Guidelines for the use of local anesthesia in office-based dermatologic surgery.

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Evaluation of orbicularis oculi muscle stripping on the cosmetic outcome of upper lid blepharoplasty: a randomized, controlled study.

BACKGROUND: Many variations in the surgical treatment of upper eyelid blepharoplasty have been described, including orbicularis oculi muscle stripping. There is no evidence in the literature to support the efficacy of this technique in improving the aesthetic results of the procedure. OBJECTIVES: To conduct a single-blind, randomized, controlled, split-face pilot study to evaluate the effects of orbicularis oculi muscle stripping on upper lid blepharoplasty. METHODS: Ten subjects were randomized to receive upper lid blepharoplasty with orbicularis oculi muscle stripping on one side and skin-only blepharoplasty on the other. Patients and two blinded physicians evaluated the aesthetics of the eyelids at 1-, 3-, and 17-month follow-up visits. RESULTS: Blinded physician evaluation failed to show a difference in the overall cosmetic appearance of the eyelids between the control and treatment sides at any time point. Analysis of the composite of all patient scores showed a trend favoring the control side at 3 months (p = .28) and the treatment side at 17 months (p = .50), but neither difference was significant. CONCLUSION: Based on the data from this pilot study, orbicularis oculi muscle stripping appears to have no affect on the aesthetic outcome of upper lid blepharoplasty.

The molecular genetics underlying basal cell carcinoma pathogenesis and links to targeted therapeutics.

Mutations in the sonic hedgehog signaling pathway play a key role in the development of basal cell carcinomas. Specifically, mutations in the PTCH1 (also known as PTCH or PTC1) and SMO genes cause tumor formation through constitutive activation of the pathway. Misregulation of the pathway has also been implicated in the nevoid basal cell carcinoma syndrome and other tumors. Understanding the function of the sonic hedgehog pathway has led to novel strategies for treatment. In this review we highlight the role of the pathway in the pathogenesis of basal cell carcinoma and review potential targeted therapies.

Safety precautions in Mohs micrographic surgery for patients with known blood-borne infections: a survey-based study.

PURPOSE: A survey-based study was conducted to gather expert experience on safety procedures used when performing Mohs micrographic surgery (MMS) on patients with known infectious hepatitis or human immunodeficiency virus (HIV). METHODS: Six hundred eighty-four fellowship-trained Mohs surgeons were surveyed to examine the types of safety protocols used when treating patients with known infectious hepatitis or HIV and the frequency of exposure injuries to laboratory and surgical personnel from these patients. RESULTS: One hundred eighty-eight (27.5%) surveys were collected; 64.7% of respondents reported at least one exposure injury to surgical or laboratory personnel in the past year, and 4.8% reported exposure from a patient with known hepatitis or HIV infection. Risk of reporting at least one injury from a patient with known infection within the past year was significantly less when also reporting disposal of the ink applicator after each use (relative risk [RR] = 0.109) and greater when employing laboratory personnel with no medical education or background (RR = 3.857). No exposures were reported from respondents using blunt skin hooks, safety scalpels, safety syringes, smoke evacuators, a separate ink supply, or 24-hour formalin fixation. CONCLUSION: Although firm associations cannot be made from this study, the data suggest that certain measures may help to reduce the rate of exposure injuries in MMS.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Optimizing closure materials for upper lid blepharoplasty: a randomized, controlled trial.

