Electrosurgical facial resurfacing: a prospective multicenter study of efficacy and safety.

BACKGROUND: A novel electrosurgical technology that uses a bipolar electrode-tipped stylet to deliver relatively low-radiofrequency energy through an electrically conductive medium has been developed. OBJECTIVE: To evaluate the efficacy and safety of the radiofrequency resurfacing system for the treatment of facial wrinkles. DESIGN: Multicenter, prospective, noncomparative study with longitudinal follow-up. SETTING: Four US academic dermatologic surgery clinics. PATIENTS: Ninety-five patients with mild to severe photodamage (Fitzpatrick classes I-III) involving periorbital (75 treatment sites) and perioral (50 sites) facial skin. INTERVENTION: Radiofrequency resurfacing with the use of 2 to 3 passes at 125 or 139 V. MAIN OUTCOME MEASURES: Wrinkle and cosmetic improvements evaluated by patients, investigators, and, by means of photographs, an independent panel of 5 evaluators. RESULTS: All evaluators determined a positive mean improvement in wrinkles for both periorbital and perioral anatomic sites, with greater improvement for patients with more severe wrinkles at baseline. An increased number of passes and higher voltage settings had a positive impact on wrinkle improvement. Transient postinflammatory hyperpigmentation occurred in 26% of periorbital and 4% of perioral sites. Hypertrophic scars occurred in 3.8% of treatment sites, with all but 1 scar resolving by 6 months. For the most part, healing was rapid, pain was minimal, and erythema largely resolved within 2 months. Other untoward effects were relatively few and short-lived. CONCLUSIONS: At the study settings used, radiofrequency resurfacing is an effective modality in the treatment of periorbital and perioral wrinkles in patients with Fitzpatrick class I, II, and III photodamage. There is less severe postoperative morbidity than seen with carbon dioxide or coagulating erbium:YAG lasers. The potential risks are similar to those seen with other resurfacing modalities.

Microcystic adnexal carcinoma: forty-eight cases, their treatment, and their outcome.

BACKGROUND: Microcystic adnexal carcinoma, or sclerosing sweat duct carcinoma, is an uncommon cutaneous neoplasm associated with extensive local invasion. The standard of care with regard to the best excisional method in treating microcystic adnexal carcinoma has not been established. OBJECTIVES: To perform a retrospective study comparing patients treated by Mohs micrographic surgery with those treated by wide excision and to elucidate the epidemiological features of microcystic adnexal carcinoma. PATIENTS AND METHODS: A retrospective analysis of a case series involving 48 primary and referral patients diagnosed as having microcystic adnexal carcinoma using standardized criteria. All cases were reviewed by the same dermatopathologists. RESULTS: Microcystic adnexal carcinoma predominantly affects the left side of the face of middle-aged women. Microcystic adnexal carcinoma is misdiagnosed 30% of the time. The recurrence rate is 1.98% per patient-year. Mohs micrographic surgery and simple excision show comparable complication rates. Clear margins were obtained in fewer procedures and, therefore, fewer office visits when the lesions were treated with micrographic surgery. The defect surface area after full extirpation following Mohs micrographic surgery was a mean of 4 times that of the clinically apparent size. The wide range of difference between the pre- and the post-Mohs micrographic surgery surface area noted in our data indicates that a margin cannot be safely predicted. CONCLUSIONS: Microcystic adnexal carcinoma is a predominantly left-sided, locally aggressive facial tumor, which results in significant morbidity. Our data do not support the use of standardized predictable margins. Mohs micrographic surgery is a reasonable initial treatment, as it accomplishes cure in fewer office visits and does not rely on predicted margins.

Efficacy of a 2-mm spot size lens for the treatment of superficial vascular lesions with a flashlamp-pumped dye laser.

BACKGROUND: The flashlamp-pumped dye laser, using either a 3 or 5 mm spot size, is an excellent instrument for the treatment of port-wine stains and other superficial cutaneous vascular lesions. Problems exist with patient acceptance due to prominent and prolonged blue-black discoloration and the pain associated with the treatment. OBJECTIVE: To assess the effectiveness of a flashlamp-pumped dye laser equipped with a 2 mm spot size lens in the treatment of superficial vascular lesions. METHODS: Twenty-one patients with telangiectasias, cherry angiomas, and angiokeratomas were treated at a variety of fluences. RESULTS: Three of 21 patients had complete clearing of their superficial vascular lesions. An improvement of greater than 75% was noted by 11 patients, and six patients noted a 50%-75% improvement. One patient had less than 50% improvement. Less post-treatment discoloration and less pain were noted with the 2 mm spot size lens. CONCLUSIONS: The 2 mm spot size lens, used with the flashlamp-pumped dye laser is an effective instrument for the treatment of superficial cutaneous vascular lesions.

