CHAPTER 37: DERMATOLOGIC SURGERY

Question 1

Px may discontinue taking aspirin ___ weeks before any surgical procedure

Answer 1

2 weeks

Question 2

post-op infections MC appear ____ days after the procedure

Answer 2

4-10 days

Question 3

MC pathogen in SSI

Answer 3

S. aureus

Question 4

what wound class?

are created on normal skin
using clean or sterile technique. Examples include excision of neoplasms, noninflamed cysts, biopsies, and most cases of Mohs surgery.

Answer 4

class I: clean wounds

Question 5

what wound class?

are created on contaminated skin or any mucosal or moist intertriginous surface, such as the oral cavity, upper respiratory tract, axilla, or perineum. The infection rate of these wounds
is 10%.

Answer 5

class II: clean-contaminated wounds

Question 6

what wound class?

involve visibly inflamed
skin with/without nonpurulent discharge and have an infection rate of 20–30%.

Examples included inflamed cysts or traumatic wounds.

Answer 6

Contaminated wounds (class III)

Question 7

what wound class?

have contaminated foreign bodies, purulent discharge, or devitalized tissue. Examples included necrotic tumors, ruptured cysts, or active hidradenitis suppurativa. These wounds have an infection rate of 40%.

Answer 7

Infected wounds (class IV)

Question 8

The most common side effect of local anesthetic is

Answer 8

injection site pain.

Question 9

Injury to the ____ nerve results in brow ptosis and inability to raise the eyebrow.

Answer 9

temporal branch of the facial nerve (CN 7)

Question 10

Injury to the ___________________ nerve causes asymmetric ipsilat- eral lip elevation and inability to show the lower teeth.

Answer 10

marginal mandibular nerve

Question 11

Damage to the ____nerve causes a winged scapula, inability to shrug the shoulder, difficulty abducting the shoulder, shoul- der drop, and chronic shoulder pain.

Answer 11

spinal accessory nerve

Question 12

Innervation of muscles of facial expression via cranial nerve VII (facial nerve)

(6)

Answer 12

1. Temporal branch
Frontalis muscle (m.)
Corrugator supercilii m.
Orbicularis oculi m. (upper portion)
Auricular m. (anterior and superior; also known as
temporoparietalis m.)
2.Posterior auricular branch
Occipitalis m. Auricular m. (posterior)
3. Zygomatic branch
Orbicularis oculi m. (lower portion) Nasalis m. (alar portion)
Procerus m.
Upper lip muscles
* Levator anguli oris m. * Zygomaticus major m.
4. Buccal branch
Buccinator m. (muscle of mastication)
Depressor septi nasi m.
Nasalis m. (transverse portion)
Upper lip muscles
* Zygomaticus major and minor muscles
* Levator labii superioris m.
* Orbicularis oris m.
* Levator anguli oris m.
Lower lip muscles (orbicularis oris m.)
5. Marginal mandibular branch
Lower lip muscles
* Orbicularis oris m.
* Depressor anguli oris m.
* Depressor labii inferioris m. * Mentalis m.
Risorius m.
Platysma m. (upper portion)
6. Cervical branch
Platysma m.

Question 13

is the ability of the suture to return to its original shape after deformation, which results in poor han- dling and decreased knot security.

Answer 13

memory

Question 14

is the ability of the suture to retain its new shape after it has been stretched.

Answer 14

Plasticity

Question 15

is the ability of a suture to return to its original length and shape after stretching, an important factor to consider in relation to the resulting edema associated with surgery.

Answer 15

Elasticity

Question 16

is the ease with which the suture slides through tissue and is directly related to knot security.

Answer 16

coefficient of friction

Question 17

is the ability of the suture to wick away fluid, with braided sutures having an increased tendency to trap fluid and bacteria.

Answer 17

Capillarity

Question 18

for procedures requiring buried suture, what suture is a common choice?

Answer 18

a syn- thetic braided suture

often used across all anatomic loca- tions.

Question 19

For procedures on the trunk and extremities (i.e., areas under tension), a __________________ may be con- sidered, because the tensile strength may last longer than with synthetic braided suture, and reports indicate decreased inci- dence of “spitting” suture.

Answer 19

monofilament absorbable suture

Question 20

Facial sutures are often taken out in ________ to decrease the risk of forming track marks from epithelialization of the suture puncture site, whereas sutures on the scalp, neck, and body are often left in for about ________.

Answer 20

facial sutures: 4-7 days
scalp, neck and body: 2 wks

Question 21

Running subcuticular sutures can be left in for how many days? to add tensile strength to wounds without the risk of suture marks.

Answer 21

3 weeks

Question 22

biopsies are best suited for pedunculated, papular, or otherwise exophytic lesions

ex. Seborrheic keratosis, solar keratosis, verrucae, benign nevi, basal cell ca

Using either a No. 15 blade scalpel or a razor blade,

Contraindicated if suspicion with malignant melanoma

Aluminum chloride is recommended for hemostasis

Answer 22

shave biopsy

Question 23

type of biopsy often used for dermal lesions/ inflammatory dermatosis, sampling deeper than shave biopsies, but requiring sutures.

