Jeff Evans

BARCELONA — Anti-tumor necrosis factor-α drugs may aid insulin resistance in rheumatoid arthritis, according to studies presented at the annual European Congress of Rheumatology.

Traditional and nontraditional risk factors, like systemic inflammation and insulin resistance, have been implicated in cardio-vascular disease in RA, said Dr. Sabrina Paolino of the University of Genova, Italy. Insulin resistance also has been shown to influence the development and progression of atherosclerotic lesions in rheumatic diseases and RA.

Dr. Paolino and colleagues compared 32 patients with active RA who were treated with either infliximab (3 mg/kg at week 0, 2, 6, and every 8 weeks thereafter) or etanercept (25 mg twice per week), with 20 RA patients not on anti-TNF-α drugs. All patients received prednisone (maximum of 7.5 mg/day) and methotrexate (10 mg/week). Subjects with frank diabetes; viral hepatitis B or C infection; any malignancy; liver or kidney disease; or endocrine or metabolic disorders, or who took medications that influence glucose metabolism were excluded.

At 24 weeks, patients on anti-TNF-α therapy had significantly greater improvement in disease activity score using 28 joint counts, the Quantitive Insulin Sensitivity Check Index, and the homeostasis model assessment of insulin resistance (HOMA) than those not on anti-TNF-α drugs. There were no differences in insulin resistance between patients on etanercept and those on infliximab.

In a poster presented at the Congress, insulin resistance as calculated on the HOMA index and hemoglobin A_1c were significantly lower in 16 nondiabetic RA patients after 1 year of anti-TNF-α therapy. No significant changes occurred during follow-up on dietary questionnaires, physical activity levels, anthropometric measurements, body mass index, or fat mass to confound the anti-TNF-α and insulin resistance link. Cholesterol and triglyceride levels did not change, said Dr. Sigrid Talaverano and associates at the University Hospital of the Canary Islands, La Cuesta, Spain.

BARCELONA — Anti-tumor necrosis factor-α drugs may aid insulin resistance in rheumatoid arthritis, according to studies presented at the annual European Congress of Rheumatology.

Traditional and nontraditional risk factors, like systemic inflammation and insulin resistance, have been implicated in cardio-vascular disease in RA, said Dr. Sabrina Paolino of the University of Genova, Italy. Insulin resistance also has been shown to influence the development and progression of atherosclerotic lesions in rheumatic diseases and RA.

Dr. Paolino and colleagues compared 32 patients with active RA who were treated with either infliximab (3 mg/kg at week 0, 2, 6, and every 8 weeks thereafter) or etanercept (25 mg twice per week), with 20 RA patients not on anti-TNF-α drugs. All patients received prednisone (maximum of 7.5 mg/day) and methotrexate (10 mg/week). Subjects with frank diabetes; viral hepatitis B or C infection; any malignancy; liver or kidney disease; or endocrine or metabolic disorders, or who took medications that influence glucose metabolism were excluded.

At 24 weeks, patients on anti-TNF-α therapy had significantly greater improvement in disease activity score using 28 joint counts, the Quantitive Insulin Sensitivity Check Index, and the homeostasis model assessment of insulin resistance (HOMA) than those not on anti-TNF-α drugs. There were no differences in insulin resistance between patients on etanercept and those on infliximab.

In a poster presented at the Congress, insulin resistance as calculated on the HOMA index and hemoglobin A_1c were significantly lower in 16 nondiabetic RA patients after 1 year of anti-TNF-α therapy. No significant changes occurred during follow-up on dietary questionnaires, physical activity levels, anthropometric measurements, body mass index, or fat mass to confound the anti-TNF-α and insulin resistance link. Cholesterol and triglyceride levels did not change, said Dr. Sigrid Talaverano and associates at the University Hospital of the Canary Islands, La Cuesta, Spain.

BARCELONA — Anti-tumor necrosis factor-α drugs may aid insulin resistance in rheumatoid arthritis, according to studies presented at the annual European Congress of Rheumatology.

Traditional and nontraditional risk factors, like systemic inflammation and insulin resistance, have been implicated in cardio-vascular disease in RA, said Dr. Sabrina Paolino of the University of Genova, Italy. Insulin resistance also has been shown to influence the development and progression of atherosclerotic lesions in rheumatic diseases and RA.

Dr. Paolino and colleagues compared 32 patients with active RA who were treated with either infliximab (3 mg/kg at week 0, 2, 6, and every 8 weeks thereafter) or etanercept (25 mg twice per week), with 20 RA patients not on anti-TNF-α drugs. All patients received prednisone (maximum of 7.5 mg/day) and methotrexate (10 mg/week). Subjects with frank diabetes; viral hepatitis B or C infection; any malignancy; liver or kidney disease; or endocrine or metabolic disorders, or who took medications that influence glucose metabolism were excluded.

At 24 weeks, patients on anti-TNF-α therapy had significantly greater improvement in disease activity score using 28 joint counts, the Quantitive Insulin Sensitivity Check Index, and the homeostasis model assessment of insulin resistance (HOMA) than those not on anti-TNF-α drugs. There were no differences in insulin resistance between patients on etanercept and those on infliximab.

In a poster presented at the Congress, insulin resistance as calculated on the HOMA index and hemoglobin A_1c were significantly lower in 16 nondiabetic RA patients after 1 year of anti-TNF-α therapy. No significant changes occurred during follow-up on dietary questionnaires, physical activity levels, anthropometric measurements, body mass index, or fat mass to confound the anti-TNF-α and insulin resistance link. Cholesterol and triglyceride levels did not change, said Dr. Sigrid Talaverano and associates at the University Hospital of the Canary Islands, La Cuesta, Spain.

WASHINGTON – Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation, said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19-S25).

Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), get referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%). Completers tended to have a higher average age (63 years vs. 59 years) and were more often male (67% vs. 60%) than were noncompleters.

On entry to the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not come back at week 2 for the walk test and did not begin the program.

This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment. Early interventions at this point could improve adherence to the program and subsequent outcomes, Dr. McGrady said.

According to the diagnostic category of patients, those who had myocardial infarction, angina, or heart failure had significantly higher anxiety scores than did patients who underwent CABG. Heart failure patients also had significantly higher depression scores than did those who underwent CABG.

No significant differences between patients in different diagnostic categories were found on walk tests or in the patients' perceptions of physical health.

WASHINGTON – Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation, said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19-S25).

Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), get referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%). Completers tended to have a higher average age (63 years vs. 59 years) and were more often male (67% vs. 60%) than were noncompleters.

On entry to the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not come back at week 2 for the walk test and did not begin the program.

This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment. Early interventions at this point could improve adherence to the program and subsequent outcomes, Dr. McGrady said.

According to the diagnostic category of patients, those who had myocardial infarction, angina, or heart failure had significantly higher anxiety scores than did patients who underwent CABG. Heart failure patients also had significantly higher depression scores than did those who underwent CABG.

No significant differences between patients in different diagnostic categories were found on walk tests or in the patients' perceptions of physical health.

WASHINGTON – Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation, said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19-S25).

Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), get referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%). Completers tended to have a higher average age (63 years vs. 59 years) and were more often male (67% vs. 60%) than were noncompleters.

On entry to the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not come back at week 2 for the walk test and did not begin the program.

This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment. Early interventions at this point could improve adherence to the program and subsequent outcomes, Dr. McGrady said.

According to the diagnostic category of patients, those who had myocardial infarction, angina, or heart failure had significantly higher anxiety scores than did patients who underwent CABG. Heart failure patients also had significantly higher depression scores than did those who underwent CABG.

No significant differences between patients in different diagnostic categories were found on walk tests or in the patients' perceptions of physical health.

WASHINGTON – Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women that is similar to the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in a cohort of 734 women with clinical symptoms of myocardial ischemia. Each underwent coronary angiography and psychosocial testing. About 30% of the patients had one event during a follow-up of 6 years.

The women were clinically symptomatic, but the rate of obstructive coronary artery disease was relatively low (39%). Risk factors tended to cluster, which was associated with about a threefold increase from the lowest group to the highest group in death and CVD rates. Those events occurred in 12% of women with none or one risk factor, 19% with two to three risk factors, and 30% with four to six risk factors. The magnitude of the effects for depression and social isolation was comparable with those for the major CVD risk factors.

WASHINGTON – Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women that is similar to the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in a cohort of 734 women with clinical symptoms of myocardial ischemia. Each underwent coronary angiography and psychosocial testing. About 30% of the patients had one event during a follow-up of 6 years.

The women were clinically symptomatic, but the rate of obstructive coronary artery disease was relatively low (39%). Risk factors tended to cluster, which was associated with about a threefold increase from the lowest group to the highest group in death and CVD rates. Those events occurred in 12% of women with none or one risk factor, 19% with two to three risk factors, and 30% with four to six risk factors. The magnitude of the effects for depression and social isolation was comparable with those for the major CVD risk factors.

WASHINGTON – Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women that is similar to the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in a cohort of 734 women with clinical symptoms of myocardial ischemia. Each underwent coronary angiography and psychosocial testing. About 30% of the patients had one event during a follow-up of 6 years.

