Winged Scapula

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There are very few arteries so close to the skin that you would injure them on incision (the neck being a notable exception).

And if this did happen, the last place you would want your patient is to be "rushed to the ER." The OR, where you presumably are making your incision, is the safest place.
 

JackADeli

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ok im completly asleep when they exsplained this.
What primary things are we ovoiding..
i dont want to strike an artary and have him rushed to the ER:scared:
My initial response was going to be different...
Please do not engage in surgery with an internet education. You have no business to be doing an incision. The question demonstrates you lack a basic understanding of whatever it is you are incising. You should always be familiar with the structures in the region that you operate in...fundamental principle of the blade wielder!

1. "im completly asleep" through the apparent explanation....
2. you lack rudimentary understandings
3. all suggests you are NOT actually being trained

In addition:
You apparently just joined in July....
"a dark pluge"
"completly"
"exsplained"
"ovoiding"
"artary"

This entire thread is beyond the pale. Maybe you are at the wrong forum. Please go back to your friends on the playground. :troll:

JAD
 
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ESU_MD

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too bad: could have been a very interesting topic- was always fascinated by all the different styles of setting up the primary exposure-

from scratching the surface with the blade and carefully using bovie to go to the fascia,

using bovie on 120 to cut the skin and everything else in its way

and my personal favorite- taking the knife straight to the fascia!! (which paradoxically bleeds less than the bovie technique)
 

JackADeli

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...could have been a very interesting topic- was always fascinated by all the different styles of setting up the primary exposure...
Nothing preventing a meaningful and intelligent discussion as you pose.
It would clearly be a different caliber and level discussion then the vaguely posed question by the "completly asleep" through the "exsplained" how to "ovoiding" the "artary" OP.....

I have actually quite enjoyed (the results of) knifing down to the fascia. Some even report a decreased incidence of post-op "fat necrosis" when the bovie is avoided.

JAD
 
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doogoshly

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My initial response was going to be different...
Please do not engage in surgery with an internet education. You have no business to be doing an incision. The question demonstrates you lack a basic understanding of whatever it is you are incising. You should always be familiar with the structures in the region that you operate in...fundamental principle of the blade wielder!

1. "im completly asleep" through the apparent explanation....
2. you lack rudimentary understandings
3. all suggests you are NOT actually being trained

In addition:
You apparently just joined in July....
"a dark pluge"
"completly"
"exsplained"
"ovoiding"
"artary"

This entire thread is beyond the pale. Maybe you are at the wrong forum. Please go back to your friends on the playground. :troll:

JAD
:laugh::laugh::laugh:
 

Fah-Q

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I have actually quite enjoyed (the results of) knifing down to the fascia. Some even report a decreased incidence of post-op "fat necrosis" when the bovie is avoided.
JAD
I agree. Sharp dissection is sooooo much better than the bovie. I do all my neck dissections with a sharp blade and a bipolar.
 

JackADeli

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There are some published papers on "sharp" & "hydro" dissection mastectomies as well. One of my friends told me her breast attending used some sort of irrigation followed by sharp dissection always.... similar to what is instilled for liposuction. I never did it or saw it but those that did swore by it.

JAD
 
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Winged Scapula

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There are some published papers on "sharp" & "hydro" dissection mastectomies as well. One of my friends told me her breast attending used some sort of irrigation followed by sharp dissection always.... similar to what is instilled for liposuction. I never did it or saw it but those that did swore by it.

JAD
Tumescent solution: Its a mixture of lido with epi and NS injected subcutaneously and then sharp dissection with Metzenbaums. Helps develop a nice plane.

I use it for prophylactic mastectomy - tumors have too much blood flow to make me comfortable that there isn't going to be post-op bleeding - haven't used it for smaller procedures.

Am tempted to go with the knife for lumpectomies although my concerns are that I make "cosmetic" incisions - ie, they aren't always right over the tumor/area of concern. So it can be a lot of tissue to go through - some breasts are so fatty and floppy, I'd worry I'd miss a bleeder using the knife.

