Plastic Surgery

PHOENIX – A fractional carbon dioxide laser at 10,600 nm was the only one of three laser treatments for hypertrophic scars that produced significant overall improvements in a comparison of data on 141 scars in 66 patients.

Less successful were treatments using a vascular KTP laser at 532 nm or a 1,550-nm nonablative fractional erbium glass laser.

"The only one that showed significant improvement compared with the control scar, adjusted for the baseline scar, was the fractional CO2 laser," Dr. Sigrid Blome-Eberwein said at the annual meeting of the American Society for Laser Medicine and Surgery.

The data came from three prospective controlled studies at one institution. The patients were burn survivors who had at least two scars of similar appearance and physiologic function in the same body area that were at least 6 months from wound healing. Patients underwent a series of at least three treatments at 4-week intervals on one or more scars, with a similar scar left untreated as the control scar.

Subjective assessments of the scars showed statistically significant improvements in scores on the Vancouver Scar Scale with all three treatments compared with control scars, but fewer changes were seen in objective measurements of scar qualities. "Measurements of these improvements are really difficult to tackle. We tried to add some objective measurement instruments to our evaluations," reported Dr. Blome-Eberwein of Lehigh Valley Regional Burn Center, Allentown, Pa.

None of the treatments produced significant changes in elasticity as measured by the Cutometer device. "It’s really a complete mix of results in this value," she said.

Courtesy Dr. Sigrid Blome-Eberwein

The fractional erbium laser produced one statistically significant improvement, compared with control scars, in thickness as measured by high-resolution ultrasound used to assess scar thickness (so that patients could avoid biopsies). The KTP laser also produced one statistically significant improvement, compared with control scars: improved sensation as assessed by Semmes Weinstein monofilaments.

The CO₂ laser, however, produced greater improvements in scar thickness and sensation, as well as significant improvements in erythema and pigment (both measured by spectrometry), compared with control scars. Measurements of pain and pruritus did not differ significantly between treated and control scars in any of the studies; pain levels tended to improve in both the treated and control areas and pruritus tended to remain steady.

The KTP laser caused blisters in some patients. The fractional CO₂ and fractional erbium lasers produced minimal damage. Increased power was more likely to produce collateral damage and blisters, Dr. Blome-Eberwein said.

Any results were persistent and additive. Because penetration of these lasers is limited, multiple treatments are needed for thick scars, she noted.

Courtesy Dr. Sigrid Blome-Eberwein

Based on these findings and her experience at the burn center, Dr. Blome-Eberwein recommended treating scars that seem to turn hypertrophic early (within 4 weeks of wound healing) and frequently (every 3 weeks) with a nonablative fractional erbium glass laser or pulsed dye laser. The erbium glass laser does seem to prevent "some degree of hypertrophy early on," she said. Either of these early treatments may decrease hypertrophic activity and prevent hypertrophy with no dermal damage.

Dr. Blome-Eberwein said she treats hypertrophic scars 3-12 months after healing with fractional CO₂ laser. Treating scar pigment remains a challenge, she added.

"In the future, there will be handheld devices" to treat scars at home "because a lot of people are affected by this problem," she said.

Most of the scars in the studies were from burns, with a few from trauma.

Dr. Blome-Eberwein reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

PHOENIX – A fractional carbon dioxide laser at 10,600 nm was the only one of three laser treatments for hypertrophic scars that produced significant overall improvements in a comparison of data on 141 scars in 66 patients.

Less successful were treatments using a vascular KTP laser at 532 nm or a 1,550-nm nonablative fractional erbium glass laser.

"The only one that showed significant improvement compared with the control scar, adjusted for the baseline scar, was the fractional CO2 laser," Dr. Sigrid Blome-Eberwein said at the annual meeting of the American Society for Laser Medicine and Surgery.

The data came from three prospective controlled studies at one institution. The patients were burn survivors who had at least two scars of similar appearance and physiologic function in the same body area that were at least 6 months from wound healing. Patients underwent a series of at least three treatments at 4-week intervals on one or more scars, with a similar scar left untreated as the control scar.

Subjective assessments of the scars showed statistically significant improvements in scores on the Vancouver Scar Scale with all three treatments compared with control scars, but fewer changes were seen in objective measurements of scar qualities. "Measurements of these improvements are really difficult to tackle. We tried to add some objective measurement instruments to our evaluations," reported Dr. Blome-Eberwein of Lehigh Valley Regional Burn Center, Allentown, Pa.

None of the treatments produced significant changes in elasticity as measured by the Cutometer device. "It’s really a complete mix of results in this value," she said.

Courtesy Dr. Sigrid Blome-Eberwein

The fractional erbium laser produced one statistically significant improvement, compared with control scars, in thickness as measured by high-resolution ultrasound used to assess scar thickness (so that patients could avoid biopsies). The KTP laser also produced one statistically significant improvement, compared with control scars: improved sensation as assessed by Semmes Weinstein monofilaments.

The CO₂ laser, however, produced greater improvements in scar thickness and sensation, as well as significant improvements in erythema and pigment (both measured by spectrometry), compared with control scars. Measurements of pain and pruritus did not differ significantly between treated and control scars in any of the studies; pain levels tended to improve in both the treated and control areas and pruritus tended to remain steady.

The KTP laser caused blisters in some patients. The fractional CO₂ and fractional erbium lasers produced minimal damage. Increased power was more likely to produce collateral damage and blisters, Dr. Blome-Eberwein said.

Any results were persistent and additive. Because penetration of these lasers is limited, multiple treatments are needed for thick scars, she noted.

Courtesy Dr. Sigrid Blome-Eberwein

Based on these findings and her experience at the burn center, Dr. Blome-Eberwein recommended treating scars that seem to turn hypertrophic early (within 4 weeks of wound healing) and frequently (every 3 weeks) with a nonablative fractional erbium glass laser or pulsed dye laser. The erbium glass laser does seem to prevent "some degree of hypertrophy early on," she said. Either of these early treatments may decrease hypertrophic activity and prevent hypertrophy with no dermal damage.

Dr. Blome-Eberwein said she treats hypertrophic scars 3-12 months after healing with fractional CO₂ laser. Treating scar pigment remains a challenge, she added.

"In the future, there will be handheld devices" to treat scars at home "because a lot of people are affected by this problem," she said.

Most of the scars in the studies were from burns, with a few from trauma.

Dr. Blome-Eberwein reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

PHOENIX – A fractional carbon dioxide laser at 10,600 nm was the only one of three laser treatments for hypertrophic scars that produced significant overall improvements in a comparison of data on 141 scars in 66 patients.

Less successful were treatments using a vascular KTP laser at 532 nm or a 1,550-nm nonablative fractional erbium glass laser.

"The only one that showed significant improvement compared with the control scar, adjusted for the baseline scar, was the fractional CO2 laser," Dr. Sigrid Blome-Eberwein said at the annual meeting of the American Society for Laser Medicine and Surgery.

The data came from three prospective controlled studies at one institution. The patients were burn survivors who had at least two scars of similar appearance and physiologic function in the same body area that were at least 6 months from wound healing. Patients underwent a series of at least three treatments at 4-week intervals on one or more scars, with a similar scar left untreated as the control scar.

Subjective assessments of the scars showed statistically significant improvements in scores on the Vancouver Scar Scale with all three treatments compared with control scars, but fewer changes were seen in objective measurements of scar qualities. "Measurements of these improvements are really difficult to tackle. We tried to add some objective measurement instruments to our evaluations," reported Dr. Blome-Eberwein of Lehigh Valley Regional Burn Center, Allentown, Pa.

None of the treatments produced significant changes in elasticity as measured by the Cutometer device. "It’s really a complete mix of results in this value," she said.

Courtesy Dr. Sigrid Blome-Eberwein

The fractional erbium laser produced one statistically significant improvement, compared with control scars, in thickness as measured by high-resolution ultrasound used to assess scar thickness (so that patients could avoid biopsies). The KTP laser also produced one statistically significant improvement, compared with control scars: improved sensation as assessed by Semmes Weinstein monofilaments.

The CO₂ laser, however, produced greater improvements in scar thickness and sensation, as well as significant improvements in erythema and pigment (both measured by spectrometry), compared with control scars. Measurements of pain and pruritus did not differ significantly between treated and control scars in any of the studies; pain levels tended to improve in both the treated and control areas and pruritus tended to remain steady.

The KTP laser caused blisters in some patients. The fractional CO₂ and fractional erbium lasers produced minimal damage. Increased power was more likely to produce collateral damage and blisters, Dr. Blome-Eberwein said.

Any results were persistent and additive. Because penetration of these lasers is limited, multiple treatments are needed for thick scars, she noted.

Courtesy Dr. Sigrid Blome-Eberwein

Based on these findings and her experience at the burn center, Dr. Blome-Eberwein recommended treating scars that seem to turn hypertrophic early (within 4 weeks of wound healing) and frequently (every 3 weeks) with a nonablative fractional erbium glass laser or pulsed dye laser. The erbium glass laser does seem to prevent "some degree of hypertrophy early on," she said. Either of these early treatments may decrease hypertrophic activity and prevent hypertrophy with no dermal damage.

Dr. Blome-Eberwein said she treats hypertrophic scars 3-12 months after healing with fractional CO₂ laser. Treating scar pigment remains a challenge, she added.

"In the future, there will be handheld devices" to treat scars at home "because a lot of people are affected by this problem," she said.

Most of the scars in the studies were from burns, with a few from trauma.

Dr. Blome-Eberwein reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

[email protected]

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

[email protected]

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

[email protected]

MAUI, HAWAII – "Slow Mohs" has gained near-universal acceptance among skin cancer specialists as a definitive surgical technique for complete removal of lentigo maligna melanoma while simultaneously sparing normal tissue, according to Dr. Ellen Marmur of Mount Sinai School of Medicine, New York.

The big advantage that slow Mohs has over standard wide local excision with 0.5- to 1-cm margins is a 5-year cure rate approaching 100%. In contrast, standard excision has a recurrence rate of up to 20%, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce C. Jancin/IMNG Medical Media

Slow Mohs is a modified form of Mohs micrographic surgery. The surgery compares with conventional Mohs: It is staged, margin-controlled excision. But in slow Mohs, rush permanent sections are sent off to the pathologist rather than the frozen sections integral to conventional Mohs.

