3 s2.0 B978070203049900004X

4
Chapter
Surgical instruments
Ashish C. Bhatia and Aashish Taneja
Surgical instruments are the most basic and Biopsy instruments

fundamental tools of the dermatologic surgeon.
Fortunately, the variety and quality of surgical Key Points
instruments available to the dermatological sur- • Biopsy instruments are those used to obtain
geon have improved tremendously over the past samples of cutaneous and/or subcutaneous
few decades. The saying “Select the right tool tissue.
for the right job” truly has relevance in this field. • Both disposable and reusable biopsy
Each instrument has its own niche and pur- instruments are available, each having their own
pose, depending on the type of procedure that distinct advantages and disadvantages.
will be performed. All surgical instruments are
available in different quality grades. In general,
selecting higher quality grade instruments will Samples of integument can be obtained via punch,
translate to longer lasting, better performing shave, or excisional biopsy. While excisional biop-
instruments. It is important that the surgeon’s sies are usually obtained using a scalpel, punch
instruments be of the highest quality possible. biopsies and shave biopsies can be performed
Using inadequate instruments or equipment of with specialized tools.
poor quality can lead to frequent replacement, Punch biopsy instruments are available in vari-
poor performance, and, in many cases, unneces- ous sizes including 1, 1.5, 2, 3, 4, 5, 6, and 8 mm.
sary tissue damage. The instruments usually consist of a cylindrical
Knowledge of the core instruments used in handle and a blade, which is generally circular
dermatologic surgery and understanding the with a hollow core. There are also elliptically
capabilities and limitations of each will not only shaped punch biopsy instruments designed to
enhance the life of the instrument and improve excise lesions in an “easy to close” manner. As the
performance of the instrument, but also expedite defect left by such a punch biopsy is elliptical
the procedure and maximize the outcome for the in shape, some minor undermining and layered
patient. In general, instruments utilized for der- sutures can provide a quick linear closure.
matologic surgery are small, fine, and lightweight, A shave biopsy can be executed with a No. 15
thus allowing for proper atraumatic handling blade, Gillette® blade, or Dermablade®. The dif-
of delicate tissue and minimal operator fatigue. ference between a Gillette® and Dermablade® is
Modern instruments may be made from various that the Dermablade® is sterile, more convenient,
metals or a combination of metals, such as sur- and more expensive than the Gillette® blade.
gical stainless steel with carbon alloy, chromium However, Gillette® blades can be sterilized prior
nickel, and tungsten carbide. Tungsten carbide to use. The Dermablade® also comes with a pro-
is a very hard alloy that enhances function and tective plastic support that offers better grip and
durability of blades of scissors and jaws of needle more safety to the surgeon.
holders, and is usually incorporated as inserts on Biopsy instruments can be disposable or re
otherwise steel-based instruments. usable. Disposable instruments (Fig. 4-1) offer the
The following instruments are reviewed in convenience of one time use, avoiding the hassle
this chapter: biopsy instruments, scalpels, cu- of instrument cleaning, packaging, and steriliza-
rettes, scissors, forceps, needle holders, chalazion tion. Another advantage of disposable instruments
clamps, skin hooks, hemostats, periosteal eleva- is that each instrument is always sharp. Reusable
tors, and bone chisels. These form the set of core instruments (Fig. 4-2) need to be monitored for
instruments most often used in dermatologic dulling and wear, and sharpened or disposed of
surgery. when they become dull or damaged. The primary
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60 Dermatologic Surgery
Figure 4-1 Disposable punch biopsies in various sizes
Figure 4-3 Blades can be stainless steel or carbon steel
Figure 4-2 Reusable punch biopsy instruments
advantage of reusable instruments lies in their

