(BQ) Part 1 book Requisites in dermatology - Dermatologic surgery presents the following contents: Surgical anatomy of the head and neck, antisepsis, local anesthetics, surgical instruments, preoperative evaluation of the dermatologic surgery patient, cutaneous wound healing, electrosurgery, cryosurgery, biopsy techniques.
Requisites in DERMATOLOGY Dermatologic Surgery Edited by Allison T Vidimos, RPh, MD, FAAD, FACMS Chair, Department of Dermatology Cleveland Clinic Foundation Cleveland, OH, USA Christie T Ammirati, MD, FAAD, FACMS Associate Professor, Department of Dermatology Penn State Milton S Hershey Medical Center Hershey, PA, USA Christine Poblete-Lopez, MD, FAAD, FACMS Associate Staff, Department of Dermatology Cleveland Clinic Foundation Cleveland, OH, USA Series editor DIRK M ELSTON Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2009 An imprint of Elsevier Limited © 2009, Elsevier Limited All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F Kennedy Boulevard, Suite 1800, Philadelphia, PA 191032899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: healthpermissions@elsevier.com You may also complete your request on-line via the Elsevier homepage (http://www.elsevier com), by selecting ‘Support and contact’ and then ‘Copyright and Permission’ First published 2009 ISBN: 978-0-7020-3049-9 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Editors assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient The Publisher Printed in China Acknowledgments We would like to thank our mentors and teachers who have taught us the art and science of dermatologic surgery, our residents, fellows and medical students who have given us the privilege and pleasure of teaching them, and our patients who put their trust in us and challenge us to be better physicians every day Special thanks go to the the art and photography departments at Cleveland Clinic, especially Joe Pangrace, Bill Garriott, Beth Halasz, and our dermatology department photographer, Flora Williams Dermatologic surgery dedications This text is dedicated to my parents Al and Audrey Vidimos, my brothers Scott, David and Dan, my husband Todd Stultz, and daughters Katherine and Kristen for their love, support, encouragement, and inspiration Allison T Vidimos This text is dedicated to my children Emma and Nicholas and my parents Bob and Bee Travelute, who inspired me to always reach higher, and to my husband Chris, who held the ladder so I could climb Christie T Ammirati This text is dedicated to my husband, Seevee, who has given me unconditional love and the support to pursue what I truly enjoy, most evident in this endeavor; to my children, Veto, Samee, and Neo, who are the source of my strength and inspiration; to my parents, who taught me the value of education; to all my mentors, from whom I learned the art of surgical technique; and to all the residents and fellows to whom I’ve tried to teach the importance of this art Christine Poblete-Lopez Contributors Erin J Allen, md Providence Dermatologic Surgery Portland, OR Christie T Ammirati, md Associate Professor of Dermatology Department of Dermatology Penn State Milton S Hershey Medical Center Hershey, PA Philip L Bailin, md Program Director, Dermatologic Surgery and Cutaneous Oncology Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Ashish C Bhatia, md Department of Dermatology and Dermatologic Surgery DuPage Medical Group, Naperville, IL Assistant Professor of Clinical Dermatology Department of Dermatology Northwestern University – Feinberg School of Medicine Chicago, IL Elizabeth Magill Billingsley, md Associate Professor of Dermatology Department of Dermatology Penn State Milton S Hershey Medical Center Hershey, PA Lisa B Campbell, md Chief of Dermatology and Dermatologic Surgery Geisinger Health System Western Region Geisinger Medical Group State College, PA T Minsue Chen, md Fellow, Mohs Research in Advanced Dermatologic Surgery Education Mohs and Dermasurgery Unit Department of Dermatology University of Texas, M D Anderson Cancer Center Houston, TX Theresa Dressler Conologue, Director, Cosmetic Dermatology Service Geisinger Medical Center Danville, PA Daihung Vu do, md Instructor in Dermatology Associate Director of Dermatologic Surgery Department of Dermatology Beth Israel Deaconess Medical Center Boston, MA John Ebner, Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Gregory J Fulchiero Jr, md, MSBioEng Dermatologic Surgery and Cutaneous Oncology Department of Dermatology UT Southwestern Medical Center Dallas, TX Christopher Charles Gasbarre, DO Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Lisa M Grandinetti, md Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Joseph F Greco, md Clinical Instructor UCLA Division of Dermatology Department of Medicine David Geffen School of Medicine at UCLA Los Angeles, CA viii Contributors Christine M Hayes, md Associate Professor of Dermatology Department of Dermatology Boston University School of Medicine Boston, MA Christine Poblete-Lopez, md Associate Program Director Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Christopher Riddell Jones, md Department of Dermatology Penn State Milton S Hershey Medical Center Hershey, PA Matthew R Ricks, md LtCol, USAF, MC, SFS Chief of Mohs Surgery Wilford Hall Medical Center Lackland AFB, TX Ken K Lee, md Director of Dermatologic and Laser Surgery Associate Professor of Dermatology, Surgery, Otolarynogology – Head and Neck Surgery Oregon Health and Science University Portland, OR Christopher B Skvarka, md Department of Dermatology Hahnemann Hospital Drexel University College of Medicine Philadelphia, PA Victor J Marks, md Department of Dermatology Geisinger Medical Center Danville, PA Aashish Taneja, md Department of Dermatology Wayne State University Dearborn, MI Edward V Maytin, md, PhD Staff, Dermatology Cleveland Clinic Foundation Assistant Professor of Molecular Medicine Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland, OH Leonid Benjamin Trost, md Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Susan Teri McGillis, md Director, Dermasurgery Center Lancaster, PA Jon G Meine, md Staff, Department of Dermatology, Section of Dermatologic Surgery and Cutaneous Oncology Cleveland Clinic Foundation Cleveland, OH Allison Jo Moosally, md Clinical Associate Staff Department of Dermatology Cleveland Clinic Foundation Cleveland, OH Tri H Nguyen, md Director of Mohs/Dermatologic Surgery Associate Professor Mohs and Dermasurgery Unit