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

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.

Laboratory assistive personnel in Mohs micrographic surgery: a survey of training and laboratory practice.

BACKGROUND: The success of Mohs micrographic surgery (MMS) is contingent on high-quality frozen tissue sections for histologic interpretation. Laboratory assistive personnel (LAP) are central to this process, but their training and tissue processing techniques are neither standardized nor certified for competence. OBJECTIVE: To evaluate processes used to train and laboratory techniques practiced by LAP. Letters were mailed to Mohs surgeons with a Web link to an online survey for LAP to complete. RESULTS: Response rate was 24%. Responders primarily received training on the job, but not from the surgeon. On-the-job training from other LAP was perceived to be the most helpful, and textbook to be the least helpful. On average, survey responders felt it took several months to become proficient. Wide variations in laboratory practice were noted for histology laboratory and Mohs tissue processing techniques and for quality assurance. Differences in training and practices were noted between certified and noncertified LAP. CONCLUSION: Patient care may be compromised because of variable practice of laboratory techniques, quality assurance, and quality control. Standardization of LAP training, along with demonstration and maintenance of competency, may be necessary to ensure the integrity of the MMS technique.

Treatment of punched-out atrophic and rolling acne scars in skin phototypes III, IV, and V with variable square pulse erbium:yttrium-aluminum-garnet laser resurfacing.

BACKGROUND: Treatment of acne scars remains a challenge, especially in dark-skinned individuals. Treatment parameters may be optimized by selecting appropriate pulse width and laser energy that enhance tissue thermal response with limited morbidity. OBJECTIVE: To determine the efficacy and side effects of variable square pulse (VSP) erbium:yttrium-aluminum-garnet (Er:YAG) laser resurfacing for treatment of punched-out atrophic and rolling acne scars. METHODS Twenty-four subjects with acne scars were treated monthly for 2 months with four passes of VSP Er:YAG laser resurfacing using a 7-mm spot size and a fluence of 0.4 J/cm(2). Subjects were divided into two groups and treated with two different pulse widths: 300 micros (short pulse, SP) and 1,500 micros (extra-long pulse, XLP). Objective and subjective assessments were obtained at baseline and 1, 2, and 4 months after treatment. RESULTS: In the SP group, skin smoothness improved significantly (p<.01); in the XLP group, skin smoothness (p<.05) and scar volume (p<.05) improved significantly from baseline. Adverse effects consisted of transient postinflammatory hyperpigmentation (18%) and acneiform eruption (9%). CONCLUSIONS: Low-fluence VSP Er:YAG laser resurfacing is a promising treatment option for acne scars, with minimal risk of side effects. Laser pulse width and energy determine the efficacy and the risk of side effects. The authors have indicated no significant interests with commercial supporters.

Treatment of melasma using variable square pulse Er:YAG laser resurfacing.

BACKGROUND: Treatment of melasma remains a challenge. Laser treatments show limited efficacy, with a high rate of recurrence and side effects. Recently, variable-pulsed erbium:yttrium aluminum garnet (Er:YAG) lasers have shown favorable results in skin resurfacing, with minimal downtime and adverse effects. OBJECTIVE: To determine the efficacy and side effects of variable square pulsed (VSP) Er:YAG laser resurfacing for treatment of epidermal type melasma. METHODS: Twenty Thai women with epidermal-type melasma were treated with two passes of VSP Er:YAG laser resurfacing using a 7-mm spot size, pulse duration of 300 micros, and a fluence of 0.4 J/cm(2). Two treatments were given 1 month apart. Visual analog scale (VAS), Melasma Area and Severity Index (MASI) score and melanin index (MI) were measured at baseline and 1, 2, and 4 months after treatment. RESULTS: There was a significant improvement in VAS from baseline at 1-, 2-, and 4-month follow-up visits (p<.001). Significant improvement in MASI score at the 2-month visit from baseline (p=.004) was also observed. The average MI measured using melanin reflectance spectrometry measurements corresponded to MASI score rating. CONCLUSIONS: VSP Er:YAG laser resurfacing effectively but temporarily improved epidermal-type melasma. Recurrence was observed after the treatment was discontinued.

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 $0.10 per operation. In contrast, commercially available surgical markers range in cost from $0.79 to $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.

Surgical pearl: a simple means of disarming the "locked and loaded" needle.

BACKGROUND: Surgery, in any setting, has several inherent risks not only to the patient, but the physician and his assistants as well. Safe handling and management of the sharps to prevent inoculation injuries is one of these risks, in particular: 1) instrument hand-off of the needle and needle driver between the physician and his assistants; 2) retrieval of instruments from the surgical tray. OBJECTIVE: The authors' review a simple means of disarming the needle loaded in the needle driver to reduce sharps injury. METHODS: Before the needle and needle driver are either handed off to the assistant or returned to the surgical tray, pivot the needle 90 degrees toward the instrument joint. The needle's point should be directed toward and touching the needle driver, and thereby, disarming the needle. To avoid dulling the needle, the point should not be grasped by the needle driver. CONCLUSIONS: Disarming the loaded needle may reduce the chance of sharps injury during instrument hand off and retrieving instruments from the surgical tray.

The use of acellular, fetal bovine dermal matrix for acute, full-thickness wounds.

BACKGROUND: Skin substitutes may be used as part of the management of acute surgical wounds. The ideal skin substitute should be biocompatible, inexpensive, free of potential pathogens, easy to store, prepare, and utilize. OBJECTIVE: To discuss the authors' direct clinical experience with an acellular, fetal bovine dermal matrix for the treatment of Mohs micrographic surgery (MMS) wound management. METHODS: After the cutaneous malignancies were cleared by MMS, a sheet of the product was prepared according to the manufacturer's instructions, trimmed to fit the defect, and then secured to the wound to enhance contact with the wound bed. RESULTS: Between June 2006 and July 2007, the product was used on a total of 10 wounds in 7 patients. Comorbidities included organ transplantation, Sezary syndrome with hepatitis C, and graft-versus-host disease. Seventy percent of the lesions were located on the lower extremities. The average defect area was 13.4 cm2 (range: 4.0-32.0 cm2). The dermal substitute was fully incorporated in 80% of defects and those that did not fully incorporate had exposed bone and tendon without the periosteum and peritendon, respectively. CONCLUSION: Skin substitutes may provide temporary coverage of acute, full-thickness surgical wounds allowed to heal by second intent. They may facilitate wound management with acceptable aesthetic outcomes. Alternate reconstructive options, however, such as cutaneous flaps, should be considered when there is exposed bone and/or tendon without their periosteum and/or peritendon.