2: Surgical and Cosmetic Dermatology

Part 2Surgical and Cosmetic Dermatology

SURGICAL DERMATOLOGY

Skin cancer

Surgical margin guidelines

Tumor Type Tumor characteristics Excision Margin
Melanoma (see melanoma guide pg.) In‐situ 0.5–1 cmor Slow Mohs
consider SLN Bx for > 0.8 mm or ulceration ≤1 mm1.01–2 mm>2 mm 1 cm1–2 cm2 cm
Basal Cell Carcinoma (BCC) Low risk BCC   Well‐defined borders  Small size    Area L < 20 mm    Area M < 10 mm    Area H < 6 mm  Nodular or superficial subtype Primary tumor 3–4 mm
High Risk BCC   Poorly defined margins  Larger Size    Area L > 20 mm    Area M > 10 mm    Area H > 6 mm High risk tumor or patient features  (see indication for mohs below) Mohs or 5–10 mm
Squamous Cell Carcinoma (SCC) Low risk SCC   Well‐defined borders  Small size    Area L < 20 mm    Area M < 10 mm    Area H < 6 mm  Well differentiated histology Primary tumor 4–6 mm
High Risk SCC   Poorly defined margins  Larger Size    Area L > 20 mm    Area M > 10 mm    Area H > 6 mm  High risk tumor location (ear, lip) High risk tumor or patient features  (see indication for mohs below) Mohs or 6–10 mm
Dermatofibrosarcoma protuberans (DFSP) NCCN favors Mohs over WLE 2–4 cm to level of deep fascia
Merkel Cell Carcinoma NCCN favors WLE. Can do Mohs if it does not interfere with SNLBx 1–2 cm to investing fascia layerAdvised SLNBx.

Source: Adapted from Nahhas AF et al. J Clin Aesthet Dermatol. 2017 Apr; 10(4):37–46. Huang C and Boyce SM. Surgical margins of excision for basal cell carcinoma and squamous cell carcinoma. Semin Cutan Med Surg. 2004; 23:167–173.

Indication for Mohs micrographic surgery

Adapted from Ad Hoc Task Force, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery. J Am Acad Dermatol 2012; 67:531.

Location

  • High risk/area “H”: “mask” areas of face (central aspect of face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermillion], chin, ear and periauricular skin/sulci, temple), genitalia (including perineal and perianal), hands, feet, nail units, ankles, and nipples/areola.

    Moderate risk/area “M”: cheeks, forehead, scalp, neck, jawline, and pretibial surface.

  • Low risk/area “L”: trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles).

High‐risk tumor features

  • Recurrence/incomplete prior excision
  • Aggressive features (high risk of recurrence):
    • BCC: with morpheaform, fibrosing, sclerosing, infiltrating, micronodular, or metatypical/keratotic type.
      • Size: Area L > 20 mm; Area M > 10 mm; Area H > 6 mm
    • SCC with sclerosing, basosquamous, small cell, poorly/undifferentiated, spindle cell, pageotid, infiltrating, keratoacanthoma on the face, single cell, clear cell, lymphoepithelial, sarcomatoid, Breslow depth 2 mm or greater, and Clark’s level IV or greater
    • Perivascular/perineural invasion
    • Other tumors: adenocystic carcinoma, adnexal carcinoma, apocrine/eccrine carcinoma, atypical fibroxanthoma, DFSP, extramammary paget disease, leiomyosarcoma, merkel cell carcinoma, and malignant fibrous histiocytoma

High‐risk patient features

  • Immunocompromised (IC): transplant recipient, HIV, hematologic malignancy, or immunosuppressive medications
  • Genetic syndromes: basal cell nevus, XP, and bazex syndromes
  • Prior radiated skin: tumor arising in site of prior radiation treatment
  • Patient with history of aggressive skin cancer with no known risk factors

Melanoma ‐ AJCC TNM classification

Major changes in AJCC eighth edition
  • Round to 0.1 mm decimal for tumor depth
  • Changes to T1a and T1b to 0.8 mm threshold
  • Removal of mitotic rate for T category (recorded but not impacting T category)
  • N category – “microscopic” vs. “macroscopic” redefined as “clinically occult” and “clinically apparent”.
  • Pregnostic stage III subgroup changed (increased to IIIA–IIID)
  • N subcategories revised based on number of tumor involved lymph nodes
  • M1 categories changed – LDH no longer upstage to M1c, additional of CNS metastases to M1d.

Tips:

  • 0.8–1.0 mm = T1b or Stage IB
  • Nodal involvement → at least stage III
  • Distant mets → stage IV
T classification
Tx 1° tumor cannot be assessed
T0 No evidence of 1° tumor
Tis Melanoma in situ
T1 ≤1.0 mm a: <0.8 mm with no ulcerationb: 0.8–1.0 mm with no ulcerationor <1.0 mm with ulceration
T2 1.0–2.0 mm a: no ulcerationb: + ulceration
T3 2.0–4.0 mm a: no ulcerationb: + ulceration
T4 >4.0 mm a: no ulcerationb: + ulceration
N classification
Survival %
5 yr 10 yr
Nx Nodes cannot be assessed/not performed
N0 No regional lymphadenopathy/metastases detected
N1 1 node a: no MSI, node clinically occultb: no MSI, node clinically detected 8476 7571
0 node c: MSI present 81 75
N2 2–3 nodes a: no MSI, node clinically occultb: no MSI, node clinically detected 7971 7171
1 node c: MSI present, node detectable or occult 69 59
N3 4+ nodes a: no MSI, node all clinically occultb: no MSI, >1 node clinically detected or matted 6064 4657
2+ more nodes c: MSI present, node clinically detectable or occult 52 43
Microsatellite instability (MSI) = any in‐transit, satellite, locally recurrent, or microsatellite metastases
M classification
M Site Serum LDH
Mx Distant mets cannot be assessed N/A
M0 No distant mets N/A
M1a Distant skin, soft tissue including muscle, and/or nonregional lymph node (0) Normal(1) Elevated
M1b Lung mets (0) Normal(1) Elevated
M1c Non‐CNS visceral mets (0) Normal(1) Elevated
M1d CNS mets (0) Normal(1) Elevated

Adapted from AJCC Cancer Staging manual, Eighth Edition (2017). Balch CM et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol 2009; 27:6199–6206. Gershenwald JE et al. Melanoma staging: evidence‐based changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin 2017;67:472–492.

Clark level
Level I Confined to the epidermis (MIS)
Level II Invasion past basement membrane into the papillary dermis
Level III Tumor filling papillary dermis to the junction of the superficial reticular dermis
Level IV Invasion into the reticular dermis
Level V Invasion into the subcutaneous tissue

Clark level is no longer recommended as a staging criterion and is used for staging tumors ≤1 mm2 only if mitotic rate cannot be determined.

