Novel Biomaterial Containing Gelatin, Manuka Honey, and Hydroxyapatite Enhanced Secondary Intention Healing Versus Standard Secondary Intention Healing in Mohs Surgical Defects on the Head and Distal Lower Extremities-A Randomized Controlled Trial: Pilot Study.

BACKGROUND: Randomized, comparative studies evaluating augmented secondary intention healing (SIH) compared with conventional SIH in dermatologic surgery are limited. This study aimed to evaluate whether the use of a novel biomaterial enhances SIH, particularly in shortening time to complete re-epithelialization. OBJECTIVE: The purpose of this study was to elucidate whether a novel biomaterial containing gelatin, manuka honey, and hydroxyapatite enhances SIH when compared with conventional SIH for surgical defects after Mohs micrographic surgery (MMS) on the head and distal lower extremities. MATERIALS AND METHODS: Thirty-seven patients were enrolled in this randomized controlled trial. Patients undergoing MMS on the head or distal lower extremities were eligible for recruitment. After clear surgical margins were obtained post-MMS, patients were randomized to receive standard SIH or biomaterial enhanced SIH. Patients had regularly scheduled follow-ups with questionnaires at each visit until complete re-epithelialization was achieved. RESULTS: Overall, there was no significant difference in time to re-epithelialization between standard SIH and biomaterial-enhanced SIH. However, there was a significant decrease in pain scores and skin thickness in the biomaterial-enhanced SIH group. CONCLUSION: Biomaterial-enhanced SIH is noninferior to standard SIH and produces less pain and favorable skin thickness compared with standard SIH. ClinicalTrials.gov listing: NCT04545476.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Sebaceous carcinoma: evidence-based clinical practice guidelines.

Sebaceous carcinoma usually occurs in adults older than 60 years, on the eyelid, head and neck, and trunk. In this Review, we present clinical care recommendations for sebaceous carcinoma, which were developed as a result of an expert panel evaluation of the findings of a systematic review. Key conclusions were drawn and recommendations made for diagnosis, first-line treatment, radiotherapy, and post-treatment care. For diagnosis, we concluded that deep biopsy is often required; furthermore, differential diagnoses that mimic the condition can be excluded with special histological stains. For treatment, the recommended first-line therapy is surgical removal, followed by margin assessment of the peripheral and deep tissue edges; conjunctival mapping biopsies can facilitate surgical planning. Radiotherapy can be considered for cases with nerve or lymph node involvement, and as the primary treatment in patients who are ineligible for surgery. Post-treatment clinical examination should occur every 6 months for at least 3 years. No specific systemic therapies for advanced disease can be recommended, but targeted therapies and immunotherapies are being developed.

Rejuvenation of the neck with liposuction and ancillary techniques.

An aesthetically pleasing neck is an important component of physical appearance and a frequently targeted area for a variety of rejuvenative procedures. In appropriately selected patients, liposuction of the neck using tumescent local anesthesia can effectively render a more youthful appearance to the anterior and lateral neck by removing superficial adipose tissue and redraping the skin. This article will review all aspects of neck liposuction, including neck and lower face anatomy, proper patient selection and evaluation, necessary equipment, as well as all peri-procedural management. An in-depth discussion of administration of tumescent local anesthesia and proper liposuction technique is also included. Lastly, a number of ancillary techniques to further enhance the appearance of the neck including laser lipolysis, fractional ablative CO(2) resurfacing, and treatment of platysmal banding will be briefly discussed.

Ablative fractional CO2 resurfacing for photoaging of the hands: pilot study of 10 patients.