Dr. Marmur relies upon slow Mohs, with "bread-loafing" of the central tumor by the pathologist, because the permanent sections better preserve the tumor’s microscopic features. Interpreting atypical melanocytes in frozen sections can be quite a challenge. However, she added, some Mohs surgeons have found that using rapid immunostains also markedly improves the sensitivity and specificity of frozen sections in lentigo maligna surgery.

Slow Mohs takes place over the course of days, she said. "Basically, you do your Wood’s lamp to define the lesion diameter, you measure out your margins, you excise the tumor, pack the area with a bandage, and send the patient home. You rush your pathology, and you don’t do any reconstruction until you get the margins clear."

A pathology report that comes back stating narrow margins are present is "a heart stopper," she added.

"You have the option of observing the area if the margin is clear but the tumor was close to the margin. That’s a good approach for an elderly patient or when the lentigo maligna was in a cosmetically important area."

Lentigo maligna melanoma accounts for 4% of all cases of melanoma. It typically arises on sun-damaged skin in individuals in their 70s or older. Common sites include the malar area, forehead, nose, and temple. The differential diagnosis includes seborrheic keratosis, pigmented actinic keratosis, and pigmented nevus.

Lentigo maligna becomes lentigo maligna melanoma when malignant melanoma cells invade the dermis and deeper appendages. Roughly 5% of lentigo malignas eventually progress to invasive melanoma, according to Dr. Marmur. Typically, a lentigo maligna undergoes extended gradual horizontal growth before beginning a vertical growth phase.

"It spreads like an oil slick for many years," Dr. Marmur said at the seminar.

Established treatment modalities for patients who aren’t surgical candidates include cryotherapy, radiotherapy, and topical imiquimod 5%. All have disadvantages, including high 5-year recurrence rates.

Dr. Marmur noted that a newer nonsurgical therapy drawing considerable interest involves off-label use of topical combination therapy with imiquimod and tazarotene gel. The concept is to use the topical retinoid to disrupt the stratum corneum in order to enhance imiquimod penetration, thereby achieving a greater inflammatory response than possible with imiquimod alone.

Initial data have been published by researchers at the University of Utah, Salt Lake City. They randomized 90 patients with 91 lentigo malignas to imiquimod 5% cream applied 5 days per week for 3 months or to the imiquimod regimen plus tazarotene 0.1% gel on the other 2 days per week. After 3 months of topical therapy, patients underwent conservative staged excision with frozen section analysis with Melan A immunostaining to confirm negative margins.

Of those treated with dual topical therapy for 3 months, 29 of 37 lesions (78%) had complete responses with no residual lentigo maligna at the time of staged excision. So did 27 of 42 (64%) treated with imiquimod alone (Arch. Dermatol. 2012;148:592-6).

The modest difference in outcome was not significant (P = .17). Nevertheless, the Utah investigators wrote that topical pretreatment appears to reduce surgical defect sizes, an important consideration in lentigo maligna because the lesions are often large and located on cosmetically sensitive facial sites. At the patient’s first visit, the researchers saucerize the entire tumor to remove all visible evidence of lentigo maligna and nip in the bud any invasive element that might be present. One month later, after the wound has healed by secondary intention, the patient begins topical imiquimod therapy 5 days per week. If no inflammation is observed, tazarotene gel is added on the other 2 days per week. After 3 months of topical therapy, the patient goes off treatment for 2 months so the inflammatory response can subside. Then a staged excision is performed with 2-mm margins around the perimeter of the original tumor outline.

"This is an interesting thought, but it’s still not considered standard of care," Dr. Marmur commented in describing the Utah research.

Bruce C. Jancin/IMNG Medical Media

Session chair Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan-Kettering Cancer Center in New York, said he and his colleagues, like the Utah group, are using a lot of topical imiquimod as adjunctive therapy for lentigo maligna.

"Because we’re a referral center, we see all those patients whose melanomas unfortunately do recur at the edge of large surgeries. We see a lot of patients whose local surgeons have chased around their faces for a certain amount of time. So I think the general concept of the cure rates of surgery is a bit overstated. I’m not trying to sell an off-label use of a drug, but I think sometimes imiquimod can be very helpful," Dr. Halpern said.

He offered a clinical pearl in diagnosing lentigo maligna: Consider a broad shave biopsy of a suspicious lesion rather than a deeper, smaller-diameter biopsy.

"Sampling errors are a real problem with lentigo maligna. We learned early on that if you take a large lentigo maligna and do multiple biopsies of the same lesion and send them to what we think are our very expert pathologists, on average, we get two or three back that were melanoma and two or three back that were pigmented actinic keratoses. The sampling error tends to be more in the horizontal than in the depth for these very early lesions," according to Dr. Halpern.

Dr. Marmur and Dr. Halpern reported having no relevant financial interests. SDEF and this news organization are owned by the same parent company.

[email protected]

MAUI, HAWAII – "Slow Mohs" has gained near-universal acceptance among skin cancer specialists as a definitive surgical technique for complete removal of lentigo maligna melanoma while simultaneously sparing normal tissue, according to Dr. Ellen Marmur of Mount Sinai School of Medicine, New York.

The big advantage that slow Mohs has over standard wide local excision with 0.5- to 1-cm margins is a 5-year cure rate approaching 100%. In contrast, standard excision has a recurrence rate of up to 20%, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce C. Jancin/IMNG Medical Media

Slow Mohs is a modified form of Mohs micrographic surgery. The surgery compares with conventional Mohs: It is staged, margin-controlled excision. But in slow Mohs, rush permanent sections are sent off to the pathologist rather than the frozen sections integral to conventional Mohs.

Dr. Marmur relies upon slow Mohs, with "bread-loafing" of the central tumor by the pathologist, because the permanent sections better preserve the tumor’s microscopic features. Interpreting atypical melanocytes in frozen sections can be quite a challenge. However, she added, some Mohs surgeons have found that using rapid immunostains also markedly improves the sensitivity and specificity of frozen sections in lentigo maligna surgery.

Slow Mohs takes place over the course of days, she said. "Basically, you do your Wood’s lamp to define the lesion diameter, you measure out your margins, you excise the tumor, pack the area with a bandage, and send the patient home. You rush your pathology, and you don’t do any reconstruction until you get the margins clear."

A pathology report that comes back stating narrow margins are present is "a heart stopper," she added.

"You have the option of observing the area if the margin is clear but the tumor was close to the margin. That’s a good approach for an elderly patient or when the lentigo maligna was in a cosmetically important area."

Lentigo maligna melanoma accounts for 4% of all cases of melanoma. It typically arises on sun-damaged skin in individuals in their 70s or older. Common sites include the malar area, forehead, nose, and temple. The differential diagnosis includes seborrheic keratosis, pigmented actinic keratosis, and pigmented nevus.

Lentigo maligna becomes lentigo maligna melanoma when malignant melanoma cells invade the dermis and deeper appendages. Roughly 5% of lentigo malignas eventually progress to invasive melanoma, according to Dr. Marmur. Typically, a lentigo maligna undergoes extended gradual horizontal growth before beginning a vertical growth phase.

"It spreads like an oil slick for many years," Dr. Marmur said at the seminar.

Established treatment modalities for patients who aren’t surgical candidates include cryotherapy, radiotherapy, and topical imiquimod 5%. All have disadvantages, including high 5-year recurrence rates.

Dr. Marmur noted that a newer nonsurgical therapy drawing considerable interest involves off-label use of topical combination therapy with imiquimod and tazarotene gel. The concept is to use the topical retinoid to disrupt the stratum corneum in order to enhance imiquimod penetration, thereby achieving a greater inflammatory response than possible with imiquimod alone.

Initial data have been published by researchers at the University of Utah, Salt Lake City. They randomized 90 patients with 91 lentigo malignas to imiquimod 5% cream applied 5 days per week for 3 months or to the imiquimod regimen plus tazarotene 0.1% gel on the other 2 days per week. After 3 months of topical therapy, patients underwent conservative staged excision with frozen section analysis with Melan A immunostaining to confirm negative margins.

Of those treated with dual topical therapy for 3 months, 29 of 37 lesions (78%) had complete responses with no residual lentigo maligna at the time of staged excision. So did 27 of 42 (64%) treated with imiquimod alone (Arch. Dermatol. 2012;148:592-6).

The modest difference in outcome was not significant (P = .17). Nevertheless, the Utah investigators wrote that topical pretreatment appears to reduce surgical defect sizes, an important consideration in lentigo maligna because the lesions are often large and located on cosmetically sensitive facial sites. At the patient’s first visit, the researchers saucerize the entire tumor to remove all visible evidence of lentigo maligna and nip in the bud any invasive element that might be present. One month later, after the wound has healed by secondary intention, the patient begins topical imiquimod therapy 5 days per week. If no inflammation is observed, tazarotene gel is added on the other 2 days per week. After 3 months of topical therapy, the patient goes off treatment for 2 months so the inflammatory response can subside. Then a staged excision is performed with 2-mm margins around the perimeter of the original tumor outline.

"This is an interesting thought, but it’s still not considered standard of care," Dr. Marmur commented in describing the Utah research.

Bruce C. Jancin/IMNG Medical Media

Session chair Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan-Kettering Cancer Center in New York, said he and his colleagues, like the Utah group, are using a lot of topical imiquimod as adjunctive therapy for lentigo maligna.

"Because we’re a referral center, we see all those patients whose melanomas unfortunately do recur at the edge of large surgeries. We see a lot of patients whose local surgeons have chased around their faces for a certain amount of time. So I think the general concept of the cure rates of surgery is a bit overstated. I’m not trying to sell an off-label use of a drug, but I think sometimes imiquimod can be very helpful," Dr. Halpern said.

He offered a clinical pearl in diagnosing lentigo maligna: Consider a broad shave biopsy of a suspicious lesion rather than a deeper, smaller-diameter biopsy.

"Sampling errors are a real problem with lentigo maligna. We learned early on that if you take a large lentigo maligna and do multiple biopsies of the same lesion and send them to what we think are our very expert pathologists, on average, we get two or three back that were melanoma and two or three back that were pigmented actinic keratoses. The sampling error tends to be more in the horizontal than in the depth for these very early lesions," according to Dr. Halpern.

Dr. Marmur and Dr. Halpern reported having no relevant financial interests. SDEF and this news organization are owned by the same parent company.

[email protected]

MAUI, HAWAII – "Slow Mohs" has gained near-universal acceptance among skin cancer specialists as a definitive surgical technique for complete removal of lentigo maligna melanoma while simultaneously sparing normal tissue, according to Dr. Ellen Marmur of Mount Sinai School of Medicine, New York.

