Procedure: Skin Removal for Scarification

This is a process document for skin removal for scarification. It is meant to be used as a checklist/reference for performing the procedure, and thus does not have sufficient detail to learn how to do this. TODO disclaimer

Table of Contents

Equipment

• Tools to sterilize
  • Splinter forceps (x2 in case of drops)
  • Adson forceps (optional)
  • Eyebrow tweezers (optional)
  • Hemostatic forceps (for scalpel changes)
  • Skin hook (optional)
  • #3 Scalpel handle x3
  • Small bowl for waste gauze/skin
  • Second small bowl, if using irrigation
• Cleaning
  • Multi-surface cleaner
  • Washcloth/other nonlinting cotton rag
  • Cavicide wipes
  • Sharps container
• Furniture
  • Massage table/standing desk (or better if available)
  • Puppy pads
  • Equipment table for non-sterile items
  • Bright lights
  • Chair for self and assistant
  • Mayo stand/salon table for sterile field (x2 if possible - one on right for tools, one on left for disposal of gauze)
• Bandaging
  • Butterfly closures in case of emergency
  • Suture kit in case of emergency, if you know how to use it
  • Hydrogel w/ silver nanoparticles
  • Xeroform dressing
  • ABD pad
  • Medical tape
  • Self-adhesive wraps
  • Bandage scissors
• PPE/wearable
  • Surgical masks
  • Gown (optional)
  • Sterile gloves xSeveral (min. 3)
  • Headlamp
  • Loupe glasses (optional, I have these ones)
  • Hair covering (optional)
• Items for sterile field
  • Scalpel blades (#10, #11, and #15, 5 of each)
  • Surgical drape sized for instrument table + 1inch, no fenestration (x2 for fuckups)
  • Surgical drape with appropriately sized fenestration for skin removal (x2 for fuckups) (OK if you can't get one with the correct size fenestration; can widen as needed)
  • Paper tape/other skin-safe tape to hold drape in place
  • Sterile saline bottle, 100ml
  • Sterile bulb syringe/bottle for irrigation (optional, can also just have a bowl to hold water and dab w/ gauze)
  • Sterile gauze pads, not tiny
  • Sterile dermal curettes, ~4mm x3
• Misc
  • Handheld roll of plastic wrap for wrapping phone
  • Snacks/food that everyone involved can eat
  • Fan, for hot flashes/nausea
  • Crystalized/candied ginger, for nausea
  • Caffeine for artist + straw
  • TV/monitor/computer to put on distracting stuff for subject (optional, one liked having wrestling videos, another skate vids)
• Equipment from:
  • Proc > Clean Tools > Equipment
  • Proc > Sterilize Tools > Equipment
  • Proc > Hand Hygiene > Equipment
  • Proc > Transfer Design and Prep Skin > Equipment
  • Skin Removal Aftercare Instructions > You Should Be Given

1-2 Weeks Prior Prep

• Have Skin Removal Pre-Procedure Discussion
  • Ensure subject knows How to Use Hibiclens Prior to Skin Removal and has a bottle
  • Recommend subject goes easy on the injuries for a bit before and after
  • Can suggest they ease up on the nicotine/smoking but we know they won't
  • Plan time and date. Ensure there is flex time after bc this can go LONG.
• Ensure we own all needed equipment (including appropriately sized bandages), reorder as needed
• Ensure you're practiced with the equipment
• Ensure equipment is comfortable for extended wear (headlamp, loupe if using)
• Confirm you know the major veins, arteries, etc around the area you'll be working in