The women were clinically symptomatic, but the rate of obstructive coronary artery disease was relatively low (39%). Risk factors tended to cluster, which was associated with about a threefold increase from the lowest group to the highest group in death and CVD rates. Those events occurred in 12% of women with none or one risk factor, 19% with two to three risk factors, and 30% with four to six risk factors. The magnitude of the effects for depression and social isolation was comparable with those for the major CVD risk factors.

WASHINGTON — Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women similar to that of the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in 734 women with clinical symptoms of MI. Each patient underwent coronary angiography and psychosocial testing. About 30% of the patients experienced one event (MI, heart failure, stroke, or death) during a median follow-up of 5.9 years, said Dr. Rutledge of the department of psychiatry at the University of California, San Diego.

The rate of obstructive coronary artery disease on quantitative angiography was relatively low (39%), even though the women were clinically symptomatic. The prevalence of individual risk factors ranged from 20% for smoking to 59% for a history of hypertension. Risk factors also tended to cluster together: 78% of patients had two or more while 26% had four or more. The most common cluster consisted of diabetes combined with other risk factors, he said.

Death or CVD events occurred in 12% of women with no or one risk factor, 19% of women with two to three risk factors, and 30% with four to six risk factors. A graded increase in the prevalence of psychosocial risk factors coincided with increases in the total number of risk factors.

“The magnitude of the effects for depression and social isolation were very comparable to those for the major CVD risk factors,” he said. Significant risk factors increased the risk of death and CVD events by 50%–100%.

WASHINGTON — Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women similar to that of the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in 734 women with clinical symptoms of MI. Each patient underwent coronary angiography and psychosocial testing. About 30% of the patients experienced one event (MI, heart failure, stroke, or death) during a median follow-up of 5.9 years, said Dr. Rutledge of the department of psychiatry at the University of California, San Diego.

The rate of obstructive coronary artery disease on quantitative angiography was relatively low (39%), even though the women were clinically symptomatic. The prevalence of individual risk factors ranged from 20% for smoking to 59% for a history of hypertension. Risk factors also tended to cluster together: 78% of patients had two or more while 26% had four or more. The most common cluster consisted of diabetes combined with other risk factors, he said.

Death or CVD events occurred in 12% of women with no or one risk factor, 19% of women with two to three risk factors, and 30% with four to six risk factors. A graded increase in the prevalence of psychosocial risk factors coincided with increases in the total number of risk factors.

“The magnitude of the effects for depression and social isolation were very comparable to those for the major CVD risk factors,” he said. Significant risk factors increased the risk of death and CVD events by 50%–100%.

WASHINGTON — Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women similar to that of the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in 734 women with clinical symptoms of MI. Each patient underwent coronary angiography and psychosocial testing. About 30% of the patients experienced one event (MI, heart failure, stroke, or death) during a median follow-up of 5.9 years, said Dr. Rutledge of the department of psychiatry at the University of California, San Diego.

The rate of obstructive coronary artery disease on quantitative angiography was relatively low (39%), even though the women were clinically symptomatic. The prevalence of individual risk factors ranged from 20% for smoking to 59% for a history of hypertension. Risk factors also tended to cluster together: 78% of patients had two or more while 26% had four or more. The most common cluster consisted of diabetes combined with other risk factors, he said.

Death or CVD events occurred in 12% of women with no or one risk factor, 19% of women with two to three risk factors, and 30% with four to six risk factors. A graded increase in the prevalence of psychosocial risk factors coincided with increases in the total number of risk factors.

“The magnitude of the effects for depression and social isolation were very comparable to those for the major CVD risk factors,” he said. Significant risk factors increased the risk of death and CVD events by 50%–100%.

WASHINGTON — Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation,” said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19–25). Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), are referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%).

On entry into the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not return at week 2 for the walk test and did not begin the program. This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment.

WASHINGTON — Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation,” said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19–25). Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), are referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%).

On entry into the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not return at week 2 for the walk test and did not begin the program. This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment.

WASHINGTON — Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation,” said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19–25). Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), are referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%).

On entry into the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not return at week 2 for the walk test and did not begin the program. This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment.

VAIL, COLO. — Efforts by cosmetic surgeons to filter out potentially troublesome patients and rein in their own desire to "fit the operation to the patient" during preoperative consultations can help to avoid unexpected postoperative quagmires, Dr. Jonathan M. Sykes said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Media exploitation of cosmetic surgery on television shows such as "Extreme Makeover" tends to trivialize the healing process, bypass typical recovery issues, and create a tacit acceptance of the "megaprocedure" without showing the patients as being involved in the decision-making process, said Dr. Sykes, professor of otolaryngology and director of facial plastic surgery at the University of California, Davis.

"We even say at these meetings, 'The patient needed a chin implant.' I've never seen a person who'd die [without] a chin implant or a facelift," Dr. Sykes said. "But we get into that mentality of thinking they need something and in fact they don't. When we think that way, our staff thinks that way, and our patients can think that we think that way."

When it is difficult to judge a patient's nature and how he or she will react to the results of surgery during the preoperative consult, it may be best to only perform a single, reversible procedure or decline to operate on the patient, he advised.

"Our consultations are different from almost every other consultation in medicine. Most people who go into a surgeon's office want the surgeon to say, 'You don't need surgery.' Our patients want us to say, 'You need this.' They are all a little insecure or are insecure people to start with, in general," he said.

The Correct Patient

The criteria for a successful outcome include a carefully selected, highly motivated patient. Good candidates for cosmetic surgery are people with a positive self-image who are easy to communicate with, are friendly to staff, and have reasonable expectations. Unsuitable candidates may be overdemanding, uncooperative, narcissistic, or litigious.

Others may have a poor self-image, body dysmorphic disorder, or prior psychiatric disorders, or they may express criticism of other physicians.

Candidates who have body dysmorphic disorder often ask at the end of their procedure, "When can I have my next operation?" Dr. Sykes said. These patients may be embarrassed by their desires and hide their true wants.

Surgeons will rarely be disappointed that they did not operate on someone, Dr. Sykes said. At the end of the year, surgeons might have a few people that they wish they had not operated on, but they won't know if any great patients were missed.

The biggest factor that affects postoperative appearance is not the surgeon's work but the patient's preoperative appearance. Other influencing factors are the choice of procedure, the execution of the surgery, and patient healing. "The happy patients really aren't necessarily the people with the best results," he said. Some people have good results but aren't necessarily happy. The patients' own perceptions will determine how they view their postoperative appearance.

The Correct Procedure

It is important to discuss and document which things are most important to patients because they may come back to complain about one small thing out of many things that were done during a surgical session, claiming that the small thing was actually what they most wanted. Dr. Sykes sometimes leaves the room for a few minutes and lets patients think about a list of the things that they would like to change, but not how they would like to change them. They give him the list in order of importance, and he includes it in their records.

By helping to choose the procedure(s), patients will be more vested in their decision because they think it is theirs and will be less likely to become angry if complications arise or they are unhappy with the result.

While going through this process, use a procedure-oriented approach with patients instead of a problem-oriented approach to diagnose what they need. "Fit the patient to the operation and not the operation to the patient," he advised.

A machine that is bought initially for a particular procedure may end up being used on patients who don't necessarily need the procedure, even though another procedure may be more appropriate. This is similar to the tendency to suggest only certain procedures to patients because of the surgeon's familiarity or comfort level with them, Dr. Sykes said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Key Consultation Concepts

Dr. Sykes said that he has learned four key elements of a successful patient consultation:

▸ Engage. In an initial visit, patients want to talk about whatever cosmetic problem they came in for. But instead of letting them talk about that, Dr. Sykes asks a few personal questions about work and what they like to do. Then he asks questions about why they are there and what their expectations and goals are. Whenever they come in for another visit, he may ask follow-up questions.

▸ Empathize. Even if the patient is unhappy and critical in a follow-up visit, it is necessary to acknowledge the patient's concern and repeat it back to him or her because this makes the patient feel heard.

▸ Educate. If a surgeon shares the knowledge of why a certain diagnosis is made and why a certain treatment or procedure is recommended, this helps the patient to collaborate on the decision-making process.

▸ Enlist. The patient will feel much better if he or she can weigh all of the available options. Once the visit is nearing its end, the surgeon can summarize all things that are planned.

VAIL, COLO. — Efforts by cosmetic surgeons to filter out potentially troublesome patients and rein in their own desire to "fit the operation to the patient" during preoperative consultations can help to avoid unexpected postoperative quagmires, Dr. Jonathan M. Sykes said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Media exploitation of cosmetic surgery on television shows such as "Extreme Makeover" tends to trivialize the healing process, bypass typical recovery issues, and create a tacit acceptance of the "megaprocedure" without showing the patients as being involved in the decision-making process, said Dr. Sykes, professor of otolaryngology and director of facial plastic surgery at the University of California, Davis.

"We even say at these meetings, 'The patient needed a chin implant.' I've never seen a person who'd die [without] a chin implant or a facelift," Dr. Sykes said. "But we get into that mentality of thinking they need something and in fact they don't. When we think that way, our staff thinks that way, and our patients can think that we think that way."

When it is difficult to judge a patient's nature and how he or she will react to the results of surgery during the preoperative consult, it may be best to only perform a single, reversible procedure or decline to operate on the patient, he advised.

