Dr Rebecca Stack Ophthalmologist Southern Eye Specialists Christchurch Eye Surgery Christchurch Mr Rob Weatherhead Ophthalmologist Southern Eye Specialists Christchurch Eye Surgery Christchurch Dr Peter Chapman-Smith Phlebologist Appearance Medicine Physician Skin and Vein Clinic Whangarei 14:00-16:00 WS #12: Basic Surgical Skills Course 16:30 18:30 WS #17: Advanced Surgical Skills Course
Surgical Skills Surgical Workshops GPCME South Meeting Christchurch August 2017 Rebecca Stack, Rob Weatherhead Peter Chapman-Smith
Thanks to Kate Heer, Mathew Leaper, Zac Moaveni and Adam Bialostocki. Sponsored by Amtech
Minor Plastic Surgical Procedures Minor in scope & complexity Not minor in importance Usually skin cancers Usually under LA Usually out-patients
Today we ll aim to cover: Local anaesthetic technique Punch biopsy Choosing aesthetic incisions Sutures Reconstructive toolbox Selecting the best reconstruction
Local Anaesthesia LA cocktail recipe: 5ml lignocaine 2% 5ml marcaine 0.5% 0.1ml adrenaline 1:1000 Or lignocaine 1% with 1:100,000 adrenaline Gives 1:100,000 adrenaline, rapid onset and prolonged duration
Where can you use adrenaline? Everywhere! But use rubber band instead on fingers
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
Block & Tackle the face
Punch Biopsy
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!
Contraindications Punch biopsy is not recommended for pigmented lesions
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
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
Choosing Aesthetic Incisions
Resting Skin Tension Lines = Langers Lines RSTLs give the most aesthetic scars Perpendicular to muscle contraction lines Often coincide with wrinkles
Elliptical & Wedge Excisions
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 pinch skin Mark lesion and excision 1 st Length 3x width
Tips Use 15 degree blade Cut vertically through dermis to subcutaneous tissue Bevel towards lesion Mark before completing excision Send everything for histology Control bleeding Undermine to help reduce tension
Tips Use deep sutures Absorbable Hold tension Eliminate dead space Start deep exit dermis
Post op care Most need no dressing Micropore option esp post suture removal Steristrips for tension or mobile areas No post op PO abs Scars 6-9 months
Sutures - An Overiew
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.
Critical Wound Healing Period (by tissue type ) Skin 7 10 days Fascia/muscle 40% @ 2 mths/max to 1 year Peritoneum heals quickly Stomach 14 21 days Bowel 14 21 days Tendon / rectum heal very slowly Organs (liver, spleen) 7 10 days
What is a Suture? A Suture is any strand of material used to approximate tissue or ligate blood vessels.
The Ideal Suture. Sterile Easy to handle Minimal tissue reaction High tensile strength Knot security Absorbable
Suture Classification 1. Absorbable or NonAbsorbable. 2. Braided or Monofilament. 3. Natural or Synthetic.
Suture Classification Absorbable Non Absorbable Hydrolysis / Enzymatic Absorption Rate Tensile Strength Encapsulated
Suture Classification Braided Multiple Strands Superior handling and tying Strength Monofilament Less traumatic Less bacterial harbouring
Suture Classification Natural Synthetic Found in nature More reactive Enzymatic breakdown Less predictable Manufactured Less Reactive Hydrolysis More predictable
Suture Sizing Hair Cotton 11/0 6/0 4/0 3/0 2/0 0 1 2 3 4 7 Smallest Largest
Covidien sutures Can purchase through Amtech Absorbable Velosorb Caprosyn Polysorb Biosyn Maxon Plain gut Chromic gut Non-absorbable Dermalon Monosof Surgilon Surgidac Ti-cron Novifil Vasculfil Sofsilk
Subcutaneous closure Hold layers together Take tension Absorbable in most cases Braided or non-braided Good tensile strength Undyed to avoid tattooing Caprosyn Vicryl Rapide Vicryl Monocryl Velosorb Velosorb Fast
Covidien Caprosyn Synthetic Monofilament Complete absorption 56 days Low reactivity to reduce inflammation and scarring Maintains integrity after frequent passes Strength 60% 5 days 20-30% 10 days
Coated VICRYL* Polyglactin 910 Suture Braided suture Minimal tissue reaction Preferred performance Soft tissue approximation Proven reliability Absorption rate 56 70 days Tensile Strength 75% @ 2 weeks 50 % @ 3 weeks 25% @ 4 weeks
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 91 119 days Tensile Strength Undyed 50 60 % @ 1 week 20 30 % @ 2 weeks Dyed 60 70 % @ 1 week 30 40 % @ 2 weeks
VICRYL* Rapide Polyglactin 910 Suture Braided Superior patient comfort Superficial closure of skin and mucosa Rapid strength loss Tissue compatibility Absorption rate 42 days Tensile Strength 50% @ 5 days 0 @ 2 weeks
Covidien Velosorb Fast Synthetic Absorbable Braided suture Used in mucosa and skin At least 45% strength at 5 days Tensile strength gone 14 days Complete absorption 40-50 days Hydoloysis? Less reaction than gut
Skin closure Absorbable or non-absorbable Monofilament vrs braided suture Tensile strength Length of time for healing Risk of scarring and inflammation
Covidien Dermalon Minimal memory Dyed blue Advantageous in regions with dark hair Excellent tensile strength
Ethicon Nylon Suture Monofilament Loses c.10-15% strength per year Degrades c. 10-15% per year
Covidien Polysorb 80% tensile strength 2 weeks 30% 3 weeks Absorbable but longer term tissue support
Packaging Code Information Suture Material Suture Size Needle Information Colour Code Don t forget the Package Insert
NEEDLES
The Ideal Needle Has the following features: Strength Stability Sharpness Ductility
Needle Anatomy
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
Point Geometry Skin, Sternum. Calcified Tissue, Periosteum, Fascia, Ligament, Tendon. Fascia, Ligament, ENT, Skin. GI, Muscle, Nerve, Fascia, Fat, Dura.
Point Geometry Fascia, Intestine, Kidney, Liver, Spleen, Cervix. Eye Eye, Microsurgery. Skin (Plastic, Cosmetic).
Reconstructive Toolbox
Reconstructive Ladder Concept
Skin Grafts
Partial Thickness Skin Grafts
Full Thickness Skin Graft
Local Flaps Consider Adjacent areas of spare Means of transfer Single stage if possible
Areas of Spares
Local Flaps Advancement flaps Rotation Flaps - a pivot point rotation transposition interpolation
Advancement Flap
Advancement Flaps
Examples of Closures Wolfe graft, VY
Transposition Flaps
How to Approach a Reconstructive Problem?
Keys to success Atraumatic, sterile technique Appropriate sutures Minimize tension Wound support Wound cover Suture removal
Post suture removal care Wound support Massage Creams Sun protection Taping
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
Cosmetic Units and Sub-units
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
Plastic Surgery is about Cheating Robbing Peter to pay Paul
V-Y Advancement Flap
Antia-Bush Repair
Romboid (Linberg) Flap
Bilobed Flap
Rotational Flap
SUMMARY > 1 solution for any given reconstructive problem Reconstructive ladder/elevator options Good surgical technique is essential SKIN STRETCHES!
Thanks www.skinandvein.co.nz 104