Skin and Soft Tissue

 

Melanoma

  • Dx:
    • ABC's of melanoma:
      • Asymmetry
      • Border
      • Color variance
      • Diameter > 6mm
      • Evolution or change in lesion
    • Types:
      • Superficial spreading
      • Nodular
      • Lentigo maligna
      • Acral lentiginous
      • Desmoplastic
    • Biopsy all suspiciou lesions.
      • < 1.5cm gets excision
      • >1.5cm gets punch to include normal skin. Do 2 areas and include thickest area.
  • Tx:
    • Margins:
      • Tis= 0.5mm
      • <1mm thick= 1cm
      • 1-2mm= 2cm
      • >2mm= 2cm
    • Sentinel lymph node biopsy is used for:
      • > 1mm thick
      • Ulceration
      • Clark level IV
      • Regression
      • Incomplete stage (shave biopsy)
      • Discuss as an option for all invasive melanoma because <1mm thick has <5% chance of nodal involvement.
    • Adjuvent Tx:
      • >4mm gets interferon alpha
      • Positive sentinel node gets:
        • Regional lymph node dissection
        • 1yr of interferon alpha
  • Subungual and digital melanomas can have Hutchinson's sign (pigment changes of cuticle.
    • worse prognosis.
    • Biopsy by removing nail.
    • Treat with amputation one joint proximal to tumor.
  • Head and face melanoma needs to have superficial parotidectomy when the parotid lights up as the sentinal lymph node or when doing regional lymph node dissection

Hernia

  • Types of surgical mesh
  • Shouldice technique= pure tissue repair
    • Incise transverses fascia and mobilize flap
    • Two layer closure of transverses fascia – tightens the internal ring
    • Join conjoint tendon to inguinal ligament in two running layers; 2nd layer includes rectus sheath and external oblique apaneurosis – closes floor
  • Bassini repair= similar to shouldice, but tightening internal ring and closing floor are each only one layer
  • Cooper ligament repair (McVay repair)= definitively repairs inguinal and femoral hernias