economy. These instruments can be cleaned and
reused many times before dulling. They can also
be packaged conveniently into bundles of instru-
Figure 4-4 Blades coated with Teflon™ to reduce
ments containing all of the necessary instruments
dragging
for a certain procedure. These bundles can be
marked as to their content and sterilized in one
package. are not as sharp but maintain their sharpness for
longer. Blades are also available with Teflon™
coatings to minimize any dragging of the blade
Scalpel against the tissue (Fig. 4-4). This allows them to
slide smoothly through the tissues being cut. In
Key Points dermatology, the most utilized blades are Nos 15,
• Scalpels consist of a handle and a blade, and 10, and 11. The No. 15 blade is the most common
both are available in a variety of sizes and shapes and popular blade used for excisional surgery
to accommodate both surgeon preference and (Fig. 4-5). Its gentle curve makes it appropriate
application. for most procedures. The sharpest portion is the
• There are various methods for holding and using tip. The greatest contact point lies where the flat
a scalpel based upon the type of scalpel, handle, side meets the curved point of the blade; there-
and application. fore the handle should be approximately 30° off
of the skin when cutting. A variant of the No. 15
is the No. 15c blade, which essentially is a smaller
A scalpel can be used for incising, puncturing, and version utilized in areas of thin, delicate skin. The
sectioning tissue as well as for scraping tissue in No. 10 is a larger version of the No. 15 (Fig. 4-6).
certain circumstances. A scalpel generally con- Its wide blade with a sharp convex belly is utilized
sists of a blade and a handle. The type of handle primarily for larger excisional procedures such as
and blade selected depends on the surgeon’s pre on the back. The No. 11 blade has a straight, sharp
ference as well as the surgical application. edge that tapers to a sharp point, and is used
Blades are made of either carbon steel or stain- primarily for incision and drainage of abscesses,
less steel (Fig. 4-3). Proponents of carbon steel milia removal, “through and through” excisions,
prefer their sharper nature, although these blades and cutting sharp angles (Fig. 4-7). It is generally
do dull rapidly with use. Stainless steel blades wielded and utilized in a stabbing fashion.
4
Chapter
Surgical instruments 61
Figure 4-5 No. 15 blade Figure 4-6 No. 10 blade Figure 4-7 No. 11 blade
Figure 4-8 The Beaver blades and handle

Figure 4-10 Various handles–from top to bottom: Siegel,
No. 7 and No. 3
Figure 4-9 The Beaver handle
Beaver blades, or the miniblade system, are

much smaller than standard blades (Fig. 4-8).
They are utilized for fine cutting, especially in
tight areas such as the medial canthus, in cavities,
and near the ear and the ear canal. Many shapes
are available. The two most commonly used in
dermatology are Nos 64 and 67. The No. 64 has
a rounded tip with a sharp cutting edge. The No.
67 is similar to the No. 15c in that it is curved
convexly with a sharp tip. These blades fit into
a beaver handle – a small pencil-like instrument
useful for working in concavities (Fig. 4-9). There
are also varieties of beaver blades that are bent
laterally at the midsection of the blade to allow
for easy maneuverability and use on the walls of a
cavity such as the ear canal. Figure 4-11 Disposable curettes in different sizes
The handle of a scalpel can be flat or round
and long or thin in shape (Fig. 4-10). The stand-
• Both disposable and reusable curettes are
ard system scalpel handles consist of the No. 3 available, and each has its advantages and
and the No. 7. The No. 3 is the most frequently disadvantages.
used handle in dermatologic surgery. It is available • The curette is held like a pencil and drawn
with an optional imprinted ruler. It can accom- towards the operator with the sharp side of the
modate a variety of scalpel blades including Nos. instrument touching the patient’s skin.
10, 11, and 15. The No. 7 is most commonly used
in plastic surgery. The Beaver handle is round or One of the first instruments used by a derma-
hexagonal. It holds much smaller, sharper blades tologist, the curette is utilized to treat benign or
such as Nos 64 and 67. These blades insert into low-grade malignant tumors and also to debulk
a collet, which tightens by rotating the collet tumors prior to Mohs micrographic surgery. It can
around the handle. also allow the surgeon to define tumor margins
better prior to excision. Curettes are available as
Curettes disposable or reusable instruments (Figs 4-11 &
4-12). The curette consists of a handle and a
Key Points head. The handle can be large or small, light or
• Curettes are a versatile therapeutic and heavy. The heads can be round or oval (Fig. 4-13),
diagnostic tool for the dermatologist. and are available in a variety of sizes, where the
Figure 4-12 Reusable curettes shown in different sizes

