Results:Median survival was 24 d.Only 20% (92/468) olpredictions were accurate (within 33% of actual survival);63% (295/468) were

overly optimisticand17% (81/468) were overly pessimistic.Overall,doctors overestimated survival by a factor of 5.3.

Conclusions: Doctors are systematically optimistic in estimating prognosis for terminally ill patients.This phenomenon may adversely

affect the quality of care given to patients near the EOL.

Summary Review Papei:

Crit Care Nuts Clin North

Am.2015 Sep:27|3):315-39

Chrlslakis et al..2000 BMJ 2000:320:469

r T

L J

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References

Abdulla A.Adams N.Bone M,elal.Guidance on the management of pain in older people.Age and Aging 2013:42:1-57.

AGS Panel onPersistent Pain inOlder Persons.The management of persistent painin older persons.J Am Geriatr Soc 2002:50(Suppl6):S205-S224.

Anderson F.Downing GM,Hill J.et al.Palliative performance scale (PPS):a new tool.JPalliat Care 1996:12|1):5-11.

Arbuckle R,Abetz -Webbl."Not just little adults":gualitative methods to support the development of pediatric patient-reported outcomes.Pabent 20t3:6< 3):143-159.

Association for Children's Palliative Cate (ACT),

'

Royal College of Paediatrics andChild Health (RCPCH).In:a guide to the development chidren'

s palliative care services:report of the join workingparty.ACT

RCPCH:Bristol.UK.1997.

Bacon C. The Palliative Approach:ImprovingCare for Canadians with Life-limitingIllnesses.The Way Forward.Government of Canada 2019.

Baile WF,Buckman R.Lenci R.et al.SPIKES-a sin-step protocol for delivering bad news:application to the patient withcancer.Oncologist 2000:5:302.

Bates AT.Addressing existential suffering.BCMJ 2016:58|5):268-273.

BC guidelines.Palliative Care for the Patient withIncurable Cancer or Advanced Disease Part 1:Approach to Care [Internet][updated 2017:cited 2019 Aug19],Available from https: www2.gov.bc.ca'assets gov

health/practitioner-pro/bc-guideIines7palliafive1.pdf.

Berry M.Brink E. Harris J.et al.Supportingrelatives and carers at the endof a patient'

s life. BMJ 2017:356.

Bluebond- langner M.Brook L.Craft A.et al. A guide to children'

s palliative care:supporting babies,children and young people with Irle-limitrng and life-threateningconditions and their families.Together for

Short Lives 2018-

Boucher S.Downing J.Shemilt R.The role of play inchildren's palliative care.Children 2014:1:302-317.

Bruera E,Kuehn N.Miller MJ,etal.TheEdmonton Symptom Assessment System (ESAS):A simple method for the assessment palliative care patients.J Palliat Care1991:7.-6-9.

Buccheri G.Ferrigno D.Tamburini M.Karnofsky and EC0G performance status scoringin lung cancer:a prospective,longitudinal study of 536 pabents from a single institution.Eur J Cancer 1996:32(7):1135-1141.

CareSearch.Dignity Conserving Care[Internet![updated 2019 Oct 21:cited 2019 Aug19[.Available from:https://www.caresearch.com.au/caresearchitabidi600. DefaulLasp>.

Chpca.net.Let's Talk About Hospice Palliative Care First [Internet][updated 2019 Dec:cited 2020 Jun 30]Available from:https:/,

'www.chpca.ca,

‘

wp-content/upioads'201912/euthanasia one page stats.pdf.

Clary P.LawsonP.PharmacologicalPearls for End-of-Life Care.Am Fam Physician 2009:79(12):1059 1065.

Downar J,Goldman R.Pinto R.et al.The “surprise question”for predicting death in seriously ill patients:a systemabereviewand meta-analysis.CMAJ 2017:189:E484-E493.

Dupuis LL.Johnston DL.Baggott C,et al.Validation of the Symptom Screening in Pediatncs Tool in children receiving cancer (realmentsJ Natl Cancer Inst 2018:110|6):661-668.

Feudtner C,KangTI.Hexem KR.et al.Pediatric palliative care patients:a prospective multicenter cohort study.Pediatrics 2011:127(6|:1094-1101.

Granek L,Buchman S.Improving physician well-being:lessons from palliativecare.CMAJ 2019:191(14):E380-E381.