Breslow depth

Breslow tumor thickness is measured in mm from the top of the granular layer of the epidermis (or the base of an ulcer) to the deepest point of tumor invasion using an ocular micrometer.

Melanoma ‐ AJCC TNM staging and survival

Clinical staging Pathologic staging Survival (%)
T N M T N M 5 yr 10 yr
IA T1a 0 0 T1a 0 0 99 98
IB T1bT2a 0 0 T1bT2a 0 0 9996 9692
IIA T2bT3a 0 0 T2bT3a 0 0 9394 8888
IIB T3bT4a 0 0 T3bT4a 0 0 8690 8183
IIC T4b 0 0 T4b 0 0 82 75
IIIA Any T* N1–3 0 T1–2aT1–2a N1aN2a 0 93 88
IIIB T0T1–2aT1–2aT2b–3a N1b–cN1b–cN2bN1a–2b 0 83 77
IIIC T0T0T1a–3aT3b–4aT4b N2b–cN3b–cN2c–3cAny NN1a–2c 0 69 60
IIID T4b N3a–c 0 32 24
IV Any T Any N M1 AnyT Any N M1aM1bM1cM1d 9–27 1636

Gershenwald JE et al. Melanoma staging: evidence‐based changes in the American Joint Committee on Cancer Eighth Edition cancer staging manual. CA Cancer J Clin 2017;67:472–492.

*There are no Stage III subgroups in clinical staging.

Melanoma: treatment guidelines

Breslow depth (mm) Margin (cm) SNL* Physical exam** Workup*** Adjuvant treatment
In situ 0.5–1 No q6 mo x 1 yrthen yearly
  • Symptom specific (CT, PET, MRI)
—
<1 1 No* q6–12 mo × 5 yrthen yearly
  • Symptom specific (CT, PET, MRI)
—
1.01–2.00 1–2 Yes
  • Symptom specific (CT, PET, MRI)
—
2.01–4.00 2 Yes q3–6 mo × 2 yr, q3–12 mo × 3 yr, then yearly
  • Clinical trial
  • Observe
>4 2 Yes
  • Clinical trial
  • Observe
  • IFN α
Stage III SLN +, micromet WLE (as above) LND or clinical trial q3–6 mo × 2 yr, q3–12 mo × 3 yr, then yearly
  • CXR, CT, brain MRI, and/or PET/CT scans q3–12 mo (optional)
  • Baseline imaging for staging and symptom‐specific evaluation (CT, PET, MRI)
  • Clinical trial
  • Observe
  • IFN α
  • High‐dose ipilimumab
Stage III Clinical + nodes, macromet WLE FNA or bx of + LN, then LND
  • Clinical trial
  • Observe
  • IFN α
  • High‐dose ipilimumab
  • Biochemotherapy┼
  • ±RT to nodal basin if Stage IIIC
Stage III in‐transit WLE + FNA or Bx of in‐transit lesions Yes q3–6 mo × 2 yr, q3–12 mo × 3 yr, then yearly
  • CXR, CT, brain MRI, and/or PET/CT scans q3–12 mo (optional)
  • Baseline imaging for staging and symptom‐specific evaluation (CT, PET, MRI)
  • Intralesional BCG, IL‐2, IFN, talimogene laherparepvec (T‐VEC)
  • IFN α
  • Limb perfusion with melphalan
  • Clinical trial (preferred)
  • Radiation tx
  • Systemic tx
Stage IV FNA or bx Yes q3–6 mo × 3 yr, q4–12 mo × 2 yr, then yearly
  • Chest/abd/pelvic CT, MRI brain and/or PET CT for baseline staging and symptom‐specific evaluation, LDH BRAF testing (metastatic disease)
  • Systemic therapy preferred
  • See NCCN Guidelines
  • Clinical trial
  • Anti‐PD1 monotherapy
  • BRAF mutated: Targeted therapy (combination therapy with dabrafenib/trametinib or vemurafenib/cobimetinib)
  • Second line:
  • Dacarbazine
  • Temozolomide
  • High‐dose IL2

Source: Adapted from NCCN Practice Guideline in Oncology‐ v.2.2016 Melanoma.

*Sentinal lymph node should be performed at the time of Wide Local Excision. Consider in tumor <1 mm if initial bx with mitotic rate ≥1 mm2, ulceration, positive deep margin, angiolymphatic invasion, or young age. The yield and clinical significance of SLNBx in Stage IA is unknown and is generally not recommended.

**Followup: At least annual skin exam for life, educate patient in monthly self‐skin and lymph node exam. (Bichakjian et al. Guidelines of care for the management of primary cutaneous melanoma. JAAD 2011; 65:1032–1047)

***Evaluation: Routine imaging/lab tests not recommended in Stage 0/IA disease. In Stage IB, may consider nodal basin ultrasound prior to SLNB for patients with equivocal regional lymph node physical exam (NCCN guidelines 2.2016). CT, PET, and MRI may be performed to evaluate specific sxs.

┼Regimens include dacarbazine, temozolomide, paclitaxel, vinblastine, IL‐2, IFNα‐2b, and combinations thereof (see NCCN guidelines).

Squamous cell carcinoma (SCC)

NCCN stratification of low versus high risk cutaneous SCC
Parameters Low risk High risk
Clinical H&P
Location/size (including peripheral rim of erythema) Area L < 20 mmArea M < 10 mm Area L ≥ 20 mmArea M ≥ 10 mmArea H
Borders Well defined Poorly defined
Primary vs. recurrent Primary Recurrent
Immunosuppression − +
Site of prior radiation or chronic inflammatory process − +
Rapidly growing tumor − +
Neurological symptoms − +
Pathology
Degree of differentiation Well or moderately differentiated Poorly differentiated
High‐risk histological subtype − +
Depth (thickness or Clark’s level) <2 mm or I, II, III ≥2 mm or IV, V
Perineural, lymphatic, or vascular involvement − +
Recommended TX
  • EDC in nonterminal hair‐bearing area
  • Standard excision with 4–6 mm margin to subq
  • RT for nonsurgical cases
  • Mohs surgery
  • Standard excision may be considered with 6 mm margins
  • RT for nonsurgical cases

Source: Adapted from National Comprehensive Cancer Network stratification of low versus high‐risk cSCC.

National Comprehensive Cancer Center. NCCN Clinical Practice Guidelines in Oncology; Squamous Cell Carcinoma (V2.2018). 2018; www.nccn.org, 1 February 2018.

Area H = “mask areas” of face (central face, eyelids, eyebrows, periorbital, nose, lips [cutaneous and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, and ear), genitalia, hands, and feet.

Area M = cheeks, forehead, scalp, neck, and pretibia.

Area L = trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles).

High‐risk histologic subtype: Acantholytic (adenoid), adenosquamous (showing mucin production), desmoplastic, or metaplastic (carcinosarcomatous) subtypes.

