Soft Tissue Filler Therapy and Informed Consent: A Canadian Review.

Soft Tissue Filler (STF) Therapy for cosmetic facial rejuvenation is associated with known complications. The manifestation of these known complications can lead to patients commencing civil litigation actions or making complaints to provincial regulatory authorities and alleging that the practitioner failed to obtain the patient's informed consent to the therapy. Data provided by the Canadian Medical Protective Association (CMPA) on medical-legal cases arising from the provision of STF therapy between 2005 and 2019 are presented. Select reported case law decisions from Canadian courts and regulatory bodies addressing the concept of informed consent are reviewed. Insights about the risk factors pertaining to the process of obtaining informed consent for STF therapy are presented to increase an understanding of the elements of communication and documentation needed to ensure patients are aware of the consequences of this treatment.

Prevention and Management of Filler Induced Iatrogenic Stroke of the Eye [Formula: see text].

In the past few decades, minimally-invasive esthetic treatments and the use of injectable Hyaluronic Acid Gels and other filling agents to treat facial esthetics have increased dramatically. Although extremely rare, a filler can cause ocular and orbital ischemia by retrograde flow from the ophthalmic artery when injected in any of the anastomosis of the face. Once filler reaches the central retinal artery, blindness is inevitable, and no treatment is effective. While the risk of blindness happening with any filler injection is rare, the life-altering irreversible consequence of a procedure that was anticipated to be simple and beautifying is a reality that each injector must be prepared for with every injection. The parameters associated with an iatrogenic stroke of the eye are the site of injection, the injection technique, patient characteristics, and the material injected. Understanding the interplay of each of these variables might help us reduce the possibility of blindness during the injection of a soft-tissue cosmetic filler. Here, we explore the causes of Hyaluronic Acid Gels Filler embolic phenomena, review the natural course of the process, and discuss appropriate immediate interventions. We also (1) propose an education plan for injectors and describe how to carry out a focused ophthalmologic examination and procedural activities for a referral to an ophthalmologist, (2) outline steps to prevent emboli during filler injection, and (3) how to manage and support a patient with a sudden loss of vision during or immediately after a Hyaluronic Acid Gels filler treatment.

Case Report: Diagnosis of a Rare Plaque-Like Dermal Fibroma Successfully Treated With Mohs Surgery.

BACKGROUND: CD34-positive plaque-like dermal fibroma (PDF) is a poorly characterised benign dermal neoplasm that has a wide differential diagnosis. It can be mistaken for other entities on superficial biopsy and be overtreated, leading to unnecessary worry and extensive surgery. OBJECTIVE: To report on an uncommon presentation of this entity, the histopathologic differential diagnosis of PDF, and a novel treatment method. METHODS: Clinical and histopathological information was obtained for a PDF lesion on a 75-year-old man. RESULTS: On superficial biopsy, the PDF lesion was misinterpreted as a possible neurothekeoma. Successful Mohs surgery and genetic testing confirmed the diagnosis of PDF, and the patient received appropriate tissue-sparing surgical management. CONCLUSION: This case adds to our current knowledge about PDF and highlights the importance of early recognition of these lesions to direct appropriate diagnostic testing (full-thickness biopsy) and management. This case confirms successful management with Mohs surgery.

Deep Tissue Sequencing Using Hypodermoscopy and Augmented Intelligence to Analyze Atypical Pigmented Lesions.

