ii
Contents
SECTION ONE Getting Started............................................ |
1 |
|
1 |
Preoperative Preparation................................................................................... |
2 |
|
Richard P. Usatine, MD • Jennifer Krejci-Manwaring, MD |
|
2 |
Setting Up Your Office: Facilities, Instruments, and Equipment.................. |
9 |
|
Richard P. Usatine, MD |
|
3 |
Anesthesia.......................................................................................................... |
20 |
|
Richard P. Usatine, MD |
|
4 |
Hemostasis......................................................................................................... |
30 |
|
Richard P. Usatine, MD |
|
5 |
Suture Material.................................................................................................. |
37 |
|
Bret R. Baack, MD • Daniel L. Stulberg, MD • |
|
|
Richard P. Usatine, MD |
|
6 |
Suturing Techniques.......................................................................................... |
46 |
|
Daniel L. Stulberg, MD • Richard P. Usatine, MD |
|
SECTION TWO Basic Procedures........................................ |
59 |
|
7 |
Laceration Repair............................................................................................... |
60 |
|
Richard P. Usatine, MD • Wendy C. Coates, MD |
|
8 |
Choosing the Biopsy Type............................................................................... |
70 |
|
John L. Pfenninger, MD • Richard P. Usatine, MD |
|
9 |
The Shave Biopsy.............................................................................................. |
86 |
|
Richard P. Usatine, MD |
|
10 |
The Punch Biopsy.............................................................................................. |
98 |
|
Richard P. Usatine, MD |
|
11 |
The Elliptical Excision...................................................................................... |
111 |
|
Daniel L. Stulberg, MD • Nikki Kattalanos, PAC • |
|
|
Richard P. Usatine, MD |
|
12 |
Cysts and Lipomas.......................................................................................... |
133 |
|
Jonathan Karnes, MD • John L. Pfenninger, MD • |
|
|
Richard P. Usatine, MD |
|
13 |
Flaps.................................................................................................................. |
146 |
|
Ryan O’Quinn, MD • Richard P. Usatine, MD |
|
14 |
Electrosurgery.................................................................................................. |
157 |
|
Richard P. Usatine, MD • John L. Pfenninger, MD |
|
15 |
Cryosurgery...................................................................................................... |
182 |
|
Richard P. Usatine, MD • Daniel L. Stulberg, MD |
|
16 |
Intralesional Injections..................................................................................... |
199 |
|
Richard P. Usatine, MD • John L. Pfenninger, MD |
|
xi
Contents
17 |
Incision and Drainage..................................................................................... |
210 |
|
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Daniel L. Stulberg, MD • Patrick Moran, DO |
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|
18 |
Nail Procedures............................................................................................... |
216 |
|
|
Richard P. Usatine, MD |
|
|
SECTION THREE |
Cosmetic Procedures ............................ |
229 |
|
19 |
Aesthetic Principles and Consultation.......................................................... |
230 |
|
|
Rebecca Small, MD |
|
|
20 |
Anesthesia for Cosmetic Procedures............................................................ |
241 |
|
|
Rebecca Small, MD |
|
|
21 |
Botulinum Toxin............................................................................................... |
248 |
|
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Rebecca Small, MD |
|
|
22 |
Chemical Peels................................................................................................. |
259 |
|
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Rebecca Small, MD • Kathleen O’Hanlon, MD |
|
|
23 |
Microdermabrasion......................................................................................... |
274 |
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Rebecca Small, MD • Racquel Quema, MD |
|
|
24 |
Skin Care Products.......................................................................................... |
286 |
|
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Rebecca Small, MD • Barbara Green, RPH, MS |
|
|
25 |
