1. Soft Tissue Surgery Scott M. Strayer, MD, MPH Assistant Professor University of Virginia Health System Department of Family Medicine

2. Case Study n A 50 year old white male presents to your office with a large, dark mole on his back that has been there for several years. He reports that he often fishes on the Chesapeake Bay without his shirt on and has been doing this for years. He reports that the mole has been enlarging. On physical exam you find a very dark mole, approximately 7mm in diameter with an irregular border. How would you approach this lesion?

3. Significance of Skin Cancer in Primary Care n Expect to encounter 6-7 cases of basal cell cancer annually n 1-2 cases of squamous cell cancer n 1 case of melanoma

7. Introduction n Soft tissue surgery is an important skill for family practitioners to learn and practice n Identifying lesions for removal and using the proper techniques is critical n Knowing when to refer is very important

8. Topics of Discussion n identifying worrisome lesions n removal options (cryotherapy, punch biopsy,shave biopsy, incisional biopsy, and excisional biopsy) n excisional techniques (3:1 ratio) n suture types

9. Informed Consent n Get it. n Complications, Indications and Alternatives. n Need pre-printed form, plus need a note describing the above.

10. Suture Selection n Absorbable (vicryl, dexon, pds) and Non-absorbable types (skin, vascular, orthopedics). n Number of “0s” (the more “Os” the smaller the suture.

11. Common Suture Use Skin (interr.) Skin (subq) Buried Removal Location Face 5-0, 6-0 4-0 or 5-0 4-0 or 5-0 4-7 days nylon prolene synthetic absorbable Extremities,trunk 4-0 or 5-0 3-0 or 4-0 3-0 or 4-0 7-14 days nylon synth. Abs. Synth. Abs.

12. Needle Selection n Cutting-most skin surgery. n FS- for skin n P, PS, PRE for cosmetic areas n Taper-fascia and bowel n Blunt-liver and kidney n Higher number=smaller needle n Use larger needles for deep tissue, smaller needle to close the skin.

13. Needle Types

14. Cosmetic Needles

15. Anesthesia n Lidocaine n Epinephrine n Location n Toxic doses

18. Worrisome Lesions n the A, B, C’s of worrisome lesions n Asymmetry n Border irregularity n Color variegation n Diameter (>6mm) n Elevation n any lesion which the patient reports is growing, changing, irritating, bleeding, etc. n Skin surveys should be done at least yearly on asymptomatic patients, more frequently on patients with histories of skin cancer

23. Removing the Lesion n Options include punch biopsy, shave biopsy, cryotherapy, incisional biopsy, and excisional biopsy n punch biopsies should be reserved for lesions with a low index of suspicion for malignancy n cryotherapy should be used on lesions such as seborrheic keratoses, actinic keratoses, and other non-malignant lesions such as plantar warts, molluscum contagiosum, etc. n If in doubt use an excisional biopsy

24. Choice of Biopsy Technique

25. Punch Biopsy Technique

27. Complications n Scarring n Wound infection n Bleeding

28. Main Suture Techniques n Buried suture n Interrupted suture n Vertical mattress suture n Subcuticular suture

29. Suturing Techniques

30. Excisional Biopsies n Avoid danger areas such as pre-auricular, angle of mandible and posterior cervical triangle n plan excision along relaxed skin tension lines n use 3:1 ratio and mark site with gentian violet marker n use appropriate anesthesia (I.e. no epinephrine on finger tips, nose tip, tip of penis)

31. Skin Tension Lines

32. Excisional Biopsy

33. Buried Suture

34. Interrupted Suture

35. Vertical Mattress Suture

36. Uses n Wound eversion n Evenly distributes tension n Dead space closure n Good for holding tension (e.g. back) n Use on: Posterior neck, concave surfaces n Avoid on: Cosmetically sensitive areas

38. Horizontal Mattress

39. Uses n Wound eversion n Anchoring stitch n Fragile skin (e.g. elderly, steroid use) n Warnings: Tend to cause scarring and can cause necrosis if too tight, remove after 3-5 days.

40. Subcuticular Suture