BACKGROUND: Over the past decade, new technologies, devices, and methods have been developed to assist in the diagnosis of cutaneous melanocytic lesions. OBJECTIVE: Our objective was to evaluate the performance of an augmented intelligence system in the assessment of atypical pigmented lesions. METHODS: Nine atypical pigmented lesions on 8 patients were evaluated prior to surgical removal. No lesions had received previous treatment other than a diagnostic biopsy. Prior to surgical removal, each lesion was evaluated by an Augmented Intelligence Dermal Imager (AID) and the assessment parameters reviewed in light of the final histopathological diagnosis. RESULTS: The AID was used to evaluate a limited set of atypical pigmented lesions and showed sensitivity and specificity of 82% and 61%, respectively, based on its internal risk assessment algorithms. LIMITATIONS: These cases represent early assessments of the AID in a clinical setting, all prior assessments having been carried out on digital images. The information received from these evaluations requires further validation and analysis to be able to extrapolate its clinical usefulness. CONCLUSION: The AID combines dermoscopy, hypodermoscopy, and a trained augmented algorithm to produce a diffusion map representing the features of each lesion compared to the learned characteristics from a database of known dermoscopy images of lesions with definitive prior diagnosis. The information gathered from the diffusion map might be used to calculate a malignancy risk factor for the lesion compared to known melanoma features. This malignancy risk factor could be helpful in providing information to justify the biopsy of an atypical pigmented lesion.

Comparison of outcomes for malignant melanoma of the face treated using Mohs micrographic surgery and wide local excision.

BACKGROUND: Mohs micrographic surgery (MMS) is an accepted treatment for nonmelanoma skin cancer and has an evolving role in melanoma. OBJECTIVE: To review oncologic outcomes of MMS and wide local excision (WLE) treatments for facial melanoma. METHODS AND MATERIALS: A retrospective review of patients with invasive melanoma of the face between 1997 and 2007 identified from the Alberta Cancer Registry (Canada) was performed. Outcome measures were local recurrence (recurrence <2 cm from excision scar), distant recurrence (regional or systemic), and disease-specific survival. RESULTS: One hundred fifty-one patients were available for analysis (60 MMS, 91 WLE). Median follow-up time was 48 months. The groups differed in tumor location and mitotic rate. Overall, there was no significant difference in 5-year local recurrence (7.9% WLE vs 6.2% MMS, p = .58), regional or systemic recurrence (18.8% vs 8.8%, p = 0.37) or disease-specific survival (82.8% vs 92.4%, p = .59). Breslow thickness was the only consistent predictor of local recurrence or other recurrence and disease-specific survival on multivariate analysis. Subset analysis of tumors with Breslow thickness less than 2 mm did not reveal any difference in outcomes. CONCLUSION: Mohs micrographic surgery has oncologic outcomes of local recurrence, distant recurrence and overall survival similar to those of WLE for invasive facial melanoma.

Invasive melanoma of the face: Management, outcomes, and the role of sentinel lymph node biopsy in 260 patients at a single institution.

BACKGROUND AND OBJECTIVES: The face is a common site of melanoma occurrence. The purpose of this study was to examine the management and outcomes of patients with invasive melanoma of the face. METHODS: Patients with invasive melanoma of the face managed at our institution from 1997 to 2008 were retrospectively reviewed. Details of sentinel lymph node biopsy (SNB), disease recurrence, and deaths were recorded. RESULTS: Two hundred sixty patients were reviewed (mean age 68, mean tumor thickness 0.87 mm). Of 100 patients eligible for SNB (tumor thickness ≥ 1 mm, Clark level ≥ IV, or ulceration) this was performed in only 29 (29%), and those who underwent SNB were younger than those who did not (mean age 59 vs. 79 years, P < 0.0001). SNB was successful in 28 (97%), and no complications occurred. SNB was positive in 3 (11%). After mean follow-up of 30 months, nodal recurrence occurred in 9 (3.5%) and distant recurrence in 20 (7.7%). There were 60 deaths (overall mortality 23%); attributed to melanoma in only 16 cases (disease specific mortality 6.2%). CONCLUSIONS: Facial melanoma is associated with low rates of regional recurrence despite underutilization of SNB. Older patients are less likely to undergo SNB. Due to the advanced age of patients with facial melanoma, most deaths occurring are from unrelated causes.

Skin care and hygiene among healthcare professionals during and after the SARS-CoV-2 pandemic.