Extrinsic aging of the hands involves alterations in pigmentation, wrinkling, and texture as a result of chronic ultraviolet and environmental exposures. Inherent tissue properties of the skin of the dorsal hand have made it challenging to safely and effectively improve all three parameters of photoaging with a single device. Recent successes with non-ablative fractional lasers on the hands, as well as success of ablative fractional lasers on the neck and chest, raise the question of potential efficacy of ablative lasers for photorejuvenation of the hands. This was a prospective pilot study of ablative fractional CO(2) laser in 10 participants, each receiving three treatments to one hand at 4-6-week intervals. Subjective assessments by investigator and participants were performed 1 month after each treatment. At 1-month follow-up after final treatment, investigators rated mean improvement of 26-50% for wrinkles, 51-75% for pigment, and 26-50% for texture. Participants rated mean improvement after final treatment as 26-50% for wrinkles, 51-75% for pigment, and 51-75% for texture. Other than significant edema noted in one participant after the first treatment, side effects were limited to transient erythema and edema, with no long-term scarring or pigmentary alteration. In this pilot study, ablative fractional resurfacing was safe and effective for the treatment of all markers of extrinsic aging of the hands. A high degree of improvement was achieved in two to three treatments with no long-term sequelae.

MAL-PDT for difficult to treat nonmelanoma skin cancer.

With an incidence of over 3.5 million nonmelanoma skin cancers (NMSCs) per year in the United States, there is an increasing need for effective, cost-effective treatments for NMSC. When surgical excision is impractical or not feasible, methyl aminolevulinate photodynamic therapy (MAL-PDT) has demonstrated consistently high long-term cure rates ranging from 70-90%, with superior cosmetic outcomes compared with other treatment modalities. With the exception of invasive squamous cell carcinoma, MAL-PDT has been successful in treating all types of NMSC, especially in patients with multiple comorbidities, field cancerization, and lesions in cosmetically sensitive locations. Herein, a step-by-step description of the procedure for MAL-PDT is provided, followed by a review of outcomes from large clinical trials performed over the past 15 years for each variant of NMSC. After reading this review, clinicians should have a thorough understanding of the benefits and limits of MAL-PDT, and should be able to add this valuable procedure to their armamentarium of therapies for NMSC.

Ultrasound-guided drainage of a seroma following tumescent liposuction.

Of the complications that can occur following tumescent liposuction, seroma formation is unusual. It is a common practice for seromas to be aspirated blindly with a needle and syringe. We present a case of seroma formation following liposuction, with a subsequent step-by-step technical description of ultrasound-guided drainage of the seroma. Utilization of ultrasound provides a safe, effective method for aspirating seromas, allowing for accurate visualization and delineation of the seroma margins, proper needle placement, and monitoring of progress. It is a simple and useful tool in postprocedural management of patients undergoing liposuction.

Novel method of minimally invasive removal of large lipoma after laser lipolysis with 980 nm diode laser.

Lipomas are the most common benign tumor of the soft tissue, often presenting as soft, mobile subcutaneous masses. These lesions are often removed for cosmetic reasons, although they may be removed secondary to considerable discomfort or paresthesias. The large majority of lipomas appear as small, solitary lesions that are best removed by surgical excision. However, surgical removal of large (>10 cm) or multiple lesions may result in significant scarring. Tumescent local anesthesia and liposuction of larger lesions has been successful in a number of cases although this technique can be hindered by overly fibrous lesions. Laser lipolysis, performed alone or before liposuction, can further facilitate removal of these lesions. This technique is a minimally invasive and effective method of lipoma removal, resulting in an excellent cosmetic outcome. This report describes step-by-step removal of a large lipoma located on the back, as well as a review of currently employed techniques for minimally invasive treatment of lipomas.

Enhanced healing of surgical wounds of the lower leg using weekly zinc oxide compression dressings.

