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Click photo to enlarge Skin
Cancer
Skin
Cancer - And Your Plastic Surgeon The purpose of this brochure is to educate you about the different types of skin cancer, their causes, and preventive measures you can take; to help you know when to consult a doctor; and to explain the role of the plastic surgeon in the diagnosis and treatment of skin cancer and other skin growths. Who
gets skin cancer ...and why Anyone
can get skin cancer-no matter what your skin type, race or age, no matter
where you live or what you do. But your risk is greater if... Your skin
is fair and freckles easily. Types
of skin cancer Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it's not treated. A third form of skin cancer, malignant melanoma, is the least common, but its incidence is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is also the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it's not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly. Other
skin growths you should know about Moles are clusters of heavily pigmented skin cells, either flat or raised above the skin surface. While most pose no danger, some-particularly large moles present at birth, or those with mottled colors and poorly defined borders-may develop into malignant melanoma. Moles are frequently removed for cosmetic reasons, or because they're constantly irritated by clothing or jewelry (which can sometimes cause pre-cancerous changes). Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and sometimes develop into squamous cell cancer. Recognizing
skin cancer Malignant melanoma is usually signaled by a change in the size, shape, or color of an existing mole, or as a new growth on normal skin. Watch for the "ABCD" warning signs of melanoma: Asymmetry-a growth with unmatched halves; Border irregularity-ragged or blurred edges; Color-a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; and Diameter- a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size. If all these variables sound confusing, the most important thing to remember is this: Get to know your skin and examine it regularly, from the top of your head to the soles of your feet. (Don't forget your back.) If you notice any unusual changes on any part of your body, have a doctor check it out. |
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Basal
cell carcinoma may come in |
Squamous
cell carsinoma may begin as |
Malignant
melanoma is often |
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Choosing
a doctor If you notice an unusual growth yourself, consult a plastic surgeon or a dermatologist. Both are skilled at diagnosing and treating skin cancer and other skin growths. A plastic surgeon can surgically remove the growth in a manner that maintains function and offers the most pleasing final appearance- a consideration that may be especially important if the cancer is in a highly visible area. If a treatment other than surgical excision is called for, the plastic surgeon can refer you to the appropriate specialist. Diagnosis
and treatment
Small
skin cancers can often be excised Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician's office, using local anesthesia. The procedure may be a simple excision, which usually leaves a thin, barely visible scar. Or curettage and desiccation may be performed. In this procedure the cancer is scraped out with an electric current to control bleeding and kill any remaining cancer cells. This leaves a slightly larger, white scar. In either case, the risks of the surgery are low.
Simple
excision usually leaves a thin If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, major surgery may be required. Other possible treat- ments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time. (Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as follow-up.) Discussing
your options and concerns You òld discuss these choices thoroughly with your doctor before beginning treatment. Find out which options are available to you...how effective they're likely to be for your particular cancer...the possible risks and side effects...who can best perform them...and the cosmetic and functional results you can expect. If you have any doubts about the outcome, get a second opinion from a plastic surgeon before you begin treatment. A
word about reconstruction In such cases, no matter who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques- ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body-can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function. |
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A
bone/soft tissue flap is used to |
The
incision lines of the flap are |
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Preventing
a recurrence Your physician, however, can't prevent a recurrence. It's up to you to reduce your risks by changing old habits and developing new ones. (These preventive measures apply to people who have not had skin cancer as well.)
Diminishing
unsightly 'spider veins' Today, many plastic surgeons are treating spider veins with sclerotherapy. In this rather simple procedure, veins are injected with a sclerosing solution, which causes them to collapse and fade from view. The procedure may also remedy the bothersome symptoms associated with spider veins, including aching, burning, swelling and night cramps. Although this procedure has been used in Europe for more than 50 years, it has only become popular in the United States during the past decade. The introduction of sclerosing agents that are mild enough to be used in small veins has made sclerotherapy predictable and relatively painless. If you're considering sclerotherapy to improve the appearance of your legs, this brochure will give you a basic understanding of the procedure - when it can help, how it's performed and what results you can expect. It won't answer all of your questions, since a lot depends on your individual circumstances. Please ask your doctor if there is anything about the procedure you don't understand. What
are spider veins? A number of factors contribute to the development of spider veins, including heredity, pregnancy and other events that cause hormonal shifts, weight gain, occupations or activities that require prolonged sitting or standing, and the use of certain medications. Spider veins usually take on one of three basic patterns. They may appear in a true spider shape with a group of veins radiating outward from a dark central point; they may be arborizing and will resemble tiny branch-like shapes; or they may be simple linear and appear as thin separate lines. Linear spider veins are commonly seen on the inner knee, whereas the arborizing pattern often appears on the outer thigh in a sunburst or cartwheel distribution.