The big advantage that slow Mohs has over standard wide local excision with 0.5- to 1-cm margins is a 5-year cure rate approaching 100%. In contrast, standard excision has a recurrence rate of up to 20%, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce C. Jancin/IMNG Medical Media

Slow Mohs is a modified form of Mohs micrographic surgery. The surgery compares with conventional Mohs: It is staged, margin-controlled excision. But in slow Mohs, rush permanent sections are sent off to the pathologist rather than the frozen sections integral to conventional Mohs.

Dr. Marmur relies upon slow Mohs, with "bread-loafing" of the central tumor by the pathologist, because the permanent sections better preserve the tumor’s microscopic features. Interpreting atypical melanocytes in frozen sections can be quite a challenge. However, she added, some Mohs surgeons have found that using rapid immunostains also markedly improves the sensitivity and specificity of frozen sections in lentigo maligna surgery.

Slow Mohs takes place over the course of days, she said. "Basically, you do your Wood’s lamp to define the lesion diameter, you measure out your margins, you excise the tumor, pack the area with a bandage, and send the patient home. You rush your pathology, and you don’t do any reconstruction until you get the margins clear."

A pathology report that comes back stating narrow margins are present is "a heart stopper," she added.

"You have the option of observing the area if the margin is clear but the tumor was close to the margin. That’s a good approach for an elderly patient or when the lentigo maligna was in a cosmetically important area."

Lentigo maligna melanoma accounts for 4% of all cases of melanoma. It typically arises on sun-damaged skin in individuals in their 70s or older. Common sites include the malar area, forehead, nose, and temple. The differential diagnosis includes seborrheic keratosis, pigmented actinic keratosis, and pigmented nevus.

Lentigo maligna becomes lentigo maligna melanoma when malignant melanoma cells invade the dermis and deeper appendages. Roughly 5% of lentigo malignas eventually progress to invasive melanoma, according to Dr. Marmur. Typically, a lentigo maligna undergoes extended gradual horizontal growth before beginning a vertical growth phase.

"It spreads like an oil slick for many years," Dr. Marmur said at the seminar.

Established treatment modalities for patients who aren’t surgical candidates include cryotherapy, radiotherapy, and topical imiquimod 5%. All have disadvantages, including high 5-year recurrence rates.

Dr. Marmur noted that a newer nonsurgical therapy drawing considerable interest involves off-label use of topical combination therapy with imiquimod and tazarotene gel. The concept is to use the topical retinoid to disrupt the stratum corneum in order to enhance imiquimod penetration, thereby achieving a greater inflammatory response than possible with imiquimod alone.

Initial data have been published by researchers at the University of Utah, Salt Lake City. They randomized 90 patients with 91 lentigo malignas to imiquimod 5% cream applied 5 days per week for 3 months or to the imiquimod regimen plus tazarotene 0.1% gel on the other 2 days per week. After 3 months of topical therapy, patients underwent conservative staged excision with frozen section analysis with Melan A immunostaining to confirm negative margins.

Of those treated with dual topical therapy for 3 months, 29 of 37 lesions (78%) had complete responses with no residual lentigo maligna at the time of staged excision. So did 27 of 42 (64%) treated with imiquimod alone (Arch. Dermatol. 2012;148:592-6).

The modest difference in outcome was not significant (P = .17). Nevertheless, the Utah investigators wrote that topical pretreatment appears to reduce surgical defect sizes, an important consideration in lentigo maligna because the lesions are often large and located on cosmetically sensitive facial sites. At the patient’s first visit, the researchers saucerize the entire tumor to remove all visible evidence of lentigo maligna and nip in the bud any invasive element that might be present. One month later, after the wound has healed by secondary intention, the patient begins topical imiquimod therapy 5 days per week. If no inflammation is observed, tazarotene gel is added on the other 2 days per week. After 3 months of topical therapy, the patient goes off treatment for 2 months so the inflammatory response can subside. Then a staged excision is performed with 2-mm margins around the perimeter of the original tumor outline.

"This is an interesting thought, but it’s still not considered standard of care," Dr. Marmur commented in describing the Utah research.

Bruce C. Jancin/IMNG Medical Media

Session chair Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan-Kettering Cancer Center in New York, said he and his colleagues, like the Utah group, are using a lot of topical imiquimod as adjunctive therapy for lentigo maligna.

"Because we’re a referral center, we see all those patients whose melanomas unfortunately do recur at the edge of large surgeries. We see a lot of patients whose local surgeons have chased around their faces for a certain amount of time. So I think the general concept of the cure rates of surgery is a bit overstated. I’m not trying to sell an off-label use of a drug, but I think sometimes imiquimod can be very helpful," Dr. Halpern said.

He offered a clinical pearl in diagnosing lentigo maligna: Consider a broad shave biopsy of a suspicious lesion rather than a deeper, smaller-diameter biopsy.

"Sampling errors are a real problem with lentigo maligna. We learned early on that if you take a large lentigo maligna and do multiple biopsies of the same lesion and send them to what we think are our very expert pathologists, on average, we get two or three back that were melanoma and two or three back that were pigmented actinic keratoses. The sampling error tends to be more in the horizontal than in the depth for these very early lesions," according to Dr. Halpern.

Dr. Marmur and Dr. Halpern reported having no relevant financial interests. SDEF and this news organization are owned by the same parent company.

[email protected]

LAS VEGAS – Hoping to make your practice’s Facebook page a success? Engage with your Facebook followers.

According to Monique Ramsey, founder of Del Mar, Calif.–based Cosmetic Social Media, the best path to social media success involves fostering. "Think about who your consumer is and what she wants to learn about," she advised.

"Provide that information to her and let her share it with her friends, because then your name is attached to that piece of content. And note it may not have anything to do with your cosmetic surgery practice, but this kind of a post will keep people coming to your page and get higher visibility for your posts in the newsfeed," she added.

The goal is to have your posts reach more than the Facebook average, which is about 16% of your Facebook followers. With more than 1 billion people using Facebook, physicians need to be able to "cut through the noise," Ms. Ramsey explained at the annual meeting of the American Academy of Cosmetic Surgery.

It’s okay for 20% of your posts to be about your practice – perhaps advertising special events and promotions – but the remaining 80% should be informative and off the topic yet engaging, meaningful, and fun.

For example, Ms. Ramsey crafted questions for one of her client’s Facebook page intended to trigger engagement in the form of comments. One read "It’s National Wine Day. Are you a red, white or bubbly?" Another post example was crafted to encourage fans to hit the "like" button and featured two cars, sporting false eyelashes which read, "Bet you the lady car uses Latisse – hit your LIKE button if you do too!" Both questions created a spike in traffic, engagement rate, and conversation on her client’s Facebook page, she said. The latter resulted in a reach of over 10,000 people and an engagement rate of over 11% (2% is average).

"You’re trying to create an emotional connection with your Facebook followers," Ms. Ramsey said. "When you’re doing your job right, you will. You will feel like a friend to people. You want people to feel like they’re part of a community. You want to be a resource for them. You want to share your own content as well as other people’s content. Social media is very reciprocal, so give a little and get a lot."

Other tips she shared for optimizing a practice’s Facebook page include the following:

• Be yourself. "Credibility and trust are important," Ms. Ramsey said. "Be authentic. Be humble. Think about influencing conversations, not controlling conversations. You can influence behavior but you don’t have to control it."

• Change your cover image at least monthly. That’s because cover images "get, on average, nine times more engagement than a regular post," she said. "Celebrate your 100th fan, or use this space to advertise a promotion you have going on."

• Make sure your avatar is superb. Ninety percent of Facebook users see your content in their newsfeed, "so it really needs to be good and easy to see," she said. "People prefer to hear from a face of the practice rather than a logo or building because we humans communicate with people, not logos."

• Monitor replies to your posts. If someone is sending abusive messages, "you can hide those messages and block that person from your page. Or it might be better to leave it there and let your community come to your defense on your behalf. I have only had to take down two messages on behalf of clients. Both were from competing physicians."

Ms. Ramsey is the founder of Cosmetic Social Media and had no other financial conflicts to disclose.

[email protected]

LAS VEGAS – Hoping to make your practice’s Facebook page a success? Engage with your Facebook followers.

According to Monique Ramsey, founder of Del Mar, Calif.–based Cosmetic Social Media, the best path to social media success involves fostering. "Think about who your consumer is and what she wants to learn about," she advised.

"Provide that information to her and let her share it with her friends, because then your name is attached to that piece of content. And note it may not have anything to do with your cosmetic surgery practice, but this kind of a post will keep people coming to your page and get higher visibility for your posts in the newsfeed," she added.

The goal is to have your posts reach more than the Facebook average, which is about 16% of your Facebook followers. With more than 1 billion people using Facebook, physicians need to be able to "cut through the noise," Ms. Ramsey explained at the annual meeting of the American Academy of Cosmetic Surgery.

It’s okay for 20% of your posts to be about your practice – perhaps advertising special events and promotions – but the remaining 80% should be informative and off the topic yet engaging, meaningful, and fun.

For example, Ms. Ramsey crafted questions for one of her client’s Facebook page intended to trigger engagement in the form of comments. One read "It’s National Wine Day. Are you a red, white or bubbly?" Another post example was crafted to encourage fans to hit the "like" button and featured two cars, sporting false eyelashes which read, "Bet you the lady car uses Latisse – hit your LIKE button if you do too!" Both questions created a spike in traffic, engagement rate, and conversation on her client’s Facebook page, she said. The latter resulted in a reach of over 10,000 people and an engagement rate of over 11% (2% is average).

"You’re trying to create an emotional connection with your Facebook followers," Ms. Ramsey said. "When you’re doing your job right, you will. You will feel like a friend to people. You want people to feel like they’re part of a community. You want to be a resource for them. You want to share your own content as well as other people’s content. Social media is very reciprocal, so give a little and get a lot."

Other tips she shared for optimizing a practice’s Facebook page include the following:

• Be yourself. "Credibility and trust are important," Ms. Ramsey said. "Be authentic. Be humble. Think about influencing conversations, not controlling conversations. You can influence behavior but you don’t have to control it."

• Change your cover image at least monthly. That’s because cover images "get, on average, nine times more engagement than a regular post," she said. "Celebrate your 100th fan, or use this space to advertise a promotion you have going on."

• Make sure your avatar is superb. Ninety percent of Facebook users see your content in their newsfeed, "so it really needs to be good and easy to see," she said. "People prefer to hear from a face of the practice rather than a logo or building because we humans communicate with people, not logos."

