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Toronto Notes 2019 Basic Surgical Techniques Excision
• planyourincisionalongrelaxedskintensionlinestominimizeappearanceofscar
• useellipticalincisiontoprevent“dogears”(heapedupskinatendofincision),sothelengthoftheellipse
should be approximately 3x the width
• if needed, undermine skin edges (separate skin from underlying fascia to allow wound edge
manipulation and decrease tension)
• uselayeredclosureincludingdeepdermalsutures(decreasestension)
Skin Biopsy Types and Techniques
SHAVE BIOPSY
• usedforsuperficiallesionswheresamplingofthefullthicknessofthedermisisnotnecessaryorpractical
• mostsuitablelesionsforshavebiopsiesarebenignlesionseitherelevatedabovetheskinorhave
pathology confined to the epidermis (e.g. seborrheic or actinic keratoses, skin tags, and warts)
• highriskofrecurrencewithshavebiopsyforanylesions,includingactinicorseborrheickeratoses
• rapid,requireslittletraining,anddoesnotrequiresuturesforclosure
• healsbysecondaryintent(moistdressingsshouldbeused)
• shouldnotbeusedforpigmentedlesions–anunsuspectedmelanomacannotbeproperlystagedif
partially removed
NEEDLE BIOPSY
• 21Gforlymphnodebiopsy
• Trucut®needlebiopsyforbreastmassessuspectedforcarcinoma
INCISIONAL BIOPSY
• canbeapunchbiopsy,anellipsewithinthelesion,oranarrowmarginexcisionofthelesion
• givespathologistsaportionofthelesionandtheborderwithnormalskin
• punchbiopsiesinvolvetheremovalofacore-shapedpieceoftissuetoallowsamplingofthedeepdermis;
performed with round, disposable knives ranging in diameter from 2-10 mm
• punchbiopsywoundscanbeclosedwithsutureorlefttohealbysecondaryintention.Punchesgreater
than 3 mm may produce scarring and are best closed with one or two sutures
• punchbiopsieshavealowincidenceofinfection,bleeding,non-healing,andsignificantscarring
EXCISIONAL BIOPSY
• performedforlesionsthatrequirecompleteremovalfordiagnosticpurposes
• performedforlesionsthatcannotbeadequatelypunchbiopsiedduetosizeordepth
• forsmallpigmentedlesionsandatypicalmoles;ifconcernedaboutmelanoma,candoanarrowmargin
excision for the diagnosis and treatment of small pigmented lesions and atypical moles • bestforsmalllesionsthatareeasilyremovedandprimarilyclosed
• requiresthegreatestamountofexpertiseandtime
• alwaysrequiressuturesforclosure
TECHNIQUE
General
• allshaveandpunchbiopsiesperformedinclinicaredoneusingaseptictechnique,butarenotsterile • sterileglovesareindicatedforbiopsiesandexcisionsinallpatients
Preparing the Site
• commonskinantiseptics(Betadine®,chlorhexidine)canbeusedtopreparethebiopsysite
• chlorhexidineisusedinconcentrationsrangingfrom0.5-4%.Thehigherconcentrationcannotbeused
on the face, as it could get into the eyes or ears and may burn or cause damage. Most chlorhexidine preps also contain alcohol, which can be flammable, so allow to dry before the biopsy and certainly before using any cautery
• Betadine®(7.5%povidone–iodine)maybesaferfortheheadandneck(astoavoidtheaboveproblems with chlorhexidine) and around the eyes and ears
• marktheintendedlesionandsurgicalmarginswithasurgicalmarker,sincetheymaybetemporarily obliterated following injection of the anesthetic
• forallbiopsies,asteriledrapetechniqueisindicated.Afenestratedsurgicaldrapeisplacedaroundthe biopsy site after the area is cleansed and anesthetized
Anesthesia
• mostcommonlyusedlocalanestheticis1%or2%lidocaine(withepinephrine)
• smallamountsofepinephrineareaddedtoconstrictbloodvessels,decreasebleeding,prolonganesthesia,
and limit lidocaine toxicity. The local with epinephrine can be injected directly into the lesion
• localanestheticswithepinephrinemaybeusedanywhereinthebody,includingthedigits(exceptifthe
digits have been significantly injured and could have vascular compromise – e.g. saw injury)
• epinephrineshouldonlybeavoidedinpatientswithhistoryofvascularcompromiseifinjectingintoan
Plastic Surgery PL7
Relaxed Skin Tension Lines
Natural skin/wrinkle lines with minimal linear tension. Placing incisions parallel to relaxed skin tension lines minimizes widening/hypertrophy and helps to camouflage scars. Relaxed
skin tension lines are usually parallel to any existing wrinkle lines and perpendicular to the orientation of underlying muscle fibres
Incision Lesion
Relaxed skin tension line
©Amy Cao 2019
Figure 14. Incision of lesions along relaxed skin tension lines
area that is compromised