BACKGROUND: Although upper eyelid blepharoplasty is a common procedure, subtleties in surgical technique can affect cosmetic outcomes. Suture materials commonly used include polypropylene, monofilament nylon, fast-absorbing gut, and ethylcyanoacrylate (ECA) tissue adhesive. OBJECTIVE: To assess upper lid blepharoplasty scars in participants whose incision had been closed with 6-0 polypropylene sutures, 6-0 fast-absorbing gut sutures, or ECA. MATERIALS AND METHODS: A randomized, split-eyelid, single-blind, prospective study of the short- (1 month) and intermediate-term (3 months) efficacy of polypropylene, fast-absorbing gut, and ECA on 36 consecutive upper lid blepharoplasties. Participants and a blinded physician evaluator evaluated cosmetic outcome 1 and 3 months after the procedure. RESULTS: Three subgroups tested were ECA versus fast-absorbing gut, ECA versus polypropylene, and fast-absorbing gut versus polypropylene. At 1 month, ECA was superior to fast-absorbing gut (p=.03) and had a marginally better outcome than polypropylene (p=.25), and polypropylene had an equivalent outcome to fast-absorbing gut (p=.46). At 3-month follow-up, ECA remained superior to fast-absorbing gut (p=.03). CONCLUSION: Although sutured epidermal closure and tissue adhesive are highly efficacious for upper eyelid blepharoplasty, physicians and participants felt that cosmesis with ECA was superior to that with fast-absorbing gut.

Subcuticular incision versus naturally sourced porcine collagen filler for acne scars: a randomized split-face comparison.

BACKGROUND: Subcuticular incision is performed to release fibrotic bands beneath acne scars and to stimulate neocollagenesis. Naturally sourced porcine collagen has been approved for filling moderate to deep facial wrinkles and nasolabial folds. To our knowledge, naturally sourced porcine collagen filler has not yet been tried as a treatment for correcting atrophic acne scars. OBJECTIVE: To objectively assess and directly compare the efficacy and safety of subcuticular incision versus naturally sourced porcine collagen dermal filler in correcting atrophic and rolling acne scars. MATERIALS AND METHODS: We performed a prospective, randomized, split-face, single-blind study to evaluate intermediate long-term efficacy of subcision and collagen dermal filler on 20 unilateral faces. Patients and blinded physicians evaluated results. RESULTS: Patients rated subcision as superior to collagen dermal filler at 3 months (p=.03). At 6 months, subcision had a slightly higher rating than collagen dermal filler (p=.12). Blinded evaluators leaned toward subcision at 3 months (p=.12) and at 6 months showed no preference (p=.69). CONCLUSION: Subcuticular incision and naturally sourced porcine collagen dermal filler appear to be efficacious for improving atrophic and rolling acne scars. Patients may prefer subcuticular incision over collagen dermal filler. Blinded evaluators found no significant difference between the treatments.

Mohs micrographic surgery for the treatment of cutaneous lymphadenoma.

Cutaneous lymphadenoma (CL) is a benign neoplasm commonly presenting on the head and neck of young and middle-aged adults. Complete surgical excision of CL is the treatment of choice and appears to be curative. As compared to local excision without margin control, Mohs micrographic surgery (MMS) may allow for more definitive tumor extirpation for large cases of CL and allow for greater tissue preservation at functionally and aesthetically sensitive sites. We present a case of cutaneous lymphadenoma presenting on the right cheek of a middle-aged male who was successfully treated with MMS.

Safety of tumescent and laser-assisted liposuction: review of the literature.

BACKGROUND: Tumescent liposuction (TL) allows the removal of large volumes of fat with minimal blood loss or postoperative morbidity, excellent cosmesis, and a remarkable safety profile. OBJECTIVE: To review the literature on the safety of tumescent liposuction, liposuction under general anesthesia and laser-assisted liposuction. RESULTS: Aggregate safety data on liposuction under tumescent anesthesia reveals over 100,000 body areas treated with liposuction. There were no serious complications of death, emboli, hypovolemic shock, perforation of thorax or peritoneum, thrombophlebitis, seizures, or toxic reactions to drugs. In contrast, in the plastic surgery literature, liposuction under general anesthesia was associated with complications of deep venous thrombosis or pulmonary embolus, abdominal or other organ perforation, infection, and bleeding. Most recently, survey data in the European literature analyzed data showed 72 cases of severe complications from liposuction, including 23 deaths in a 5-year period from 1998 to 2002. The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism. CONCLUSION: Tumescent local anesthesia utilizing lidocaine with epinephrine allows the removal of large volumes of fat with minimal associated blood loss and postoperative morbidity.

Review of fractional photothermolysis: treatment indications and efficacy.