Department of Dermatology University of Texas, M D Anderson Cancer Center Houston, TX Allison T Vidimos, RPh, md Chair, Dermatology Cleveland Clinic Foundation Cleveland, OH Paula S Vogel, md Col (Ret), USA, MC Mohs Surgeon Dermatology Associates San Antonio, TX Rungsima Wanitphakdeedecha, md Department of Dermatology Faculty of Medicine Siriraj Hospital Mahidol University Bangkok, Thailand Andrea Willey, md Assistant Clinical Professor Department of Dermatology University of California, Davis Davis, CA Brittany Wilson, md Department of Dermatology Oregon Health and Science University Portland, OR Contributors Oliver J Wisco, Maj, USAF, MC, FS Department of Dermatology Wilford Hall Medical Center Lackland AFB, TX Justin G Woodhouse, md University Dermatologists, Inc South Euclid, OH Summer R Youker, md Assistant Professor of Dermatology Saint Louis University St Louis, MO ix Also in the series Requisites in Dermatology Series Editor: Dirk M Elston Dermatopathology Dirk M Elston and Tammie Ferringer Cosmetic Dermatology Murad Alam, Hayes B Gladstone, and Rebecca C Tung Pediatric Dermatology Howard B Pride, Albert C Yan, and Andrea L Zaenglein Dermatologic Surgery Allison T Vidimos, Christie T Ammirati, and Christine Poblete-Lopez General Dermatology Kathryn Schwarzenberger, Andrew E Werchniak, and Christine J Ko Series foreword The Requisites in Dermatology series of textbooks is designed around the principle that learning and retention are best accomplished when the forest is clearly delineated from the trees Topics are presented with an emphasis on the key points essential for residents and practicing clinicians Each text is designed to stand alone as a reference or to be used as part of an integrated teaching curriculum Many gifted physicians have contributed their time and energy to create the sort of texts we wish we had had during our own training and each of the texts in the series is accompanied by an innovative on-line module Each on-line module is designed to complement the text, providing lecture material not possible in print format, including video and lectures with voice-over These books have been a labor of love for all involved We hope you enjoy them Series dedication This series of textbooks is dedicated to my wife Kathy and my children, Carly and Nate Thank you for your love, support and inspiration It is also dedicated to the residents and fellows it has been my privilege to teach and to the patients who have taught me so much Dirk M Elston Volume preface This text is designed to cover the essentials of dermatologic surgery in a style that is straight forward and easily understood Each topic is presented as a concise, yet thorough, review, and each chapter is paired with an on-line lecture In this manner, the text acts as an over view for students learning the surgical aspects of dermatology, a focused study guide for dermatology residents, and a ready reference for those in practice Acknowledgments We would like to thank our mentors and teachers who have taught us the art and science of dermatologic surgery, our residents, fellows and medical students who have given us the privilege and pleasure of teaching them, and our patients who put their trust in us and challenge us to be better physicians every day Special thanks go to the the art and photography departments at Cleveland Clinic, especially Joe Pangrace, Bill Garriott, Beth Halasz, and our dermatology department photographer, Flora Williams Dermatologic surgery dedications This text is dedicated to my parents Al and Audrey Vidimos, my brothers Scott, David and Dan, my husband Todd Stultz, and daughters Katherine and Kristen for their love, support, encouragement, and inspiration Allison T Vidimos This text is dedicated to my children Emma and Nicholas and my parents Bob and Bee Travelute, who inspired me to always reach higher, and to my husband Chris, who held the ladder so I could climb Christie T Ammirati This text is dedicated to my husband, Seevee, who has given me unconditional love and the support to pursue what I truly enjoy, most evident in this endeavor; to my children, Veto, Samee, and Neo, who are the source of my strength and inspiration; to my parents, who taught me the value of education; to all my mentors, from whom I learned the art of surgical technique; and to all the residents and fellows to whom I’ve tried to teach the importance of this art Christine Poblete-Lopez Leonid Benjamin Trost and Philip L Bailin Key Points • Cryosurgery is a versatile and cost-effective method of treating many benign, premalignant, and malignant lesions • The most commonly used cryogen is liquid nitrogen • The most common cryosurgical technique is the open spray technique • To kill all malignant cells, a final temperature of −20 to −30°C must be achieved • For malignant lesions, the depth of freeze should be roughly equal to the radius of the surface frozen area A thermocouple can be inserted at the base of the lesion for greater accuracy • If an intermittent spray technique is used, the resultant ice ball will have a greater depth and more limited lateral spread If a continuous spray technique is used, the resultant ice ball will be more shallow and will have a greater lateral spread • The greatest possible depth of the ice ball is about 10 mm • Benign lesions usually require only one freeze– thaw cycle • Premalignant lesions usually require one freeze–thaw cycle, although two may be used • For cryosurgery of malignant lesions, the goal of therapy is to destroy the same mass of malignant tissue by freezing as would be removed by excision Therefore, an adequate margin around the tumor must be frozen Malignant lesions usually require two freeze–thaw cycles, although three may be used in some cases • For malignant lesions, the halo thaw time, or the duration of surface thawing of marginal tissue beyond the target site, should be greater than 60 s The total thaw time of the entire lesion should be more than 90 s • A large lesion may first be debulked surgically to create a thinner lesion that freezes more rapidly • The combination of rapid freezing and slow thaw produces maximal tissue damage Introduction Cryosurgery is a versatile and cost-effective method of treating many benign, premalignant, and malignant lesions A cryogenic agent is applied Chapter Cryosurgery directly or indirectly to the skin This causes local tissue destruction, and healing occurs by second intention Today, cryosurgery