lesions, but
One study showed that children had complete should not be considered definitive treatment. A
clearance with fewer sessions and a lower com- combination of treatments to target the superfi-
plication rate when the QS ruby laser was used cial aspect first, followed by QS Nd:YAG treat-
for nevi of Ota. ment for further removal of residual pigment, has
Hori’s nevus (acquired bilateral nevus of Ota- been shown to be effective. One study that em-
like macules) is a common condition of dermal ployed a combined laser treatment (abrading the
melanocytic hyperpigmentation. The QS Nd: surface epithelium with a carbon dioxide laser,
YAG laser can be used for treatment, but the re- then treating with a QS alexandrite laser) found
sults do not appear to be as good as those seen a favorable clinical outcome with safer, less pain-
with nevus of Ota. A retrospective study showed ful treatments, and relative nonscarring. Patients
effective treatment of Hori’s nevus with QS had a short recovery period and required fewer
alexandrite. Postoperative pigmentary changes sessions compared with conventional treatments.
were frequent and the use of topical bleaching Early treatment has been argued, based on the
agents was necessary to achieve a satisfactory smaller size of early lesions, better tolerance of
result. A transient hypopigmentation risk oc- treatment by younger patients, and cosmetic ben-
curred in up to 50% of the patients. A recent efit prior to school years, but the benefit of early
study showed that concurrent use of the QS treatment with regard to decreasing recurrence or
532-nm Nd:YAG laser in combination with the malignant potential has yet to be proven. Con-
1064-nm laser was more effective in pigment genital nevi of the palms and soles tend to re-
clearance than using the QS 1064-nm Nd:YAG spond better to laser treatment, perhaps because
laser alone. of the absence of hair follicles.
Congenital nevi Café-au-lait macules
Key Points Key Points
• Laser treatment should be reserved for lesions • The success of laser treatment is highly variable,
that are disfiguring and cannot be excised with high recurrence rates.
surgically. • QS frequency-doubled Nd:YAG, QS ruby, and
• Many congenital nevi are resistant to laser QS alexandrite lasers are useful, with a low risk of
treatment, and even successfully removed side-effects.
lesions have a high rate of repigmentation. • Patients should be instructed to avoid sun
• Congenital nevi of the palms and soles tend to exposure because of the increased risk of
respond better. repigmentation of the lesion.
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240 Dermatologic Surgery
• Multiple treatment sessions and a relatively low Melasma is a common condition presenting to
fluence should be used. the dermatologist. Multiple medical therapies
• In general, lesions that remain clear at 12 months exist to treat the epidermal hyperpigmentation
have long-lasting results. of melasma, but many patients appear to have a
mixed degree of epidermal and dermal pigmenta-
Café-au-lait macules (CALMs) occur in up to tion. Epidermal melasma responds well to topi-
20% of the population, with an increased prev- cal bleaching creams, retinoids, azaleic acid, and
alence during infancy decreasing into adult life. a host of procedural treatments such as chemical
Lesions present with light or dark brown, uni- peels, IPL, and laser treatments.
form melanin pigmentation. The success rate of IPL has been shown to provide 76–100%
laser treatment is highly variable, with recurrence clearance for epidermal melasma after two pulses.
rates of up to 50%. Review of the literature shows Deeper mixed melasma had poor clearance after
variable results with different laser systems, with four pulses and a high risk of postinflammatory
no one system standing out from the others. QS hyperpigmentation. IPL works best as an adju-
frequency-doubled 532-nm Nd:YAG, QS ruby, vant to topical therapy and sunscreens in resistant
or QS alexandrite lasers are useful for treating cases. One study showed a 39.8% improvement
CALMs, with a low risk of side-effects. Many le- in the IPL group when compared to the control
sions lighten or clear after treatment only to recur group who received hydroquinone and sunscreens
a few months later; other lesions have transient alone.
darkening; and others show no change at all. A Melasma appears to have a variable response to
retrospective study in Japan showed that the QS pigment-specific QS laser treatment. One study
alexandrite laser was not very efficient for nevus compared the Nd:YAG and the QS ruby laser, re-
spilus/café-au-lait spots, especially when the porting that neither was effective. The QS ruby
pigmentation had appeared after 1 year of age, laser has been shown to be effective, especially in
was treated after 5 years of age, was located on patients with a fair complexion, but recurrence
the face, was oval with a smooth border, and the is common.