"Our consultations are different from almost every other consultation in medicine. Most people who go into a surgeon's office want the surgeon to say, 'You don't need surgery.' Our patients want us to say, 'You need this.' They are all a little insecure or are insecure people to start with, in general," he said.

The Correct Patient

The criteria for a successful outcome include a carefully selected, highly motivated patient. Good candidates for cosmetic surgery are people with a positive self-image who are easy to communicate with, are friendly to staff, and have reasonable expectations. Unsuitable candidates may be overdemanding, uncooperative, narcissistic, or litigious.

Others may have a poor self-image, body dysmorphic disorder, or prior psychiatric disorders, or they may express criticism of other physicians.

Candidates who have body dysmorphic disorder often ask at the end of their procedure, "When can I have my next operation?" Dr. Sykes said. These patients may be embarrassed by their desires and hide their true wants.

Surgeons will rarely be disappointed that they did not operate on someone, Dr. Sykes said. At the end of the year, surgeons might have a few people that they wish they had not operated on, but they won't know if any great patients were missed.

The biggest factor that affects postoperative appearance is not the surgeon's work but the patient's preoperative appearance. Other influencing factors are the choice of procedure, the execution of the surgery, and patient healing. "The happy patients really aren't necessarily the people with the best results," he said. Some people have good results but aren't necessarily happy. The patients' own perceptions will determine how they view their postoperative appearance.

The Correct Procedure

It is important to discuss and document which things are most important to patients because they may come back to complain about one small thing out of many things that were done during a surgical session, claiming that the small thing was actually what they most wanted. Dr. Sykes sometimes leaves the room for a few minutes and lets patients think about a list of the things that they would like to change, but not how they would like to change them. They give him the list in order of importance, and he includes it in their records.

By helping to choose the procedure(s), patients will be more vested in their decision because they think it is theirs and will be less likely to become angry if complications arise or they are unhappy with the result.

While going through this process, use a procedure-oriented approach with patients instead of a problem-oriented approach to diagnose what they need. "Fit the patient to the operation and not the operation to the patient," he advised.

A machine that is bought initially for a particular procedure may end up being used on patients who don't necessarily need the procedure, even though another procedure may be more appropriate. This is similar to the tendency to suggest only certain procedures to patients because of the surgeon's familiarity or comfort level with them, Dr. Sykes said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Key Consultation Concepts

Dr. Sykes said that he has learned four key elements of a successful patient consultation:

▸ Engage. In an initial visit, patients want to talk about whatever cosmetic problem they came in for. But instead of letting them talk about that, Dr. Sykes asks a few personal questions about work and what they like to do. Then he asks questions about why they are there and what their expectations and goals are. Whenever they come in for another visit, he may ask follow-up questions.

▸ Empathize. Even if the patient is unhappy and critical in a follow-up visit, it is necessary to acknowledge the patient's concern and repeat it back to him or her because this makes the patient feel heard.

▸ Educate. If a surgeon shares the knowledge of why a certain diagnosis is made and why a certain treatment or procedure is recommended, this helps the patient to collaborate on the decision-making process.

▸ Enlist. The patient will feel much better if he or she can weigh all of the available options. Once the visit is nearing its end, the surgeon can summarize all things that are planned.

VAIL, COLO. — Efforts by cosmetic surgeons to filter out potentially troublesome patients and rein in their own desire to "fit the operation to the patient" during preoperative consultations can help to avoid unexpected postoperative quagmires, Dr. Jonathan M. Sykes said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Media exploitation of cosmetic surgery on television shows such as "Extreme Makeover" tends to trivialize the healing process, bypass typical recovery issues, and create a tacit acceptance of the "megaprocedure" without showing the patients as being involved in the decision-making process, said Dr. Sykes, professor of otolaryngology and director of facial plastic surgery at the University of California, Davis.

"We even say at these meetings, 'The patient needed a chin implant.' I've never seen a person who'd die [without] a chin implant or a facelift," Dr. Sykes said. "But we get into that mentality of thinking they need something and in fact they don't. When we think that way, our staff thinks that way, and our patients can think that we think that way."

When it is difficult to judge a patient's nature and how he or she will react to the results of surgery during the preoperative consult, it may be best to only perform a single, reversible procedure or decline to operate on the patient, he advised.

"Our consultations are different from almost every other consultation in medicine. Most people who go into a surgeon's office want the surgeon to say, 'You don't need surgery.' Our patients want us to say, 'You need this.' They are all a little insecure or are insecure people to start with, in general," he said.

The Correct Patient

The criteria for a successful outcome include a carefully selected, highly motivated patient. Good candidates for cosmetic surgery are people with a positive self-image who are easy to communicate with, are friendly to staff, and have reasonable expectations. Unsuitable candidates may be overdemanding, uncooperative, narcissistic, or litigious.

Others may have a poor self-image, body dysmorphic disorder, or prior psychiatric disorders, or they may express criticism of other physicians.

Candidates who have body dysmorphic disorder often ask at the end of their procedure, "When can I have my next operation?" Dr. Sykes said. These patients may be embarrassed by their desires and hide their true wants.

Surgeons will rarely be disappointed that they did not operate on someone, Dr. Sykes said. At the end of the year, surgeons might have a few people that they wish they had not operated on, but they won't know if any great patients were missed.

The biggest factor that affects postoperative appearance is not the surgeon's work but the patient's preoperative appearance. Other influencing factors are the choice of procedure, the execution of the surgery, and patient healing. "The happy patients really aren't necessarily the people with the best results," he said. Some people have good results but aren't necessarily happy. The patients' own perceptions will determine how they view their postoperative appearance.

The Correct Procedure

It is important to discuss and document which things are most important to patients because they may come back to complain about one small thing out of many things that were done during a surgical session, claiming that the small thing was actually what they most wanted. Dr. Sykes sometimes leaves the room for a few minutes and lets patients think about a list of the things that they would like to change, but not how they would like to change them. They give him the list in order of importance, and he includes it in their records.

By helping to choose the procedure(s), patients will be more vested in their decision because they think it is theirs and will be less likely to become angry if complications arise or they are unhappy with the result.

While going through this process, use a procedure-oriented approach with patients instead of a problem-oriented approach to diagnose what they need. "Fit the patient to the operation and not the operation to the patient," he advised.

A machine that is bought initially for a particular procedure may end up being used on patients who don't necessarily need the procedure, even though another procedure may be more appropriate. This is similar to the tendency to suggest only certain procedures to patients because of the surgeon's familiarity or comfort level with them, Dr. Sykes said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Key Consultation Concepts

Dr. Sykes said that he has learned four key elements of a successful patient consultation:

▸ Engage. In an initial visit, patients want to talk about whatever cosmetic problem they came in for. But instead of letting them talk about that, Dr. Sykes asks a few personal questions about work and what they like to do. Then he asks questions about why they are there and what their expectations and goals are. Whenever they come in for another visit, he may ask follow-up questions.

▸ Empathize. Even if the patient is unhappy and critical in a follow-up visit, it is necessary to acknowledge the patient's concern and repeat it back to him or her because this makes the patient feel heard.

▸ Educate. If a surgeon shares the knowledge of why a certain diagnosis is made and why a certain treatment or procedure is recommended, this helps the patient to collaborate on the decision-making process.

▸ Enlist. The patient will feel much better if he or she can weigh all of the available options. Once the visit is nearing its end, the surgeon can summarize all things that are planned.

NAPLES, FLA. — Well-known flaps can be modified in innovative ways to reconstruct facial defects made during Mohs micrographic surgery, speakers said at the annual meeting of the American College of Mohs Surgery.

Physicians described flaps that can reduce tension, spare skin in heavily scarred and damaged areas, repair difficult anatomic structures, waste less tissue, or allow much greater tissue advancement.

▸ Wave flap. This flap involves advancement, rotation, and some spinning, hence the name. "The advantage of doing this wave flap is that it recruits tissue from primarily one direction and most of the movement is perpendicular to what would otherwise be used to close a defect in a linear fashion," said Dr. Michael R. Migden of the department of dermatology at the University of Texas M.D. Anderson Cancer Center, Houston.

Dr. Migden uses the technique in situations where there are two adjacent defects. He creates small primary and large secondary Burow's triangles and frees the intervening isthmus of tissue to close the bigger defect.

He extensively undermines the base of the isthmus flap's pedicle. The superior edge and the base of this pedicle are then spun around the midpoint between the two by suturing the outside edge of the pedicle obliquely rather than at the inside edge further across the defect. The flap is then advanced. At the end of the procedure, the base of the pedicle has moved superiorly and laterally.

He has used the wave flap in areas with anatomic boundaries—in defects around the orbital rim it keeps the tension vector off of the eyelid to avoid ectropion. It is also helpful for situations in which all of the tissue needs to be taken from one direction, such as in patients with lots of previous surgical scars and/or radiation adjacent to the defect.

The wave flap requires the use of "relatively thinner skin." Dr. Migden said that he might not use the flap "on the back because there is some of that spinning motion that requires the tissue to be more distensible or plastic."

