Surgical Lamps

Adequate lighting is best achieved by using surgical lamps that are either ceiling mounted or on a rolling base. There are many lamps from which to choose. We are pleased with the Burton Outpatient II light in our main procedure room (Figure 2-1A). It is very bright but does not get hot. This is Burton’s number one surgical light and is shadow free, can be focused, and is guaranteed to have a no-drift arm. We have found the light to be too bright at times so we have taped photo diffuser sheets over the lights. Another option is to put in a dimmer so you can control the light output. This light focuses with a central handle. The central handle can be covered with a sterile cover, but we just ask our medical assistant to reposition the light when needed. Many other lights are available, but it is worth getting a good one.

FIGURE 2-1 (A) Ceiling-mounted surgical light. (B) Exam room with Mayo stand, lift chair, Burton SuperNova exam light, and poster of the skin.

(Copyright Richard P. Usatine, MD.)

If you get a better quality light in your main procedure room, it will be easier to see for more complex surgeries. A floor lamp may be used in your other exam rooms, but if you count on it in your procedure room, you may have lower quality light and need to deal with the inconvenience of the stand taking up floor space.

Floor Lamps

You should have at least one good-quality movable floor lamp for your exam rooms. One per room is optimal but one good movable lamp is a good start. Look for a lamp that provides excellent illumination, ease of movement, and stability in a small exam light for the floor. The Burton SuperNova exam light (Figure 2-1B) is one lamp that works well for us, but many other floor lamps are available that provide similar features. A gooseneck lamp with a bare incandescent light bulb gets hot and the light is not optimal for skin procedures.

Woods Lamp

The Woods lamp (Figure 2-2) uses an ultraviolet light and is useful for diagnosing or evaluating fungal infections including Microsporum canis and Malassezia furfur. It is also helpful for identifying the coral red fluorescence of erythrasma. It can be used for accentuating the hypopigmentation of vitiligo. In melasma, it is used to see if the hyperpigmentation is within the epidermal or dermal layer. Outside of dermatology the Woods lamp helps to diagnose corneal abrasions.

FIGURE 2-2 Woods lamp. Ultraviolet light for the diagnosis of fungal infections, erythrasma, vitiligo, and melasma.

(Copyright Richard P. Usatine, MD.)

We use the Burton ultraviolet light. It uses fluorescent bulbs that produce UV-A at an approximately 360-nm wavelength. This is not harmful to the eyes or skin. It has a magnifier lens with three power magnifications and a focal length of 8 in.

Cutting

Scalpels

A scalpel has two parts, the handle and blade. The four most useful blades (Figure 2-3A) for skin surgery are:

FIGURE 2-3 (A) Scalpel blades used in skin surgery. (B) Scalpel handles with ruler markings. Note the round handle was designed by a surgeon for increased dexterity during more challenging surgeries (Siegel handle).

(Copyright Richard P. Usatine, MD.)

• No. 15 blade: most commonly used blade for skin surgery.

• No. 15C blade: shorter and thinner blade with a finer point than the traditional No. 15 blade. It is useful for fine plastics work on the face.

• No. 11 blade: sharply pointed with a cutting blade on both sides, making it useful for incision and drainage of an abscess or cyst.

• No. 10 blade: larger than a No. 15 blade with the same shape. It is useful for doing a shave biopsy of a large lesion or for cutting a thick callus on the foot. Some surgeons prefer it for large skin excisions on the back because the skin is so thick in this location.

 

Blades are disposable and can be purchased separately or preattached to disposable plastic handles. The advantage of a totally disposable scalpel is that it eliminates the risk of being cut while attaching or removing a disposable blade from a nondisposable metal handle. The risk of being cut is low with good dexterity and experience. A needle holder or hemostat is helpful when placing a blade on the handle or taking it off. Blade-removal instruments can also be purchased. Although disposable scalpels are convenient, they are not as stable or as sharp as a metal scalpel handle with a disposable blade. For elliptical excisions and flaps, I prefer the sharp blades on a nondisposable metal handle. Special scalpel handles have been designed by surgeons for increased dexterity during more challenging surgeries (Figure 2-3B). Most metal scalpel handles come with a ruler marking for measuring the size of your surgical cuts (Figure 2-3B).

Personna Plus Microcoat blades are particularly sharp Teflon-coated blades. However, sharp disposable blades are also available from Bard-Parker, Cincinnati Surgical, and Swann-Morton. It may be worthwhile to try out more than one type to determine which one meets your personal needs and budget.

