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Using technology tools
Jayne Joo, MD
Director of Mohs surgery, Sacramento VA Medical Center
Assistant Clinical Professor, Department of Dermatology, University of California, Davis
S008: Dermatologic Surgery Pearls: Optimizing
Safety, Satisfaction, Efficiency
February 16, 2018
Outline
• Efficient undermining
• Adhesive strip skin closure
• Negative pressure device
• Phone based apps
Electrosurgical Undermining
• Advantages
– Decreased operative time
– Decreased bleeding
• Disadvantages
– Collateral tissue damage
– Wound edge necrosis
– Vascular compromise
Chen DL, Carlson EO, Fathi R, Brown MR. Undermining and Hemostasis. Dermatol Surg. 2015 Oct;41 Suppl 10:S201-15.
Surgical smoke
• Health risk
• Particulate matter
• Toxic chemicals
• Infectious agents
• Patient dissatisfaction
Lewin JM, Brauer JA, Ostad A. Surgical smoke and the dermatologist. J Am Acad Dermatol. 2011 Sep;65(3):636-41.
Yonan Y, Ochoa S. Impact of Smoke Evacuation on Patient Experience During Mohs Surgery. Dermatol Surg. 2017
Nov;43(11):1363-1366
Golda N, Huber A, Gole H. Determining the impact of intraoperative smoke evacuation on the patient experience during outpatient
surgery: A Randomized Controlled Trial. J Am Acad Dermatol. 2017 Nov 11. pii: S0190-9622(17)32685-3.
Surgical smoke
• Ablation of 1 gram of tissue produces a
smoke plume with an equivalent
mutagenicity to 6 unfiltered cigarettes
• On average the smoke produced daily in
plastics OR was equivalent to 27 to 30
cigarettes
Hill DS, O'Neill JK, Powell RJ, Oliver DW. Surgical smoke - a health hazard in the operating theatre: a study to quantify
exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg. 2012
Jul;65(7):911-6.
1,000 Mohs cases/year = 50 hours
of continuous smoke exposure
Oganesyan G, Eimpunth S, Kim SS, Jiang SI. Surgical smoke in dermatologic surgery. Dermatol Surg. 2014
Dec;40(12):1373-7.
Chemicals identified in surgical smoke
• Acetonitrile Furfural (aldehyde)
• Acetylene Hexadecanoic acid
• Acroloin Hydrogen cyanide
• Acrylonitrile Indole (amine)
• Alkyl benzene Isobutene
• Benzaldehyde Methane
• Benzene 3-Methyl butenal (aldehyde)
• Benzonitrile 6-Methyl indole (amine)
• Butadiene 4-Methyl phenol
• Butene 2-Methyl propanol (aldehyde)
• Formaldehyde
• 3-Butenenitrile Methyl pyrazine
• Carbon monoxide Phenol
• Creosol Propene
• 1-Decene (hydrocarbon) 2-Propylene nitrile
• 2,3-Dihydro indene Pyridine
• Ethane Pyrrole (amine)
• Ethene Styrene
• Ethylene Toluene (hydrocarbon)
• Ethyl benzene 1-Undecene (hydrocarbon)
• Ethynyl benzene Xylene
Hill DS, O'Neill JK, Powell RJ, Oliver DW. Surgical smoke - a health hazard in the operating theatre: a study to quantify
exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg. 2012
Jul;65(7):911-6.
Karlinsky JB, Blanchard M, Alpern R, Eisen SA, Kang H, Murphy FM, Reda DJ. Late prevalence of respiratory symptoms and
pulmonary function abnormalities in Gulf War I Veterans. Arch Intern Med. 2004 Dec 13-27;164(22):2488-91.
• The distribution of pulmonary function test
results was identical among deployed and non-
deployed veterans.
• Findings did not confirm the hypothesis that
deployment to the Gulf War in 1990-1991
resulted in an increased prevalence of clinically
significant pulmonary abnormalities 10 years
later.
American Journal of Respiratory and
Critical Care Medicine 2014;189:A6496
Falvo MJ, Osinubi O, Klein JC et al. Durbin D, Kallan M, Elliott M. Late Prevalence of Pulmonary Function Abnormalities In
Iraq/Afghanistan Veterans. Paper presented at: 2014 American Thoracic Society International Conference. May 2014; San Diego.
• 63 Gulf War veterans approximately 20 years post-deployment
• Significantly higher rates of small airway obstruction (5x) and restrictive lung physiology (2x) at 20-years post-deployment compared to at 10-years post-deployment
Adhesive strips
• Quicker than sutures for
closing surgical wounds
• Reduces wound care burden
• Barrier function
• No risk of sharps injury
Gkegkes ID, Mavros MN, Alexiou VG, Peppas G, Athanasiou S, Falagas ME. Adhesive strips for the closure of surgical incisional
sites: a systematic review and meta-analysis. Surg Innov. 2012 Jun;19(2):145-55.
Lazar HL, McCann J, Fitzgerald CA, Cabral HJ. Adhesive strips versus subcuticular suture for mediansternotomy wound closure. J
Card Surg. 2011 Jul;26(4):344-7.