patient was male. Success has been reported us- The outcomes of combined modalities to
ing the 510-nm short-pulsed dye laser to remove treat melasma have also been variable. One study
CALMs completely in childhood, and in type V demonstrated effective treatment using a com-
skin. The erbium (Erb):YAG 2940-nm laser has bination of QS alexandrite laser with carbon
been reported to be successful without repigmen- dioxide resurfacing. A split-faced study of re-
tation for a year in treating CALMs. fractory melasma also found better results with
Long-term follow-up is needed but, consider- a combined protocol using ultrapulse carbon
ing that most repigmentation occurs within 1 year, dioxide and QS alexandrite, but with more fre-
CALMs may respond well to resurfacing. Patients quent adverse effects such as postinflammatory
should be instructed to avoid sun exposure, owing hyperpigmentation.
to an increased risk of repigmentation of the le- More recently, fractionated technology has
sion. CALMs require multiple treatment sessions been applied to the treatment of melasma. Ten
at 6–8-week intervals, and a relatively low fluence patients who were unresponsive to previous
should be used. In general, lesions that remain therapy were treated at 1- to 2-week intervals
clear at 12 months have long-lasting results. with the Fraxel laser (Reliant Technologies,
Palo Alto, CA, USA). Wavelengths of 1535 and
Melasma 1550 nm were used, with treatment parameters
of 6–12 mJ per microthermal zone with 2000–
Key Points
3500 MTZ/cm2. After four to six treatment
• The underlying etiology must be addressed first. sessions, 60% of patients achieved 75–100% clear-
• All patients should be placed on bleaching creams ance and 30% had less than 25% improvement.
and high skin protection factor (SPF) sunscreens,
Patients required no downtime; one patient had
with instructions for strict sun avoidance.
• Epidermal melasma responds well to topical postinflammatory hyperpigmentation and there
bleaching creams, retinoids, azaleic acid, and a were no cases of hypopigmentation. According
host of procedural treatments such as chemical to the authors, patients with melasma should be
peels, IPL, and laser treatments. treated monthly with low energies of 6–8 mJ at
• There is a variable response to pigment-specific 1000–2000 MTZ/cm2. Patients can expect to
QS lasers in the treatment of deeper mixed have two or three treatments in total, with a
melasma. “touch-up” at 6 months.
• Effective treatment has been reported using a Prior to any laser treatment, the underlying
combination of the QS alexandrite laser with etiology must be addressed. In addition, all pa-
carbon dioxide resurfacing.
tients should be given bleaching creams and high
• The Fraxel laser has recently been shown to be
effective in treating melasma. SPF sunscreens, with instructions for strict sun
avoidance.
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Lasers: physics and medical indications 241
ERRNVPHGLFRVRUJ
242 Dermatologic Surgery
Alster TS, Lupton JR. Laser in dermatology: an over- Chong SJ, Jeong E, Park HJ, Lee JY, Cho BK. Treat-
view of types and indications. Am J Clin Dermatol ment of congenital neovomelanocytic nevi with
2001;2:291–303. the CO2 and Q-switched alexandrite lasers. Der-
Alster TS, Williams CM. Café-au-lait macule in type matol Surg 2005;31(5):518–521.
V skin: successful treatment with a 510 nm pulsed Chowdhury MM, Harris S, Lanigan SW. Potassium
dye laser. J Am Acad Dermatol 1994;33: titanyl phosphate laser treatment of resistant port-
1042–1043. wine stains. Br J Dermatol 2001;144:814–817.
Altshuler G, Anderson RR, Nanstein D, et al. Ex- Dave R, Mahaffey PJ. Combined early treatment of
tended theory of selective photothermolysis. Laser congenital melanocytic naevus with carbon dioxide
Surg Med 2001;29:416–432. and NdYag lasers. Br J Plast Surg 2004;57(8):
Anderson RR. Infant hemangiomas: a controversy 720–724.
worth solving. Lasers Surg Med 2006;38(2):92–93. David LR, Malek MM, Argenta LC. Efficacy of pulse
Anderson RR, Parrish JA. The optics of human skin. dye laser therapy for the treatment of ulcerated
J Invest Dermatol 1981;77:13–19. haemangiomas: a review of 78 patients. Br J Plast
Anderson RR, Parries JA. Selective photothermolysis: Surg 2003;56(4):317–327.
precise microsurgery by selective absorption of Downs AM, Rickard A, Palmar J. Laser treatment
pulsed radiation. Science 1983;220:524–527. of benign pigmented lesions in children: effective
Angsuwarangsee S, Polnikorn N. Combined ultra long-term benefits of the Q-switched frequency-
pulse CO2 and Q-switched alexandrite laser doubled Nd:YAG and long-pulsed alexandrite
compared with Q-switched alexandrite laser alone lasers. Pediatr Dermatol 2004;21(1):88–90.