is commonly used by most dermatologists History In 1845, James Arnott, an English physician, used salt solutions containing crushed ice (−8 to −12°C) to treat advanced cancers in sites that were easily accessible, such as breast and cervical cancer The goal was reduction in tumor size and pain control Olszenski was the first to liquefy air in 1885 In 1899, A Campbell White used liquefied air to treat nevi, warts, boils, and herpes zoster Over the next several decades, carbon dioxide snow (−78.5°C) and liquid oxygen (−182.9°C) were used In 1950, Allington was the first to use liquid nitrogen (−195.6°C) to treat skin diseases such as warts, keratoses, hemangiomas, and keloids Initially, cotton-tipped applicators and solid copper cylinder disks chilled in the cryogen were used For the next several years, cryosurgery was limited by the depth of tissue damage that could be achieved (maximum 7 mm) In 1961, Cooper and Lee developed a closed system with a vacuum-insulated probe that was used in neurosurgery to treat conditions such as Parkinsonism In 1965, two American dermatologists, Douglas Torre and Setrag Zacarian, helped to develop a nitrogen spray device that could be used with different cryoprobe tips These developments allowed deeper tissue injury In 1968, a handheld spray device was first developed at Brooke Army Medical Center, using a rubber bulb to create pressure and force the liquid nitrogen through the aperture Later versions were high-pressure systems that harnessed the pressure created by the evaporating nitrogen The most common method of cryosurgery uses a handheld device that contains liquid nitrogen A direct spray is used most commonly, but a cryoprobe is sometimes used as well 108 Dermatologic Surgery Table 8-1 Cryogens and their boiling points Table 8-2 Factors that affect the freezing of tissue Cryogen Boiling point (°C) Factor Key principles Chlorodifluoromethane −40.8 Rate of tissue freezing Solidified carbon dioxide −78.5 Rapid freezing (90 s) causes more cell death Tissue temperature Final tissue temperature of < −20 to −30°C will kill all malignant cells Duration of freezing Having the tissue remain adequately frozen for a longer period of time causes more tissue injury Maximum cell death rate occurs at 100 s Repetition of freeze–thaw cycles More freeze–thaw cycles cause more cell death Malignant tumors require multiple freeze–thaw cycles All cellular structures show damage by electron microscopy after two cycles Figure 8-1 Temperature gradients formed within the ice ball during cryosurgery Note that the gradient ranges from 0°C at its most lateral edge to-195.6°C at its center, corresponding to the temperature of the liquid nitrogen Cryogenic agents Many cryogens have been used, but liquid nitrogen (boiling point −195.6°C) is employed most widely (Table 8-1) Cryobiology During cryosurgery, an ice ball is formed in the skin Within the ice ball are temperature gradients ranging from 0°C at its most lateral edge to -195.6°C at its center, corresponding to the temperature of the liquid nitrogen (Fig 8-1) Cryosurgery causes injury via two mechanisms First, ice crystals form within the cells Second, vascular thrombosis occurs during freezing, and vascular stasis occurs after thawing These changes in the vasculature lead to ischemic necrosis Table 8-2 describes factors that affect the freezing of tissue This includes the rate of tissue freezing, rate of intermittent spraying, rate of thawing, tissue temperature, duration of freezing, and repetition of freeze–thaw cycles Figures 8-02 and 8-03 depict how some of these factors relate to the surface radius and depth of freeze Rapid freezing (100–260°C per min) leads to increased cellular death When cells are frozen rapidly, intracellular ice formation damages organelles and leads to irreversible cell destruction Larger ice crystals cause more damage and may even rupture the cell membrane If cells are frozen slowly, the cytoplasm becomes hypertonic and resistant to freezing Extracellular rather than intracellular ice is formed This is less lethal to cells Slow thawing (10°C per min) is associated with recrystallization and increased cellular death Intracellular water is increased, and rapid electrolyte transfer further damages cellular proteins A second freeze–thaw cycle greatly increases tissue injury After two freeze–thaw cycles, all cellular structures show damage on electron microscopy Malignant tumors require multiple freeze–thaw cycles This is discussed in greater detail below Tissue temperature is crucial to achieving cellular death Table 8-� shows the key events during freezing For malignant lesions, a final temperature of −20 to −30°C is necessary to kill all malignant cells A final temperature of −50 to −60°C kills all cells in the field Having the tissue remain Figure 8-2 Relationship between depth of freeze to spraying factors (a) The depth of the ice ball is equal to the surface radius of the ice ball This tends to occur when the spray is intermittent and when the spray tip is close to the skin (b) The depth of the ice ball is less than the surface radius of the ice ball (R΄ < R) This tends to occur when the spray is continuous and when the spray tip is further from the skin It can also occur when the liquid nitrogen is “painted on’’ and/or the rate of intermittent spray is too slow Note that if the depth of the ice ball is too shallow, then entire tumor may not be destroyed even though the frozen surface margins appear to be adequate Chapter Cryosurgery Figure 8-3 Relationship between the Therapeutically Lethal Isotherm (TLI) (–30°C) and the edge of the ice ball (0°C isotherm) In both A and B, the sizes and shapes of the ice balls (0°C isotherm) are the same In A, the TLI is close to the edge of the ice ball This tends to occur when the spray is intermittent and when the spray tip is close to the skin In B, TLI is farther from the edge of the ice ball (Y > X) Note that if the location of the TLI is too far from the edge of the ice ball, the entire tumor may not be destroyed even though the frozen surface margins appear to be adequate adequately frozen for longer periods of time leads to higher rates of cell death, but at 100 s the rate of cell death rates reaches a plateau Table 8-3 Key events during freezing Temperature (°C) Event +11 to +3 65% of capillaries and 35–40% of arterioles and venules develop thrombosis −0.6 Freezing begins to occur in tissue −4 to −7 Melanocytes die −15 to −20 