northland dhb skin service plastics update
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Northland DHB SKIN Northland DHB SKIN SERVICESERVICE
Plastics updatePlastics update
Northland DHB SKIN Northland DHB SKIN SERVICESERVICE
Plastics updatePlastics update
Peter Allen, plastics moss
David J M Crabb FRACS (GEN), FRACS (plastic)
Peter Allen, plastics moss
David J M Crabb FRACS (GEN), FRACS (plastic)
Nested within general surgery
Primary triage Peter Allen
Secondary triage D. Crabb
supported by Clinic staff, Pathway coordinator
General surgery, Gypsy service network, combined clinics with Opthalmology
and TBA with ENT.
Nested within general surgery
Primary triage Peter Allen
Secondary triage D. Crabb
supported by Clinic staff, Pathway coordinator
General surgery, Gypsy service network, combined clinics with Opthalmology
and TBA with ENT.
The DHB SKIN SERVICE
Plastic section
The DHB SKIN SERVICE
Plastic section
Introduction non surgical treatment
of skin cancer
Introduction non surgical treatment
of skin cancer
categorizes the clinical picture at glance
includes full spectrum of progression
useful tool to decide approach
helpful to decide surgery/topical
combined with photo, biopsy ,growth rate
categorizes the clinical picture at glance
includes full spectrum of progression
useful tool to decide approach
helpful to decide surgery/topical
combined with photo, biopsy ,growth rate
The Hutt DHB Plastics visual scale
Non Melanomatous lesions
The Hutt DHB Plastics visual scale
Non Melanomatous lesions
The clinical Picture The clinical Picture
Is mixed
Presenting lesion
with background of many others
Deciding which are surgical?
Which are non surgical?
2
Is mixed
Presenting lesion
with background of many others
Deciding which are surgical?
Which are non surgical?
2
The borderline The borderline
digital palpation
Thickened lesion implies dermal invasion
Ulceration
Failure to respond
Beware the Morphoeic BCC
exception, scarring feels flat
Biopsy, biopsy, biopsy
digital palpation
Thickened lesion implies dermal invasion
Ulceration
Failure to respond
Beware the Morphoeic BCC
exception, scarring feels flat
Biopsy, biopsy, biopsy
Problem can be staged
Progression and evolvement is non linear
Problem can be staged
Progression and evolvement is non linear
Ephemeral solar keratosis, comes and goes
in various places
Ephemeral solar keratosis, comes and goes
in various places
Persisting solar keratosis, waxes and wanes
in same place
Persisting solar keratosis, waxes and wanes
in same place
progresses to established lesion, such as superficial
BCC but may be SCC or more aggressive lesion
progresses to established lesion, such as superficial
BCC but may be SCC or more aggressive lesion
Background photo-ageingBackground photo-ageing
Irradiation damage UV+UVB Irradiation damage UV+UVB
Total life time dose in exposed areas, about 100,000hrs
graduated change over life course
Accelerates in older age
Made worse by suppressed or impaired immunity
Related to genetics of skin type and evolutionary biology
Total life time dose in exposed areas, about 100,000hrs
graduated change over life course
Accelerates in older age
Made worse by suppressed or impaired immunity
Related to genetics of skin type and evolutionary biology
Biological Anthropology Biological Anthropology
all Humans migrating from Africa were black, 65,000 yrs
Migration behind melting ice sheets required adaptation to lower northern light levels
skin becomes whiter/lighter and thinner
Allows penetration of available light for Vit D synthesis
Nature very precisely calibrates the skin, thickness and color
Optimised for Vit D production without collateral damage
all Humans migrating from Africa were black, 65,000 yrs
Migration behind melting ice sheets required adaptation to lower northern light levels
skin becomes whiter/lighter and thinner
Allows penetration of available light for Vit D synthesis
Nature very precisely calibrates the skin, thickness and color
Optimised for Vit D production without collateral damage
36 degree latitude is same as southern spain or northern morocco
36 degree latitude is same as southern spain or northern morocco
stem cells in dermal base have 5 different enzymes to repair fragmented
nucleic acids
stem cells in dermal base have 5 different enzymes to repair fragmented
nucleic acidsDendritic cells that mediate immunity have large target nuclei,
vulnerable
Dendritic cells that mediate immunity have large target nuclei,
vulnerable
Treatment Principles RequireTreatment Principles Require
reduced irradiation into dermis equivalent to (pureblood) maori skinreduced irradiation into dermis equivalent to (pureblood) maori skin
repair/restoration assistance to dendritic and stem cell
population
repair/restoration assistance to dendritic and stem cell
population
assisted apoptosis of abnormal cell populationassisted apoptosis of abnormal cell population
treat the whole problemtreat the whole problem
Treatment Treatment
A screening cream with equivalent protection to Maori skin
addition of anti oxidants into cream to assist self repair by damaged cells to
assist
Stem cells for cell replacement and Dendtritic cell for cell monitoring/tagging
A screening cream with equivalent protection to Maori skin
addition of anti oxidants into cream to assist self repair by damaged cells to
assist
Stem cells for cell replacement and Dendtritic cell for cell monitoring/tagging
Clears ephemeral solar keratoses
dampens cellular background activity
Assists Dendritic cell role in Apoptosis
When combined with seasonal therapeutic creams (Effudix/Aldara) will
dramatically reduce frequent flyers
Clears ephemeral solar keratoses
dampens cellular background activity
Assists Dendritic cell role in Apoptosis
When combined with seasonal therapeutic creams (Effudix/Aldara) will
dramatically reduce frequent flyers
Result Result
seasonal Treatment
My practice
seasonal Treatment
My practice
winter 5 flurouracil to treat background ephemeral and