Razor Blades

The full range of razor blades (Figure 2-4) is discussed in detail in Chapter 9, The Shave Biopsy. The DermaBlade is a particularly easy and sharp blade to use for the novice and the expert. The Personna super double-edge blade is very sharp and can be broken in half for easy use. Although these do not come in sterile packaging, they can be used for shave biopsies without putting them through the autoclave. At pennies a blade, these are the most cost-effective tool for shave biopsies. They can be broken in half within their paper container to avoid cutting your hand prior to use.

FIGURE 2-4 Razors and scalpels for shave biopsies. The DermaBlade is the blue-handled blade in the bottom right corner.

(Copyright Richard P. Usatine, MD.)

Scissors

Figure 2-5 shows different types of scissors used in skin surgery. The most versatile and affordable scissor for snip excisions and cutting the base of a punch biopsy is the iris scissor, a small, sharp-tipped scissor that may be straight or curved. Use of the straight or curved iris is a matter of personal preference. The curved scissor is a bit more expensive and may allow the operator to get under a punch biopsy specimen with some ease. Scissor length varies from 3 to 5 in. The iris scissor can be used for suture removal and cutting sutures, but the ones used for this purpose should be kept separate from tissue-cutting scissors to avoid dulling your best surgical scissors. The iris scissor can also be used for blunt dissection and undermining. Scissors need periodic sharpening, but properly cleaned and treated instruments will generally last a long time and are worth the investment.

FIGURE 2-5 Assorted scissors for skin surgery: Supercut iris scissor, gold-handled iris scissor, Gradle scissor, and a tissue undermining scissor.

(Copyright Richard P. Usatine, MD.)

Gradle scissors have very small blades for fine cutting and undermining. These scissors can be invaluable with a punch biopsy of the nail matrix in which the tissue is friable and would be easy to crush if a less fine pair of scissors were used. Gradle scissors are more expensive than standard iris scissors.

Many companies make specific undermining scissors with sharp or blunt tips and sharp blades. Some of these are tenotomy scissors or Metzenbaum scissors. These could be used instead of the all-purpose iris scissor. New technologies are being used to make the blades of scissors sharper. For a premium price you can now buy scissors that are as sharp as a scalpel (e.g., Supercut scissors). Endarterectomy scissors, which have a longer handle with blunt tips, also provide excellent control and precision for delicate work, but at a somewhat higher price.¹

Punches

Punches come in sizes ranging from 2 to 10 mm. Clinicians may choose between disposable, one-use punches and reusable steel punches (Figure 2-6). Disposable punches are presterilized and need no maintenance. Reusable punches require cleaning and sterilization between procedures and must be sharpened periodically. We use disposable punches only because they are always sharp and convenient.

FIGURE 2-6 Assortment of punch types, including two nondisposable punches, two open punches, and one closed punch.

(Copyright Richard P. Usatine, MD.)

The new Huot VisiPunch has the wonderful advantage of allowing the clinician to see through the punch instrument while performing the procedure. This allows you to place the punch on the skin and make sure the whole lesion is within the punch before starting the cut. Also, you can see the depth better and have a better idea of when the punch core releases from the dermis below. These come in the full range of sizes between 2 and 10 mm. Although a wide range of punch instruments is produced by many manufacturers from 2 to 10 mm, the most useful punch biopsy instruments range from 3 to 6 mm. See Chapter 10, The Punch Biopsy, for more information on this surgical tool.

Curettes

Dermal curettes (Figure 2-7) are useful for treating pyogenic granulomas, molluscum contagiosum, seborrheic keratoses, basal cell carcinomas, and squamous cell carcinomas. The head of the curette may be round (Fox curette) or oval (Piffard curette). One side of the curette head is dull. The other side has a sharp blade that is designed to cut through friable or soft tissue but is not so sharp as to cut normal skin. This allows the curette to distinguish between abnormal and normal tissue and to selectively remove the abnormal tissue.

FIGURE 2-7 One reusable curette and three disposable curettes ranging from 7, 5 to 3 mm.

(Copyright Richard P. Usatine, MD.)