Dr. Migden has revised the technique so that he uses most of the tip of the flap to help close the defect rather than trim it away. This allows for a smaller primary Burow's triangle.

▸ Alar rotation flap. Reconstruction of the nasal ala should take into account airflow and the shape and curvature of the nasal ala, as well as symmetry of the alar rims, said Dr. Arash Kimyai-Asadi, who is with a dermatologic surgery group in Houston.

Many flaps in this area have problems involving effacement of boundaries of the nasal ala (alar crease, alar-facial sulcus, or melolabial fold) and alar notching, elevation, flare, or nasal valve collapse. "Trapdooring" and swelling also can be problematic, he said.

Many Mohs surgeons use skin grafts to reconstruct the nasal ala because of these problems, but the quality of the graft in matching the color and texture of the skin of the ala can vary widely. Second-intention healing can be good for superficial and smaller defects, but contracture is a possibility for deeper or larger defects.

The ideal alar reconstruction uses local alar skin to match color and texture, avoid crossing the nasal cosmetic subunit boundaries or creases, prevent distortion of the alar rim or nasal shape or symmetry, and prevent impediment of airflow, he said.

Dr. Kimyai-Asadi frequently uses a rotation flap that incorporates lateral alar skin. The flap is constructed by making an incision in the alar crease from the superior edge of the defect laterally to the alar-facial sulcus or the nasal sill and then undermining to the superficial subcutaneous plane.

The flap is then rotated into the defect. Sometimes nasal swelling can occur because of the anesthetic, but this can be treated by placing nasal packing for 48 hours. It is also common for the lateral ala to pull up with this flap, but this goes away by the time of suture removal.

Use of this flap too close to the alar rim runs the risk of elevating the rim. It is best to limit the flap to defects on the nasal ala and inferior part of the alar crease that are about 20%–35% of the alar surface area, he said.

Of 55 alar rotation flaps that he has performed on 33 patients, Dr. Kimyai-Asadi repaired defects with an average size of 0.9 by 0.7 cm. His only complications have been four cases of transient intranasal swelling.

▸ Subcutaneous pedicle nasolabial transposition flap. Classical nasolabial transposition flaps are limited by the requirement of a 1:1 ratio with the diameter of the primary defect, the frequent need for extensive undermining for proper flap rotation, and the creation of a large secondary defect, said Dr. Steven Chow, a second-year dermatology resident at the University of Minnesota in Minneapolis.

The subcutaneous pedicle nasolabial transposition flap uses a pedicle with an amount of full-thickness skin that is only one-half the diameter of the primary defect. The other half of the pedicle is formed by the subcutaneous fat in the primary defect.

Once the flap is freed, it is transposed into the defect. No Burow's triangle is needed for proper flap transposition. The subcutaneous fat portion of the pedicle is placed along the adjacent undermined region. Any excess tissue is removed and the defect then is closed.

Compared with the classic nasolabial transposition flap, the subcutaneous pedicle technique provides greater flap mobility because it has a smaller width of full-thickness skin at the base, better "tissue economy" because of its smaller secondary defect and the use of the primary defect itself as part of the flap, and a lower rate of pin cushioning as a result of the fat redistribution involved, Dr. Chow said at the meeting.

▸ Twisted and transposed island pedicle flaps. The traditional island pedicle flap is a random pattern advancement flap that provides excellent vascular supply and can repair small- to intermediate-sized facial defects, but it does have a tendency to form pin cushioning and is difficult to camouflage because all of the incisions cannot be placed within relaxed skin tension lines, explained Dr. Todd E. Holmes, who is a procedural dermatology fellow at the University of Vermont in Burlington.

Dr. Holmes described Mohs cases on the nose, forehead, and cheek in which unilaterally or anteriorly based muscular pedicles were twisted and transposed up to 180°. Traditional advancement of an island pedicle flap in some of the cases would have been "very difficult or not possible," he said.

NAPLES, FLA. — Well-known flaps can be modified in innovative ways to reconstruct facial defects made during Mohs micrographic surgery, speakers said at the annual meeting of the American College of Mohs Surgery.

Physicians described flaps that can reduce tension, spare skin in heavily scarred and damaged areas, repair difficult anatomic structures, waste less tissue, or allow much greater tissue advancement.

▸ Wave flap. This flap involves advancement, rotation, and some spinning, hence the name. "The advantage of doing this wave flap is that it recruits tissue from primarily one direction and most of the movement is perpendicular to what would otherwise be used to close a defect in a linear fashion," said Dr. Michael R. Migden of the department of dermatology at the University of Texas M.D. Anderson Cancer Center, Houston.

Dr. Migden uses the technique in situations where there are two adjacent defects. He creates small primary and large secondary Burow's triangles and frees the intervening isthmus of tissue to close the bigger defect.

He extensively undermines the base of the isthmus flap's pedicle. The superior edge and the base of this pedicle are then spun around the midpoint between the two by suturing the outside edge of the pedicle obliquely rather than at the inside edge further across the defect. The flap is then advanced. At the end of the procedure, the base of the pedicle has moved superiorly and laterally.

He has used the wave flap in areas with anatomic boundaries—in defects around the orbital rim it keeps the tension vector off of the eyelid to avoid ectropion. It is also helpful for situations in which all of the tissue needs to be taken from one direction, such as in patients with lots of previous surgical scars and/or radiation adjacent to the defect.

The wave flap requires the use of "relatively thinner skin." Dr. Migden said that he might not use the flap "on the back because there is some of that spinning motion that requires the tissue to be more distensible or plastic."

Dr. Migden has revised the technique so that he uses most of the tip of the flap to help close the defect rather than trim it away. This allows for a smaller primary Burow's triangle.

▸ Alar rotation flap. Reconstruction of the nasal ala should take into account airflow and the shape and curvature of the nasal ala, as well as symmetry of the alar rims, said Dr. Arash Kimyai-Asadi, who is with a dermatologic surgery group in Houston.

Many flaps in this area have problems involving effacement of boundaries of the nasal ala (alar crease, alar-facial sulcus, or melolabial fold) and alar notching, elevation, flare, or nasal valve collapse. "Trapdooring" and swelling also can be problematic, he said.

Many Mohs surgeons use skin grafts to reconstruct the nasal ala because of these problems, but the quality of the graft in matching the color and texture of the skin of the ala can vary widely. Second-intention healing can be good for superficial and smaller defects, but contracture is a possibility for deeper or larger defects.

The ideal alar reconstruction uses local alar skin to match color and texture, avoid crossing the nasal cosmetic subunit boundaries or creases, prevent distortion of the alar rim or nasal shape or symmetry, and prevent impediment of airflow, he said.

Dr. Kimyai-Asadi frequently uses a rotation flap that incorporates lateral alar skin. The flap is constructed by making an incision in the alar crease from the superior edge of the defect laterally to the alar-facial sulcus or the nasal sill and then undermining to the superficial subcutaneous plane.

The flap is then rotated into the defect. Sometimes nasal swelling can occur because of the anesthetic, but this can be treated by placing nasal packing for 48 hours. It is also common for the lateral ala to pull up with this flap, but this goes away by the time of suture removal.

Use of this flap too close to the alar rim runs the risk of elevating the rim. It is best to limit the flap to defects on the nasal ala and inferior part of the alar crease that are about 20%–35% of the alar surface area, he said.

Of 55 alar rotation flaps that he has performed on 33 patients, Dr. Kimyai-Asadi repaired defects with an average size of 0.9 by 0.7 cm. His only complications have been four cases of transient intranasal swelling.

▸ Subcutaneous pedicle nasolabial transposition flap. Classical nasolabial transposition flaps are limited by the requirement of a 1:1 ratio with the diameter of the primary defect, the frequent need for extensive undermining for proper flap rotation, and the creation of a large secondary defect, said Dr. Steven Chow, a second-year dermatology resident at the University of Minnesota in Minneapolis.

The subcutaneous pedicle nasolabial transposition flap uses a pedicle with an amount of full-thickness skin that is only one-half the diameter of the primary defect. The other half of the pedicle is formed by the subcutaneous fat in the primary defect.

Once the flap is freed, it is transposed into the defect. No Burow's triangle is needed for proper flap transposition. The subcutaneous fat portion of the pedicle is placed along the adjacent undermined region. Any excess tissue is removed and the defect then is closed.

Compared with the classic nasolabial transposition flap, the subcutaneous pedicle technique provides greater flap mobility because it has a smaller width of full-thickness skin at the base, better "tissue economy" because of its smaller secondary defect and the use of the primary defect itself as part of the flap, and a lower rate of pin cushioning as a result of the fat redistribution involved, Dr. Chow said at the meeting.

▸ Twisted and transposed island pedicle flaps. The traditional island pedicle flap is a random pattern advancement flap that provides excellent vascular supply and can repair small- to intermediate-sized facial defects, but it does have a tendency to form pin cushioning and is difficult to camouflage because all of the incisions cannot be placed within relaxed skin tension lines, explained Dr. Todd E. Holmes, who is a procedural dermatology fellow at the University of Vermont in Burlington.

Dr. Holmes described Mohs cases on the nose, forehead, and cheek in which unilaterally or anteriorly based muscular pedicles were twisted and transposed up to 180°. Traditional advancement of an island pedicle flap in some of the cases would have been "very difficult or not possible," he said.