SCC TNM classification: tumor classification AJCC vs BWH

BWH classification provides better prognostication in patients with localized disease (stratifies T2 into a and b)

AJCC eighth ed Brigham and Women’s Hospital
Tx 1° tumor cannot be assessed 1° tumor cannot be assessed
Tis/T0 SCC in situ SCC in situ
T1 <2 cm in greatest diameter with fewer than two “high‐risk” features 0 risk factors
T2 2–4 cm, or with two or more “high‐risk” features T2a: 1 risk factorT2b: 2–3 risk factors
T3
  • >4 cm
  • minor bone erosion
  • perineural invasion (tumor cells within nerve sheath > 0.1 mm or clinical/radiographic involvement of names nerves)
  • or deep invasion (beyond subq fat or >6 mm to the base of tumor)
4 risk factors or bone invasion
T4a Tumor with gross cortical bone/marrow invasion
T4b Tumor with skull base invasion and/or skull base foramen involvement
AJCC high‐risk factors:
  • >2 mm thickness
  • Clark level ≤IV
  • perineural invasion
  • primary site ear, non‐hair‐bearing lip
  • Poorly differentiated histology
BWH risk factors:
  • tumor diameter ≥2 cm
  • poorly differentiated histology
  • perineural invasion
  • tumor invasion beyond the subcutaneous fat

SCC AJCC TNM staging

T N M
0 Tis 0 0
I T1 0 0
II T2 0 0
III T3T1–3 01 00
VI T1–3Any TT4Any T 23Any NAny N 01
N1 = 1 LN+ ≤3 cm ENE−N2 = 1 LN+ ≤3 cm ipsilateral ENE+1 LN+, >3 and ≤6 cm ipsilateral ENE− or1 LN+ ≤3 cm ipsilateral ENE+≥2 LN+ all ≤6 cm ipsilateral ENE−N3 = ≥1 LN+ >6 cm ENE+1 LN+ ≤3 cm ENE+ contralateral or≥1 LN+ >3 cm ipsilateral ENE+ or ≥2 LN+, any ENE+ENE+, with extranodal extension; ENE−, without extranodal extension M0 = no distant metsM1 = distant mets

SCC ‐ Treatment of advanced disease

  • Regional disease (in‐transit and regional LN mets) – LN dissection, adjuvant radiation ± concurrent systemic therapy
  • Distal mets – Multidisciplinary approach (NCCN)
    • First line: Cisplatin ± 5‐Fluorouracil
    • Second line: Epidermal Growth Factor Receptor (EGFR) inhibitors
      • Monoclonal antibodies: Cetuximab, Panitumumab
      • Tyrosine kinase inhibitors: Erlotinib, Gefitinib
    • Emerging: Checkpoint inhibitors – Anti‐PD‐1 inhibitors: Nivolumab, Pembrolizumab

Prophylactic antibiotics and antivirals

Guideline for Prophylactic antibiotics

Use of antibiotic prophylaxis for endocarditis indicated for surgical procedure on infected tissue in patients with high‐risk cardiac lesion or as detailed below

Antibiotic (trade size) Adults Children
All sites except oral and groin/lower extremity:
Cephalexin (500 mg, 250 mg/5 ml) 2 g 50 mg/kg
Dicloxacillin (500 mg, 250 mg/5 ml) 2 g 50 mg/kg
If penicillin allergic
Azithromycin (250, 500 mg) 500 mg 15 mg/kg
Clarithromycin (500 mg, 250 mg/5 ml) 500 mg 15 mg/kg
Clindamycin (300 mg) 600 mg 20 mg/kg
Oral site:
Amoxicillin (500 mg, 250 mg/5 ml) 2 g 50 mg/kg
If penicillin allergic
Azithromycin (250, 500 mg) 500 mg 15 mg/kg
Clarithromycin (500 mg, 250 mg/5 ml) 500 mg 15 mg/kg
Clindamycin (300 mg) 600 mg 20 mg/kg
Groin and lower extremity site
Cephalexin (500 mg, 250 mg/5 ml) 2 g 50 mg/kg
If penicillin allergic
Trimethoprim‐Sulfamethoxazole, double strength 1 tab
Levofloxacin 500 mg

One hour prior to surgery: (all p.o. doses).

Algorithm for antibiotic prophylaxis

Algorithm from a box with lists of high-risk cardiac conditions and high risk for prosthetic joint infection to a box with list of the nature of the surgery, and then to boxes labeled no antibiotic and antibiotic prophylaxis.

Guideline for prophylactic antivirals

History of HSV infection of the orofacial area is an indication for prophylaxis for facial resurfacing, chemical peels, dermabrasion, PDT, and orofacial surgery. Treat for 7–14 days with acyclovir, valacyclovir, or famciclovir to suppress viral reactivation during reepithelialization.

Acyclovir (Zovirax) 400 mg tid × 7–14 d
Valacyclovir (Valtrex) 500 mg bid × 7–14 d
Famciclovir (Famvir) 250 mg bid × 7–14 d

Antiseptic scrubs

Agent Mechanism of action Gram + Gram − Mycobacteria Viruses Fungi Spores Speed of action Residual activity Other
Alcohol60–95% Denature proteins (bacterial cell wall) +++ +++ +++ +++ +++ − Fast None Flammable with laser/cauteryAllow to dry on surface
Chlorhexidine2–4% (Hibiclens) Impairs cell membrane +++ ++ + +++ + − Intermed Excellent Ototoxicity, keratitis, skin irritant
Iodine 3%(Lugol) Oxidation +++ +++ +++ +++ ++ + Intermed Minimal Skin irritantInactivated by blood/sputum
Iodophors–(Betadine)Povidone–iodine 7.5–10% Oxidation/ substitution by free iodine: disrupts S─H and N─H bonds, C═C bonds in fatty acids +++ +++ + ++ ++ − Intermed(needs to dry) Minimal Skin irritant (less than iodine)Inactivated by blood/sputumMay cross‐react with radiopaque iodineSurfactant + iodine = iodophor
TechniCare PCMXChloroxylenol Disrupts cell membrane +++ + + + + Unknown Slow Good Addition of EDTA increases its activity against pseudomonas
Triclosan0.2–2% Disrupts cell wall, inhibits fatty acid synthesis, binds bacterial enoyl–acyl carrier protein reductase (ENR, fabI) +++ ++ + +++ − Unknown Intermed Good Forms chloroform and dioxins when combined with chlorine in tap water
Benzalkonium(Quaternary ammonium) Dissociation of cell membranes; disrupts intermolecular interactions ++ + +/− +Lipophilic +/− Unknown Slow Good Use only in combination with alcoholsEyedrop preservativeEasily inactivated by cotton gauze/ organic materials

Source: Adapted from CDC. MMWR Recomm Rep. 2002 Oct 25;51(RR‐16):1–48.