• Monitor replies to your posts. If someone is sending abusive messages, "you can hide those messages and block that person from your page. Or it might be better to leave it there and let your community come to your defense on your behalf. I have only had to take down two messages on behalf of clients. Both were from competing physicians."

Ms. Ramsey is the founder of Cosmetic Social Media and had no other financial conflicts to disclose.

[email protected]

LAS VEGAS – Hoping to make your practice’s Facebook page a success? Engage with your Facebook followers.

According to Monique Ramsey, founder of Del Mar, Calif.–based Cosmetic Social Media, the best path to social media success involves fostering. "Think about who your consumer is and what she wants to learn about," she advised.

"Provide that information to her and let her share it with her friends, because then your name is attached to that piece of content. And note it may not have anything to do with your cosmetic surgery practice, but this kind of a post will keep people coming to your page and get higher visibility for your posts in the newsfeed," she added.

The goal is to have your posts reach more than the Facebook average, which is about 16% of your Facebook followers. With more than 1 billion people using Facebook, physicians need to be able to "cut through the noise," Ms. Ramsey explained at the annual meeting of the American Academy of Cosmetic Surgery.

It’s okay for 20% of your posts to be about your practice – perhaps advertising special events and promotions – but the remaining 80% should be informative and off the topic yet engaging, meaningful, and fun.

For example, Ms. Ramsey crafted questions for one of her client’s Facebook page intended to trigger engagement in the form of comments. One read "It’s National Wine Day. Are you a red, white or bubbly?" Another post example was crafted to encourage fans to hit the "like" button and featured two cars, sporting false eyelashes which read, "Bet you the lady car uses Latisse – hit your LIKE button if you do too!" Both questions created a spike in traffic, engagement rate, and conversation on her client’s Facebook page, she said. The latter resulted in a reach of over 10,000 people and an engagement rate of over 11% (2% is average).

"You’re trying to create an emotional connection with your Facebook followers," Ms. Ramsey said. "When you’re doing your job right, you will. You will feel like a friend to people. You want people to feel like they’re part of a community. You want to be a resource for them. You want to share your own content as well as other people’s content. Social media is very reciprocal, so give a little and get a lot."

Other tips she shared for optimizing a practice’s Facebook page include the following:

• Be yourself. "Credibility and trust are important," Ms. Ramsey said. "Be authentic. Be humble. Think about influencing conversations, not controlling conversations. You can influence behavior but you don’t have to control it."

• Change your cover image at least monthly. That’s because cover images "get, on average, nine times more engagement than a regular post," she said. "Celebrate your 100th fan, or use this space to advertise a promotion you have going on."

• Make sure your avatar is superb. Ninety percent of Facebook users see your content in their newsfeed, "so it really needs to be good and easy to see," she said. "People prefer to hear from a face of the practice rather than a logo or building because we humans communicate with people, not logos."

• Monitor replies to your posts. If someone is sending abusive messages, "you can hide those messages and block that person from your page. Or it might be better to leave it there and let your community come to your defense on your behalf. I have only had to take down two messages on behalf of clients. Both were from competing physicians."

Ms. Ramsey is the founder of Cosmetic Social Media and had no other financial conflicts to disclose.

[email protected]

BOSTON – The appearance of radiation-induced telangectasias of the breast can be significantly improved by treatment with a pulsed-dye laser, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

There were no adverse treatment-associated effects, and the treatment was safe to use in breast cancer patients and women with reconstructed breasts, said Dr. Anthony Rossi, a fellow in procedural dermatology/Mohs surgery at Memorial Sloan-Kettering Cancer Center in New York.

"After treatment, all patients reported improvement, including an improved sense of confidence and aesthetic appearance, and one patient commented that she was now able to change in front of her partner without embarrassment," said Dr. Rossi.

Chronic radiation dermatitis can occur within 1 or 2 years of treatment for breast cancer. In one study, 59% of women had telangectasias within 5 years of undergoing electron-beam radiotherapy, and 72% had telangectasias at the treatment site within 7 years (Br. J. Radiol. 2002;75:444-7).

The clinical characteristics include skin atrophy, hypo- or hyperpigmentation, and prominent lesions believed to be caused by dilation of reduced or poorly supported skin vasculature. Telangectasias of the breast are typically confined to the site of the highest radiation dose and to areas that received radiation boosts, such as surgical scars.

For women who have undergone breast cancer therapy, telangectasias "can serve as a reminder of their cancer, almost akin to a surgical scar, and can prompt fears of recurrence or even social anxiety," Dr. Rossi said.

He and his colleagues conducted a retrospective study of 11 patients treated with a pulsed-dye laser for radiation-induced telangectasias, looking at radiation type and dose received; onset, color, thickness, and distribution of telangectasias; laser fluence parameters; and complications. They also evaluated patient perceptions and quality of life, and had pre- and postlaser clinical photos assessed by two independent raters to judge percentage clearance of telangectasias.

The women had received an average of 5,000 cGy (50 Gy) in 25 fractions, often with radiation boosts to the surgical scars. The telangectasias developed a mean of 3.7 years after radiation exposure.

Five patients were treated with a 595-nm pulsed-dye laser, and two with a 585-nm laser. The endpoint for all treatments was transient purpura.

The mean clearance was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9). The average laser fluence used was 7.2 J/cm². The energy was applied with a 10-mm spot size in 3- to 6-ms pulses.

The investigators saw no adverse effects of therapy, including in women with reconstructed breasts, whether with implants or flaps.

Based on their findings, the investigators are embarking on a prospective study designed to evaluate the effect of radiation-induced telangiectasias on patient quality of life and changes in quality of life measures after laser therapy, using the Skindex-16 and BREAST-Q validated scales. They also plan to assess long-term effects on quality of life and recurrence, if any, of treated telangectasias.

The study was internally funded. Dr. Rossi reported having no financial disclosures.

BOSTON – The appearance of radiation-induced telangectasias of the breast can be significantly improved by treatment with a pulsed-dye laser, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

There were no adverse treatment-associated effects, and the treatment was safe to use in breast cancer patients and women with reconstructed breasts, said Dr. Anthony Rossi, a fellow in procedural dermatology/Mohs surgery at Memorial Sloan-Kettering Cancer Center in New York.

"After treatment, all patients reported improvement, including an improved sense of confidence and aesthetic appearance, and one patient commented that she was now able to change in front of her partner without embarrassment," said Dr. Rossi.

Chronic radiation dermatitis can occur within 1 or 2 years of treatment for breast cancer. In one study, 59% of women had telangectasias within 5 years of undergoing electron-beam radiotherapy, and 72% had telangectasias at the treatment site within 7 years (Br. J. Radiol. 2002;75:444-7).

The clinical characteristics include skin atrophy, hypo- or hyperpigmentation, and prominent lesions believed to be caused by dilation of reduced or poorly supported skin vasculature. Telangectasias of the breast are typically confined to the site of the highest radiation dose and to areas that received radiation boosts, such as surgical scars.

For women who have undergone breast cancer therapy, telangectasias "can serve as a reminder of their cancer, almost akin to a surgical scar, and can prompt fears of recurrence or even social anxiety," Dr. Rossi said.

He and his colleagues conducted a retrospective study of 11 patients treated with a pulsed-dye laser for radiation-induced telangectasias, looking at radiation type and dose received; onset, color, thickness, and distribution of telangectasias; laser fluence parameters; and complications. They also evaluated patient perceptions and quality of life, and had pre- and postlaser clinical photos assessed by two independent raters to judge percentage clearance of telangectasias.

The women had received an average of 5,000 cGy (50 Gy) in 25 fractions, often with radiation boosts to the surgical scars. The telangectasias developed a mean of 3.7 years after radiation exposure.

Five patients were treated with a 595-nm pulsed-dye laser, and two with a 585-nm laser. The endpoint for all treatments was transient purpura.

The mean clearance was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9). The average laser fluence used was 7.2 J/cm². The energy was applied with a 10-mm spot size in 3- to 6-ms pulses.

The investigators saw no adverse effects of therapy, including in women with reconstructed breasts, whether with implants or flaps.

Based on their findings, the investigators are embarking on a prospective study designed to evaluate the effect of radiation-induced telangiectasias on patient quality of life and changes in quality of life measures after laser therapy, using the Skindex-16 and BREAST-Q validated scales. They also plan to assess long-term effects on quality of life and recurrence, if any, of treated telangectasias.

The study was internally funded. Dr. Rossi reported having no financial disclosures.

BOSTON – The appearance of radiation-induced telangectasias of the breast can be significantly improved by treatment with a pulsed-dye laser, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

There were no adverse treatment-associated effects, and the treatment was safe to use in breast cancer patients and women with reconstructed breasts, said Dr. Anthony Rossi, a fellow in procedural dermatology/Mohs surgery at Memorial Sloan-Kettering Cancer Center in New York.

"After treatment, all patients reported improvement, including an improved sense of confidence and aesthetic appearance, and one patient commented that she was now able to change in front of her partner without embarrassment," said Dr. Rossi.

Chronic radiation dermatitis can occur within 1 or 2 years of treatment for breast cancer. In one study, 59% of women had telangectasias within 5 years of undergoing electron-beam radiotherapy, and 72% had telangectasias at the treatment site within 7 years (Br. J. Radiol. 2002;75:444-7).

The clinical characteristics include skin atrophy, hypo- or hyperpigmentation, and prominent lesions believed to be caused by dilation of reduced or poorly supported skin vasculature. Telangectasias of the breast are typically confined to the site of the highest radiation dose and to areas that received radiation boosts, such as surgical scars.

For women who have undergone breast cancer therapy, telangectasias "can serve as a reminder of their cancer, almost akin to a surgical scar, and can prompt fears of recurrence or even social anxiety," Dr. Rossi said.

He and his colleagues conducted a retrospective study of 11 patients treated with a pulsed-dye laser for radiation-induced telangectasias, looking at radiation type and dose received; onset, color, thickness, and distribution of telangectasias; laser fluence parameters; and complications. They also evaluated patient perceptions and quality of life, and had pre- and postlaser clinical photos assessed by two independent raters to judge percentage clearance of telangectasias.

The women had received an average of 5,000 cGy (50 Gy) in 25 fractions, often with radiation boosts to the surgical scars. The telangectasias developed a mean of 3.7 years after radiation exposure.

Five patients were treated with a 595-nm pulsed-dye laser, and two with a 585-nm laser. The endpoint for all treatments was transient purpura.

