12R34Y

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This is for all of the new/old attending and senior EM guys.

so, I I&D a ton of abscesses in my department. no biggie, big 'ole slash with the eleven blade, break up loculations, pack loosely blah blah blah.

so, I've done them in axilla's, groin's, thighs, backs, arms, shoulders etc....

however, I've never done one on the face.........so what if someone comes in with a big abscess over there forehead? do you just lance the thing and leave that big gaping loosely packed hole open on their face?!

We always send our wound check follow ups to fast track so I never see how all of these I&D's I'm doing actually look and heal. Any thoughts on how they look weeks down the road......do they just heal by secondary intention and have huge nasty scars?

I picked up patient with a decent sized abscess above his eye on his forehead and he has some swelling over his eyelid and onto his nose and down into his ear. It wasn't very painful and he wasn't toxic appearing at all.
I ended up checking him out to another resident.

what would I have done? cut on his face? does he need IV antibiotics since it is spread over his eye etc.??

just curious to hear thoughts on this.

later
 

southerndoc

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Just remember to cut along the lines of Borges and you'll be ok. A small puncture is usually all that's needed. People cut like crazy for draining abscesses. In reality, a small puncture is all that's needed for the majority of them, unless you suspect it is loculated. (Take a peek with the ultrasound before you do it.)
 

Apollyon

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southerndoc said:
Just remember to cut along the lines of Borges and you'll be ok. A small puncture is usually all that's needed. People cut like crazy for draining abscesses. In reality, a small puncture is all that's needed for the majority of them, unless you suspect it is loculated. (Take a peek with the ultrasound before you do it.)
Although I know what you are saying, this advice is opposite to what is taught in the major textbooks.
 
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Apollyon said:
Although I know what you are saying, this advice is opposite to what is taught in the major textbooks.
I usually have difficulty extracting all of the loculated material without making an incision that's at least half as long the diameter of the abscess cavity. Small incisions also tend to increase the chance that the purulent material will squirt out forcefully when you apply pressure (think about popping a zit), increasing the risk of biohazard exposure for you and your staff, even with proper PPE. I'd also be concerned that a small puncture would close up too quickly, increasing the likelihood of recurrence, although packing would help prevent this.

On the face, however, I'd try to get away with using as small an incision as possible, for cosmetic reasons. Always make incisions parallel to the natural skin lines.
 

augmel

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you guys get worried at all about nicking facial nerves? Lips and midline structures are one thing but more lateral I think I'd get too nervous. My brother has a sebacious (sp?) cyst over his cheekbone that I thought about grabbing but decided I wasn't confident I wouldn't do some nerve damage.
 

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augmel said:
you guys get worried at all about nicking facial nerves? Lips and midline structures are one thing but more lateral I think I'd get too nervous. My brother has a sebacious (sp?) cyst over his cheekbone that I thought about grabbing but decided I wasn't confident I wouldn't do some nerve damage.
Don't do plastics on your brother. Even if you do it right he may not be happy and you'll be living with it for 60 years!

Also, the facial nerve branches are subcutaneous. A sebaceous cyst should be dissectable without much danger. But if you have to worry about it, you're not the person to do it.
 

augmel

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BKN said:
Don't do plastics on your brother. Even if you do it right he may not be happy and you'll be living with it for 60 years!

Also, the facial nerve branches are subcutaneous. A sebaceous cyst should be dissectable without much danger. But if you have to worry about it, you're not the person to do it.
I agree with everything you said, idea was considered and rejected.
 

drewpydog

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southerndoc said:
Just remember to cut along the lines of Borges and you'll be ok. A small puncture is usually all that's needed. People cut like crazy for draining abscesses. In reality, a small puncture is all that's needed for the majority of them, unless you suspect it is loculated. (Take a peek with the ultrasound before you do it.)
You mean Langer's lines. I hate eponyms.
 

southerndoc

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drewpydog said:
You mean Langer's lines. I hate eponyms.
No, I meant what I said. Try Googling it. Langer's lines were never intended to be used an incision lines. You should read up on lines of Borges and Kraissl.


EDIT: Here, I've saved you the trouble:

Plast Reconstr Surg. 1999; 104(1):208-14 (ISSN: 0032-1052)

Wilhelmi BJ; Blackwell SJ; Phillips LG
Department of Surgery, University of Texas Medical Branch, Galveston 77555-0724, USA.

Thirty-six differently named guidelines have developed as surgeons have searched for an ideal guide for elective incisions. Many surgeons prefer Langer's lines. These lines were developed by Karl Langer, an anatomy professor, from cadavers in rigor mortis. However, Kraissl preferred lines oriented perpendicular to the action of the underlying muscles. Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. However, these are only guidelines; there are many contributors to the camouflaging of scars, including wrinkle and contour lines. Borges's and Kraissl's lines (not Langer's) may be the best guides for elective incisions of the face and body, respectively.
 

drewpydog

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Cool, thanks for the info. It's good to have people smarter than me here for when I stick my foot in my mouth....

I can't find a pic online comparing the 3 sets of lines. I'll get the article you quoted today at work to see if they have one.
 

mikecwru

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Touchy today? You guys must be good, how you follow skin lines on a big fluctuant abscess with a head, I don't know... but God bless you.

If cosmesis were a large consideration, I would also consider the approach I use for peritonsillar abscesses; needle drain them and use the bevel of the needle to extend the hole a little bit. No, this won't work for loculations, but you have a chance to heal the thing without making a gigantic scar. I tend to make smaller cuts on my abscesses, and at least in following up on mine, they seem to heal fine.

mike


southerndoc said:
No, I meant what I said. Try Googling it. Langer's lines were never intended to be used an incision lines. You should read up on lines of Borges and Kraissl.


EDIT: Here, I've saved you the trouble:

Plast Reconstr Surg. 1999; 104(1):208-14 (ISSN: 0032-1052)

Wilhelmi BJ; Blackwell SJ; Phillips LG
Department of Surgery, University of Texas Medical Branch, Galveston 77555-0724, USA.

Thirty-six differently named guidelines have developed as surgeons have searched for an ideal guide for elective incisions. Many surgeons prefer Langer's lines. These lines were developed by Karl Langer, an anatomy professor, from cadavers in rigor mortis. However, Kraissl preferred lines oriented perpendicular to the action of the underlying muscles. Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. However, these are only guidelines; there are many contributors to the camouflaging of scars, including wrinkle and contour lines. Borges's and Kraissl's lines (not Langer's) may be the best guides for elective incisions of the face and body, respectively.
 
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