BACKGROUND: Fractional photothermolysis (FP) is one of the most significant milestones in laser technology and resurfacing. METHODS: Review of the Medline English literature and recent international conferences regarding FP technology, applications, and indications. RESULTS: Successful conditions treated with nonablative FP reported in the literature include acne scarring; dyschromia and fine wrinkling of photoaging on the face, chest, neck, and hands; melasma; poikiloderma of Civatte; nevus of Ota; scars; minocycline hyperpigmentation; telangiectatic matting; residual hemangioma; granuloma annulare; colloid milium; and disseminated superficial actinic porokeratosis. An advance in 2007 was the introduction of ablative FP (AFP), which results in significantly greater improvement in skin laxity and textural abnormalities. Most recently, AFP has demonstrated significantly greater improvement than nonablative FP in reducing acne scarring and skin redundancy and laxity associated with photoaging. CONCLUSIONS: Through the induction of microthermal zones of injury, FP technology stimulates a robust and rapid wound healing response resulting in improvement in a diversity of aesthetic, inflammatory, and preneoplastic skin disorders. Further investigation into the technology and diverse array of cutaneous conditions that can benefit from FP is highly needed.

Treatment of surgical scars with nonablative fractional laser versus pulsed dye laser: a randomized controlled trial.

OBJECTIVE: Comparison of the efficacy of nonablative fractional laser (NAFL) and the V-beam pulsed dye laser (PDL) for improvement of surgical scars. METHODS: A randomized blinded split-scar study. Fifteen scars in 12 patients were treated a minimum of 2 months after Mohs surgery. Patients were treated on half of the scar with a 1,550-nm NAFL and on the contralateral half with the 595 nm PDL. MAIN OUTCOME MEASURE(S): A nontreating physician investigator evaluated the outcome of the scar in terms of scar dyspigmentation, thickness, texture, and overall cosmetic appearance (5-point grading scale). RESULTS: After a series of four treatments at 2-week intervals, greater improvements were noted in the portion of surgical scars treated with NAFL (overall mean improvement 75.6%, range 60-100%, vs. PDL, 53.9%, range 20-80%; p<.001). CONCLUSION: These data support the use of NAFL as a highly effective treatment modality for surgical scars, with greater improvement in scar appearance than with PDL. It is likely that the greater depth of penetration and focal microthermal zones of injury with NAFL, inducing neocollagenesis and collagenolysis, account for its greater improvement in scar remodeling. These encouraging results lead us to recommend that NAFL be added to the current treatment armamentarium for surgical scars.

Photodynamic therapy for the treatment of cutaneous neoplasia, inflammatory disorders, and photoaging.

BACKGROUND: Photodynamic therapy (PDT) has demonstrated high efficacy, minimal side effects, and improved cosmetic outcome when used for the treatment of actinic keratoses (AK), basal cell carcinoma (BCC), squamous cell carcinoma, and photoaging. METHODS: To review the literature on the use of PDT in dermatologic surgery using MEDLINE. RESULTS: Published clinical studies using PDT in the treatment of AKs yield overall efficacy rates ranging from 50% to 71% with one treatment to as high as 88% to 90% with two or more treatments. For superficial BCC, initial clearance rates were 76% to 97%, and for Bowen's disease, initial clearance rates ranged from 72% to 94% overall. The use of PDT for photorejuvenation is a relatively new application of this technology, which has shown promise in improving the appearance of fine lines, pigmentary variation, and telangiectasias. CONCLUSIONS: The advantages of photodynamic therapy include the capacity for noninvasive targeted therapy through topical application of aminolevulinic acid and methyl aminolevulinic acid, with outstanding cosmetic results. Although the theory behind the use of chemical photosensitizers and ultraviolet light to treat a wide variety of skin disorders is straightforward, the practical application of this technology is evolving. Additional research into the precise mechanisms of action for specific photosensitizers and optimal light sources will be highly beneficial to the advancement of this technology.

Rapid absorbing gut suture versus 2-octylethylcyanoacrylate tissue adhesive in the epidermal closure of linear repairs.

