After my first 'real' patient for a skin excision...

Today was great as expected. I got to draw up and give a couple more injections, I am getting better at recognizing different sounds in the chest and I did my first 'real' excision.

I am much more confident with anaesthetising with local anaesthetics. Dr F showed me a few cool tricks and helped me redraw the margins for excision (you need to feel the skin - to determine the tension and therefore might avoid making the ellipse so big!). I cut the skin and as I peeled the skin back, dissected the skin from the underlying tissue. As I used 2% xylocaine with 1:80000 adrenaline, there wasn't too much bleeding, but still a fair bit...being quick helps! Using 3/0 monofilament non-absorbable sutures I set to work. I used a vertical mattress suture in the centre to pull the wound together (most of the way), then using the rule of halves, placed the rest of the sutures (simple, interrupted). I must say that human skin is much more resiliant than you would initally think, but much easier to handle than the pork trotters and bellies I have practiced on. Happy I was doing well, Dr F left me to finish up while she saw some patients. I tried my best to place even sutures tension wise (I put a few more in the middle as there was a bit more tension on the skin there). I removed that original holding suture and replaced it with a simple suture, tidied the ends and cleaned the wound site. I placed a few steri strips for extra hold (it was on the proximal anteriolater aspect of the leg) after I swabbed the site with betadine. I am paranoid about wound dehisence or infection, so after I was sure Dr F was satisfied, it was dressed and a water proof covering was added and the patient was instructed to leave them covered for at least two days and that they will need to be removed in two weeks. When tying I used 5 throws (2+1+1+1). I think they normally don't do the last, but as I said, I didn't want dehiscence. My only regret is that I think I may have actually tightened the sutures too much (too much tension) and considering, they will be left in for 2 weeks. I am hoping the tissue doesn't become necrotic, but I am expecting cross-hatch scarring. I hope not, but it probably will happen. I hope I am there in 2 weeks when he comes for the removal of stiches...I will give the verdict then.

Dr F asked me this afternoon if I could remove a small, but troubling lesion on her wrist for her tomorrow. She must have some confidence in me!