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2009| August | Volume 75 | Issue 8
August 11, 2009
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Guidelines for administration of local anesthesia for dermatosurgery and cosmetic dermatology procedures
Venkataram Mysore, KC Nischal
August 2009, 75(8):68-75
Introduction, definition, rationale and scope:
Dermatosurgery and Cosmetic dermatology procedures are being performed by increasing number of dermatologists. Most dermatosurgeries are performed in an outpatient setting and as day care surgeries, under local anesthesia. Hence, it is important to improve patient comfort during all procedures. These guidelines seek to lay down directives in the use of local anesthesia, outline the different local anesthetics, the mode of administration, complications arising out of such procedure and management of the same.
Facility for administration of local anesthesia:
Local anesthesia is usually administered in the dermatologist's procedure room. The room should be equipped to deal with any emergencies arising from administration of local anesthesia.
Qualifications of local anesthesia administrator:
Local anesthesia administrator is a person who applies or injects local anesthetic agent for causing analgesia. Procedures done under local anesthesia are classified as Level I office procedures and require the administrator to have completed a course in Basic Cardiac Life Support (BCLS).
Evaluation of patients for topical or infiltrative anesthesia:
Details of patient's past medical history and history of medications should be noted. Allergy to any medications should be specifically enquired and documented. Patients for tumescent anesthesia need additional precautions to be observed as described in these guidelines.
Methods of administration of local anesthesia:
Different methods include topical anesthesia, field block, ring block, local infiltration and nerve block. Also, it includes use of local anesthetics for anesthetizing oral and genital mucosa. Tumescent anesthesia is a special form of local anesthesia used in liposuction and certain selected procedures.
Local anesthetic agents:
Different local anesthetics are available such as lignocaine, prilocaine, bupivacaine. The dermatologist should be aware of the onset, duration of action, side effects and drug interactions of these agents.
Side effects of local anesthetics:
Various local and systemic side effects and complications arising from administration of local anesthetics have to be timely recognized and treated effectively. Skin testing prior to administration of local anesthetic is recommended.
Guidelines for cryotherapy
Vinod K Sharma, Sujay Khandpur
August 2009, 75(8):90-100
Cryotherapy is a controlled and targeted destruction of diseased tissue by the application of low temperatures. It is a simple, cost-effective, efficacious and esthetically acceptable modality for the treatment of various dermatoses.
It is indicated in the treatment of a wide variety of skin conditions, including benign tumors, acne, pigmented lesions, viral infections, inflammatory dermatoses, infectious disorders and various pre-malignant and malignant tumors.
Cryosurgery is an out patient department procedure and can be undertaken in a clinic or minor procedure room.
Instrumentation and Equipment:
Several cryogens such as liquid nitrogen, nitrous oxide and carbon dioxide are available, but liquid nitrogen is the most commonly used.
Different techniques of application of the cryogen include the timed spot freeze technique (open spray and confined spray method), use of cryoprobe or the dipstick method. The choice of the method is based on the type of lesion. The procedure is undertaken under aseptic conditions, usually without any anesthesia. The number of freeze thaw cycles needed may vary from lesion to lesion. It is important to know the freeze time for each condition, number of sessions required and the interval between the sessions to achieve good cosmetic results with minimal complications.
The treating physician should be aware of the absolute and relative contraindications of the procedure, such as cold urticaria, cryoglobulinemia, Raynaud's disease, collagen vascular diseases, etc.
While cryosurgery is usually a safe procedure, complications may occur due to inappropriate patient selection, improper duration of freezing and freeze thaw cycles. The complications may be acute, delayed or protracted. In Indian skin, post-inflammatory pigmentary changes are important but are usually transient.
Cryotherapy may be administered by a dermatologist who has acquired adequate training during post-graduation or through recognized fellowships and workshops dedicated to cryotherapy. He should have adequate knowledge of the equipment and pre- and post-operative care. Understanding the underlying pathology of the lesion to be treated, particularly in malignant and pre-malignant lesions, is important.
Standard guidelines for electrosurgery with radiofrequency current
August 2009, 75(8):83-89
Radiofrequency (RF) induces thermal destruction of the targeted tissue by an electrical current at a frequency of 0.5 MHz (RF). As the electrode tip is not heated, there is minimal thermal damage to the surrounding tissues, producing good esthetic results. Therefore, RF ablation is also known as cold ablation or "coblation."
