T. Minsue Chen

Flash Freezing of Mohs Micrographic Surgery Tissue Can Minimize Freeze Artifact and Speed Slide Preparation

BACKGROUND In Mohs micrographic surgery, excised tissue is traditionally prepared for cryotomy by freezing in the cryostats refrigerated chamber. Any delay may cause drying artifact and tissue autolysis and affect slide turn around time (TAT). Flash freezing is used in frozen section processing of general pathology specimens to expedite TAT and enhance tissue histology by minimizing ice crystal formation (freeze artifact). DESIGN This was a pilot quality improvement study to compare flash freezing of Mohs sections with the traditional method of freezing in the cryostat. Mohs layers divided into at least two sections (one set) were enrolled. One half was flash frozen in an isopentane histobath (−56 to −62°C); the other half was frozen in the cryostat (−27 to −30°C). RESULTS Forty‐one sets were enrolled. Average cryostat and histobath freeze times (range) were 144 seconds (90–240 seconds) and 22 seconds (15–40 seconds), respectively. Laboratory technicians felt that it was easier to achieve smooth, wrinkle‐free sections in histobath frozen tissue in 90% of tissue sets. Physicians favored histology from flash frozen specimens (range 65–85%) over the traditional method of cryostat freezing. CONCLUSION Flash freezing in a histobath produced a more rapidly opacified (frozen) specimen ready for cryotomy, expediting slide TAT. Tissue histology also demonstrated better quality and minimized freeze artifact. The authors have indicated no significant interest with commercial supporters.

Carbon dioxide laser ablation and adjunctive destruction for Darier-White disease (keratosis follicularis).

An otherwise healthy 31-year-old Caucasian female presented with a diagnosis of Darier’s disease since 11 years of age. She sought treatment to ameliorate the malodorous crusting and recurrent skin infection. On physical examination, keratotic papules coalesced into large macerated, hyperkeratotic plaques that were predominately located in the flexural areas (inframammary area, axilla, and groin). The lesions covered more than 30% to 40% of her total body surface area (Figure 1). She tried medical (isotretinoin, hormone), surgical (Er:YAG laser, CO2 laser, and deep wire-brush dermabrasion), and complementary medical (acupuncture, herbal) therapies with temporary and disappointing results. The details of her treatment and clinical outcome are described in Table 1.

Precautions with gentian violet: Skin marking made sterile, effective, and economical

BACKGROUND Surgical site infections have been caused by gentian violet (GV) marking solutions that were contaminated with Mycobaterium chelonae. GV solution is also used in surgery to mark surgical sites. It is commercially available as a solution that may not have been prepared under sterile conditions. OBJECTIVE Our objective is to describe a skin marking method that is sterile, effective, and economical. METHODS GV solution; microcentrifuge tubes; and round, wood toothpicks are used as an alternative to the standard surgical marker. GV (4 drops) is dispensed into a microcentrifuge tube. After capping, the tube is autoclaved. The toothpick is used as the writing instrument and dipped into the GV as needed for intraoperative skin marking. Unlike commercially available skin markers, skin moisture will not cause the writing implement (toothpick) to become ineffective; merely dry the skin before skin marking. RESULTS Autoclaving the commercially available shelved GV solution ensures sterility. The cost of the GV, toothpicks, and microcentrifuge tubes is approximately

The banana: a surgery training model to refine blade control for Mohs layer removal and skin incisions.

0.10 per operation. In contrast, commercially available surgical markers range in cost from

In Vivo Intraoperative Relaxing Incisions for Tissue Flattening in Mohs Micrographic Surgery

0.79 to

Hematoxylin and eosin tissue stain in Mohs micrographic surgery: a review.

3.89 per pen (manufactured suggested retail price), a 8- to 39- fold difference. CONCLUSION Infectious precautions should be taken with surgical site marking. Marking solutions should be prepared under sterile conditions in a pharmacy. Alternatively, commercially available nonsterile solutions can be autoclaved to ensure sterility.

Polyangulated specimen and tissue nicks to facilitate orientation and re-excision in Mohs micrographic surgery.

The current teaching of Mohs surgery involves lectures, observation, assisting, and supervised execution of the procedure. Surgical education in Mohs surgery presents a unique set of challenges, including a patient who is awake during the procedure and, consequently, limiting most ‘‘real-time’’ feedback. Additionally, in a procedure where tissue sparing is the goal, there is little room for mistakes and/or opportunity for redos. Therefore, surgical simulation is ideal because it allows for critical evaluation and feedback as well as ample opportunity to practice and refine this important technical skill before in vivo execution.

A Simple, Inexpensive Means to Minimize Suture “Hitchhiker” Sharps Injury in the Setting of a Limited Surgical Workspace

Complete surgical margin evaluation is paramount to successful Mohs micrographic surgery. Various methods have been described to prepare and preserve the surgical margin integrity for histologic examination, including tumor debulking (either en bloc or with curettage), excision with a degree of inward bevel, ex vivo tissue relaxing incisions in a cross-hatch pattern, mechanical tissue flattening, and division into smaller pieces. These various techniques are neither standard for all Mohs layers nor universally used by all Mohs surgeons. Tissue flattening techniques should be selected after careful consideration of tissue characteristics.

Electronically Linked: Wireless, Discrete, Hands‐Free Communication to Improve Surgical Workflow in Mohs and Dermasurgery Clinic

BACKGROUND Several factors may affect Mohs micrographic surgery (MMS) tissue section quality. Although other factors may affect section integrity and ease of processing, tissue stains are the cornerstone of histologic diagnosis. When performed incorrectly, visualization and discrimination of microscopic details may be suboptimal and even impossible. Patient harm may result if an accurate diagnosis cannot be made. OBJECTIVE To review hematoxylin and eosin (H&E) technique, the most commonly used staining technique in MMS tissue preparation. MATERIALS AND METHODS Review of literature. Tissue sections were H&E stained using a linear stainer where one reagent container was omitted on each trial run to evaluate microscopic differences in staining quality. RESULTS The chemical nature of H&E staining is discussed, along with commonly encountered problems, pitfalls, and troubleshooting tips. H&E stained sections are presented to demonstrate histologic appearance in the absence of certain reagents. CONCLUSIONS The success of MMS depends on high‐quality tissue sections. The staining process should be optimized to be reproducible and reliable. To readily identify and resolve poor staining quality, a firm understanding of the principles upon which tissue staining is based and its pitfalls is necessary. The authors have indicated no significant interest with commercial supporters.

Unilateral superficial musculoaponeurotic system plication in facial reconstructive surgery.

Meticulous surgical margin evaluation is critical for successful Mohs micrographic surgery (MMS). Various methods have been described to orient tissue and map positive surgical margins, including hand-drawn pictures of the specimen, preprinted maps or cartoons of anatomic sites, and digital and Polaroid photography. Tissue shrinkage and skin viscoelasticity contribute to the potential inexactness of tissue orientation and, if indicated, further resection for margin control. These tissueprocessing challenges are compounded in larger specimens, which require division into multiple tissue blocks for processing.