Hydrodissection and Hydroinflation in Mohs Micrographic Surgery—Pearls for Skin Surgeons

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Journal of the American Academy of Dermatology




Hydrodissection is a valuable yet underrecognized technique that involves the injection of sterile fluids for hydraulic elevation and separation of tissues in a desired surgical plane. Hydroinflation involves direct injection of sterile fluids into thin soft tissues to artificially expand them in the vertical dimension. Neither hydroinflation nor hydrodissection has been described in Mohs micrographic surgery (MMS), despite the latter being widely established in general and breast surgeries. Herein, we visually demonstrate and describe steps to execute these simple, versatile, and novel techniques in MMS. A 58-year-old Caucasian man with a 4-cm left superior forehead tethered scar at the site of recurrent BCC after conventional excision presented for MMS (Figure 1). A challenging second Mohs layer resection was necessary to strip the scarred-down periosteum of the left frontal bone. 6 mL of 1% lidocaine with epinephrine solution was slowly injected into and then beneath the targeted, thin periosteal tissue via hydroinflation and hydrodissection, respectively. The newly thickened, intact, elevated target layer was optimized for a contiguous Mohs resection without the aid of a periosteal elevator. At 1 week of follow-up, the repaired surgical site demonstrated resolving ecchymoses surrounding a well-healing 6.2-cm scar. Sensation to noxious and soft cutaneous stimuli, as well as motor function, remained intact over the left forehead where these techniques were used. Hydroinflation and hydrodissection may facilitate multiple MMS resections of a newly elevated, nonperforated, thickened target layer, while concomitantly preserving a well-vascularized wound bed for when a full-thickness skin graft (FTSG) is a reconstructive option adjacent to bone.

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