Hanks G,Cherny HI,Christakis NA.et al.Oxford Textbook of Palliative Medicine.4th.Oxford University Press:1551.

Health Canada.Framework on Palliative Care in Canada.Government of Canada 2019.

Kearney MK,Weininger RB,Vachon MLS,et al.Self-care of physicians caring for pabentsat the end of life.JAMA 2009;301|11):11S5-1164.

KittelsonSM,Elie MC.Pennypacker L.Palliative Care Symptom Management.Crit Care NursClin North Am.2015Sep;27(3):31S-39.

Knowles S.Symptom management inpalliative care.On Continuing Practice1993:20:20-25.

Lindsay J.Dooley M.Marbn J. et al.Reducing potentially inappropriate medications inpalliative cancer patients:evidence tosupport depresenbrng approaches.Supportive Care inCancer 2014:22(41:11131119.

MacLeod R,van den 8lock L (editors).Textbook of Palliative Care.Cham:Springer.2018.1-16.

Mahoney FI.Barthel DW.Functional evaluation:the Barthel Index:a simple index of independence useful inscoringimprovement in the rehabilitation of the chronicallyillMarylandState Med J 1965:14:61 65

Mills J.Wand T.Fraser JA.Exploring the meaning and pracbce of self-care among palliative care nursesand doctors:a qualitative study.BMC PalliatCare 2018:17:63.

Medical cate of the dying.4th ed.Victoria:Victoria HospiceSociety.2006.Chapter:Palliative performance scale,version 2120-121.

Okon TR.ChristensenA.Overview of comprehensive patient assessment inpalliative care.In:UpToDate,Post.TW (Ed).UpToDate 2020.

OncoLink Team.Addressing Spiritual Concerns Across the Cancer Continuum [Internet],OncoLink:[updated 2020 Jun19:cited 2020 June30)_ Available from:https:

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,

support.

'pracbcal-andemotional/integrative-therapies-spirituality/addressing-spiritual-concems-across-the-cancer-continuum.

Parikh RB,Kirch RA.Smith TJ,et al.Early Specialty Palliative Care:Translating Data in Oncology into Practice.NEJM 2013:369(24)2347-2351.

RuijsC.Kerkhof A,van der Wal G,et al.The broad spectrum of unbearable suffering inend-of-life cancer studiedin dutch primary care.BMC PalliatCare 2012:11:12.

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Sanchez-Reilly S,Morrison LJ,Carey E,et al.Caring for oneself to care for others:physicians and their self-care.JSupport Oncol 2013:11(20):75-81.

Sanso N.Galiana L. Olivet A.et al.Palliative care professionals' inner life: exploring the relationships among awareness,self- care,and compassion satisfaction and fabgue.burnout,and copingwithdeath.JPam

Symptom Manag 2015;50[2|:200-207.

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Slocum-Gori S.Hemsworth D. Chan W \V. et al.Understanding compassion satisfacbon.compassion fatigue,and burnout a survey of the hospice palliative care workforce.Palhat Med 2013:27(21:172-178.

Sorensen JB,Klee M, Palshof T, etal.Performance status assessment in cancer patients.An inter-observer variability study.8rJCancer1993:67|4):773-775.

Sourkes B.Frankel L,Brown M.et al.Food,toys,andlove:pediatric palliative care.Curr ProblPediatrAdolesc Health Care 2005:35(9|:350-386.

Star A,Boland JW.Updates in palliative care •recent advancements in the pharmacological management of symptoms.ClinMed(Lond) 2018:18(1):11-16.

Taboada P.Caregivers'Ability to Deal withSuffering •International Association for Hospice & PalliativeCare [Internet][cited 2019 Aug19],Available from:https:

1

, hosp:cecare.com'po:icy'and-eUucs:eth;cal'issues

'

essays•and-arlicles-on-elhics-in-palliative-care/caregivers-ability-to-deal-with-suffering/.

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Van der Geest IM,Darlington AS,Streng 1C,etal.Parents’experiences of pediatric palliative care and the impact onlong-term parental grief.JPainSymptom Manag 2014:47:1043-1053.

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World Health Organization.Cancer:WHO Definition of Palliative Care[Internet],World HealthOrganization:[cited 2019 Aug 20],Available from:https:/,’www.who.mt'cancer.

’

palliabvedefinitional!