for refractory melasma: split-face design. Dermatol Eremia S, Li CY. Treatment of face veins with a cryo-
Surg 2003;29:59–64. gen spray variable pulse width 1064 nm Nd:YAG
Barton JK, Frangineas G, Pummer H, Black J. laser: a prospective study of 17 patients. Dermatol
Cooperative phenomena in two-pulse, two-color Surg 2002;28(3):244–247.
laser photocoagulation of cutaneous blood vessels. Eremia S, Li C, Umar SH. A side-by-side compara-
Photochem Photobiol 2001;73(6):642–650. tive study of 1064nm nd:YAG, 810 nm diode and
Batta K, Goodyear HM, Moss C, Williams HC, Hiller L, 755 alexandrite lasers for treatment of 0.3-3 mm
Waters R. Randomised controlled study of early leg veins. Dermatol Surg 2002;28(3):224–230.
pulsed dye laser treatment of uncomplicated child- Fodor L, Ramon Y, Fodor A, Carmi N, Peled IJ,
hood haemangiomas: results of a 1-year analysis. Ullmann Y. A side-by-side prospective study of
Lancet 2002;360:521–527. intense pulsed light and Nd:YAG laser treatment
Bjerring P, Christiansen K, Troilius A. Intense pulsed for vascular lesions. Ann Plast Surg 2006;56(2):
light sourse for the treatment of dye laser resistant 164–170.
port-wine stains. J Cosmet Laser Ther 2003;5:7–13. Garden JM. Viral disease transmitted by laser-
Carroll L, Humphreys TR. LASER–tissue interac- generated plume (aerosol). Arch Dermatol
tions. Clin Dermatol 2006;24:2–7. 2002;38(10):1303–1307.
Chan HH, Kono T. The use of lasers and intense Goldberg DJ. Laser physician legal responsibility for
pulsed light sources for the treatment of pigmen- physician extender treatments. Lasers Surg Med
tary lesions. Skin Therapy Lett 2004;9(8):5–7. 2005;37(2):105–107.
Chan HH, King WW, Chan ES, et al. An in-vivo trial Gottschaller C, Hohenleutner U, Landthaler M. Me-
comparing the patients’ tolerability of Q-switched tastasis of malignant melanoma 2 years after carbon
alexandrite (QS alex) and the Q-switched neo- dioxide laser treatment of a pigmented lesion: case
dymium:yttrium–aluminum–garnet (QS Nd-YAG) report and review of the literature. Acta Derm
lasers in the treatment of nevus of Ota. Laser Surg Venereol 2006;86(1):44–47.
Med 1999;24:24–28. Groot D, Rao J, Johnston P, Nakatsui T. Algorithm
Chan HH, Leung RS, Ying SY, et al. A retrospec- for using a long-pulsed Nd:YAG laser in the treat-
tive analysis of complications in the treatment of ment of deep cutaneous vascular lesions. Dermatol
nevus of Ota with the Q-switched alexandrite Surg 2003;20(1):35–42.
and Q-switched Nd:YAG lasers. Dermatol Surg Hock LE, Chee LG, Khoo EY, et al. Treatment
2000;26(11):1000–1006. of acquired bilateral nevus of Ota-like macules
Chan HH, Ying SY, Ho WS, Kono T, King WW. An (Hori’s nevus) with a combination of the 532 nm
in vivo trial comparing the clinical efficacy and Q-switched Nd:YAG laser followed by the 1064
complications of Q-switched 755 nm alexan- nm Q-switched Nd:YAG is more effective: pro-
drite and Q-switched 1064 nm Nd:YAG lasers spective study. Dermatol Surg 2006;32:1–34.
in the treatment of nevus of Ota. Dermatol Surg Huikeshoven M, Koster PH, de Borgie CA, et
2000;26:919–922. al. Redarkening of port-wine stains 10 years
Chan HH, Xiang L, Leung J, Tsagn K. Lai K. In after pulsed-dye laser treatment. N Engl J Med
vitro study examining the effect of sub-lethal QS 2007;356(12):1235–1240.
755 nm lasers on the expression of p16INK4a of Kagami S, Asahina A, Watanabe R, et al. Treatment of
melanoma cell lines. Laser Surg Med 2003;32: 153 Japanese patients with Q-switched alexandrite
88–93. laser. Lasers Med Sci 2007;22(3):159–163.
ERRNVPHGLFRVRUJ
19
Chapter
Lasers: physics and medical indications 243
Kelly KM, Choi B, McFarlane S, et al. Description Renfro L, Geronemus RG. Anatomical differences of
and analysis of treatments for port-wine stain port-wine stains in response to treatment with the
birthmarks. Arch Facial Plast Surg 2005;7(5): pulsed dye laser. Arch Dermatol 1993;129(2):
287–294. 182–188.
