Pediatric Dermatologic Surgery

Opis

A complete guide to the surgical techniques used to treat childhood skin conditions

Recent advances have expanded the role of pediatric dermatologic surgery in both specialist and primary care settings. However, such surgeries can pose unique challenges to trainees and experienced practitioners alike. Procedures are carried out under local anesthesia and can be a source of distress and concern among young patients. Moreover, child’s skin poses its own set of complicating factors, making the business of performing these procedures especially delicate and precise.

This book provides a step-by-step primer on invasive and non-invasive treatments of childhood skin disorders, offering concise and clearly illustrated guidance on current methods and best practices. Addressing conditions’ effects, the impact of recent developments in their treatment, the ethics of operative procedures on children, and multiple treatment options for childhood dermatologic disease, Pediatric Dermatologic Surgery is an indispensable resource for trainee dermatologists and pediatricians, as well as practicing specialists.

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Title Page 6
Copyright Page 7
Contents 8
List of Contributors 10
Chapter 1 The Embryogenesis of the Skin 14
- 1.1 Introduction 14
- 1.2 Stages of Skin Development 15
  - 1.2.1 Embryonic Stage (Specification) 15
  - 1.2.2 Embryonic-Fetal Transition (Morphogenesis) 16
  - 1.2.3 Fetal Stage (Differentiation) 17
- 1.3 Special Features of Developing Human Skin 18
  - 1.3.1 Periderm 18
- References 21
- 1.4 Conclusion 21
Chapter 2 Basic Structure and Function of the Neonatal, Infantile, and Childhood Skin 26

