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Skin markings fixed with iodine: The surgical marking Gram stain
Skin markings fixed with iodine: The surgical marking Gram stain Julia Pettersen Neckman, MD, and Suguru Imaeda, MD New Haven, Connecticut Key words: chlorhexidine; gentian violet; iodine; povidone-iodide; skin Gram stain; skin marking; skin preparation; sterilization; surgery; surgery preparation.
SURGICAL CHALLENGE Maintaining clear skin markings after preparation before a skin procedure was the challenge.
SOLUTION Skin marking fixation with iodine is the solution. Before surgical procedures, the skin is marked with a skin marker to draw out planned excisions, identify skin tension lines, note anatomic landmarks, and delineate accurate margins. The skin (save the periorbital and ear regions) is then commonly sterilized with chlorhexidinealcohol. This often results in fading of marked areas. We report a technique that prevents markings from significant fading and smearing during sterilization. The traditional skin marking ink is gentian violet, also known as crystal violet or basic violet, and it is found in most marking pens today. After mapping out surgical plans with a common skin marker, one can more durably stain the skin with the drawn markings by applying a layer of iodine solution (povidone-iodine) over the marked site. This process uses the same principle of the bacterial Gram stain.1 The primary stain (gentian violet) is applied to the skin and soaks into the basket-woven stratum corneum. Next, a layer of sterilizing iodine solution is applied and should remain on the skin for at least 30 seconds to allow the iodide to complex with the gentian violet. This new bulky complex is now trapped in the stratum corneum and not easily washed away by alcohol/chlorhexidine solutions. The site can then be further prepared with chlorhexidine solutions without decolorization of the markings (Fig 1). To conclude, this simple technique allows for enduring markings of surgical sites that withstand thorough sterilization.
Fig 1. Left circle: greatly faded after 1 application of chlorhexidine solution alone. Center circle: before any sterilization solution. Right circle: after one 30-second application of povidone-iodide solution followed by 1 application of chlorhexidine solution. Note the center circle has begun to run from neighboring chlorhexidine solution. Inset, all 3 markings before chlorhexidine. REFERENCE 1. Gram HC. Ueber ide isolirte F€arbung der Schizomyceten in Schnittund Trockenpr€aparaten. Fortschritte der Medicin. 1884;2(6):185-189.
From the Department of Dermatology, Yale University School of Medicine. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Suguru Imaeda, MD, Department of Dermatology, Yale University School of Medicine, 333 Cedar St, LCI 501, PO Box
208059, New Haven, CT 06520-8059. E-mail: suguru.imaeda@ yale.edu. J Am Acad Dermatol 2015;72:e165. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.01.053
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SURGICAL CHALLENGE Maintaining clear skin markings after preparation before a skin procedure was the challenge.
SOLUTION Skin marking fixation with iodine is the solution. Before surgical procedures, the skin is marked with a skin marker to draw out planned excisions, identify skin tension lines, note anatomic landmarks, and delineate accurate margins. The skin (save the periorbital and ear regions) is then commonly sterilized with chlorhexidinealcohol. This often results in fading of marked areas. We report a technique that prevents markings from significant fading and smearing during sterilization. The traditional skin marking ink is gentian violet, also known as crystal violet or basic violet, and it is found in most marking pens today. After mapping out surgical plans with a common skin marker, one can more durably stain the skin with the drawn markings by applying a layer of iodine solution (povidone-iodine) over the marked site. This process uses the same principle of the bacterial Gram stain.1 The primary stain (gentian violet) is applied to the skin and soaks into the basket-woven stratum corneum. Next, a layer of sterilizing iodine solution is applied and should remain on the skin for at least 30 seconds to allow the iodide to complex with the gentian violet. This new bulky complex is now trapped in the stratum corneum and not easily washed away by alcohol/chlorhexidine solutions. The site can then be further prepared with chlorhexidine solutions without decolorization of the markings (Fig 1). To conclude, this simple technique allows for enduring markings of surgical sites that withstand thorough sterilization.
Fig 1. Left circle: greatly faded after 1 application of chlorhexidine solution alone. Center circle: before any sterilization solution. Right circle: after one 30-second application of povidone-iodide solution followed by 1 application of chlorhexidine solution. Note the center circle has begun to run from neighboring chlorhexidine solution. Inset, all 3 markings before chlorhexidine. REFERENCE 1. Gram HC. Ueber ide isolirte F€arbung der Schizomyceten in Schnittund Trockenpr€aparaten. Fortschritte der Medicin. 1884;2(6):185-189.
From the Department of Dermatology, Yale University School of Medicine. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Suguru Imaeda, MD, Department of Dermatology, Yale University School of Medicine, 333 Cedar St, LCI 501, PO Box
208059, New Haven, CT 06520-8059. E-mail: suguru.imaeda@ yale.edu. J Am Acad Dermatol 2015;72:e165. 0190-9622/$36.00 Ó 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.01.053
e165