Spider
veins on the leg usually appear Varicose veins differ from spider veins in a number of ways. Varicose veins are larger - usually more than a quarter-inch in diameter, darker in color and tend to bulge. Varicose veins are also more likely to cause pain and be related to more serious vein disorders. For some patients, sclerotherapy can be used to treat varicose veins. However, often surgical treatment is necessary for this condition. The
best candidates for sclerotherapy If you are pregnant or breastfeeding, you may be advised to postpone sclerotherapy treatment. In most cases, spider veins that surface during pregnancy will disappear on their own within three months after the baby is born. Also, because it's not known how sclerosing solutions may affect breast milk, nursing mothers are usually advised to wait until after they have stopped breastfeeding. Spider veins in men aren't nearly as common as they are in women. Men who do have spider veins often don't consider them to be a cosmetic problem because the veins are usually concealed by hair growth on the leg. However, sclerotherapy is just as effective for men who seek treatment. What
to expect from sclerotherapy You should also be aware that the procedure treats only those veins that are currently visable; it does nothing to permanently alter the venous system or prevent new veins from surfacing in the future. Before you decide to have sclerotherapy, think carefully about your expectations and discuss them with your doctor. Risks
related to treatment A common cosmetic complication is pigmentation irregularity - brownish splotches on the affected skin that may take months to fade, sometimes up to a year. Another problem that can occur is "telangiectatic matting," in which fine reddish blood vessels appear around the treated area, requiring further injections. You can reduce the risks associated with treatment by choosing a doctor who has adequate training in sclerotherapy and is well versed in the different types of sclerosing agents available. A qualified doctor can help you select which type of sclerosing medication is most appropriate for your needs.
Before
treatment, spider veins are quite Planning
your treatment If such problems are identified, your surgeon may refer you to a different specialist for further evaluation. Problems with the larger veins must be treated first, or sclerotherapy of the surface veins will be unsuccessful. Your doctor will ask you about any other problems you may have with your legs, such as pain, aching, itching or tenderness. You will also be asked about your medical history, medications you take, or conditions that would preclude you from having treatment. Individuals with hepatitis, AIDS or other blood-borne diseases may not be candidates for sclerotherapy. Patients with circulatory problems, heart conditions, or diabetes may also be advised against treatment. It's important to be open in discussing your history and treatment goals with your doctor. Don't hesitate to ask any questions or express any concerns you may have. Your doctor should explain the procedure in detail, along with its risks and benefits, the recovery period and the costs. (Medical insurance usually doesn't cover cosmetic procedures.) Preparing
for the procedure You'll be instructed not to apply any type of moisturizer, sunblock or oil to your legs on the day of your procedure. You may want to bring shorts to wear during the injections, as well as your physician-prescribed support hose, and slacks to wear home. When scheduling your procedure, keep in mind that your legs may be bruised or slightly discolored for some weeks afterward. You probably won't be comfortable wearing shorts, a swimsuit or a mini skirt until after your legs have cleared up a bit. Where
your treatment will be performed The
procedure Approximately one injection is administered for every inch of spider vein - anywhere from five to 40 injections per treatment session. A cotton ball and compression tape is applied to each area of the leg as it is finished. During the procedure, you may listen to music, read, or just talk to your practitioner. You will be asked to shift positions a few times during the process. As the procedure continues, you will feel small needle sticks and possibly a mild burning sensation. However, the needle used is so thin and the sclerosing solution is so mild that pain is usually minimal.
The
skin is held taut while the injection After
your treatment
A
cotton ball and compression tape are It's not uncommon to experience some cramping in the legs for the first day or two after the injections. This temporary problem usually doesn't require medication. You should be aware that your treated veins will look worse before they begin to look better. When the compression dressings are removed, you will notice bruising and reddish areas at the injection sites. The bruises will diminish within one month. In many cases, there may be some residual brownish pigmentation which may take up to a year to completely fade.
One
month after the first treatment, Getting
back to normal You will be encouraged to walk to prevent clots from forming in the deep veins of the legs. However, during the period of time to complete your treatment program, prolonged sitting and standing should be avoided, as should squatting, heavy weight lifting and "pounding" type exercises, including jogging. A one-month healing interval must pass before you may have your second series of injections in the same site. After each treatment, you will notice further improvement of your legs' appearance. Your
new look Although sclerotherapy will obliterate the noticeable veins for good, it's important to remember that treatment will not prevent new spider veins from emerging in the future. As time passes, you may find that you need "touch-ups" or full treatments for new veins that surface. But even if you choose not to have further sclerotherapy, your legs will look better than if you never had treatment at all.