Yang S, Ozog D. Comparison of Traditional Superficial Cutaneous Sutures Versus Adhesive Strips in Layered Dermatologic
Closures on the Back-A Prospective, Randomized, Split-Scar Study. Dermatol Surg. 2015 Nov;41(11):1257-63.
Soni A, Narula R, Kumar A, Parmar M, Sahore M, Chandel M. Comparing cyanoacrylate tissue adhesive and conventional
subcuticular skin sutures for maxillofacial incisions--a prospective randomized trial considering closure time, wound morbidity, and
cosmetic outcome. J Oral Maxillofac Surg. 2013 Dec;71(12):2152.e1-8.
Krishnamoorthy B1, Najam O, Khan UA, Waterworth P, Fildes JE, Yonan N. Randomized prospective study comparing
conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting. Ann Thorac Surg. 2009
Nov;88(5):1445-9.
Buchweitz O, Frye C, Moeller CP, Nugent W, Krueger E, Nugent A, Biel P, Juergens S. Cosmetic outcome of skin adhesives versus
transcutaneous sutures in laparoscopic port-site wounds: a prospective randomized controlled trial. Surg Endosc. 2016
Jun;30(6):2326-31.
Dumville JC, Coulthard P, Worthington HV, Riley P, Patel N, Darcey J, Esposito M, van der Elst M, van Waes OJ. Tissue
adhesives for closure of surgical incisions. Cochrane Database Syst Rev. 2014 Nov 28;(11):CD004287.
Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure of surgical
incisions. Cochrane Database Syst Rev. 2010 May 12;(5):CD004287.
Custis T, Armstrong AW, King TH, Sharon VR, Eisen DB. Effect of Adhesive Strips and Dermal Sutures vs Dermal Sutures Only on
Wound Closure: A Randomized Clinical Trial. JAMA Dermatol. 2015 Aug;151(8):862-7.
“Combination closure with adhesive strips and buried interrupted
subcuticular suturing was not significantly associated with improved overall
scar assessment compared with buried interrupted subcuticular suturing
alone when evaluated by blinded observers or the patients themselves.
Our results do not support the use of adhesive strips as a means to
improve cosmetic outcomes or reduce scar width.”
PICO NPWT Dressing
• Pocket device for negative pressure
wound therapy (NPWT)
http://www.smith-nephew.com/key-products/advanced-wound-management/pico/
Indications
• Chronic wounds
• Acute wounds
• Traumatic wounds
• Subacute and dehisced wounds
• Partial-thickness burns
• Ulcers (such as diabetic or pressure)
• Flaps and grafts
• Closed surgical incisions
http://www.smith-nephew.com/key-products/advanced-wound-management/pico/
Benefits of Negative Pressure
• Accelerates wound healing
• Promotes moist wound healing milieu
• Decreases complications, such as surgical
site infection, dehiscence,
seroma/hematoma, and wound edge
necrosis
Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing
and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound
Therapy. A systematic review of the literature. Int Wound J. 2016 Dec;13(6):1260-1281.
Ingargiola MJ, Daniali LN, Lee ES. Does the application of incisional negative pressure therapy to high-risk wounds prevent
surgical site complications? A systematic review. Eplasty. 2013 Sep 20;13:e49. eCollection 2013.
Mechanism of NPWT
• Decreases interstitial edema
• Removal toxic inflammatory mediators
• Increases cutaneous blood flow
• Promotes angiogenesis
• Splints against tensile forces across
wound
Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing
and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound
Therapy. A systematic review of the literature. Int Wound J. 2016 Dec;13(6):1260-1281.
Ingargiola MJ, Daniali LN, Lee ES. Does the application of incisional negative pressure therapy to high-risk wounds prevent
surgical site complications? A systematic review. Eplasty. 2013 Sep 20;13:e49. eCollection 2013.
Relative Contraindications
• Adhesive tape reaction
• Ischemia
• Excessive exudative wounds
• Inadequate hemostasis
• Cellulitis
• Open/dehiscent surgical wounds
• [Profuse perspiration]
High complication risks
• Surgery-related – Location
– Surgical site contamination
– Technique
– Operative time
• Patient-related – Morbid obesity
– Comorbidities
– Nicotine abuse
– Drugs (systemic steroids, immunosuppression)
Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing
and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound
Therapy. A systematic review of the literature. Int Wound J. 2016 Dec;13(6):1260-1281.
Webster J, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for skin grafts and surgical wounds
healing by primary intention. Cochrane Database Syst Rev. 2014 Oct 7;(10):CD009261.
Coding and Reimbursement
• CPT code 97607
– Surface area ≤ 50 cm2
• CPT code 97608
– Surface area ≥ 50 cm2
• Includes:
– Provision of exudate management collection system
– Topical application
– Wound assessment
– Instructions for ongoing care
• 2016 Medicare national average payment $225.55
Apps
• Haiku
• Tiger Text
• Doximity dialer
• Evernotes
• VisualDx
• Appointment reminder
• Photo collage
Best Note-taking apps of 2018
https://www.pcmag.com/roundup/347537/the-best-note-taking-and-syncing-apps
Appointment reminders
https://www.solutionreach.com/
https://www.televox.com/
http://www2.relatient.net/
https://ezderm.com/
https://www.lumahealth.io/