Kono T, Chan HH, Ercocen AR, et al. Use of Rohrer TE, Chatrath V, Iyengar V. Does pulse stack-
Q-switched ruby laser in the treatment of nevus ing improve the results of treatment with variable-
of Ota in different age groups. Lasers Surg Med pulsed-dye lasers? Dermatol Surg 2004;30
2003;32:391–395. (2 Pt1):163–167.
Kono T, Manstein D, Chan HH, Nozaki M, Anderson RR. Rokhsar CK, Fitzpatrick RE. The treatment of
Q-switched ruby versus long-pulsed dye laser delivered melasma with fractional photothermolysis:
with compression for treatment of facial lentigines a pilot study. Dermatol Surg 2005;31(12):
in Asians. Lasers Surg Med 2006;38:94–97. 1645–1650.
Kono T, Sakurai H, Groff WF, et al. Compari- Ross EV, Domankevitz Y. Laser treatment
son study of traditional pulsed dye laser versus of leg veins: physical mechanisms and
a long-pulsed dye laser in the treatment of theoretical considerations. Lasers Surg Med
early childhood hemangiomas. Lasers Surg Med 2005;36:105–116.
2006;38(2):112–115. Sadick NS. Laser treatment with a 1064-nm laser for
Lu Z, Fang L, Jiao S, Huang W, Chen J, Wang X. lower extremity class I–III veins employing vari-
Treatment of 522 patients with nevus of Ota with able spots and pulse width parameters. Dermatol
Q-switched alexandrite laser. Chin Med J (Engl) Surg 2003;20(9):916–919.
2003;116(2):226–230. Shilesh I, Fitzpatrick RE. Long-pulsed dye laser
Lupton JR, Alster TS, Romero P. Clinical compari- treatment for facial telangiectasias and ery-
son of sclerotherapy versus long-pulsed Nd:YAG thema: evaluation of single purpuric pass versus
laser treatment for lower extremity telangiectases. multiple subpurpuric passes. Dermatol Surg
Dermatol Surg 2002;28(8):694–697. 2005;31(8):898–903.
Mandal A, Al-Nakib K, Quaba AA. Treatment of Suzuki H, Anderson RR. Treatment of melanocytic
small congenital nevocellular naevi using a com- nevi. Dermatol Ther 2005;18:217–226.
bination of ultrapulse carbon dioxide laser and Tanzi EL, Lupton JR, Alster TS. Lasers in dermatol-
Q-switched frequency-doubled Nd:YAG laser. ogy: four decades of progress. J Am Acad Dermatol
Aesthetic Plast Surg 2006;30(5):606–610. 2003;49:1–31.
Mariwalla K, Dover JS. The use of lasers in the pediat- Uebelhoer NS, Bogle M, Stewart B, Arndt KA,
ric population. Skin Therapy Lett 2005;10(8):7–9. Dover JS. A split-face omparison study of pulsed
Min RJ, Aimmet SE, Isaacs MN, Forestal MD. 532-nm KTP laser and 595-nm pulsed dye laser in
Endovenous laser treatment of the incompetent the treatment of facial telangiectasias and diffuse
greater saphenous vein. J Vasc Interv Radiol telangiectatic facial erythema. Dermatol Surg
2001;12(10):1167–1171. 2007;33(4):441–448.
Moreno Arias GA, Ferrando J. Intense pulsed Waldorf HA, Kauvar AN, Geronemus RG. Treat-
light for melanocytic lesions. Dermatol Surg ment of small and medium congenital nevi
2001;27:397–400. with the Q-switched ruby laser. Arch Dermatol
Nguyen CM, Yohn JJ, Weston WL. Facial port 1996;132(3):301–304.
wine stains in childhood: prediction of the rate Wang CC, Cy Hui, Sue YM, Wong WR, Hong HS.
of improvement as a function of the age of the Intense pulsed light for the treatment of refrac-
patient, size and location of the port wine stain tory melasma in Asian persons. Dermatol Surg
and the number of treatments with the pulsed dye 2004;30:1196–1200.
(585nm) laser. Br J Dermatol 1998;38:821–825. Wang CC, Sue YM, Yang CH, Chen CK. A compari-
Nouri K, Bowes L, Chartier T, Romagosa R, Spencer J. son of Q-switched alexandrite laser and intense
combination treatment of melasma with pulsed pulsed light for the treatment of freckles and len-
CO2 laser followed by Q-switched alexandrite tigines in Asian persons: a randomized, physician-
laser: a pilot study. Dermatol Surg 1999;25: blinded, split-face comparative trial. J Am Acad
494–497. Dermatol 2006;54(5):804–810.
