Roenigk's Dermatologic Surgery: Current Techniques in Procedural Dermatology, Third Edition

886 Pages·2006·30.09 MB·English

by  K. Roenigk Randall

Roenigk's
Dermatologic
Surgery
Current Techniques in
Procedural Dermatology
Third Edition
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Roenigk's
Dermatologic
Surgery
Current Techniques in
Procedural Dermatology
Third Edition
Edited by
Randall K. Roenigk
Mayo Clinic
Rochester, Minnesota, U.S.A.
John Louis Ratz
Center for Dermatology and Skin Cancer
Tampa, Florida, U.S.A.
Henry H. Roenigk, Jr.
Arizona Advanced Dermatology
Scottsdale, Arizona, U.S.A.
New York London
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DEDICATION
To those who learn from this book and are happy with their success practicing
dermatologic surgery
Tothepatientswhoentrustuswiththeircareandbenefitfromaphysician’sdedicationto
life-long learning
To institutions such as Cleveland Clinic, Mayo Clinic, Northwestern University, and
others that provided training for our authors
Toprofessionalcolleagueswithwhomwehaveinteractedovertheyearsteachingcourses,
working with professional societies, educating the public and who appreciate our efforts
on behalf of the specialty
To supportstaff at our institutionsand private practices without whom we could not do
what we do
And to our wives Julie, Kathie, and Shirley, along with our children, who put up with
manyextrahoursawayfromthemtoseepatients,write,teach,anddoresearch.Without
yoursupportwewouldnotbeabletosucceedatworkandourliveswouldbeincomplete.

Preface
Thefirsteditionofthistextbookwaspublishedin1988and skillsofdermatologicsurgeonshaveexpandedconsiderably.
at that time, we felt we were helping to define a growing Dermatologic surgeons now repair most of their defects,
subspecialty in dermatology—dermatologic surgery. We including many that would have been referred to other
asked a prominent plastic surgeon and an otolaryngologist surgeonsinthepast.Wedotheseprocedureswithbetterskill
to write forewords for the book. Both acknowledged the because of the number of cases we perform. Based on
dermatologist’s expertise in some surgical procedures but Medicare data, dermatologists perform more skin lesion
reminded us that collaboration across specialties was excisions, Mohs surgery for skin cancer, primary repairs,
important. We continued that theme in the second edition and skin flaps than any other medical specialty. Because
published in 1996. In both editions, we mentioned the dermatologicsurgeonstodayroutinelyperformtheseproce-
experience of Dr. Jacques Joseph who was dismissed from duresonanoutpatientbasisinsteadofahospitaloperating
Wolff’sClinicin1896forperformingacosmeticprocedure. room, the cost of care has greatly reduced while quality
His example serves as a reminder that change is not easy, andaccesshavealsoimproved.Asaresult,thereconstruc-
andagents ofchangeareoftenostracized. tivesurgerysectionofourbookhasbeengreatlyexpanded
FredMohs,ageneralsurgeonfromMadisonWisconsin, inthisedition.
published his first paper on chemosurgery in 1941. At that All population and demographic studies tell us that
time, Dr. Mohs was not highly regarded by the surgical skin cancer will continue to increase because of the aging
community.WhenIcametoMayo,Iheardcommentsfrom ofthebabyboomers.Atthesametime,evenmorepatients
general surgeons, such as ‘‘we hoped the Mohs procedure are looking for ways to avoid the signs of aging. Combine
woulddiewhenDr.Mohsdied!’’Ittakestimeandpersever- patient demand with the surgical skills learned through
ance, but good ideas with real value normally prevail to removing cancer along with the dermatologist’s apprecia-
become the standard of care. It turns out Dr. Mohs had tion for the appearance of the skin, and the third major
two good ideas: a better method to completely check the area—cosmetic dermatologic surgery—becomes a logical
margins of a specimen and, since he used zinc chloride extension of our subspecialty and ever-expanding body of
paste to fix the tissue and did not close the wounds, we knowledge. This edition of Roenigk’s Dermatologic Surgery
learnedagreatdealaboutsecondintentionwoundhealing. has added new chapters on technology used for cosmetic
General surgeons and other surgical specialties procedures,suchaslasersandlightsourcesaswellasmini-
ignoredMohs’procedurebecausetheydidnotwanttoread mallyinvasiveproceduressuchassofttissueaugmentation,
1
the pathology, andit wasnot practical toperform thispro- ambulatory phlebectomy, and Botox . We have greatly
cedure in a traditional operating room. In the late 1960s, expanded ourcosmetic dermatologic surgery section while
somebolddermatologistswhowerewillingtopracticeout- also maintaining a balance, since many older procedures
side the normal bounds of dermatology began to expand still have value,having withstood the testoftime.