BACKGROUND: Management of lower extremity wounds after Mohs micrographic surgery can pose a challenge to the surgeon. Postoperative reactive edema and inflammation can lead to a painful and protracted healing course. Unna boots deliver zinc oxide to the wound bed and surrounding skin while providing compression and occlusion of the wound. OBJECTIVE: To evaluate the utility of weekly Unna boot therapy in decreasing postoperative edema, inflammation, and morbidity; minimizing postoperative wound care; and improving the rate of wound healing in patients with lower leg surgical defects. METHODS: Ten patients (6 men, 4 women) aged 72 to 91 with postoperative defects on the distal lower extremity were treated with weekly Unna boots until wounds had sufficiently granulated or re-epithelialized. RESULTS: In all 10 patients, weekly Unna boot therapy was well tolerated, with high satisfaction levels relating to minimal postoperative wound care, rapid granulation, minimal pain, and excellent esthetic outcome of postoperative wounds. No infections or other complications were noted during the healing process. LIMITATIONS This was not a randomized, controlled trial. CONCLUSIONS: In patients with postoperative wounds of the lower leg, weekly Unna boots significantly improve the healing process, decrease postoperative pain, and minimize wound care.

Human cadaveric dermal matrix for management of challenging surgical defects on the scalp.

BACKGROUND: Biologic scaffolds have shown promise in patients unable to tolerate prolonged surgical closure or extensive wound care, but there has been little research in the field of Mohs micrographic surgery (MMS) on human cadaveric dermis in this capacity. OBJECTIVE: To evaluate the utility of human cadaveric dermis as a means of decreasing operative time, minimizing postoperative wound care, and improving aesthetic outcomes in selected patients with deep surgical defects, including those with exposed bone. METHODS: Fourteen patients (8 men, 6 women) with deep postoperative defects after MMS were treated with a cadaveric dermal allograft as part or all of their postoperative wound management. RESULTS: Allograft placement was well tolerated, with high satisfaction levels relating to minimal postoperative wound care and aesthetic outcome. Significantly shorter operative times were noted in all patients than with primary closure or grafting. CONCLUSION: In patients with significant comorbidities, inability to tolerate extended surgical repairs, or inability to perform extensive wound care, human cadaveric dermal allografts can decrease operative time and minimize wound care complexity while providing an excellent aesthetic outcome in many cases. Shorter healing times than expected were also noted in a number of patients. The authors have indicated no significant interest with commercial supporters.

Sentinel lymph node biopsy and melanoma: 2010 update Part I.

UNLABELLED: Sentinel lymph node biopsy for melanoma was introduced in the early 1990s as a minimally invasive method of identifying and pathologically staging regional lymph node basins in patients with clinical stage I/II melanoma. Numerous large trials have demonstrated that sentinel lymph node evaluation has utility in improving accuracy of prognostication and for risk stratifying patients into appropriate groups for clinical trials. However, there remains a great deal of controversy regarding the therapeutic role of removal of the remainder of locoregional lymph nodes should metastatic cells be identified in the sentinel node. This CME article will outline a brief history of the sentinel node concept before reviewing updates in surgical technique, histopathologic evaluation of nodal tissue, and cost effectiveness of sentinel node biopsy. LEARNING OBJECTIVES: After completing this learning activity, participants should be able to describe the concept of sentinel lymph node biopsy, to discuss the risks and benefits associated with this procedure, and to summarize the role of sentinel lymph node biopsy in management of patients with melanoma.

Sentinel lymph node biopsy and melanoma: 2010 update Part II.

UNLABELLED: This article will discuss the evidence for and against the therapeutic efficacy of early removal of potentially affected lymph nodes, morbidity associated with sentinel lymph node biopsy and completion lymphadenectomy, current guidelines regarding patient selection for sentinel lymph node biopsy, and the remaining questions that ongoing clinical trials are attempting to answer. The Sunbelt Melanoma Trial and the Multicenter Selective Lymphadenectomy Trials I and II will be discussed in detail. LEARNING OBJECTIVES: At the completion of this learning activity, participants should be able to discuss the data regarding early surgical removal of lymph nodes and its effect on the overall survival of melanoma patients, be able to discuss the potential benefits and morbidity associated with complete lymph node dissection, and to summarize the ongoing trials aimed at addressing the question of therapeutic value of early surgical treatment of regional lymph nodes that may contain micrometastases.

