Efficacy of maggot debridement therapy on refractory leg ulcers of Behçet disease: an open-label study.

BACKGROUND: Cutaneous ulcers of Behçet disease (BD) are rare but have high morbidity and resistance to conventional therapies. An important and essential aspect of ulcer management is debridement. Regarding maggot therapy (MT), excretions of the green bottle fly, Lucilia sericata, have been shown to have the ability to remove necrotic debris and promote healing. AIM: To evaluate the efficacy of MT for cutaneous ulcers of BD. METHODS: In this open-label trial, patients with BD with refractory leg ulcers suitable for MT were enrolled. Maggot application was performed until complete debridement was achieved, and all patients were followed up for 12 months afterwards to assess the total healing of ulcers. RESULTS: In total, 24 patients with 32 ulcers were enrolled. Using MT, 91.6% of all ulcers were completely debrided. Mean time to debridement was 14.9 days and mean number of cycles required was 5.3. Mean ulcer size was decreased by 23% with treatment. Time to debridement was positively correlated with pretreatment ulcer size and ulcer duration (P = 0.01 and P < 0.01) but not with ulcer depth, comorbidities, smoking, age or sex (P > 0.05 for all). During follow-up, 79.1% of all ulcers healed completely. Mean time required for total healing was positively correlated with ulcer duration, pretreatment and post-treatment ulcer area, ulcer depth and mean time to total debridement (P < 0.03, P = 0.00, P = 0.04 and P < 0.01, respectively). CONCLUSIONS: To our knowledge, the findings presented in this first and unique study may provide key answers about factors affecting success rate of MT in BD cutaneous ulcers.

A Review of the Use of Telemedicine in Dermatologic Surgery.

BACKGROUND: Telemedicine is an emerging field with numerous applications within medicine. Previous review articles describe its use within plastic surgery and otolaryngology but none, to the authors' knowledge, within dermatologic surgery. OBJECTIVE: To provide a review of the applications of telemedicine within dermatologic surgery. MATERIALS AND METHODS: A PubMed search of articles published on teledermatology was conducted in July 2018. Articles were selected based on their relevance to dermatologic surgery and reviewed for their discussion of the applications of telemedicine in surgical and cosmetic dermatology. RESULTS: The initial search resulted in 156 articles. Eleven ultimately met inclusion criteria: 2 in referral and consultation, 5 in telepathology, 2 in intraoperative uses, and 2 in postprocedural care. CONCLUSION: For preoperative consultation, teledermatology enables the surgeon to plan ahead and increases access to care by reducing the number of clinic visits. Telepathology has the potential to allow intraoperative consultation with a dermatopathologist to achieve accurate tumor clearance without delay. Smartglasses represent a promising technology for greater care coordination and a teaching tool. Postprocedural monitoring via text messaging provides convenient access to expert advice and early detection of postoperative complications. With increasing technologic advancements, telemedicine holds great potential to augment the dermatologic surgeon's daily practice.

Surgical management of hidradenitis suppurativa: procedural trends and risk factors.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic debilitating cutaneous disorder. The recalcitrant nature of this disease may require surgery in severe cases. We aimed to delineate the types of operations performed, the risk factors associated with these operations, and the surgical services involved based on a national database. METHODS: Data were collected through the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2016. Current Procedural Terminology (CPT) and International Classification of Disease, Ninth Revision, (ICD-9) codes were used for data extraction and analysis as type of surgery and complication rates were extracted. RESULTS: There were 2594 patients diagnosed with HS: 1405 (54.2%) incision and drainage, 1017 (39.2%) debridement, 31 (1.2%) skin graft, and 141 (5.4%) flap reconstruction. There were significant differences in transfusion rates and operation time among the four procedures. Skin graft and flap reconstruction had the highest complications and longest operation time. Bleeding requiring preoperative transfusion and a number of comorbidities were significant risk factors for postoperative complications. Flap reconstructions by plastic surgeons compared to general surgeons had significantly shorter operation times (134.89 versus 209.82 min, P = 0.022) and lower transfusion rates (2.2% versus 12.8%, P = 0.024). CONCLUSIONS: The management of HS can be complex and may require a multidisciplinary approach. Bleeding requiring preoperative transfusion and other baseline comorbidities are independent risk factors that should be addressed when definitive surgical treatment of hidradenitis is planned. Appropriate surgical specialty involvement may better optimize the surgical outcomes for HS.

Arm Contouring: Review and Current Concepts.