_

World Health Organization. Cancer:WHO's cancer pain ladder for adults [Internet],World Health Organization:[cited 2020Jun 30].Available from:http:

,vww.woo.nlcancer 'palliative pa n adder err.

Yennurajalingam S,Bruera E.Oxford AmericanHandbook of Hospice and Palliative Medicine and Supportive Care.2nd ed.New York:Oxford University Press:2016.510 p.

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Plastic Surgery

Shaishav Datta and Tiffany Ni, chapter editors

Yrati M. Mehra and Chunyi Christie Tan, associate editors

Arjan S. Dhoot, EBM editor

Dr.|oel Fish and Dr. Siba Haykal, staff editors

..PL2 Gender-Affirming Surgery (Transition-Related Surgery)....PL41

..PL2 Paediatric PlasticSurgeryCraniofacial Anomalies

Congenital Hand Anomalies

References.

Acronyms

Basic Anatomy Review.

Skin

Hand

Brachial Plexus

Face

Skin Lesions and Masses.

Differential Diagnosis of Skin Lesions/Masses

Surgical Management of Malignant Skin Lesions

Basic Surgical Techniques

Sutures and Suturing

Excision

Skin Biopsy Types and Techniques

Wounds.

Types of Wounds

Infected Wounds

Dressings

Reconstruction

Meshed Grafts

Soft Tissue Infections

Erysipelas

Cellulitis

Necrotizing Fasciitis

Ulcers.

Lower Limb Ulcers

Pressure Ulcers

Bums

Burn Injuries

Pathophysiology of Burn Wounds

Diagnosis and Prognosis

Indicationsfor Transfer to Burn Centre

Acute Care of Burn Patients

Special Considerations

Hand.

Traumatic Hand

General Management of Hand Injuries (Categorized by Tissue)

Hand Infections

Amputations

Tendons

Fractures and Dislocations

Dupuytren'

s Disease

Carpal Tunnel Syndrome

Brachial Plexus

Craniofacial Injuries

Approach to Facial Injuries

Mandibular Fractures

Maxillary Fractures

Nasal Fractures

Zygomatic Fractures

Orbital Floor Fractures

Traumatic Auricular Hematoma (Cauliflower Ear)

Anatomy

Breast Reduction

Mastopexy (Breast Lift)

Breast Augmentation

Gynecomastia

Breast Reconstruction

Aesthetic Surgery.

Aesthetic Procedures

PL42

-

PL43

PL5

PL6

PL8

PL15

PL17

PL18

PL24

PL30

PL31

PL35

r T

4.J

......PL40

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Acronyms

MCP metacarpophalangeal joint

NAC nipple-areola complex

NCS nerve conduction studies

NPWT negative pressure wound

therapy

normal saline

OM otitis media

ORIF open reduction and internal

fixation

OT occupational therapy

PAP profunda artery perforator

PIP proximal interphalangeal joint

polymorphonuclear

physiotherapy

PVD peripheral vascular disease

rheumatoid arthritis

Ringer's lactate

A6I ankle-brachial index

A6G arterial blood gas

AIN anterior interosseous nerve

APL abductor pollicislongus

ARDS acute respiratory distress

syndrome

AILS advanced trauma life support

BIA-ALCL breast implant-associated

anaplastic large celllymphoma GBS

BMR basal metabolic rate

creatine kinase

CMC carpometacarpal

carbon monoxide

D5W 5% dextrose in water

D1EP deep inferior epigastric

perforator

DIP distal interphalangeal joint

ENT ear.nose, throat

EOM extraocular movement

EPB extensor pollicis brevis

FDP flexor digitorumprofundus

flexor digitorum superficialis

FTSG full thickness skin graft

GAS group A (5-hemolytic

Streptococcus

group B Streptococcus

GnRH gonadotropin-releasing

hormone

ICP intracranial pressure

IGAP inferior gluteal artery perforator PMN

interphalangeal

IVIg intravenous immunoglobulin

MAP mean arterial pressure

metacarpal

ROM range of motion

SGAP superior glutealartery

perforator

SIADH syndrome of inappropriate

antidiuretic hormone

SIEA superficial inferior epigastric

artery

SLP speech-language pathology

SOF superior orbital fissure

STSG split thickness skin graft

TBSA total body surface area

TMJ temporomandibular joint

TUG transverse upper gracilis

UCL ulnar collateral ligament

ultraviolet

VCA vascularized composite

allotransplantation

FDS

NS

CK

CO

IP PI

uv

RA

MC RL

Basic Anatomy Review

Skin

Thin

— Epidermis

Split thickness— Medium Upper (papillary!