The severe acute respiratory syndrome coronavirus 2 pandemic has necessitated enhanced protection against viral transmission among healthcare professionals, particularly relating to handwashing and personal protective equipment. Some of these requirements may persist for years to come. They bring associated concerns around skin hygiene and general care, with damage to the face and hands now a well-documented consequence among healthcare professionals. This review assesses optimal skin care during the severe acute respiratory syndrome coronavirus 2 pandemic and in the "new normal" that will follow, identifies current knowledge gaps, and provides practical advice for the clinical setting. Regular, systematic hand cleaning with soap and water or an alcohol-based hand rub (containing 60%-90% ethanol or isopropyl alcohol) remains essential, although the optimal quantity and duration is unclear. Gloves are a useful additional barrier; further studies are needed on preferred materials. Moisturization is typically helpful and has proven benefits in mitigating damage from frequent handwashing. It may be best practiced using an alcohol-based hand rub with added moisturizer and could be particularly important among individuals with pre-existing hand dermatoses, such as psoriasis and eczema. Face moisturization immediately prior to donning a mask, and the use of dressings under the mask to reduce friction, can be helpful dermatologically, but more work is required to prove that these actions do not affect seal integrity. Nonetheless, such measures could play a role in institutional plans for mitigating the dermatologic impact of transmission control measures as we exit the pandemic.

Superficial leiomyosarcoma: a clinicopathologic review and update.

BACKGROUND: Superficial leiomyosarcomas (SLMSs) are rare soft tissue malignancies. A clinicopathologic review of 25 cases was undertaken. METHODS: Twenty-five cases diagnosed between 1990 and 2007 were reviewed. Clinical information was obtained from patient charts. Histologic slides were reviewed, and immunohistochemical stains were performed. RESULTS: All patients presented with a nodule. Fourteen tumors were confined to the dermis and 11 involved subcutaneous tissue. Smooth muscle markers were positive in all cases. CD117 was consistently negative. Novel histological features included epidermal hyperplasia, sclerotic collagen bands and increasing tumor grade with the depth of the lesion. Poor outcome was associated with size > 2 cm, high grade and depth of the lesion. CONCLUSIONS: SLMSs are rare but important smooth muscle tumors of the skin. The clinical presentation may be non-specific. The histologic appearance is that of a smooth muscle lesion, but epidermal hyperplasia and thickened collagen bands are previously underrecognized features. Immunohistochemical stains are useful in confirming smooth muscle differentiation, but CD117 is of limited utility. SLMS can appear low grade or even benign on superficial biopsies, leading to undergrading or a delay in the correct diagnosis. Clinicians and pathologists alike should therefore be aware of these pitfalls and must approach these cases with caution.

Anatomic location of hyaluronic acid filler material injected into nasolabial fold: a histologic study.

BACKGROUND Products instilled within or beneath the skin to improve its physical features are known as fillers. The position of the filler within the skin is one determinant of the end cosmetic result. OBJECTIVE The objective was to histologically determine the anatomic location of injected hyaluronic acid (HA) filler within nasolabial fold (NLF) skin. METHODS AND MATERIALS Sixteen patients (12 females, 4 males; median age, 59 years) undergoing Mohs micrographic surgery for basal cell carcinoma of the NLF area consented to injection of Burow's triangle or dog-ear redundant skin with HA gel (Juvederm), ex vivo, in vivo, or in vivo with delayed (1-4 weeks) removal. Sections of alcohol-fixed, paraffin-embedded tissue specimens were stained with hematoxylin and eosin and with Hale's colloidal iron for detection of acid mucins. Dermal thickness was measured and HA distribution assessed. RESULTS NLF dermal thickness was 1.37+/-0.27 mm (mean+/-SD), with a range of 1.04 to 1.86 mm. All 16 patients showed HA filler localized to the subcutis. In 9/16 tissue samples, some HA was present in the deep dermis, but filler was only observed in more superficial dermis in 1 patient. The thickness of injected filler was 2.11+/-0.63 mm, but filler was often transected at the specimen base. CONCLUSION The predominant localization of injected HA filler is within the subcutis. A relatively thin NLF dermal thickness, typically <1.50 mm, likely precludes accurate injection of filler into dermal collagen. The results suggest that dermal localization of HA filler products is not required for an excellent cosmetic result.