Dermal Fillers |
................................................................................................... |
298 |
|
Rebecca Small, MD |
|
|
26 |
Hair Reduction .............................................................................with Lasers |
309 |
|
|
Rebecca Small, MD • Jimmy Chen, MD |
|
|
27 |
Photorejuvenation .......................................................................with Lasers |
322 |
|
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Rebecca Small, MD • Dalano Hoang, DC |
|
|
28 |
Wrinkle Reduction ................................................with Nonablative Lasers |
336 |
|
|
Rebecca Small, MD |
|
|
29 |
Skin Resurfacing ..........................................................with Ablative Lasers |
351 |
|
|
Ken Yu, MD • Rebecca Small, MD • Corey Maas, MD |
|
|
30 |
Tattoo Removal ...........................................................................with Lasers |
367 |
|
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William Kirby, DO, FAOCD • Francisca Kartono, DO • |
|
|
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Rebecca Small, MD |
|
|
31 |
Combination Cosmetic ..............................................................Treatments |
377 |
|
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Rebecca Small, MD • Dalano Hoang, DC |
|
|
SECTION FOUR .......................... |
Putting it All Together |
383 |
|
32 |
Dermoscopy..................................................................................................... |
|
384 |
|
Ashfaq Marghoob, MD • Richard P. Usatine, MD |
|
|
33 |
Procedures to .......................................................Treat Benign Conditions |
404 |
|
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Daniel L. Stulberg, MD • Robert Fawcett, MD • |
|
|
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Rebecca Small, MD • Richard P. Usatine, MD |
|
|
34 |
Diagnosis and Treatment of Malignant and Premalignant |
|
|
|
Lesions.............................................................................................................. |
|
427 |
|
Daniel L. Stulberg, MD • Richard P. Usatine, MD |
|
|
xii
|
|
Contents |
|
35 |
Wound Care..................................................................................................... |
440 |
|
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Lucia Diaz, MD • Richard P. Usatine, MD |
|
|
36 |
Complication: Postprocedural Adverse Effects and Their |
|
|
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Prevention........................................................................................................ |
446 |
|
|
Richard P. Usatine, MD |
|
|
37 |
When to Refer/Mohs Surgery........................................................................ |
456 |
|
|
John L. Pfenninger, MD • Richard P. Usatine, MD |
|
|
38 |
Surviving Financially........................................................................................ |
463 |
|
|
John L. Pfenninger, MD • Rebecca Small, MD |
|
|
Appendices................................................................................................... |
481 |
|
|
Appendix A Consent Forms and Patient Education Handouts......................... |
483 |
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|
Appendix B Supply Sources for Lasers................................................................. |
506 |
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Appendix C Procedures to Consider for Benign, Premalignant and |
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Malignant Conditions............................................................................................... |
509 |
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Appendix D CPT Codes for Dermatology Procedures....................................... |
511 |
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Index........................................................................................................................... |
515 |
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|
xiii
Video Contents
Chapter 3: Anesthesia
Anesthesia For Shave Biopsy
Anesthesia For Punch Biopsy Anesthesia For Elliptical Excision Digital Block
Cyst Excision Behind Ear With Ring Block (see Chapter 12 for this listing as well)
Epidermal Cyst Excision From Back With Ring Block (see Chapter 12 for this listing as well)
Chapter 4: Hemostatis
Hemostasis With Aluminum Chloride After Shave
Biopsy
Electrosurgical Hemostasis After Removing An
Ellipse
Using Electrosurgery In An Undermined Area
Hemostasis With Forceps And Electrosurgery
