Cooperative frozen section surgery

Mohs surgery and processing: novel optimizations and enhancements

OBJECTIVE

Simple yet effective modifications to Mohs surgery and processing may enhance procedural efficiency, ensure proper tissue orientation and tracking, while greatly reducing "recuts." Using the methods described, Mohs specimens no longer need to be incised or excised with any bevel, thus conserving tissue and facilitating closure.

METHODS

A streamlined Mohs surgical tray is convertible to a closure tray within seconds. The excised tissue specimen is oriented on a sterile paper square on a reusable sterilized aluminum palette where partial thickness circumferential and radial scalpel cross-hatching allows epidermal edges complete freedom to later adhere to a flattening glass. The sterile paper can be labeled with patient name, stage number, and chuck number; then the specimen is inked. Rapid chuck freezing in a specially positioned liquid nitrogen immersion is followed by OCT (embedding compound) application. Uniquely numbered and modified cryostat chucks eliminate the possibility of OCT-chuck disunion. Rapid liquid nitrogen immersion of a glass surface allows the inked, cross-hatched specimen's epidermal edges and base to lay perfectly flat once forced against the supercooled glass surface using a special polymer glove. Inversion of the specimen-containing glass onto a frozen and gel state OCT interface of the chuck completes the embedding.

RESULTS/CONCLUSION

These reproducible approaches to Mohs surgery described herein utilize multiple modifications that enhance the speed, efficiency, and reproducibility of Mohs specimen embedding, specimen preparation, while maintaining accuracy of interpretation.

Hairline reconstruction utilizing modified winged V-plastic hair-bearing flaps and focal anastomotic line excisions

BACKGROUND

A large, recurrent basal cell carcinoma involving the left forehead and suprajacent hair-bearing scalp was excised, following which an esthetically acceptable reconstruction of the scalp and hairline margin was accomplished.

OBJECTIVE

A method of utilizing two hair-bearing flaps to cover a large defect at the hair-bearing scalp margin will be photographically demonstrated, and the maneuvers to precisely reconstruct the scalp's anastomotic margin with the forehead will be shown and discussed.

METHODS

Dual hair-bearing "winged" V-plastic flaps were evolved anteriorly, the two flaps joined, an M-plasty (Webster) was then incorporated to spare hair-bearing scalp posteriorly, and the entire conjoined scalp flap then advanced anteriorly to the forehead. The precise curvatures of the anastomotic line were reestablished by exact excisions of forehead skin underlying the hair-bearing scalp flaps, or amputations of overlying hair-bearing scalp in excess of forehead needs.

RESULTS

An esthetically pleasing and reasonably exact reconstruction of the hair-bearing scalp and forehead anastomotic line was accomplished.

CONCLUSION

A precise reconstruction of the forehead/scalp margin can be accomplished utilizing a combination of techniques, including hair-bearing "winged" V-plastic flaps, an M-plasty, and the serial removal of segments of both glabrous and nonglabrous skin to reestablish the frontal hairline margin.

Pitfalls of Mohs micrographic surgery

This article discusses some of the pitfalls and disadvantages of Mohs micrographic surgery for the excision of skin cancer. These include (1) frozen section quality; (2) interpretation of frozen sections; (3) holes in fragmented tissue margins; (4) tissue orientation problems; (5) excessively narrow or wide margins; (6) transection of the tumor itself; (7) problems with multifocal tumor; and (8) the tedious, time-consuming nature of the procedure. Despite these problems, the importance of the procedure in the treatment of cutaneous neoplasms should not be underestimated.

Blunt liposuction cannula dissection with and without suction-assisted lipectomy in reconstructive surgery

Efforts continue to expand the role of blunt liposuction cannulae in flap elevation and reconstructive surgery. Suction-assisted lipectomy to reduce the actual volume of fat tissue present may allow the further reach and compressibility of mobilized flaps. These instruments find the safest possible plane for continued undermining dissection even at great distances. Applications yet unknown await discovery.