Arm contour improvement is a desired goal of the massive weight loss and the aging population who want to maintain the arm aesthetics. Brachioplasty is a growing and safe procedure to improve the arm contour and different approaches and innovative treatment options have been described since the 1930s. This paper reviews the relevant literature in arm contouring including surgical and nonsurgical procedures used to aesthetically improve the arm. A comprehensive literature review was performed using the words "brachioplasty," "arm lift," "arm contouring," "arm liposuction," "noninvasive arm lift," "minimally invasive arm lift." Commonly used techniques, classification systems, and procedure outcomes are described. The review demonstrated that there are several methods to accomplish good arm contouring. There is no consensus about the best incision type and location, but the classification systems help guide treatment. Assessment of fat excess, skin excess, and location of the deformity (proximal, entire arm, arm and chest) help determine the best approach including liposuction only, skin resection only, a combination of liposuction and excision, or even the use of nonsurgical devices. Infection, hematoma, and unsatisfactory scars are the most commonly reported complications. Brachioplasty is a growing procedure and can be performed with low complication rates and good patient satisfaction. Classification systems stratify deformities to the ideal treatment but no studies have shown the superiority of any technique. Nonsurgical fat removal and skin tightening of the arms are promising procedures for selected patients and higher levels of evidence are needed to show clear indication for different technologies and devices.

The Photodynamic Therapy Experience of a High Volume Laser and Dermatologic Surgery Center.

BACKGROUND: Photodynamic therapy (PDT) is an FDA approved treatment for actinic keratoses (AK's) although multiple off-label indi- cations are reported. Despite frequent use for AK's, no clear consensus exists regarding protocols for overall treatment parameters. METHODS: Retrospective chart review of 1,491 subjects who underwent PDT between 2007 and 2011 at a high volume laser surgery center. Demographic information, clinical history, treatment data, and subsequent diagnosis of skin cancers were recorded. An ex- ploratory subgroup analysis was performed for patients treated for AK and/or squamous cell carcinoma (SCC) that developed SCC or remained SCC-free one year after treatment. RESULTS: The most common indications for PDT were actinic keratoses (n=1404, 94.9%) then NMSC (n=45, 3.0%) The most common treatment site was the head and neck (n=1274, 86.1%). Blue light activation (405-420nm) was used more frequently than red light and visible light. (73.8% vs. 22.8% vs. 6.8%). The most commonly used photosensitizer was aminolevulinic acid (ALA) (98.6%, n=1456). Topical application (97.7% n=1437) of photosensitizer was used more frequently than intralesional administration (2.0%, n=29). 580 patients met subgroup analysis criteria. 66 developed SCC at treatment site (11%). Factors associated with developing SCC were older age, SCC history, Fitzpatrick skin-type 1, and sixty-minute or less incubation times (P less than 0.05 for all factors). The SCC subgroup had a unique distribution of treatment sites (P less than.001). No statistically significant differences were observed for gender or wavelength. CONCLUSION: There are differences in protocols based on indication and location of lesion. Blue light is preferable for superFIcial lesions and red light for deeper lesions. Intralesional delivery is used more commonly for NMSC. Extremities require longer incubation times. PDT may be more effective with younger patients and longer than sixty-minute incubation times. PDT chemoprevention is independent of light source used. J Drugs Dermatol. 2016;15(11):1420-1426..

[Cryosurgery in dermatology]. / Kryochirurgie in der Dermatologie.

This article provides information on the clinical development of skin reactions after cryosurgery/cryotherapy and the indications, complications and contraindications of skin cryosurgery. Successful skin cryosurgery requires rapid freezing and slow thawing, minimum tissue temperature of -25 to -60℃ and, in malignant lesions, repetition of the freeze-thaw cycle. Frozen tissue reacts with peripheral erythema immediately after thawing, followed by edema, bulla formation, exudation and mumification. Lesions usually heal with a fine atrophic scar after approximately 4 weeks. Nowadays, cryosurgery is considered the treatment of choice in hypertrophic scars and keloids, granuloma annulare, small capillary infantile hemangioma and isolated actinic keratoses. It is also a valuable alternative therapy for various other skin diseases, including common warts, solar lentigo, superficial basal cell carcinoma and Kaposi's sarcoma. Cryosurgery is a safe regimen with relatively few adverse effects and contraindications. Pain during and/or shortly after treatment, bulla formation and local edema are the major temporary adverse effects; lesional hypopigmentation and/or peripheral hyperpigmentation is the most common long-term complication.

Current diagnosis and treatment of basal cell carcinoma.