100% of blood vessels develop thrombosis −20 Cells in sebaceous glands and hair follicles die −21.8 Ice crystals theoretically form in the tissue (the eutectic temperature of sodium chloride solution) −20 to −30 Keratinocytes and malignant cells die −30 to −35 Fibroblasts die −50 to −60 All cells die Indications and contraindications Cryosurgery is effective at treating benign, premalignant, and malignant lesions (Boxes 8-1–8-3) For malignant lesions, cryosurgery is especially appropriate for primary lesions less than 2 cm in diameter with clearly demarcated borders in the elderly, high-risk surgical patients, patients with pacemakers or coagulopathy, patients who not wish to have excisional surgery, and when excisional surgery is not practical Cryosurgery also can be used as a palliative therapy in metastatic cancers to reduce tumor size Cryosurgery is contraindicated in patients with cold sensitivity or diseases that are aggravated by cold (cryoglobulinemia, cryofibrinogenemia, pernio, etc.) It is also inappropriate for lesions that overlie nerves, tumors with poorly demarcated 109 110 Dermatologic Surgery B ox - B ox - Benign lesions that can be treated with cryosurgery Premalignant lesions and in situ cancers that can be treated with cryosurgery • Acne vulgaris, cystic • Actinic cheilitis • Angiolymphoid hyperplasia • Actinic keratosis • Angiokeratoma – Fordyce and solitary type • Squamous cell carcinoma in situ • Angioma, cherry and spider • Leukoplakia • Chondrodermatitis nodularis chronicus helicis • Dermatofibroma • Disseminated superficial actinic porokeratosis • Epidermal nevi • Granuloma faciale B ox - Malignant lesions that can be treated with cryosurgery • Granuloma fissuratum • Basal cell carcinoma • Hemangioma, strawberry and cavernous • Squamous cell carcinoma (invasive) – includes keratoacanthoma • Hidradenitis suppurativa • Keloid • Leishmaniasis • Kaposi’s sarcoma • Other malignancies (palliative only) • Lentigines, lentigo simplex, solar lentigo • Lichen planus, hypertrophic form • Lichen sclerosus et atrophicus • Lymphocytoma cutis • Molluscum contagiosum • Mucocele • Myxoid cyst • Nevus flammeus • Porokeratosis of Mibelli • Porokeratosis plantaris discreta • Prurigo nodularis • Psoriatic plaques • Pyogenic granuloma • Rosacea • Sebaceous hyperplasia • Seborrheic keratosis • Steatocystoma multiplex Figure 8-4 Storsge Tank • Syringoma • Trichiasis • Venous lake • Verrucae (bowenoid papulosis, condyloma acuminatum, periungual verruca, verruca plana, verruca palmaris et plantaris, verruca vulgaris) borders, and tumors with deep invasion Some sites, such as the inner canthi, are more prone to deep invasion Finally, cryosurgery is contra indicated for recurrent tumors, as well as tumors larger than 2 cm in diameter Cryosurgery is relatively contraindicated for lesions on the scalp, lower legs, and digits, as well as for lesions for lesions near the vermilion border, free margins of the ala nasi, and near the auditory canal Caution should be used in dark-skinned patients because of the risk of postinflammatory hypopigmentation Techniques Liquid nitrogen is stored long term in storage tanks (Fig 8-4) For temporary storage, portable storage units are available (Fig 8-5) Chapter Cryosurgery a Figure 8-5 Portable storage unit b Table 8-4 Cryosurgery techniques and the lesions that can be treated with each technique Lesion type Technique Benign Premalignant Malignant Dipstick Yes No No Open spray Yes Yes Yes Closed Yes Yes Yes Figure 8-6 Instruments used in the dipstick technique: (a) a cotton-tipped applicator and (b) a metal cryoprobe applicator The three main cryosurgery techniques are the dipstick, open spray, and closed techniques The open spray technique is used most commonly Table 8-� describes the techniques that may be used for benign, premalignant, and malignant lesions Dipstick technique The dipstick technique involves dipping a cottontipped applicator (Fig 8-6a) to absorb the liquid nitrogen or a metal applicator (Fig 8-6b) chilled to the temperature of the liquid nitrogen and then applying it to the lesion The latter method may be safer clinically as there is no risk of dripping liquid nitrogen onto the patient This may have to be repeated multiple times in one session until the clinical endpoint is reached The freezing spread is slow compared with other techniques This method is generally reserved for small benign epidermal lesions, especially warts, lentigo simplex, and solar lentigo It is inappropriate for malignant lesions Once the applicator has been used on a patient, it should never be placed back into the original liquid nitrogen supply Rather, a small amount of liquid nitrogen should be poured into a disposable container (such as a styrofoam cup) for each Figure 8-7 Handheld liquid nitrogen unit patient This small temporary supply can then be reused for the patient Open spray technique The open spray technique is probably the most common technique used by dermatologists Liquid nitrogen is stored in a handheld unit (Fig 8-7) and emitted as a spray through a specialized tip (Fig 8-8) The tip is held 1–2 cm from the target site at a 90° angle The handheld unit should be vertical – otherwise liquid nitrogen may leak from 111 112 Dermatologic Surgery Figure 8-8 Spray tips (A) has the largest diameter, (D) the smallest Figure 8-10 Cryoprobe attached to a handheld liquid nitrogen unit cone is chosen corresponding to the measurement of the target lesion and the desired margins, respectively The appropriate amount of freezing is achieved when the lateral spread of the freeze is seen beyond the walls of the cone This is most appropriate for round lesions and lesions close to sensitive areas, such as the eye Closed technique Figure 8-9 Neoprene cones used in the closed cone technique the unit In addition to the factors listed in Table 8-� 2, the distance between the tip and the target tissue plays an important role in tissue freezing A greater distance between the tip and the target tissue results in a slower rate of tissue freezing In addition, the width of freeze will increase and the depth of freeze will decrease The most common lesions treated with the open spray technique are seborrheic keratoses, cystic acne, actinic keratoses, warts, actinic cheilitis, squamous cell carcinoma in situ (Bowen’s disease), squamous cell carcinoma, and basal cell carcinoma Cone spray technique The cone spray technique is similar to the open spray technique