Title Page 6
Copyright Page 7
Contents 8
List of Contributors 10
Chapter 1 The Embryogenesis of the Skin 14
- 1.1 Introduction 14
- 1.2 Stages of Skin Development 15
  - 1.2.1 Embryonic Stage (Specification) 15
  - 1.2.2 Embryonic-Fetal Transition (Morphogenesis) 16
  - 1.2.3 Fetal Stage (Differentiation) 17
- 1.3 Special Features of Developing Human Skin 18
  - 1.3.1 Periderm 18
- References 21
- 1.4 Conclusion 21
Chapter 2 Basic Structure and Function of the Neonatal, Infantile, and Childhood Skin 26
- 2.2 Neonatal Skin 26
  - 2.2.2 Adaptation at Birth 26
  - 2.2.1 Development 26
  - 2.2.3 Structure and Composition 27
  - 2.2.4 Function 27
- 2.1 Introduction 26
- 2.3 Infantile Skin 28
  - 2.3.1 Infant Skin Structure 29
  - 2.3.2 Infant Skin Composition 30
- 2.4 Infant Skin Function 31
  - 2.4.2 Water-Handling Properties 31
  - 2.4.3 Skin pH 31
  - 2.4.1 Skin Barrier Function 31
  - 2.4.5 Cell Proliferation 32
  - 2.4.4 Immune Regulation 32
- 2.5 Childhood and Adolescent Skin 32
  - 2.5.1 Structure and Composition 32
  - 2.5.2 Function 33
- References 34
- 2.6 Conclusion 34
Chapter 3 Approach to the Child as a Patient 36
- 3.2 Initial Consultation 36
- 3.1 Introduction 36
- 3.3 Establishing a Correct Diagnosis 37
  - 3.3.4 Adolescence Period 38
  - 3.3.2 Infancy Period 38
  - 3.3.3 Childhood Period 38
  - 3.3.1 Neonatal Period 38
- 3.4 Parent Education About the Nature of Skin Lesion 39
- 3.5 Discussing Any Necessary Further Evaluations 39
- 3.6 Discussion of Different Treatment Modalities 40
- 3.7 Timing of Surgical Procedures 40
- 3.8 Pediatric Procedures: Developmental Approach to Anxiety 40
  - 3.8.3 Adolescents 41
  - 3.8.1 Infants and Toddlers 41
  - 3.8.2 Preschool and School‐Age Children 41
- References 42
- 3.9 Assessment and Management of Parental Anxiety 42
- 3.10 Conclusion 42
Chapter 4 Preoperative and Postoperative Care of Children Undergoing Pediatric Dermatology Procedures 44
- 4.2 Preoperative Care 44
  - 4.2.2 Medical Evaluation 44
  - 4.2.1 Approach to the Patient 44
  - 4.2.3 Developmental Evaluation 45
  - 4.2.4 Communicating the Plan with the Patient and Family 45
  - 4.2.5 Preparation Before the Procedure 46
  - 4.2.6 Explanation of Anesthesia 46
  - 4.2.7 Explanation of the Procedure 47
  - 4.2.8 What to Do After the Surgery 48
- 4.1 Introduction 44
- 4.3 Postoperative Care 48
- 4.4 Conclusion 49
Chapter 5 The Pediatric Surgical Tray 50
- 5.2 The Biopsy Tray 50
- 5.1 Introduction 50
- 5.3 The Local Excision Tray 54
- 5.4 The Suture Removal Tray 57
- 5.5 The Nail Tray 58
- References 60
- 5.6 Conclusion 60
Chapter 6 Anesthesia for Children 62
- 6.2 Topical Anesthetics 62
- 6.1 Indications for Local Anesthesia 62
- 6.3 EMLA Cream 63
- 6.4 Topical Lidocaine 63
- 6.7 Topical Anesthesia for Mucosal Surface 64
- 6.5 Tetracaine Formulations 64
- 6.6 Iontophoresis 64
- 6.10 Lidocaine 65
- 6.8 Limitations of Topical Anesthetics 65
- 6.11 Bupivacaine 65
- 6.9 Types of Injectable Local Anesthetics 65
- 6.13 Techniques to Decrease Injection Pain 66
- 6.12 Side Effects of Local Anesthetics 66
- 6.14 Limitations of Injectable Local Anesthesia 67
- 6.15 Nerve Blocks 68
- 6.16 Indications for General Anesthesia 69
- 6.17 Types of Anesthesia Used in Pediatric Patients 69
- 6.18 Safety 70
- 6.19 Conclusion 71
- References 72
Chapter 7 Skin Biopsy Techniques 76
- 7.1 Introduction 76
  - 7.1.1 Preparation for a Procedure 76
- 7.2 Punch Biopsy 77
  - 7.2.2 Procedure 77
  - 7.2.1 Supplies 77