Figure 4-14 Tissue scissors–from top to bottom: iris, baby
Metzenbaum and strabismus
Figure 4-13 Reusable oval curettes
size refers to the width of the opening. The width Figure 4-15 Scissors consist of tips, blades and handles
ranges from 1 to 10 mm. In general, smaller sizes
are utilized for finer procedures. Scissors are a common instrument in the derma-
Some dermatologists prefer the reusable tologist’s office. They come in a variety of shapes
curettes because of their physical weight and and sizes suited to different tasks (Fig. 4-14).
“dullness.” This combination allows the physician Common types of scissors include Gradle scissors,
to get a better feel of the difference in consistency tissue scissors, undermining scissors, suture-
between various tissue types, such as tumor, der- cutting scissors, and bandage-cutting scissors.
mis, and subcutaneous tissues. These practitioners Dozens of specialty varieties of scissors are also
find disposable curettes too sharp and light, essen- available for special purposes.
tially cutting through any tissue almost equally The basic anatomy of scissors consists of three
well, and providing minimal sensory feedback parts: the handle, the blade and the tip (Fig. 4-15).
regarding the tissue being curettaged. The handle may be short or long. Generally, short
To obtain optimal sensory feedback from a handles provide better control but less leverage,
curette, it should be held like a pencil with the and are utilized for fine work such as delicate sur-
sharp side of the tip angled downward. The scrap- geries on thinner tissues of the face. Long han-
ing motion is towards the operator, and can be dles not only provide greater leverage, but are
performed in a linear or curvilinear method. also optimal for surgeries requiring a long reach.
A longer reach may be necessary when operating
Scissors in cavities or undermining deeply under tissues.
Scissor handles are available in straight, curved,
Key Points or bent contours for increased visibility and
• A variety of scissors are available for the many hand/wrist comfort for the surgeon. The blades
tasks involving cutting in a dermatology practice. of scissors can also be straight or curved, for the
• There are a host of specialty scissors available same reasons (Fig. 4-16). Straight blades allow for
for very specific tasks in a dermatology office. straight cuts such as for gross trimming of flaps
• Common uses for scissors in dermatology and grafts, and are commonly used for cutting
include cutting or trimming tissue or grafts and
sutures. Curved blades are often utilized for dis-
flaps, trimming bandages, cutting sutures, and
undermining tissues prior to closure. section, allowing easy movement around tumors
or cysts. They increase the surgeon’s visibility and
4
Chapter
Figure 4-16 Scissors with a straight blade (top) Figure 4-18 Scissors reinforced with tungsten carbide
and a curved blade (bottom) (note the gold handle)
Figure 4-17 Scissors with serrated blade
allow a contoured cutting or dissecting path to be

followed easily.
The blades of scissors may be smooth or ser-
rated (Fig. 4-17). The serration on the blades of Figure 4-19 Scissors with blunt tips (left) and pointed tips
with ribbon handle (right)
surgical scissors are often very fine and difficult to
visualize; however, the “teeth” can easily be felt
when touching the blade. The advantage of the
serrated blade is that it helps to prevent slippage
of tissue out of the blades during cutting. The
serrated blade is particularly useful in areas with
thin skin and little subcutaneous fat, or when
trimming delicate flaps or grafts.
There are many different choices for the metal
used for the blades of scissors. Generally, they are
made with stainless steel. This can be reinforced
with tungsten carbide (TC) inserts to strengthen
the blade and prevent dulling. Scissors with
TC inserts are identified by their gold handles
(Fig. 4-18).
There are several options for scissor tips as well.
A scissor tip can be pointed, blunt, or occasion- Figure 4-20 Gradle scissors
ally hooked on one of the two blades (Fig. 4-19).
Pointed tips are optimal for more aggressive
dissection, whereas blunt tips are used for more
atraumatic dissection such as when undermining delicate features and their sharpness and preci-
and freeing up of flaps. The single hooked tip can sion make them ideal for harvesting thin stages
be used to assist with suture removal. during Mohs micrographic surgery, or for cutting
and undermining delicate tissues.
Specialty scissors Iris scissors are the most commonly used in-
strument for dissecting and undermining on the
Gradle scissors have a high handle to blade ratio head and neck (Fig. 4-21). They generally have
and a small, delicate, sharp tip that is tapered to heavier handles and blades than Gradle scissors.
a fine point with a gentle curve (Fig. 4-20). Their The handle can be straight or curved, the blade
Figure 4-21 Iris scissors Figure 4-22 Westcott and Castroviejo Figure 4-23 O’ Brien suture-cutting
scissors scissors
Figure 4-24 Mayo scissors Figure 4-25 Metzenbaum scissors Figure 4-26 Standard operating
scissors
can be smooth or serrated, and the tip can be tissues that are more difficult to cut or dissect.
sharp or blunt. They are commonly used for larger excisions
Westcott and Castroviejo scissors are one of the and undermining in areas such as the trunk and
most delicate and complicated scissors used in scalp.
dermatologic surgery (Fig. 4-22). Unlike other Like the Metzenbaum scissors, the Lagrange
scissors, they are held like forceps and gently scissors also have a high handle to blade ratio. Its
squeezed to cut (Fig. 4-23). They are also unique strongly curved tip with a reverse curve on the
because of their spring action, which is used to handle shank makes this instrument useful to
open the blades as pressure is released on the harvest hair transplant donor grafts. It can also be
handles. They generally have very fine, pointed useful for freeing punch biopsy specimens with a
tips and are good for delicate dissections such as deep base.
in periorbital surgery. Tissue scissors, such as most of the scissors
Mayo scissors are generally heavier scissors with mentioned above, should generally be reserved
nearly a one to one handle to blade ratio (Fig. 4-24). for cutting tissue. Surgical kits should contain
They are useful as general-use scissors. They are dedicated suture scissors for trimming and cut-
not usually used for fine or delicate work, but ting sutures. Using the same scissors to cut tissue
rather for coarse dissection. and sutures may result in premature dulling of
Metzenbaum scissors are heavier, with a high the tissue scissors. These scissors generally have
handle to blade ratio for maximal leverage and large, heavy-duty blades. Examples of good suture
length (Fig. 4-25). These long-handled scissors scissors include standard operating scissors (Fig.
are available in varying lengths. The blade can 4-26) and Northbent scissors, which are specifi-
be straight or curved, and the tip can be sharp cally designed with a half-moon hook on the low-
or blunt. These qualities make this instrument er blade to remove sutures (Fig. 4-27). O’Brien
ideal in areas that require long reach and for scissors have a short-angled blade that allows the
4
Chapter
Figure 4-29 Variety of forceps
Figure 4-27 Northbent scissors

