Surgical Instruments in Dermatologic Surgery
Thorough guide to surgical instruments used in Mohs micrographic surgery and dermatologic surgery. Covers scissors, forceps, scalpel handles and blades, needle drivers, and specialized instruments with their specific indications and proper use.
By Dr. Yehonatan Kaplan (M.D., Fellow ACMS)·Published: 2025-03-01·Updated: 2026-03-07·Reviewed: 2026-03-07
instrumentsscissorsforcepsscalpelneedle driverskin hookelectrosurgerysurgical instruments
Scissors
Scissors are essential for undermining, tissue dissection, graft defatting, and suture cutting. Selecting the correct scissor type for each task improves efficiency and reduces tissue trauma. Scissors are described by their blade geometry (straight or curved), tip configuration (sharp-sharp, sharp-blunt, blunt-blunt), and overall size.
| Scissor Type | Blade/Tip | Primary Use | Key Features |
|---|---|---|---|
| Iris scissors | Fine, sharp tips; straight or curved | Sharp facial dissection, precise undermining | The workhorse dissecting scissors in derm surgery; delicate tips allow precise plane dissection on the face |
| Gradle scissors | Very fine, short blades; curved | Periorbital dissection | Specifically designed for periorbital and eyelid surgery; shorter blades than iris for confined spaces |
| Westcott scissors | Spring-action; very fine tips | Ophthalmic and eyelid surgery | Spring-action (tenotomy-style) allows single-hand operation with fine finger movements; ideal for delicate eyelid work |
| Mayo scissors | Heavy, thick blades; straight or curved | Cutting heavy tissue, fascia, sutures | Coarse cutting scissors (1:1 ratio of cut-to-crush); NOT for delicate facial dissection; useful for fascia, scar tissue |
| Metzenbaum scissors | Long shanks, short blades; curved | Blunt undermining, deep tissue dissection | Long handles relative to blade length allow deep reach with blunt spreading technique; gentler than Mayo |
| Supercut scissors | One micro-serrated blade, one razor-sharp blade | Precision cutting of tissue, flap trimming | Identified by BLACK handle; the micro-serrated blade grips tissue while the razor blade cuts. Prevents tissue slippage during cutting |
| Spencer / O'Brien scissors | Small, angled blades; one hooked tip | Suture removal | The hook tip slides under the suture loop; the angled blade cuts against the hook. Specifically designed for safe, efficient suture removal |
Forceps (Tissue Pickups)
Forceps are used for tissue handling, retraction, and stabilization during suturing. Tissue handling with forceps should be gentle and atraumatic. Excessive crushing causes wound edge necrosis and impairs healing. Toothed forceps are preferred over smooth forceps for skin surgery because the teeth grip tissue with less overall compression.
| Forceps Type | Tip Design | Primary Use | Key Features |
|---|---|---|---|
| Adson forceps | Small teeth (1x2 or 2x3); medium width | General tissue handling on trunk and extremities | The standard tissue forceps in derm surgery; moderate tip width suits most applications on thicker skin |
| Bishop-Harmon forceps | Very fine teeth; narrow tips with fenestrated (perforated) platform | Delicate facial tissue handling | The "HOLEY bishop". Fenestrated platforms reduce tissue crush; ideal for thin facial skin where atraumatic handling is critical |
| Jeweler's forceps (#3, #5, #7) | Very fine pointed tips; no teeth | Suture removal, fine tissue manipulation, microsurgery | Extremely fine pointed tips allow precise grasping of individual sutures; #5 is most commonly used in derm |
| DeBakey forceps | Atraumatic serrated tips (no teeth); long | Vascular surgery, deep tissue handling | Rows of fine longitudinal serrations provide grip without puncturing tissue; used for delicate or vascular tissue |
| Russian forceps | Round, cupped, interlocking tips | Grasping tough tissue (fascia, tendon) | Cup-shaped tips surround and compress tissue rather than puncturing; good for fascia |
Scalpel Handles and Blades
The scalpel is the primary cutting instrument in dermatologic surgery. Understanding handle and blade options allows the surgeon to select the optimal configuration for each task.
Scalpel Handles
Two handle types dominate dermatologic surgery.
| Handle | Shape | Compatible Blades | Key Features |
|---|---|---|---|
| Bard-Parker #3 | Flat, wide profile | #10, #11, #15, #12 | Most common handle in dermatologic surgery; flat shape provides stability during incision; used with the pen grip or palm grip |
| Beaver (round handle) | Round or hexagonal, narrow profile | Beaver-specific miniblades | Round handle allows rotation for precise, delicate incisions; ideal for periorbital, perioral, and intranasal work; commonly used in Mohs histology (scoring) |
Scalpel Blades
Blade selection depends on the tissue being cut and the type of incision required.
| Blade | Shape | Primary Use | Key Features |
|---|---|---|---|
| #10 | Large, curved belly | Incisions on thick skin (back, trunk, scalp) | Largest standard blade; long curved cutting edge for sweeping incisions through thick tissue |
| #11 | Pointed, triangular | Incision & drainage (I&D), stab incisions, sharp angles | Pointed tip allows puncture entry; ideal for I&D of abscesses and cysts; used for creating sharp-angled incision corners |
| #15 | Small, curved belly (smaller #10) | Most common blade in dermatologic surgery | The workhorse blade. Ideal size for facial incisions, excisions, and Mohs layer debulking; precise control for curved incisions |
| #15C | Slightly shorter curve than #15 | Delicate incisions, similar to #15 | Some surgeons prefer its slightly more compact profile for very fine work |
| #12 | Crescent/sickle-shaped | Suture removal in tight spaces (rarely used) | Hooked shape allows cutting in confined spaces; rarely needed with proper suture removal scissors available |
Needle Drivers (Needle Holders)
Needle drivers are locking clamp instruments used to grasp and drive suture needles through tissue. Jaw design is the critical variable that determines needle driver performance.