The mean clearance was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9). The average laser fluence used was 7.2 J/cm². The energy was applied with a 10-mm spot size in 3- to 6-ms pulses.

The investigators saw no adverse effects of therapy, including in women with reconstructed breasts, whether with implants or flaps.

Based on their findings, the investigators are embarking on a prospective study designed to evaluate the effect of radiation-induced telangiectasias on patient quality of life and changes in quality of life measures after laser therapy, using the Skindex-16 and BREAST-Q validated scales. They also plan to assess long-term effects on quality of life and recurrence, if any, of treated telangectasias.

The study was internally funded. Dr. Rossi reported having no financial disclosures.

LAS VEGAS – Knowing and respecting the anatomy of the levator muscle can help clinicians steer clear of complications from blepharoplasty and manage ptosis, according to Dr. Marc S. Cohen.

"It’s very helpful if you have a good understanding of how to find the levator muscle during eyelid surgery," said Dr. Cohen, an ophthalmic plastic surgeon at the Wills Eye Institute, Philadelphia. "In order to do this, you need to understand the relationship between the levator and the other eyelid structures."

The levator muscle elevates the eyelid and helps form the eyelid crease. It also creates the margin contour. As the levator muscle approaches the eyelid, it changes direction from vertically oriented to horizontally oriented. The muscle then advances inferiorly toward the eyelid margin, "and for the final centimeter or so, it becomes a fibrous aponeurosis, which attaches to the tarsus posteriorly," said Dr. Cohen, who also has a private cosmetic surgery practice. Behind the levator muscle are Müller’s muscle and the conjunctiva.

Whether a surgeon performs blepharoplasty with a CO₂ laser, a blade, cautery, or radiofrequency, the first structure encountered posteriorly is the orbicularis oculi muscle, which closes the eyelid. "It’s highly vascular, and is the site where most of the bleeding occurs during blepharoplasty," Dr. Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

The next layer contains the orbital septum. "It’s important to understand that the septum does not travel all the way to the eyelid margin," he added. "The septum starts at the orbital rim and attaches to the levator muscle. This layer really has two structures: the septum and the levator. Behind the septum are the eyelid fat pads."

In a dissection above and behind in the eyelid, the septum and the fat precede the levator muscle. However, in the inferior eyelid, the levator is just deep to the orbicularis muscle. Beneath the fat, the levator muscle moves posteriorly into the orbit; this causes it to narrow.

"Lateral to the muscle at this point is the lacrimal gland, but medially is just orbital fat," Dr. Cohen said. Upon reaching the orbicularis muscle, the goal is to protect the levator muscle. "The levator muscle is protected by septum fat superiorly, whereas more inferiorly the levator fuses with the orbicularis, so this is a danger zone," Dr. Cohen said. "Laterally is the lacrimal gland and supramedially is the safest point, because there you have the fat, and nothing else to really worry about superficially. So what you do is press on the globe through the eyelid, have the fat prolapse forward, and dissect there."

Reattaching the levator muscle can be tricky in the context of levator resection ptosis surgery, said Dr. Cohen. "Where you make the attachment is going to affect the contour postoperatively," he said. "Grasp the tarsus and pull it upward to see if you have obtained a natural curve. If you grasp it at the wrong point, you’ll have a curve that’s not aesthetically pleasing," he cautioned.

"When you get the right point, that is where you are going to put the sutures to reattach the levator. A double-armed 6-0 suture is passed in a horizontal mattress fashion, partial thickness, through the tarsus. The suture is then passed in a posterior to anterior direction, which shortens the levator muscle."

Placement of the suture determines how much the muscle shortens. "The suture is then temporarily tied, and the patient is asked to open their eyes to assess the height and the contour," Dr. Cohen said. "If you need to adjust height vertically, you can move the suture vertically on the levator muscle. If there’s a problem with the contour, you change the fixation point to the tarsus. Then the suture is permanently tied and the skin is closed."

Dr. Cohen warned about the risk of complications from blepharoplasty in patients with active Graves’ disease, a common autoimmune condition that can cause hyperthyroidism and fibrosis of the extraocular tissues. The severe form of Graves’ disease can cause eyelid retraction, difficulty closing the eyes, double vision, and anterior displacement of the globes. "Many patients present with much more subtle findings," he noted. "For example, fibrosis of the levator with lid retraction is a common presentation in women aged 40-60 – the same demographic that tends to have blepharoplasty. It’s often subtle and underdiagnosed."

Patients with undiagnosed Graves’ disease prior to a blepharoplasty "can develop signs and symptoms which are indistinguishable from the complications of blepharoplasty," Dr. Cohen said. "You need to make the diagnosis before surgery and make sure the disease has stabilized before you do any surgery. That happens on average in about 18 months but is variable."

Dr. Cohen disclosed that he is a member of the advisory board for Allergan and that he is a speaker for Allergan and Medicis.

[email protected]

LAS VEGAS – Knowing and respecting the anatomy of the levator muscle can help clinicians steer clear of complications from blepharoplasty and manage ptosis, according to Dr. Marc S. Cohen.

"It’s very helpful if you have a good understanding of how to find the levator muscle during eyelid surgery," said Dr. Cohen, an ophthalmic plastic surgeon at the Wills Eye Institute, Philadelphia. "In order to do this, you need to understand the relationship between the levator and the other eyelid structures."

The levator muscle elevates the eyelid and helps form the eyelid crease. It also creates the margin contour. As the levator muscle approaches the eyelid, it changes direction from vertically oriented to horizontally oriented. The muscle then advances inferiorly toward the eyelid margin, "and for the final centimeter or so, it becomes a fibrous aponeurosis, which attaches to the tarsus posteriorly," said Dr. Cohen, who also has a private cosmetic surgery practice. Behind the levator muscle are Müller’s muscle and the conjunctiva.

Whether a surgeon performs blepharoplasty with a CO₂ laser, a blade, cautery, or radiofrequency, the first structure encountered posteriorly is the orbicularis oculi muscle, which closes the eyelid. "It’s highly vascular, and is the site where most of the bleeding occurs during blepharoplasty," Dr. Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

The next layer contains the orbital septum. "It’s important to understand that the septum does not travel all the way to the eyelid margin," he added. "The septum starts at the orbital rim and attaches to the levator muscle. This layer really has two structures: the septum and the levator. Behind the septum are the eyelid fat pads."

In a dissection above and behind in the eyelid, the septum and the fat precede the levator muscle. However, in the inferior eyelid, the levator is just deep to the orbicularis muscle. Beneath the fat, the levator muscle moves posteriorly into the orbit; this causes it to narrow.

"Lateral to the muscle at this point is the lacrimal gland, but medially is just orbital fat," Dr. Cohen said. Upon reaching the orbicularis muscle, the goal is to protect the levator muscle. "The levator muscle is protected by septum fat superiorly, whereas more inferiorly the levator fuses with the orbicularis, so this is a danger zone," Dr. Cohen said. "Laterally is the lacrimal gland and supramedially is the safest point, because there you have the fat, and nothing else to really worry about superficially. So what you do is press on the globe through the eyelid, have the fat prolapse forward, and dissect there."

Reattaching the levator muscle can be tricky in the context of levator resection ptosis surgery, said Dr. Cohen. "Where you make the attachment is going to affect the contour postoperatively," he said. "Grasp the tarsus and pull it upward to see if you have obtained a natural curve. If you grasp it at the wrong point, you’ll have a curve that’s not aesthetically pleasing," he cautioned.

"When you get the right point, that is where you are going to put the sutures to reattach the levator. A double-armed 6-0 suture is passed in a horizontal mattress fashion, partial thickness, through the tarsus. The suture is then passed in a posterior to anterior direction, which shortens the levator muscle."

Placement of the suture determines how much the muscle shortens. "The suture is then temporarily tied, and the patient is asked to open their eyes to assess the height and the contour," Dr. Cohen said. "If you need to adjust height vertically, you can move the suture vertically on the levator muscle. If there’s a problem with the contour, you change the fixation point to the tarsus. Then the suture is permanently tied and the skin is closed."

Dr. Cohen warned about the risk of complications from blepharoplasty in patients with active Graves’ disease, a common autoimmune condition that can cause hyperthyroidism and fibrosis of the extraocular tissues. The severe form of Graves’ disease can cause eyelid retraction, difficulty closing the eyes, double vision, and anterior displacement of the globes. "Many patients present with much more subtle findings," he noted. "For example, fibrosis of the levator with lid retraction is a common presentation in women aged 40-60 – the same demographic that tends to have blepharoplasty. It’s often subtle and underdiagnosed."

Patients with undiagnosed Graves’ disease prior to a blepharoplasty "can develop signs and symptoms which are indistinguishable from the complications of blepharoplasty," Dr. Cohen said. "You need to make the diagnosis before surgery and make sure the disease has stabilized before you do any surgery. That happens on average in about 18 months but is variable."

Dr. Cohen disclosed that he is a member of the advisory board for Allergan and that he is a speaker for Allergan and Medicis.

[email protected]

LAS VEGAS – Knowing and respecting the anatomy of the levator muscle can help clinicians steer clear of complications from blepharoplasty and manage ptosis, according to Dr. Marc S. Cohen.

"It’s very helpful if you have a good understanding of how to find the levator muscle during eyelid surgery," said Dr. Cohen, an ophthalmic plastic surgeon at the Wills Eye Institute, Philadelphia. "In order to do this, you need to understand the relationship between the levator and the other eyelid structures."

The levator muscle elevates the eyelid and helps form the eyelid crease. It also creates the margin contour. As the levator muscle approaches the eyelid, it changes direction from vertically oriented to horizontally oriented. The muscle then advances inferiorly toward the eyelid margin, "and for the final centimeter or so, it becomes a fibrous aponeurosis, which attaches to the tarsus posteriorly," said Dr. Cohen, who also has a private cosmetic surgery practice. Behind the levator muscle are Müller’s muscle and the conjunctiva.

Whether a surgeon performs blepharoplasty with a CO₂ laser, a blade, cautery, or radiofrequency, the first structure encountered posteriorly is the orbicularis oculi muscle, which closes the eyelid. "It’s highly vascular, and is the site where most of the bleeding occurs during blepharoplasty," Dr. Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

The next layer contains the orbital septum. "It’s important to understand that the septum does not travel all the way to the eyelid margin," he added. "The septum starts at the orbital rim and attaches to the levator muscle. This layer really has two structures: the septum and the levator. Behind the septum are the eyelid fat pads."