etween the thumb and index finger, and pressed
b
to bring the tips together.
Their anatomy consists of the handles, the tips,
and occasionally a platform which precedes the
tips. The handles can be long or short, heavy or
delicate, and occasionally textured or drilled for
added grip (Fig. 4-29).
The tips of these instruments can be delicate
(0.6 mm or less), regular (0.7–1.5 mm) or heavy
(greater than 1.6 mm) based upon the intended
use. Tips can be straight or curved (Fig. 4-30)
and can vary from smooth, serrated to toothed.
Smooth tips (Fig. 4-31) are good for removing su-
tures and splinters, and for grasping small bleeding
vessels. Serrated tips (Fig. 4-32) are generally used
Figure 4-28 Bandage scissors
for grasping tissues more firmly. Misuse of serrated
tips in delicate areas can lead to crush injury of
the tissue. Tips with teeth (Fig. 4-33) are used
to obtain a firm grasp of compliant tissue. These
surgeon to cut the suture with the tip of the blade also should not be used too aggressively because
see (Fig. 4-23). they can leave marks on external tissues. Teeth
Bandage-cutting scissors tend to be large and on a forceps vary in size and number. They can
have blunt tips (Fig. 4-28). The blunt tips help be small, medium, or large. The most commonly
protect the patient’s skin during removal of band- used toothed forceps has 1 × 2 teeth, meaning
ages. One blade generally slides under a dressing one tooth on one tip and two teeth on the other
without injuring the underlying integument. tip. Forceps with more teeth, such as 2 × 3 teeth
These scissors are also used to trim bandages to and multiple-tooth patterns, are also available
size prior to application. (Fig. 4-34). Furthermore, multiple-tooth patterns
may be arranged vertically or horizontally. Some
Forceps forceps come with a raised platform proximal to
the tooth to allow the surgeon to grasp the suture
Key Points needle firmly and to help remove it from tissues
• Forceps are versatile instruments in the (Fig. 4-35).
dermatology practice. Adson forceps are the most common and versa-
• They are used to hold or grasp items such as tile tissue forceps used in dermatology (Fig. 4-36).
tissue, sutures, or any other item handled in the They are generally large forceps (4–5 inches in
surgical field. length) used for grasping tissue during excisional
• Like scissors, several types of forceps are usually surgery on the trunk and extremities. They have a
ordered for various procedures to be performed
relatively broad handle that tapers to a narrow tip.
in the office.
The tip can be smooth, serrated, or toothed, and
is available with a suture-tying platform if desired
Forceps are commonly used instruments in der- (see Fig. 4-35). The tying platform may be made
matology. They are used to hold or grasp items of stainless steel or of a TC insert. One variation
such as tissue, sutures, or any other item han- of the Adson forceps is the Brown–Adson forceps,
dled in the surgical field. They are generally held which has a row of eight or nine minute teeth
Figure 4-30 Straight- and curved-tip Figure 4-31 Pointed smooth forceps Figure 4-32 Forceps with serrated tip
Semken forceps
Figure 4-33 Forcep with 1 × 2 teeth Figure 4-34 Brown–Adson forceps Figure 4-35 Forceps with needle
with multiple 8 × 9 teeth platform
Figure 4-37 Bishop–Harmon forceps without (left)

