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  • The Double-Bladed Scalpel in Mohs Micrographic Surgery: DISCUSSION

The double-bladed scalpel consists of a handle, blade holder and metal-spacers, as is shown on Fig. 2; this instrument can hold two blades and the distance between the two blades can be adjusted. This device was described in 1977 by Coiffman, and it was originally developed for harvesting strip grafts from the scalp for hair transplantation. Up to 16 parallel blades have been placed on a single knife for this purpose. The double-bladed scalpel has been employed for scar removal, staged excision of lentigo maligna melanoma with permanent vertical section margin control and excision of small basal cell carcinoma.

To get full analysis of the margin of tumor, the surgeon must perform some type of “en face” resection of the margin, meaning that the entire peripheral margin must be excised and examined. For standard surgical approaches, this usually implies taking a 1 mm rim of tissue cut at 90 degrees to the tissue and sending it in quadrants to patho­logy for frozen section analysis. Importantly, the thinner the rim of tissue, the less chance there is for a false-negative analysis occur. There have been recent reports of double bladed scalpels that are designed specifically for this purpose. The use of this device in Mohs micrographic surgery of basal cell carcinoma has not previously been reported. We used a modified vertical method of Mohs micro- graphic surgery using the double-bladed scalpel, allowing to achieve a margin with uniform and even thickness. viagra plus

Fig. 2. Double-bladed scalpel

Fig. 2. Double-bladed scalpel.

Kopke et al classifies Mohs micrographic surgery into three categories: conventional method, marginal strip method and munich method.

While not necessary for the majority of routine Mohs cases, utilization of the double-bladed scalpel may be time-saving, especially when used for peripheral margin control. Moossavi M et al suggested the most important advantage of the double-bladed scalpel over the single blade is that it improves the ability of the surgeon to harvest uniform strips of tissue. Operator error is therefore reduced, since a precise tissue margin may be removed around any given lesion. The uniform strips are more easily processed for frozen section evaluation. The double bladed knife may lose the traditional beveling tech¬nique of Mohs micrographic excision, since the double-bladed scalpel is typically held perpendicular to the skin. Nevertheless, an experienced Mohs tech¬nician should be able to manipulate the tissue for sectioning so that the epidermal edge is visible pathologically. The use of the double-bladed scalpel in Mohs micrographic surgery for peripheral margin control of tumors increases intraoperative efficiency and allows for conservation of normal tissue. This available tool would be useful to unskilled surgeons operating on tumors requiring accurate peripheral margin control.

The advantages of this method are: 1) a margin with a uniform, even thickness can be gained, 2) due to the even thickness, the frozen section could be easily and precisely cut, requiring fewer tissue sections, 3) false negative results could be decreased, and 4) the operation time could also be decreased. canadian pharmacy viagra

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