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PREOPERATIVE EVALUATION
PREOPERATIVE EVALUATION
The preoperative consultation for most linear excisions and closures can safely take place on the day of surgery, and includes a detailed medical and social history, with particular attention to the use of medications or supplements that may affect bleeding as well as tobacco use, which has a marked effect on the postoperative healing process.
The details of the preoperative evaluation in general are addressed in Chapter 3.
Patients should understand that there is always more than one way to skin a cat; all surgical procedures present risk, and all surgical procedures have alternativesโ including avoiding surgery altogether. It is the balance of risk and benefit that must be addressed with each patient individually.
This individualized approach to patient consent and education should extend to the preoperative evaluation of the planned procedure as well. Thus, the planned surgical site should be carefully assessed visually, palpated, and the range of motion of the planned surgical site and surrounding tissues should be closely assessed. For example, when designing facial repairs the surgeon should sequentially have the patient move through the entire range of motion (frown, smile, grimace) in order to better gauge the relaxed skin tension lines (RSTLs) and the presence of any underlying fibrous attachments. In recent years, there has been a better understanding of the retaining ligaments in the cheek and beyond, which may have a significant impact on tissue mobility, particularly during larger repairs.13
On the hands, patients should similarly move through flexion and extension, and should be asked to make a fist. Querying the patients regarding occupational and leisure activities may also be particularly helpful, as a dorsal hand repair on a masseuse may be approached differently to that on a professional golfer. The potential for range-ofmotion variation is also seen on the upper back, where baseline patient posture may affect the planned closure vector.
Linear closures near free margins should be carefully planned and assessed, and patients should understand potential risks, such as ectropion or eclabium, before the procedure is started. When assessing the potential for ectropion, the patient may be asked to gaze upward with their mouth wide open while in a semi-reclined position in order to better assess the potential for ectropion development.
As part of the informed consent process, the patient should understand that there will be a scar every time the skin is cut. The goal is not to avoid scarring altogether, which is impossible regardless of surgeon or surgical technique; it is to create the least cosmetically obvious scar while definitively treating the underlying disease process. The assessment of scar quality has been the focus of renewed interest of late, particularly as this may be used as an outcome measure for quality-of-care assessments. The SCAR scale (Scar Cosmesis Assessment and Rating scale) is a recently developed validated scale that may be particularly helpful when determining the quality of postoperative scarring.14,15
The informed consent and consultation process, while unique to each patientโs circumstances, should always move through the same steps. Thus all patients are handed a mirror and asked to confirm the surgery site prior to marking, and then again asked to confirm the site verbally once the site has been marked. This approach is invaluable in
engaging the patient as partner regarding biopsy-site identification, and may help limit potential liability exposure in cases where wrong site surgery is alleged. In cases where the biopsy-site location is equivocal, surgery should be delayed, and consultation should be undertaken with the referring physician (if applicable), or a small scouting biopsy may be performed.16,17
Prior to beginning the surgical procedure, the patient should be informed of the postoperative healing course. This includes a detailed explanation regarding limitations on physical activity, as well as an explanation regarding postoperative wound care. Furthermore, most patients (and many physicians) are not aware of the need to hyperevert the wound edges postoperatively, and explaining that this is analogous to a subcutaneous splint that is present only temporarily until buried suture absorption is complete may be very helpful.18