some persisting solar keratoses, 3 pulsed cycles
winter 5 flurouracil to treat background ephemeral and
some persisting solar keratoses, 3 pulsed cycles
Atumn check repose, identify non responders, surgical propositions
Summer then escalate Aldara / cryotherapy
Atumn check repose, identify non responders, surgical propositions
Summer then escalate Aldara / cryotherapy
winter back to 5FU if neededwinter back to 5FU if needed
spring check up prior to
aldara/screening cream, surgical
propositions
spring check up prior to
aldara/screening cream, surgical
propositions
Seasonal topical treatment cycle
Winter
Seasonal topical treatment cycle
WinterWinter topical, 5 Fluorouracil given in pulsed mode 3 to 4 cycles
With Hydrocortisone 1% in rest periods
Ideal for the multiple persisting solar keratotic background activity
Winter topical, 5 Fluorouracil given in pulsed mode 3 to 4 cycles
With Hydrocortisone 1% in rest periods
Ideal for the multiple persisting solar keratotic background activity
Hutt stage 1 and above will be present in all lesions as a
background to the presenting lesion
Hutt stage 1 and above will be present in all lesions as a
background to the presenting lesion
Patient is often motivated to act on prevention after
surgical episode
Patient is often motivated to act on prevention after
surgical episode
11
Seasonal topical treatment cycle
Atumn
Seasonal topical treatment cycle
AtumnPersisting solar keratosis if it is non responsive to
5FU
(suitable Hutt 1 and 2, not all may respond)
will need Aldara or cryotherapy
Persisting solar keratosis if it is non responsive to
5FU
(suitable Hutt 1 and 2, not all may respond)
will need Aldara or cryotherapy
Aldara ideal for early lesions including Hutt 3
superficial BCC
Suitable for up to 6 lesions, otherwise systemic effect
5 weeks, 5 days and then stop, pm application
combined with Am screening cream
Aldara ideal for early lesions including Hutt 3
superficial BCC
Suitable for up to 6 lesions, otherwise systemic effect
5 weeks, 5 days and then stop, pm application
combined with Am screening cream
Seasonal topical treatment cycle
summer
Seasonal topical treatment cycle
summer
Superficial BCC with little infiltration should
respond To Aldara but may not
Adjacant Hutt 1 and 2 will go with Effudix
Superficial BCC with little infiltration should
respond To Aldara but may not
Adjacant Hutt 1 and 2 will go with EffudixCryotherapy about the same effectiveness to Aldara
Good for scalp and non facial area
often more convienant than topical ie shorter
White scar on face
If not effective first time unlikely second will do
Surgery for non responders
Cryotherapy about the same effectiveness to Aldara
Good for scalp and non facial area
often more convienant than topical ie shorter
White scar on face
If not effective first time unlikely second will do
Surgery for non responders
33
Surgical reconstructive treatmentSurgical reconstructive treatmentAll incomplete removals come forward to frozen
section
all prior surgery and scar must be removed
F/S control for all margins and then immediate or
delayed reconstruction
Same for significant primary tumours involving
sensitive structures in the face
Perineurial invasion on SCC treated as Melanoma
All incomplete removals come forward to frozen
section
all prior surgery and scar must be removed
F/S control for all margins and then immediate or
delayed reconstruction
Same for significant primary tumours involving
sensitive structures in the face
Perineurial invasion on SCC treated as Melanoma
Reconstructive surgery is often but not always stagedReconstructive surgery is often but not always staged
Avoiding the unescessary escalationAvoiding the unescessary escalation
Fat grafting for subcutaeous contour regeneration
additional toolbox in staged reconstruction
Fat grafting for subcutaeous contour regeneration
additional toolbox in staged reconstruction
two flap nose and
cheek extensive
BCC
frozen section
clearance
two flap nose and
cheek extensive
BCC
frozen section
clearance
fat grafting compensates for
loss of cheek sub cutaneous
volume
fat grafting compensates for
loss of cheek sub cutaneous
volume
Recontruction often multi staged with large
step escalation
Recontruction often multi staged with large
step escalation
small lesions can be much
larger on Frozen Section
small lesions can be much
larger on Frozen Sectionlarge defects with lining often need tissue
expansion
large defects with lining often need tissue
expansion
where do we start
first consult
where do we start
first consultbody check
background activity
history of lesions/prior surgery/recurrence
get your fingers on it
surgical propositions first
Screening cream with anti oxidant will calm and treat S/K
Aldara for 6 worst non surgical ones/repeat
Cryotherapy about equivalent to Aldara but white mark
Effudix given early if needed or delayed to winter
body check
background activity
history of lesions/prior surgery/recurrence
get your fingers on it
surgical propositions first
Screening cream with anti oxidant will calm and treat S/K
Aldara for 6 worst non surgical ones/repeat
Cryotherapy about equivalent to Aldara but white mark
Effudix given early if needed or delayed to winter
summary, treat the entire problemsummary, treat the entire problem
Early lesions need management
train the patient to self manage
A stitch in time saves 9
biopsy is a wonderful operation
if you cant get it all don't try it might need a really big hole
Multiple biopsies give useful information
If in doubt always skin graft as local tissue is precious
Early lesions need management
train the patient to self manage
A stitch in time saves 9
biopsy is a wonderful operation
if you cant get it all don't try it might need a really big hole
Multiple biopsies give useful information
If in doubt always skin graft as local tissue is precious
Thank you for your attention
Best of luck its a big problem
Thank you for your attention
Best of luck its a big problem
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