theirskillsinsurgery.Thisincludednovelproceduressuch In the 1970s, several societies were founded to pro-
as hair transplantation, dermabrasion, and laser, among mote education in dermatologic surgery, including the
others. Since dermatologists were learning surgery and are AmericanSocietyforDermatologicSurgeryandtheAmerican
trainedduringtheirresidencyintheclinicalandpathology College of Mohs Micrographic Surgery and Cutaneous
diagnosisofskincancer,theMohsprocedurewasanatural Oncology,amongothers.Apeer-reviewjournal,nownamed
fit. The efficiency of this practice was helped because der- Dermatologic Surgery, was started, which currently enjoys
matologists routinely practice in a clinic, not an operating the seventh highest impact factor among 35 peer-reviewed
room, and frozen section technology became readily avail- dermatology journals. It became clear that residents must
ableinthe1970s.Asaresult,adermatologistcouldoperate learn dermatologic surgery as part of their dermatology
onthreeorfourpatientsatonetimeintheclinicusinglocal training.TheAmericanBoardofDermatologyandtheResi-
anesthesia,getafrozensectioninaboutonehour,andread dency Review Committee for Dermatology recognized this
thehistologybeforetakingadditionaltissue.Inthose days, changeinpracticeandadoptednewprogramrequirements
most wounds were left to heal by second intention. It did for dermatology training and reorganized the certifying
nottakelongbeforedermatologistsrealizedthattheycould exam in dermatology, adding a section on surgery. It also
closesurgicaldefectsafterMohssurgeryforskincancer,so becameclear thatfellowship trainingbeyondtheresidency
thewoundhealedbetterandfaster.Thuswasbornoncolo- was an important way for some residents to gain added
gic and reconstructive dermatologic surgery, two of the skills. Most of these fellowships were established by the
three major areas that make up the body of knowledge of AmericanCollegeofMohsMicrographicSurgeryandCuta-
oursubspecialty. neous Oncology, but in 2003, the Accreditation Council for
SincethefirsteditionofRoenigk’sDermatologicSurgery Graduate Medical Education approved the adoption of a
in 1988 and the second edition in 1996, the reconstructive newsubspecialtyofdermatology—proceduraldermatology.
v
vi Preface
The Residency Review Committee now accredits 35 unavailable. Our mission as editors of the Third Edition of
fellowships in this subspecialty while the American Board Roenigk’s Dermatologic Surgery: Current Techniques in Pro-
of Dermatology is considering a subspecialty-certifying cedural Dermatology has been to provide one source for
exam in procedural dermatology. Regardless of when a the most up-to-date yet comprehensive information that
dermatologist was a resident or how much surgery was broadly describes what is currently accepted as state of
taught in their training program, it is incumbent on all the art in dermatologic surgery. Reading this text is an
physicians to maintain their skills and engage in lifelong important way for dermatologists who perform surgery to
learning. maintain or improve their surgical skills. We hope that
Population demographics and the increasing cost of the pages of this book become wrinkled and the binding
healthcarehavesupportedthegrowthofdermatologicsur- crackedwith regular use.
