Surgical Approach to Skin Conditions

Surgical Approach Overview

• A surgical approach depends on whether a diagnosis is known, unknown or if the patient had a prior biopsy
• Clean field conditions are needed for surgical procedures

Known Diagnosis

• If there is a known diagnosis, the location determines the surgical approach
• For epidermal conditions like seborrheic dermatitis, freckles, or psoriasis, an epidermal approach is appropriate
• In epidermal approaches, treatment is confined to the epidermis and is superficial
• Cryo-electro surgical curettage is used for intradermal issues such as cherry angiomas or intradermal nevi
• Intradermal approaches treat areas within the dermis, or middle layer of the skin
• Use surgical excision for subdermal issues like lipomas
• A subdermal approach treats conditions beneath the dermis, deeply

Unknown Diagnosis

• Wide excision or biopsy might be needed
• If diagnosis is unknown, refer it out

Other approaches

• Shave excision is used for all

Instruments

• Essential suturing instruments include scalpels, needle drivers, toothed tissue forceps (Adson), iris scissors, and hemostats (curved and straight)
• Additional instruments can include nail splitters, curettes (scoop and dermal), skin hooks, and trocars for hormone pellet implantation

Sterile vs. Clean Technique

• Sterile technique minimizes micro-organism exposure via hand washing, sterile fields, instruments, gloves, and dressings
• Clean technique reduces overall micro-organism numbers through hand washing, clean fields, gloves, and instruments

Sharps and Biohazard

• Sharps (needles, blades) require designated containers, collected quarterly based on weight
• Biohazards (blood, bodily fluids, tissue) also require specific disposal methods

Pyogenic Granuloma

• These grow rapidly over 1-4 weeks
• They are a pencil eraser in size
• Bleed easily, are raised, and have a scale at the base due to disruption of the stratum corneum
• Occur most commonly on the palmer surface of the hand but also on the lips, temple, finger, flank, and abdomen
• Often caused by microtrauma
• Are removed by shave removal with hemostasis (pressure)

Prescription Writing Elements

• Key elements include patient name, date of birth, drug name, dosage and quantity
• Include instructions on how to take the medication (Sig), refills
• Indicate whether generic substitution is allowed, and physician signature, and whether to dispense as written

Pilar Cyst

• This is also known as a Trichilemmal cyst
• Most likely to occur on the scalp
• Lacks a visible central punctum, allowing the cyst to communicate with the outside world
• Genetic, when presenting with multiple lesions
• Characterized by thick capsular walls
• Tends to pop out of the incision
• Bleeding may occur due to being very vascular

Aseptic Technique

• This is used in surgery to minimize surgical site infection
• Surgical site infections are mostly due to contamination
• The four potential contamination sources are personnel, surgical environment, patient, and instruments

Preoperative Preparation

• Wash hands and forearms for 1-2 minutes, concentrating on fingernails, wrists, and thumbs
• Required surgical attire includes scrubs, cover gowns, face masks, surgical footwear, hair covers, and surgical gloves

Preparing the Patient

• A surgical site preparation lowers the risk of surgical site infection through removal of skin debris, dirt, and microorganisms
• Common antiseptic agents include alcohols, chlorhexidine gluconate, and povidine-iodine
• 60-95% alcohols are broad-spectrum, have a fast onset, and short acting
• Chlorhexidine gluconate is broad-spectrum, fast acting, long-acting, and has additive effects with repeated use
• Povidone-iodine it is crucial for Povidone-iodine to dry and remain uncovered

Surgical Hand Scrubs

• Surgical hand scrubs aren't a necessity for minor or short procedures
• Under the nails, remove majority of the flora, and make sure to keep nails trimmed
• Talking should be kept to a minimum during surgical procedures

Surgical Gloves

• Wearing gloves are not a substitution for cleaning hands
• You must properly put on gloves, inspect them for imperfections before proceeding
• Gloves should be switched out when compromised

Removal of the Patient's Hair

• This should only be done if it obscures the surgical field or hinders performance of proper surgical technique

Environmental Cleaning

• Equipment, lights, and countertops should be damp-dusted with a disinfectant and a clean lint free cloth
• Perform a check at the conclusion of each procedure to get rid of any discarded materials that might have fallen

Instrument Cleaning & Sterilization

• Instruments require high-grade stainless steel to persevere amidst recurrent use
• Laceration or disposable instrument kits are acceptable
• Take out residual blood, tissue and organic matter from the implements meticulously
• Devices should be placed in separate packets in preparation for the autoclave
• Instruments must either be autoclaved or soaked in a disinfectant solution

Anesthesia

• A ND cannot administer general anesthesia
• Nerve conduction can be blocked reversibly
• Action potential generation can be prevented by inhibiting Na+ influx through Na+ channels

Nerve Fiber Sensitivity

• Sensation via A-delta fibers and unmyelinated C fibers of Temperature and agony

Local Anesthetics – Amides

• Anesthetics is usually used due to its rapid onset, and minimal secondary health issues

Esters – Procaine AKA Novocaine

• Commonly used by dentists
• Moderate onset occurs over several minutes
• A moderate duration lasts 30-90 minutes
• It has a larger propensity to cause a reaction to anaphylaxis or some other secondary health issue
• 1% (10mg/cc)

Topical Anesthetics

• Routinely used with laser hair eradications and micro-needling
• Astringents are sold OTC, prepared, and with a prescription
• Ethyl chloride creates a cold ambient temperature to anesthetize

Epinephrine

• Caused vasconstriction of arterioles
• Reduces bleeding and systemic absorption
• Extends duration
• Beta-blockers can potentiate alpha stimulation that causes unopposed vasoconstriction