Repair of central upper lip (philtral) surgical defects with island pedicle flaps.

BACKGROUND: Surgical defects of the central upper lip (philtrum) are a particularly difficult area to achieve satisfactory cosmetic and functional repair. Reconstruction of the central upper lip has been accomplished primarily through the use of side-to-side closure, bilateral advancement or rotation flap, and full-thickness graft. Repair may be complicated by distortion of the vermilion border, obliteration of the normal contour of the philtrum, eclabium, and trapdooring of the flap. OBJECTIVE: We review the options for reconstruction of this area and describe our experience using an island pedicle flap to complete reconstruction. METHODS: Four patients presented with basal cell carcinomas of the mid upper lip (philtrum). Tumors were cleared by Mohs micrographic surgery. Reconstruction was achieved by island pedicle flaps utilizing donor tissue from the superior philtrum. RESULTS: The patients had excellent cosmetic results with minimal distortion of the vermilion border or obliteration of the philtrum or philtral ridges. Scars healed in a nearly imperceptible fashion, keeping within one cosmetic unit (the philtrum) without extending along the vermilion border as seen in bilateral advancement or rotation flaps. CONCLUSIONS: Island pedicle flaps may be an effective cosmetic and functional repair of selected surgical defects of the central upper lip involving the philtrum.

Treatment of adenoma sebaceum with the copper vapor laser.

BACKGROUND: Angiofibromas of the central part of the face (adenoma sebaceum) occur pathognomonically in tuberous sclerosis, causing significant cosmetic and hygienic morbidity. Treatment has included excision, dermabrasion, cryosurgery, carbon dioxide laser, and argon laser. Copper vapor lasers emit light at 511 nm (green) ad 578 nm (yellow), useful for treating pigmented and vascular lesions, respectively. OBJECTIVE: Because of the vascular nature and progressive pigmentation of adenoma sebaceum, we examined the utility of the copper vapor laser in treating this disorder. METHODS: Nine patients with adenoma sebaceum were treated with the copper vapor laser. Individual lesions were treated with the yellow light (578 nm) at 0.4 to 0.6 mW. Pigmented lesions or lesions resistant to treatment were treated with the green light (511 nm) at 0.4 to 0.9 mW. Intervals between treatments were at least 6 weeks. RESULTS: Good to excellent cosmetic results were seen in all treated patients. Scarring or hyperpigmentation occurred in none of the patients. Most patients required additional treatments with the copper vapor laser as new lesions developed. CONCLUSION: The copper vapor laser is safe and effective for the treatment of adenoma sebaceum in tuberous slerosis.

Antibiotic prophylaxis in dermatologic surgery.

Antibiotic prophylaxis is generally administered either to prevent wound infection or to hinder the development of endocarditis. Although the use of antibiotics in certain circumstances to prevent wound infection can be straightforward, there are other circumstances in which the decision to use antibiotics is much less clear. Endocarditis prophylaxis has traditionally been based on the American Heart Association's guidelines, which do not cover dermatologic surgery. This article discusses the rationale and controversies surrounding the use of antibiotic prophylaxis for prevention of both wound infection and endocarditis, reviews the few studies that pertain to dermatology, and provides recommendations for antibiotic prophylaxis on a case-by-case basis for those who perform dermatologic surgery.

Sterilization of the handengine. Is it a necessity?

BACKGROUND: The risk of interpatient infection through a dermabrasion handpiece is not known, nor is there a published standard of handpiece maintenance. OBJECTIVE: To investigate the possibility of transferring material through the handpiece and evaluate the methods used by dermatologists to disinfect and/or sterilize dermabrasion equipment. METHODS: Handengines run while immersed in fluorescein-dyed alcohol were observed for fluorescence. After dermabrasion of a fluorescein-basted pig's foot the instrument was inspected. A survey of handpiece disinfection/sterilization procedures was sent to 114 members of the American Society for Dermatologic Surgery. RESULTS: Although material can be transmitted to the motor/handpiece through the chuck and vice versa, contamination of the instrument did not occur in a dermabrasion simulation. 58.7% of respondents sterilize the chuck and only 38.1% sterilize the motor/handpiece. CONCLUSIONS: No absolute requirement to sterilize the handengine is warranted. It is prudent however to sterilize the chuck in a steam autoclave and gas sterilize the motor/handpiece to eliminate the rare possibility of cross-contamination.

