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Figure 2. Excising the cartilage using the flexible blade fenestration technique. Figure 4. The patient’s ear 6 weeks after second intention healing.

granulation that result from a punch fenestration technique along with several other potential advantages. The flexibility of the blade allows for variation of the width of the fenestration, and the length can also be adjusted to the needs in a particular situation. The gradual slope of the resulting cartilage defect makes spot hemostasis more precise and easier to achieve

with better visualization of the bleeding source. This naturally lends to a decreased risk of electrocoagulation damage to the surrounding cartilage. Furthermore, although unproven, the gentle slope gradation of the flexible fenestration theoretically provides a better scaffolding to hasten granulation than the vertical walls of cartilage produced with the standard punch technique. References 1. Galadari HI, Abrou AE, Rogers GS. Fenestration of auricular cartilage to expedite secondary intention healing. Surgical Practice 2007;11:159–61. 2. Larson PO, Ragi G, Mohs FE, Snow SN, et al. Excision of exposed cartilage for management of Mohs surgery defects of the ear. J Dermatol Surg Oncol 1991;17:749–52.

Lance D. Wood, MD Department of Dermatology Geisinger Health System State College, Pennsylvania

Figure 3. Appearance of the exposed cartilage after the procedure.

Michael Ramsey, MD Department of Dermatology Geisinger Medical Center Danville, Pennsylvania

Earlobe Freedom Clamp Surgeons face the problem of excessive bleeding during earlobe surgery because of the inherent vascular structure of the earlobe. We anticipate the need for a simple tool that can efficiently control bleeding and

thus render a clean operative field. Here, we present a simple design of an effective hemostatic clamp, which is effectively used under the earlobe anesthetic block during surgery.

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Materials and Methods The Snellen entropion clamp is modified as a hemostatic clamp in earlobe surgery. The materials needed are Snellen entropion clamp and a single-loop 2-arm stainless steel spring (Figure 1). One-sided plate of the Snellen entropion clamp is filed off by the file to make an open incomplete ring. The part of the plate rubbed off is shown in Figure 1 using shaded area. Hardened stainless steel wire is used to make a single-loop 2-arm spring. This spring is placed underneath the knob of the clamp screw and is used to keep apart the parts of the earlobe for paring the margin of the cleft (Figure 2). The earlobe surgery is performed under the earlobe anesthetic block. A maximum of 2 mL of the local anesthetic 0.5% bupivacaine without adrenaline is

Figure 2. Hemostatic earlobe clamp applied on the earlobe, and the screw is appropriately tightened to obtain hemostasis. Spring arms are used to hold the parts of the earlobe apart using suture while paring and repairing.

used. A 2-mL syringe with a 26-gauge needle is used for the earlobe block. The needle is inserted at the site where the earlobe is attached to the side of the cheek. This area is infiltrated with 2 mL of the local anesthetic solution. The area is given a massage for 2 to 3 minutes so that the anesthetic solution gets dispersed.

Figure 1. Snellen entropion clamp and a single-loop 2-arm stainless steel spring. The shaded area of the plate of the clamp is removed.

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After the anesthetic block, the clamp is applied on the earlobe. The screw is tightened to control bleeding from the cut margins. Traction sutures are fixed to earlobe margins to make quick and clean paring (Figures 2 and 3). This clamp allows simultaneous viewing of both sides of the lobe for final alignment in the clamped position (Figure 4). All the operations of the earlobe such as split ear, earlobe trauma,

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Figure 3. Traction sutures relaxed by rotating the spring arm while suturing to avoid parrot beak deformity.

Figure 4. Back of the earlobe repair. View of both sides of the earlobe remains excellent throughout.

inclusion cyst, and keloid take approximately 20 minutes.

possible for a surgeon with minimal assistance from theater staff to perform this technique.

