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Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma
Journal of the American Academy of Dermatology Volume 39, Number 3
unwise as to do this, the buffering capacity of the tissues would rapidly neutralize the sodium bicarbonate to become the equivalent of sodium chloride. When sodium bicarbonate is used to neutralize the acidity of lidocaine hydrochloride, it becomes sodium chloride, hardly a toxic molecule. The question is not whether commercial, acidic, lidocaine, or epinephrine solutions inhibit bacterial and fungal growth, but whether the lidocaine molecule and the epinephrine molecule interfere with bacterial and fungal replication. That is the relevant question, and unfortunately this study does not address it. The authors do not mention whether commercial multidose lidocaine with a preservative was used, or whether the epinephrine was free of preservatives. The preservatives inhibit bacterial and fungal growth; that is why they are added to multidose vials. When removing tissue for culture, the prudent physician will use a preservative-free anesthetic. In summary, by overlooking the role of pH, the study provides misleading data as to the in vivo antimicrobial properties of injected lidocaine, bicarbonate, and epinephrine. Their warning against using bicarbonate-neutralized lidocaine is wrong. Ernst Epstein, MD 100 S Ellsworth Ave, Suite 707 San Mateo, CA 94401
Correspondence
519
provide virtually 100% peripheral margins for vertical sectioning. They used the technique for lentigo maligna melanoma and the results seem encouraging. We also used a similar technique for basal cell carcinoma using both a 2-bladed scalpel (Taylor variablewidth knife) and a double-punch specifically developed for this purpose in 1979. 1* The reason for development was a similar wish to have a permanent section of the entire lateral surgical margins. Johnson et al stage their procedure awaiting histologic results. This is certainly a helpful modification for many lesions. We also agree that the procedure was "quick, simple to perform, easy on the patient, and easy for the histotechnician to orient tissue for standard vertical sections." Bryan C. Schultz, MIJa (Correspondent) Henry H. Roenigk, Jr, MDb Affiliates in Diseases and Surgery of the Skin, S.c. 1050 W Chicago Ave Oak Park, IL 60302a Department of Dermatology Northwestern University School of Medicine Chicago, Illinois b REFERENCE 1. Schultz BC, Roenigk HH Jr. The double scalpel and double punch excision of skin tumors. J Am Acad Dermatol 1982;7 :495-9.
Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma To the Editor: We read with interest the article by Johnson et al entitled "Usefulness of the Staged Excision for Lentigo Maligna and Lentigo Maligna Melanoma: The 'Square' Procedure" (J Am Acad Dermatol 1997;37:758-63), using a 2-bladed scalpel to
*The Taylor knife and Schultz double-punch are available from Padgett Instruments, 2838 Warwick Trafficway, Kansas City, MO 64108. The punches were custom-made for different sizes, and the company indicates this is still possible (authors have no financial interest in these).
unwise as to do this, the buffering capacity of the tissues would rapidly neutralize the sodium bicarbonate to become the equivalent of sodium chloride. When sodium bicarbonate is used to neutralize the acidity of lidocaine hydrochloride, it becomes sodium chloride, hardly a toxic molecule. The question is not whether commercial, acidic, lidocaine, or epinephrine solutions inhibit bacterial and fungal growth, but whether the lidocaine molecule and the epinephrine molecule interfere with bacterial and fungal replication. That is the relevant question, and unfortunately this study does not address it. The authors do not mention whether commercial multidose lidocaine with a preservative was used, or whether the epinephrine was free of preservatives. The preservatives inhibit bacterial and fungal growth; that is why they are added to multidose vials. When removing tissue for culture, the prudent physician will use a preservative-free anesthetic. In summary, by overlooking the role of pH, the study provides misleading data as to the in vivo antimicrobial properties of injected lidocaine, bicarbonate, and epinephrine. Their warning against using bicarbonate-neutralized lidocaine is wrong. Ernst Epstein, MD 100 S Ellsworth Ave, Suite 707 San Mateo, CA 94401
Correspondence
519
provide virtually 100% peripheral margins for vertical sectioning. They used the technique for lentigo maligna melanoma and the results seem encouraging. We also used a similar technique for basal cell carcinoma using both a 2-bladed scalpel (Taylor variablewidth knife) and a double-punch specifically developed for this purpose in 1979. 1* The reason for development was a similar wish to have a permanent section of the entire lateral surgical margins. Johnson et al stage their procedure awaiting histologic results. This is certainly a helpful modification for many lesions. We also agree that the procedure was "quick, simple to perform, easy on the patient, and easy for the histotechnician to orient tissue for standard vertical sections." Bryan C. Schultz, MIJa (Correspondent) Henry H. Roenigk, Jr, MDb Affiliates in Diseases and Surgery of the Skin, S.c. 1050 W Chicago Ave Oak Park, IL 60302a Department of Dermatology Northwestern University School of Medicine Chicago, Illinois b REFERENCE 1. Schultz BC, Roenigk HH Jr. The double scalpel and double punch excision of skin tumors. J Am Acad Dermatol 1982;7 :495-9.
Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma To the Editor: We read with interest the article by Johnson et al entitled "Usefulness of the Staged Excision for Lentigo Maligna and Lentigo Maligna Melanoma: The 'Square' Procedure" (J Am Acad Dermatol 1997;37:758-63), using a 2-bladed scalpel to
*The Taylor knife and Schultz double-punch are available from Padgett Instruments, 2838 Warwick Trafficway, Kansas City, MO 64108. The punches were custom-made for different sizes, and the company indicates this is still possible (authors have no financial interest in these).