510-nm pigmented lesion dye laser. Its characteristics and clinical uses.

BACKGROUND: Benign pigmented lesions are of a cosmetic concern to many individuals. Numerous treatments exist, including several types of lasers. The Candela 510 nm pigmented lesion dye laser has recently been added to this armamentarium. It is designed specifically for the treatment of superficial pigmented lesions while significantly decreasing the risk of scarring and prolonged hypopigmentation. OBJECTIVES: To describe the characteristics of the Candela pigmented lesion dye laser and report on the therapeutic outcome of patients treated for actinic lentigines, café-au-lait macules, melasma and red tattoos by one of the authors (RCG). METHODS: The Candela 510 nm pigmented lesion dye laser was used to treat solar lentigines, café-au-lait macules, melasma and red tattoo. RESULTS: Excellent outcomes resulted on facial and hand lentigines (89% and 88% of patients had greater than 75% clearing, respectively), but often required more than one treatment. Lentigines located on the upper extremities and trunk improved less dramatically. Immediate greying occurred universally. Bruising was often noted. Treatment failures have been observed especially in treating lentigines located on the lower extremities. Café-au-lait macules responded inconsistently, with facial lesions giving the best results. Melasma responded poorly, often with hyperpigmentation. Three red tattoos cleared. Treatment failure may be related to inaccurate clinical assessment of pigment depth or regrowth of the lesion. Several cases are presented to demonstrate clinical and histologic effects of the laser. CONCLUSION: The Candela 510-nm pigmented lesion dye laser is an effective treatment for superficial pigmented lesions. Its associated morbidity is minimal.

Distinct infrared spectroscopic patterns of human basal cell carcinoma of the skin.

Infrared spectroscopy combined with high pressure (pressure-tuning infrared spectroscopy) was applied to the study of paired sections of basal cell carcinomas (BCC) and normal skin from ten patients. Atmospheric pressure IR spectra from BCC were dramatically different from those from the corresponding normal skin. Compared to their normal controls, BCCs displayed increased hydrogen bonding of the phosphodiester group of nucleic acids, decreased hydrogen bonding of the C--OH groups of proteins, increased intensity of the band at 972 cm-1, a decreased intensity ratio between the CH3 stretching and CH2 stretching bands, and accumulation of unidentified carbohydrates. Some of these changes are shared by all human epithelial malignancies studied to date, while some others appear as yet unique to basal cell carcinoma. The diagnostic value of infrared spectroscopy in BCC remains to be determined.

Pulsed-dye laser therapy for cutaneous Kaposi's sarcoma associated with acquired immunodeficiency syndrome.

BACKGROUND: Cutaneous lesions of Kaposi's sarcoma associated with acquired immunodeficiency syndrome (AIDS-KS) are disfiguring. OBJECTIVE: This study assesses the response of AIDS-KS to pulsed-dye laser (PDL) therapy. METHODS: The PDL was used to treat 15 AIDS-KS patients. Treatment was repeated at 4-week intervals. On average, patients received three treatments per treated lesion. RESULTS: At 6 weeks' follow-up, the patients' treated lesions were reduced in size when compared with their matched control lesions (p less than 0.002). A complete or partial clinical response occurred in 44% of treated lesions (17 of 39) compared with 18% of matched control lesions (7 of 39) [corrected]. Patients experienced limited pain, infrequent blistering, and no scarring. However, histopathologic findings of treated lesions throughout therapy correlated poorly with clinical response. At 12 weeks, all treated lesions had recurred. CONCLUSION: PDL therapy for AIDS-KS is not recommended. Although safe, the rapid recurrence of disease at initially responsive sites would require costly, long-term therapy to maintain cosmetic improvement.

Nonmelanoma skin cancers and infection with the human immunodeficiency virus.