and with (right) teeth
Figure 4-38 Jeweler’s forceps
are much smaller than the Adson forceps, with

Figure 4-36 Adson single-toothed and dressing forceps a total length of approximately 3½ inches with
the handles tapering to a fine tip that extends
for about 20% of the total length. They are de-
along the length of the tips for firmly grasping signed with three holes drilled into each side of
tissue (see Fig. 4-34). Both Adson and Brown– the handle. These holes contribute to their light
Adson forceps can be ordered with fenestrated weight and sure grip. The tips on these forceps are
handles for increased grip. available with or without teeth.
Bishop–Harmon forceps are generally the in Jeweler’s (splinter) and epilating forceps
strument of choice for grasping more delicate are small and delicate forceps that taper to a
tissues, such as those of the face (Fig. 4-37). They sharp pointed tip (Fig. 4-38). The tips of these
4
Chapter
instruments are available in fine, extra fine, or being removed, such as the wall of a cyst, or the
super fine varieties. These instruments are ideal nail plate during an avulsion. They can also be
for grasping very small vessels, retrieving su- utilized as towel clamps for securing towels or to
ture fragments, or removing splinters. Jeweler’s secure the electrosurgical handle within the sur-
forceps with angled or curved tips are often gical field or on the surgical tray.
utilized in hair transplantation when placing the The tremendous variety and subtypes of forceps
delicate micrografts in the small recipient sites available make it a difficult choice when purchas-
on the scalp. ing forceps. It is best to purchase a few sets with
Iris forceps come in several varieties for various the type of forceps that one knows to be best
uses. They have a narrower handle like that of the suited for the appropriate task. Once the basic kits
Bishop–Harmon forceps, but of varying lengths have been assembled, different varieties and sizes
(Fig. 4-39). They have a high tip to handle ratio, of forceps can be tried to see whether they are well
allowing less gripping force, which minimizes suited for the task and for the surgeon’s hands. Not
trauma to the tissues being handled. They of- all forceps work best for every surgeon, so finding
ten have a guiding pin, which extends from one the right fit for the surgeon and task is essential to
handle and is received by a hole in the opposing help perform procedures efficiently and safely.
handle. This helps prevent misalignment of the
tips when applying grasping force. The tips can be
smooth, serrated, or toothed. Iris forceps tend to Needle holders (needle
be utilized for more delicate tissues, with longer drivers)
Iris forceps used for working in deeper cavities.
Other varieties of forceps are the DeJardin Key Points
forceps (Fig. 4-40) and the Graefe and Harmon • Needle holders come in a variety of shapes,
Fixation forceps. These all have wide, horizontally sizes, and compositions.
oriented, tips with eight or more horizontal teeth. • Choosing needle holders for a practice is based
They are used in dermatologic surgery to prima- upon the type of procedures being done in the
rily handle cartilage. practice.
• Generally, two or more sizes of needle holders
Another style of forceps with a horizontally
are required in most dermatology practices to
oriented tip is the Allis forceps or clamp (Fig. accommodate various suture needle types.
4-41). Unlike many other forceps, these have
ringed finger loops in the handle as well as a
mechanism to click the jaws closed with various Although needle holders or drivers (Fig. 4-42) are
jaw pressure, much like towel clamps and needle available in a variety of sizes and configurations,
drivers. These are generally used to grasp tissues one basic premise holds true: small needle holders
Figure 4-39 Iris forceps Figure 4-40 DeJardin forceps Figure 4-41 Allis forceps or clamp
Figure 4-42 Large (top) and small Figure 4-43 Smooth surfaced needle Figure 4-44 Serrated-surface needle
(bottom) needle holder holder holder
Figure 4-45 Crile–Wood needle holder Figure 4-46 Baumgartner needle Figure 4-47 Webster (Halsey) needle
holder holders
should be used for small needles and large needle Webster (Halsey) needle holders are shorter dri
holders for large needles.The options available with vers with narrow jaws and tapered tips (Fig. 4-47).
needle holders include their size, the texture of The surface of the jaws can be smooth or serrated.
the jaws, the metal of the jaws, and the shape These drivers are suitable for finer needles.
of the jaws. The jaws of needle holders can be Castroviejo needle holders are delicate instru-
smooth or fine toothed. A smooth surface ments that have a spring lock handle (Fig. 4-48).
minimizes damage to finer needles (Fig. 4-43). They do not have finger loops in the handles. In-
One drawback, however, is that on a smooth sur- stead, they are held like forceps. As the handles
face the small needles may tend to slip. As a re- are partially brought together, with a click, the
sult, small needle holders are available with fine mechanism locks the jaws firmly to clamp the
serrations that will not damage the needle. Nee- needle in the needle holder. To release the needle,
dle holders that have fine serrations prevent the the handles are compressed further until they
twisting of needles during suturing (Fig. 4-44). click. At that point, the spring action separates
TC inserts are also available for increased durabil- the jaws as the surgeon releases the handles. The
ity of the jaws. These inserts increase the strength jaws of these instruments are very fine, making
and hardness of the instruments, and also allow them suitable for extremely delicate procedures
for secure gripping of needles. around the eyes and ears.
Crile–Wood needle holders are large instru- Another type of needle driver used by derma-
ments with blunt tips that are best utilized when tologists is the Olsen–Hegar needle holder (Fig.
working on the trunk or extremities where larger 4-49). These, too, are available in several different
suture materials and needles are needed (Fig. sizes. They differ from other needle holders be-
4-45). Similarly, Baumgartner and Mayo Hegar cause they serve a dual purpose. Just proximal to
needle holders are strong, durable drivers with ser- the jaws, there is a suture-cutting scissor surface,
rated jaws, making them suitable for procedures allowing the surgeon to suture and cut suture
on the trunk or extremities (Fig. 4-46). with the same instrument. Care must be taken
4
Chapter
Figure 4-48 Castroviejo needle holder with (left) and