NAPLES, FLA. — Well-known flaps can be modified in innovative ways to reconstruct facial defects made during Mohs micrographic surgery, speakers said at the annual meeting of the American College of Mohs Surgery.

Physicians described flaps that can reduce tension, spare skin in heavily scarred and damaged areas, repair difficult anatomic structures, waste less tissue, or allow much greater tissue advancement.

▸ Wave flap. This flap involves advancement, rotation, and some spinning, hence the name. "The advantage of doing this wave flap is that it recruits tissue from primarily one direction and most of the movement is perpendicular to what would otherwise be used to close a defect in a linear fashion," said Dr. Michael R. Migden of the department of dermatology at the University of Texas M.D. Anderson Cancer Center, Houston.

Dr. Migden uses the technique in situations where there are two adjacent defects. He creates small primary and large secondary Burow's triangles and frees the intervening isthmus of tissue to close the bigger defect.

He extensively undermines the base of the isthmus flap's pedicle. The superior edge and the base of this pedicle are then spun around the midpoint between the two by suturing the outside edge of the pedicle obliquely rather than at the inside edge further across the defect. The flap is then advanced. At the end of the procedure, the base of the pedicle has moved superiorly and laterally.

He has used the wave flap in areas with anatomic boundaries—in defects around the orbital rim it keeps the tension vector off of the eyelid to avoid ectropion. It is also helpful for situations in which all of the tissue needs to be taken from one direction, such as in patients with lots of previous surgical scars and/or radiation adjacent to the defect.

The wave flap requires the use of "relatively thinner skin." Dr. Migden said that he might not use the flap "on the back because there is some of that spinning motion that requires the tissue to be more distensible or plastic."

Dr. Migden has revised the technique so that he uses most of the tip of the flap to help close the defect rather than trim it away. This allows for a smaller primary Burow's triangle.

▸ Alar rotation flap. Reconstruction of the nasal ala should take into account airflow and the shape and curvature of the nasal ala, as well as symmetry of the alar rims, said Dr. Arash Kimyai-Asadi, who is with a dermatologic surgery group in Houston.

Many flaps in this area have problems involving effacement of boundaries of the nasal ala (alar crease, alar-facial sulcus, or melolabial fold) and alar notching, elevation, flare, or nasal valve collapse. "Trapdooring" and swelling also can be problematic, he said.

Many Mohs surgeons use skin grafts to reconstruct the nasal ala because of these problems, but the quality of the graft in matching the color and texture of the skin of the ala can vary widely. Second-intention healing can be good for superficial and smaller defects, but contracture is a possibility for deeper or larger defects.

The ideal alar reconstruction uses local alar skin to match color and texture, avoid crossing the nasal cosmetic subunit boundaries or creases, prevent distortion of the alar rim or nasal shape or symmetry, and prevent impediment of airflow, he said.

Dr. Kimyai-Asadi frequently uses a rotation flap that incorporates lateral alar skin. The flap is constructed by making an incision in the alar crease from the superior edge of the defect laterally to the alar-facial sulcus or the nasal sill and then undermining to the superficial subcutaneous plane.

The flap is then rotated into the defect. Sometimes nasal swelling can occur because of the anesthetic, but this can be treated by placing nasal packing for 48 hours. It is also common for the lateral ala to pull up with this flap, but this goes away by the time of suture removal.

Use of this flap too close to the alar rim runs the risk of elevating the rim. It is best to limit the flap to defects on the nasal ala and inferior part of the alar crease that are about 20%–35% of the alar surface area, he said.

Of 55 alar rotation flaps that he has performed on 33 patients, Dr. Kimyai-Asadi repaired defects with an average size of 0.9 by 0.7 cm. His only complications have been four cases of transient intranasal swelling.

▸ Subcutaneous pedicle nasolabial transposition flap. Classical nasolabial transposition flaps are limited by the requirement of a 1:1 ratio with the diameter of the primary defect, the frequent need for extensive undermining for proper flap rotation, and the creation of a large secondary defect, said Dr. Steven Chow, a second-year dermatology resident at the University of Minnesota in Minneapolis.

The subcutaneous pedicle nasolabial transposition flap uses a pedicle with an amount of full-thickness skin that is only one-half the diameter of the primary defect. The other half of the pedicle is formed by the subcutaneous fat in the primary defect.

Once the flap is freed, it is transposed into the defect. No Burow's triangle is needed for proper flap transposition. The subcutaneous fat portion of the pedicle is placed along the adjacent undermined region. Any excess tissue is removed and the defect then is closed.

Compared with the classic nasolabial transposition flap, the subcutaneous pedicle technique provides greater flap mobility because it has a smaller width of full-thickness skin at the base, better "tissue economy" because of its smaller secondary defect and the use of the primary defect itself as part of the flap, and a lower rate of pin cushioning as a result of the fat redistribution involved, Dr. Chow said at the meeting.

▸ Twisted and transposed island pedicle flaps. The traditional island pedicle flap is a random pattern advancement flap that provides excellent vascular supply and can repair small- to intermediate-sized facial defects, but it does have a tendency to form pin cushioning and is difficult to camouflage because all of the incisions cannot be placed within relaxed skin tension lines, explained Dr. Todd E. Holmes, who is a procedural dermatology fellow at the University of Vermont in Burlington.

Dr. Holmes described Mohs cases on the nose, forehead, and cheek in which unilaterally or anteriorly based muscular pedicles were twisted and transposed up to 180°. Traditional advancement of an island pedicle flap in some of the cases would have been "very difficult or not possible," he said.

WASHINGTON — Efforts to take patient comfort and safety into account when giving anesthesia for nail surgery may pay off in greater self-confidence during procedures, Dr. Nathaniel J. Jellinek said at the annual meeting of the American Academy of Dermatology.

When the topic of nail surgery or biopsy arises, most patients will be "quite apprehensive;" therefore, it is crucial to achieve total anesthesia with as little discomfort as possible and to approach the procedure with confidence, said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.

"If you're not successful at [anesthesia], the patients will never come to you. You'll never do [the surgery] again because you'll be intimidated by the procedure that went wrong," he said.

When giving anesthesia, it's advisable to recline patients even if they say they don't need it and to have an assistant hold their hand and distract them with conversation.

It is also a good idea to use a distracting stimulus prior to needle insertion (gripping the finger firmly, flicking the finger, or anesthetizing the injection site with a cryogen spray) and to tell patients that the injection is coming, he said.

"It's very important to not fill the nail fold quickly, because it's probably the distention of the tissue as much as the needle prick that causes a lot of pain," he said.

There have been two randomized, double-blind studies that examined the value of using a topical anesthetic to prevent the pain of a digital nerve block of the great toenail: One found that EMLA cream (2.5% lidocaine and 2.5% prilocaine) significantly reduced visual analog pain scores, compared with placebo (Eur. J. Anaesthesiol. 2000;17:182–4), whereas the other showed no benefit for EMLA cream (Acta Anaesthesiol. Scand. 2002;46:203–6).

Dr. Jellinek said that he uses topical anesthetic only when a patient is really apprehensive about the anesthesia.

In such cases, he said that applies EMLA cream 2 hours ahead of time and occludes it with plastic wrap or Tegaderm dressing and tells the patient that it may help a little bit.

"I think it helps with the pinprick," he said. Some people think that the effect of EMLA cream extends 5 mm deep, but "I don't think it's going to help with the slow distension of tissues," he said.

Although epinephrine has traditionally not been "allowed" during a digital block, Dr. Jellinek does not view it as an absolute contraindication. He does not usually use it, however, because most nail surgeries last fewer than 30 minutes and do not need prolonged anesthesia. "You can do [a distal block] competently, without any epinephrine, without any neurovascular damage risk," he said.

Of 50 cases of digital gangrene associated with local anesthesia in the literature, 21 occurred with the use of epinephrine. Most cases occurred before 1950, when procaine was used. Epinephrine was not a component of the anesthetic in most cases of gangrene, but when it was, very high concentrations were used, he noted.

If epinephrine is used, Dr. Jellinek made several recommendations:

▸ Use a 1:200,000 concentration with a minimal volume that corresponds to the size of the digit.

▸ Avoid a circumferential buildup of fluid when performing a ring block.

▸ Buffer anesthetics to avoid greater tissue acidosis than already present in ischemia.

▸ Avoid postoperative hot soaks.

▸ Look out for vasospastic patients.

▸ Consider having nitroglycerin or phentolamine on hand.

Dr. Jellinek performs most of his nail surgeries with a distal wing (local) block, which is infiltrative and gives immediate-onset anesthesia.

Epinephrine is not really necessary because the volume of anesthetic solution provides hemostasis.

An injection at each lateral nail fold is usually enough to carry the anesthetic to the junction of the hyponychium and the lateral nail folds. It is necessary to have a distracting stimulus for a wing block, such as a cryogen spray, Dr. Jellinek advised.

In a digital block, two nerves on each side of the digit are blocked at its base. He usually reserves the digital block for Mohs surgery on nail tumors. It also is necessary to wait at least 10 minutes for the nerve block to take effect.