- 7.3 Shave Biopsy 78
  - 7.3.2 Procedure 78
  - 7.3.1 Supplies 78
- 7.4 Scissors Biopsy 80
  - 7.4.1 Lips 80
  - 7.4.2 Tongue 80
  - 7.4.4 Fingers and Toes 81
  - 7.4.3 Genitalia 81
  - 7.4.5 Dorsal Hands and Feet 82
  - 7.4.6 Scalp 82
- 7.7 Complications 82
- 7.5 Incisional Biopsy 82
- 7.6 Excisional Biopsy 82
- 7.8 Conclusion 83
- References 83
Chapter 8 Common Pediatric Dermatologic Surgery Procedures 86
- 8.1 Introduction 86
- 8.2 Cryosurgery 86
  - 8.2.1 Introduction 86
  - 8.2.2 Indications 87
  - 8.2.3 Contraindications 88
  - 8.2.4 Techniques 88
  - 8.2.5 Complications/Adverse Effects 88
  - 8.2.6 Conclusion 90
- 8.3 Curettage 90
  - 8.3.2 Indications 90
  - 8.3.1 Introduction 90
  - 8.3.4 Technique 91
  - 8.3.3 Contraindications 91
  - 8.3.5 Complications/Adverse Events 92
  - 8.3.6 Conclusion 92
- 8.4 Chemosurgery 92
  - 8.4.1 Introduction 92
  - 8.4.3 Contraindications 93
  - 8.4.4 Mode of Action 93
  - 8.4.2 Indications 93
  - 8.4.5 Adverse Events/Complications 94
  - 8.4.6 Conclusion 94
- 8.5 Electrosurgery 94
  - 8.5.1 Introduction 94
  - 8.5.2 Electrosurgical Modalities 94
  - 8.5.3 Electrofulguration, Electrodesiccation, Electrocoagulation, and Electrosection 96
  - 8.5.4 Burn Prevention 97
  - 8.5.5 Adverse Events/Complications 97
  - 8.5.6 Transmission of Infection 98
  - 8.5.7 Tissue Destruction/Scarring 98
  - 8.5.8 Conclusion 98
- 8.6 Techniques for Intra-Lesional Injection 98
- 8.7 Indications for Intralesional Injections 99
  - 8.7.2 Intralesional Steroids for Scars and Keloids 99
  - 8.7.1 Intralesional Steroids for Alopecia Areata of Brows and Scalp 99
  - 8.7.3 Intralesional Steroids for Hemangiomas of Infancy 100
  - 8.7.4 Intralesional Steroids for Acne and Inflamed Cysts 101
  - 8.7.5 Botox for Localized Hyperhidrosis 101
- References 102
Chapter 9 Suturing Techniques 106
- 9.1 Introduction 106
- 9.2 Principles of Suturing 107
  - 9.2.1 Preparing to Close 107
  - 9.2.2 Loading the Suture 107
  - 9.2.4 The Instrument Tie 108
  - 9.2.3 Suture Placement 108
  - 9.2.5 Suture Techniques 109
  - 9.2.6 Deep Sutures 110
  - 9.2.7 The Buried Vertical Mattress 110
  - 9.2.8 Wound Gaps 112
  - 9.2.9 Other Deep Suture Techniques 113
- 9.3 Superficial Sutures 113
  - 9.3.1 Simple Interrupted Sutures 113
  - 9.3.4 Horizontal Mattress Sutures 114
  - 9.3.2 Simple Running Sutures 114
  - 9.3.5 Vertical Mattress 114
  - 9.3.3 Running Sub-Cuticular Sutures 114
- 9.4 Closure Material Alternatives 115
  - 9.4.1 Staples 115
  - 9.4.2 Tissue Adhesives 115
  - 9.4.3 Skin Closure Tapes 115
- 9.5 Conclusion 116
- References 116
Chapter 10 Wound Closure Technique 118
- 10.1 Introduction 118
- 10.2 Common Pediatric Dermatologic Surgical Indications 118
- 10.3 The Basics of Wound Closure 119
  - 10.3.1 Primary and Secondary Intention 119
  - 10.3.2 Principles of Wound Closure Design 120
- 10.4 The Perfect Ellipse 121
- 10.5 Variations on the Standard Elliptical Excision 122
  - 10.5.1 Crescentic Excision 122
  - 10.5.2 M-Plasty 123
  - 10.5.3 Lazy S Closure 123
- 10.6 Partial Closures 123
  - 10.6.1 Purse String Closure 123
  - 10.6.2 Guiding Sutures 124
- 10.7 Simple Flaps 124
  - 10.7.1 A-T Closure 124
  - 10.7.2 Other Flaps 125
- 10.8 Large Lesions 125
  - 10.8.1 Staged Excision 125
  - 10.8.2 Tissue Expansion 126
- References 126
- 10.9 Complications and Poor Outcomes 126
- 10.10 Conclusion 126
Chapter 11 Wound Closure Material 128
- 11.1 Introduction 128
- 11.2 Suture Material 130