Answer 23

Punch biopsies

3 mm punch: for small lesions of biopsies from the face

4mm punch: adequate for histologic studies in most instances

6mm ; for scalp biopsy

Question 24

type of bipsy w/c removes an entire clinical lesion and are the biopsy of choice for pigmented lesions suspi- cious for melanoma.

for atypical pigmented lesion

for deep dermal/ subcutaneous nodules

for evaluation of margins

Answer 24

Excisional biopsies

Question 25

remove a portion of a clinical lesion and are often performed on larger plaques or patches when an excisional biopsy is not cosmetically accept- able or feasible.

ex.panniculitis, Connective tissue nevi, anetoderma, atrophoderma

Answer 25

Incisional biopsies

Question 26

is a deep incisional biopsy that can sample pathologic tissue and adjacent normal tissue; it is especially useful for pathologic diagnosis of certain inflamma- tory conditions (e.g., panniculitis, fasciitis)

Answer 26

wedge biopsy

Question 27

The mechanism of injury is the result of mul- tiple factors, including mechanical damage to cells resulting from intracellular and extracellular ice crystal formation, expo- sure to high electrolyte concentrations in surrounding nonfro- zen or thawing fluid, recrystallization patterns during thaw, and ischemia caused by vascular stasis and damage.

tx for BCC

Answer 27

cryosurgery

Question 28

best suited for use on soft or friable lesions such as warts, seborrheic and actinic keratoses, the papules of molluscum contagiosum, and select BCCs and squamous cell carcinomas (SCCs).

Answer 28

curretage

Question 29

Curettage combined with electrodesiccation (C&E) is widely used for the treatment of ?

Answer 29

BCC and SCC

Question 30

Direct current is passed through a metal treatment tip. Resistance to the flow of current causes heat to be generated, which can be adjusted
by the intensity of the current.

Hemostasis is achieved by direct heating of the tissue;

Answer 30

Electrocautery

Question 31

difference bet electrodessication and electrofulguration

Answer 31

• Electrodesiccation (desiccate, “dry up”) and electrofulguration (fulgur, “lightning”)
• In electrodesiccation, the electrode tip is in contact with the tissue; with electrofulguration, a 1–2 mm separation between the tip and the tissue produces a spark.
• Electrodesiccation causes a deeper wound, whereas electrofulguration is more superficial.

Question 32

used for very superficial lesions
ex. seborrheic or actinic keratosis, achrochordons, verrucae plana, and small epidermaln nevi

clinical endpoint: punctate bleeding

Answer 32

elctrodessication

Question 33

employs moderately damped current with a lower voltage and higher amperage.

The patient is incorporated into a biterminal circuit.

causes greater tissue damage and deeper penetration than electrodessication or electrofulguration.

used for primary BCC and SCC, trichoepitheliomas, superficial telangiectasisa, unwanted hair and ingrown toenails

Answer 33

Electrocoagulation

Question 34

employs an undamped, low-voltage, high- amperage current in a biterminal manner. This technique has the advantage of cutting with simultaneous hemostasis. As such, it is used for bloodless excisional surgery of protuber- ant masses and growths, such as rhinophyma.

Answer 34

Electrosection

Question 35

permanent hair removal of hair by causing a destructive chemical rxn at the hair root or by relying on heat for hair destruction

predates laser hair removal

Answer 35

electroepilation

Question 36

electric current introduces ions from the from the soln to the px skin and inhibits sweating by occluding eccrine ducts at the level of stratum corneum

for hyperhydrosis of palms, soles and axilla

Answer 36

iontophoreses

Question 37

are geometric segments of tissue contiguous with a skin defect that are advanced, rotated, or transposed to close a wound.

Answer 37

Local skin flaps

Question 38

are employed when primary closure or flap closure is not an available option.

it is completely excised from the donor site and is devitalized (i.e., no intrinsic Z-plastyblood supply).

Success is predicated on the reattachment of vascular supply to the graft from the defect.

Answer 38

Skin grafts

Question 39

is a tissue-sparing technique that employs frozen-section control of 100% of the surgical margin

This evaluation of the entire surgical margin using horizontal sections (not vertical, as used in standard sectioning) combined with precise mapping allows for the highest cure rate of cutaneous neoplasms

Answer 39

Mohs micrographic surgical excision

Question 40

Indications for Mohs surgery

Answer 40

• Recurrent or incompletely excised nonmelanoma skin cancer
• Tumors with aggressive histologic subtypes (infiltrative, morpheaform, micronodular, perivascular, or perineural involvement)
• Tumors with poorly defined clinical margins
• High-risk location >0.4 cm (H-zone of the face, eyes, ears, nose)
• Large tumors (>1.0 cm on face; >2.0 cm on trunk or extremities)
• Cosmetically and functionally important areas, including
  genital, anal, perianal, hand, foot, and nail units
• Tumors arising in immunosuppressed patients
• Tumors arising in previously irradiated skin or scar
• Genetic conditions with increased risk of neoplasms (basal cell nevus syndrome or xeroderma pigmentosa)

Question 41

involves the activation of a pho- tosensitizer by visible light in the presence of oxygen, resulting in the creation of reactive oxygen species, which selectively destroy the target tissue.

Answer 41

Photodynamic therapy (PDT)

Question 42

is the most common photosensitizing agent used in dermatology.

It is applied and left on the skin for a sufficient period to allow for accumulation within the target cells.

Answer 42

Delta-aminolevulinic acid (ALA)

ALA is subsequently con- verted to the photosensitizer protoporphyrin IX (PpIX), which can then be stimulated through the controlled use of a light source.

Question 43

Photodynamic therapy (PDT) is use to treat __

Answer 43

• actinic keratosis
• SCC in situ (not recommended as standard therapy for invasive SCC.