Ozturk S, Hoopman J, Brown SA, et al. A useful Weiss RA, Weiss MA. Early clinical reselects with a
algorithm for determining fluence and pulse width multiple synchronized pulse 1064 nm laser for leg
for vascular targets using 1064 nm Nd:YAG laser telangiectasias and reticular veins. Dermatol Surg
in animal model. Lasers Surg Med 2004;34: 1999;25:399–402.
420–425. West TB, Alster TB. Comparison of the long-pulse
Park SH, Koo SH, Choi EO. Combined laser therapy dye (590–595 nm) and KTP (532 nm) lasers in the
for difficult dermal pigmentation: resurfacing treatment of facial and leg telangiectasias. Derma-
and selective photothermolysis. Ann Plastic Surg tol Surg 1999;24:221–226.
2001;47:31–36. Woo WK, Jasim Z, Handley J. 532-nm Nd:YAG
Rahman Z, Alam M, Dover JS. Fractional laser treat- and 595-nm pulsed dye laser treatment of leg
ment for pigmentation and texture improvement. telangiectasias using ultralong pulse duration.
Skin Therapy Lett 2006;11(9):7–11. Dermatol Surg 2003;29(12):1176–1180.
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244 Dermatologic Surgery
Woodrow SL, Burrows NP. Malignant melanoma Yu HS, Wu CS, Yu CL, et al. Helium–neon laser
occurring at the periphery of a giant congenital irradiation stimulates migration and prolifera-
naevus previously treated with laser therapy. Br J tion in melanocytes and induces repigmentation
Dermatol 2003;149(4):886–888. in segmental-type vitiligo. J Invest Dermatol
Yamashita T, Negishi K, Hariya T, et al. Intense 2003;120:56–64.
pulsed light therapy for superficial pigmented Zelickson B. Laser treatment of leg veins in pearls
lesions evaluated by reflectance-mode confocal from the 10th international symposium on
microscopy and optical coherence tomography. cosmetic laser surgery, Las Vegas, April 2001.
J Invest Dermatol 2006;126(10):2281–2286. J Cosmet Laser Ther 2001;3:185–204.
Yang MU, Yaroslavsky AN, Farinelli WA, et al. Long-
pulsed neodymium: yttrium–aluminum–garnet
laser treatment for port wine stains. J Am Acad
Dermatol 2005;52:480–490.
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20
Chapter
Photodynamic therapy
Christopher Charles Gasbarre and Edward V. Maytin
Clinical overview singlet state (S1). From this state, the molecule
may relax to its ground state (S0), generating heat
Key Points or fluorescence, or it may cross to a triplet state
• Photodynamic therapy requires a photosensitizer, (T1). Triplet state molecules activate ground state
activating light, and oxygen. oxygen, creating singlet oxygen (1O2), or initiat-
• Absorption of light energy by the photosensitizer ing direct photochemical effects. The majority of
leads to generation of reactive oxygen species. the effect of PDT is derived from the action of
• Singlet oxygen is the primary effector molecule, singlet oxygen (Fig. 20-1).
leading to cell necrosis, apoptosis, or induction The fluorescence emitted by the photosensi-
of inflammatory signaling cascades. tizer when decaying to the ground state may be
• Protoporphyrin IX (PpIX) is the photosensitizer
used to delineate tumor margins via a procedure
utilized in most dermatologic applications of PDT.
• Topically applied δ-aminolevulinic acid (ALA) or called fluorescence detection. This is an area of
methyl aminolevulinate (MAL) are precursors of current investigation.
PpIX. Intracellular accumulation and conversion Photosensitizer
via the heme synthesis pathway produce PpIX.
• ALA and MAL accumulate preferentially inside The first “photodynamic reaction” was described
dysplastic or rapidly proliferating cells. more than 100 years ago when it was noted that
• The light source chosen must be able to deliver light potentiated the cytotoxicity of acridine orange
light of sufficient energy and appropriate against protozoa. Since then, a variety of photo-
wavelength to the tissue of interest to be
sensitizers have been investigated in the treatment
absorbed by the photosensitizer.
of infection and malignancy. Chlorine derivatives,
phthalocyanines, and hematoporphyrin derivatives
(HPDs) have received the most attention. Der-
Mechanism matologic use has centered on the HPDs, though
The goal of photodynamic therapy (PDT) is to recent investigations have been made into the use
deliver a treatment effect preferentially to a par- of the silicon phthalocyanine Pc4.
ticular tissue via a photochemical reaction. This is The HPDs used in dermatologic applications
accomplished through the simultaneous delivery of PDT are δ-aminolevulinic acid (ALA) and
of three key components to the target tissue: methyl aminolevulinate (MAL) (Table 20-1). These
two molecules are small enough to pass through
1 a photosensitizer the epidermis. ALA has been developed in the
2 activating light of the proper wavelength USA, whereas MAL is used primarily in Europe
3 oxygen. and abroad. MAL is approved in Europe for the
treatment of actinic keratosis, basal cell carcinoma
A photosensitizer is chosen that will accumu- (BCC), and in-situ squamous cell carcinoma (SCC).