BACKGROUND AND DESIGN: Forty-eight human immunodeficiency virus-infected patients with nonmelanoma skin cancers seen during a four-year period were evaluated in a retrospective, case-control study. Patients were followed up after therapy and recurrence rates were determined. RESULTS: One hundred and sixteen nonmelanoma skin cancers were identified, 101 of which were basal cell carcinomas (87%), mostly superficial multicentric (67%) of the trunk (62%). There were 15 low-grade squamous cell carcinomas, most commonly of the head and neck. Half of the patients had multiple cancers. Compared with age-matched controls, the patients with skin cancer more commonly had blue/hazel eyes (89% vs 66%; odds ratio [OR] 4.1; confidence interval [CI], 1.25 to 13.44; P = .033), blond hair (42% vs 13%; OR = 4.53; CI, 1.40 to 13.74, P = .003), a family history of skin cancer (45% vs 5%; OR = 11.88; CI, 2.85 to 49.57; P = .00), and a history of regular sunbathing (92% vs 48%; OR = 11.24; CI, 3.17 to 39.83; P = .00). The number of cancers or the presence of squamous cell carcinoma did not correlate with the degree of immunosuppression. The recurrence rate for basal cell carcinomas following standard treatment methods (mostly curettage and electrodesiccation and excision) was 5.4% for those tumors followed up for longer than 12 months. Three of the 15 squamous cell carcinomas recurred, all following curettage and electrodesiccation. CONCLUSION: Nonmelanoma skin cancers are a not uncommon cutaneous finding in human immunodeficiency virus-infected patients. The major risk factors for developing skin cancer in association with human immunodeficiency virus disease seem to be the same as in the normal population--fair skin, a positive family history, and sun exposure. Standard treatment methods seem to be associated with acceptable cure rates, except for squamous cell carcinomas, which had a high (20%) recurrence rate following curettage and electrodesiccation.

Laser skin testing.

In order to accomplish more uniformity for standardization of allergy skin testing, a technique using a CO2 laser in place of a needle was developed. The dose of laser light was based on comparison of biopsies of punctures with Morrow-Brown Needles and varying combinations of laser energy parameters. The resulting laser settings were tested in twenty volunteers who had been referred for skin testing. Blinded tests were conducted with both procedures in parallel using histamine, saline, Dermatophagoides pteronyssinus, and Lolium perenne. Comparable whealing reactions were produced by laser skin testing and puncture testing with a Morrow-Brown Needle. These results suggest several potential advantages of laser skin testing over the existing test.

Synthetic membranes and cultured keratinocyte grafts.

Significant progress has been made in skin replacement options in the past several decades. Although initially various materials have been used mainly for burn coverage, their application to dermatologic practice has increased significantly. We review the research, progress, and other aspects of wound coverage with synthetic membranes and cultured epithelial sheets in both burn and nonburn wound management.

Cancer of the forehead and temple regions.

Several characteristics inherent in tumors of the forehead and temple provide therapeutic challenges for the physician. These include spread along anatomic structures, a propensity toward aggressive growth patterns, the risk of nerve damage, and the preservation of important cosmetic landmarks. As a result of these problems, Mohs micrographic surgery is often indicated in the treatment of skin cancer of the forehead and temple. The high cure rates afforded by micrographic surgery, even for aggressive tumors, and tissue conservation are benefits to the patient. Although most BCCs and SCCs in this region can be handled by a dermatologic surgeon, patients may present with aggressive or neglected tumors exhibiting extensive invasion. These patients may require a cooperative approach between the dermatologic and head and neck surgeon to achieve complete tumor extirpation or appropriate reconstruction. In this article, we have tried to indicate the rationale behind the use of Mohs micrographic surgery for tumors of the forehead and temple. In selected tumors, a team approach between the micrographic and other surgeons will maximize both tumor excision and functional and cosmetic repair for the patient.

The use of carbon dioxide laser in lichen myxedematosus.

Lichen myxedematosus is characterized by deposits of mucin in the dermis. Treatment can be systemic or local, depending on the clinical findings. We present a patient with pedunculated lesions on his nose, and a generalized thickening of his facial skin. The patient requested treatment of his nasal lesions. We elected to remove his nodules surgically using the carbon dioxide (CO2) laser. The technique is described and treatment options are reviewed.

Local anesthesia in dermatologic surgery.

With the growth of dermatologic surgery the appropriate use of local anesthesia is becoming an important issue. Thoughtful use of local anesthesia can improve the patient's experience and facilitate the surgical procedure. In this review we discuss historical and pharmacologic aspects of local anesthetic agents. Emphasis is placed on clinical considerations, including contraindications, toxic reactions, and detailed descriptions of anesthetic use.