Curettes range in size from 2 to 7.5 mm. Nondisposable and disposable curettes are available. The size and shape of the curette used are in part determined by personal preference. Larger curettes allow for removal of larger lesions with fewer strokes. Smaller curettes are more precise and can be used on smaller lesions and for curettage of small pockets of tumor that are more difficult to reach with larger curettes. A range of curettes should be available in the office. Disposable curettes that range from 2 to 7 mm can be purchased. We keep 3-, 5-, and 7-mm curettes in our office and find that this covers our needs (Figure 2-7). Currently we are using the Acu-Dispo-Curette by Acuderm, but other companies also produce excellent disposable curettes.

Tissue Holding

A large variety of forceps and skin hooks are available that enable a clinician to handle skin in a means that facilitates cutting, undermining, and suturing. The goal of tissue holding is to provide the most stability during these procedures while minimizing skin trauma and scarring.

Forceps

Basic types of forceps include tissue forceps, dressing forceps, and splinter forceps. To aid in removing splinters, splinter forceps have sharp tips and no teeth. Dressing and tissue forceps are available with and without teeth. Opinions vary about the value of teeth on forceps. Some clinicians believe that they can handle skin more atraumatically when forceps have teeth, whereas others believe there is less tissue trauma without teeth. This is an issue that may be determined by personal preference.

The most commonly used type of forceps in skin surgery is the Adson forceps, which has a broad handle and a long narrow tip (Figure 2-8). One common configuration is one tooth on one tip fitting into two teeth on the other tip. Many variations of this configuration exist. We suggest you start with the basic -in. Adson forceps, with and without teeth, and experiment with others as needed. I personally prefer the teeth for suturing and the forceps without teeth when lifting the punch specimen up to cut the base. Adson forceps without teeth may tend to crush healthy tissue if one is applying a strong force to hold skin under tension.

FIGURE 2-8 Instruments for holding skin: Adson forceps with micro-fine teeth, one single-pronged skin hook and one double-pronged skin hook.

(Copyright Richard P. Usatine, MD.)

The use of good-quality forceps with small teeth and accurate apposition is important. This allows you to pass the suture needle back and forth between the forceps and needle holder without touching the needle with your fingers, thereby decreasing your risks for a needlestick. Most cheap disposable forceps do not hold suture needles well at all.

Skin Hooks

Skin hooks are capable of holding tissue in the least traumatic manner. They are better than forceps for reflecting skin while undermining without crushing skin edges. Skin hooks are especially useful for holding skin while undermining and while placing deep sutures (Figure 2-9). Skin hooks are available with single- or double-pronged hooks and with sharp or blunt prongs (Figure 2-8). Single, sharp-pronged hooks are the most versatile type of skin hook. The double-pronged skin hook can be useful in retracting the proximal nail fold and in office gynecologic surgery.

FIGURE 2-9 Skin hooks being used to hold up skin atraumatically while providing visualization for undermining tissue.

(Copyright Richard P. Usatine, MD.)

Skin hooks may be used for many of the same purposes as forceps and for additional procedures such as the following:

• Holding a wound edge while undermining the skin.

• Retracting a skin edge to expose bleeding sites and to obtain hemostasis.

• Pulling together the edges of an ellipse to see if there was sufficient undermining to allow for closure.

• Moving a flap into place while placing the key suture.

• Determining the degree of skin redundancy while treating dog ears (standing cones).

• Holding traction on the corners of an ellipse while placing sutures or staples.

Undermining

The skin may be undermined with any type of sharp tissue scissor. Blunt dissection will cause less trauma to the tissue and displace vessels and nerves rather than cut through them. Undermining with a scalpel is more likely to cut vessels and nerves, but can be done. A sharp iris scissor is a good affordable choice for blunt dissection and cutting tissue while undermining. Other options include tenotomy scissors, Gradle scissors, Metzenbaum scissors, endarterectomy scissors, and specific undermining scissors (Figure 2-5).

Hemostasis

Hemostats are useful to clamp bleeding vessels selected for electrocoagulation or ligation. Hemostats may also be used to break up loculations after opening an abscess or for blunt dissection around cysts and lipomas. Hemostats may be curved or straight and are useful for clamping and tying bleeding vessels and tissue. These come in sizes between 3.5 and 5 in. Larger hemostats are known as Kelly clamps and smaller hemostats are called mosquitos. Personal preference determines the size and shape used. Curved hemostats are particularly useful for blunt dissection around subcutaneous masses and for reaching inside an abscess to break up loculations. Straight heavy-duty hemostats can be useful in partial and full toenail removal.