It has three modes of operation: (a) Cut, (b) cut and coagulate and (c) coagulate. Therefore, it can be used for various purposes like incision, ablation, fulguration, shave excision and coagulation. Because of the coagulation facility, hemostasis can be achieved and operation becomes easier and faster.
It is effective in treating various skin conditions like dermatosis papulosa nigra, warts, molluscum contagiosum, colloid milia, acquired junctional, compound and dermal melanocytic nevi, seborrheic keratosis, skin tags, granuloma pyogenicum, verrucous epidermal nevi, xanthelesma, rhinophyma, superficial basal cell carcinoma and telangiectasia. It can also be used for cosmetic indications such as resurfacing, earlobe repair and blepharoplasty.
The procedure is accomplished either under topical anesthesia eutactic mixture of local anesthetics or local injectable anesthesia, under all aseptic precautions.
While operating, only the tip of the electrode should come in contact with the tissue. Actual contact of the electrode with the tissue should be very brief in order to prevent excessive damage to the deeper tissues. This can be accomplished by moving the electrode quickly.
Complications are uncommon and mainly occur due to an improper technique. The treating physician should be aware of the contraindications of the procedure as listed in these guidelines.
RF surgery may be performed by a dermatologist who has acquired adequate training during post-graduation or through recognized fellowships and workshops dedicated to RF surgery. He/she should have adequate knowledge of the equipment and pre- and post-operative care. Blepharoplasty and full-face resurfacing need specialized training at dedicated workshops/centers.
The procedure may be performed in a physician's minor procedure room. For advanced procedures and situations like treating certain lesions such as vascular lesions, facial resurfacing and blepharoplasty, a fully equipped minor theater may be preferred.
Minimum standard guidelines of care on requirements for setting up a laser room
August 2009, 75(8):101-110
Introduction, definition, rationale and scope:
Lasers are now becoming an integral part of dermatological practice in India, with more and more dermatologists starting laser dermatology practice. Lasers, when are used with care, by properly trained operators, in carefully designed environment, can deliver a range of useful aesthetic and dermatologic treatments.
Laser treatment is an office procedure, hence it does not require hospital set-up. The laser room facility requires careful planning keeping in mind safety of both patient and operator, convenience of operating, and optimum handling of costly equipments. The facility should be designed to handle procedures under local anesthesia and sedation. Facilities, staff and equipment to handle any emergencies should be available.
A room in existing dermatology clinic can be adequately converted to a laser room. Dimensions of laser room, its door and patient's table should be such that it should facilitate easy movement of patient, machine trolley, operator and assistant in case of routine procedures and in emergency.
Any dermatologist with MD or diploma in dermatology can do laser procedures, provided he/ she has acquired necessary skills by virtue of training, observing a competent dermatologist. Such training may be obtained during post graduation or later in specified workshops or courses under a competent dermatologist or at centre which routinely performs such procedures.
Electricity and uninterrupted power supply:
Laser equipments should be connected to stabilizer or UPS circuits only. Preferably an on line UPS as recommended by the laser company should be installed. Earthing of the equipment is essential to avoid damage to the equipment and electrical shocks to the operator. Sufficient power back up to complete the procedure if power is off midway, is essential.
Laser machines should be operated in low ambient temperature, with low humidity and dust free environment for longer life of machines.
A dental/cosmetic chair with adjustable task light is a suitable option for patient positioning. The chair should have the option to tilt head down or 'syncope position' to facilitate resuscitation of a patient in vaso-vagal shock.
Annual maintenance contract (AMC) is essential after warranty period is over and is essential for insurance purposes.
Mobile Laser Unit:
Mobile laser units are of relevance in the Indian context to render laser facility available in smaller towns. A laser with fiber optic delivery system can be made mobile after consultation with supplier. However a laser with an articulated arm delivery cannot be made mobile. Proper packing with shock absorbing material is necessary during transportation. The area where lasers are to be moved to and operated should have appropriate facilities as mentioned above.
Patient's health declaration questionnaires, laser register are essential records. Digital photography before and at regular intervals after procedure is an essential record. Detailed informed consent in patients language for each procedure explaining nature of procedure, anesthesia used, and machine used, post operative down time should be signed by patient.
Drugs, anesthesia and sterilization:
An electrocautery machine to control bleeding, equipments for airway maintenance, other instruments for emergency resuscitation and an emergency drug tray are essential. Standard sterilization practices are adopted. For most of laser procedures topical anesthesia is sufficient.