skin graft

Thick

—

Oernksj—Lower (reticular)

Full thickness

skin graft =

I

— Subcutaneous tissue

2

t rr 0

-vasCL*-'

Figure 1. Split and full thickness skin grafts

Hand

Table 1. Muscles of the Forearm and Hand

Muscle Insertion Action

Extrinsic Flexors

flexor carpiulnaris (FCU)

Palmaris longus

flexor carpiradialis|fC8)

flexor digitorum superficialis (fDS)

flexor digitorum profundus (FOP)

flexor pollicis longus (fPL)

Extrinsic Extensors

Extensor pollicisbrevis (EPS)

Abductor pollicis longus (APL)

Extensor carpi radialislongus|ECRL)

Extensor carpi radialis brevis (ECRB)

Extensor pollicis longus(EPl)

Extensor digitorum communis (EDC)

Extensor indicis proprtus (EIP)

Extensor carpi ulnaris (ECU)

Extensor digiti minimi (EOM)

Pisiform and hamate

Palmar aponeurosis

Base of 2nd and 3rd metacarpal

Base of 02-05 middle phalanx

Base of 02 05 distal phalanx

Base of 01distal phalanx

flexion and adduction at wrist

flexion at wrist

flexion and abduction at wrist

flexion at 02- 05 PIP and MCP.and wrist

flexion at 02- 05 DIP.PIP.and MCP. and wrist

flexion at 01IP and MCP

Base of 01proximal phalanx

Base of1st metacarpal

Base of 2nd metacarpal

Base of 3rdmetacarpal

Base of 1st metacarpal

Base of 02-05 distal and middlephalanx

Base of 02 distal and middle phalanx

Base of 5th metacarpal

Base of 05distal and middle phalanx

Extension at D1MCP and CMC

Abduction at 01

r T

Extension and abduction atwrist

Extension and abduction at wrist

i j

Extension at 01IP.MCP.and CMC

Extension at 02-05 MCP.PIP.and DIP.and wrist

Extension at D2 MCP.PIP.and DIP,and wrist +

Extension and adduction at wrist

Extension at D5 MCP.PIP,and DIP.and wrist

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PL-1 Plastic Surgery Toronto Notes 202J

Palmar

Palmarls longus

tendon

Ulnar artery

Ulnar nerve

Flexor digitorum

superficialis tendons

Flexor digitorum

profundus tendons

Hamate

Flexor retinaculum

Median nerve

Flexor Tendons

All require OR repair

Flexor carpi

radialis tendon

Flexor pollicis ——“

longustendon

TrapeziumExtensor Tendons

Emergency room repair unless proximal

'

'

multiple tendons

Trapezoid . Capitate Carpal Bone Mnemonic

Dorsal So Long To Pinky. Here Comes The Thumb

Scaphoid

Lunate

Triquetrum

Pisiform

Hamate

Capitate

Trapezoid

Trapezium

Figure 7. Carpal tunnel

1.Extsnsor retinaculum

Compartment1

2.Abductor po licis longus

3.Extensor polbcis brevis

Compartment 2

4.Extensor carpi radialis brevis

5.Extensor carpiradialis longus

Compartment3

6.Extensor pollicis longus

IEPItendon passes around lister'

s tubercle!

Compartment 4

7.Extensor digitorum

8.Extensor indicts

Compartment 5

9.Extensor digit minimi

Compartments

10- Extensor carpi ulnahs

Figure 8. Extensor compartment of the wrist (dorsal view and cross-sectional view)

Brachial Plexus

IfiarWii Fie • JS

A

Rugby Teams Drink Cold Beers

Roots

Trunks

Divisions

Cords

Branches

Dorsal scapUa

Suprascapular)

(C5-C6) C,PS®

'Nerve to subclavius

IC5-C6I

Lateral pectoral

(C5-C7) Cl

Musculocutaneou

iri Male

(C5-C7)

rsi

s

Axillary

(C5-C6) <

Radial^

*

(C5-T1)

I

1

C6

4

'

°'

'/ //Upper subscapular 1

( (J (C5-C6I

Thoracodorsal

(C6-C8)

§

-

Median

(C5-T1I Lower subscapular

(C5-CB)

z

ledial pectoral

IC8-TI)

Ulnar!