WASHINGTON — Efforts to take patient comfort and safety into account when giving anesthesia for nail surgery may pay off in greater self-confidence during procedures, Dr. Nathaniel J. Jellinek said at the annual meeting of the American Academy of Dermatology.

When the topic of nail surgery or biopsy arises, most patients will be "quite apprehensive;" therefore, it is crucial to achieve total anesthesia with as little discomfort as possible and to approach the procedure with confidence, said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.

"If you're not successful at [anesthesia], the patients will never come to you. You'll never do [the surgery] again because you'll be intimidated by the procedure that went wrong," he said.

When giving anesthesia, it's advisable to recline patients even if they say they don't need it and to have an assistant hold their hand and distract them with conversation.

It is also a good idea to use a distracting stimulus prior to needle insertion (gripping the finger firmly, flicking the finger, or anesthetizing the injection site with a cryogen spray) and to tell patients that the injection is coming, he said.

"It's very important to not fill the nail fold quickly, because it's probably the distention of the tissue as much as the needle prick that causes a lot of pain," he said.

There have been two randomized, double-blind studies that examined the value of using a topical anesthetic to prevent the pain of a digital nerve block of the great toenail: One found that EMLA cream (2.5% lidocaine and 2.5% prilocaine) significantly reduced visual analog pain scores, compared with placebo (Eur. J. Anaesthesiol. 2000;17:182–4), whereas the other showed no benefit for EMLA cream (Acta Anaesthesiol. Scand. 2002;46:203–6).

Dr. Jellinek said that he uses topical anesthetic only when a patient is really apprehensive about the anesthesia.

In such cases, he said that applies EMLA cream 2 hours ahead of time and occludes it with plastic wrap or Tegaderm dressing and tells the patient that it may help a little bit.

"I think it helps with the pinprick," he said. Some people think that the effect of EMLA cream extends 5 mm deep, but "I don't think it's going to help with the slow distension of tissues," he said.

Although epinephrine has traditionally not been "allowed" during a digital block, Dr. Jellinek does not view it as an absolute contraindication. He does not usually use it, however, because most nail surgeries last fewer than 30 minutes and do not need prolonged anesthesia. "You can do [a distal block] competently, without any epinephrine, without any neurovascular damage risk," he said.

Of 50 cases of digital gangrene associated with local anesthesia in the literature, 21 occurred with the use of epinephrine. Most cases occurred before 1950, when procaine was used. Epinephrine was not a component of the anesthetic in most cases of gangrene, but when it was, very high concentrations were used, he noted.

If epinephrine is used, Dr. Jellinek made several recommendations:

▸ Use a 1:200,000 concentration with a minimal volume that corresponds to the size of the digit.

▸ Avoid a circumferential buildup of fluid when performing a ring block.

▸ Buffer anesthetics to avoid greater tissue acidosis than already present in ischemia.

▸ Avoid postoperative hot soaks.

▸ Look out for vasospastic patients.

▸ Consider having nitroglycerin or phentolamine on hand.

Dr. Jellinek performs most of his nail surgeries with a distal wing (local) block, which is infiltrative and gives immediate-onset anesthesia.

Epinephrine is not really necessary because the volume of anesthetic solution provides hemostasis.

An injection at each lateral nail fold is usually enough to carry the anesthetic to the junction of the hyponychium and the lateral nail folds. It is necessary to have a distracting stimulus for a wing block, such as a cryogen spray, Dr. Jellinek advised.

In a digital block, two nerves on each side of the digit are blocked at its base. He usually reserves the digital block for Mohs surgery on nail tumors. It also is necessary to wait at least 10 minutes for the nerve block to take effect.

WASHINGTON — Efforts to take patient comfort and safety into account when giving anesthesia for nail surgery may pay off in greater self-confidence during procedures, Dr. Nathaniel J. Jellinek said at the annual meeting of the American Academy of Dermatology.

When the topic of nail surgery or biopsy arises, most patients will be "quite apprehensive;" therefore, it is crucial to achieve total anesthesia with as little discomfort as possible and to approach the procedure with confidence, said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.

"If you're not successful at [anesthesia], the patients will never come to you. You'll never do [the surgery] again because you'll be intimidated by the procedure that went wrong," he said.

When giving anesthesia, it's advisable to recline patients even if they say they don't need it and to have an assistant hold their hand and distract them with conversation.

It is also a good idea to use a distracting stimulus prior to needle insertion (gripping the finger firmly, flicking the finger, or anesthetizing the injection site with a cryogen spray) and to tell patients that the injection is coming, he said.

"It's very important to not fill the nail fold quickly, because it's probably the distention of the tissue as much as the needle prick that causes a lot of pain," he said.

There have been two randomized, double-blind studies that examined the value of using a topical anesthetic to prevent the pain of a digital nerve block of the great toenail: One found that EMLA cream (2.5% lidocaine and 2.5% prilocaine) significantly reduced visual analog pain scores, compared with placebo (Eur. J. Anaesthesiol. 2000;17:182–4), whereas the other showed no benefit for EMLA cream (Acta Anaesthesiol. Scand. 2002;46:203–6).

Dr. Jellinek said that he uses topical anesthetic only when a patient is really apprehensive about the anesthesia.

In such cases, he said that applies EMLA cream 2 hours ahead of time and occludes it with plastic wrap or Tegaderm dressing and tells the patient that it may help a little bit.

"I think it helps with the pinprick," he said. Some people think that the effect of EMLA cream extends 5 mm deep, but "I don't think it's going to help with the slow distension of tissues," he said.

Although epinephrine has traditionally not been "allowed" during a digital block, Dr. Jellinek does not view it as an absolute contraindication. He does not usually use it, however, because most nail surgeries last fewer than 30 minutes and do not need prolonged anesthesia. "You can do [a distal block] competently, without any epinephrine, without any neurovascular damage risk," he said.

Of 50 cases of digital gangrene associated with local anesthesia in the literature, 21 occurred with the use of epinephrine. Most cases occurred before 1950, when procaine was used. Epinephrine was not a component of the anesthetic in most cases of gangrene, but when it was, very high concentrations were used, he noted.

If epinephrine is used, Dr. Jellinek made several recommendations:

▸ Use a 1:200,000 concentration with a minimal volume that corresponds to the size of the digit.

▸ Avoid a circumferential buildup of fluid when performing a ring block.

▸ Buffer anesthetics to avoid greater tissue acidosis than already present in ischemia.

▸ Avoid postoperative hot soaks.

▸ Look out for vasospastic patients.

▸ Consider having nitroglycerin or phentolamine on hand.

Dr. Jellinek performs most of his nail surgeries with a distal wing (local) block, which is infiltrative and gives immediate-onset anesthesia.

Epinephrine is not really necessary because the volume of anesthetic solution provides hemostasis.

An injection at each lateral nail fold is usually enough to carry the anesthetic to the junction of the hyponychium and the lateral nail folds. It is necessary to have a distracting stimulus for a wing block, such as a cryogen spray, Dr. Jellinek advised.

In a digital block, two nerves on each side of the digit are blocked at its base. He usually reserves the digital block for Mohs surgery on nail tumors. It also is necessary to wait at least 10 minutes for the nerve block to take effect.

NAPLES, FLA. — The use of anticoagulants during and after skin cancer surgery involves a low risk of bleeding complications for most patients, especially aspirin users, but the risk may be greater in the elderly, warfarin users, and those on multiple agents, according to the results of two studies presented at the annual meeting of the American College of Mohs Surgery.

"It's been said by many that … bleeding from skin surgery is never life threatening. Well, that was certainly what we noticed," said Dr. Anthony J. Dixon, a dermatologic surgeon who practices in Belmont, Australia.

He and his colleagues conducted a prospective study of bleeding complications in skin cancer surgery on 5,990 lesions. During the 44-month enrollment period, 40 bleeding events (26 hemorrhages and 14 hematomas) occurred.

Analysis showed that, at the time of surgery, age 67 years or older and warfarin use were significant and independent risk factors for bleeding complications.

A large age difference in the rate of bleeding complications was "perhaps the most surprising feature we found," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia.

In surgery for 2,947 lesions in patients younger than 67 years, there were only 5 bleeding complications, compared with 35 complications in 2,939 lesions in patients 67 years or older.

Bleeding events developed in 8 (2.5%) of 320 lesions in patients who were taking warfarin. Patients who were using warfarin prior to surgery were included in the study unless their international normalized ratio (INR) was greater than 3 in the days immediately before surgery. Two patients on warfarin were the only ones to have late bleeding events in the study. Their INRs were less than 3 at the time of surgery but then increased after surgery.

It is important to measure INR not only in the days before surgery, but also in the days afterward, Dr. Dixon suggested. In all, warfarin should only be stopped in "very limited circumstances" and definitely not if the patient had a deep vein thrombosis or a pulmonary embolism within 1 month of the surgery.

Aspirin users developed bleeding complications in 9 (1%) of 890 total cases. All patients who were taking aspirin at the time of surgery were included. "Aspirin is not a risk factor. It's just that older people take aspirin, and older people are more likely to be on a combination of warfarin and aspirin," he said.

Among patients who took both anticoagulants, bleeding complications occurred in 2 (6%) of 35 lesions.

