Surgical Instruments & Electrosurgery

The #3 handle accommodates blades #10, #11, and #15. The #7 handle (longer, thinner) is used for precision work. The #15 blade is the workhorse of dermatologic surgery. Its curved cutting edge is ideal for elliptical excisions. The #15c (carbon steel) variant has a shorter cutting edge for fine detail work. The #10 blade has a larger curved belly and is preferred for long incisions (scalp excisions, large flaps). The #11 blade is pointed and used for stab incisions (I&D, creating relaxing incisions).

Iris scissors (straight and curved) are fine-tipped for precise cutting of skin and sutures. Metzenbaum scissors are longer with blunt tips, used for undermining and blunt dissection in the subcutaneous plane. Undermining scissors (blunt-blunt, curved) are specifically designed for developing the subdermal plane during flap mobilization. Gradney scissors combine heavy construction with curved tips for cutting through thick tissue.

Adson forceps (toothed) are the standard tissue forceps. The teeth grip tissue without crushing. Bishop-Harmon forceps are finer for delicate work (eyelids, ears). Non-toothed (smooth) forceps are used for grasping sutures and dressings, never for handling skin edges (crush injury causes poor wound healing). Skin hooks (single and double) are preferred over forceps for handling wound edges in cosmetically sensitive areas. They cause less tissue trauma.

Webster needle drivers are the standard in dermatologic surgery. Smooth jaws and fine tip for precise suture placement. Halsey needle drivers have a heavier construction for larger needles and high-tension closures. The needle should be grasped at the junction of the anterior and middle thirds of the needle arc, perpendicular to the driver jaws.

Fox curettes are small (1–4 mm) with a fenestrated loop, ideal for curettage of BCC. Cannon curettes are larger and more strong. Curettes work by exploiting the difference in texture between tumor (soft, friable) and normal dermis (firm, gritty). The “feel” of firm dermis signals complete tumor removal.

The four modes differ in current delivery, tissue contact, and clinical effect:

Patients with pacemakers and implantable cardioverter-defibrillators (ICDs) require precautions during electrosurgery: • Use bipolar electrosurgery when possible (current flows between two prongs, not through the body) • Use short bursts (<5 seconds) with monoterminal devices • Keep the electrode >15 cm from the device when possible • For ICDs: consider having the ICD deactivated by cardiology for the procedure (with external defibrillator on standby) • Newer devices have improved shielding, but precautions remain standard of care

Surgical smoke generated by electrosurgery contains toxic byproducts including benzene, hydrogen cyanide, formaldehyde, and viable viral particles (HPV DNA has been detected in laser and electrosurgery plume). Smoke evacuation should be used for all procedures generating visible plume. N95 masks provide additional protection beyond standard surgical masks.