Indications in Wounds and Conditions that Cause Systemic Effects

• Don't use for large wounds or underlying conditions like hyperthyroidism, pheochromocytoma, severe HTN, and CAD, where it would exacerbate effects
• Don't use digital anesthesia if patients have compromised digital circulation
• Do not administer if pt already has catecholamine sensitivity
• Drug interactions include: Lurasidone and ergot alkaloids

Choosing an Anesthetic

• The best choice depends on secondary health effects or history using the substance
• Use PABA in case of allergy; procedure time or post-operative hazard

Technique

• Use topical or infiltration
• Local infiltration includes:
  • Blebs
  • Intradermal
  • Subcutaneous
• Field block for larger areas prevents the BV from sustaining damage with retraction

Reasons for Pain

• Difference in pH can cause pain as anesthetics are acidic
• Size of needle can be a factor
• Space compression may be a factor from the procedure

Reducing Pain Using Aseptic Technique;

• Add sodium bicarbonate to reduce the pH difference
• Use needles with small gauges and tiny syringes to reduce the force
• Warm the syringe by holding it in your hand

Complications And Issues that Arise

• Technique-related complications can happen by administering the substance incorrectly
• These problems can also occur by including epinephrine
• The treatment, is local injection of Phentolamine and topical nitroglycerin, these can turn around peripheral vasospasm when induced by epinephrine
• Injury caused by paresthesia / nerve damage

Systemic Adverse Effects

• The body's defense can range from slight to anaphylactic. It is more typical to transpire with PABA

Allergic/Anaphylactic Reactions

• Should be dealt with swiftly. In certain instances itching, accompanied by breathlessness can ensue
• Apply epinephrine, and provide Trendelenburg positioning alongside some Benadryl

Methemoglobinemia

• Complication of anesthetics that's very rare but very serious
• Reduced O2 in the blood, due to hemoglobin oxidized, leading to it not being able to hold O2

Wounds - Three key elements

• Wounds, the phase of healing and methods of closure
• The four phases of wound healing are Hemostasis, Inflammation, Proliferation, and Maturation & Remodeling

Complications of wound healing

• Hypertrophic scar
• Non-healing wound
• Keloid scar

Acute Wounds

• Injury mechanism breaching the tissue that constitutes the layers of the skin
• Surgical and traumatic wounds

Wound Classification

• Contaminated (non-sterile debris in the field)
• Clean (Exploratory laparotomy or thyroidectomy, hernioplasty or mastectomy, hip and knee replacements,
• Clean-Contaminated (small bowel resections, hysterectomy, laryngectomy and or TURP)
• Dirty (Surgical Management of abscess / Perforated bowels)

Chronic Wounds Considerations

• Usually because of impairments that decelerate the healing
• Acute wounds can turn into chronic if care has been neglected for over 4 weeks

Factors Responsible for slowing wound healing

• Immobilization / Malnutrition / Vascular disease / Infections, etc

The minor wound

• Assessment involves considering the allergies present
• Also be mindful of injuries and damages

The older, the higher the risk for infection;

• Small wounds need to be closed less than 18 hours after
• It can either irregular or Sharp
• And injury to adjacent tissue

Primary vs Secondary wound closure

• Primary includes clean, closed cuts
• There can also be delayed primary closures

Max Dosing of Common Anesthetics

• Dosing for drug utilization needs to be conservative

Surturing

Surturing is selected because one can monitor hemorrhage, bringing the layers as approximated

Ideal Strands include a few critical points;

• It should not be easily broken as the strands have enough elasticity
• Strands also have no reactivity in the skin and also tie a knot tightly
• Threads that are wrapped twice and sealed, inner layer is sterile

Surturing Traits

• Surture strength should be at its best and made of silk as well as nylon or polyprolylene

Surturing Needles

• Needles are swarged and its body is measured for the suture, these are chosen because these hold the inner circle of the thread
• Also includes Radius and Length

Types of Procedures

• Procedures separate and the tension is lessened by making them bend rather cutting
• Conventional, and reverse cutting techniques make it easier for the suture to be drawn into the skin

Instrumentation With Technique

• There is a procedure for putting the suture to ensure safety such as needle, and holding or pulling the skin with first suture

There is also surgeon's hand technique

• For instance , hold force and secure skin and create loops to prevent air pockets from forming

Different Suture Patterns that can be applied

• Interrupted Suturing Patterns are chosen because If one Knot fails , the approximation in others ensure that only the affected region is compromised

Wound Repair Involving Closure

• This is an crucial incision for ensuring the stratum lies underneath for the best result

Additional Skin Closure

Here are a Few More Important Points of Skin Closure For Consideration-

• Staple use is most useful in the scalp because when lacerating scalp you need to quickly place closure, you can also use skin adhesives as well as tape

Cryotherapy

• Procedure freezes out abnormalities or infected region and It is NOT to be accompanied by or require a local anesthetic
• The damage is done on cellular level

Treatment Applications Considerations for Cyrotherapy

• The number of cyrotherapy applications/attempts corresponds with the size of skin or area
• In general the area may blister then crusty and will be restored normally on its own

Dessication

• Procedures use energy to remove cells that may have been exposed
• One may need to use injected medicine in some cases

Review of Wounded Regions

• It's is important to first identify how deep that is (subcutis and dermis and hypodermis, etc)
• Some infections require prescriptions or have to be incised to provide an escape for fluid-filled sacs

Differentials to take into account if these features are in the region

• Infection, acne, or reactions may occur from bacterial origins

Key Procedure Points

• Be on the clean field. In the clinic you would choose depending on the features in that particular region

Post procedure instructions

• In rare cases some infection occurs
• It is important to understand how these lesions or region developed