THE 14TH ANNUAL BASIC DERMATOLOGIC SURGERY COURSE AND WORKSHOP “A CUT ABOVE THE REST”
In the midst of the pandemic, the practice of medicine is more crucial than ever as a supplement to training and clinical practice. At this time, continuing medical education is vital for the further advancement of our specialty. The importance of experts in the field of dermatologic surgery will forever be indispensable. Hence, imparting knowledge on proper preparation, indication and proper technique in procedural dermatology is important not only for therapeutic but as well as cosmetic purposes.
The Dermatologic Surgery Core Team of the Jose R. Reyes Memorial Medical Center (JRRMMC) Department of Dermatology and the Skin Research Foundation of the Philippines held its 14th Annual Basic Dermatologic Surgery Course and Workshop entitled “A Cut Above the Rest” on December 5, 2020. This is the very first time that the department held its suture workshop virtually via Zoom meeting. The event was formally opened by the Chairman of the JRRMMC Department of the Dermatology, Dr. Ma. Flordeliz Abad-Casintahan and was hosted by Dr. Karla Ligeralde-Bascones. It was well attended with 101 participants.
The morning conference focused on the discussion of series of significant and comprehensive concepts that would benefit its participants with the knowledge about the essential principles of dermatologic surgery. Expert speakers in the field of dermatology, plastic & reconstructive and, aesthetic surgery were invited to ensure a holistic, innovative and multidisciplinary approach in the discussion of the lectures. The lectures were as follows: Surgical Anatomy of the Face & Neck, Pre-operative Assessment, Instrumentation & Materials, Antibiotic Prophylaxis, Asepsis & Antisepsis Techniques, Topical Anesthesia, Local & Regional Blocks, Hemostasis, Wound Healing & Post-operative Management, Wound Care and Optimizing Surgical Results.
In the afternoon, the participants were given a live demonstration of the different types of proper suture techniques including simple interrupted suture, simple running suture, running interlocking suture, vertical mattress suture, horizontal mattress suture, buried vertical mattress suture, buried horizontal mattress suture and subcuticular suture. Indications, advantages & disadvantages of each technique were also thoroughly discussed by Dr. Karla Ligeralde-Bascones. They were then divided in to seven groups, each supervised by a proctor to guide the participants as they are required to perform a return demonstration. This is to assess if they were able to understand and able to do the technique correctly. The enthusiasm and eagerness to learn of every individual were shown through their work. Truly, the success of the event can be reflected not only on those who organized it but also through the knowledge and technique imparted on all its participants.
PEARLS THAT THE AUDIENCE DERIVED FROM THE CME:
- Knowing the anatomy of the face and neck is essential for effective & safe surgery, avoidance of adverse outcomes, preservation of functional and optimal aesthetic reconstruction, and anticipation of possible spread of infection and metastasis of cutaneous malignancies.
- A thorough patient history and a complete medication list are crucial to predict adverse outcomes and complications in dermatologic surgery.
- Screening for symptoms and exposure to COVID-19 in the pre-operative assessment is important as we adapt to the new normal.
- Most wounds in dermatologic surgery are clean and clean-contaminated and do not require antibiotics. Also, routine use of antibiotics postoperatively is discouraged due to risk of developing microbial antibiotic resistance.
- Correct surgical techniques and patient education regarding wound care and management are essential in the prevention of surgical site infection.
- Studies show that to prevent infection, antibiotics must be given within 2-3 hours after inoculation and that antibiotics give maximal suppression against infection if given before bacteria colonize tissue.
- Appropriate antibiotic regimen for cutaneous procedures based on anatomic location is 2g of cephalexin (or 600mg of clindamycin in penicillin allergic patients) 1 hour before the procedure.
- The WHO recommends the use of 70% Ethyl Alcohol to disinfect reusable dedicated equipment; or 0.5% sodium hypochlorite for disinfecting surfaces.
- Use of Personal Protective Equipment is guided by the established risk categorization of aesthetic procedures.
- Identification and knowledge on when and how to use surgical instruments and their proper care are essential to a dermatologic surgeon. Organization of the instruments on a mayo tray during actual surgery is also important.
- Local anesthetics function by impairing neuronal transmission of sensory input, specifically by blocking neuronal sodium channels.
- Addition of epinephrine to local anesthesia improves the quality of the block by producing vasoconstriction that prolongs duration of anesthesia by 100-200%, minimizes intraoperative bleeding and decreases volume of anesthesia needed, rendering less discomfort for the patient.
- Adding one part of 8.4% sodium bicarbonate to 10 parts lidocaine with epinephrine reduces pain of anesthetic injection by neutralizing the acidic pH of lidocaine.
- Certain dermatologic skin conditions like syringoma and ingrown toenail require peripheral nerve block.
- Tumescent anesthesia is used for surgeries that require large volumes of anesthesia like liposuction, laser resurfacing, and dermabrasion
- Hemostatic process occurs in three phases: initiation, amplification, and propagation.
- In the pre-operative evaluation, history is the most useful tool in screening for bleeding conditions.
- In the selection of an appropriate wound dressing, one must consider the need for absorption of exudate (foams and alginates), need for additional moisture (hydrogels) and whether the epithelial edges of the wound can tolerate subtle trauma that comes from removal of the adhesive dressing.
- Tranexamic acid can be incorporated in anesthetic solutions to improve hemostasis.
- Optimizing anesthesia and alleviating anxiety and situational hypertension will reduce the risk of post-operative bleeding.
- Firm pressure over a bleeding wound for 15-20 minutes will achieve hemostasis for most vessels.
- Electrosurgery and suture ligation for hemostasis should be precise.
- The principle of wound management includes examining the whole patient, treating the cause of the wound and addressing patient-centered concerns before focusing solely the wound.
- The Triangle of Wound Assessment model enables evaluation of the wound bed, wound edge and periwound skin in the context of holistic patient care.
- Optimal wound healing requires a well vascular network, free of devitalized tissue, clear of infection, and adequate moisture.
- Wound dressings are categorized by its functionality. An ideal dressing must be cost-effective, able to protect the wound, prevents bacterial proliferation, achieves hemostasis, eliminates dead space, debrides necrotic tissue, and eliminates pain during dressing.
- Fusiform incision should maintain a ratio of length to breadth at 3:1. The ends of the fusiform should have an angle of 30 degrees or less and when closing the wound the ends should be placed parallel to the RSTLs to promote blending and prevent dog ear deformity.
- Peripheral undermining about the recipient site of the flap is done in the prevention of trapdoor deformity.