Figure Of Eight Suture For Hemostasis
Chapter 6: Suturing Techniques
Loading The Needle Holder
Instrument Tie
Simple Interrupted Suture
Simple Running Suture On Face
Simple Running Suture On Arm
Deep Vertical Mattress Suture With Skin Hook
Deep Vertical Mattress Suture With Skin Hook After Rotation
Flap
Deep Vertical Mattress Suture With Forceps
Deep Horizontal Mattress Suture
Chapter 9: The Shave Biopsy
Shave Of Benign Nevus On Face With DermaBlade (see Chapter 33 for this listing as well)
Shave Of Benign Nevus On Neck With DermaBlade (see Chapter 33 for this listing as well)
Shave Of Scalp Nevus With DermaBlade (see Chapter 33 for this listing as well)
Shave Excision Of Keloid From Earlobe With DermaBlade (see Chapter 33 for this listing as well)
Shave Biopsy Of Small BCC With DermaBlade (see Chapter 34 for this listing as well)
Shave Of Nevus With #15 Blade (see Chapter 33 for this listing as well)
Shave Biopsy On Neck Of Suspicious Lesion With DermaBlade
Shave a Benign Nevus With DermaBlade And Electrosurgery of Remaining Edge
Snip Excision Of Two Skin Tags With Anesthesia (see Chapter 33 for this listing as well)
Snip Excision Of One Skin Tag Without Anesthesia (see Chapter 33 for this listing as well)
Chapter 10: The Punch Biopsy
Punch Biopsy Of Suspected Melanoma—Not Sutured (see Chapter 34 for this listing as well)
Punch Biopsy Of Pityriasis Rosea With One Suture Punch Biopsy Of Palmar Psoriasis With Two Sutures
Placed
Chapter 11: The Elliptical Excision
Elliptical Excision Of Chondrodermatitis (see Chapter 33 for this listing as well)
Elliptical Excision Of SCC on Thigh (see Chapter 34 for this listing as well)
Elliptical Excision Of BCC On Arm (see Chapter 34 for this listing as well)
Elliptical Excision Of SCC on Face (see Chapter 34 for this listing as well)
Repair Of Standing Cone (Dog Ear)
Chapter 12: Cysts and Lipomas
Epidermal Cyst Excision From Back With Ring Block (see Chapter 3 for this listing as well)
Cyst Excision Behind Ear With Ring Block (see Chapter 3 for this listing as well)
Lipoma Excision—Full Procedure Lipoma Expressed Manually
Chapter 13: Flaps
Mohs Surgery And Repair Of SCC On Neck (see Chapters 34 and 37 for this listing as well)
Primary Repair After Mohs Surgery Of BCC On Face (see Chapters 34 and 37 for this listing as well)
Wedge Excision On The Ear After Mohs Surgery (see Chapters 34 and 37 for this listing as well)
Rotation Flap On Cheek After Mohs Surgery (see Chapters 34 and 37 for this listing as well)
Chapter 14: Electrosurgery
Electrosurgery Of Cherry Angioma (see Chapter 33 for this listing as well)
Electrosurgery Loop Shave Of Nevus With Feathering Electrodessication And Curettage Of SCC In Situ On Dorsum Of Hand (see Chapter 34 for this listing
as well)
Removal Of Ingrown Toenail With Digital Block And Electrosurgery (see Chapter 18 for this listing as well)
Electrosurgery With Sharp Tip Electrode (Banana Model) Electrofulguration And Electrodessication With Blunt Tip
Electrode (Banana Model) Bipolar Electrode (Banana Model)
Comparison Of Electrosurgery Methods (Banana Model)
Chapter 15: Cryosurgery
Cryo-Tweezer Of Warts On Face (see Chapter 33 for this listing as well)
Cryo-Spray Of Seborrheic Keratosis On Face—Long Bent Spray Tip (see Chapter 33 for this listing as well)
Pulsatile Spray Of Seborrheic Keratosis On Neck—Aperture C Tip (see Chapter 33 for this listing as well)
Cryosurgery Of Flat Warts (see Chapter 33 for this listing as well)
Cryo-Tracker Of Seborrheic Keratosis (see Chapter 33 for this listing as well)
Cryo-Spray With Long Bent Spray Tip Of Actinic Keratosis (see Chapter 34 for this listing as well)
Cryoprobe Of Actinic Keratosis (see Chapter 34 for this listing as well)
xv
Video Contents
Cryo-Spray Of Actinic Keratosis With Aperture C Tip (see Chapter 34 for this listing as well)
Keloid Treated With Cryo-Spray Then Intralesional Injection (see Chapter 16 for this listing as well)
Cryo-Spray With Straight Short-Tip (Banana Model) Cryo-Spray With Aperture C Tip (Banana Model) Cryo-Spray With Short Bent Spray Tip (Banana Model) Cryo-Spray With Long Bent Spray Tip (Banana Model) Cryo-Spray With Acne Tip (Banana Model)
Small Closed Probe With Liquid Nitrogen (Banana Model) Large Closed Probe With Liquid Nitrogen (Banana Model) Comparison Of Cryosurgery Methods (Banana Model)
Liquid Nitrogen Removed From Dewar Using Withdrawal Tube
Chapter 16: Intralesional Injections
Keloid Treated With Cryo-Spray Then Intralesional Injection (see Chapter 15 for this listing as well)
Chapter 18: Nail Procedures
Removal Of Ingrown Toenail With Digital Block And Electrosurgery (see Chapter 14 for this listing as well)