However, the spray is directed into a neoprene cone (Fig 8-9) placed over the target lesion The cone serves to contain the liquid nitrogen within a specified area The cone has two important characteristics: the diameter of the opening that covers the target lesion, and the diameter of the wall of the cone An appropriate The closed technique is also called the cryoprobe technique or contact therapy A cryoprobe is used (Fig 8-10) The handheld liquid nitrogen unit is connected to the cryoprobe by a tube, forming a closed system The probe is made of a metal conductor and can come in different shapes, which can match the shape of the lesion This technique is used primarily for malignant lesions It also may also be used with venous lakes, hemangiomas, dermatofibromas, myxoid cysts, sebaceous hyperplasia, and granuloma annulare Cold instrument technique In this technique, a pair of flat forceps or a hemostat is placed in a cup of liquid nitrogen until it is chilled The lesion is then grasped The process is repeated until the ice ball extends proximally to the base of the lesion This technique is sometimes used for pedunculated lesions as little discomfort is felt until the very end of the procedure Monitoring The depth of freeze can be monitored in several ways It is roughly equal to the radius of the surface area If an intermittent spray technique is used, the resultant ice ball will have a greater depth and more limited lateral spread If a continuous spray technique is used, the resultant ice ball will be more shallow and will have a greater lateral Chapter Cryosurgery Benign lesions Figure 8-11 Pyrometer–thermocouple needle device spread Using liquid nitrogen, the greatest possible depth of the ice ball is roughly 10 mm Larger lesions should be debulked surgically (e.g curetted) before cryosurgery is performed For malignant lesions, tissue temperature and depth of freezing may be monitored by a pyrometer–thermocouple device (Fig 8-11) using implanted 25–30-guage needles The tip of the needle should lie beneath or lateral to the lesion For malignant lesions, the final tissue temperature should be −20 to −30°C This pyrometer– thermocouple technique is rarely used today, and then only in specialized circumstances Applications Cryosurgery technique depends on the type of lesion being treated Table 8-� shows the general treatment guidelines for benign, premalignant, and malignant lesions Benign lesions usually require only one freeze– thaw cycle See Table 8-� for treatment parameters Some of the most common benign lesions treated are warts, molluscum contagiosum, seborrheic keratoses, and lentigines Each lesion on a patient may require a slightly different technique The open spray technique is used most frequently If the cryoprobe is used, the time for which the tissue remains adequately frozen may be two to three times longer The lateral spread of freeze is usually to the edge of the lesion or 2–3 mm beyond its border Benign neoplasms such as seborrheic keratoses and senile lentigos should be frozen superficially, as they are epidermal Vascular lesions such as venous lakes and spider nevi can be frozen with one freeze–thaw cycle with or without a 2–3-mm margin For other benign neoplasms such as warts, dermatofibromas, and myxoid cysts, the lateral spread of freeze may be 2–3 mm Premalignant lesions Premalignant lesions usually require one freeze– thaw cycle, although two may be used See Table 8-� for treatment parameters For actinic keratoses, the lateral spread of the freeze may go just to the edge of the lesion or slightly beyond For squamous cell carcinoma in situ, the optimal lateral spread depends on the lesion and location The lateral spread of the freeze is usually 3–5 mm, but may be less Table 8-5 Treatment guidelines for cryosurgery Lesion No of freeze– thaw cycles Freeze time (s) Total thaw time (s) Halo thaw time (s) Tissue temperature (°C) Benign 3–60 Variable NA 60 −20 to −30 Basal cell carcinoma 2–3 90 >60 −20 to −30 >98.6 Squamous cell carcinoma, invasive 2–3 90 >60 −20 to −30 >98.6 Cure rate (%) Lateral spread of freeze beyond lesion (mm) Premalignant 2–3 Malignant Times are for open spray technique NA, not applicable 113 114 Dermatologic Surgery Malignant lesions Malignant lesions usually require two freeze– thaw cycles, although three may be used in some cases See Table 8-� for treatment parameters The most common technique is the open spray technique because of its speed and ease of use Other options are the cone spray and closed (cryoprobe) techniques A thermocouple-mounted needle may be used to monitor tissue depth of freeze to detect a temperature of −20 to −30°C Large lesions may first be debulked surgically to create a thinner lesion that requires less spraying The halo thaw time, or the duration of marginal surface thawing of tissue beyond the lesion border, should be greater than 60 s The total thaw time of the entire lesion should be more than 90 s Large tumors may be treated in sections, in either one or several sessions, if appropriate freeze–thaw parameters cannot be achieved by freezing the entire lesion at one time Keratoacanthomas should be treated as squamous cell malignancies with two freeze– thaw cycles Cryosurgery is not recommended for lentigo maligna because of the documented high rate of recurrence Postoperative course and care During cryosurgery, pain is minimal and is worse during thawing than during freezing More painful areas include the forehead (where migraine headaches may be triggered), plantar surfaces of the feet, paronychial areas, ears, eyelids, lips, and mucous membranes Local anesthesia is used if thermocouple needles are to be placed, but it will not effectively block the discomfort of the actual cryogenic effect Common postoperative responses include pain, tenderness, swelling, and erythema Blisters and crusting also may occur, as well as eschar formation following treatment of deeper malignant tumors The resulting scar is usually hypopigmented and atrophic Although acceptable to lightskinned patients, the scar may not be acceptable to darker-skinned patients Hyperpigmentation may also occur, usually in intermediate skin types These pigmentation changes are usually transient, but may be permanent The postoperative course is relatively simple Healing time can be from to 5 weeks As with other modalities of surgery, factors such as increased age, comorbidities such as diabetes, and location (e.g lower legs) can prolong healing