late in the cells of interest. Light is absorbed by Currently, it is not readily available in the USA.
the photosensitizer and energy is transferred to After topical application, ALA and MAL are
molecular oxygen, creating reactive oxygen spe- preferentially absorbed by damaged skin and taken
cies, which are the primary mediators of cell and up by dysplastic, metabolically active, cells. Be-
tissue damage through necrosis, apoptosis, and cause these molecules are precursors that bypass
induction of inflammatory cascades. Specifically, the rate-limiting enzyme of the heme synthesis
the photosensitizer molecule absorbs light energy pathway (ALA synthase), feedback inhibition of
(photon), thereby promoting it to the first excited the pathway does not occur and protoporphyrin
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246 Dermatologic Surgery
Photodynamic therapy
Electron excited state (S1 ) Triplet state (T1 ) Singlet oxygen ( 1O2 )
Phosphorescence
Fluorescence
Light
Figure 20-1 Diagram showing energy levels of photosensitizer excitation (adapted from Hasan et al 2006)
ERRNVPHGLFRVRUJ
20
Chapter
Photodynamic therapy 247
Cytosol
Heme Mitochondrion
Fe ferrochelatase
coproporphyrinogen III
oxidase
Coproporphyrinogen III
Hydroxymethylbilane
Figure 20-2 Heme synthesis pathway
4.0
Blu-U 417 nm
2. The wavelength must be sufficiently 3.5
absorbed by the photosensitizer used 3.0
Absorption
0.40
necessarily have to be fancy or expensive. In fact, 0.35
early topical PDT experiments were conducted 0.30
using a slide projector bulb. The absorption spec- 0.25
trum of PpIX with an overlay of a few of the 0.20
more commonly used light sources can be seen in 0.15
Figures 20-3 & 20-� 4. 0.10
450 500 550 600 650 700 750
Oxygen Wavelength (nm)
Oxygen is critical to the generation of singlet oxy- Figure 20-4 PpIX spectrum above 450 nm. IPL, intense
gen species. This may be of clinical relevance in pulsed light; KTP, potassium titanyl phosphate (green) light
hypoxic tissues. source; PDL, pulsed dye laser
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248 Dermatologic Surgery
A variety of dermatologic conditions amenable to Medical treatment options other than PDT
medical therapies have been treated with topical
Actinic keratoses
PDT (Box 20-1). To date in the USA, only treat-
ment of nonhypertrophic actinic keratoses of the Topical 5-fluorouracil
head and scalp is Food and Drug Administration Topical imiquimod
Topical diclofenac
Topical retinoids (tretinoin, adapalene, tazarotene)
B ox 2 0 - 1
Squamous cell carcinoma in situ (Bowen’s disease,
Dermatologic uses for photodynamic therapy erythroplasia of Queyrat)
FDA approved Topical 5-fluorouracil
Actinic keratoses (approval is for nonhypertrophic actinic Topical imiquimod
keratosis of head and scalp)
Oral acitretin (chemoprevention)
Commonly used in North America or Europe
Superficial basal cell carcinoma
Squamous cell carcinoma (SCC) in situ
Topical imiquimod
Basal cell carcinoma (superficial or nodular subtypes)
Photorejuvenation
Acne vulgaris
Small case series, anecdotal reports, or investigational (FDA) approved. Current international consen-
sus guidelines support the use of topical PDT
Acne inversa (hidradenitis suppurativa) for the treatment of actinic keratoses, SCC in
Verrucae vulgaris situ (Bowen’s disease), and superficial BCC.
Chemoprevention of nonmelanoma skin cancer Specifically MAL-PDT is recommended for the
treatment of nodular BCC. Medical treatment
Cutaneous T-cell lymphoma
alternatives to the afore-mentioned are listed in
Cutaneous B-cell lymphoma Box 20-2.
Keratoacanthoma
Rosacea/rhinophyma Surgical approach
Molluscum contagiosum There is a great deal of variation in published
Actinic cheilitis ALA-PDT treatment protocols. Variations in tis-
Morphea/lichen sclerosus
sue pretreatment (e.g. mild chemical peels or cu-
rettage), ALA formulation, ALA application time,
Scleroderma light source, light dose, or treatment frequency
Psoriasis may have significant effects on outcome. How-
Lichen planus ever, general consensus guidelines have been pub-
lished for topical ALA-PDT and are listed below.