Toenail Matrix Ablation With Phenol And Electrosurgery
Chapter 21: Botulinum Toxin
Botox Frown
Botox Horizontal Forehead Lines
Botox Crow’s Feet
Chapter 25: Dermal Fillers
Dermal Filler Nasolabial Fold
Chapter 33: Procedures to Treat Benign Tumors
Milia Extraction
Electrosurgery Of Cherry Angioma (see Chapter 14 for this listing as well)
Shave Of Benign Nevus On Face With DermaBlade (see Chapter 9 for this listing as well)
Shave Of Benign Nevus On Neck With DermaBlade (see Chapter 9 for this listing as well)
Shave Of Scalp Nevus With DermaBlade (see Chapter 9 for this listing as well)
Shave Excision Of Keloid From Earlobe With DermaBlade (see Chapter 9 for this listing as well)
Shave Biopsy On Neck Of Suspicious Lesion With DermaBlade (see Chapter 9 for this listing as well)
Shave Of Nevus With #15 Blade (see Chapter 9 for this listing as well)
Snip Excision Of Two Skin Tags With Anesthesia (see Chapter 9 for this listing as well)
Snip Excision Of One Skin Tag Without Anesthesia (see Chapter 9 for this listing as well)
Elliptical Excision Of Chondrodermatitis (see Chapter 11 for this listing as well)
Cryo-Spray Of Seborrheic Keratosis On Face—Long Bent Spray Tip (see Chapter 15 for this listing as well)
Pulsatile Spray Of Seborrheic Keratosis On Neck— Aperture C Tip (see Chapter 15 for this listing as well)
Electrosurgery Loop Shave Of Nevus With Feathering (see Chapter 14 for this listing as well)
Cryo-Tracker Of Seborrheic Keratosis (see Chapter 15 for this listing as well)
Cryosurgery Of Flat Warts (see Chapter 15 for this listing as well)
Cryo-Tweezer Of Warts On Face (see Chapter 15 for this listing as well)
Chapter 34: Diagnosis and Treatment of Malignant Lesions
Cryo-Spray With Long Bent Spray Tip Of Actinic Keratosis (see Chapter 15 for this listing as well)
Cryoprobe Of Actinic Keratosis (see Chapter 15 for this listing as well)
Cryo-Spray Of Actinic Keratosis With Aperture C Tip (see Chapter 15 for this listing as well)
Shave Biopsy Of Small BCC With DermaBlade (see Chapter 9 for this listing as well)
Elliptical Excision Of SCC on Thigh (see Chapter 11 for this listing as well)
Elliptical Excision Of BCC On Arm (see Chapter 11 for this listing as well)
Punch Biopsy Of Suspected Melanoma—Not Sutured (see Chapter 10 for this listing as well)
Elliptical Excision Of SCC on Face (see Chapter 11 for this listing as well)
Mohs Surgery And Repair Of SCC On Neck (see Chapters 13 and 37 for this listing as well)
Primary Repair After Mohs Surgery Of BCC On Face (see Chapters 13 and 37 for this listing as well)
Wedge Excision On The Ear After Mohs Surgery Of SCC (see Chapters 13 and 37 for this listing as well)
Rotation Flap On Cheek After Mohs Surgery Of BCC (see Chapters 13 and 37 for this listing as well)
Electrodessication And Curettage Of SCC In Situ On Dorsum Of Hand (see Chapter 14 for this listing as well)
Chapter 37: When to Refer/Mohs Surgery
Mohs Surgery And Repair Of SCC On Neck (see Chapters 13 and 34 for this listing as well)
Primary Repair After Mohs Surgery Of BCC On Face (see Chapters 13 and 34 for this listing as well)
Wedge Excision On The Ear After Mohs Surgery Of SCC (see Chapters 13 and 34 for this listing as well)
Rotation Flap On Cheek After Mohs Surgery Of BCC (see Chapters 13 and 34 for this listing as well)
We acknowledge Robert D. Long, Jr., Lester Rosebrook, Bob Merill and the UTHSCSA video production department. I especially thank Robb Long for all the long hours of shooting and editing.
xvi
8 
Choosing the Biopsy Type
JOHN L. PFENNINGER, MD • RICHARD P. USATINE, MD
A biopsy of the skin is performed to ascertain or confirm the diagnosis of skin lesions, both benign and malignant, and in many cases, to simultaneously remove them. Skin biopsies can be categorized into five types (Figure 8-1):
1.Shave
2.Punch
3.Curettement
4.Wedge (incisional)
5.Excisional (elliptical)
See video on the DVD for further learning. 
Choosing which type of biopsy to perform influences the diagnostic yield, the cosmetic result, and the cost and time required for the physician to perform the procedure. The clinician must also understand the parameters for selecting that portion of a lesion that will provide the most information to a pathologist.1–3
•It is a particularly useful procedure in certain anatomic areas, such as the back and the shin, that are difficult to suture due to skin tension.
•Cosmetic results of a shave biopsy are generally excellent; in many cases, but not all, results will be superior to those achieved with a full-thickness excision biopsy with suture closure.
