Procedure: Transfer Design and Prep Skin

This page has information about how to transfer a design onto skin, and how to prepare that skin for a skin removal procedure.

Quick links: Transfer Design, Prep Skin

Equipment

• Transfer paper (I used this)
• Normal pen
• Scissors to cut design out
• Clean (not sterile) gloves
• Non-antimicrobial soap
• Wet washcloth
• 85% ethanol (v/v) sanitizer or liquid
• Alcohol prep pads
• Activator for transfer paper
• Gentian violet surgical skin pen

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• Betadine (or other 10% PVP-I) solution
• Sterile gauze
• Distilled water
• PVP-I 10% swab

Procedure

Transfer Design

1. Trace design, pressing hard, onto transfer paper (dull side down). Cut out design.
   • Make design be where you want the cuts to be. Instead of having a thick line, try to have the outline. This is easier than doing it in post.
2. Perform Proc > Hand Hygiene (before touching) and put on clean gloves
3. If subject's skin is visibly dirty/sweaty, wash with soap/water and thoroughly dry
4. Wipe down the skin with alcohol (85% ethanol v/v) in a wide area around the incision site, for 3 minutes
5. Position subject so skin is under minimal tension/appropriate tension for how design should look
6. Apply a few drops of activator to skin. Rub in like a lotion.
7. Press design onto skin. Remove design and set aside as reference.
   • Be aware that lines will distort as the flat surface of the paper is projected onto the curved surface of the skin. Consider applying large designs in smaller parts to minimize this.
8. Confirm with subject that design is correct.
9. Use wet but not soapy part of washcloth to wash off activator, but not design
10. Trace design with thin end of gentian violet pen (have assistant open, if possible)
    • Lines go exactly where you want to cut
    • Use alcohol wipes (quickly) to remove mistake lines
    • Allow ink to dry thoroughly before prepping

Prep Skin

1. If no design was transferred, wipe down the skin with alcohol (85% ethanol v/v) for 3 minutes
2. Wet skin with water
3. Apply Betadine scrub in wide area (1 mL covers 20-30 square inches); develop lather and scrub thoroughly for about 5 minutes
   • For example scrub/paint, see this video.
   • Begin at the planned incision site and move to the periphery, using an ever-widening circular motion. The used portion of the washcloth should not be brought back over the already cleaned area. Always progress from the clean to the dirty area.
4. Rinse off Betadine using sterile gauze saturated with distilled water
5. Paint with PVP-I swabstick in wide area and allow to dry
6. Doff gloves and perform Proc > Hand Hygiene (after touching)
7. (Have assistant) set timer for 10 minutes; do not cut skin before then

Reasoning

We use gentian violet because it stains the skin. We want this so that it doesn't come off when prepping the skin, or during the procedure.

Gentian violet is banned in Canada, as it's a potential carcinogen. However, after a day or so of reading, I am judging the risk from infrequent topical use to be very low. The research cited for banning it was about ingesting large quantities of it daily. I'd switch to something else if I found a good option (henna? could b cute) but this isn't a priority. Sorry I don't have my sources saved for this one!

We can't use sterile gentian violet pens to draw the design on already-prepped skin, because we want to be able to transfer the design, and transfer paper isn't sterile. If we weren't transferring the design, and were drawing directly on the skin, we could use a better prep solution. Because of this, I have us do an 85% alcohol rub beforehand. We do this for the same reasons as in Proc > Hand Hygiene > Reasoning.

We use povidone-iodine because it is widely used for this, and is compatible with gentian violet pens. CHG in alcohol would be better, SSI-risk-wise.

ChloraPrep is expensive :(

I forget why I use 10% PVP-I scrub instead of 7.5%.

We wait 10 minutes after PVP-I application because of this research

References

• Directions For Use Surgical Markers (Gentian Violet Ink)
• Betadine Surgical Scrub
• A Review of Anti-septic Agents for Pre-operative Skin Preparation (2007)
• AST Standards of Practice for Skin Prep of the Surgical Patient (2008)
• Info from friend who works in a hospital

Todo

• Amend instructions for when going over existing scar
• Investigate tattoo transfer paper
• Import shave instructions from AST/hospital info
• Investigate “clean” versus “sterile” skin preparation kit controversy
• Investigate if we can use chloraprep with surgical skin pens somehow; the additional alcohol should be useful
• Add chloraprep instructions for when not using skin pen
• Is there a cheap alcohol-based chlorhexadine solution we can use instead of chloraprep?