without (right) lock
Figure 4-51 Variety of skin hooks Courtesy of Acuderm
flat surface upon which the surface may cut, cu-

rette, or otherwise operate on the tissue. The clamp-
ing tension is adjusted by a thumbscrew, which can
be gradually tightened or released. It is important
to release these clamps quickly once the procedure
is completed, to avoid a tourniquet effect. They are
available in a variety of ring diameters.
Figure 4-49 Olsen–Hegar needle holder Skin hooks

Key Points
• Skin hooks are available in single, double, or
multiple-pronged patterns.
• Skin hooks aid in manipulating tissue.
Skin hooks assist the surgeon in manipulating

tissue that needs to be sutured, assessing flap
movements, visualizing the surgical field for
electrocautery, reflecting skin edges during un-
dermining, placing dermal tissue, and correcting
dog ear defects. Skin hooks are available in single,
Figure 4-50 Chalazion clamp double, or multiple-pronged patterns (Fig. 4-51).
The prongs can be blunt or sharp tipped. Single
not to cut the suture material accidentally during pronged hooks are commonly used for flap eleva-
the suturing process. tion and undermining of delicate skin. Skin rakes,
on the other hand, are utilized mainly for rhytid-
Chalazion clamps ectomies and large truncal procedures.
Key Points
• Chalazion clamps are useful when operating on Hemostats
mobile surfaces.
• Chalazion clamps are available in a variety of ring Key Points
diameters. • Hemostats assist the surgeon in hemostasis.
• Hemostats are available in a variety of sizes; the
Chalazion clamps are a specialty instrument and are tips can be curved or straight, and delicate or
regular tipped.
quite useful when operating on mobile surfaces (Fig.
4-50). These clamps consist of a flat arm that is op-
posed by a ring-shaped arm. As these are clamped Hemostats assist the surgeon in hemostasis by
down on a mobile, vascular surface such as a lip, eye- clamping the vessel, which later can be cauterized
lid, or earlobe, the ringed arm provides stabilization or ligated with sutures. Hemostats vary in tip size,
and hemostasis, while the flat arm provides a firm curvature, and degree of serration (Fig. 4-52).
Figure 4-52 Curved, serrated Figure 4-53 Jacobsen hemostat Figure 4-54 Halstead mosquito
hemostat hemostats
Figure 4-55 Periosteal elevator
Jacobsen hemostats are fine-tipped hemostats,