IC8-T1) Long thoracic nerve 1

(C5-C7) r

.

Medial cutaneous nerves of arm and forearm 5

(C8-T1)

BRANCHES CORDS DIVISIONS TRUNKS ROOTS

-

5

Figure 9. Brachial plexus anatomy +

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PL5 Plastic Surgery Toronto Notes 2023

Figure 10. Skull and facial bones

Skin Lesions and Masses

Differential Diagnosis of Skin Lesions/Masses

• for background information see Dermatology. D4 and D8

• for biopsy techniques,seeSkin Biopsy Types and Techniques, PL7

Surgical Management of Malignant Skin Lesions

•surgical treatment for all malignant skin lesions involves total excision of the primary lesion

•for pathophysiology and diagnosis see Dermatology. D40

•excision margin of lesion depends on the type of lesion and the lesion depth

•for decisions regarding reconstruction using llaps or skin grafts,see Reconstruction, PL12

Precursors of Malignant Lesions

Table 2. Precursors

Basal Cell Carcinoma Squamous Cell Carcinoma Malignant Melanoma

Nevus sebaceousolJadassohn Aclinic keratosis

Bowen'sdisease

Bowcnoid papulosis

lentigo maligna

Giant congenital nevus

Dysplaslic nevus

Surgical Margins

Table 3. Surgical Margins for Basal Cell Carcinoma

Type of Lesion Surgical Margins

3 mm

3-5 mm

Low- Risk

High-Risk*

'High-risk features include:diameter and location (>20mm trunk,>6 mm face,hands,and teet).poorly defined borders,recurrent lesion,poor

ditterenUation.and type ol lesion (e.g.sclerosing,morphealorm)

Table 4. Surgical Margins for Squamous Cell Carcinoma

ri

Type of Lesion Surgical Margins

L J

Low-Risk 4 mm

High-Risk' 6 mm

’High-risk features include:immunosuppressed patient depth>6 mm,ear/lip,non-sun exposed sites,poorly defined borders,recurrent lesion,

poor differentiation,andhistologic features (acantholytic.spindle, desmoplastic,perineural invasion)

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Table 5. Surgical Margins for Malignant Melanoma

Depth o( Lesion' Surgical Margins

5 mm

10 mm

10 - 20 mm

>20mm

Inulu

<1mm"

11.99mm"

'Determined via excisional biopsy

"With or without ulceration

Basic Surgical Techniques

Sutures and Suturing

ANESTHESIA

• irrigate before injecting anesthetic, followed by debridement and more vigorous irrigation

Table 6. Toxic Limit and Ouration of Action (1 cc of 1% solution contains 10 mg lidocaine)

With Epinephrine (vasoconstrictor,

limits bleeding)

Without Epinephrine

Traumatic tattoos are permanent

discolourations resulting (

tom new skin

growth over foreign material or dirt left

behind in the dermis.Copious Irrigation

and debridement should be done A SAP

in order to prevent traumatic tattoos, as

they are very difficult to treat later

5 mg/kg,lasts 45 60 min

2 mg/kg.lasts 2- 4 h

lidocaine (XylocaineT

Bupivicaino (Marcainc )

7 mgfkg,lasts 2 6 h

3 mg/kg,lasts 3-7 h

* Lidocaine toxicity symptoms include:circumoral numbness,light

-headedness,and drowsiness followed by tremorsand seizures.Cardiac and

respiratory signs are late findings

• e.g. when using 1% lidocaine without epinephrine in a 70 kg patient:

1% = lg/100 cc = 1000 mg/100 cc = 10 mg/cc

toxic limit = 5 mg/kg x 70 kg = 350 mg

max bolus injection = 350 mg * 10 mg/cc = 35 cc (may add more after 30 min)

IRRIGATION AND DEBRIDEMENT

• irrigate copiously with a physiologic solution such as RL or NS to remove surface clots,foreign

material, and bacteria

• debride all obviously devitalized tissue; irregular or jagged wounds must be excised to produce sharp

wound edges that will assist healing when approximated

• there is high-risk of infection for any wound closed primarily after 8 h

SUTURES

• use of a particular suture material is dependent on surgeon preference; however,skin should be closed

with a non-absorbable, monofilament suture material when traumatic mechanisms are involved to

prevent harboring bacteria in suture material

Sirnplo Interrupted

Sub-culicular

Table 7. Suture Materials: Absorbable vs. Non-absorbable and Monofilament vs. Multifilament