After
two or more treatments, the leg
Looking
after your feet Most people pay no particular attentions to foot care. As a diabetic, however, you must take special care of your feet to keep them in good condition. If you do not look after your feet properly, ulcers may form; these could become infected. In serious cases, gangrene can develop and amputation of toes, the foot or lower leg may be necessary. The chances of such problems can be minimized with a simple routine of daily foot care. Following these guidelines can help you stay mobile without relying on others for help. Daily
foot care Examine your feet every day for blisters cuts and scratches. If you find a change in the condition of your feet report it to your doctor immediately. If you have problems seeing the soles of your feet because of arthritis or obesity, use a mirror to help you, or ask a friend or relative to check your feet. Go to the clinic immediately if you notice any of the following danger sings: 1. Swelling 2. Colour change of a nail, toe, or part of a foot. 3. Pain or throbbing. 4. Thick hard skin or corns. 5. Breaks in the skin, including cracks or blisters. Wash (do not soak) your feet daily in warm water using mild soap. Dry thoroughly, especially between the toes, by applying light pressure. Do not rub your feet dry. If you have dry skin on your feet, you may use a little moisturizing lotion, but do not apply the lotion between you toes. Dewderm cream or Glyaha is what we recommend for topical use. Cut toe nails straight across. Do not cut down the sides of the nail. How
does diabetes affect feet? Circulation
problems Diabetes can lead to narrowing of the arteries, caused by a build up of cholesterol and fat in the arteries (atherosclerosis). This can lead to poor circulation of blood in the lower legs and feet, and to any of the following symptoms: Cold feet.
In atherosclerosis, cholesterol and fats build up inside the arteries and reduce blood flow.Eventually, the fatty deposits cause hardening of the arterial walls. Damage to the nerves in your feet The feeling in your feet may change because diabetes can damage the nerves(neuropathy) which transmit signals to and from your feet. This can cause pain in the feet, especially at night. As nerve damage progresses, your feet will become numb. This can be very serious because you may not notice cuts, blisters or sores until they become infected. If nerves in your legs and feet are damages, you feet will have reduced feeling. Your nervous system will not be able to send normal pain signals to your brain. Therefore, you may feel no pain when you injure your feet. Footwear Do’s Pur1. Purchase shoes that fit properly, do not expect your shoes to stretch. 2 2. Carefully check the insides of shoes for rough edges, 3. Cotton sports shoes (keds) are best, but all shoes which let your feet breathe, such as sports shoes, are good for your feet. 4. 4. Wear cotton or woolen socks while allow your feet to breathe. 1.
Footwear
Don’ts
Minor
Injuries
If you wear ill-fitting shoes, or shoes that have rough edges inside them, corns and calluses may develop. Commercial corn preparations contain mild acid and are too harsh for your feet. To remove corns and calluses soak your feet in lukewarm water for 10 minutes and then gently rub off excess tissue with a towel or file. Avoid ‘bathroom surgery’ -do not cut off corns and calluses. Prevention is always the best option: wearing comfortable shoes is most important, but exercises such as curling and stretching the toes several times a day can help prevent callus formation. When walking, adjusting your gait so that you finish each step on your toes, not on the balls of your feet, will also help to prevent callus formation. Athlete’s foot, which causes itching and skin peeling between the toes or thickening of the toenails, should be treated immediately by your doctor. Proper first aid is important, even for apparently minor injuries to the feet. Avoid strong antiseptics {e.g. tincture of iodine), which may irritate the skin. Cover injuries with sterile gauze, using paper tape if necessary. Do not apply adhesive tape to the skin. From the time of injury until recovery, affected feet should be raised for as long as possible; i.e. sit with your feet resting on a footstool. Minimizing
problems As
a diabetic you should be in regular contact with your doctor, who will
closely monitor the condition of your feet. Notify your doctor immediately
if there is any change in the state of your feet. Careful control of your
blood sugar level with diet, exercise and medication {as prescribed by
your physician) will keep your diabetes in check. You should also use a
strict daily foot care routine. This will minimize your risk of developing
serious foot and leg problems in the future. Cold
feet
As well as delivering oxygen and essential nutrients around the body, blood keeps the body warm. When the circulation of blood is restricted, the amount of heat transported around the body is also limited. This means that extremities, such as your feet, will quickly feel cold. To ensure maximum blood flow to your feet, adhere to the following rules:
DO'S
DON’T
Surgery in infertility has seen a sea change in the past decade because of wider application of microsurgical techniques. Thus salpingolysis, salpingostomy, repair of fallopian tube and vas deferens following resection of localized obstruction, and vaso-epididymal anastomosis are surgeries in which magnification has radically changed the outcome. Microvascular transfer of very high abdominal testis into scrotum is now a possibility for those cases of cryptorchidism in whom conventional surgery finds the testicular vessels too short for adequate descent. A
thorough pre operative physical and psychological assessment of the patient
and her partner is of paramount importance for the success of any procedure.