In a dissection above and behind in the eyelid, the septum and the fat precede the levator muscle. However, in the inferior eyelid, the levator is just deep to the orbicularis muscle. Beneath the fat, the levator muscle moves posteriorly into the orbit; this causes it to narrow.

"Lateral to the muscle at this point is the lacrimal gland, but medially is just orbital fat," Dr. Cohen said. Upon reaching the orbicularis muscle, the goal is to protect the levator muscle. "The levator muscle is protected by septum fat superiorly, whereas more inferiorly the levator fuses with the orbicularis, so this is a danger zone," Dr. Cohen said. "Laterally is the lacrimal gland and supramedially is the safest point, because there you have the fat, and nothing else to really worry about superficially. So what you do is press on the globe through the eyelid, have the fat prolapse forward, and dissect there."

Reattaching the levator muscle can be tricky in the context of levator resection ptosis surgery, said Dr. Cohen. "Where you make the attachment is going to affect the contour postoperatively," he said. "Grasp the tarsus and pull it upward to see if you have obtained a natural curve. If you grasp it at the wrong point, you’ll have a curve that’s not aesthetically pleasing," he cautioned.

"When you get the right point, that is where you are going to put the sutures to reattach the levator. A double-armed 6-0 suture is passed in a horizontal mattress fashion, partial thickness, through the tarsus. The suture is then passed in a posterior to anterior direction, which shortens the levator muscle."

Placement of the suture determines how much the muscle shortens. "The suture is then temporarily tied, and the patient is asked to open their eyes to assess the height and the contour," Dr. Cohen said. "If you need to adjust height vertically, you can move the suture vertically on the levator muscle. If there’s a problem with the contour, you change the fixation point to the tarsus. Then the suture is permanently tied and the skin is closed."

Dr. Cohen warned about the risk of complications from blepharoplasty in patients with active Graves’ disease, a common autoimmune condition that can cause hyperthyroidism and fibrosis of the extraocular tissues. The severe form of Graves’ disease can cause eyelid retraction, difficulty closing the eyes, double vision, and anterior displacement of the globes. "Many patients present with much more subtle findings," he noted. "For example, fibrosis of the levator with lid retraction is a common presentation in women aged 40-60 – the same demographic that tends to have blepharoplasty. It’s often subtle and underdiagnosed."

Patients with undiagnosed Graves’ disease prior to a blepharoplasty "can develop signs and symptoms which are indistinguishable from the complications of blepharoplasty," Dr. Cohen said. "You need to make the diagnosis before surgery and make sure the disease has stabilized before you do any surgery. That happens on average in about 18 months but is variable."

Dr. Cohen disclosed that he is a member of the advisory board for Allergan and that he is a speaker for Allergan and Medicis.

[email protected]

ATLANTA – The use of a threading technique, rather than the standard depot injection technique, when using botulinum toxin A to treat perioral and glabellar rhytides provides a more uniform and natural cosmetic result, according to Dr. H. William Higgins II.

Threading involves injecting the muscle along its normal anatomic course to paralyze the related muscle more evenly, he explained at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy Dr. H. William Higgins II

For upper and lower lip treatment, for example, injections are made at a 20- to 30-degree angle, entering the skin at a location just lateral to the targeted rhytid. The toxin is dispensed while withdrawing, thereby threading the injection along the length of the orbicularis oris. This differs from the typical approach, which often involves a depot injection at an angle more perpendicular to the skin, said Dr. Higgins of Brown University in Providence, R.I.

For the glabellar lines, the threading technique involves four symmetrical injection points, with two points targeting each corrugator. Injections at the more medial points are made directly above the inner canthus, with intramuscular injections made perpendicularly to the skin in the traditional depot manner.

At the two lateral injection points, however, the needle is inserted in most cases just medial to the mid-pupillary lines, thereby targeting the "tail" of the corrugators, he explained.

"Similar to our approach at the orbicularis oris, rather than injecting at an angle more perpendicular to the skin, we inject at an angle of roughly 20-30 degrees, entering the skin at a location just medial to the glabellar rhytid we intend to treat. The needle is then directed laterally and slightly superiorly in order to follow the anatomy of the corrugator supercilii, and the injection is threaded along the muscle’s length while withdrawing," he explained.

This approach corrects for the inadequate responses sometimes seen when using the typical method of placing subepidermal blebs to produce localized microparesis of the targeted muscle, and could reduce the need for touch-up injections.

Cosmetic outcomes have been excellent and patient satisfaction high with the use of this technique, he said. In his experience, the technique has dramatically reduced the incidence of adverse effects.

"It has been documented that, even with conservative dosing, neuromodulator treatment of perioral rhytides can affect mouth function by weakening the lip sphincter, but this has not been the case in our patient population when using this technique," he said.

Similarly, when treating glabellar rhytides, the injection of the toxin at a more precise depth – and more evenly along the tail of the corrugators, has resulted in a reduced incidence of brow ptosis as well as more natural smoothing.

"This approach helps prevent the undesirable appearance of a 'forehead freeze,' " he said.

The threading technique also results in fewer needle sticks, which means less pain and bruising for the patients.

The use of a longer 1- or 1.5-inch needle could potentially allow for even fewer injections without compromising the result, Dr. Higgins noted.

"Furthermore, this technique could conceivably be applied on other areas of the face. Crow's feet, for example, could be treated with fewer threading injections rather than with multiple depot injections," he said.

Dr. Higgins reported having no relevant financial disclosures.

ATLANTA – The use of a threading technique, rather than the standard depot injection technique, when using botulinum toxin A to treat perioral and glabellar rhytides provides a more uniform and natural cosmetic result, according to Dr. H. William Higgins II.

Threading involves injecting the muscle along its normal anatomic course to paralyze the related muscle more evenly, he explained at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy Dr. H. William Higgins II

For upper and lower lip treatment, for example, injections are made at a 20- to 30-degree angle, entering the skin at a location just lateral to the targeted rhytid. The toxin is dispensed while withdrawing, thereby threading the injection along the length of the orbicularis oris. This differs from the typical approach, which often involves a depot injection at an angle more perpendicular to the skin, said Dr. Higgins of Brown University in Providence, R.I.

For the glabellar lines, the threading technique involves four symmetrical injection points, with two points targeting each corrugator. Injections at the more medial points are made directly above the inner canthus, with intramuscular injections made perpendicularly to the skin in the traditional depot manner.

At the two lateral injection points, however, the needle is inserted in most cases just medial to the mid-pupillary lines, thereby targeting the "tail" of the corrugators, he explained.

"Similar to our approach at the orbicularis oris, rather than injecting at an angle more perpendicular to the skin, we inject at an angle of roughly 20-30 degrees, entering the skin at a location just medial to the glabellar rhytid we intend to treat. The needle is then directed laterally and slightly superiorly in order to follow the anatomy of the corrugator supercilii, and the injection is threaded along the muscle’s length while withdrawing," he explained.

This approach corrects for the inadequate responses sometimes seen when using the typical method of placing subepidermal blebs to produce localized microparesis of the targeted muscle, and could reduce the need for touch-up injections.

Cosmetic outcomes have been excellent and patient satisfaction high with the use of this technique, he said. In his experience, the technique has dramatically reduced the incidence of adverse effects.

"It has been documented that, even with conservative dosing, neuromodulator treatment of perioral rhytides can affect mouth function by weakening the lip sphincter, but this has not been the case in our patient population when using this technique," he said.

Similarly, when treating glabellar rhytides, the injection of the toxin at a more precise depth – and more evenly along the tail of the corrugators, has resulted in a reduced incidence of brow ptosis as well as more natural smoothing.

"This approach helps prevent the undesirable appearance of a 'forehead freeze,' " he said.

The threading technique also results in fewer needle sticks, which means less pain and bruising for the patients.

The use of a longer 1- or 1.5-inch needle could potentially allow for even fewer injections without compromising the result, Dr. Higgins noted.

"Furthermore, this technique could conceivably be applied on other areas of the face. Crow's feet, for example, could be treated with fewer threading injections rather than with multiple depot injections," he said.

Dr. Higgins reported having no relevant financial disclosures.

ATLANTA – The use of a threading technique, rather than the standard depot injection technique, when using botulinum toxin A to treat perioral and glabellar rhytides provides a more uniform and natural cosmetic result, according to Dr. H. William Higgins II.

Threading involves injecting the muscle along its normal anatomic course to paralyze the related muscle more evenly, he explained at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy Dr. H. William Higgins II

For upper and lower lip treatment, for example, injections are made at a 20- to 30-degree angle, entering the skin at a location just lateral to the targeted rhytid. The toxin is dispensed while withdrawing, thereby threading the injection along the length of the orbicularis oris. This differs from the typical approach, which often involves a depot injection at an angle more perpendicular to the skin, said Dr. Higgins of Brown University in Providence, R.I.

For the glabellar lines, the threading technique involves four symmetrical injection points, with two points targeting each corrugator. Injections at the more medial points are made directly above the inner canthus, with intramuscular injections made perpendicularly to the skin in the traditional depot manner.

At the two lateral injection points, however, the needle is inserted in most cases just medial to the mid-pupillary lines, thereby targeting the "tail" of the corrugators, he explained.

"Similar to our approach at the orbicularis oris, rather than injecting at an angle more perpendicular to the skin, we inject at an angle of roughly 20-30 degrees, entering the skin at a location just medial to the glabellar rhytid we intend to treat. The needle is then directed laterally and slightly superiorly in order to follow the anatomy of the corrugator supercilii, and the injection is threaded along the muscle’s length while withdrawing," he explained.

This approach corrects for the inadequate responses sometimes seen when using the typical method of placing subepidermal blebs to produce localized microparesis of the targeted muscle, and could reduce the need for touch-up injections.

Cosmetic outcomes have been excellent and patient satisfaction high with the use of this technique, he said. In his experience, the technique has dramatically reduced the incidence of adverse effects.

"It has been documented that, even with conservative dosing, neuromodulator treatment of perioral rhytides can affect mouth function by weakening the lip sphincter, but this has not been the case in our patient population when using this technique," he said.

Similarly, when treating glabellar rhytides, the injection of the toxin at a more precise depth – and more evenly along the tail of the corrugators, has resulted in a reduced incidence of brow ptosis as well as more natural smoothing.

"This approach helps prevent the undesirable appearance of a 'forehead freeze,' " he said.

The threading technique also results in fewer needle sticks, which means less pain and bruising for the patients.

The use of a longer 1- or 1.5-inch needle could potentially allow for even fewer injections without compromising the result, Dr. Higgins noted.