Suture Materials Uses Examples Notes

Plain gut-.Vicryl '

.Polysorb -, loses at least 50% of their strength in 4

Biosyn -.Monocryl®,Caprosyn wk:eventually absorbed

chromic gut,fast absorbing gut

Nylon,polypropylene (Prolene;

), Lower likelihoodof wound dehiscence,

stainless steel,silk.Ticron®, more difficult to tie,makes track marks

Ethibond -

Monosofr.Monocryl -.Biosyn1

-, Slides through tissue withless friction:

more memory/stiffness:more difficult to

tie;requiresmultiple throws (lower knot

security)

less memory/stiffness,thus easier to

work with (higher knot security):greater

infection risk

Absorbable Deep sutures undershort- term

tension

Skin closure in children

Skin closure

Sites of long-term tension

Non-Absorbable

Horizontal Mattress

Monofilament Everyday use and optimal for

contaminated and infected wounds Prolene1

(lower likelihoodof bacterial

trapping in suturematerial)

Multililamonl Used to close deep layers,such as in Vicryl'

and silk,Ticron -

,

traumatic degloving injuries Ethibond'

Verticil Miittross

BASIC SUTURING TECHNIQUES

Basic Suture Methods

• simple interrupted: can be used in almost all situations

• sub-cuticular:good cosmetic result but weak, used in combination with deep sutures; not used in

trauma

c. j

Deep + Dermal

Figure 11. Basic suture methods

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PL7 Plastic Surgery Toronto Notes 2023

•vertical/horizontal mattress:for areas difficult to evert (e.g. volar hand)

•continuous over and over (i.e.

“running,

" “baseball stitch"): time-saving, good for hemostasis

•deep/buried dermal:simple interrupted sutures placed in dermal layer, reduces skin tension for

improved healing and are the only sutures that close the wound

Steps to Ensuring an Optimized Scar

• Incisionsshould be made along

resting skin tension lines

• Attain close apposition of wound

edges

• Minimize tension on skin by closing

in layers

• Evert wound edges

• Use a ppropriately sized suture for

skin closure (5-0on face:3-0.4-0

elsewhere)

• Ensure equal width and depth of

tissue on both sides

• Remove sutures within 5-7 d from

the face,10-14 d from scalplotsof

extremities

Other Skin Closure Materials

•tapes: (e.g. steri-strips) may be indicated for superficial wounds and those with opposable edges; tape

marks and can be used asthe primary closing material or as additional reinforcement after primary

surface sutures have been removed

•skin adhesives: (e.g. 2-octyl cyanoacrylate, Dermabond*) works well on small areas without much

tension or shearing;may cause irreversible tattooing

•staples:steel-titanium alloys that incite minimal tissue reaction (healing is comparable to wounds

closedby suture)

Excision

• plan your incision along relaxed skin tension linesto minimize appearance ofscar

• use elliptical incision to preventstanding cone deformity (heaped up skin at end of incision),so the

length of the ellipse should be approximately 3x the width

. if needed, undermine skin edges (separate skin from underlying fascia to allow wound edge

manipulation and decrease tension)

• use layered closure including deep dermal sutures (decreases tension)

Relaxed Skin Tension Lines

Naturalskin/wrinkle lines with minimal

linear tension. Placing incisions parallel

to resting skin tension lines minimizes

widening/hypertrophy and helpsto

camouflage scars. Rrlaxed skin tension

lines are usually parallel to any existing

wrinkle lines and perpendicular to the

orientation of underlying muscle fibres

(perpendicular to lines of maximum

extensibility)

Skin Biopsy Types and Techniques

SHAVE BIOPSY

• used for superficial lesions where sampling of the full thickness ofthe dermisis not necessary or

practical

• most suitable lesionsfor shave biopsies are benign lesions either elevated above the skin or have

pathology confined to the epidermis (e.g. seborrheic or actinickeratoses,skin tags, and warts)

• high-risk of recurrence with shave biopsy for any lesions, including actinic or seborrheic keratoses

• rapid, requireslittle training, and does not require sutures for closure (caution in patients on

anticoagulant treatment)

• healsby secondary intent (moist dressingsshould be used)