Discussion The post-traumatic split ear and epidermal inclusion cyst of earlobe have some inconveniences that do not permit accurate incisions and surgery, the reason being the vascular structure of the earlobe. To facilitate surgery, Samper used Desmarres palpebral clamp in the earlobe on its vertical axis to perform bloodless surgery.1,2 The major advantage of this technique is that it reduces the length of the incision on earlobe because of the precision of the clamp that fixes the lobe. This clamp also facilitates surgery because of its hemostatic effect, which reduces the duration of surgery and makes it easy to maneuver the earlobe, thus making it

The traditional Desmarres palpebral clamp has an open ring on one side; this device requires that it be turned around during the procedure to provide exposure to both sides of the earlobe. This adds further steps to the procedure and does not allow simultaneous viewing of both sides of the lobe for final alignment in the clamped position. It also needs a brief interruption of the hemostatic effects provided by clamp pressure. Miles and Smith3 devised a doublering clamp to overcome this problem. It is similar to a large Desmarres palpebral clamp in design, but has open rings on each side. This earlobe clamp achieves good hemostatic effect, but the rings obstruct the vision and limit free use of the

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surgical tools. We have devised an earlobe clamp without rings by modifying the Snellen entropion clamp. Our clamp stabilizes the earlobe and therefore minimizes the help from assistants. The screw of the clamp is appropriately tightened to obtain perfect hemostasis. The ultimate hemostatic effect and unobstructed simultaneous viewing on both sides of the earlobe are excellent. Conclusion Modified Snellen entropion clamp along with 2-arm single-loop spring makes an effective new hemostatic clamp that is quite different from the original one for earlobe stability and bloodless surgery. This clamp is free from all the shortcomings faced by the operating surgeons earlier. We call it “Freedom Clamp,” as

it minimizes the help from an assistant, makes the earlobe immobile, and presents absolute bloodless field for meticulous surgical work.

References 1. Samper A, Bazan A. Traumatic earlobe cleft repair by using a Desmarres clamp. Plast Reconstr Surg 1999;103:739. 2. Samper A. Earlobe epidermal inclusion cyst excision using a Desmarres clamp. Ann Plastic Surg 1999;43:577. 3. Miles EJ, Smith B. A useful device for minor earlobe procedures. Plast Reconstr Surg 2008;121:339e–40e.

Devendra Kumar Gupta, MBBS, MS, MCh Shruti Devendra, MBBS Devendra Hospital & Yuva Cosmetic Clinic Bareilly, India

Topical 0.5% Timolol Heals a Recalcitrant Irradiated Surgical Scalp Wound A 76-year-old white man presented for Mohs surgery with a 5-year history of a 3-time recurrent, moderately differentiated squamous cell carcinoma on the left parietal and frontal scalp. An otolaryngologist twice excised the tumor within a span of 3 years, with each surgery followed by 6 weeks of adjuvant radiation therapy. The patient’s last excision and irradiation was 1 year ago (2013). Examination of the left frontal and parietal scalp revealed ulceration and poorly delineated hyperkeratotic plaques measuring 8 · 9 cm. After 2 stages of Mohs surgery, the defect measured 10 · 11 cm (Figure 1) and uncovered bone pitting. Computer tomography imaging with and without contrast revealed outer table frontal cortical bone irregularity with no lymphadenopathy. The patient chose to heal by granulation and epidermization (second intention). Wound care consisted of washing the scalp with soap and water daily or every other day and covering the wound with petroleum jelly and a nonadherent bandage. Healing was initially brisk but slowed significantly over the first year (Figure 2). The wound modestly

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improved over the next 3 years, during which the patient diligently adhered to the same wound care routine. Poorly vascularized, friable, granulation tissue persisted over the central zone of pitted bone (Figure 3). There was no evidence of tumor recurrence, hypergranulation (“proud flesh”), nor wound desiccation.

Figure 1. A 10- · 11-cm surgical defect after 2 stages of Mohs micrographic surgery used to remove a 3-time recurrent, twice irradiated, moderately differentiated squamous cell carcinoma on the left parietal and frontal scalp. Bone pitting is evident at the center of the wound.

DERMATOLOGIC SURGERY

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