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LIVE BLOG: Skin Cancer and Surgical Treatment Pearls

In this live blog, Dr. Jaeyoung Yoon lectures at the Summer SDPA 2013 Conference on Skin Cancer and Surgical Pearls including post-operative antibiotics and suture techniques.
 
Skin Cancer & Surgery Pearls
 
1. Respect the Basal Cell Carcinoma 
2.Caution in Immunosuppressed patients with SCC
3. Do not transect an invasive melanoma
4. Post operative antibiotics after leg surgery
5. Epinephrine effect 
6. Purse string suture 
7. Patient comfort during local anesthesia 
8. Beautiful scars for skin repairs
 
*Pearl #1: Respect the Basal Cell Carcinoma
It is true that:
+ BCC’s and recurrences are easily treated 
+ Never metastasize 
+ Very few patients die
However:
+ High Incident Rate
+ Costly 
+ Can be locally aggressive
Aggressive BCC’s:
+ Rarely can cause death 
+ Lead to disfigurement
Never:
+ Leave positive margins on high risk areas
+ Aldara/Imiquimod 
+ 5’ FU (Efudex, Carac) 
+ PDT
+CO2 Laser
Be complacent in high risk patients 
+ History of radiation therapy in childhood 
+ Recurrent tumors in high risk areas 
+ Neglected tumors
Treatment of High Risk BCC
+ Surgery still provides the highest cure rate 
+ Surgery still the gold standard of care
 
*Pearl #2: Beware of Squamous Cell Carcinoma in Immunosuppressed Patients
Immunosuppression
+ Chronic Lymphocytic Leukemia (CLL) 
+ Organ Transplant Patients
High Risk SCC: Host Immunosuppression
Incidence in Transplant Patients 
+ Sqaumous cell carcinoma: 65 fold
+ Basal cell carcinma: 10 fold
+ Melanoma: 3.4 fold
+ Kaposi: 85 fold
High Risk SCC Has Poor Differentiation
+ Minimal keratinization
+ Pleomorphic cells
+ Infilrative
+ 14% of all SCC
+ 36% of all SCC metastasis
Treatment Strategy:
+ Excisions with wide margins 
+ Mohs surgery 
+ Adjuvant radiation therapy 
+ Sentinel Lymph Node Biopsy (SLNB)
+ Close follow-up with for new cancers and recurrences
 
*Pearl #3: Do not transect an invasive melanoma
Malignant Melanoma
+ 3% of all cancers
+ >40,000 new cases per year
+ 1% of all cancer deaths, 7,800 American deaths/year
Lifetime Risk of Developing Melanoma in the U.S.
1935: 1/1500 
1960: 1/600  
1980: 1/105  
1996: 1/88
2000: 1/75
Melanoma Biopsy
+ Excisonal biopsy 
+ Punch Biopsy 
+ Shave excision
Melanoma Biopsies
+ Biopsy with any clinical suspicion
+ Biopsy if a patient is concerned
+ Biopsy using techniques to minimize Breslow thickness transection
 
*Pearl #4: Provide post-operative antibiotics for patients who have surgery below the knee
Lower Leg Surgery
+ Minimal laxity
+ Increased incidence of Poor circulation
+ Increased incidence of Infection 
+ Increased incidence of Poor healing
Chronic Venous Hypertension
+ Edema 
+ Hyperpigmentation 
+ Stasisdermatitis 
+ Chroniccellulitis 
+ Atrophyblanche 
+ Lipodermatosclerosis
+Ulceration
Lower Leg Complications
+ Flap dehiscence
+ Potential for wound infection
Post Operative Antibiotics
+ Keflex 500 mg bid for 10-14 days 
+ Clindamycin 300 mg bid for 10-14 days 
+ Ciprofloxacin 500 mg bid for 10-14 days
 
 
* Pearl #5: In situations where significant bleeding is expected, use local anesthesia with epinephrine and wait 15 minutes before starting surgery.
Lidocaine
+ Anesthetic component
+ Effect almost immediate
Epinephrine
+ Effect is vasoconstriction 
+ Prolongs the effect of lidocaine 
+ Decreases bleeding intraoperatively
Epinephrine Effect
+ Allow anesthesia and epinephrine to sit
+ Look for blanching cause by vasoconstriction
 
Pearl #6: Use purse string sutures to compress wounds that are at risk for bleeding
 
Option to Leave Wounds Open
+ With Staged Excisions
+ Wounds healing by second intention
+ Delated closure
+Patients with bleeding Risk
+ High blood resuuse
+ Anticoagulants
+ High risk anatomic sites: Scalp, Ear
Purse String Suture
+ Use a monofilament suture
+Bites into the dermis
+ Vertical or horizontal bites
+ This descreases bleeding potential
+ Reduces wound size
+ Simple, quick and requires only one suture
 
*Pearl 7: Make the injection of local anesthisia as painless as possible
 
+ Use 30 gauge needle
+ Use distraction
+ Squeeze skin around injection site to alleviate the prick feeling
+ Inject slowly very 
+ Subsequent injections into numb areas 
+ Neutralize lidicane pH 4.5 can be added 8.4% Sodium Carbonate
 
* Pearl 8: Strive for the best cosmetic outcome
 
Cosmesic in Skin Procedures
+ Punch biopsy sites heal better than large shave biopsy sites
– Exception in concave areas
+ Excision and closure provide better scars than ED&C
Subcutaneous sutures
+ Subcutaneous sutures are the most important
+ There should be minimal tension along the epidermis before top sutures are placed
+Top sutures should approximate epidermis 
+ Remove top sutures at appropriate times

[image by Tudor]




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