Anesthetics

Mechanism of action

Reversibly inhibit nerve conduction by blocking sodium ion influx into peripheral nerve cells = prevent depolarization of nerves.

Practical tips to decrease pain with injections:

The patient

  • Distract, pinch the skin
  • Consider topical anesthesia (i.e. LMX) prior to infiltration

The anesthetic agent

  • Warming to 37–42 ºC
  • Buffered lidocaine with bicarb (increase the pH 3.3 → 7.4)

    Add 1 cc 8.4% NaHCO3 to 10 cc Lidocaine 1% with epi

The injection technique

  • Fine needle (27, 30, or 32 gauge)
  • Inject slowly
  • If possible, through a dilated pore or wound edge
  • Deeper injections into SQ area hurts less (go from deep subdermal to tight dermal)
  • Minimize needle punctures by moving in a fan shape
  • Consider nerve blocks or ring blocks

Standard formula for buffered Lidocaine

1% Lidocaine with epinephrine 1:100 000

Ingredient Quantity
Lidocaine 1% 50 ml
Sodium bicarbonate 8.4% 5 ml
Epinephrine 1:1000 0.5 ml

Tumescent anesthesia

Lidocaine 0.05–0.1% + Epinephrine 1:1 000 000

Max Tumescent is 35–50 mg/kg

Peak Lidocaine level at 12–14 hours

Ingredient Quantity
Normal saline 0.9% 1000 ml
Lidocaine 1% 50–100 ml
Sodium bicarbonate 8.4% 10 ml
Epinephrine 1:1000 1 ml

Topical anesthetic (see drug section pg 197)

EMLA cream* lidocaine 2.5% and prilocaine 2.5%
LMX lidocaine 4 and 5% in liposomal delivery cream
Lida‐Mantle lidocaine 3% cream
Topicaine lidocaine 4% and 5% gel
Pliaglis lidocaine 7% and tetracaine 7% cream

Source: Cavef et al. Arch Derm 2007;143:1074–1076.

*Risk of methemoglobinemia. Also, may create artefactual vacuolization/swelling of the upper epidermis and basal layer damage/clefting.

Pharmaceutically compounded topical anesthetic
BLT 20% benzocaine, 6% lidocaine, 4% tetracaine
TAC 0.5% tetracaine, 1:2000 epineprine, 11.8% cocaine
LET 4% lidocaine, 1:2000 epineprine, 0.5% tetracaine
Lasergel 10% lidocaine, 10% tetracaine
23/7 23% lidocaine, 7% tetracaine

Adverse reaction to local anesthetics

Condition Pulse BP Signs and symptoms Management
Vasovagal Rxn ▼ ▼ Diaphoresis, hyperventilation, nausea Trendelenburg, cool compress
Epinephrine Rxn ▲ ▲ Sweating, tachypnea, HA, palpitation Reassurance, beta‐blocker
Anaphylaxis ▲ ▼ Tachycardia, bronchospasm Epinephrine 1:1000 × 0.3 ml SQ. Antihistamine, airway maintenance
Lidocaine toxicity
1–6 μg/ml Nl Nl Tongue and circumoral paresthesia, metallic taste, tinnitus, lightheadedness Observe
6–9 μg/ml Nl Nl Tremors, nausea, vomiting, hallucination, muscle fasciculations Diazepam, airway maintenance
9–12 μg/ml ▼ ▼ Seizures, cardiopulmonary depression Respiratory support
>12 μg/ml — — Coma, cardiopulmonary arrest CPR/ACLS

Source: Adapted from Snow SN and Mikhail GR. Mohs Micrographic Surgery Second Edition. Chapter 14. Table 14–3.

Local anesthetic

Generic name Trade name Pregnancy category† Potency Onset (min) Without epinephrine With epinephrine†
Duration (min) Max dose (mg/kg) for adults Duration (min) Max dose (mg/kg) for adults
Amide (“i” before – caine = amide)
Lidocaine Xylocaine B Intermed <2 30–120 4.5(30 cc for 70 kg) 60–400 7(50 cc for 70 kg)
Bupivacaine Marcaine, Sensorcaine C* High 2–10 120–240 2.5 240–480 3
Mepivacaine Carbocaine C* Intermed 3–20 30–120 6 60–400 8
Prilocaine Citanest B Intermed 5–6 30–120 7 60–400 10
Etidocaine Duranest B High 3–5 200 4.5 240–360 6.5
Ester
Procaine Novocain C Low 5 15–30 10 30–90 14
Chloroprocaine Nesacaine C Low 5–6 30–60 10 — —
Tetracaine Pontocaine C High 7 120–240 2 240–480 2
Other – in patients who might be allergic to above
Diphenhydramine hydrochloride1% solution B — 5 15–180 Sedation with >25 mg (2.5 cc of 1%) — —
Normal saline with benzoyl alcohol preservative — — — — — — —

†Epinephrine is pregnancy category C. Low doses (diluted 1:300,000 can be used during pregnancy)

*Bupivacaine and mepivacaine: pregnancy category C due to potential for fetal bradycardia

Metabolized by Excretion Allergic reaction
Amide Liver p450 enzyme (caution in patients with liver disease) Kidney Rare, due to preservative methylparaben(if allergic: switch to preservative‐free lidocaine)
Ester Tissue pseudocholinesterase Kidney More commonDue to metabolite to PABA (p‐aminobenzoic acid)(if allergic: switch to amides)

Nerve blocks*

See Plates 1–4.

Surgical Anatomy

Anatomy of the face

Cosmetic unit of the central face
Diagram of the a human face with lines indicating the Lateral ridge, nasofacial sulcus, alar crease, columella, philtral crest, melolabial fold, vermilion-cutaneous junction, mentolabial crease, etc.

From Robinson JK (ed.). Atlas of Cutaneous Surgery, first edition. WB Saunders: 1996, p. 2, figure 1.2, with permission.

Cosmetic units of the cheek
Diagram of the anterolateral view of the face with lines indicating preauricular, malar, lower cheek, alar base nasolabial, and supramedial.

From Robinson JK (ed.). Atlas of Cutaneous Surgery, first edition. WB Saunders: 1996, p. 2, figure 1.4, with permission.

Cosmetic units of the forehead
Diagram of the anterolateral view of the face with lines indicating superior eyebrow, glabellar, general forehead, and temporal.

From Robinson JK (ed.). Atlas of Cutaneous Surgery, first edition. WB Saunders: 1996, p. 2, figure 1.3, with permission.

Cosmetic units of the nose
Diagram displaying the cosmetic units of the nose in anterior (left) and lateral (right) view. Lines indicate the nasal root, nasal dorsum, lateral sidewall, supratip, tip, ala nasi, columella, philtrum, etc.