One of my Surg Onc attendings in fellowship tried to get me to use the knife for a mastectomy and I guess I complained so bitterly that he gave up and told me to use whatever I wanted. :laugh:
 

surgres88

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Tumescent solution: Its a mixture of lido with epi and NS injected subcutaneously and then sharp dissection with Metzenbaums. Helps develop a nice plane...:laugh:
One of our surg onc attendings only uses a scalpel for mastectomies. I don't think he lets the scrub RN put the Bovie on the field. Another attending used to use the Tumescent solution, but she had some complications (flap necrosis/infection) so she stopped. Have you heard of this being because too shallow of an injection/too much volume/too much local of an injection? Just curious.
 

Winged Scapula

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One of our surg onc attendings only uses a scalpel for mastectomies. I don't think he lets the scrub RN put the Bovie on the field. Another attending used to use the Tumescent solution, but she had some complications (flap necrosis/infection) so she stopped. Have you heard of this being because too shallow of an injection/too much volume/too much local of an injection? Just curious.
it would be hard to ascertain whether the flap necrosis was due to the epi or due to an extremely thin flap. Both are reasonable causes but I'd venture its the latter.

I have not see flap necrosis or infection with the tumescent solution but have seen it with very thin flaps. Infection is just the nature of the beast; we are now quoting 10% risk or higher of infection with all breast surgeries. Reported by the Mayo at the most recent ASBS meeting, which was nice because it seemed to fit with everyone's clinical experience.
 

surg

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I do a tumescent mastectomy for all my mastectomies virtually. Works great. No thermal damage to the flap hardly at all. Really haven't had any problems with bleeding as if you are in the right plane the number of vessels is minimal, and I can work basically in the dark through a small hole since I'm doing the dissection sharply by feel. Still use the bovie on the bottom though to get it off the muscle as there are more bleeders there. Also, for me I'm much faster this way. I'm averaging ~20 (non-skin sparing) - 25 (skin sparing) minutes/breast at this point from infusion to breast out. Haven't had any problems with flap necrosis yet. *knock on wood*

I also use the knife for my lumpectomies. I like the haptic feedback I get from the knife if I stray into the tumor. No question though that I have to spend a lot more time at the end though tidying up little bleeders. Really have to be religious about looking around thoroughly, although it is often surprisingly dry. Also, as a bonus, I find that I can get the tumor out faster and with a smaller overall incision since I don't need to get the space to get down and bovie. Then while I wait for radiology to film the specimen on my wire localized ones, I have time to leisurely look around for bleeders. (no faxitron here, wish I had one). The only downside is I find it hard to teach residents how to do it safely. Still working that out.
 

maxheadroom

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One of our surg onc attendings only uses a scalpel for mastectomies. I don't think he lets the scrub RN put the Bovie on the field. Another attending used to use the Tumescent solution, but she had some complications (flap necrosis/infection) so she stopped. Have you heard of this being because too shallow of an injection/too much volume/too much local of an injection? Just curious.
I would say that your necrosis is from thin flaps. Epi doesn't kill flaps. In breast recon we complain about thin flaps all the time. Of course, you guys need to do the right cancer operation, so we deal with it.
 

toxic-megacolon

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Winged, have you ever used the EnSeal for a mastectomy? Truly bloodless. I've heard people rave about using the knife for mastectomies, saying that they work great if you are in the right plane, but then those same attendings tend up loosing 400cc of blood! I'll remain skeptical till I see it work! There really is no excuse for loosing that much blood in a 30 minute procedure.

As far as incisions, opening the very superficial layer with a knife, and then powering through the dermis with the bovie on COAG at 80 is fast and almost no bleeding. But if yo don't go fast enough you burn the hell out of the skin.
 

homealone3

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Winged, have you ever used the EnSeal for a mastectomy? Truly bloodless. I've heard people rave about using the knife for mastectomies, saying that they work great if you are in the right plane, but then those same attendings tend up loosing 400cc of blood! I'll remain skeptical till I see it work! There really is no excuse for loosing that much blood in a 30 minute procedure.
I'm not so sure that I agree that it's so bad to lose 400 cc of blood, regardless of the surgery length.