In a separate presentation at the meeting, Ikue Shimizu reported that the use of multiple anticoagulants may increase the risk of bleeding complications. She and her colleagues at Brown University in Providence, R.I., found that only four bleeding complications developed in 760 patients who were undergoing Mohs surgery, but that three of these occurred in patients who were taking two or more oral anticoagulants.

Patients who took two or more anticoagulants were significantly more likely to have bleeding complications than were those who took no agent or only one, she said.

The investigators reviewed the charts of patients who underwent the procedure and received postoperative care at one center during a 1-year span. Patients who received outside postoperative care or had incomplete data were excluded from the trial.

Most of the patients (62%) were not taking any anticoagulants at the time of surgery; the others took one (30%) or two or more agents (8%).

Other studies that have examined the risk of developing bleeding complications after dermatologic surgery have analyzed the effect of using only one anticoagulant agent and not two or more, said Ms. Shimizu, a medical student at the university.

For patients who are on multiple anticoagulants, surgeons at the Brown University Mohs surgery unit try to use extra caution in obtaining hemostasis, and they decrease the use of epinephrine during repair and follow up with patients the next day.

"We feel that there is a need for more prospective studies with increased numbers to properly assess the risks of different complications," Ms. Shimizu said.

NAPLES, FLA. — The use of anticoagulants during and after skin cancer surgery involves a low risk of bleeding complications for most patients, especially aspirin users, but the risk may be greater in the elderly, warfarin users, and those on multiple agents, according to the results of two studies presented at the annual meeting of the American College of Mohs Surgery.

"It's been said by many that … bleeding from skin surgery is never life threatening. Well, that was certainly what we noticed," said Dr. Anthony J. Dixon, a dermatologic surgeon who practices in Belmont, Australia.

He and his colleagues conducted a prospective study of bleeding complications in skin cancer surgery on 5,990 lesions. During the 44-month enrollment period, 40 bleeding events (26 hemorrhages and 14 hematomas) occurred.

Analysis showed that, at the time of surgery, age 67 years or older and warfarin use were significant and independent risk factors for bleeding complications.

A large age difference in the rate of bleeding complications was "perhaps the most surprising feature we found," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia.

In surgery for 2,947 lesions in patients younger than 67 years, there were only 5 bleeding complications, compared with 35 complications in 2,939 lesions in patients 67 years or older.

Bleeding events developed in 8 (2.5%) of 320 lesions in patients who were taking warfarin. Patients who were using warfarin prior to surgery were included in the study unless their international normalized ratio (INR) was greater than 3 in the days immediately before surgery. Two patients on warfarin were the only ones to have late bleeding events in the study. Their INRs were less than 3 at the time of surgery but then increased after surgery.

It is important to measure INR not only in the days before surgery, but also in the days afterward, Dr. Dixon suggested. In all, warfarin should only be stopped in "very limited circumstances" and definitely not if the patient had a deep vein thrombosis or a pulmonary embolism within 1 month of the surgery.

Aspirin users developed bleeding complications in 9 (1%) of 890 total cases. All patients who were taking aspirin at the time of surgery were included. "Aspirin is not a risk factor. It's just that older people take aspirin, and older people are more likely to be on a combination of warfarin and aspirin," he said.

Among patients who took both anticoagulants, bleeding complications occurred in 2 (6%) of 35 lesions.

In a separate presentation at the meeting, Ikue Shimizu reported that the use of multiple anticoagulants may increase the risk of bleeding complications. She and her colleagues at Brown University in Providence, R.I., found that only four bleeding complications developed in 760 patients who were undergoing Mohs surgery, but that three of these occurred in patients who were taking two or more oral anticoagulants.

Patients who took two or more anticoagulants were significantly more likely to have bleeding complications than were those who took no agent or only one, she said.

The investigators reviewed the charts of patients who underwent the procedure and received postoperative care at one center during a 1-year span. Patients who received outside postoperative care or had incomplete data were excluded from the trial.

Most of the patients (62%) were not taking any anticoagulants at the time of surgery; the others took one (30%) or two or more agents (8%).

Other studies that have examined the risk of developing bleeding complications after dermatologic surgery have analyzed the effect of using only one anticoagulant agent and not two or more, said Ms. Shimizu, a medical student at the university.

For patients who are on multiple anticoagulants, surgeons at the Brown University Mohs surgery unit try to use extra caution in obtaining hemostasis, and they decrease the use of epinephrine during repair and follow up with patients the next day.

"We feel that there is a need for more prospective studies with increased numbers to properly assess the risks of different complications," Ms. Shimizu said.

NAPLES, FLA. — The use of anticoagulants during and after skin cancer surgery involves a low risk of bleeding complications for most patients, especially aspirin users, but the risk may be greater in the elderly, warfarin users, and those on multiple agents, according to the results of two studies presented at the annual meeting of the American College of Mohs Surgery.

"It's been said by many that … bleeding from skin surgery is never life threatening. Well, that was certainly what we noticed," said Dr. Anthony J. Dixon, a dermatologic surgeon who practices in Belmont, Australia.

He and his colleagues conducted a prospective study of bleeding complications in skin cancer surgery on 5,990 lesions. During the 44-month enrollment period, 40 bleeding events (26 hemorrhages and 14 hematomas) occurred.

Analysis showed that, at the time of surgery, age 67 years or older and warfarin use were significant and independent risk factors for bleeding complications.

A large age difference in the rate of bleeding complications was "perhaps the most surprising feature we found," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia.

In surgery for 2,947 lesions in patients younger than 67 years, there were only 5 bleeding complications, compared with 35 complications in 2,939 lesions in patients 67 years or older.

Bleeding events developed in 8 (2.5%) of 320 lesions in patients who were taking warfarin. Patients who were using warfarin prior to surgery were included in the study unless their international normalized ratio (INR) was greater than 3 in the days immediately before surgery. Two patients on warfarin were the only ones to have late bleeding events in the study. Their INRs were less than 3 at the time of surgery but then increased after surgery.

It is important to measure INR not only in the days before surgery, but also in the days afterward, Dr. Dixon suggested. In all, warfarin should only be stopped in "very limited circumstances" and definitely not if the patient had a deep vein thrombosis or a pulmonary embolism within 1 month of the surgery.

Aspirin users developed bleeding complications in 9 (1%) of 890 total cases. All patients who were taking aspirin at the time of surgery were included. "Aspirin is not a risk factor. It's just that older people take aspirin, and older people are more likely to be on a combination of warfarin and aspirin," he said.

Among patients who took both anticoagulants, bleeding complications occurred in 2 (6%) of 35 lesions.

In a separate presentation at the meeting, Ikue Shimizu reported that the use of multiple anticoagulants may increase the risk of bleeding complications. She and her colleagues at Brown University in Providence, R.I., found that only four bleeding complications developed in 760 patients who were undergoing Mohs surgery, but that three of these occurred in patients who were taking two or more oral anticoagulants.

Patients who took two or more anticoagulants were significantly more likely to have bleeding complications than were those who took no agent or only one, she said.

The investigators reviewed the charts of patients who underwent the procedure and received postoperative care at one center during a 1-year span. Patients who received outside postoperative care or had incomplete data were excluded from the trial.

Most of the patients (62%) were not taking any anticoagulants at the time of surgery; the others took one (30%) or two or more agents (8%).

Other studies that have examined the risk of developing bleeding complications after dermatologic surgery have analyzed the effect of using only one anticoagulant agent and not two or more, said Ms. Shimizu, a medical student at the university.

For patients who are on multiple anticoagulants, surgeons at the Brown University Mohs surgery unit try to use extra caution in obtaining hemostasis, and they decrease the use of epinephrine during repair and follow up with patients the next day.

"We feel that there is a need for more prospective studies with increased numbers to properly assess the risks of different complications," Ms. Shimizu said.

NAPLES, FLA. — Muscular flaps that supply soft tissue volume and a good vascular supply can provide some of the best cosmetic results in the reconstruction of Mohs surgery facial defects that penetrate to bone or cartilage, speakers said at the annual meeting of the American College of Mohs Surgery.

▸ Muscular hinge flaps. These flaps are useful for replacing soft-tissue volume in deep defects that may extend to bone or cartilage and require coverage with a full-thickness skin graft for practical or functional reasons, said Dr. Neil J. Mortimer, a Mohs surgery fellow at the Skin Centre in Tauranga, New Zealand.

"These are generally defects where you'd want to choose a full-thickness skin graft repair over other reconstructive options," Dr. Mortimer pointed out.

Since reconstruction of the vermilion of the lower lip with a simple mucosal flap would leave a substantial loss of volume, Dr. Mortimer recommended the use of orbicularis oris hinge flaps. A flap from the underlying orbicularis muscle is dissected out laterally and is then turned back or hinged into the defect.

"We've found from experience that if the surgical defect is deeper than a millimeter or so, it's useful to dissect these flaps from both sides and overlap them in the defect," Dr. Mortimer said.

Deep defects on the nose can be reconstructed with flaps derived from the superficial nasalis musculoaponeurotic system without causing a functional compromise. The flap can be dissected by separating it from its superior and inferior attachments to work as a simple hinge. These flaps can be unilateral or bilateral.