Courtesy of Dr. Quan Vu

Anatomy of the nasal cartilage
Diagram displaying the front and lateral views of the nasal cartilage with lines marking the nasal bone, septal cartilage, lateral cartilage, lateral crus, medial crus, and alar cartilage.

Courtesy of Dr. Quan Vu

Anatomy of the ear
Diagram displaying the anatomy of the ear with lines marking the tubercle of tragus, triangular fossa, scapha, concha, crura of antihelix, helix, exterior meatus, anterior incisura, lobe, antitragus, etc.

From Robinson JK (ed.). Atlas of Cutaneous Surgery, first edition. WB Saunders: 1996, p. 186, figure 3.1, with permission.

Cosmetic units of the eye
Diagram displaying the cosmetic units of the eye with lines marking the iris, upper lid, eyebrow, lateral angle of eye, lateral canthus, lower lid, medial canthus, caruncula lacrimalis, lacrimal puncta, etc.

From Robinson JK (ed.). Atlas of Cutaneous Surgery, first edition. WB Saunders: 1996, p. 3, figure 1.5, with permission.

Anatomy of the eye
Diagram displaying a lateral cross section of the eye with lines marking the frontalis muscle, orbital fat, orbital septum, retroorbicularis fat, orbicularis oculi muscle, levator aponeurosis, tarsus, etc.

From Robinson JK (ed.). Atlas of Cutaneous Surgery, first edition. WB Saunders: 1996, p. 3, figure 1.5, with permission.

Danger zones in surgery

Diagram displaying the lateral view of a human head with parts of temporal, zygomatic, buccal, and marginal mandibular branches enclosed by a box. At the right are magnified views (detailed) of the enclosed parts.

From G Bernstein. J Dermatol Surg Oncol, 1986; 12(7):725, figure 6, with permission.

  1. Temporal branch of CN VII:
    • Most vulnerable location: mid‐zygomatic arch.
    • Nerve course: Nerve exits the superior–anterior portion of the parotid gland, then courses 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow. Nerve lies just beneath the skin, subcutaneous fat, and SMAS.
    • Motor innervation: frontalis, upper portion of the orbicularis oculi and corrugator supercilii
    • Damage: inability to raise eyebrow and wrinkle forehead. Results in a flat forehead and droopy eyebrow.
  2. Marginal mandibular branch of CN VII:
    • Most vulnerable location: mid‐mandible 2 cm lateral to the oral commissure.
    • Nerve course: Nerve exits the inferior–anterior portion of the parotid gland, then courses along the angle of the mandible across the facial artery and vein. May be 2 cm or more below the inferior edge of the mandible if the head is rotated or hyperextended. Lies beneath the skin, subcutaneous fat, and SMAS.
    • Motor innervation: orbicularis oris, risorius, mentalis, and depressor muscles of the mouth.
    • Damage: drooping of the mouth, inability to pull the lip laterally and inferiorly with smiling.
  3. Great auricular nerve (C2 and C3):
    • Most vulnerable location: 6.5 cm below the external auditory canal along the posterior border of the sternocleidomastoid muscle.
    • Nerve course: Nerve courses toward the lobule posterior to the external jugular vein.
    • Damage: Sensory innervation, results in numbness of the inferior 2/3 of the ear and adjacent cheek and neck
  4. Spinal accessory nerve (CN XI):
    • Most vulnerable location: Erb’s point.
    • Nerve course: Nerve exits from behind the SCM at Erb’s point and courses diagonally and inferiorly across the posterior triangle. Draw a line from the angle of the jaw to the mastoid process – Erb’s point is located 6 cm vertically below the midpoint of this line at the posterior border of the sternocleidomastoid (within a 2 cm area). Also may define area by drawing a line horizontally across the neck from the thyroid notch to the posterior border of the sternocleidomastoid (1 cm above and 1 cm below).
    • Innervation: location of the great auricular, less occipital, and spinal accessory nerve. The spinal accessory nerve innerves the trapezius muscle.Damage: winged scapula – inability to shrug the shoulder and abduct the arm.

Danger zone of the neck: Erb’s point

Diagram displaying anatomy of the neck with lines marking the lesser occipital nerve, great auricular nerve, external jugular vein, transverse cervical nerve, supraclavicular nerve, trapezius muscle, etc.

From RG Wheeland RG (ed.). Cutaneous Surgery, first edition. WB Saunders: 1994, p. 61, figure 5.13, with permission.

Dermatomal distribution of sensory nerves

Front and back views of the human body depicting the dermatomal distribution of sensory nerves, with C2, C3, C4, C5, C6, T1, T2, T3, T4, T5, T6,T7, T8, T9, T10, T11, T12, L1, L2, L3, L4, L5, etc. being marked.

From Leventha: Fractures, dislocations, and fracture‐dislocations of the spine. In Canale et al (eds.) Campbell’s Operative Orthopaedics, tenth edition. Mosby: 2003, Figure 35.1, with permission.

Anatomy of the lower extremity venous system

Modified from Min RJ, et al. Duplex ultrasound evaluation of lower extremity venous insufficiency. J Vasc Interv Radiol 2003 14: 1233–1241, with permission.

Anatomy of the great saphenous vein
Diagram displaying the anatomy of the lower extremity venous system, with lines marking the superficial circumflex iliac vein, femoral vein, anterior lateral tributary, anterior tributary vein, etc.
Left: Anatomy of the perforator veins with lines marking the proximal thigh PV, distal thigh PV, etc. Right: Anatomy of the short saphenous vein with lines marking the small saphenous vein, popliteal vein, etc.

Anatomy of the nail

Diagram displaying the anatomy of the nail with lines marking the distal edge of plate, plate, lunula, cuticle, proximal nail fold, eponychium, lateral nail fold, and onychodermal band.

From RK Scher and CR Daniel. Nails: Therapy, Diagnosis, Surgery, second edition. WB Saunders: 1997, p. 13–14, figures 2.1, 2.2a, 2.2b, with permission.

Top: Diagram of a fingernail with plate, bed, solehorn, distal nail fold hyponychiyum, matrix, etc. being marked. Bottom: Diagram of a toe nail with eponychium, plate, bed horny layer, volar skin, etc. being marked.

Cutaneous reconstruction

Diagram displaying a human head with circle markers on the head, forehead, eyelids, nose, philtrum, ears, chin, and cheek. Each part has a corresponding magnified view (detailed).

From Wheeland RG (ed.). Cutaneous Surgery, first edition. WB Saunders: 1994, p. 51, figure 5.6, with permission.