Mohs micrographic surgery and dermatofibrosarcoma protuberans: a multidisciplinary approach in 44 patients.

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue tumor with a high recurrence rate. The goal of this study was to review patients with DFSP treated by Mohs micrographic surgery (MMS) and to compare demographics and recurrence rates with cases in the literature treated by standard excision methods. Medical charts were used to evaluate patient and tumor characteristics, number of stages for tumor clearance, reconstructive methods used, and recurrence rate after MMS. Data were compared with published recurrence rates in the literature. Our results indicate that there were no recurrences in 44 of 44 patients with DFSP resected by MMS after a mean follow-up of 3.3 years. This compares with recurrence rates in the literature of 10% to 60% using standard excision methods. We conclude that MMS provides recurrence-free treatment of DFSP tumors and promotes a collaborative approach between dermatologic and plastic surgeons.

Squamous cell carcinoma in situ of the skin: history, presentation, biology and treatment.

Squamous cell carcinoma in situ (SCCIS) of the skin is a problem commonly dealt with by dermatologists. The classic presentation, originally described by Bowen, is easily recognized, but presentation on some anatomical surfaces may be associated with less than typical features. Major aetiological factors for this disease are UV light, human papillomavirus infection and immunosuppression. The natural course of SCCIS is usually prolonged, with treatment being appropriate, but not urgent. The choice of therapy requires consideration of the location of the lesion, and a desire for a high cure rate without causing loss of form, function or cosmesis. The immunomodulatory agent imiquimod has offered a significant advance for the topical treatment of SCCIS. Our improved understanding of the underlying biology of SCCIS permits us to make rational choices of treatment. In the future we may be able to determine which of these lesions may progress to invasive disease, and help us select the most effective therapy.

Increased melanoma risk in Parkinson disease: a prospective clinicopathological study.

OBJECTIVE: To evaluate the possible association of Parkinson disease (PD) and melanoma in North America. DESIGN, SETTING, AND PATIENTS: Thirty-one centers enrolled patients with idiopathic PD. At visit 1, a neurologist obtained a medical history. At visit 2, a dermatologist recorded melanoma risk factors, performed a whole-body examination, and performed a biopsy of lesions suggestive of melanoma for evaluation by a central dermatopathology laboratory. We compared overall prevalence of melanoma with prevalence calculated from the US Surveillance Epidemiology and End Results (SEER) cancer database and the American Academy of Dermatology skin cancer screening programs. RESULTS: A total of 2106 patients (mean [SD] age, 68.6 [10.6] years; duration of PD, 7.1 [5.7] years) completed the study. Most (84.8%) had received levodopa. Dermatology examinations revealed 346 pigmented lesions; dermatopathological findings confirmed 20 in situ melanomas (0.9%) and 4 invasive melanomas (0.2%). In addition, histories revealed 68 prior melanomas (3.2%). Prevalence (5-year limited duration) of invasive malignant melanoma in the US cohort of patients with PD (n = 1692) was 2.24-fold higher (95% confidence interval, 1.21-4.17) than expected in age- and sex-matched populations in the US SEER database. Age- or sex-adjusted relative risk of any melanoma for US patients was more than 7 times that expected from confirmed cases in American Academy of Dermatology skin cancer screening programs. CONCLUSIONS: Melanoma prevalence appears to be higher in patients with PD than in the general population. Despite difficulties in comparing other databases with this study population, the study supports increased melanoma screening in patients with PD.

Mohs micrographic surgery in the treatment of lentigo maligna and melanoma.

