« Back to Treatment of Skin Disorders

Fundamentals of Cutaneous Surgery

»	What does the term “dermatologic surgery” embrace?
»	Local anesthetics can be broadly classified into one of two groups. Name these two groups and give a few examples of each.
»	How do the local anesthetics work?
»	What are the onset of action and the duration of action of the most commonly used local anesthetics in skin surgery?
»	How are the amide and ester anesthetics metabolized?
»	What is the greatest practical drawback of the ester anesthetics?
»	What are the maximum total dosages for 1% lidocaine (10 mg/mL) in adults and children?
»	What are the symptoms and signs of lidocaine toxicity and how is it treated?
»	Do true allergic reactions to local anesthetics exist?
»	Describe the clinical features of true local anesthetic allergy. How is this best treated?
»	What is the clinical presentation of patients with a vasovagal response to local anesthesia? How is this presentation best treated?
»	How does one manage the patient who refuses, or is truly allergic to, both the ester and the amide anesthetics?
»	What concentrations of epinephrine are the most effective for skin surgery? What is the safe maximum total dose?
»	What is the onset of action for epinephrine?
»	What are the clinical features of epinephrine toxicity?
»	Are allergic reactions to epinephrine possible?
»	When should epinephrine be used with great caution?
»	Which local anesthetics are “the safest” to use in pregnancy?
»	Describe measures that can be employed to diminish the pain associated with the injection of local anesthetics.
»	Discuss injection techniques that can be used to diminish pain.
»	What are the two most commonly used skin preparation antiseptics in dermatologic surgery?
»	Describe the mechanisms of action and spectra of coverage for these two preparations.
»	What are the most important advantages and disadvantages of povidone-iodine and chlorhexidine gluconate?
»	What is meant by absorbable and nonabsorbable suture material?
»	How does multifilament suture differ from monofilament suture?
»	Which types of suture material are best suited for subcutaneous stitches?
»	Which types of suture material are best suited for cutaneous stitches?
»	Which sutures are good choices for mucosal surfaces, the vermilion lip, and intertriginous areas?
»	How is suture sized?
»	Which suture needles are best suited to skin surgery?
»	What are the indications for a punch biopsy?
»	Describe how a punch biopsy should be performed.
»	What is the preferred technique for removing the punch biopsy?
»	What is meant by electrosurgery, electrocautery, and electrocoagulation?
»	Describe what is meant by electrofulguration and electrodesiccation.
»	What precautions need to be taken in patients with pacemakers who require electrosurgery?
»	Is it necessary to discontinue anticoagulant medications before elective surgery of the skin?
»	What are the so-called relaxed skin tension lines (RSTLs)? Why are they important?
»	How does one determine the direction of the RSTLs in planning a surgical wound closure?
»	Which areas of the body typically scar worst?
»	What is the superficial muscular aponeurotic system (SMAS)?
»	Describe the boundaries of the danger area for transecting the temporal branch of the facial nerve.
»	Describe the clinical signs of damage to this nerve.

What are the maximum total dosages for 1% lidocaine (10 mg/mL) in adults and children?

See Table 51-1.

	Table 51-1. Recommended Maximum Total Dosages for 1% Lidocaine (10 mg/mL) with and without Epinephrine in Adults and Children
	ADULTS		CHILDREN
	4.5 mg/kg (300 mg or 30 mL), without epinephrine		1.5–2.5 mg/kg, without epinephrine
	7.0 mg/kg (500 mg or 50 mL), with epinephrine		3.0–4.0 mg/kg, with epinephrine