ideal for grabbing small vessels (Fig. 4-53). The tip
can be curved or straight.
Halstead mosquito hemostats are available in Figure 4-56 Bone chisel and hammer
3.5 or 5.0 inches, straight or curved, and delicate
or regular tipped (Fig. 4-54).
Conclusion
Periosteal elevators and bone
The selection of proper surgical instruments can
chisels be a daunting task when setting up a dermatologic
surgery practice. Many surgical instrument com-
Key Point
panies offer “excision packs” and various other
• Periosteal elevators and bone chisels are used instrument packages. Most dermatologists will
to elevate periosteum or perichondrium, scrape develop preferences for certain instruments dur-
hard surfaces, and assist in nail surgery.
ing their residency training, and gravitate towards
purchasing similar instruments. If one chooses
Both periosteal elevators and bone chisels are flat, that route for the initial set of instruments, much
long, solid instruments. Generally, periosteal el- of the information can be gathered by recording
evators have flattened, rounded tips on both ends the make and model numbers of the instruments
(Fig. 4-55). They are used to elevate periosteum used in training.
or perichondrium, or scrape hard surfaces. They Choosing the right instruments for one’s hand
are versatile tools that can also be used to help size and types of procedure to be performed is
elevate and avulse fingernails and toenails. crucial for efficient excisions, repairs and other
Chisels have a sharpened, flattened end on one procedures.
side and a solid, wide end on the other (Fig. 4-56). Many varieties of instruments are available,
The wider end is used to strike the chisel with providing an overwhelming number of choices
a hammer, usually to biopsy bone or perios- in both cost and quality of surgical instruments.
teum where it is suspected to be invaded by a A dermatologic surgeon’s instruments are a very
neoplasm. important investment, thus one should avoid low
4
Chapter
cost or poor quality instruments. Higher quality Further reading

surgical instruments are usually covered by longer
warranties as well. Although much can be learned Bernstein G. Choosing the correct surgical instru-
about the quality of various instruments from ments. Adv Dermatol 1995;10:245–283.
speaking with colleagues and mentors, many Melissa BA, Joseph AK. Instruments and materials.
of the decisions will be personal ones, based upon In: Robinson JK, Hanke WC, Sengelmann R, Siegle D,
the surgeon’s hand size and practice type. Once eds. Surgery of the Skin. London: Elsevier-Mosby,
the proper instruments have been acquired, it is 2005:59–66.
important to keep them in good condition with Neuberg M. Instrumentation in dermatologic surgery.
proper care, including periodic sharpening and Semin Dermatol 1994;13:10–19.
replacement when necessary. It is good to try out Olhoffer IH, Goldman G, Leffell DJ. Wound closure
new varieties of instruments if it may benefit one’s materials and instruments. In: Bolognia JL, Jorizzo
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efficiently for many years. 1998;16:17–24.

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4

Surgical instruments are the most basic and Biopsy instruments

Figure 4-1 Disposable punch biopsies in various sizes

Figure 4-3 Blades can be stainless steel or carbon steel

Figure 4-2 Reusable punch biopsy instruments

advantage of reusable instruments lies in their

Figure 4-8 The Beaver blades and handle

Figure 4-9 The Beaver handle

Beaver blades, or the miniblade system, are

Figure 4-12 Reusable curettes shown in different sizes

Figure 4-13 Reusable oval curettes

Figure 4-17 Scissors with serrated blade

allow a contoured cutting or dissecting path to be

Figure 4-29 Variety of forceps

Figure 4-27 Northbent scissors

Figure 4-37 Bishop–Harmon forceps without (left)

Figure 4-38 Jeweler’s forceps

are much smaller than the Adson forceps, with

Figure 4-48 Castroviejo needle holder with (left) and

Figure 4-51 Variety of skin hooks Courtesy of Acuderm

flat surface upon which the surface may cut, cu-

Figure 4-49 Olsen–Hegar needle holder Skin hooks

Skin hooks assist the surgeon in manipula­ting

Figure 4-55 Periosteal elevator

Jacobsen hemostats are fine-tipped hemostats,

cost or poor quality instruments. Higher ­ quality Further reading

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Skin hooks assist the surgeon in manipulating

cost or poor quality instruments. Higher quality Further reading