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New technique for bloodless surgery to the scalp
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British Journal of Oral and Maxillofacial Surgery 54 (2016) e55–e56
Technical note
New technique for bloodless surgery to the scalp K. Jolly ∗ , D. Hammond, M. Maher, D. Evriviades Queen Elizabeth Hospital Birmingham Accepted 10 February 2016
Keywords: Scalp; Head and neck cancer; Wide local excision; Haemostasis
Skin cancers such as malignant melanoma, squamous cell carcinoma, and basal cell carcinoma are common on the scalp,1 and the usual treatment is wide local excision with disease- free margins. Margins vary depending on the type of cancer, the size and depth of invasion, and the cytological findings, as described in the British Association of Dermatology guidelines.2 Because the blood supply of the scalp is rich, excision is usually accompanied by brisk bleeding, which can be troublesome and even affect the success of the graft. The layer of connective tissue between the skin and the epicranial aponeurosis consists of lobules of fat bound in tough fibrous septa, through which the main blood vessels that supply the scalp travel. Because these vessels are attached to this fibrous layer, they do not easily go into vasospasm when cut, which results in profuse bleeding. When lacerated they may also retract between the septa, which causes more pronounced bleeding and it may take a considerable time to achieve haemostasis. Diathermy may injure hair follicles in the remaining skin and induce additional alopecia. Here we present a new technique that considerably reduces bleeding and consequently saves time and reduces the need to use diathermy.
Operative technique The lesion to be excised is marked around the edges, and the excision margins drawn on to the skin according to the British ∗
Corresponding author. E-mail address: [email protected] (K. Jolly).
Fig. 1. Placing of haemstatic sutures.
Association of Dermatologists’ guidelines.2 Local anaesthetic with adrenaline is then infiltrated around the whole lesion just outside the incision line. Simple, interrupted, nonabsorbable sutures such as 2/0 polypropylene (Prolene) are placed all the way round, about 1 cm away from the excision margins (Fig. 1). Sutures must be placed close together to minimise bleeding, but a small gap should be left between them. It is important when placing these to take a deep bite through all the layers of the scalp to include the blood vessels in the subcutaneous layer. The lesion can then be excised quickly under clear vision with little bleeding from the edges of the wound (Fig. 2). Minor dermal bleeding is invariably seen from the cut edge of the skin, which shows that sufficient blood supply has been preserved to the skin edge. After complete excision, often
http://dx.doi.org/10.1016/j.bjoms.2016.02.015 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
e56
K. Jolly et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) e55–e56
Fig. 2. Easier, bloodless dissection.
Fig. 4. Removal of sutures with no bleeding.
The technique is effective for scalp lesions, and can also be used in other areas where bleeding is an issue. Blood loss is considerably reduced, and the few minutes it takes to insert the sutures is outweighed by the time saved by the almost complete avoidance of diathermy. Theoretical advantages include minimisation of the risk of development of a collection or haematoma, which are recognised causes of loss of a graft. Conflict of Interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission Fig. 3. Lesion completely excised.
The patient gave informed consent to the publication of the photographs. no additional haemostasis is required (Fig. 3). The graft is then laid on and secured in place. In this case we used a dermal regeneration template (Integra® ), but we have also used the technique successfully followed by immediate split skin grafting. The haemostatic sutures are left in place for a week, and removed at the same time as the graft is checked (Fig. 4).
References 1. Ouyang YH. Skin cancer of the head and neck. Semin Plast Surg 2010;24:117–26. 2. British Association of Dermatologists: Clinical guidelines. URL: www.bad.org.uk (accessed 10 February 2016).
British Journal of Oral and Maxillofacial Surgery 54 (2016) e55–e56
Technical note
New technique for bloodless surgery to the scalp K. Jolly ∗ , D. Hammond, M. Maher, D. Evriviades Queen Elizabeth Hospital Birmingham Accepted 10 February 2016
Keywords: Scalp; Head and neck cancer; Wide local excision; Haemostasis
Skin cancers such as malignant melanoma, squamous cell carcinoma, and basal cell carcinoma are common on the scalp,1 and the usual treatment is wide local excision with disease- free margins. Margins vary depending on the type of cancer, the size and depth of invasion, and the cytological findings, as described in the British Association of Dermatology guidelines.2 Because the blood supply of the scalp is rich, excision is usually accompanied by brisk bleeding, which can be troublesome and even affect the success of the graft. The layer of connective tissue between the skin and the epicranial aponeurosis consists of lobules of fat bound in tough fibrous septa, through which the main blood vessels that supply the scalp travel. Because these vessels are attached to this fibrous layer, they do not easily go into vasospasm when cut, which results in profuse bleeding. When lacerated they may also retract between the septa, which causes more pronounced bleeding and it may take a considerable time to achieve haemostasis. Diathermy may injure hair follicles in the remaining skin and induce additional alopecia. Here we present a new technique that considerably reduces bleeding and consequently saves time and reduces the need to use diathermy.
Operative technique The lesion to be excised is marked around the edges, and the excision margins drawn on to the skin according to the British ∗
Corresponding author. E-mail address: [email protected] (K. Jolly).
Fig. 1. Placing of haemstatic sutures.
Association of Dermatologists’ guidelines.2 Local anaesthetic with adrenaline is then infiltrated around the whole lesion just outside the incision line. Simple, interrupted, nonabsorbable sutures such as 2/0 polypropylene (Prolene) are placed all the way round, about 1 cm away from the excision margins (Fig. 1). Sutures must be placed close together to minimise bleeding, but a small gap should be left between them. It is important when placing these to take a deep bite through all the layers of the scalp to include the blood vessels in the subcutaneous layer. The lesion can then be excised quickly under clear vision with little bleeding from the edges of the wound (Fig. 2). Minor dermal bleeding is invariably seen from the cut edge of the skin, which shows that sufficient blood supply has been preserved to the skin edge. After complete excision, often
http://dx.doi.org/10.1016/j.bjoms.2016.02.015 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
e56
K. Jolly et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) e55–e56
Fig. 2. Easier, bloodless dissection.
Fig. 4. Removal of sutures with no bleeding.
The technique is effective for scalp lesions, and can also be used in other areas where bleeding is an issue. Blood loss is considerably reduced, and the few minutes it takes to insert the sutures is outweighed by the time saved by the almost complete avoidance of diathermy. Theoretical advantages include minimisation of the risk of development of a collection or haematoma, which are recognised causes of loss of a graft. Conflict of Interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission Fig. 3. Lesion completely excised.
The patient gave informed consent to the publication of the photographs. no additional haemostasis is required (Fig. 3). The graft is then laid on and secured in place. In this case we used a dermal regeneration template (Integra® ), but we have also used the technique successfully followed by immediate split skin grafting. The haemostatic sutures are left in place for a week, and removed at the same time as the graft is checked (Fig. 4).
References 1. Ouyang YH. Skin cancer of the head and neck. Semin Plast Surg 2010;24:117–26. 2. British Association of Dermatologists: Clinical guidelines. URL: www.bad.org.uk (accessed 10 February 2016).