"Furthermore, this technique could conceivably be applied on other areas of the face. Crow's feet, for example, could be treated with fewer threading injections rather than with multiple depot injections," he said.

Dr. Higgins reported having no relevant financial disclosures.

ATLANTA – Applying the topical fluorocarbon perfluorodecalin prior to Q-switched laser treatment for tattoo removal allows for immediate retreatment of the tattoo, thereby improving results while decreasing overall treatment time, according to Dr. Roy Geronemus.

The findings have important implications for improving outcomes and patient satisfaction, given that tattoo removal can require 10-20 sessions, depending on factors such as the age and colors of the tattoo, and that tattoos – and thus tattoo removal – continue to increase in popularity, he said. "For a busy practice or impatient patients like we have in New York, this has been a nice advance," Dr. Geronemus said at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy Wikimedia/gemteck1/Creative Commons License

The approach builds on the "R20 technique" described earlier this year in a study published in the Journal of the American Academy of Dermatology. R20 involves the use of multiple treatment passes that are made at 20-minute intervals.

Typically, after an initial pass, tiny white bubbles form in the superficial papillary dermis, appearing as a whitening of the skin. Retreatment while these bubbles are present elicits a limited reaction.

The R20 technique was developed when investigators found that the bubbles disappear after 20 minutes, and, thus, tested the technique in a study of 12 adults. The patients were randomized to a single treatment pass with a Q-switched alexandrite laser (5.5 J/cm², 755 nm, 100-nanosecond pulse duration, 3-mm spot size) or to four passes at 20 minute intervals.

The first treatment caused an immediate whitening reaction, but little or no whitening occurred after subsequent passes at 20-minute intervals. However, at 90-day follow-up, significant improvement was seen in the R20 group, compared with the single-treatment group, and light microscopy demonstrated greater dispersion of tattoo ink with the R20 approach. (J. Am. Acad. Dermatol. 2012;66:271-7).

Despite the increased efficacy using this approach, the time required to complete four passes at 20-minute intervals makes it impractical in the clinical setting, said Dr. Geronemus, a dermatologist in private practice in New York.

"So with this idea in mind, we began to look at a concept that would allow us to re-treat tattoos immediately without waiting 20 minutes," he said, explaining that topical perfluorodecalin helps dissolve the gas seen after the application of the Q-switched laser and speeds the resolution of the whitening.

"Rather than waiting 20 minutes, the gas dissolves almost immediately, allowing you to re-treat, and we’re now re-treating three or four times in a matter of minutes rather than waiting the 80 minutes that the R20 technique would take for a four-time treatment session," he said.

In his experience, results with perfluorodecalin are comparable to those seen with the R20 technique – but with greater convenience for the patient.

His observations were confirmed on optical coherence tomography scanning, which demonstrated that cavitation levels are indeed reduced by the use of perfluorodecalin.

Dr. Geronemus is an investigator for Cutera, Cynosure, Palomar, Solta Medical, and Syneron. He is also on the medical advisory board for Cynosure, Lumenis, Photomedex, Syneron, and Zeltiq. He reported that he is a Zeltiq shareholder.

ATLANTA – Applying the topical fluorocarbon perfluorodecalin prior to Q-switched laser treatment for tattoo removal allows for immediate retreatment of the tattoo, thereby improving results while decreasing overall treatment time, according to Dr. Roy Geronemus.

The findings have important implications for improving outcomes and patient satisfaction, given that tattoo removal can require 10-20 sessions, depending on factors such as the age and colors of the tattoo, and that tattoos – and thus tattoo removal – continue to increase in popularity, he said. "For a busy practice or impatient patients like we have in New York, this has been a nice advance," Dr. Geronemus said at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy Wikimedia/gemteck1/Creative Commons License

The approach builds on the "R20 technique" described earlier this year in a study published in the Journal of the American Academy of Dermatology. R20 involves the use of multiple treatment passes that are made at 20-minute intervals.

Typically, after an initial pass, tiny white bubbles form in the superficial papillary dermis, appearing as a whitening of the skin. Retreatment while these bubbles are present elicits a limited reaction.

The R20 technique was developed when investigators found that the bubbles disappear after 20 minutes, and, thus, tested the technique in a study of 12 adults. The patients were randomized to a single treatment pass with a Q-switched alexandrite laser (5.5 J/cm², 755 nm, 100-nanosecond pulse duration, 3-mm spot size) or to four passes at 20 minute intervals.

The first treatment caused an immediate whitening reaction, but little or no whitening occurred after subsequent passes at 20-minute intervals. However, at 90-day follow-up, significant improvement was seen in the R20 group, compared with the single-treatment group, and light microscopy demonstrated greater dispersion of tattoo ink with the R20 approach. (J. Am. Acad. Dermatol. 2012;66:271-7).

Despite the increased efficacy using this approach, the time required to complete four passes at 20-minute intervals makes it impractical in the clinical setting, said Dr. Geronemus, a dermatologist in private practice in New York.

"So with this idea in mind, we began to look at a concept that would allow us to re-treat tattoos immediately without waiting 20 minutes," he said, explaining that topical perfluorodecalin helps dissolve the gas seen after the application of the Q-switched laser and speeds the resolution of the whitening.

"Rather than waiting 20 minutes, the gas dissolves almost immediately, allowing you to re-treat, and we’re now re-treating three or four times in a matter of minutes rather than waiting the 80 minutes that the R20 technique would take for a four-time treatment session," he said.

In his experience, results with perfluorodecalin are comparable to those seen with the R20 technique – but with greater convenience for the patient.

His observations were confirmed on optical coherence tomography scanning, which demonstrated that cavitation levels are indeed reduced by the use of perfluorodecalin.

Dr. Geronemus is an investigator for Cutera, Cynosure, Palomar, Solta Medical, and Syneron. He is also on the medical advisory board for Cynosure, Lumenis, Photomedex, Syneron, and Zeltiq. He reported that he is a Zeltiq shareholder.

ATLANTA – Applying the topical fluorocarbon perfluorodecalin prior to Q-switched laser treatment for tattoo removal allows for immediate retreatment of the tattoo, thereby improving results while decreasing overall treatment time, according to Dr. Roy Geronemus.

The findings have important implications for improving outcomes and patient satisfaction, given that tattoo removal can require 10-20 sessions, depending on factors such as the age and colors of the tattoo, and that tattoos – and thus tattoo removal – continue to increase in popularity, he said. "For a busy practice or impatient patients like we have in New York, this has been a nice advance," Dr. Geronemus said at the annual meeting of the American Society for Dermatologic Surgery.

Courtesy Wikimedia/gemteck1/Creative Commons License

The approach builds on the "R20 technique" described earlier this year in a study published in the Journal of the American Academy of Dermatology. R20 involves the use of multiple treatment passes that are made at 20-minute intervals.

Typically, after an initial pass, tiny white bubbles form in the superficial papillary dermis, appearing as a whitening of the skin. Retreatment while these bubbles are present elicits a limited reaction.

The R20 technique was developed when investigators found that the bubbles disappear after 20 minutes, and, thus, tested the technique in a study of 12 adults. The patients were randomized to a single treatment pass with a Q-switched alexandrite laser (5.5 J/cm², 755 nm, 100-nanosecond pulse duration, 3-mm spot size) or to four passes at 20 minute intervals.

The first treatment caused an immediate whitening reaction, but little or no whitening occurred after subsequent passes at 20-minute intervals. However, at 90-day follow-up, significant improvement was seen in the R20 group, compared with the single-treatment group, and light microscopy demonstrated greater dispersion of tattoo ink with the R20 approach. (J. Am. Acad. Dermatol. 2012;66:271-7).

Despite the increased efficacy using this approach, the time required to complete four passes at 20-minute intervals makes it impractical in the clinical setting, said Dr. Geronemus, a dermatologist in private practice in New York.

"So with this idea in mind, we began to look at a concept that would allow us to re-treat tattoos immediately without waiting 20 minutes," he said, explaining that topical perfluorodecalin helps dissolve the gas seen after the application of the Q-switched laser and speeds the resolution of the whitening.

"Rather than waiting 20 minutes, the gas dissolves almost immediately, allowing you to re-treat, and we’re now re-treating three or four times in a matter of minutes rather than waiting the 80 minutes that the R20 technique would take for a four-time treatment session," he said.

In his experience, results with perfluorodecalin are comparable to those seen with the R20 technique – but with greater convenience for the patient.

His observations were confirmed on optical coherence tomography scanning, which demonstrated that cavitation levels are indeed reduced by the use of perfluorodecalin.

Dr. Geronemus is an investigator for Cutera, Cynosure, Palomar, Solta Medical, and Syneron. He is also on the medical advisory board for Cynosure, Lumenis, Photomedex, Syneron, and Zeltiq. He reported that he is a Zeltiq shareholder.

SAN DIEGO – Principles for lip repair are based on size and location of the defect, etiology of the lesions, and patient age and gender, said Dr. Michael A. Keefe.

Surgical goals of lip reconstruction are to cover the skin and oral lining, leave a semblance of a vermilion and an adequate stomal diameter, make sure sensation is intact, and ensure that the patient has a competent oral sphincter. "The vermilion is the most visible component of the lips, and it’s also the sensory unit of the lip," Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery. The meeting was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic.

"Scars are very well hidden at the vermilion-cutaneous border. If you have to cross the vermilion-cutaneous junction, cross at 90 degrees."

Lower Lip

The lower vermilion is the most affected target of solar radiation injury. In cases of premalignant lesions such as actinic cheilitis or leukoplakia, Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego, said he often performs a total vermilionectomy (lip shave). This involves resection from the white roll to the contact area with opposite lip. "Primary closure is possible," he said. "You can get tension and dehiscence and flattening of the lip, but generally it heals up pretty well. An option for vermilion reconstruction of larger defects is the buccal mucosal advancement flap, which involves elevating the mucosa deep to salivary glands and superficial to the orbicularis oris muscle."

An advantage of treating the lower lip is that there is increased soft tissue laxity and there is no Cupid’s bow, philtrum, or nose, "so it’s nice that there are no dominant central structures," he said. "The downside is that you have to be mindful of the effect of gravity on the repair, so there is a greater need for tone to prevent drooling and incompetence."

Photos courtesy Dr. Michael Keefe

He recommends a staged approach based on the extent of the defect and the age of the patient. For small defects (those less than one-third of the lip size) he uses primary closure. Options for medium defects (those that involve one-third to two-thirds of the lip size) include the Estlander flap, the Abbe flap, Bernard Burow’s procedure, the Karapandzic flap, and the stairstep repair, while the options for large defects (those that involve more than two-thirds of the lip size) include Bernard Burow’s procedure, the Karapandzic flap, and the free flap. "You have a lot of tools, depending on what you feel comfortable with," Dr. Keefe said.

