clearly stated that we do not use tangential shave

at these sites (Study Design page 388). It is true

that attempting this method on fragile distal

extremity skin would be challenging, but curettage

at those sites has the same drawback. I have seen

plenty of providers bury a curette right into the

subcutis.

In the body of their comment, the authors note

that 60% to 80% of basal cell carcinomas are nod-

ular. In our study, we noted that 141 of 184

lesions were superficial only (77%). The technique

we use is most effective for superficial lesions or

superficial lesions with minor nodular components.

Also in the body of their letter, the authors note

that “A great advantage of curettage over scalpel

or laser surgery arises from the ability of a semi-

sharp curette to differentiate and remove friable

abnormal tissue from the normal surrounding

tissue.” Many would question the validity of this

statement. There are multiple studies demonstrat-

ing that a dermatologist with a curette cannot

always differentiate tumor by feel.2–4

We cannot agree that curettage offers “great

advantage.” The evidence simply dose not support

this overly strong statement. Small basal cell

carcinomas can be destroyed using curettage,

excised, or removed by shave. All methods have

their advantages and disadvantages. Comparing

them is probably not even necessary, as to each his

own in treating a smaller tumor in a cost-conscious

fashion. I would never claim that the shave

removal method has “great advantage” because

there can be no “great advantage” when treating a

straightforward lesion.

References

1. Taheri A, Mansoori P, Laffer MS, Feldman SR. Tangential

shave removal of basal cell carcinoma. Dermatol Surg

2013;39:387–392.

2. Salasche SJ. Curettage and electrodesiccation in the treatment of

midfacial basal cell carcinoma. J Am Acad Dermatol

1983;8:496–503.

3. Suhge d’Aubermont PC, Bennett PG. Failure of curettage and

electrodesiccation for removal of basal cell carcinoma. Arch

Dermatol 1984;120:1456–1460.

4. Spencer JM, Tannenbaum A, Sloan L, Amonette RA. Does

inflammation contribute to the eradication of basal cell

carcinoma following curettage and electrodesiccation? Dermatol

Surg 1997;25:183–185.

GLENN GOLDMAN

Department of Dermatology

Fletcher Allen Health Care

University of Vermont College of Medicine

Burlington, Vermont

Making and Using a Mouse Pad Model of Skin to Practice Suturing Techniques

The recent article by Olson and colleagues, “Foam

Dressing as a Suturing Model,”1 describes a unique

and valuable model to enable dermatologic sur-

geons to teach or practice suturing techniques.

Another recent article by Nicholas and colleagues,

“Simulation in Dermatologic Surgery: A New Para-

digm in Training,”2 that emphasizes the impor-

tance of simulation training to enhance procedural

skills supports the need for such a model.

Given the myriad suturing techniques available, it

is important that even seasoned dermatologic sur-

geons practice innovative suturing methods before

using them on patients. Likewise, it is imperative

that medical students, residents, and fellows have

the opportunity to practice suturing techniques to

learn and perfect their skills, but it is difficult to

obtain traditional training tools, such as pigs’ feet,

or models of the skin that come close to simulating

human skin and are convenient to use.

Using readily available and inexpensive materials,

it is easy to construct a durable mouse pad model

for skin that imitates the skin’s elasticity, strength,

LETTERS AND COMMUNICATIONS

39 :12 :DECEMBER 2013 1947

and texture. This mouse pad model can be used

over and over again so that surgeons can practice

and perfect new suturing techniques for optimal

surgical results. For utmost convenience, the mouse

pad model of skin can even be turned over and

used as a traditional mouse pad when not being

used as a training tool.

The materials required to construct a mouse pad

model for skin are two fabric-covered mouse pads

(available at local office supply stores); a scalpel;

hot glue from a hot glue gun; and a cutting board

or similar hard, heat-resistant, scratch-resistant sur-

face. Place one mouse pad fabric side up on the

hard surface. Using the scalpel, make a centrally

located, lengthwise linear incision through the

entire thickness of the pad, being sure to start and

stop the incision no less than one inch from the

edges of the mouse pad. If desired, also make a

widthwise linear incision at each end and perpendi-

cular to the lengthwise incision to form an “H”

pattern that allows for excellent reflection of the

simulated skin and mimics a flap formation. Turn

the second mouse pad fabric side down next to the

first mouse pad. Using the hot glue gun, place hot

glue along the outside edges of the second mouse

pad. Place the first mouse pad fabric side up on

top of the second mouse pad such that the foam

sides of the two mouse pads are in apposition (Fig-

ure 1). Firmly press the edges together.

With the superior (incised) mouse pad representing

the epidermis (fabric) and dermis (foam) and the

inferior mouse pad representing the undermined

subcutaneous fat (Figure 2), the mouse pad model

mimics an undermined incision line in human skin.

When a surgical needle and suture pass through

the makeshift tissue, the mouse pad model mimics

human skin in consistency as well. For best results,

use P-3 or PC needles because the thin foam of a

mouse pad prohibits use of larger needles. The

mouse pad model is intended to be used for prac-

ticing suturing techniques, not tension-

bearing repair techniques such as adjacent tissue

transfers.

Although most dermatologic surgeons close their

surgical defects using simple interrupted or simple

running sutures,3 a wide variety of suturing

techniques can be used in various situations to

achieve outstanding surgical results. Using the

mouse pad model, dermatologic surgeons, fellows,

residents, and medical students are able to practice

closing linear defects using a variety of suturing

techniques (Figure 3), including traditional

subcutaneous and transepidermal sutures, as well

Figure 1. Placement of first (incised) mouse pad oversecond mouse pad.

Figure 2. Demonstration of mouse pad model mimickinghuman skin. On the superior mouse pad, the blue fabricand foam represent the epidermis and dermis, respec-tively. The space between the two mouse pads representsthe undermined space between dermis and subcutaneousfat.

LETTERS AND COMMUNICATIONS

DERMATOLOGIC SURGERY1948

as less common and innovative techniques that,

with practice, may lead to better surgical out-

comes.

References

1. Olson J, Kalina C, Berg D. Foam dressing as a suturing model.

Dermatol Surg 2013;39:952–3.

2. Nicholas L, Toren K, Bingham J, Marquart J. Simulation in

dermatologic surgery: a new paradigm in training. Dermatol Surg

2013;39:76–81.

3. Adams B, Levy R, Rademaker AE, Goldberg LH, et al.

Frequency of use of suturing and repair techniques preferred by

dermatologic surgeons. Dermatol Surg 2006;32:682–9.

CYNDI YAG-HOWARD, MD, FAAD

Advanced Dermatology and Skin Surgery

Specialists, PA

Naples, FloridaFigure 3. Demonstration of how the mouse pad model ofskin can be used to practice stitching techniques.

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39 :12 :DECEMBER 2013 1949