BACKGROUND AND OBJECTIVES: The treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM) is challenging due to lesion location, size, patient age, and potential for recurrence and spread. The largest studies to date confirm that for melanocytic tumours, MMS provides high local control rates while minimizing tissue loss. Herein we report our local control rate for melanoma treated by MMS over a decade. METHODS: Charts were reviewed on all patients with melanocytic tumors treated by a single physician (JPA) using MMS over the time period of 1993-2002. Demographic, surgical and pathological details were recorded. Patients were followed for local, regional and distant recurrences. RESULTS: The patient population was comprised of 199 patients with 202 melanomas. There were 69 invasive lesions, with a mean Breslow depth of 0.92 mm (0.2-3.6 mm). The mean number of levels required to clear the lesions was 2.7 (1-7), resulting in a mean defect size of 11.8 cm2 (0.9-70.7 cm2). Patients with LMM were significantly older (73.2 vs. 66.5 yrs, p = 0.012) and had larger defects after MMS (16.74 cm2 vs. 10.27 cm2) than patients with LM. At a mean follow-up of 29.8 months, there were no local recurrences, four regional recurrences, and two distant recurrences. CONCLUSION: MMS is an effective modality for the clearance of melanocytic tumors.

Metastatic basal cell carcinoma: report of two cases and literature review.

BACKGROUND: Metastatic basal cell carcinoma (MBCC) is defined as primary cutaneous basal cell carcinoma (BCC) that spreads to distant sites as histologically similar metastatic deposits of BCC. There are less than 300 reported cases of MBCC in the literature. METHODS: This article examines two cases of MBCC and provides a literature review of risk factors inherent in epidemiology, patient demographics, and the clinicohistopathological characteristics of primary and metastatic BCC lesions. RESULTS: MBCC is a rare complication of BCC with high morbidity and mortality rates. Patients with MBCC often begin with long-standing primary BCC lesions that are either large or recurrent after treatment. Cases of MBCC have a higher incidence of the more aggressive histologic patterns (morpheic, infiltrating, metatypical, and basosquamous). Perineural space invasion may be an indicator of aggressive disease. Metastases often involve regional lymph nodes, lungs, bone, and skin. CONCLUSION: These case reports and review provide important diagnostic and management considerations for primary BCC and MBCC. Early intervention with aggressive treatment measures may improve the prognosis and survival of MBCC patients.

Treatment of cutaneous melanoma of the face by Mohs micrographic surgery.

BACKGROUND: The treatment of cutaneous malignant melanoma of the face presents a challenge to ensure eradication of disease with maximum preservation of tissue. Mohs micrographic surgery provides a means for histologically controlled removal of malignant melanoma. OBJECTIVE: This study evaluates the efficacy of Mohs micrographic surgery, at a single institution, for the treatment of facial melanoma and assesses the accuracy of margin control by frozen section techniques. METHODS: Ninety-seven patients with biopsy-confirmed melanoma in situ or invasive melanoma of the face were treated by Mohs micrographic surgery over a 6-year period. In 25 patients, tissue margins defined as negative for melanoma at the time of frozen section were re-evaluated on permanent section histology of formalin-fixed, paraffin-embedded tissue. RESULTS: Ninety-two of 97 patients had followup information available (8-72 months; mean 33 months). There were no cases of local recurrence. Eighty-nine of the 92 patients were alive and well with no evidence of disease. One patient died of metastatic melanoma. In situ or invasive melanoma was not identified on permanent sections of 117 tissue margins which had been interpreted as negative on frozen section. CONCLUSION: Mohs micrographic surgery appears to be an effective treatment for facial melanomas. Our study showed complete correlation between frozen section tissue margins and permanent section controls.

Management of lentigo maligna and lentigo maligna melanoma: seminars in surgical oncology.

Lentigo maligna (LM) and lentigo maligna melanoma (LMM) represent a character, histogenetic subclass of melanocytic malignancies. They often present with a prolonged phase of slow growth but once invasion has occurred, the prognostic features are identical to all other melanomas. These lesions occur primarily on the head and neck where they evolve from areas of pigmented staining to the more typical features identifiable with malignant melanomas on other skin surfaces. The treatment options and recent advances in management are reviewed.