Minor Office Procedures: Advanced Skills
Robert T. Smithing, MSN, NP
ObjectivesAs a result of attending this session, the participant will be able to:
- Describe one of two approaches to removing a sebaceous cyst.
- Demonstrate the correct technique for dealing with a dog ear defect.
- Demonstrate closure of a flap laceration.
- Demonstrate the correct technique for using an M-plasty during a biopsy.
Based on class participants input we will review other selected biopsy techniques.
Prerequisites for this class are knowledge of basic wound closure technique and proficiency in infiltration of local anesthetics.
A companion handouts entitled “Wound Management Core Information: Suturing and Biopsies” and “Sharpen Your Biopsy Techniques: Cut, Punch, and Shave Away” will be found in the conference handouts. Additional material may be available on www.npcentral.net/talks.
A sebaceous cyst is an encapsulated collection of fatty material and cellular debris. They start small then increase in size over time. Normally they are painless nodules. It is not unusual for the capsule to be firmly adherent to the surrounding tissues making removal more difficult. Complete removal of the capsule is necessary in order to reduce the likelihood of recurrence. There are 2 approaches that may be taken. On smaller sebaceous cysts an incisional technique can be used. For larger cysts, in order to reduce the size of the scar, a punch biopsy technique can be used. No known comparison studies are available at this time.
Incision Technique: Generally used on smaller cysts. After the anesthetic is infiltrated a slightly curved incision is made at the base of the cyst. This incision is roughly the length of the cyst. Then gently using mosquito hemostats and other instruments the cyst is slowly and gently freed from the surrounding tissue. Avoid puncturing the cyst and try to remove it intact. Close the wound with simple interrupted sutures, skin staples or Dermabond.
Punch Biopsy Technique: This is generally used on larger cysts. After the anesthetic is infiltrated a 4-5 mm punch biopsy instrument is used to make an opening in the center of the cyst. Remember to twist the punch while inserting it into its hub. Pull the punch straight out. At this point you should have a hole going into the soft cheesy center of the cyst. Applying gentle pressure express the contents of the cyst. Next, using mosquito hemostats and other instruments the cyst is slowly and gently freed from the surrounding tissue. This can be quite time consuming if it is a large cyst that is firmly adherent to the surrounding tissue. Irrigate the wound well with normal saline and close it with a single vertical mattress suture. (Alternative closures can also be used.)
Dog Ear Defect
This occurs when one edge of the wound becomes longer than the other. The result is an extra bit of tissue at the end of the wound being closed. Do not suture it under because it will not work!
- Determine the longer side of the wound. (It's the one that has the extra bump of tissue.)
- Mark a line on the skin angled 45 degrees away from the incision line going in the direction of the longer side of the wound.
- Undermine the surrounding area
- Using sharp scissors cut along the marked line.
- Apply gentle traction to the excess tissue and cut off the excess to match the extended wound margin. (Use sharp scissors.)
- The final result is a wound that looks similar to a hockey stick.
These must be treated extremely gently or the flap tissue will die. Even with the best of handling this will sometimes occur. A flap, which is connected with the wide end on the heart side of the wound, stands a better chance of healing than one that is attached at the distal end of the wound.
Suture the flap: This is the first option. If the flap is likely to be viable it's an excellent choice. Using the gentlest method that will work you close the wound. Handle the flap as little as possible. First tack the narrow end down using a half-buried horizontal mattress suture. Then use simple interrupted sutures to approximate the remainder of the wound.
Convert flap to ellipse: In this case you convert the flap into an ellipse by removing the mirror image of the flap. Then close the wound as you would an elliptical excision.
This is an elliptical excision with the ends turned around so it looks vaguely like an “M”. It is used to reduce the overall length of the wound from a lesion you are removing and still get the proper closure. You start by drawing an ellipse. Then flip the ends inward. This is a visual experience that will be illustrated in class.
Please ask any questions you may have during the session. If unable to attend the session or if questions come up later you can contact the speaker at his office, which is listed below. You can also talk with him through out the conference.