Gorlin’s syndrome (basal cell nevus syndrome)
Perioral dermatitis
Sebaceous hyperplasia Topical ALA-PDT treatment algorithm
Melasma
(Fig. 20-5)
Alopecia areata Pretreatment
Darier’s disease • Continue current topical and systemic
medications.
Hailey–Hailey disease
• Consider pretreatment of hypertrophic
Infected leg ulcers actinic keratoses or severe photodamage with
Dermatophytoses a short course of 5-fluorouracil or imiquimod.
Cutaneous leishmaniasis Light sources
Extramammary Paget’s disease • Commonly used light sources are listed in
Nevus sebaceous Table 20-2.
Disseminated superficial actinic porokeratosis • Blue light: 15 min when used as single light
source, 5–8 min when used in addition
Port wine stain to intense pulsed light (IPL) or laser for
increased photobleaching.
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Chapter
Photodynamic therapy 249
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250 Dermatologic Surgery
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20
Chapter
Photodynamic therapy 251
pulsed-dye laser.
treatment benefit. Of note, DUSA currently 1–3 h. There is some evidence to suggest that time
holds US patents related to the use of ALA in to optimal ALA uptake and PpIX production
topical PDT regimens. Pharmacies compounding varies depending on the condition being treated.
other formulations of ALA in the USA have lost Therefore, these short contact times may not be
lawsuits brought by DUSA for patent infringe- ideal for the treatment of conditions other than
ment. Pretreatment of the skin with agents such actinic keratoses.
as 40% urea to improve tissue penetration has
demonstrated little to no treatment benefit for
Light source
actinic keratoses. As demonstrated above, numerous light sources
are capable of delivering an appropriate wave-
Application time length and energy to activate PpIX. Advocates of
FDA-approved use of Levulan Kerastick for the different light sources suggest improved efficacy
treatment of actinic keratoses of the face or scalp or tolerability. In general, the use of lasers does not
specified a 14–18-h application. However, since seem to be necessary, as similar efficacy and toler-
the approval of Levulan in 1999, authors have re- ability have been noted with noncoherent light
ported similar efficacy with improved tolerability sources. Some contend that greater tolerability can
using abbreviated contact times of approximately be achieved by utilizing laser sources rather than
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252 Dermatologic Surgery
broadband noncoherent light, but this has been Kennedy JC, Pottier RH, Pross DC. Photodynamic
an inconsistent finding. Longer wavelengths (red therapy with endogenous protoporphyrin IX:
and green light) have greater tissue penetration basic principles and present clinical experience.
than blue light, leading to a general conclusion J Photochem Photobiol B 1990;6(1–2):
that blue light sources, although appropriate for 143–148.
the treatment of actinic keratoses, are inferior to Morton CA, Whitehurst C, Moseley H, McColl JH,
red or green wavelengths for the treatment of Moore JV, Mackie RM. Comparison of photo-
dynamic therapy with cryotherapy in the
other conditions, such as cutaneous malignancies.
treatment of Bowen’s disease. Br J Dermatol
The flashlamp PDL (585 or 595 nm) has shown
1996;135(5):766–771.
promise as a light source in PDT protocols for the
Morton CA, Whitehurst C, Moore JV, MacKie RM.
treatment of actinic keratoses and acne. However,
Comparison of red and green light in the treat-
it is controversial whether this is due to the direct ment of Bowen’s disease by photodynamic therapy.
photoactivation of PpIX or vascular damage. Br J Dermatol 2000;143(4):767–772.
Pain control Piacquadio DJ, Chen DM, Farber HF, et al. Photo-
dynamic therapy with aminolevulinic acid topical
Tolerability of topical PDT regimens varies from solution and visible blue light in the treatment of
study to study, but most patients achieving the multiple actinic keratoses of the face and scalp:
desired treatment effect will experience at least investigator-blinded, phase 3, multicenter trials.
some discomfort (burning sensation) during, and Arch Dermatol 2004;140(1):41–46.
immediately after, the administration of light. This Salim A, Leman JA, McColl JH, Chapman R,
can usually be managed with the use of cooling Morton CA. Randomized comparison of photo-
devices and fans. The use of topical or injectable dynamic therapy with topical 5-fluorouracil in
anesthetics has unfortunately been of little ben- Bowen’s disease. Br J Dermatol 2003;148(3):
efit. More recently, some authors have reported 539–543.
improved tolerability utilizing lower fluence rates Smith S, Piacquadio D, Morhenn V, Atkin D,
during light delivery. Fitzpatrick R. Short incubation PDT versus 5-FU
in treating actinic keratoses. J Drugs Dermatol
2003;2(6):629–635.