Undermining depths in reconstruction

Scalp Subgaleal (relatively avascular)
Forehead Subgaleal (for large defects) or subcutaneous fat above frontalis fascia
Temple/zygomatic arch Superficial subcutaneous fat above temporal branch of facial nerve
Mandible Superficial subcutaneous fat above marginal mandibular branch of facial nerve
Ear Above perichondrium
Lip Above orbicularis oris
Nose Above perichondrium/periosteum
Rest of face Superficial subcutaneous fat, above the parotid duct
Terminal hair‐bearing area Deep to hair papillae
Lateral neck Superficial subcutaneous fat above spinal accessory nerve
Trunk/extremities Above muscular fascia
Hands and feet Subdermal

Reconstruction algorithm: STAIRS

Schematic displaying a stair step with steps labeled skin graft, rotation, interpolation, advancement, transposition, and second intention/simple linear (bottom–top).

Second intention

Cosmetic result of wound healing by second intention according to anatomical site
Diagram displaying a human head with discrete shades for satisfactory, variable, and excellent cosmetic result (light–dark).
  • Ideal for
    1. Concave areas: Periorbital (medial canthus), temple, conchal bowl, and alar crease
    2. Shallow defects: i.e. shins
    3. Fair‐skinned patient (wound tends to heal with whiten scar)
    4. Poor operative candidates
  • May take weeks/months to heal, so patient must be able to perform wound care
  • May heal with atrophic, hypertrophic, white scar
  • Can perform delayed repair/graft at 2–4 weeks

Cosmetic result of wound healing by secondary intention according to anatomical site.From Zitelli JA. Wound healing by secondary intention. JAAD 1983;9(3) 407–415; with permission

Simple linear closure

  • 3–4:1 Length:width ratio
  • Orient along relaxed skin tension lines (RSTLs) at junction of cosmetic subunits
Diagram illustrating RSTL on the human face displaying orientation of simple linear closure (depicted by leaf-like shapes with shaded ellipses at the center).
RSTL on the face showing orientation of simple linear closure.
Schematic of an eye with length of 3–4 x (depicted by a horizontal two-headed arrow) and diameter of x (depicted by a vertical two-headed arrow). At the right is a horizontal line with short vertical lines.

From S Burge, R Rayment. Simple Skin Surgery. Blackwell Scientific Publications: 1986; with permission.

M‐plasty
  • Modification of the linear closure
  • GOAL: Shortens the length of a scar
Schematic of an eye with 30° angle at the left and right (with V-shaped cut) sides, with a right arrow pointing to a horizontal line with a V-shaped line at the right.

Transposition flap

  • GOAL: Redistribute tension vectors
  • Flap rotates about a pivotal point at the base of the pedicle and is transposed over an island of normal skin
  • Pivotal restraints may limit its movement
  • Wide undermining necessary to prevent pincushioning
  • Common flaps: rhombic, bilobe, z‐plasty, banner, and nasolabial (melolabial)
Rhombic
  • Used for small defects where adjacent tissue is available to rotate onto defect.
  • Changes the tension vector along the secondary defect (perpendicular to tension across primary defect).
  • Classic rhombic (Limberg) consists of parallelogram with 60º and 120º.
  • Common locations: medial canthus, upper 2/3 of nose, lower eyelid, temple, and peripheral cheek.
Schematic displaying a rhombus containing an oval, with an angle of 60° from a horizontal line (linked to the rhombus) and an oblique line (top) and a rhombus with horizontal lines connected to 2 V-shaped lines (bottom).

Modifications of rhombic flaps

Webster 30º

Narrower flap, easier to close secondary defect

Less reorientation of tension vectors

Schematic of the modifications of rhombic flaps, with a diamond shape containing a circle. The diamond is linked to a 30° angle. At the right is representation of the diamond with its bottom right side being flapped upward.

Dufourmentel

Compromise between Limberg and Webster flap

Extend dotted lines then bisect them

Second incision parallel to defect midline

Schematic of a Dufourmental flap depicted by a diamond shape with an ellipse. The diamond is linked to a 60° angle. At the right is the representation of the diamond at the left with its bottom right side being flapped upward.

Bi‐rhombic flap

Schematic depicting a bi-rhombic flap, with a rightward arrow linking a diamond shape containing a shaded ellipse (left) and an S-shaped curve with hatched lines (right).
Bilobe
  • Used for small defects 1–1.5 cm in size. Common location: lower 1/3 of nose
  • Tension is shared between the secondary and tertiary defects
Schematic with 3 irregular shapes linked by arrows, depicting a bilobed flap. Each has 4 circle markers paired into shaded and unshaded labeled 1 and 2.

Zitelli modified bilobe flap

  • Determine the location of standing cone, then draw ~90º (Zitelli modification) line
  • First lobe is at 45º – equal or slightly smaller than defect
  • Second lobe is at 90º to the standing cone
  • Wide undermining in the submuscular plane to prevent trapdoor effect
Schematic depicting Zitelli modified bilobe flap, displaying a circle, a cone shape and a wave with arrow for angle of 90° (left), linked to an irregular wave with an arrow labeled “First stitch here” (right).
Z‐plasty
  • GOAL: changing the direction of a scar or to elongate a scar.
  • Limbs of the Z should be equal lengths.
Schematic of Z-plasty, illustrated by 4 Z-shaped lines linked by arrows. A line segment and a double headed-arrow below depicts the length of initial scar and direction of initial scar, respectively.
  • The degree of the limbs determines both the direction and length of final scar.
3 Schematics of Z-plasty depicting 75% length gain with direction of final scar at 90°, 50% length gain with direction of final scar at ~65°, and 25% length gain with direction of final scar at ~40° (top–bottom).

Advancement flap

  • GOAL: modification of the linear closure, with standing cones (burow triangle) displaced to a more desirable position (i.e. away from free margin).
  • Tension vector remains parallel to the motion of the flap.
  • Types of advancement flaps: U‐plasty, H‐plasty, burow advancement, modified crescentic advancement, O → T, and island pedicle.
U‐plasty/O → U: unilateral advancement
  • Burow triangles created away from defect in one direction.
  • Useful along eyebrow and helical rim.
Schematic depicting U-plasty/0 to U: unilateral advancement, with arrows linking a diamond containing an ellipse, an irregular shape with an ellipse, and a rectangular shape with hatched lines, opened on the right side.
H‐plasty/O → H: bilateral advancement
  • Burow triangles created away from defect bilaterally.
  • Useful if tissue reservoir is available bilaterally.
Schematic depicting H-plasty/0 to H: bilateral advancement, with arrows linking a diamond containing an ellipse, a box with an ellipse, and an I-shape with hatched lines.
Burow’s advancement flap: unilateral advancement
  • Displaces one of the standing cone to a more desirable location.
  • Useful if defect is along lateral upper cutaneous lip → may displace one of the standing cone to the nasolabial folds.
Schematic depicting Burow’s advancement flap: unilateral advancement, with arrows linking a diamond containing an ellipse, an irregular shape with an ellipse, and an L-shape with hatched lines.
Modified crescentic advancement flap: unilateral advancement
  • Modification of the burow triangle.
  • Crescentic standing cone removed along the flap to lengthen it.
  • Eliminates the need for excision of a standing cone.
Schematic depicting a modified crescentic advancement flap: unilateral advancement, with arrows linking from a diamond shape with ellipse to 2 irregular shapes with ellipses, then to 2 L shapes with hatched lines.
O→ T/T‐plasty/A → T: bilateral advancement
  • Displaces one of the standing cone bilaterally.
  • Useful adjacent to a free margin or along the junction between two cosmetic units (brow, eyelid, forehead, and lip).
Schematic depicting Q→T/T-plasty/A→T: bilateral advancement, with a diamond shape with an ellipse linked by arrows to an irregular shape with an ellipse, then to 2 perpendicular lines with hatched lines.
V→Y advancement/Island pedicle/Kite flap
  • Island of tissue detached from periphery but with underlying subcutaneous and muscular pedicle.
  • Caution: no undermining to base of island – must keep flap attached to underlying pedicle to ensure good blood supply.
Schematic illustrating the V→Y advancement, island pedicle, and kite flap.