Upper Lip

Cancerous tumors of the upper lip are less common, "but there are some unique structures to pay attention to, including the nose, columella, Cupid’s bow, and the philtrum," he said. "In men there’s a hair-bearing skin issue, but scars can be disguised in a mustache."

The aesthetic subunits to keep in mind, he continued, are the medial subunit, which is one-half of the philtrum, and the lateral subunit, which consists of the philtral column, the nostril sill, the alar base, and the nasolabial crease. Primary closure is used for upper lip defects that involve less than one-third of the lip size. "You can make some perialar crescentic skin excisions, which can help advance things," Dr. Keefe said.

For centrally located medium-sized defects of the upper lip, he often uses primary closure with perialar crescentic skin excisions. "If it’s greater than one-half of the lip size, you can add an Abbe flap," he said. "That’s nice because that recreates the philtrum area."

Photos courtesy Dr. Michael Keefe

For medially located medium-sized defects of the upper lip, "you can use the Abbe flap if the commissure is not involved and the Estlander flap if the commissure is involved."

Options for cases with large defects and adequate cheek tissue, he said, include the reverse Karapandzic flap, the reverse fan flap, inverted Bernard Burow’s procedure, superiorly based cheek flaps, and the bilateral levator anguli oris flap combined with the Abbe flap. Options for cases with inadequate cheek tissue include the distal pedicle flap and the free flap.

Repair Risks

A lot of these patients have medical problems," he said. "When you do your first injection to resect the tumor or put the lip back together, make sure you don’t cause a myocardial infarction. Generally you should be comfortable with patients who have an INR [International Normalized Ratio] of 2.5 and below."

For patients with large cancerous tumors of the lip, be mindful of lymphatic drainage, because larger tumors have an increased risk of metastases, said Dr. Keefe. For tumors larger than 2 cm in length or 6 mm in spread, or if there is perineural spread, the patient should be referred for radiation therapy.

Dr. Keefe said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Principles for lip repair are based on size and location of the defect, etiology of the lesions, and patient age and gender, said Dr. Michael A. Keefe.

Surgical goals of lip reconstruction are to cover the skin and oral lining, leave a semblance of a vermilion and an adequate stomal diameter, make sure sensation is intact, and ensure that the patient has a competent oral sphincter. "The vermilion is the most visible component of the lips, and it’s also the sensory unit of the lip," Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery. The meeting was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic.

"Scars are very well hidden at the vermilion-cutaneous border. If you have to cross the vermilion-cutaneous junction, cross at 90 degrees."

Lower Lip

The lower vermilion is the most affected target of solar radiation injury. In cases of premalignant lesions such as actinic cheilitis or leukoplakia, Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego, said he often performs a total vermilionectomy (lip shave). This involves resection from the white roll to the contact area with opposite lip. "Primary closure is possible," he said. "You can get tension and dehiscence and flattening of the lip, but generally it heals up pretty well. An option for vermilion reconstruction of larger defects is the buccal mucosal advancement flap, which involves elevating the mucosa deep to salivary glands and superficial to the orbicularis oris muscle."

An advantage of treating the lower lip is that there is increased soft tissue laxity and there is no Cupid’s bow, philtrum, or nose, "so it’s nice that there are no dominant central structures," he said. "The downside is that you have to be mindful of the effect of gravity on the repair, so there is a greater need for tone to prevent drooling and incompetence."

Photos courtesy Dr. Michael Keefe

He recommends a staged approach based on the extent of the defect and the age of the patient. For small defects (those less than one-third of the lip size) he uses primary closure. Options for medium defects (those that involve one-third to two-thirds of the lip size) include the Estlander flap, the Abbe flap, Bernard Burow’s procedure, the Karapandzic flap, and the stairstep repair, while the options for large defects (those that involve more than two-thirds of the lip size) include Bernard Burow’s procedure, the Karapandzic flap, and the free flap. "You have a lot of tools, depending on what you feel comfortable with," Dr. Keefe said.

Upper Lip

Cancerous tumors of the upper lip are less common, "but there are some unique structures to pay attention to, including the nose, columella, Cupid’s bow, and the philtrum," he said. "In men there’s a hair-bearing skin issue, but scars can be disguised in a mustache."

The aesthetic subunits to keep in mind, he continued, are the medial subunit, which is one-half of the philtrum, and the lateral subunit, which consists of the philtral column, the nostril sill, the alar base, and the nasolabial crease. Primary closure is used for upper lip defects that involve less than one-third of the lip size. "You can make some perialar crescentic skin excisions, which can help advance things," Dr. Keefe said.

For centrally located medium-sized defects of the upper lip, he often uses primary closure with perialar crescentic skin excisions. "If it’s greater than one-half of the lip size, you can add an Abbe flap," he said. "That’s nice because that recreates the philtrum area."

Photos courtesy Dr. Michael Keefe

For medially located medium-sized defects of the upper lip, "you can use the Abbe flap if the commissure is not involved and the Estlander flap if the commissure is involved."

Options for cases with large defects and adequate cheek tissue, he said, include the reverse Karapandzic flap, the reverse fan flap, inverted Bernard Burow’s procedure, superiorly based cheek flaps, and the bilateral levator anguli oris flap combined with the Abbe flap. Options for cases with inadequate cheek tissue include the distal pedicle flap and the free flap.

Repair Risks

A lot of these patients have medical problems," he said. "When you do your first injection to resect the tumor or put the lip back together, make sure you don’t cause a myocardial infarction. Generally you should be comfortable with patients who have an INR [International Normalized Ratio] of 2.5 and below."

For patients with large cancerous tumors of the lip, be mindful of lymphatic drainage, because larger tumors have an increased risk of metastases, said Dr. Keefe. For tumors larger than 2 cm in length or 6 mm in spread, or if there is perineural spread, the patient should be referred for radiation therapy.

Dr. Keefe said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Principles for lip repair are based on size and location of the defect, etiology of the lesions, and patient age and gender, said Dr. Michael A. Keefe.

Surgical goals of lip reconstruction are to cover the skin and oral lining, leave a semblance of a vermilion and an adequate stomal diameter, make sure sensation is intact, and ensure that the patient has a competent oral sphincter. "The vermilion is the most visible component of the lips, and it’s also the sensory unit of the lip," Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery. The meeting was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic.

"Scars are very well hidden at the vermilion-cutaneous border. If you have to cross the vermilion-cutaneous junction, cross at 90 degrees."

Lower Lip

The lower vermilion is the most affected target of solar radiation injury. In cases of premalignant lesions such as actinic cheilitis or leukoplakia, Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego, said he often performs a total vermilionectomy (lip shave). This involves resection from the white roll to the contact area with opposite lip. "Primary closure is possible," he said. "You can get tension and dehiscence and flattening of the lip, but generally it heals up pretty well. An option for vermilion reconstruction of larger defects is the buccal mucosal advancement flap, which involves elevating the mucosa deep to salivary glands and superficial to the orbicularis oris muscle."

An advantage of treating the lower lip is that there is increased soft tissue laxity and there is no Cupid’s bow, philtrum, or nose, "so it’s nice that there are no dominant central structures," he said. "The downside is that you have to be mindful of the effect of gravity on the repair, so there is a greater need for tone to prevent drooling and incompetence."

Photos courtesy Dr. Michael Keefe

He recommends a staged approach based on the extent of the defect and the age of the patient. For small defects (those less than one-third of the lip size) he uses primary closure. Options for medium defects (those that involve one-third to two-thirds of the lip size) include the Estlander flap, the Abbe flap, Bernard Burow’s procedure, the Karapandzic flap, and the stairstep repair, while the options for large defects (those that involve more than two-thirds of the lip size) include Bernard Burow’s procedure, the Karapandzic flap, and the free flap. "You have a lot of tools, depending on what you feel comfortable with," Dr. Keefe said.

Upper Lip

Cancerous tumors of the upper lip are less common, "but there are some unique structures to pay attention to, including the nose, columella, Cupid’s bow, and the philtrum," he said. "In men there’s a hair-bearing skin issue, but scars can be disguised in a mustache."

The aesthetic subunits to keep in mind, he continued, are the medial subunit, which is one-half of the philtrum, and the lateral subunit, which consists of the philtral column, the nostril sill, the alar base, and the nasolabial crease. Primary closure is used for upper lip defects that involve less than one-third of the lip size. "You can make some perialar crescentic skin excisions, which can help advance things," Dr. Keefe said.

For centrally located medium-sized defects of the upper lip, he often uses primary closure with perialar crescentic skin excisions. "If it’s greater than one-half of the lip size, you can add an Abbe flap," he said. "That’s nice because that recreates the philtrum area."

Photos courtesy Dr. Michael Keefe

For medially located medium-sized defects of the upper lip, "you can use the Abbe flap if the commissure is not involved and the Estlander flap if the commissure is involved."

Options for cases with large defects and adequate cheek tissue, he said, include the reverse Karapandzic flap, the reverse fan flap, inverted Bernard Burow’s procedure, superiorly based cheek flaps, and the bilateral levator anguli oris flap combined with the Abbe flap. Options for cases with inadequate cheek tissue include the distal pedicle flap and the free flap.

Repair Risks

A lot of these patients have medical problems," he said. "When you do your first injection to resect the tumor or put the lip back together, make sure you don’t cause a myocardial infarction. Generally you should be comfortable with patients who have an INR [International Normalized Ratio] of 2.5 and below."

For patients with large cancerous tumors of the lip, be mindful of lymphatic drainage, because larger tumors have an increased risk of metastases, said Dr. Keefe. For tumors larger than 2 cm in length or 6 mm in spread, or if there is perineural spread, the patient should be referred for radiation therapy.

Dr. Keefe said that he had no relevant financial conflicts to disclose.

SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.

The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.

"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."

And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."

Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.

Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.

A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."

The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.

He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.

Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.

Dr. Keefe said that he had no relevant financial conflicts to disclose.

SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.

The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.

"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."

And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."

Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.

Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.

A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."

The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.

He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.

Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.

Dr. Keefe said that he had no relevant financial conflicts to disclose.

SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.

The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.

"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."

And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."

Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.

Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.

A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."

The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.

He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.

Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.

Dr. Keefe said that he had no relevant financial conflicts to disclose.