- 11.3 Suture Selection 130
- 11.4 Needles 133
- 11.5 Staples 134
- 11.6 Adhesives 134
- 11.7 Tapes 135
- 11.8 Complications 135
- 11.9 Conclusion 136
- References 136
Chapter 12 Dressings 138
- 12.1 Introduction 138
- 12.2 Types 138
  - 12.2.1 The Basic Wound Dressing 138
  - 12.2.2 Occlusive Dressings 139
  - 12.2.4 Wound Classifications (Based on the American College of Surgeons and Center of Disease Control) 142
  - 12.2.3 Wound Classifications Based on Depth 142
- 12.3 Conclusion 143
- References 143
Chapter 13 Nail Surgery 144
- 13.1 Introduction 144
- 13.2 Nail Anatomy 144
- 13.3 History and Pre-Operative Evaluation 145
- 13.4 Preparation Prior to Nail Surgery 145
- 13.5 Nail Procedures 146
  - 13.5.1 Nail Avulsion 146
  - 13.5.2 Punch Biopsy 149
  - 13.5.3 Matrix Shave 150
  - 13.5.4 Nail Excisions 150
- 13.6 Post-Operative Management 151
- 13.7 Home Care 152
- 13.9 Conclusion 153
- 13.8 Potential Complications 153
- References 154
Chapter 14 Complications of Surgery and Invasive Procedures 156
- 14.1 Postoperative Pain 156
  - 14.1.1 Non-Pharmacologic Pain Management 157
  - 14.1.2 Pharmacologic Pain Management, Non-opioid Analgesics 157
  - 14.1.3 Pharmacologic Pain Management, Opioid Analgesics 159
  - 14.1.4 Other Techniques for Pain and Anxiety Relief 160
- 14.2 Postoperative Bleeding and Hematoma 161
- 14.3 Postoperative Seroma 163
- 14.4 Postoperative Infections 163
- 14.5 Suture Reactions and Granulomas 167
- 14.6 Wound Dehiscence 168
  - 14.6.2 Intraoperative Techniques to Decrease Risk of Dehiscence 169
  - 14.6.1 Pre-Operative Considerations to Prevent Dehiscence 169
  - 14.6.3 Post-Operative Techniques to Minimize Wound Dehiscence 170
- 14.7 Postoperative Scar Formation 170
- Acknowledgements 170
- References 170
Chapter 15 Improving Scars 174
- 15.1 Introduction 174
- 15.2 Massage 176
  - 15.2.3 Efficacy and Benefits 176
  - 15.2.1 Appropriate Usage 176
  - 15.2.4 Side Effects and Contraindications 176
  - 15.2.2 Mechanism of Action 176
- 15.4 Intralesional Corticosteroid Therapy 177
  - 15.4.1 Formulations and Usage 178
  - 15.4.4 Side Effects and Contraindication 178
  - 15.4.2 Mechanism of Action 178
  - 15.4.3 Efficacy and Benefits 178
- 15.3 Silicone Scar Products 177
  - 15.3.1 Formulations and Usage 177
  - 15.3.4 Side Effects and Contraindications 177
  - 15.3.2 Mechanisms of Action 177
  - 15.3.3 Efficacy and Benefits 177
- 15.5 Laser Therapy 179
  - 15.5.2 Mechanism of Action 179
  - 15.5.3 Efficacy and Benefits 179
  - 15.5.1 Formulations and Usage 179
  - 15.5.4 Side Effects and Contraindications 180
- 15.6 Other Topical Therapies 180
- References 180
Chapter 16 Special Dermatologic Surgery 184
- 16.1 Nevus Sebaceus of Jadassohn 184
- 16.2 Congenital Nevus 185
- 16.3 Acquired Nevi 186
- 16.4 Spitz Nevus 186
- 16.5 Hemangiomas 187
- 16.6 Pyogenic Granulomas 188
- 16.7 Vascular Malformations 188
- 16.8 Epidermal Nevus 189
- 16.9 Aplasia Cutis 189
- 16.11 Pilomatricoma 190
- 16.10 Dermoid Cysts 190
- 16.13 Epidermolysis Bullosa 191
- 16.12 Giant Juvenile Xanthogranuloma 191
- References 192
- 16.14 Basal Cell Nevus Syndrome 192
- 16.15 Dermatofibrosarcoma Protuberans 192
Chapter 17 Lasers for Vascular Lesions 202
- 17.2 Vascular Lasers 202
- 17.1 Introduction 202
- 17.3 Types of Vascular Lesions 203
- 17.4 Common Vascular Lesions 204
  - 17.4.1 Port-Wine Stains 204
  - 17.4.2 Hemangiomas 204
  - 17.4.3 Spider Angiomas 205

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