SURGICAL PEARLS FOR THE MEDICAL DERMATOLOGIST

Key Points

To that end, one expert gives his fellow physicians a leg up on the techniques to use when getting started. Robert T. Brodell, M.D., clinical professor of dermatopathology in pathology, Master Teacher at Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, and associate clinical professor of the department of dermatology at Case Western Reserve University School of Medicine, Cleveland, walks through several "beginner" procedures for those dermatologists who would like to break into the world of aesthetic/surgical procedures in their offices.

Sebaceous hyperplasia

The technique he uses to treat xanthelasmas and sebaceous hyperplasias consist of simply applying bichloracetic acid to the lesions. The acid will turn white as the protein denatures. Dr. Brodell then applies Polysporin ointment (Pfizer) twice a day to the treated areas.

"This very inexpensive treatment modality is highly effective for the treatment of xanthelasmas and sebaceous hyperplasias. Some lesions, though, may require a second treatment after three to six months," Dr. Brodell tells Dermatology Times.

Ingrown toenails and split nails

This technique is a simple and less-invasive treatment option compared to more surgically oriented therapies.

Dr. Brodell cautions, though, that physicians must be careful to carefully weigh the risk/benefit ratio for diabetic, atherosclerotic and immunosuppressed patients who could be expected to heal slowly or be at greater risk of infectious complications.

He uses USP phenol (86 percent) in this outpatient procedure. This technique is highly effective, though regrowth of the ingrown nail can occur.

"Though postop pain is possible, the pain the patient experiences here is much less than that following a surgical matrixectomy. It is important that the physician not forget to neutralize the phenol with alcohol, as this omission will cause severe pain to the patient," he says.

Dr. Brodell performs a complete phenol-alcohol (USP phenol 86 percent) nail matrixectomy in patients with onychogryphotic nails. Typical patients will be those who prefer not to take long-term systemic antifungals, non-responders to systemic antifungals, and those who do not prefer the palliative option of grinding and trimming every eight weeks at the podiatrist. He says that this very effective outpatient procedure carries a low cost comparable to excisional surgery.

Vascular lesion laser surgery for warts

"The goal here is to destroy the blood supply to the wart, though this is sometimes hard to believe in view of the infectious nature of the process," Dr. Brodell says.

"This method works extremely well with flat warts on the face, as well as periungual and palmo-plantar warts which are recalcitrant to other traditional treatment modalities," he says.

After applying an EMLA cream (AstraZeneca) under occlusion two to four hours prior to procedure, Dr. Brodell usually proceeds with three pulses of 9 to 10 J/cm for plantar, palmar, large genital and periungual warts. For flat warts on the face and small genital warts, usually one pulse at 6 to 8 J/cm suffices. Dr. Brodell then applies Polysporin ointment twice a day for five days, and repeats the treatments every two weeks until clear. This treatment modality is 70 percent to 90 percent effective with a series of treatments.

Biopsy punch for removal of lipoma

"Lipomas can vary greatly in size, and the larger the lesion, the larger the excision," Dr. Brodell says.

"The aim of this method is to extract a larger-diameter lipoma through a small hole created by a biopsy punch, optimizing a faster and more aesthetic healing."