time Postoperative care includes washing daily with soap and water, and keeping the wound protected Hydrogen peroxide may be added if a crust develops If a tense blister forms, it can be drained with a sterile needle, leaving the roof of the blister intact Acetaminophen is usually sufficient for pain control Complications Hypopigmentation, large bullae, nerve damage, and secondary infection are the most important complications Rarely, hypertrophic scars and keloids may form Hemorrhage, either early or delayed, has been reported Surrounding structures may be damaged permanently Common examples include alopecia (hair follicles), nail dystrophy (nail matrix), dysesthesia (superficial cutaneous nerves), and notching of the ear or nose (cartilage) PEARLS • Make sure the handheld liquid nitrogen unit is vertical at all times If it is held at an acute angle or horizontally during treatment, liquid nitrogen may leak from the unit or the pressure valve may discharge • Pare down hypertrophic lesions before freezing them so that the base may be treated sufficiently • Darker-skinned individuals have a higher risk of hypopigmentation • Prolonged spraying may cause the valve in the handheld liquid nitrogen unit to freeze in an open position, making it spray continuously without closing Running the valve under warm water will unfreeze the valve and allow the unit to shut off • Be certain that the spray tip (or any attachment) is tightly screwed onto the handheld unit If the tip is loose, the force of the liquid nitrogen may propel it against the patient • Steady continuous spraying leads to a relatively wide, but shallow, zone of frozen tissue This is ideal for benign or premalignant lesions • Intermittent spraying results in a relatively narrow, but deeper, zone of freeze This is ideal for malignant or deeper lesions • Likewise, “painting” the target by moving the spray back and forth yields a wide but shallow freeze For deeper malignant lesions, the spray should be held on a central target zone, allowing the zone of freeze to be deep enough • Pain from cryogens is not blocked effectively by local anesthesia Therefore, unless thermo couple needles are being inserted, infiltration with a local anesthetic is of little value and may actually interfere with effective tissue freezing • Many units come with a choice of apertures Become familiar with how quickly and broadly each delivers the cryogen Be sure the correct aperture is in place • Some storage tanks have a metal hose This should never be grasped by hand, as the hand may freeze to the hose while the unit fills Further reading Alam M, Ratner D Cutaneous squamous-cell carcinoma N Engl J Med 2001;344:975–983 Arlette JP, Trotter MJ, Trotter T, Temple CLF Management of lentigo maligna and lentigo maligna melanoma: seminars in surgical oncology J Surg Oncol 2004;86:179–186 Castro-Ron G, Pasquali P Cryosurgery In: Robinson JK, Hanke CW, Sengelmann RD, Siegel DM, eds Surgery of the Skin Philadelphia: Elsevier Mosby, 2005: 191–202 Dachow-Siwiec E Treatment of cryosurgery in premalignant and benign lesions of the skin Clin Dermatol 1990;8:69–79 Drake LA, Ceilley RI, Cornelison RL, et al Guidelines of care for cryosurgery J Am Acad Dermatol 1994;31:648–653 Elton RF Complications of cutaneous cryosurgery J Am Acad Dermatol 1983;8:518–519 Gage AA History of cryosurgery Surg Oncol 1998;14:99–109 Gage AA, Caruana JA, Garamy G A comparison of instrument methods of monitoring freezing in cryosurgery J Dermatol Surg Oncol 1983;9:209–214 Chapter Cryosurgery Graham GF Cryosurgery Clin Plast Surg 1993;20:131–147 James WD, Berger TG, Elston DM Dermatologic surgery In: Andrews’ Diseases of the Skin: Clinical Dermatology, 10th edn Canada: Saunders Elsevier, 2006: 869–887 Kokoszka A, Scheinfeld N Evidence-based review of the use of cryosurgery in treatment of basal cell carcinoma Dermatol Surg 2003;29:566–571 Kuflik EG Cryosurgery updated J Am Acad Dermatol 1994;31:925–944 Kuflik EG Cryosurgery for cutaneous malignancy Dermatol Surg 1997;23:1081–1087 Kuflik EG, Gage AA, Lubritz RR, Graham GF History of dermatologic cryosurgery Dermatol Surg 2000;26:715–722 Lubritz RR, Smolewski SA Cryosurgery cure rate of actinic keratoses J Am Acad Dermatol 1982;7:631–632 Mallon E, Dawber R Cryosurgery in the treatment of basal cell carcinoma: assessment of one and two freeze–thaw cycle schedules Dermatol Surg 1996;22:854–858 Sterling JC, Handfield-Jones S, Hudson PM Guidelines for the management of cutaneous warts Br J Dermatol 2000;144:4–11 Zouboulis CC Principles of cutaneous cryosurgery: an update Dermatology 1999;198:111–117 115 Lisa B Campbell and Victor J Marks Biopsies are vital in dermatology and dermatologic surgery, allowing for dermatopathologic assessment with resulting diagnostic information Clinicians choose from several biopsy techniques, although the ultimate goal is to provide adequate tissue for microscopic examination In doing a biopsy, the clinician may wish to sample part of or a whole lesion or inflammatory process Also taken into consideration are the size and location, cosmetic concerns, and depth of the pathologic process Overview • Preoperative planning • Choosing the appropriate biopsy technique based on diagnosis • Incisional vs excisional biopsy • Shave biopsy technique • Punch biopsy technique • Full-thickness/elliptical biopsy technique • Biopsy specimen handling Preoperative planning Key Points • Obtain informed consent, verbal or written • Be aware of underlying medical conditions and adjust procedure accordingly • Take photographs where appropriate • Consider biopsy location for healing characteristics Planning any surgical procedure, including a simple biopsy, requires consideration of the following: • Informed consent Notify your patient of the most common adverse outcomes: bleeding, infection and scarring Discuss the possibility of requiring more surgery or other therapy based on the biopsy results Chapter Biopsy techniques • Underlying medical conditions Atrial fibrillation, hypertension, pregnancy, prosthetic heart valve or joint surgery, prior vasovagal response, and other medical conditions may alter your preoperative management of a patient • Photography Digital photography is now easily accessed in many dermatology clinics Consider utilizing this technology as it can be useful in clinicopathologic correlation, assist in confirming location of biopsy at a later time, and serve as visual history in a medical chart • Location