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October 2005

The ASDS Technology Report is a member service designed to inform dermatologic surgeons of new technologies or procedures in the marketplace. The series represents a distillation of available published scientific data and anecdotal information on a specific technology or procedure and should not be misconstrued as an endorsement by the ASDS. The Society encourages its members to use their independent judgment in applying any technology or procedure in the care and treatment of their patients.

Definition and History:The sharpness of the diamond scalpel has long been recognized in surgery and basic science. A diamond scalpel is estimated to be over 40 times sharper than the finest surgical steel. This correlates to more exact cuts without tearing of tissue or ragged tissue edges. Diamond scalpel blades are routinely used in corneal surgery as well as in tissue preparation prior to electron microscopy to produce smooth tissue edges. The use of diamond cutting instruments for dermatologic, oculoplastic and facial plastic surgery is now possible

Mechanism:Diamond scalpel blades are made from synthetic diamonds, are honed to precision edges and are then mounted onto surgical handles. The diamond scalpel is then used like any other scalpel blade for skin incision or soft tissue excision. The sharpness of the blade allows microfine cuts with smooth edges and is thus ideal for delicate cosmetic or microsurgical techniques.

A diamond scalpel is also available with coagulation abilities. The Diamond LaserKnife (Clinicon Corp., Oceanside, CA) consists of a diamond scalpel mounted onto a handpiece that simultaneously delivers infrared energy through a fiber optic CO2 laser. The laser energy passes through the diamond blade and delivers infrared energy to the adjacent tissue providing simultaneous controlled coagulation.

Steam sterilization and the ability to re-sharpen the tips allow long-term repeated use of these instruments.
 

Indications:The diamond scalpel can be used for any skin or soft tissue surgical technique. It is most valuable where delicate and precise incisions are required. The most likely application in dermatologic surgery would be for eyelid surgery where precise incisions in a bloodless field are desired. Application to Mohs micrographic surgery is also a possibility for generating ultrafine tissue specimens with exact edges.

Compared to standard “cold steel” blades, the diamond scalpel offers more precise tissue cutting with the option of combined simultaneous coagulation. An advantage of the diamond scalpel over CO2 laser incisions is that the diamond scalpel provides cutting and coagulation with tactile feedback whereas the laser fails to do so.

Two small series studies have been published that compare the diamond knife to standard cutting techniques. The first study compared the diamond knife to “cold steel” for standard elliptical skin excisions and failed to show any visible difference in the cosmetic outcome between the two groups. The diamond knife, however, did show a superior but not statistically significant difference in its ability to achieve intraoperative hemostasis. The second study compared CO2 laser incision to the diamond knife incision for upper eyelid blepharoplasty. There was no detectable difference in the surgical outcomes from either group in this study. The diamond knife, however, did have the significant advantage over the CO2 laser by providing the surgeon with tactile feedback.

Technique:The diamond scalpel is used like any other cutting instrument. The blade produces its effect through direct contact with the tissue. The depth of the incision is varied relative to the amount of pressure applied on the blade.

Coagulation is delivered via a fiberoptic CO2 laser directly through the diamond blade. This allows for simultaneous coagulation as the surgeon cuts the tissue and thus provides the possibility of operating in a bloodless field. The amount of coagulation varies depending upon the fluence delivered through the scalpel as well as with the contact time.

Complications:Complications with the diamond scalpel combined with CO2 laser are usually related to effects of over-coagulation. Dwelling too long with continuous energy delivery will result in tissue desiccation and poor wound healing.

Conclusions:Diamond scalpel blades provide ultra-fine tissue incision and are ideal for delicate surgical applications where precision edges are required or will provide a visibly superior result. When combined with infrared energy, they also have the capability to create a bloodless operative field. The practical applications of diamond surgical instruments in the dermatologic surgery field may be limited to only a few procedures such as blepharoplasty or Mohs micrographic surgery. Available studies have failed to show a significant difference in the surgical outcomes when using the diamond knife compared to traditional methods.

References: 

  1. Keel DM ,Goldman MP, Fitzpatrick RE, Butterwick KJ. Diamond laser scalpel vs. steel scalpel: a side by side comparison of cutaneous wound healing. Lasers Surg Med. 2002;31(1):41-4.
  2. Baker SS, Hunnewell JM, Muenzler WS, Hunter GJ. Laser blepharoplasty: diamond laser scalpel compared to the free beam CO2 laser. Dermatol Surg. 2002 Feb;28(2):127-31.

 

New Technologies Subcommittee on Advanced Dermatologic surgery
Hayes Gladstone, MD, Chair
Sorin Eremia, MD
Victor Neel, MD
Edgar Fincher, MD, Invited Guest

 

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