The Double-Bladed Scalpel in Mohs Micrographic Surgery: CASE REPORT
A 58-year-old man presented with a 1-year history of a black mass measuring 2.0×0.5 cm on the right nasolabial fold. No pain, tenderness or itching was associated with the lesion which was pathologically diagnosed by biopsy as basal cell carcinoma.
Basal cell carcinoma on the right nasolabial fold was completely removed with two stages of Mohs micrographic surgery. Similar to the routine method, incision is performed with a double-bladed scalpel using 11th blade after determining 2 mm safety margin (Fig. 1A). Vertical excision is done with the outer blade of the scalpel by following the excision width. At this time, two important points are 1) an 11th blade is generally used because it enables the surgeon to turn along the curving area easier than any other blade such as the 15th or 10th blade. 2) metal-spacers can control the excision width space as much as 1.5~2.0 mm. For instance, a 1.5 mm excision width is preferred when cancer occurs on the forehead because of the hardness of the forehead tissue. When the tissue is soft like those of the cheek, we use a 2.0 mm excision width. When the incision is sufficient to reach the subcutaneous fat layer, then the basal area is cut with a single-11th bladed scalpel, which divides the area into two sections (the margin and the main tumor) (Fig. 1B). Between these two sections, the direction of the margin strip must be marked and the margin strip must be subdivided into four segments. Then place the lateral side facing upwards and cut the basal segment from the main tumor so that the basal surface should also face upwards (Fig. 1C). The tissue is transferred to a Cryostat chuck with the lateral side up and being compressed. A few drops of OCT (Optimal Cutting Temperature) are placed over in such way that the edges and the depth are frozen at the same plane. The processes after this are identical as the routine Moh’s technique. There were no tumor cells. The final surgical defects measured 2.5×1.5 cm. The tumor defect was covered by direct closure. The final shape and texture were satisfactory. No local recurrence or regional metastasis occurred for the following 2 years.
Fig. 1. A 58-year-old Korean man was admitted with a 2.0 x0.5 cm sized black colored mass on his right nasolabial fold. He was diagnosed with basal cell carcinoma and treated with Mohs micrographic sur¬gery. (A) Incision is performed with a double-bladed scalpel after determining the margin. (B) The margins strip and the main tumor. (C) The margin strip is subdivided into four pieces. The base is cut from the main tumor.