Legs heal poorly in many individuals and upper trunk procedures may result in hypertrophic scarring • Antibiotics Preoperative antibiotics are not necessary for biopsy (considered a clean surgical procedure) according to American Heart Association guidelines, when the biopsy is performed through clinically uninfected skin (See Chapter 5: Preoperative evaluation.) • Antisepsis Generally, an alcohol swab for 10 s is adequate antisepsis for small biopsies Other surgical scrubs can be employed for larger procedures or for patients at higher risk for infection (See Chapter 2: Antisepsis.) • Anesthesia Most dermatologists use lidocaine (0.5–1%) with or without 1:100,000 or 1:200,00 epinephrine (See Chapter 3: Local anesthetics.) Choosing the appropriate biopsy technique Key Points • Consider type of lesion, depth, and location • In general, melanoma requires full-thickness biopsy • Broad, thin shaves may show lentigo maligna best 118 Dermatologic Surgery The appropriate technique is ultimately the decision of the clinician based on diagnostic concerns and suspicion The two major techniques are incisional and excisional biopsy (Table 9-� 1) Special diagnostic considerations (Figs 9-1 & 9-2) • Most melanomas: a Depth is critical for prognosis and therapeutic decision-making b Full-thickness excisional biopsy preferred, with 2-mm margin • Lentigo maligna: a Broad, superficial shaves are preferred over smaller biopsies b Broad, thin biopsies usually establish the diagnosis, whereas the false-negative rate for a 4-mm punch is as high as 80% Table 9-1 Major biopsy techniques Incisional biopsy Excisional biopsy Goal To remove a part of the lesion for diagnosis To remove entire lesion to subcutaneous fat Considerations Too large for excisional biopsy Depth needed for diagnosis (i.e suspected melanoma) Cosmesis of complete removal not acceptable if benign process Cosmesis improved if lesion removed completely Diffuse inflammatory process not amenable to excisional biopsy Malignant process suspected Shave Deep “scoop” shave Punch Punch Ellipse Ellipse Method • Inflammatory lesions: a Consider biopsy of both established and new areas, and possibly multiple areas of similar duration, to maximize diagnostic information b If a dermal process is suspected, a deep shave or punch is preferable If epidermal, a thinner shave may be adequate • Scalp biopsy for hair pathology: a A minimum of one 4-mm punch biopsy parallel to the direction of hair growth b A second punch biopsy can provide the pathologist with tissue for transverse sections, vertical sections, and immunofluorescence One specimen is bisected transversely, 1 mm above the fat The other is bisected vertically, with half sent for immunofluorescence and the other half placed in the same bottle as the transversely bisected specimen Let the lab know what you are doing Pathologic examination utilizing both horizontal and vertical sectioning enhances diagnostic yield c A biopsy from a burnt-out scar can demonstrate characteristic elastic tissue patterns of scarring when other biopsies have not been diagnostic They can also demonstrate the potential for regrowth d Suturing a scalp biopsy site can be cumbersome Gel foam produces rapid hemostasis and is generally preferred Location • Nail biopsy is discussed in Chapter 15: Nail surgery • Eyelid (or other thin skin) biopsy may be accomplished with the use of Gradle or curved Iris scissors as a modified excisional or shave biopsy (Fig 9-� 3) a Lift lesion gently with forceps b Snip at base with Gradle scissors c Hemostasis is achieved with gentle pressure or cautious use of aluminum chloride Pigmented lesions Large,diffuse or sensitive cosmetic area Suspected lentigo maligna Suspected melanoms Nevus Incisional biopsy Broad, thin shave Excision 2-mm margin Shave or punch 2-mm margin if dysplastic Figure 9-1 Algorithm for pigmented lesion biopsy Chapter Biopsy techniques Inflammatory lesions Dermal process Epidermal process Deep Shave Punch Shave Figure 9-2 Algorithm for an inflammatory lesion Figure 9-4 Biopsy tools From left to right: scalpel blade, double-edged razor blade, DermaBlade™, curette, disposable curette Figure 9-3 Eyelid or pedunculated lesion biopsy A forceps is used to grasp and elevate the lesion while a Gradle scissors evenly cuts the lesion at its base • Pedunculated lesions are also easily biopsied with scissors technique • Mucosal lesions are quickly anesthetized with topical anesthetic gel followed by injection of anesthetic Also consider a chalazion clamp to control bleeding, and silk or other soft suture material to avoid irritation • Scalp lesions along suture lines or midline spine lesions may involve intracranial or spinal structures Consider preoperative imaging or consultation with neurosurgery Surgical instruments • Shave biopsies may be performed with a scalpel blade, razor blade (available with plastic handle), or curette (disposable or multiple use with sterilization) (Fig 9-� 4) • Punch biopsy devices may be either disposable or reusable (Fig 9-� 5) • Elliptical incisional or excisional biopsies are accomplished utilizing a scalpel and standard excisional technique (see Chapter 10: Basic excisional surgery) Blade choice depends on the location and thickness of the skin For fine surgery on thinner skin, consider a small blade (15, 15c) Trunk and extremity lesions may require a larger blade (10) (For further discussion see Chapter 4: Surgical instruments.) Figure 9-5 Punch biopsy tools Disposable (left); multiple use (right) Shave technique Key Points • Become comfortable with several biopsy techniques • Practice with a skin substitute – tomatoes and oranges work well Scalpel blade (Fig 9-� 6) • Enter skin with curve of blade (15 or 10 blade most common) while holding skin taut • Use a short sawing motion with blade parallel to skin surface • Depth is controlled by downward pressure of the blade • Exit the skin by decreasing downward pressure and angling slightly upward, allowing the blade to resurface smoothly to complete biopsy • A cup-shaped defect is produced in the skin • Hemostasis can be achieved with 35% aluminum chloride on a cotton-tipped applicator Alternatives include Monsel’s solution and electrocautery 119 120 Dermatologic Surgery b a c d Figure 9-6 Scalpel shave technique After anesthetizing the skin, hold the blade parallel to the skin surface, entering with the curve of the blade (a) Using a short sawing motion, draw the blade across the