| Jaw Type | Surface | Best For | Advantage | Disadvantage |
|---|---|---|---|---|
| Smooth jaw | Polished, no serrations | Small needles (5-0, 6-0), delicate suturing | Less damage to fine needles; smoother passage | May slip with larger needles or heavy tissue |
| Serrated jaw | Cross-hatched or diamond serrations | Larger needles (2-0, 3-0, 4-0), thick tissue | Superior grip prevents needle rotation or slippage | Can damage fine needles by bending or flattening |
| Tungsten carbide inserts | Gold-colored, diamond-dusted | General purpose; extended lifespan | Excellent grip with minimal needle damage; durable | More expensive; inserts can wear over time |
Specialized Instruments
Several specialized instruments serve specific roles in dermatologic surgery that cannot be replicated by general instruments.
Skin Hook
The single-prong skin hook is the LEAST traumatic tissue handling instrument available. It engages tissue with a single fine point, providing countertraction without the crushing force of forceps. Skin hooks are used for wound edge retraction during suture placement and tissue manipulation during undermining. They should be used whenever possible in place of forceps to minimize wound edge trauma. The double-prong (rake) version provides broader retraction but with slightly more tissue trauma.
Chalazion Clamp
The chalazion clamp is a specialized clamping instrument originally designed for chalazion excision on the eyelid. In dermatologic surgery, it serves as a hemostatic platform for surgery on the eyelid and lip. The clamp stabilizes the tissue, compresses blood vessels for hemostasis, and protects underlying structures (the globe for eyelid, the oral cavity for lip). The flat plate is placed on the deep surface (conjunctival/mucosal side) and the ring is placed on the superficial (skin) side. The clamp can be tightened to provide a bloodless field for excision or biopsy.
Periosteal Elevator (Freer Elevator)
The periosteal elevator is a flat, blunt instrument used to elevate periosteum from bone and perichondrium from cartilage. In dermatologic surgery, its primary uses are nail plate elevation/avulsion during nail unit surgery, periosteal elevation from bone (scalp, forehead), and perichondrial elevation from auricular or nasal cartilage. The Freer elevator is double-ended. One end is sharp (for incising periosteum) and the other is blunt (for elevating/sweeping periosteum off bone).
Hemostats
Hemostats (mosquito clamps, Kelly clamps) are locking clamp instruments used to grasp bleeding vessels for hemostasis. In dermatologic surgery, they are used to clamp transected arterioles or venules before electrocautery or suture ligation. The mosquito hemostat has fine, delicate jaws ideal for small dermal vessels; the Kelly clamp has larger jaws for bigger vessels. Hemostats can also serve as blunt dissection instruments and as needle holders in emergencies (though this dulls the jaws).
Curettes
The dermal curette is a round or oval loop of sharp-edged steel attached to a handle. It is used to debulk tumor tissue before Mohs layer excision (tumor tissue is softer than normal dermis and preferentially separates with curettage), for electrodesiccation and curettage (ED&C) of superficial skin cancers, and for wound bed preparation. In Mohs surgery, the curette serves a dual role: debulking the clinically apparent tumor mass and providing a tactile assessment of tumor extent. The surgeon can feel the gritty, friable texture of residual tumor versus the firm, smooth feel of normal dermis.
Electrosurgical Instruments
Electrosurgical devices use electrical current to cut tissue or achieve hemostasis. The two primary modes are electrosection (cutting current. Continuous waveform, high temperature, minimal lateral thermal damage) and electrodesiccation/fulguration (coagulation current. Interrupted/damped waveform, lower temperature, wider zone of thermal damage for hemostasis). Electrocautery (true cautery) uses a heated element without electrical current passing through the patient. It is battery-powered and does not require a grounding pad.
Instrument Care and Selection Principles
Proper instrument selection and care optimize surgical outcomes. Each instrument should be used only for its intended purpose. Using scissors for suture cutting dulls the blades for dissection, using hemostats as needle holders damages both the hemostat and the needle. Sharp instruments (scalpel blades, scissors) should be replaced when dulled, as dull instruments require more force and cause greater tissue trauma. Stainless steel instruments should be cleaned, sterilized, and stored properly to maintain function.
Frequently Asked Questions
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References
- [1]Robinson JK, Hanke CW, Siegel DM, Fratila A. Surgery of the Skin: Procedural Dermatology, 3rd Edition. Elsevier. 2019.
- [2]Zitelli JA, Moy RL, Abell E. Mohs Micrographic Surgery: Principles and Practice. Elsevier. 2015.
- [3]Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: Part I. Cutting, handling, and suturing tissue. J Am Acad Dermatol. 2015. doi:10.1016/j.jaad.2015.02.1143
About This Article
Author: Dr. Yehonatan Kaplan, M.D., Fellow ACMS
Last Medical Review:
Audience: Dermatologic Surgeons
Clinic: Kaplan Clinic · DermUnbound Research Program