Svanberg K, Andersson T, Killander D, et al. Pho-
References todynamic therapy of non-melanoma malignant
tumours of the skin using topical delta-amino
Alexiades-Armenakas MR, Geronemus RG. Laser- levulinic acid sensitization and laser irradiation.
mediated photodynamic therapy of actinic kera- Br J Dermatol 1994;130(6):743–751.
toses. Arch Dermatol 2003;139(10):1313–1320.
Touma D, Yaar M, Whitehead S, Konnikov N,
Avram DK, Goldman MP. Effectiveness and safety of Gilchrest BA. A trial of short incubation, broad-
ALA-IPL in treating actinic keratoses and photodam- area photodynamic therapy for facial actinic
age. J Drugs Dermatol 2004;3(1 Suppl):S36–S39. keratoses and diffuse photodamage. Arch Dermatol
Calzavara-Pinton PG. Repetitive photodynamic 2004;140(1):33–40.
therapy with topical delta-aminolaevulinic acid as Wang I, Bendsoe N, Klinteberg CA, et al. Photody-
an appropriate approach to the routine treatment namic therapy vs. cryosurgery of basal cell carcino-
of superficial non-melanoma skin tumours. mas: results of a phase III clinical trial.
J Photochem Photobiol B 1995;29(1):53–57. Br J Dermatol 2001;144(4):832–840.
Fijan S, Honigsmann H, Ortel B. Photodynamic Wennberg AM, Lindholm LE, Alpsten M, Larkö O.
therapy of epithelial skin tumours using delta- Treatment of superficial basal cell carcinomas
aminolaevulinic acid and desferrioxamine. Br J using topically applied delta-aminolaevulinic acid
Dermatol 1995;133(2):282–288. and a filtered xenon lamp. Arch Dermatol Res
Goldman M, Atkin D. ALA/PDT in the treatment of 1996;288(10):561–564.
actinic keratosis: spot versus confluent therapy.
J Cosmet Laser Ther 2003;5(2):107–110.
Haller JC, Cairnduff F, Slack G, et al. Routine double Further reading
treatments of superficial basal cell carcinomas
using aminolaevulinic acid-based photodynamic Braathen LR, Szeimies RM, Basset-Seguin N, et al.
therapy. Br J Dermatol 2000;143(6):1270–1275. Guidelines on the use of photodynamic therapy
Hasan T, Ortel B, Solban N, Pogue BW. Photo for nonmelanoma skin cancer: an international
dynamic therapy of cancer. In: Kufe D, Bast R, consensus. International Society for Photodynamic
Hait W, et al, eds. Cancer Medicine, 7th edn. Therapy in Dermatology, 2005. J Am Acad Der-
Hamilton, Ontario: BC Decker, 2006: 537–548. matol 2007;56(1):125–143.
Jeffes EW, McCullough JL, Weinstein GD, Kaplan R, Fink-Puches R, Soyer HP, Hofer A, Kerl H, Wolf P.
Glazer SD, Taylor JR. Photodynamic therapy of Long-term follow-up and histological changes of
actinic keratoses with topical aminolevulinic acid superficial nonmelanoma skin cancers treated with
hydrochloride and fluorescent blue light. J Am topical delta-aminolevulinic acid photodynamic
Acad Dermatol 2001;45(1):96–104. therapy. Arch Dermatol 1998;134(7):821–826.
ERRNVPHGLFRVRUJ
20
Chapter
Photodynamic therapy 253
Fotinos N, Campo MA, Popowycz F, Gurny R, Nestor MS, Gold MH, Kauvar AN, et al. The use
Lange N. δ-Aminolevulinic acid derivatives of photodynamic therapy in dermatology: results
in photomedicine: characteristics, application of a consensus conference. J Drugs Dermatol
and perspectives. Photochem Photobiol 2006;5(2):140–154.
2006;82(4):994–1015. Sato N, Moore B, Keevey S, Drazba J, Hasan T,
Gold MH. Aminolevulinic acid photodynamic Maytin EV. Vitamin D enhances ALA-mediated
therapy: medical evidence for its expanded use. protoporphyrin IX production and photodynamic
Expert Rev Med Devices 2006;3(3):357–371. cell death in 3-D organotypic cultures of keratino-
Morton CA, Brown SB, Collins S, et al. Guidelines cytes. J Invest Dermatol 2007;127:925–934.
for topical photodynamic therapy: report of a Strasswimmer J, Grande DJ. Do pulsed lasers pro-
workshop of the British Photodermatology Group. duce an effective photodynamic therapy response?
Br J Dermatol 2002;146(4):552–567. Lasers Surg Med 2006;38(1):22–25.
Moseley H, Ibbotson S, Woods J, et al. Clinical and
research applications of photodynamic therapy
in dermatology: experience of the Scottish PDT
Centre. Lasers Surg Med 2006;38(5):403–416.
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260 Index
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