Day Of Prep

1. Follow Proc > Clean Tools and then Proc > Sterilize Tools for your reusable tools.
2. Charge headlamp
3. Review sterile technique
4. Clean self (shower). Put up hair if it's long.
5. Clean environment (tidy, sweep/vacuum, mop, wipe down surfaces with standard cleaner)
6. Set up furniture and put other equipment on secondary equipment table
   • Adjust height of instrument table to be between waist and shoulder height, seated and standing
   • If using a non-comfortable table (i.e. a desk instead of a massage table), add blankets/pillows until it won't suck terribly to be on for a few hours. Have subject lie on it to check. Cut open a trash bag and put it down, inside facing up, to protect the fabric around the working area.
   • Put down puppy pad on table
7. Get consent to take pictures. Ask the following, in order, and write down the results:
   • Can we take pictures for personal reference?
   • Can we share those pictures with others privately?
   • Can we post pictures/videos publicly that don't include your face?
   • Can we post pictures/videos publicly that do include your face?
   • What name, if any, should we use for you when posting pictures?
8. Ensure water or electrolyte beverage in reach of subject
9. Ensure everyone is fed and watered. Non-negotiable! Eat something!
10. Caffeinate appropriately
11. Ensure pets are put away, or assistant present to keep them busy
12. Assistant should wrap their phone in plastic wrap (leaving hole for camera)

Immediately Pre-Procedure

1. Ensure everyone has used the bathroom.
2. Reiterate the following:
   • It's important to know how you're doing - you need to communicate
   • It's never a bad thing if we need to stop or pause
   • There's no rush to complete this
   • Let us know if you need a stretch/bathroom break
   • We can be done for good at any time. If you can though, please yellow before red, so we can take a breather, touch up the current section, and bandage you up.
3. Start some music, with a playlist going
4. Disinfect environment with cavicide wipes
5. Give subject surgical mask
6. Put on headlamp. Set at appropriate angle and turn it on.
7. Perform Proc > Hand Hygiene with soap/water. Apply clean gloves.
8. Follow Proc > Transfer Design and Prep Skin
9. Get subject laying down on table. Position subject so it will be easy to keep scalpel perpendicular to skin, using dominant hand, without crossing forceps and blade.
10. Perform Proc > Hand Hygiene and put on new clean gloves.
11. Assistant performs Proc > Hand Hygiene and dons clean gloves
12. Create sterile field
    • Apply drape to subject, only touching outer one inch. Tape in place.
    • Apply drape to instrument trays, only touching outer one inch
    • If no assistant, add items to sterile field now by dropping them 6in. Add scalpel blades if no assistant, otherwise we can open as we go
13. Don PPE
    1. Don gown. Pull the sleeves down to the wrists, and tie at neck and waist.
    2. Apply surgical mask.
    3. Perform Proc > Hand Hygiene.
    4. Pull on sterile gloves to cover the wrist of the gown.
14. With help of assistant, add items to instrument tray:
    • Sterile tools from pouch
    • Container for saline (close to edge)
    • Have assistant pour saline into container
    • Sterile gauze pads (close to edge)
    • Waste bowl
    • #10, #11, #15 scalpel blades
15. If fenestration in drape is too small, tear or cut it until you can see the whole area.

Procedure

Line a piece of the design, remove it, repeat. Clean up supersection depth with curette. This section intentionally left as a stub, as this document is more of a checklist than a repository for notes.

Completion

1. Use saline-soaked gauze to remove debris
2. Apply sterile gauze with pressure until it stops bleeding
3. Use saline-soaked gauze to remove any remaining debris, and clean up periwound PVP-I
4. Apply hydrogel directly in wound, then xeroform, then ABD pad. Tape it to skin, wrap in gauze and/or self-adhesive wrap. Subject is now free to move around.
5. Use forceps to put blades in sharps container.
6. Doff PPE
   1. Gloves: glove to glove, skin to skin.
   2. Gown
   3. Perform Proc > Hand Hygiene.
   4. Remove mask
   5. Perform Proc > Hand Hygiene.
7. Don clean gloves. Follow Proc > Clean Tools.
8. Clean up most visibly soiled items (gauze with blood, drapes)
9. Perform Proc > Hand Hygiene.
10. You can now rest for a while. Go sit outside and talk. Eat something.
11. Give subject aftercare instructions and relevant bandages/equipment.
12. Have assistant help finish cleaning up. Use clean hand/dirty hand technique. Disinfect surfaces.