Age, previous obstetric history, pelvic inflammatory disease, whether
patient is ovulating regularly and whether the partner is fertile should
be assessed before hand. Operating notes of the sterilization procedure
helps as results of mid tubal Pomeroy procedure are far better than diathermy
close to the cornual junction. We
routinely perform our tubal recanalizations by a very low Pfanenstiel
incision just above the inguinal ligament ( Panty line incision ) because
at the end of the procedure we routinely excise the infra-umblical fold
of loose skin and fat and perform a mini abdominoplasty. We are of the
opinion that an improved body contour augments the patient’s self esteem
and keeps the partner more involved and interested. Once
the tubal block is identified only finest instruments are used for tissue
handling and damage is thus kept to a minimum. Constant irrigation of
peritoneal surfaces with heparinised Ringer lactate solution to avoid
blood clots, bipolar coagulation and magnification are now used. Relatively
minor trauma to serosa can result in avoidable adhesion formation after
surgery, this being the most serious consequence of tubal surgery. So
finger manipulation, big traumatic instruments and soabs are best avoided.
The blocked segment is excised with a new triangular blade and the mesosalpinx
is freshened. Serial sections of the tube are removed under magnification
till a clear open lumen is visualized on either sides. We make it a point
not to do any intra-luminal stenting or instrumentation for the fear of
damaging the mucosa. In one side the serosa is gently pulled with No.2
Jewels forceps and snipped to let the mucosa and muscles protrude out
by 2mm and in the other side the mucosa and muscles are pulled out and
snipped to let the serosal layer project out. Now we do a two layered
anastomosis using 8-0 nylon for muscle layer, not touching the mucosa
, and 6-0 vicryl for the serosal layer. Thus a two layered staggered anastomosis
is established and because it is done under magnified vision no patency
tests are necessary. For reversal of sterilization at tubo-cornual junction every attempt is made to preserve the utero-tubal junction and yet produce a leak proof anastomosis. All scarring in the uterine wall is removed under magnification and diameter discrepancy is handled by a small longitudinal incision into the intramural tube. All pathological tissues should be removed from the cornu to avoid re-occlusion. Mere patency is insufficient. The signs that all diseased tissue have been removed are 1. Four or five mucosal folds can be seen in the cornual lumen 2. No mucosal polyps visible and no diverticulum present 3. Fine blood vessels can be seen running in the epithelium close to its cut edge 4. All white gritty fibrous tissue has been resected A
stay suture of 6-0 vicryl holds the mesosalpinx just beneath the tube
to the uterine wall to relieve tension on the 8-0 proline sutures at 3,6,9
and 12’O clock positions which are positioned thereafter to approximate
the muscular layer. Serosal layer of 6-0 vicryl completes the anastomosis.
At times the intramural portion of the tube may be completely obliterated
by dense scar tissue and a cornual anastomosis is thus rendered impossible.
In such situations an utero-tubal implant is performed Post
operatively antibiotics, steroids and rest in bed are essential. Hydrocortisone
sodium phosphate 200 mg. intra-peritoneally during surgery and dexamethasone
for four days after surgery is our routine. There is no room for hydrotubation
after tubal microsurgery. Patients should be encouraged to have intercourse
as soon as they are comfortable after tubal surgery. There appears to
be no extra risk of ectopic pregnancy and sexual activity may encourage
tubal motility. Good results depend upon assiduous follow up, fortnightly for three months and three monthly intervals thereafter. Particular attention to the endocrine status and stimulation of ovulation whenever required should be done. Repeated sperm counts of the partner as well as post coital tests should be performed. Those
who fail to become pregnant in 6 months need a hystero-salpingogram and,
if required, a subsequent laparoscopy. Microvascular
transplantation of human fallopian tube as a homograft after proper ABO
and HL-A tissue typing is on the anvil. Microvascular homotransplantation
of ovary was performed by Chow in 1982 in which a 44 year old lady donated
an ovary to a 20 year old girl with congenital absence of ovary. The graft
survived and in 2 years time the signs of ovarian deficiency decreased. Surgery
for male infertility particularly vas re-canalization and vaso-epididymal
anastomosis also show vast improvement in the results when performed under
magnification by a trained personnel. Gentle tissue handling, use of fine
sutures, two layered staggered anastomosis with no suture or stent in
the lumen and secure haemostasis forms the basis of microsurgery
in these situations. A testicular biopsy should be taken as a routine
to determine spermatogenesis. Ambulation within 24 hours with a proper
scrotal support, sexual intercourse after 3 weeks and semen analysis after
six weeks is our protocol. Sperm count while relatively high in the early
post-operative period may gradually decrease in the first 6 months and
the couple should take the maximum advantage of this early sperm count. The tripod of proper case selection, meticulous microsurgical technique and very careful follow up should always be remembered as this alone decides the success of the surgical treatment of infertility.
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