base, elevating slightly to exit the skin (b) A thin defect results (c) and aluminum chloride can be used for hemostasis (d) a b c Figure 9-7 Razor shave technique After anesthesia, hold curved edge of blade parallel to skin surface (a) Using a short sawing motion, push the blade across the base, elevating to exit the skin (b) The resulting specimen and defect can be seen in (c) Razor blade (Fig 9-� 7) • Curve the blade by applying inward pressure on the blade from the sides • Stretch the skin taught for a superficial shave • Enter the skin in the center of the curved blade • Use a short sawing motion with the center of the blade • Depth is controlled by the amount of curve on the blade (more curve, more depth; less curve, more shallow) as well as downward pressure • Exit the skin by decreasing downward pressure and angling slightly upward, allowing the blade to resurface smoothly to complete the biopsy • May produce a cup-shaped defect in the skin (minimized by flattening the blade) • Useful for deep saucerizations • Can also produce broad, thin specimens with little to no cup-shaped defect when the blade curvature is minimized • Blade curvature can be inverted for convex surfaces • Surgeons with small hands generally prefer to break the blade in half This is done by folding the blade in half lengthwise with the wrapper still in place Curette (Fig 9-� 8) • The desired biopsy area must fit within the circumference of the curette • Stretch skin to provide a firm surface • Entry, central depth, and exit are controlled by downward pressure • A single fluid motion is preferred, as a fragmented specimen can compromise diagnosis and margin analysis Chapter Biopsy techniques • Tissue scissors may be required to free base of biopsy • Hemostasis may be achieved with surgical gel foam, suturing, or pressure • Apply pressure dressing PEARLS • To avoid inadvertent pinching with forceps, a bent needle may be used to elevate the biopsy out of the skin • To make an oval defect with a circular punch, PEARLS apply lateral pressure on the skin in the direction in which the short radius of the oval is desired (Fig 9-12) • Techniques may be practiced on tomatoes or oranges to simulate required force and motions to achieve even, controlled biopsies of appropriate depth (Fig 9-� 9) • To avoid a cup-like defect and maintain an even skin surface after biopsy of a raised lesion, anesthetic should be placed in the deep dermis and allowed to diffuse for 10–15 min (Fig 9-10) The skin should be stretched taught during the shave Punch technique Using a disposable or reusable punch (Fig 9-11): • Punch should be placed perpendicular to skin surface • Stretch the surface of the skin to provide a firm surface • Apply even downward pressure while rotating the punch until desired thickness is achieved • Withdraw punch • Grasp gently with toothed forceps without crushing the specimen Elliptical incisional/excisional biopsy technique When performed as a standard excision (see also Chapter 10: Basic excisional surgery): • Place scalpel perpendicular to skin surface and incise through to subcutaneous fat along predetermined outline • Outline may be elliptical to allow linear closure, or circular for healing by secondary intention • Once appropriate depth is obtained, elevate the tissue to reveal its base • Using scalpel or tissue scissors, free the base of the biopsy parallel to the surface • Undermine edges for linear closure • Achieve hemostasis • Place buried absorbable sutures to relieve tension, and top sutures to align skin edges Biopsy specimens Figure 9-8 Curette technique Begin with curette nearly perpendicular to the skin a b Figure 9-9 Shave technique practice Each laboratory will have specific handling instruc tions for biopsy As a minimum, specimens must be labeled with the patient’s name and, if there are multiple specimens, an appropriate number or letter They should be placed in an appropriate medium: formalin is used for routine light microscopy Alternatively, specimens sent for direct immunofluorescence should be placed in Michel’s solution or taken directly to the laboratory in normal saline Any special requests should first be discussed with the pathologist to ensure optimal specimen processing Clinical history and lesion c d 121 122 Dermatologic Surgery a b Cut Cut Figure 9-10 Deeper placement of anesthesia minimizes the depth of the defect (a) Shallow placement which displaces skin upward, obscuring the edge of a raised lesion (b) Deeper placement, preserving the elevation of the lesion and allowing a more shallow biopsy defect a c b Figure 9-11 Punch biopsy technique After anesthesia, place the punch perpendicular to the skin While applying downward pressure, rotate the punch until desired depth is achieved (a) Elevate the specimen and snip the base (b) Hemostasis can be achieved with a suture or gel foam (c) a b c Figure 9-12 Oval defect from a punch To make an oval shape, apply tension outward on the skin perpendicular to relaxed skin tension lines (a–c) description are also imperative so that clinicopathologic correlation can be made Further reading Chen TM, Mellette JR Surgical pearl: Tomato – an alternative model for shave biopsy training J Am Acad Dermatol 2006;54(3):517–518 Dalton SR, Gardner TL, Libow LF, Elston DM Contiguous lesions in lentigo maligna J Am Acad Dermatol 2005;52(5):859–862 Dzubow LM, Halpern AC, Leyden JJ, et al Comparison of preoperative skin preparations for the face J Am Acad Dermatol 1988;19:437–441 Elston DM, Ferringer T, Dalton S, Fillman E, Tyler W A comparison of vertical versus transverse sections in the evaluation of alopecia biopsy specimens J Am Acad Dermatol 2005;53(2):267–272 Garcia C Skin biopsy techniques In: Robinson JK, Hanke CW, Sengelmann RD, Siegel DM, eds Surgery of the Skin: Procedural Dermatology Philadelphia: Elsevier Mosby, 2005:203–212 ... facial nerve, particularly via the zygomatic and buccal branches, may be predicted by dropping 11 12 Dermatologic Surgery Table 1- 9 Muscles innervated by the facial nerve Table 1- 1 0 Areas of... vulnerable to injury as it courses over the zygomatic arch within this zone Figure 1- 1 0 The facial nerve: danger zone Table 1- 1 1 The muscles of facial expression Muscle Contraction Origin Insertion... surgeon’s fourth finger overlying the infraorbital foramen (1 cm below the infraorbital rim) Some 1. 0 1. 5 mL of anesthetic can be injected in this location The intraoral block offers less pain to the