• should not be used for pigmented lesions - an unsuspected melanoma cannot be properly staged if

partially removed

NEEDLE BIOPSY

• 21 G for lymph node biopsy

• Trucut * needle biopsy for breast masses suspected for carcinoma

« needle biopsy hasfallen out of favour for lymph node biopsies; excisional biopsy isthe preferred

method in this circumstance Figure 12.Incision of lesions along

relaxed skin tension lines

INCISIONAL BIOPSY

• can be a punch biopsy, oran ellipse within the lesion (normal tissue must be included in biopsy)

• gives pathologists a portion of the lesion and the border with normal skin

• punch biopsies involve the removal of a full thickness core of tissue to allow sampling of the

epidermis,dermis, fat, and potentially muscle depending on the area;performed with a round,

disposable circular cutting surface on a plastic handle ranging in diameter from 2-10 mm

• punch biopsy wounds can be closed with suture or left to heal by secondary'intention

EXCISIONAL BIOPSY

• performed for lesionsthat require complete removal for diagnostic purposes

• performed for lesionsthat cannot be adequately punch biopsied due to depth oflesion below surface

• for small pigmented lesions and atypical moles; if concerned about melanoma, can do a narrow

margin excision for diagnosis and treatment (depending on depth in the case ofmelanoma)

• best for small lesionsthat are easily removed and primarily closed

• requires the greatest amount of expertise and time

• always requiressuturesfor closure

TECHNIQUE

General

• all shave and punch biopsies performed in clinic are done using aseptic technique, but are not sterile

• sterile gloves are indicated for biopsies and excisions in all patients +

Preparing the Site

• common skin antiseptics (Betadine’, chlorhexidine) can be used to prepare the biopsy site

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PL8 Plastic Surgery Toronto Notes 2023

•chlorhexidine is used in concentrations ranging from 0.5-!- %.It is not typically used on the face, as it

could get into the eyes or ears and may burn or cause damage.Most chlorhexidine preps also contain

alcohol, which can be flammable,so allow to dry before the biopsy and certainly before using any

cautery

•Betadine* (7.5% povidone-iodine) issafer for the head and neck (asto avoid the above problems with

chlorhexidine) and around the eyes and ears.It is also used in "

contaminated'

areas such as the feet

and groin

•mark the intended lesion and surgical margins with a surgical marker asthe first step,since they may

be temporarily obliterated following injection of the anesthetic

•for all biopsies, a sterile drape technique is indicated.Sterile towels are placed around the biopsy site

after the area is cleansed and anesthetized

Anesthesia

• most commonly used local anesthetic is 1% or 2% lidocaine (with epinephrine)

•small amounts of epinephrine are added to constrict blood vessels,decrease bleeding, prolong

anesthesia, and limit lidocaine toxicity.

'

Ihe local with epinephrine can be injected directly into the

lesion

•local anesthetics with epinephrine may be used anywhere in the body, including the digits

Wounds s

• wound:disruption of the normal anatomical relationships of tissue as a result of injury

Types of Wounds

laceration:sharply cut tissue

• abrasion:superficial skin layer is removed,variable depth

• contusion:injury caused by forceful blow to the skin and soft tissue;entire outer layer ofskin intact,

yet injured

• avulsion:skin and soft tissue forcefully separated from deeper structures, potentially compromising

blood supply or resulting in full detachment (amputation)

• puncture wounds:cutaneous opening relatively small as compared with depth (e.g. needle),including

bite wounds

• crush injuries:caused by compression

• burns:thermal, chemical,electrical

• ulcers:an open wound that develops on skin as a result of injury,poor circulation,or pressure

Principles of Wound Healing

Table 8. Factors Influencing Wound Healing

Local General

Mechanical (local trauma,significant crush,avulsion,tension)

Stood supply (ischemia/circulation)

Technique and suture materials

Retained foreign body

Infection

Venous HTN

Age (affects healing rate)

lutrition

Tobacco smoking

Alcohol consumption

Chronic loess(eg.Oil.cancer,dyslipidemia.renalfailure,stroke)

Immunosuppression (steroids,chemotherapy)

Tissue irradiation

Senetic predisposition to abnormal healing (e.g.hypertrophic or keloid

scarring, collagen vascular disease)

Skin type

RVD

STAGES OF WOUND HEALING

• growth factors released by tissues play an important role

• scar is mature once it has completed the final stage, usually after 1-2 yr s

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