Surgical Skills Surgical Workshop GPCME South Meeting Dunedin August Kate Heer, Mathew Leaper Peter Chapman-Smith

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1 Surgical Skills Surgical Workshop GPCME South Meeting Dunedin August 2014 Kate Heer, Mathew Leaper Peter Chapman-Smith

2 Thanks to Zac Moaveni and Adam Bialostocki.

3 Minor Plastic Surgical Procedures Minor in scope & complexity Not minor in importance Usually skin cancers Usually under LA Usually out-patients

4 Today we ll aim to cover: Local anaesthetic technique Punch biopsy Choosing aesthetic incisions Sutures Reconstructive toolbox Selecting the best reconstruction

5 Local Anaesthesia LA cocktail recipe: 5ml lignocaine 2% 5ml marcaine 0.5% 0.1ml adrenaline 1:1000 Gives 1:100,000 adrenaline, rapid onset and prolonged duration

6 Where can you use Adrenaline? Everywhere! But use rubber band instead on fingers

7 Tips & Tricks Keep talking (and apologising!) to patient as you inject slowly Use nerve blocks where possible Use field blocks Wait a sufficient amount of time

8 Block & Tackle the face

9 Punch Biopsy

10 Punch Biopsy To obtain full-thickness specimens for histological diagnosis. Sizes 1.5,2,3,4,5,6,8mm etc Stretch skin to ellipse ONLY useful if representative of the lesion. Always trust your instincts!

11 Contraindications Punch biopsy is not recommended for pigmented lesions

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13 Technique Inform patient and obtain consent Mark the most abnormal / thickest area of the lesion. For ulcers, include an edge with normal skin. Prep with alcohol swab Infiltrate LA with zone around lesion

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16 Technique Punch Biopsy Sterile gloves, minimal touch technique Stabilize skin and hold punch vertically Steady downward force and twisting motion Stop when you reach subcutaneous fat Use sterile needle to lift specimen (avoids crush) and cut with scissors Steristrips or suture

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18 Choosing Aesthetic Incisions

19 Resting Skin Tension Lines = Langers Lines RSTLs give the most aesthetic scars Perpendicular to muscle contraction lines Often coincide with wrinkles

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21 Elliptical & Wedge Excisions

22 Tips Longer scars better if tension is minimized. Upper trunk - make scars vertical in the midline, more oblique as you move laterally. If unsure of RSTL, use the circle to ellipse test.

23 Sutures - An Overiew

24 What will we cover? Why do we need a variety of Sutures? What is a Suture? The Ideal Suture. Suture Classifications and Sizing. Suture Materials and Common Uses.

25 Critical Wound Healing Period (by tissue type ) Skin 7 10 days Fascia/muscle 2 mths/max to 1 year Peritoneum heals quickly Stomach days Bowel days Tendon / rectum heal very slowly Organs (liver, spleen) 7 10 days

26 What is a Suture? A Suture is any strand of material used to approximate tissue or ligate blood vessels.

27 The Ideal Suture. Sterile Easy to handle Minimal tissue reaction High tensile strength Knot security Absorbable

28 Suture Classification 1. Absorbable or NonAbsorbable. 2. Braided or Monofilament. 3. Natural or Synthetic.

29 Suture Classification Absorbable Non Absorbable Hydrolysis / Enzymatic Absorption Rate Tensile Strength Encapsulated

30 Suture Classification Braided Multiple Strands Superior handling and tying Strength Monofilament Less traumatic Less bacterial harbouring

31 Suture Classification Natural Synthetic Found in nature More reactive Enzymatic breakdown Less predictable Manufactured Less Reactive Hydrolysis More predictable

32 Suture Sizing Hair Cotton 11/0 6/0 4/0 3/0 2/ Smallest Largest

33 VICRYL* Rapide Polyglactin 910 Braided Suture Superior patient comfort Superficial closure of skin and mucosa Rapid strength loss Tissue compatibility Absorption rate 42 days Tensile Strength 5 days 2 weeks

34 Coated VICRYL* Polyglactin 910 Suture Braided suture Minimal tissue reaction Preferred performance Soft tissue approximation Proven reliability Absorption rate days Tensile Strength 2 weeks 50 3 weeks 4 weeks

35 MONOCRYL* Poliglecaprone 25 Suture Knot security of a braid Easy to handle and tie Low tissue reaction Extremely strong Monofilament Smooth passage, less trauma Absorption Rate days Tensile Strength Undyed week weeks Dyed week weeks

36 PDSII* Polydiaxonone Suture Outstanding pliability Monofilament Smooth passage = Less trauma Strength for slow healing tissue Absorption 3 6 months Tensile strength 2 weeks 4 weeks 6 weeks

37 Nylon Suture Monofilament Loses c.10-15% strength per year Degrades c % per year

38 Packaging Code Information. Suture Size. Suture Material. Needle Information. Colour Code. Don t forget the Package Insert!

39 NEEDLES

40 The Ideal Needle Has the following features: Strength Stability Sharpness Ductility

41 Needle Anatomy

42 Needle Shape Straight - Skin,Tendon, Vessels ENT, Nerve. Half Curved - Skin (rarely used) 1/4 Circle - eye, Microsurgery 1/2 Circle - GI, Skin, Pelvis, ENT, Subcutaneous fat 5/8 Circle - CV, Pelvis, Urogenital. 3/8 Circle Fascia, Muscle, Tendon Periosteum Compound Curved Eye/Palate

43 Point Geometry Skin, Sternum. Calcified Tissue, Periosteum, Fascia, Ligament, Tendon. Fascia, Ligament, ENT, Skin. GI, Muscle, Nerve, Fascia, Fat, Dura.

44 Point Geometry Fascia, Intestine, Kidney, Liver, Spleen, Cervix. Eye Eye, Microsurgery. Skin (Plastic, Cosmetic).

45 Reconstructive Toolbox

46 Reconstructive Ladder Concept

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52 Skin Grafts

53 Partial Thickness Skin Grafts

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57 Full Thickness Skin Graft

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59 Local Flaps Consider Adjacent areas of spare Means of transfer Single stage if possible

60 Areas of Spares

61 Local Flaps Advancement flaps Flaps rotating about a pivot point rotation transposition interpolation

62 Advancement Flap

63 Advancement Flaps

64 Examples of Closures

65 Transposition Flaps

66 How to Approach a Reconstructive Problem?

67 Keys to success Atraumatic, sterile technique Appropriate sutures Minimize tension Wound support Wound cover Suture removal

68 Post suture removal care Wound support Massage Creams Sun protection Taping

69 Reconstructive Principles Define the problem Replace like tissue with like tissue Always have a Plan B Only living tissue heals Respect cosmetic units/sub-units

70 Cosmetic Units and Sub-units

71 Reconstructive Principles Consider potential donor sites Secondary donor defect must be acceptable Function is no less important than survival Cosmesis is no less important than function One-stage reconstruction if possible

72 Plastic Surgery is about Cheating Robbing Peter to pay Paul

73 V-Y Advancement Flap

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75 Antia-Bush Repair

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78 Romboid (Linberg) Flap

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80 Bilobed Flap

81 Rotational Flap

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89 SUMMARY > 1 solution for any given reconstructive problem Reconstructive ladder/elevator options Good surgical technique is essential SKIN STRETCHES!

90 Thanks 102