Interpolation flap

  • GOAL: coverage of large defects requiring flap with robust blood supply.
  • Commonly axial pattern flap – based on named direct cutaneous artery.
  • Robust blood supply allow greater length:width ratio.
  • Two‐staged procedure.
  • Base is usually located at some distance from defect. Pedicle must pass over or under an intervening bridge of intact skin.
  • Types of flaps: paramedian, nasolabial, and abbe.
    Flap Arterial supply Defect location Pedicle division
    Paramedian forehead Supratrochear artery Large distal nasal defect 2–3 wk
    Retroauricular helical Random flap: rich vascular supply from posterior auricular, superficial temporal, and occipital branches Large helical rim defect 3 wk
    Nasolabial Angular artery Large ala defects 2–3 wk
    Abbe Superior or inferior labial artery Large lip defect 3 wk

Rotation flap

  • GOAL: covering a defect when there is an abundant surrounding tissue reservoir.
  • Pivotal flap with a curvilinear incision – the flap and defect form a semicircle.
  • Rotates in an arc about a pivotal point near the defect.
  • Distributes the tension vector along the curvilinear line.
  • Common locations: scalp, lateral cheek, infraorbital, and temple.
  • Types of rotation flaps: unilateral rotation, bilateral rotation (O → Z), pinwheel, dorsal nasal flap, and Tenzel/ Mustarde flaps.
Unilateral rotation flap
  • Usually flap is inferiorly/laterally based to improve lymphatic drainage and decrease flap edema.
  • Consider backcut to improve mobility.
Schematic illustrating the process of unilateral rotation flap with the standing cone take anywhere along the length of the flap.
O–Z plasty/bilateral rotation flap
  • Useful when there is insufficient tissue reservoir for unilateral flap.
  • Common location: scalp.
Schematic illustrating the process of O–Z plasty/bilateral rotation flap.
Dorsal nasal rotation/Reiger/Hatchet flap
  • Useful for nasal defect <2.5 cm on the lower 2/3 of the nose, best if midline.
  • Flap along the entire nasal dorsal.
  • Undermine at the level of the perichondrium/periosteum
  • Backcut in the glabella.
Mustarde/Tenzel rotation flap
  • Laterally based cheek rotation flap.
  • Useful for defect along supramedial cheek/lower eyelid.
  • Mustarde flap mobilizes entire cheek for defect >½ of eyelid.
  • Tenzel flaps mobilizes partial cheek for defect <½ eyelid.

Skin graft

  • GOAL: surgical defect which cannot be closed with adjacent local skin or allowed to heal by second intention; useful for larger wounds, especially in areas that require tumor surveillance.
  • Stages of skin graft
    Stage Events Graft Timeline
    Imbibition “Ischemic period” – nutrient through osmosis (bolster improves osmosis) Dark color, edematous 24–48 h
    Inosculation Anastomosis of existing blood vessels Pink 48–72 h (up to 10 d)
    Neovascularization New capillary ingrowth to graft from wound bed Hypopigment, less edema 6–7 d
  • Three major types:
    1. Full thickness skin graft (FTSG) = epidermis + full dermis
    2. Split thickness skin graft (STSG) = epidermis + partial dermis
    3. Composite graft = skin (epidermis and dermis) + additional component (cartilage or fat)
FTSG
  • Minimal contraction ~15%.
  • Better cosmesis than STSG – good color, texture, and thickness match.
  • Must have intact perichondrium/periosteum for survival – higher metabolic demand than STSG = higher rates of graft failure.
  • Most useful for defects less than 3 cm.
  • Common sites: eyelids, medial canthus, helical rim, conchal bowl, nasal tip, and digits.
  • Good donor sites: preauricular/postauricular area, supraclavicular, standing cones (burow graft), conchal bowl, upper eyelid, and forehead.
STSG
  • Higher risk for contraction, poor cosmesis.
  • Useful for very large defects: can use fenestration/meshing to enlarge size.
  • Donor site heal by second intention can be painful.
  • Large grafts need to be harvested with special equipment.
  • Better survival than FTSG due to low nutritional requirements
    • Thin: 0.005–0.012 in.
    • Medium: 0.012–0.018 in.
    • Thick: 0.018–0.028 in.
Composite graft
  • Less likely to contract, better cosmesis.
  • Highest risks for necrosis due to avascular tissue (cartilage) and thicker graft.
  • Useful when bulk and structural support is needed – i.e. nasal alar defects.
Type of graft Nutritional needs Risk of graft failure Cosmesis and tissue match Contraction risk Durability/strength Sensation
FTSG High Higher Good Low Good Good
STSG Low Lower Poor High Poor Fair
Composite High Highest Good Low Excellent Fair

Causes of graft failure

  • Poor blood and nutritional supply: nicotine use, nutritional deficiency, and collagen vascular disease.
  • Poor graft bed contact: graft movement (activity, trauma, and poor immobilization), hematoma, seroma.
  • Infection: immunosuppression, diabetes, systemic disease, and poor wound care.
  • Physician technique: incomplete defatting, high tension due to inadequate size, rough tissue handling, and excessive cautery.

Sutures

Absorbable

Material Origin Filament Tensile strength 50% Absorption Reactivity Degradation
Plain gut Animal collagen* Twisted 1 wk 14–80 d High Proteolysis
Fast absorbing gut Animal collagen* Twisted 3–7 d 21–42 d High Proteolysis
Vicryl rapide Polyglactin Braided 5 d 42 d Moderate Hydrolysis
Monocryl Poliglecaprone Monofil 1 wk 90–120 d Low Hydrolysis
Chromic gut Plain gut tanned with chromium salts Twisted 2–3 wk 30–80 d High, less than plain gut Proteolysis
Dexon Polyglycolic acid Braided 2–3 wk 90 d Low Hydrolysis
Vicryl Polyglactin Braided 3 wk 80–90 d Moderate Hydrolysis
PDS Polydioxanone Monofil 4 wk 180 d Low Hydrolysis
Maxon Polyglyconate Monofil 4 wk 180 d Very low Hydrolysis

*Gut made from mucosa/submucosa of sheep or beef intestine.