Wound Closure

Needle Holders

Needle holders for skin surgery should be relatively short because the suturing is not being done in a deep cavity. A short handle allows for more precise needle handling. Smooth rather than serrated jaws are less likely to fray sutures while doing instrument ties. The Webster needle holder with smooth jaws is commonly used in skin surgery and is available in – and 5-in. sizes. Larger and heavier needle holders may be helpful when suturing tougher, thicker skin (e.g., on the back). Small, fine-needle holders are useful for fine work on the face and other delicate areas. It is important to have good-quality needle holders. Needle holders with gold-plated finger rings and tungsten carbide inserts are worth the price if you do skin surgery on a regular basis (Figure 2-10).The gold-plated handle is not crucial but it is often a sign that the needle holder is of excellent quality.

FIGURE 2-10 High quality needle holder with gold-plated finger rings and tungsten carbide inserts for stable needle holding.

(Copyright Richard P. Usatine, MD.)

Small Instrument Sets

To save time and expense, it helps to establish standard instrument sets for use in the office. Suggested sets for different surgical needs include the following:

Punch or Small Excision Set (Figure 2-11)

Ellipse or Large Excision Set (Figure 2-12)

FIGURE 2-11 Punch instrument set.

(Copyright Richard P. Usatine, MD.)

FIGURE 2-12 Elliptical excision set.

(Copyright Richard P. Usatine, MD.)

Adding clean cotton-tipped applicators (CTAs) and clean cotton gauze (purchased in bulk packs) to be autoclaved in surgical sets is an efficient way to prepare for surgery and save money. This saves setup time and money over individually packaged sterile gauze and CTAs. It also avoids wasting of the paper that covers individually wrapped sterile gauze and CTAs, making for a greener office.

Information on nail surgery equipment is found in Chapter 18, Nail Procedures.

Surgical Skin Markers

It is extremely helpful to draw lines where you intend to cut. This is true for all types of biopsies and excisions and not just for large ellipses and flaps. It is best to mark the skin before administering anesthesia because the anesthesia may distort the lesion or make it less visible.

A number of various types of surgical markers are available. The standard markers use gentian violet and are nontoxic. Preoperative prepping with alcohol will rub off the gentian violet, but povidone-iodine and chlorhexidine will not. These markers can be purchased in sterile packages for single use in a sterile procedure. However, for procedures such as shave biopsies and snip excisions that will not be sutured, the marker need not be sterile. A fine-point marker is most useful. Twin-tipped markers are available that have a broad tip on one end and a fine tip on the other. A sterile marker costs approximately $1 to $2. A nonsterile marker is less expensive. A sterile marker can be used over again as long as it has not touched body fluids and the patient is prepped after marking. These markers do not tattoo the skin.

Cryotherapy Equipment

Cryotherapy equipment for liquid nitrogen includes the following:

FIGURE 2-17 Storage tank (Dewar) with method to remove liquid nitrogen.

(Copyright Richard P. Usatine, MD.)

FIGURE 2-18 Methods for cryosurgery: Cryo-Tracker, Cryo Tweezer, and Cry-Ac.

(Copyright Richard P. Usatine, MD.)

FIGURE 2-19 Cryo Tweezer for skin tags.

(Copyright Richard P. Usatine, MD.)

Although this equipment can cost from $500 to $1000, it will pay for itself many times over and allow you to treat actinic keratoses, warts, condyloma, seborrheic keratoses, and other benign lesions. See Chapter 15, Cryosurgery, for more on this topic.

Electrosurgery Equipment

Having at least one electrosurgical instrument is essential before performing elliptical excisions (see Chapter 14, Electrosurgery). While the bleeding of shave biopsies can easily be stopped with chemicals, deeper excisions will often require electrocoagulation to obtain adequate hemostasis.

The least expensive way to begin is to get one single electrosurgical unit that is capable of electrocoagulation and electrodestruction but is not a cutting device. These can be obtained for about $1000 and if on wheels can be easily moved from one exam room to another. The next step up is to have multiple units of this type mounted in each exam room (Figure 2-20). For many thousands of dollars an electrosurgical unit with cutting capability can be purchased. Generally one unit per office practice is sufficient and this is usually kept in the principal surgical/procedural room. A smoke evacuator is especially important if a cutting unit is used because cutting produces more smoke (plume).

FIGURE 2-20 Electrosurgical instrument mounted on the wall.

(Copyright Richard P. Usatine, MD.)

Electrosurgery without Cutting

Electrosurgery with Cutting

Smoke evacuators are made by all of the companies listed above. The equipment for cosmetic procedures will be covered in Chapters 19 through 31.