Disadvantages
•A possible indentation scar may result if a deep shave is performed.
•The lesion could recur.
•Transecting a melanoma can alter the interpretation of true depth, which is required for treatment. However, the type of biopsy does not appear to affect long-term outcomes.4
•The clinician may not shave deep enough for fear of scarring and thus not provide the pathologist with enough material for evaluation.
GENERAL PRINCIPLES
Shave Biopsy
See video on the DVD for further learning. 
The choice of biopsy technique has much to do with the physician’s initial assessment of the lesion. It is particularly important to consider the depth of involvement within the skin. The shave method is particularly suited to lesions confined to the epidermis and upper dermis, such as seborrheic or actinic keratoses, basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs), and many benign nevi. Chapter 9, The Shave Biopsy, provides detailed information on this topic.
Advantages
•Minimal equipment is needed.
•The risk of bleeding is minimal, making the procedure suitable for patients on anticoagulants.
•It is a fast procedure because no sutures are required.
•It allows for rapid healing because a full-thickness wound is not created.
•Relatively large, raised lesions can be easily removed with the biopsy. With the entire lesion removed, there is much less risk of missing an abnormality as can happen with a punch or partial curettement biopsy, which does not remove the entire lesion. The pathology report will indicate whether the entire lesion has been removed or not.
Punch Biopsy
See video on the DVD for further learning. 
A punch biopsy is the method of choice for most inflammatory or infiltrative diseases and for other lesions in which the predominant pathology lies in the dermis, such as a dermatofibroma. A punch biopsy produces a full-thickness specimen of the skin that, when done properly, extends to the subcutaneous fat. Chapter 10, The Punch Biopsy, provides detailed information on this topic.
Advantages
•Minimal equipment is needed.
•The procedure is quick, easy, and simple.
•It provides a full-depth specimen.
Disadvantages
•Bleeding may be more of a problem than with a shave biopsy but usually is controlled with pressure, topical hemostatic agents, or a suture.
•Care must be taken not to penetrate too deeply over nerves, arteries, and thin skin.
•The most advanced area of the lesion may not be the site chosen for the biopsy. This sampling error can result in a missed diagnosis such as in a melanoma when only a portion of a pigmented lesion is cancer.
70
8 • Choosing the Biopsy Type |
8 |
A B C
D E
FIGURE 8-1 Five biopsy methods: (A) Shave; (B) punch; (C) curettement; (D) incision; (E) excision. (Copyright Richard P. Usatine, MD.)
Curettement Biopsy
Using a sharp curette is another method of biopsy. A disposable 3-mm curette is a good choice. This size of curette is best suited for difficult areas such as in the canthal folds where the skin is thin and mobile or in areas that are difficult to access such as an ear canal or nostril. Care must be taken not to go too deep and injure vital tissue. A small lesion can be curetted off and sent to pathology (Figure 8-2).
FIGURE 8-2 Squamous cell carcinoma in the upper pinna. A 3-0 curette is able to obtain tissue more easily than a scalpel, razor, or punch in this location. However, if the curette is not adequately sharp, a scalpel may obtain a better sample. (Copyright Richard P. Usatine, MD.)
Incisional and Excisional Biopsy
See video on the DVD for further learning. 
The term incisional biopsy refers to the process of excising a portion of a lesion using full-thickness excision techniques. It is used for obtaining a large sample of a large lesion, but not the entire lesion. The term excisional biopsy refers to full-thickness excision of the entire lesion. Both generally require some type of closure, which is usually done with sutures. See Chapter 11 for more detailed information about elliptical excisions.
Excision may be the biopsy method of choice for large potentially malignant lesions since a more focal biopsy may miss the malignant portion of the abnormality. Lesions highly suggestive of malignant melanoma (Figure 8-3) are often excised since the resulting specimen will provide a full-depth sample, which is needed for prognosis and treatment. The disadvantages of excising all “suspicious” lesions are that (1) it can lead to overtreatment for benign lesions and more tissue is removed than what is needed, which adds to the cost and increases scarring and other complications (e.g., excising a totally benign nevus or minimally atypical one), and (2) another surgery is often required because the initial ellipse is often performed with margins smaller than recommended for definitive treatment.
The excisional technique is also used to diagnose and remove dermal lesions, subcutaneous cysts and tumors (epidermal cysts and lipomas), and lesions that are too deep or too large to be removed by punch (generally greater than 5 mm in diameter) or shave. Cysts and especially lipomas may be removed with a deep linear
71