Extranodal natural killer cell/t-cell lymphoma, nasal type, presenting as cutaneous nodules and a small-bowel perforation.

Extranodal natural killer (NK) cell/T-cell lymphoma, nasal type, is a rare aggressive neoplasm, most commonly presenting as a destructive lesion in the nasal cavity and nasopharynx in middle-aged to older adults. About one third of cases present in an extranasal location, commonly involving skin and gastrointestinal tract, and usually occur in the absence of superficial lymphadenopathy. Diagnosis of this malignancy can be missed given its rarity and heterogeneous presentation. We describe a patient with an extranodal NK cell/T-cell lymphoma, nasal type, who was initially diagnosed and treated for a presumed Mycobacterium marinum infection, after biopsies were unrevealing. However, after more serious complications developed, repeat biopsy was performed. An atypical lymphocytic infiltrate was noted, with cells being positive for NK cell/T-cell markers CD2, CD7, and CD3 (subset), as well as for cytotoxic lymphocyte markers perforin, T-cell intracellular antigen, and CD56. In situ hybridization for Epstein-Barr virus-encoded RNA was also positive. This case demonstrates an important diagnostic pitfall of confusing cutaneous involvement by an aggressive NK cell/T-cell lymphoma with an antibiotic-resistant infection. Repeat biopsies and close clinicopathologic correlation are essential for establishment of correct diagnosis.

Evidence-Based Clinical Practice Guidelines for Microcystic Adnexal Carcinoma: Informed by a Systematic Review.

IMPORTANCE: Microcystic adnexal carcinoma (MAC) occurs primarily in older adults of white race/ethnicity on sun-exposed skin of the head and neck. There are no formal guiding principles based on expert review of the evidence to assist clinicians in providing the highest-quality care for patients. OBJECTIVE: To develop recommendations for the care of adults with MAC. EVIDENCE REVIEW: A systematic review of the literature (1990 to June 2018) was performed using MEDLINE, Embase, Web of Science, and the Cochrane Library. The keywords searched were microcystic adnexal carcinoma, sclerosing sweat gland carcinoma, sclerosing sweat duct carcinoma, syringomatous carcinoma, malignant syringoma, sweat gland carcinoma with syringomatous features, locally aggressive adnexal carcinoma, and combined adnexal tumor. A multidisciplinary expert committee critically evaluated the literature to create recommendations for clinical practice. Statistical analysis was used to estimate optimal surgical margins. FINDINGS: In total, 55 studies met our inclusion criteria. The mean age of 1968 patients across the studies was 61.8 years; 54.1% were women. Recommendations were generated for diagnosis, treatment, and follow-up of MAC. There are 5 key findings of the expert committee based on the available evidence: (1) A suspect skin lesion requires a deep biopsy that includes subcutis. (2) MAC confined to the skin is best treated by surgery that examines the surrounding and deep edges of the tissue removed (Mohs micrographic surgery or complete circumferential peripheral and deep margin assessment). (3) Radiotherapy can be considered as an adjuvant for MAC at high risk for recurrence, surgically unresectable tumors, or patients who cannot have surgery for medical reasons. (4) Patients should be seen by a physician familiar with MAC every 6 to 12 months for the first 5 years after treatment. Patient education on photoprotection, periodic skin self-examination, postoperative healing, and the possible normal changes in local sensation (eg, initial hyperalgesia) should be considered. (5) There is limited evidence to guide the treatment of metastasis in MAC due to its rarity. Limitations of our findings are that the medical literature on MAC comprises only retrospective reviews and descriptions of individual patients and there are no controlled studies to guide management. CONCLUSIONS AND RELEVANCE: The presented clinical practice guidelines provide an outline for the diagnosis and management of MAC. Future efforts using multi-institutional registries may improve our understanding of the natural history of the disease in patients with lymph node or nerve involvement, the role of radiotherapy, and the treatment of metastatic MAC with drug therapy.