Australasian Journal of Dermatology (2016) 57, e64–e65
doi: 10.1111/ajd.12332
BRIEF REPORT
Flexible razor blade for harvesting tumours in Mohs micrographic surgery Eugene Tan, Neil Mortimer and Paul J Salmon Dermatologic Surgery Unit, Skin Cancer Institute, Tauranga, New Zealand
ABSTRACT A useful application of the flexible razor blade in Mohs micrographic surgery that can save time and result in a well-presented specimen is described. Key words: flexible, harvesting, Mohs, razor blade, tumour.
INTRODUCTION The flexible razor blade has an established history in basic dermatological surgery where it is most commonly utilised in biopsies and excision of small, superficial skin tumours.1–3 Recently, its use has been broadened to advanced dermatological surgery settings such as the harvesting of skin grafts and thinning of paramedian forehead flaps.4–6 The use of the razor blade in Mohs micrographic surgery was first mentioned more than two decades ago.2,7 In that setting, the authors routinely debulked the tumour with a curette and recommended the technique for superficial basal cell carcinomas of the nasal ala and tip. A more recent description of the use of the razor blade in Mohs micrographic surgery trumps its benefit in creating shallower defects suitable for second intent healing.8
REPORT In this report the authors build upon previous experience and confirm the usefulness of the flexible razor blade as a technique that can expedite the harvesting of tumours in Mohs micrographic surgery.
Correspondence: Dr Tan Eugene, Dermatologic Surgery Unit, Skin Cancer Institute, Tauranga, 3110, New Zealand. Email: [email protected] Eugene Tan, FRACP. Neil Mortimer, MRCP. Paul J. Salmon, FRACP. Conflict of interest: none Submitted 4 November 2014; accepted 22 February 2015.
The authors used a Wilkinson Sword flexible razor blade (Energizer Holdings, High Wycombe, UK) (Fig. 1a). However, an acceptable alternative is a custom-made shave biopsy blade (e.g., Dermablade [Personna American Safety Razor Company, Verona, VA, USA]). This Dermablade has the added benefit of sterility, together with only one sharp cutting edge and a consequently reduced risk of injuring the surgeon from either breaking the blade in half or handling its sharp back. The skin is first marked with a surgical pen. Ideally, orientation hashes are made at this stage. The skin is then stretched and stabilised while the blade is flexed (to produce desired curvature and depth) and advanced under the tumour from right to left (Fig. 1a). When the blade has reached its furthest point the tumour is then stabilised with a finger tip while the hand carrying the blade advances. If hash marks were not placed earlier, a scalpel can be used at this stage to create hash marks (Fig. 1b). The flexible razor blade can also be used to harvest a second stage, but only when the epidermis and dermis are required (fat is too soft to be harvested with the blade alone). As a general rule, firm and convex skin is ideal for the flexible razor blade. We do not use this technique on soft skin such as the eyelid, neck or lateral face. Likewise, concave surfaces such as the conchal bowl, scaphoid or triangular fossae, upper lip and alar crease are not amendable to this technique. Ideal specimens are produced from small and superficial tumours (often less than 1.5 cm in diameter) on the scalp, forehead, nasal tip, helix and antihelix. With this technique there is a risk of tumour extirpation if the blade is used at a very shallow angle, which could produce a positive Mohs specimen and hence lead to more stages of tumour extirpation than necessary. Clinical dexterity and experience will minimise this risk. We have found the flexible razor blade technique useful for harvesting tumours in Mohs micrographic surgery. When used in the appropriate setting this technique saves time and results in a well-presented Mohs specimen (Fig. 2a); obviating any need for debulking the tumour or releasing incisions. In this technique the epidermal edges are acute and rest uniformly on the microscopic slide (Fig. 2b). The technique allows for the orientation of the Mohs specimen and creates a defect that can be shallow, allowing for the option of second intent healing at selected sites. © 2015 The Australasian College of Dermatologists
Flexible razor blade use in Mohs
(a)
(a)
(b)
(b)
Figure 1 (a) Pressure is applied to the antihelix posteriorly to maintain a flatter surface for Mohs extirpation with the flexible razor blade; (b) scoring and orientation of the specimen (no. 15 blade used).
REFERENCES 1. 2. 3. 4.
Field LM. Improving razor blade biopsy techniques. Dermatol. Surg. 1996; 22: 482–4. Grabski WJ, Salasche SJ, Mulvaney MJ. Razor-blade surgery. J. Dermatol. Surg. Oncol. 1990; 16: 1121–6. Levy SB. The razor blade in dermatologic practice. Cutis 1976; 17: 402. Justiniano H, Edwards J, Eisen DB. Paramedian forehead flap thinning using a flexible razor blade. Dermatol. Online J. 2009; 15: 12.
e65
Figure 2 (a) The Mohs defect post staging with the flexible razor blade; (b) a well-presented Mohs specimen with uniformly laid epidermal edges on the microscope slide.
5. 6.
7.
8.
Kontos AP, Qian Z, Urato NS et al. The use of a flexible razor blade in skin graft harvesting. Dermatol. Surg. 2009; 35: 120–3. Foroozan M, Pouaha J, Truchetet F. Simple method for harvesting split-thickness skin grafts. Dermatol. Surg. 2010; 36: 1743–5. Grabski WJ, Salasche SJ. Razor blade excision of Mohs specimens for superficial basal cell carcinomas of the distal nose. J. Dermatol. Surg. Oncol. 1988; 14: 1290–2. Jaffe AT, Proper SA. An alternate approach for harvesting Mohs specimens with a flexible scalpel. Dermatol. Surg. 2001; 27: 851–3; discussion 4.