Basal cell carcinoma represents is most common tumor in fair-skinned individuals. In Germany, age-standardized incidence rates are 63 (women) and 80 (men) per 100,000 population per year. Early lesions may be difficult to diagnose merely on clinical grounds. Here, noninvasive diagnostic tools such as optical coherence tomography and confocal laser scanning microscopy may be helpful. The clinical diagnosis is usually confirmed by histology. Standard therapy consists of complete excision with thorough histological examination, either by means of micrographic surgery or, depending on tumor size and location as well as infiltration, using surgical margins of 3-5 mm or more. In particular, multiple basal cell carcinomas (such as in Gorlin-Goltz syndrome) and locally advanced as well as rarely also metastatic basal cell carcinoma may pose a therapeutic challenge. In superficial basal cell carcinoma, nonsurgical therapies such as photodynamic therapy or topical agents may be considered. In case of locally advanced or metastatic basal cell carcinoma, an interdisciplinary tumor board should issue therapeutic recommendations. These include radiation therapy as well as systemic therapy with a hedgehog inhibitor.

[New aspects in reconstructive nasal surgery]. / Neue Aspekte bei der rekonstruktiven Nasenchirurgie.

Developments in surgical procedures have led to improved results in the field of reconstructive nasal surgery. In this article, the authors focus on the forehead flap technique in one of its smallest forms to cover three-layered alar defects. The example of a complete nasal reconstruction shows how, despite the use of a proven surgical concept, serious complications could occur. In the case shown, a satisfactory outcome was achieved by starting anew with the forehead flap in one of the largest forms-the expanded lateral forehead flap. The authors ascribe particular importance to preoperative analysis with standardized series of photographs. Such series should be made before each surgical step. These are indispensable for structured planning and, thus, are prerequisite for an excellent outcome.

Evolution of laser skin resurfacing: from scanning to fractional technology.

BACKGROUND: Laser skin resurfacing was popularized for photoaged and scarred skin 2 decades ago. Since then, several technologic advancements have led to a new generation of delivery systems that produce excellent clinical outcomes with reduced treatment risks and faster recovery times. OBJECTIVES: To review the evolution of laser skin resurfacing from pulsed and scanned infrared laser technology to the latest techniques of nonablative and ablative fractional photothermolysis. MATERIALS AND METHODS: All published literature regarding laser skin resurfacing was analyzed and collated. RESULTS: A comprehensive review of laser skin resurfacing was outlined and future developments in the field of fractionated laser skin treatment were introduced. CONCLUSION: Laser skin resurfacing has evolved such that excellent clinical outcomes in photodamaged and scarred skin are achieved with rapid wound healing. As newer devices are developed, the applications of this technology will have a dramatic effect on the delivery of medical and aesthetic dermatology.

Dermatologists perform the majority of cutaneous reconstructions in the Medicare population: numbers and trends from 2004 to 2009.

BACKGROUND: Dermatologists are experts in skin cancer treatment. Their experience with cutaneous reconstruction may be underrecognized. OBJECTIVE: We sought to determine the percentage of skin reconstruction claims submitted to Medicare by dermatologists relative to other specialists. METHODS: The Medicare Physician Supplier Procedure Master File from 2004 to 2009 was accessed to determine the proportion of layered closures, grafts, and flaps by specialty. RESULTS: In 2009, dermatologic surgeons' (DS) claims accounted for 60.8% of intermediate closures, 75.1% of complex repairs, 55.5% of local tissue rearrangements, and 57.5% of full-thickness skin grafts in the Medicare population. DS billed for the majority of skin reconstructions except simple repairs, split-thickness skin grafts, and interpolation flaps. DS claims represented far more reconstructions of aesthetically important regions of the head and neck-including ears, eyes, nose, and lips-than other fields including plastic surgery and otolaryngology. Over the study period, DS increased the percentage of skin reconstructions in nearly every category relative to other specialists. LIMITATIONS: This analysis is limited to the Medicare population and addresses claim volumes only. Cosmetic outcomes or appropriateness of closure selection or coding cannot be addressed. CONCLUSIONS: DS perform the highest volumes of repairs in the Medicare population. DS play a primary role in routine and advanced cutaneous reconstructive surgery, especially of aesthetically important regions.

Lasers for cutaneous congenital vascular lesions: a comprehensive overview and update.

The use of laser to treat cutaneous lesions began with Dr. Leon Goldman and his coworkers in 1963. Ten years later, these authors described promising effects on angiomas using the continuous-wave neodymium:yttrium-aluminum-garnet laser. In 1983, Anderson et al. proposed the photothermolysis theory. The selective destruction of vascular lesions is based on this principle, and it is still a guide for treatment of vascular lesions. Over the past 25 years, laser treatment of cutaneous vascular lesions has progressed significantly. Vascular lasers such as argon, tunable dye, krypton, and copper vapor were used in the past and were associated not only with risk of scarring but also hyper- and hypopigmentation. Since then, new devices were developed in order to minimize these side effects. This article presents an overview and update of the current available treatment of cutaneous vascular lesions and covers future directions for vascular laser technology.