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Procedural/Surgical Dermatology

Jennifer Lucas, MD,FAAD

Cleveland Clinic

Cleveland, OH

I Have No Conflict of Interest to Disclose

Jennifer Lucas, MD, FAAD

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Procedural/Surgical Dermatology

1.) Identify the scissors shown in the photo.– A.) Castroviejo

– B.) Iris

– C.) Metzenbaum

– D.) Tenotomy

– E.) Shortbent

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Gradle Iris Castroviejo Tenotomy

Tissue Scissors - Examples

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Metzenbaum Scissors

Undermining

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Suture Scissors – Examples

ShortbentO’Brien Standard Operating

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Other Instruments To Know

Forceps

Blades

Nail Equipment

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Forceps - Examples

Brown AdsonMultiple fine teethTissue handling/grasping

Toothed AdsonTissue HandlingMinimize trauma

Bishop HarmonSmall sizeDelicate

SemkenInternal postThin, sleek

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Forceps - Examples

Foerster

Jeweler's

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Nail Equipment - Examples

Periosteal ElevatorRaise nail fold

HemostatGripping

Hemostasis

Nail SplittersDividing nail plate

Allis Forceps/ClampGrasping tissue or

Nail plate

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Blades - Examples

11 BladeSharp point

I&D, stabbing

15 BladeMost derm surgery

10 BladeThick skin – backLarger procedures

67 Blade – Beaver bladeSmall, thin, roundedDelicate, concavities

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2.) The suture technique designated by the arrow was most appropriately utilized for which of the following reasons?– A.) Wound inversion

– B.) Wound eversion

– C.) Hemostasis

– D.) Minimize tram tracking

– E.) Minimize trauma to poorly vascularized tissue

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Far-Far-Near-Near

Vertical Mattress

Eversion

Tension

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Horizontal Mattress

Tension

Hemostasis

Eversion

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D.) Minimize Tram Tracking –

Running Subcuticular

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E.) Minimize trauma to poorly vascularized tissue

Half Buried Horizontal Mattress

Tip Stitch

Approximate

a corner

Minimize Necrosis

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3.) In designing the excision

and repair of the lesion shown,

which of the following would be

most appropriate?

– A.) Z-plasty to elongate the scar

– B.) Incorporation of 2 week, pulley

stitches to account for tension

– C.) S-plasty to minimize the

standing cones

– D.) Secondary intention healing as

the wound cannot be closed

– E.) Elliptical excision with a 2:1

ratio of width to length

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S-Plasty

Convex Surfaces

– Minimizes standing cones, puckering, & contraction

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A

CD

ab

B

B

A

D

C

b

a

Z-PlastyLengthen

Reorient

S-PlastyMinimize Standing Cones,

Puckering, & Contraction

Convex Surface

M-PlastyDecrease Length

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B.) Incorporation of 2 week, pulley stitches to

account for tension Possible Tissue Necrosis

Temporary

Tension Relief

Alignment

Far-Near-Near-FarBoards Blitz 2018

Other Answers

Wound Can Be Closed

– Secondary Intention Healing Not Mandated

Elliptical Excision – > 3:1 Length to Width Ratio

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4.) The location of the surgical

defect in the photo receives its

sensory innervation from

which of the following?

– A.) Trigeminal nerve - V3

– B.) Trigeminal nerve – V2

– C.) Mental nerve

– D.) Infraorbital nerve

– E.) External nasal branch of the

anterior ethmoidal nerve

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V1

V2

V3

Supratrochlear

Supraorbital

Infratrochlear

Infraorbital

External Nasal Branch of the

Anterior Ethmoidal

Mental

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Radial

Radial

Median

Median

Ulnar Ulnar

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Sural

SuperficialPeroneal

Saphenous

Deep Peroneal

Deep Peroneal

Sural

Posterior Tibial

Saphenous

SuperficialPeroneal

SuperficialPeroneal

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5.) This 84-year-old female presents for Mohs micrographic surgery for a squamous cell carcinoma. Which of the following is a potential risk of the surgery?