Frontalis hinge flaps can resurface exposed bone on the forehead. Postauricular defects with exposed partial-thickness cartilage can be repaired with an auricularis posterior hinge flap, which carries a good vascular supply from the auricular branch of the posterior auricular artery, he said.

▸ Galeal hinge flap. "This is a reconstruction that we found particularly useful for repairing defects of the scalp, extending to bone, as a single-stage procedure," said Dr. Matthew Halpern, a fellow in procedural dermatology at Columbia University, New York.

The galea aponeurotica is a strong, inelastic fibrous sheath situated between subcutaneous and loose areolar tissue that covers the calvaria and represents the tendinous connection between the frontalis muscle anteriorly and the occipitalis muscle posteriorly.

In constructing the flap, the galea is lightly scored so that it can be advanced and hinged over the top of the exposed periosteum. A galeal hinge flap is different from a muscular hinge flap because the galea is relatively inelastic, so defects often require bilateral flaps for coverage of the exposed bone. The galea also is thin and will not make an overall change in wound depth.

Dr. Halpern places full-thickness skin grafts on top of the galeal hinge flap to close the rest of the wound. He uses local anesthesia for the whole procedure.

▸ Nasalis myocutaneous island pedicle flap. This flap can be used to repair defects that cover two anatomic units on the nose—the ala and sidewall—with the alar groove as an anatomic boundary line. It can be used in place of a full-thickness skin graft, an island pedicle flap from the side, or a medially based cheek-to-nose transposition flap, said Dr. Robert J. Willard, a Mohs surgery fellow at Brown University, Providence, R.I.

The flap is made superior to the defect, with wide undermining to provide mobility and avoid pin cushioning. The first key sutures are made by stitching the lateral and medial aspects of the leading edge of the flap anteriorly and posteriorly to the origin of the alar groove. The leading edge of the flap is aligned with the alar groove, which recreates the anatomic boundary. No sutures are placed at the inferior portion of the defect since this would create a vertical tension vector and risk alar elevation.

Placement of a guiding suture roughly parallel to the alar rim in the residual alar portion redirects the tension vector to avoid alar elevation while the residual alar defect heals by second intention, he said.

NAPLES, FLA. — Muscular flaps that supply soft tissue volume and a good vascular supply can provide some of the best cosmetic results in the reconstruction of Mohs surgery facial defects that penetrate to bone or cartilage, speakers said at the annual meeting of the American College of Mohs Surgery.

▸ Muscular hinge flaps. These flaps are useful for replacing soft-tissue volume in deep defects that may extend to bone or cartilage and require coverage with a full-thickness skin graft for practical or functional reasons, said Dr. Neil J. Mortimer, a Mohs surgery fellow at the Skin Centre in Tauranga, New Zealand.

"These are generally defects where you'd want to choose a full-thickness skin graft repair over other reconstructive options," Dr. Mortimer pointed out.

Since reconstruction of the vermilion of the lower lip with a simple mucosal flap would leave a substantial loss of volume, Dr. Mortimer recommended the use of orbicularis oris hinge flaps. A flap from the underlying orbicularis muscle is dissected out laterally and is then turned back or hinged into the defect.

"We've found from experience that if the surgical defect is deeper than a millimeter or so, it's useful to dissect these flaps from both sides and overlap them in the defect," Dr. Mortimer said.

Deep defects on the nose can be reconstructed with flaps derived from the superficial nasalis musculoaponeurotic system without causing a functional compromise. The flap can be dissected by separating it from its superior and inferior attachments to work as a simple hinge. These flaps can be unilateral or bilateral.

Frontalis hinge flaps can resurface exposed bone on the forehead. Postauricular defects with exposed partial-thickness cartilage can be repaired with an auricularis posterior hinge flap, which carries a good vascular supply from the auricular branch of the posterior auricular artery, he said.

▸ Galeal hinge flap. "This is a reconstruction that we found particularly useful for repairing defects of the scalp, extending to bone, as a single-stage procedure," said Dr. Matthew Halpern, a fellow in procedural dermatology at Columbia University, New York.

The galea aponeurotica is a strong, inelastic fibrous sheath situated between subcutaneous and loose areolar tissue that covers the calvaria and represents the tendinous connection between the frontalis muscle anteriorly and the occipitalis muscle posteriorly.

In constructing the flap, the galea is lightly scored so that it can be advanced and hinged over the top of the exposed periosteum. A galeal hinge flap is different from a muscular hinge flap because the galea is relatively inelastic, so defects often require bilateral flaps for coverage of the exposed bone. The galea also is thin and will not make an overall change in wound depth.

Dr. Halpern places full-thickness skin grafts on top of the galeal hinge flap to close the rest of the wound. He uses local anesthesia for the whole procedure.

▸ Nasalis myocutaneous island pedicle flap. This flap can be used to repair defects that cover two anatomic units on the nose—the ala and sidewall—with the alar groove as an anatomic boundary line. It can be used in place of a full-thickness skin graft, an island pedicle flap from the side, or a medially based cheek-to-nose transposition flap, said Dr. Robert J. Willard, a Mohs surgery fellow at Brown University, Providence, R.I.

The flap is made superior to the defect, with wide undermining to provide mobility and avoid pin cushioning. The first key sutures are made by stitching the lateral and medial aspects of the leading edge of the flap anteriorly and posteriorly to the origin of the alar groove. The leading edge of the flap is aligned with the alar groove, which recreates the anatomic boundary. No sutures are placed at the inferior portion of the defect since this would create a vertical tension vector and risk alar elevation.

Placement of a guiding suture roughly parallel to the alar rim in the residual alar portion redirects the tension vector to avoid alar elevation while the residual alar defect heals by second intention, he said.

NAPLES, FLA. — Muscular flaps that supply soft tissue volume and a good vascular supply can provide some of the best cosmetic results in the reconstruction of Mohs surgery facial defects that penetrate to bone or cartilage, speakers said at the annual meeting of the American College of Mohs Surgery.

▸ Muscular hinge flaps. These flaps are useful for replacing soft-tissue volume in deep defects that may extend to bone or cartilage and require coverage with a full-thickness skin graft for practical or functional reasons, said Dr. Neil J. Mortimer, a Mohs surgery fellow at the Skin Centre in Tauranga, New Zealand.

"These are generally defects where you'd want to choose a full-thickness skin graft repair over other reconstructive options," Dr. Mortimer pointed out.

Since reconstruction of the vermilion of the lower lip with a simple mucosal flap would leave a substantial loss of volume, Dr. Mortimer recommended the use of orbicularis oris hinge flaps. A flap from the underlying orbicularis muscle is dissected out laterally and is then turned back or hinged into the defect.

"We've found from experience that if the surgical defect is deeper than a millimeter or so, it's useful to dissect these flaps from both sides and overlap them in the defect," Dr. Mortimer said.

Deep defects on the nose can be reconstructed with flaps derived from the superficial nasalis musculoaponeurotic system without causing a functional compromise. The flap can be dissected by separating it from its superior and inferior attachments to work as a simple hinge. These flaps can be unilateral or bilateral.

Frontalis hinge flaps can resurface exposed bone on the forehead. Postauricular defects with exposed partial-thickness cartilage can be repaired with an auricularis posterior hinge flap, which carries a good vascular supply from the auricular branch of the posterior auricular artery, he said.

▸ Galeal hinge flap. "This is a reconstruction that we found particularly useful for repairing defects of the scalp, extending to bone, as a single-stage procedure," said Dr. Matthew Halpern, a fellow in procedural dermatology at Columbia University, New York.

The galea aponeurotica is a strong, inelastic fibrous sheath situated between subcutaneous and loose areolar tissue that covers the calvaria and represents the tendinous connection between the frontalis muscle anteriorly and the occipitalis muscle posteriorly.

In constructing the flap, the galea is lightly scored so that it can be advanced and hinged over the top of the exposed periosteum. A galeal hinge flap is different from a muscular hinge flap because the galea is relatively inelastic, so defects often require bilateral flaps for coverage of the exposed bone. The galea also is thin and will not make an overall change in wound depth.

Dr. Halpern places full-thickness skin grafts on top of the galeal hinge flap to close the rest of the wound. He uses local anesthesia for the whole procedure.

▸ Nasalis myocutaneous island pedicle flap. This flap can be used to repair defects that cover two anatomic units on the nose—the ala and sidewall—with the alar groove as an anatomic boundary line. It can be used in place of a full-thickness skin graft, an island pedicle flap from the side, or a medially based cheek-to-nose transposition flap, said Dr. Robert J. Willard, a Mohs surgery fellow at Brown University, Providence, R.I.

The flap is made superior to the defect, with wide undermining to provide mobility and avoid pin cushioning. The first key sutures are made by stitching the lateral and medial aspects of the leading edge of the flap anteriorly and posteriorly to the origin of the alar groove. The leading edge of the flap is aligned with the alar groove, which recreates the anatomic boundary. No sutures are placed at the inferior portion of the defect since this would create a vertical tension vector and risk alar elevation.

Placement of a guiding suture roughly parallel to the alar rim in the residual alar portion redirects the tension vector to avoid alar elevation while the residual alar defect heals by second intention, he said.