1515_Jabra.pdf

1、Mohs Procedure for Limb Salvage:A Case of Squamous Cell CarcinomaAnthony Jabra,DPM FACFASObjectives When to consider biopsy of a foot lesion?How do we biopsy and properly bill?Made the diagnosis,now what?Case presentation When to Consider a Biopsy?Non-healing lesionsAtypical appearanceChronicity(4 w

2、eeks without resolution)Recurrent or rapidly growing lesionsImmunocompromised patientsNasr MR,Elston DM.When to biopsy skin lesions.Am Fam Physician.2012;85(6):580-585.High Suspicion=Immediate Action“It is better to explain to insurance why you acted swiftly than to explain to a patient why you didn

3、t.”BiopsyBiopsy TypeToolUse When.Shave biopsyRazor blade,curved scalpelLesion is raised,superficial,suspected BCC or superficial SCCPunch biopsyCircular punch tool(26 mm)Lesion is flat,ulcerated,or pigmented;need full dermal depthIncisional biopsyScalpel(ellipse or wedge)Large/deep lesions,or you ne

4、ed edge of ulcer or tumor for histopathologyExcisional biopsyScalpel(elliptical excision)Small lesion that can be completely removed in one pieceCurettageDermal curetteNot diagnosticused for superficial removalor treatment,not biopsyPunch BiopsyWhat is a Punch Biopsy:circular blade(usually 26 mm)Wha

5、t is biopsied:epidermis,dermis,and into the subcutaneous fat to remove a full-thickness core of skin.It is the gold standard for:Diagnosing non-healing ulcers Evaluating depth of suspected SCC or melanoma Lesions that are flat,indurated,or ulceratedStep by StepMark the lesion:Identify the most viabl

6、e part like the edge of an ulcer or the most indurated/pigmented portion.Anesthetize:Inject 1%lidocaine/200,000 epinephrine intradermally and subcutaneously.Apply punch tool perpendicular to skin.Rotate with downward pressure until the tool enters the subcutaneous tissue.Lift the core with forceps a