S008: Dermatologic Surgery Pearls: Optimizing Safety ... · S008: Dermatologic Surgery Pearls: Optimizing Safety, Satisfaction, Efficiency February 16, 2018 . ... improve cosmetic

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

Disclosure

I have no relevant relationship with industry.

Outline

• Efficient undermining

• Adhesive strip skin closure

• Negative pressure device

• Phone based apps

Undermining techniques

• Cold steel

– Sharp

– Blunt

• Electrosurgery

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.

Undermining with bi-terminal

electrosurgical unit

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/

Wound dressings

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




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)




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

“Peripheral Brain”

Appointment reminders

https://www.solutionreach.com/

https://www.televox.com/

http://www2.relatient.net/

https://ezderm.com/

https://www.lumahealth.io/

Photo Collage Editor

Thank you for your attention

Questions?

S008: Dermatologic Surgery Pearls: Optimizing Safety ... · S008: Dermatologic Surgery Pearls: Optimizing Safety, Satisfaction, Efficiency February 16, 2018 . ... improve cosmetic

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