– A.) Upward displaced ipsilateral oral commissure

– B.) Loss of forehead sensation extending to the scalp

– C.) Injury to the tear duct/canaliculi

– D.) Ectropion

– E.) Frozen/drooped ipsilateral eyebrow

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Cranial Nerve VII – Temporal Branch

Danger Zone

– Earlobe to most superficial

forehead crease

– Earlobe to lateral eyebrow

– Crosses over zygomatic arch

Injury affects the following

muscles

– Frontalis frozen eyebrow

– Corrugator supercilii

– Obicularis Oculi (upper portion)

– AuricularBoards Blitz 2018

Marginal Mandibular Nerve

CN VIIInnervates:

– Orbicularis oris (lower portion), Depressor anguli oris,

Depressor labii inferioris, Mentalis

– Injury

Asymmetric smile

Inability to protrude the lower lip/whistle

Upward and lateral pull on the mouth

– Resting grimace

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C.) Injury to the tear duct/canaliculi

Medial Location

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Puncta

Canaliculi

Lacrimal Sac

Nasolacrimal Duct

Puncta

6.) A biopsy is required of the lesion shown in the photo. Which of the following is essential to achieve an accurate diagnosis?– A.) Biopsy of the nail bed is required

– B.) A nail plate clipping is sufficient

– C.) A vertical excision to include all visible pigmentation

– D.) Biopsy of the most proximal aspect of the pigment

– E.) A transverse/horizontal excision of the matrix to avoid nail thinning

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Image: Longitudinal Melanoychia

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Nail Anatomy

Proximal nail matrix external surface

Distal nail matrix under surface

Proximal

Distal

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Nail Matrix Biopsy – A Few Pearls

Biopsy most proximal aspect of pigment

Proximal placement Higher risk of visible defect

< 3mm punch can be left unsutured

Transverse ellipse - Can lead to nail thinning

Vertical ellipse Potential loss of nail

– Can be used for lateral nail

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7.) Identify the flap

shown in the photo?

– A.) Advancement

– B.) Island Pedicle

– C.) Rotation

– D.) Transposition

– E.) Interpolation

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Advancement Flap

Linear movement of adjacent skin into the defect

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A-T (O-T) Advancement Flap Island Pedicle Flap

V – Y advancement flap

Kite flap

Dermis is circumferentially

transected

Blood supply maintained at

the base

– Myocutaneous

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Rotation Flap

Curvilinear Line

Transposition Flaps

Flap crosses over normal tissue

Examples:

– Rhombic

– Bilobe

– Melolabial

– Trilobe

– Banner

Interpolation Flap

Transposed tissue

Maintenance of a pedicle

– 3 weeks

Examples:

– Paramedian forehead

– Melolabial

– Abbe flap (Lip switch)

Helpful Resources

Baker SR. (2014) Baker Local Flaps in Facial Reconstruction, Third

Edition; Saunders Elsevier

Robinson, June K., et. al (Eds.) (2015) Surgery of the Skin: Procedural Dermatology,

Third Edition; Saunders Elsevier

Vidimos, Allison T. Ammirati, Christie T., Poblete-Lopez, Christine (Eds.) (2009)

Requisites in Dermatology: Dermatologic Surgery; Saunders Elsevier

8.) Identify where the star will be located when the flap is sutured into place?– A.) A– B.) B– C.) C

– D.) D– E.) E

AB

C

DE

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9.) Identify where the

star will be located

when the flap is

sutured into place.

– A.) A

– B.) B

– C.) C

– D.) D

– E.) E

C

B

A

D

E

Rhombic Transposition Flap

C

C

10.) Identity where the

star will be located

when the flap is

sutured into place?

– A.) A

– B.) B

– C.) C

– D.) D

– E.) None of the above

A

B

C

D

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Helpful Resources

Baker SR. (2014) Baker Local Flaps in Facial Reconstruction, Third

Edition; Saunders Elsevier

Robinson, June K., et. al (Eds.) (2015) Surgery of the Skin: Procedural Dermatology,

Third Edition; Saunders Elsevier

Vidimos, Allison T. Ammirati, Christie T., Poblete-Lopez, Christine (Eds.) (2009)

Requisites in Dermatology: Dermatologic Surgery; Saunders Elsevier

11.) A healthy 67-year-old male

presents 5 days post surgery

with the findings shown. He is

complaining of pain. What

would be the most appropriate

next course of treatment?

– A.) Topical triamcinolone

– B.) Topical mupirocin

– C.) Open the wound to manage

active bleeding

– D.) Oral dicloxacillin

– E.) Debride the necrotic tissue

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Post-Op Wound Infection

Bacterial

– Pain, Purulent Drainage

– Antibiotics

– MRSA

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Necrosis

General Rule: Try not to debride too quickly

“Biologic Bandage”

– Underlying tissue is often viable

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12.) The electrosurgery

technique shown in the

photo would be best utilized

for which of the following

treatments?