© 2015 The Australasian College of Dermatologists
doi: 10.1111/ajd.12332
BRIEF REPORT
Flexible razor blade for harvesting tumours in Mohs micrographic surgery Eugene Tan, Neil Mortimer and Paul J Salmon Dermatologic Surgery Unit, Skin Cancer Institute, Tauranga, New Zealand
ABSTRACT A useful application of the flexible razor blade in Mohs micrographic surgery that can save time and result in a well-presented specimen is described. Key words: flexible, harvesting, Mohs, razor blade, tumour.
INTRODUCTION The flexible razor blade has an established history in basic dermatological surgery where it is most commonly utilised in biopsies and excision of small, superficial skin tumours.1–3 Recently, its use has been broadened to advanced dermatological surgery settings such as the harvesting of skin grafts and thinning of paramedian forehead flaps.4–6 The use of the razor blade in Mohs micrographic surgery was first mentioned more than two decades ago.2,7 In that setting, the authors routinely debulked the tumour with a curette and recommended the technique for superficial basal cell carcinomas of the nasal ala and tip. A more recent description of the use of the razor blade in Mohs micrographic surgery trumps its benefit in creating shallower defects suitable for second intent healing.8
REPORT In this report the authors build upon previous experience and confirm the usefulness of the flexible razor blade as a technique that can expedite the harvesting of tumours in Mohs micrographic surgery.
Correspondence: Dr Tan Eugene, Dermatologic Surgery Unit, Skin Cancer Institute, Tauranga, 3110, New Zealand. Email: [email protected] Eugene Tan, FRACP. Neil Mortimer, MRCP. Paul J. Salmon, FRACP. Conflict of interest: none Submitted 4 November 2014; accepted 22 February 2015.
The authors used a Wilkinson Sword flexible razor blade (Energizer Holdings, High Wycombe, UK) (Fig. 1a). However, an acceptable alternative is a custom-made shave biopsy blade (e.g., Dermablade [Personna American Safety Razor Company, Verona, VA, USA]). This Dermablade has the added benefit of sterility, together with only one sharp cutting edge and a consequently reduced risk of injuring the surgeon from either breaking the blade in half or handling its sharp back. The skin is first marked with a surgical pen. Ideally, orientation hashes are made at this stage. The skin is then stretched and stabilised while the blade is flexed (to produce desired curvature and depth) and advanced under the tumour from right to left (Fig. 1a). When the blade has reached its furthest point the tumour is then stabilised with a finger tip while the hand carrying the blade advances. If hash marks were not placed earlier, a scalpel can be used at this stage to create hash marks (Fig. 1b). The flexible razor blade can also be used to harvest a second stage, but only when the epidermis and dermis are required (fat is too soft to be harvested with the blade alone). As a general rule, firm and convex skin is ideal for the flexible razor blade. We do not use this technique on soft skin such as the eyelid, neck or lateral face. Likewise, concave surfaces such as the conchal bowl, scaphoid or triangular fossae, upper lip and alar crease are not amendable to this technique. Ideal specimens are produced from small and superficial tumours (often less than 1.5 cm in diameter) on the scalp, forehead, nasal tip, helix and antihelix. With this technique there is a risk of tumour extirpation if the blade is used at a very shallow angle, which could produce a positive Mohs specimen and hence lead to more stages of tumour extirpation than necessary. Clinical dexterity and experience will minimise this risk. We have found the flexible razor blade technique useful for harvesting tumours in Mohs micrographic surgery. When used in the appropriate setting this technique saves time and results in a well-presented Mohs specimen (Fig. 2a); obviating any need for debulking the tumour or releasing incisions. In this technique the epidermal edges are acute and rest uniformly on the microscopic slide (Fig. 2b). The technique allows for the orientation of the Mohs specimen and creates a defect that can be shallow, allowing for the option of second intent healing at selected sites. © 2015 The Australasian College of Dermatologists
Flexible razor blade use in Mohs
(a)
(a)
(b)
(b)
Figure 1 (a) Pressure is applied to the antihelix posteriorly to maintain a flatter surface for Mohs extirpation with the flexible razor blade; (b) scoring and orientation of the specimen (no. 15 blade used).
REFERENCES 1. 2. 3. 4.
Field LM. Improving razor blade biopsy techniques. Dermatol. Surg. 1996; 22: 482–4. Grabski WJ, Salasche SJ, Mulvaney MJ. Razor-blade surgery. J. Dermatol. Surg. Oncol. 1990; 16: 1121–6. Levy SB. The razor blade in dermatologic practice. Cutis 1976; 17: 402. Justiniano H, Edwards J, Eisen DB. Paramedian forehead flap thinning using a flexible razor blade. Dermatol. Online J. 2009; 15: 12.
e65
Figure 2 (a) The Mohs defect post staging with the flexible razor blade; (b) a well-presented Mohs specimen with uniformly laid epidermal edges on the microscope slide.
5. 6.
7.
8.
Kontos AP, Qian Z, Urato NS et al. The use of a flexible razor blade in skin graft harvesting. Dermatol. Surg. 2009; 35: 120–3. Foroozan M, Pouaha J, Truchetet F. Simple method for harvesting split-thickness skin grafts. Dermatol. Surg. 2010; 36: 1743–5. Grabski WJ, Salasche SJ. Razor blade excision of Mohs specimens for superficial basal cell carcinomas of the distal nose. J. Dermatol. Surg. Oncol. 1988; 14: 1290–2. Jaffe AT, Proper SA. An alternate approach for harvesting Mohs specimens with a flexible scalpel. Dermatol. Surg. 2001; 27: 851–3; discussion 4.
© 2015 The Australasian College of Dermatologists