Nonabsorbable

Material Origin Filament Tensile strength Reactivity Elasticity Handling
Silk Silk Braided or twisted Low, 3–6 mo High InelasticSoft suture Best
Prolene/Surgilene Polypropylene Monofil High, 2 yr Least Very elasticStiff suture Fair–good
Ethilon/Monosol/Dermalon Nylon Monofil High, losing 10–20%/yr Low Mild elasticityStiff suture Fair
Surgilon/Nurolon/Mersilene Nylon Braided High, Losing 10–20%/yr Moderate Mild elasticity Good
Ethibond/Dacron/Novafil Polyester Monofil or braided High, Permanent Low Mild elasticity Very good
Polybutester Monofil High Low Very elastic Very good

Suture removal time

Area Removal time (days)
Face 4–5
Neck 5–7
Scalp 7
Trunk 7–12
Extremities 10–14

Electrosurgery*

Modality Terminals Gap output Voltage Amperage Capability
Electrodessication 1 Markedly damped High Low Superficial destruction
Electrofulguration 1 Markedly damped High Low Superficial destruction (Spark gap)
Electrocoagulation 2 Moderately damped Mod Mod Deep penetration and destruction, Good hemostasis
Electrosection 2 Undamped Low High Cutting

*Electrocautery = not electrosurgery, no electric current, uses heat conduction.

Wound healing

Time Tensile strength vs. baseline
1 wk 5%
1 mo 40%
1 yr 80%
  • Three phases of wound healing: Inflammatory (days) → Proliferation (weeks) → Remodeling (months)
  • Platelets are the first cells to appear
  • Collagen: Early in wound healing, Collagen III predominates, then later replaced by Collagen I.

Wound dressing

Type Brand name Composition Absorptive Others Indications
Adhesive dressing
Hydrocolloids DuodermHydrocol Hydrophilic base and adhesive with polyurethane Good, absorbs water and forms gel with exudates May leave in place 1–7 d depending on exudate Pressure ulcers, second intention woundsWound with low‐to‐moderate exudates
Film dressing TegedermOp‐siteBioocclusive Polyurethane file None (may cause fluid collection)Gas permeable Impermeable to bacteria Best used in conjunction with alginate/hydrogen. Good for monitoring wounds. Lacerations/abrasions/STSG donor site
Nonadhesive dressing
Alginates SorbsanAlgiderm Cellulose like polysaccharideAlginic acid Highly Hemostatic agent: releases Ca++ Highly exudative woundsContraindicated for dry wounds
Hydrogels TegagelFlexigelCuragel Cross‐linked polymers with up to 80–90% waterSemitransparent gel Limited, not suitable for exudative wounds Cooling/pain reliefUseful for dry wounds by rehydrating the area Abrasion wounds (post laser, peels)
Foam dressing FlexzanAllevynAquacelKendall Hydrophilic foam, polyurethane, silicone Highly, gas and water permeable Compresses chronic leg wounds, conforms to body contours Pressure ulcer, exudative wound
Gauze dressing Telfa padVaseline gauze, Xeroform Excellent Cheap, readily available Use to cover nonocclusive, nonadherent dressing

Cosmetic Dermatology

Laser

Laser fundamentals: type, wavelength, depth, target and usage

Laser Wavelength (nm) Type Depth(μm) Target Usage
CO2 10 600 IR 20 Water Resurface, destruction, coagulation, cut
Erbium: YAG 2 940 IR 1 Water Superficial resurface, destruction
Thulium 1 927 IR 400 Water Nonablative fractional resurfacing
Erbium:glass 1 550 IR 400–1500 Water Nonablative fractional resurfacing
Nd:YAG 1 440, 1 450 IR 400–2000 Water Nonablative resurfacing, nonablative fractional resurfacing
Long pulsed Nd:YAG 1 320 IR 400–2000 Water Nonablative resurfacing
Nd:YAG 1 064 IR 1600–3000 Mel, Hb Deep dermal pigment, black/ blue tattoo, hair removal, non‐ablative resurface, leg veins, telangiectasia
Diode 800, 810, 930 R 1400 Mel Dermal pigment, hair removal, leg veins, vascular
Q‐Switched Alexandrite 755 R 1300 Mel Tattoo (black, blue, and green), epilation, pigmentation
Q‐Switched Ruby 694 R 1200 Mel Epidermal/dermal pigment, tattoo (black, blue, and green), hair removal
Argon‐pumped dye 630, 514, 488 O, G, B 600 Hb, mel Vascular, epidermal pigment
Pulsed dye laser (PDL) 585–595 Y 600 Hb, mel Vascular, hypertrophic scar
Copper (Bromide) vapor 578, 511 Y, G 400,300 Hb, mel Vascular, epidermal pigment
Krypton 568531 YG 400 Hb, mel Vascular, epidermal pigment
Frequency‐doubled Q‐switched Nd:YAG/ KTP 532 G 400 Mel, Hb Vascular, epidermal pigment, red tattoo
Flash lamp pumped PDL 510 G 300 Mel, Hb Vascular, hypertrophic scar
Argon 488, 514 B 200,300 Mel, Hb Vascular, epidermal pigment
Excimer 351, 308, 193 UV 0.5 Protein Psoriasis, vitiligo, LASIK
Intense pulsed light (IPL) 515–1,200 Up to 3000 Hb, mel Epidermal/dermal pigment, vascular, hair removal

IR: infrared; R: red; O: orange; Y: yellow; G: green; B: blue; UV: ultraviolet; Mel: melanin; Hb: hemoglobin; KTP: Potassium‐titanyl‐phosphate.

Laser definitions

Unit Definition
Wavelength nm —
Energy J —
Power W Rate of energy delivery, laser output
Fluence J/cm2 Amount of energy delivered per area
Pulse width sec Duration of laser exposure
Spot size mm Diameter of laser beam
Thermal relaxation time sec Time needed for the heated target to cool by 50% of its peak temperature through diffusion
Chromophore Target of laser

Laser principles (LASER = Light Amplification by Stimulated Emission of Radiation)

  1. monochromatic (single wavelength)
  2. coherent (in phase with time and space)
  3. collimated (parallel waves)

Selective photothermolysis: selective heating of a target chromophore occurs:

  1. selected wavelength is preferentially absorbed by the target chromophore
  2. energy is high enough to damage the chromophore
  3. pulse duration of the laser is shorter than the thermal relaxation of the target
equation

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Mar 13, 2021 | Posted by in Dermatology | Comments Off on 2: Surgical and Cosmetic Dermatology

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