– A.) Dermatosis papulosa nigra

– B.) Intraoperative hemostasis

– C.) Electrodessication and

curettage

– D.) Hemostasis in a wet field

– E.) Cutting of tissue

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Electrosurgery

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ElectrodessicationMonoterminal Voltage Amperage

ElectrofulgurationMonoterminal Voltage Amperage

ElectrocoagulationBiterminal Voltage Amperage

ElectrosectionBiterminal Voltage Amperage

Undamped current

12.) The electrosurgery technique shown in the photo

would be best utilized for which of the following

treatments?

– A.) Dermatosis papulosa nigra

– B.) Intraoperative hemostasis

– C.) Electrodessication and curettage

– D.) Hemostasis in a wet field

– E.) Cutting of tissue

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Electrofulguration

Electrocoagulation

Electrocautery

Electrosection

Electrodessication

13.) The biopsy proven melanoma in the photo above, has the synoptic report

shown. What would be the most appropriate treatment for this patient?

– A. Excision with 1 cm margins to mid subcutaneous tissue

– B. Excision with 2 cm margins to mid subcutaneous tissue

– C. Excision with 0.5 cm margins to fascia

– D. Excision with 1 cm margins to fascia

– E. Excision with 1 cm margins to fascia and sentinel lymph node biopsy

Subtype: Superficial Spreading

Depth 0.3 mm

No lymphovascular invasion

Mitotic Rate : 0/ sq mm

No Regression

No Ulceration

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Melanoma: Surgical Treatment

AADNCCN (1.2018)

– In-situ: 0.5 cm to 1

cm

– < 1.0 mm: 1 cm

– > 1-2 mm: 1-2 cm

– >2-4 mm: 2 cm

– > 4 mm: 2 cm

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Sentinel Lymph Node Biopsy

AAD

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14.) This patient has involvement

of the upper and lower right

eyelids with the clinical lesion

shown. You are planning to

proceed with laser treatment.

Which of the following would be

the most appropriate eye

protection for the patient?

– A.) Eye protection is not required

– B.) Lubricant to the periocular field

– C.) Laser goggles

– D.) Plastic corneal shield

– E.) Stainless steel corneal shield

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Laser Safety

Eye protection required for all

Treatment of the eyelids (Inside the orbital rim)

– Stainless steel corneal shield

Risk for corneal abrasion

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15.) After receiving onabotulinumtoxinA injections for

glabellar and forehead rhytides your patient develops the

changes shown. He is upset and requesting treatment.

Which of the following is the most appropriate treatment

option?

– A.) Apraclonodine 0.5% drops to stimulate muller’s muscles

– B.) OnabotulinumtoxinA injections of the lower eyelid

– C.) Topical Lidocaine

– D.) Oral glycopyrrolate

– E. ) CanthopexyBoards Blitz 2018

Image: Unilateral Upper Eyelid PtosisEyelid Ptosis Following

OnabotulinumtoxinA

Cause: Paralysis of the Levator Palpebre Superioris

– Diffusion through the orbital septum

– Improper Placement

– Large Volume

– Large Dose

Develops 2-10 days after treatment

Persists for 2-4 weeks

Alam M, Gladstone H, Tung R (Eds.( (2009) Cosmetic Dermatology. Edinburgh ; Saunders Elsevier

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Eyelid Ptosis

Treatment:

– Apraclonidine 0.5% or phenylephrine 2.5% ophthalmic

solution

– Stimulation of Muller’s muscle

Inferior to the levator palpebre superioris

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Other Answers

B.) OnabotulinumtoxinA injections of the lower eyelid

– Upper eyelid affected

C.) Topical Lidocaine

– No anesthetic required

D.) Oral glycopyrrolate

– Anticholinergic

E. ) Canthopexy

– Surgical procedure to tighten the lower eyelid

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References

Baker SR. (2014) Baker Local Flaps in Facial Reconstruction, Third Edition.

Philadelphia, PA: Elsevier Saunders

Vidimos, Allison T. Ammirati, Christie T., Poblete-Lopez, Christine (Eds.) (2009)

Dermatologic Surgery. Edinburgh ; Saunders Elsevier

Jain, Sima (2012) Dermatology: Illustrated study guide and comprehensive

board review New York : Springer

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Robinson, June K., et. al (Eds.) (2015) Surgery of the Skin: Procedural Dermatology,

Third Edition; Saunders Elsevier

Alikhan Ali, Hocker Thomas L.H. (Eds.) (2017) Review of Dermatology; Elsevier lucasj2@ccf.org

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