Safe laser use:
Protocols of safe laser use to avoid burns or eye damage to patients or operator are adopted. Reflective surfaces like mirrors, reflective jewelleries are not allowed in laser room. Machine should always be on standby mode when not in direct use. It should be used by authorized operator only.
Goggles of sufficient optical density (OD) intended to protect from specific laser wavelength are to be used by all persons in laser room. Patient is given either same goggle or laser opaque shield. For procedures around eyes or on eyelids, internal eye shield made of laser opaque material are to be used. Fire extinguisher complying with local authority fire rules should be available and staff should be trained to use that.
Safety and emergency protocols:
Protocols for certain situations like vasovagal attack, anaphylaxis, uncontrolled bleeding, fire, accidental eye exposure should be in place and staff should be trained for these situations.
Standard guidelines of care: Lasers for tattoos and pigmented lesions
Sanjeev Aurangabadkar, Venkataram Mysore
August 2009, 75(8):111-126
Lasers have revolutionized the treatment of pigmentary disorders and have become the mainstay of therapy for many of them.
Though different laser machines are used, Quality-switched (QS) lasers are considered as the gold standard for treatment of pigmented lesions. Proper knowledge of the physics of laser machine, methodology, dosage schedules, etc., is mandatory.
Laser may be administered by a dermatologist, who has received adequate background training in lasers during postgraduation or later at a center that provides education and training in lasers, or in focused workshops which provide such trainings. He should have adequate knowledge of the machines, parameters, cooling systems, and aftercare.
The procedure may be performed in the physician's minor procedure room.
Epidermal lesions: Cafι au lait macules (CALM), lentigines, freckles, solar lentigo, nevus spilus, pigmented seborrheic keratosis, dermatosis papulosa nigra (DPN). Dermal lesions: Nevus of Ota, Blue nevus, Hori's nevus (acquired bilateral nevus of Ota-like macules).
Amateur, professional, cosmetic, medicinal, and traumatic. Mixed epidermal and dermal lesions: Postinflammatory hyperpigmentation (PIH), nevus spilus, periorbital and perioral pigmentation, acquired melanocytic nevi (moles), melasma and Becker's Nevus.
Absolute: Active local infection, photo-aggravated skin diseases and medical conditions, tattoo granuloma, allergic reactions to tattoo pigment, unstable vitiligo and psoriasis. Relative: Keloid and keloidal tendencies, patient on isotretinoin, history of herpes simplex, patient who is not co-operative or has unrealistic expectation.
Proper patient selection is important. Investigations to identify any underlying cause for pigmentation are important; concurrent topical and systemic drug therapy may be needed. History of scarring, response to previous injuries, degree of tanning needs to be considered. Detailed counseling about the need for multiple sessions is required. Informed consent should be taken in all cases.
Epidermal lesions need an average of 1−6 sessions, while dermal lesions need average of 4−10. Some tattoos may need up to 20 sessions. All lesions may not clear completely and only lightening may be achieved even after multiple sessions in many cases. Future maintenance treatments may be needed. Hence, a realistic expectation and proper counseling is very important. Epidermal lesions are likely to recur even after complete clearing. Therefore, there is a need for continued sun protection. Dermal lesions and tattoos tend to remain clear after treatment (except conditions as dermal melasma).
Laser parameters vary with area, type of pigmentation and machine used.
Complications and their management:
Postinflammatory pigmentation changes are common in dark skin patients. Textural changes and scarring occur rarely.
Standard guidelines for setting up a dermatosurgery theatre
SC Rajendran, HM Omprakash
August 2009, 75(8):76-82
Introduction, definition, rationale and scope:
Dermatologists in India are now increasingly performing surgical and cosmetic procedures in their practice. This calls for minimum standards at the national level with the main focus of patient safety and hence the guidelines for setting up a dermatosurgical theatre.
The dermatosurgery theatre can be created in either physician's clinic, or a hospital depending on the procedure to be performed. The dermatosurgery theatre requires careful planning with regards to - location, dimension, shell design, lighting, electrical requirements, operation table, chair, trolley, surgical instruments, sterilization of devices, asepsis and advanced life support. Apart from physical considerations, other considerations including theatre etiquettes, consent for surgery, safety of dermatosurgeon, theatre staff and lastly biomedical waste management should be looked into. These issues are discussed in detail in the recommendations.
Guest editor's remarks
August 2009, 75(8):65-66
Message from the President, IADVL
Vinod K Sharma
August 2009, 75(8):67-67
Message from Chairman, Dermatosurgery Guidelines - Taskforce
August 2009, 75(8):67-67
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