BACKGROUND: While a variety of epidermal wound closure techniques are utilized, there are few evidence based studies comparing techniques in head-to-head studies. OBJECTIVE: To compare the aesthetic outcomes and wound healing properties of 2 epidermal closure mechanisms: 2-octylethylcyanoacrylate adhesive and rapid absorbing gut suture in skin closures. METHODS: A total of 8 patients were enrolled in this randomized right-left comparative trial. Patients were randomized for epidermal closure with one half of their wounds (chest [n=6] and upper extremities [n=2]) with tissue adhesive and the contralateral with rapid absorbing gut suture. RESULTS: Three months following wound closure, overall cosmetic outcome was slightly greater on the half closed with rapid absorbing gut suture (mean=3.56) relative to the tissue adhesive (mean=3.19, P=.05). For dyspigmentation, the half of the scar treated with the suture had a better outcome (mean=3.50) relative to tissue adhesive (mean=2.75) (P<.05). All other variables (i.e., scar thickness, wound approximation, patient outcome, and preference) were highly equivalent. CONCLUSION: Both rapid absorbing gut suture and tissue adhesive appear to be highly efficacious techniques for epidermal closure. It appears that tissue adhesive may not be as effective in achieving optimal cosmesis for defects after Mohs micrographic surgery on the trunk and extremities in follow-up at 3 months.

Dual nasal sidewall and lip defects combined into a single arcuate advancement flap.

The authors have indicated no significant interest with commercial supporters.

Reductions in thigh and infraumbilical circumference following treatment with a novel device combining ultrasound, suction, and massage.

Liposuction is the gold standard of body contouring procedures. Many patients, however, will not tolerate the invasiveness and subsequent recovery time associated with this procedure, despite the likelihood of superior results. Consequently, patients opt for minimally invasive forms of body contouring that require several treatments, have fewer associated side effects, and afford more modest improvements. The MedSculpt device is one such modality that combines computerized massage, vacuum suction, and ultrasound with a continuous sinusoidal pulse delivered at a frequency of 3 Hz. The efficacy of this device was assessed in the reduction of thigh and abdominal circumferences. Five patients were included in this pilot study. A total of 12 treatments were performed on a semiweekly basis to 2 abdomens and 3 pairs of thighs. Photographs and circumferential measurements of each area were obtained prior to, and at the conclusion of, the treatment course. The treatments were well tolerated and without side effects. The mean reduction in thigh circumference was 2.25 cm or 4%, with a 5 cm reduction in 1 subject. Although limited improvement was seen in supraumbilical circumference, the mean reduction in infraumbilical circumference was 6.5 cm or 7.3%, with a 10 cm reduction in 1 subject. Mild improvement in skin tone, texture, and the appearance of cellulite was observed in all study participants. The results observed after 12 treatments were similar to or better than those seen with other minimally invasive, body contouring devices.

Early improvement in rhytides and skin laxity following treatment with a combination fractional laser emitting two wavelengths sequentially.

BACKGROUND: Carbon dioxide laser resurfacing remains the gold standard for the treatment of photoaged skin. Today, however, fewer patients will tolerate the postoperative downtime associated with the use of this device. Fractional photothermolysis was designed to overcome the disadvantages associated with ablative resurfacing. Prototype fractional lasers (Fraxel, Reliant Technologies Inc.) have required the use of blue tracking dye to give evenly spaced microtreatment zones, and treatments are associated with moderate levels of discomfort because of microtreatment zone depths reaching nearly 1000 microm. Newer technologies have evolved that do not require tracking dye, and are less painful than older prototypes because microtreatment zones are more superficial (100 to 300 microm) than that of the Fraxel laser. Newer devices offer advances in treating facial rhytides and skin laxity through the use of 2 laser wavelengths (1320 nm/1440 nm) emitted sequentially through a specialized diffractive lens array that produces high-intensity microtreatment zones surrounded by deeper low level heating. OBSERVATIONS: One to 3 treatments with this combination fractional laser device were performed on 16 Caucasian females with static periocular rhytides or skin laxity affecting the nasolabial crease. There was a 3-week period between treatments. Improvement was noted in both areas after a small number of treatments. CONCLUSION: The technology behind fractional lasers is rapidly evolving, and new devices offer significant advances over older prototypes.