geryoverthepast40yearsbecauseweprovidereadyaccess
Randall K. Roenigk, MD
to cost-effective, high-quality outpatient care for skin
JohnLouis Ratz, MD
disease and the signs of aging, which was heretofore
Henry H. Roenigk, Jr., MD
Contents
Preface / v
Contributors / ix
PARTI:BASICPRINCIPLES
1. SurgicalPreparation, Facilities, andMonitoring / DiegoE.Marra,EdgarF.Fincher,and
RonaldL.Moy / 1
2. Instrumentation / SaadiaLakhanyRazaandCarlV.Washington / 11
3. ClosureMaterials / MistyD.Caudell,CliffordWarrenLober,andNeilA.Fenske / 17
4. MedicalEvaluation / PriyaZeikusandRaymondG.Dufresne,Jr. / 33
5. PreoperativePsychological Evaluation / HughM.Gloster,Jr.andRandallK.Roenigk / 39
6. InformedConsent / AbelTorres,RichardF.Wagner,Jr.,andStevenProper / 45
7. StandardPrecautions / CliffordS.PerlisandRaymondG.Dufresne,Jr. / 51
8. Cutaneous Anesthesia / AndreaWilleyandPeterK.Lee / 55
9. Tumescent Anesthesia / P.Lillis / 61
10. Wound Healing / HannLee,YongLi,TaniaPhillips,andDavidT.Woodley / 71
11. Complications inCutaneous Procedures / ThomasStaskoandWilliamB.Henghold / 79
12. Emergencies inthe DermatologyOffice / ChristopherB.KruseandJoshuaE.Lane / 103
13. SurgicalCoding: CurrentProcedural Terminology / BrettColdiron,EricAdelman,and
VernellSt.John / 111
PARTII:STANDARDPROCEDURES
14. Skin Biopsy / BryanC.SchultzandThomasA.Victor / 121
15. Excision / MarkJ.ZallaandR.StevenPadilla / 131
16. Scissor Surgery / RogerI.Ceilley / 141
17. SimpleRepairs / JeffLanderandFrederickFish / 147
18. Suturing Techniques / CliffordWarrenLober / 159
19. Electrosurgery andElectroepilation / SheldonV.PollackandRoyC.Grekin / 165
20. Cryosurgery / EmanuelG.Kuflik / 173
PARTIII:REGIONALDERMATOLOGICSURGERY
21. TheScalp / JerryD.BrewerandRandallK.Roenigk / 187
22. TheEar / RogerI.Ceilley / 197
23. TheEyeandEyelid / JuneK.Robinson / 207
24. TheNose / TriH.Nguyen / 219
25. TheLips andOralCavity / HubertT.Greenway / 231
26. TheFace(Forehead,Cheeks,andChin) / JonG.MeineandAllisonJ.Moosally / 239
27. TheNeck / AllisonJ.MoosallyandTerriMcGillis / 247
28. TheTorsoandAppendages / MichaelE.ContrerasandR.StevenPadilla / 255
29. TheHand / JohnLouisRatz,JeffersonJ.Kaye,andRandallJ.Yetman / 261
30. TheFoot / ChristinePoblete-LopezandAllisonT.Vidimos / 271
31. TheNail / DeborahF.MacFarlane,NorChiao,andRichardK.Scher / 281
32. TheGenitalia / RochelleTorgerson / 289
PARTIV:SURGICALMANAGEMENTOFSKINTUMORSANDDISEASE
33. EpidermalTumors / GlennKolansky,ChristopherTignanelli,BarryLeshin,andDuaneC.Whitaker /
301
34. BenignSoft Tissue Tumors / RichardM.RubensteinandKevinSpohr / 313
35. BenignPigmented Lesions / MelanieWarycha,RobertJ.Friedman,andDarrellS.Rigel / 321
36. Noninvasive IntraepidermalNeoplasia (PremalignantLesions) / JeffryA.Goldes,
WynnH.Kao,andGraceF.Kao / 329
vii