Fillers for postsurgical depressed scars after skin cancer reconstruction.

Traditional scar revision has addressed issues of thickness with intralesional corticosteroids, superficial contours with dermabrasion or laser resurfacing, and postrepair erythema with hemoglobin-targeted laser therapy. Historically, collagen fillers have been used to address several types of scars, including acne, varicella, and trauma, as well as larger soft tissue contour defects. With the introduction of new types of fillers to the dermatologic surgeon's armamentarium, many types of scars with longer lasting results can be addressed. Success has been noted with the use of these newer and more durable fillers, such as hyaluronic acid and calcium hydroxylapatite, to fill and blend postsurgical depressed scars following the reconstruction of skin cancer defects.

Management of visible granulomas following periorbital injection of poly-L-lactic Acid.

PURPOSE: Injectable poly-L-lactic acid (PLA) is a recently FDA-approved soft-tissue filler. Although approved only for treatment of HIV-associated lipoatrophy, there has been increased interest in its use for cosmetic purposes. Here we describe a case of a granulomatous reaction to injectable PLA in the inferior periorbital region resulting in visible papules and discuss treatment options. METHODS: We review literature pertaining to medical and surgical treatment options for our patient, and we discuss relevant techniques for both the injection of PLA and the management of this complication with surgical techniques. RESULTS: After failing several nonsurgical treatment options, our patient had excellent results with surgical excision of her persistent visible nodules. This technique is minimally invasive, provides definitive removal of the nodules, and can leave minimal residual scarring. CONCLUSIONS: Given the high frequency of subcutaneous nodule formation reported in early trials of injectable PLA, it is important for physicians to be well informed regarding its potential side-effects and how to minimize risk of adverse reactions. Based on our experience, we suggest that surgical excision is an excellent treatment option for persistent papules and nodules that arise after injection of PLA in the periorbital area.

Bone morphogenetic protein antagonist gremlin 1 is widely expressed by cancer-associated stromal cells and can promote tumor cell proliferation.

Although tissue microenvironments play critical roles in epithelial development and tumorigenesis, the factors mediating these effects are poorly understood. In this work, we used a genomic approach to identify factors produced by cells in the microenvironment of basal cell carcinoma (BCC) of the skin, one of the most common human cancers. The global gene expression programs of stromal cell cultures derived from human BCCs showed consistent, systematic differences from those derived from nontumor skin. The gene most consistently expressed at a higher level in BCC tumor stromal cells compared with those from nontumor skin was GREMLIN 1, which encodes a secreted antagonist of the bone morphogenetic protein (BMP) pathway. BMPs and their antagonists are known to play a crucial role in stem and progenitor cell biology as regulators of the balance between expansion and differentiation. Consistent with the hypothesis that BMP antagonists might have a similar role in cancer, we found GREMLIN 1 expression in the stroma of human BCC tumors but not in normal skin in vivo. Furthermore, BMP 2 and 4 are expressed by BCC cells. Ex vivo, BMP inhibits, and Gremlin 1 promotes, proliferation of cultured BCC cells. We further found that GREMLIN 1 is expressed by stromal cells in many carcinomas but not in the corresponding normal tissue counterparts that we examined. Our data suggest that BMP antagonists may be important constituents of tumor stroma, providing a favorable microenvironment for cancer cell survival and expansion in many cancers.