Aesthetic Dermatology

Naples, Fla. - Effective, noninvasive fat removal is here, according to Dr. Mathew Avram.

"Efficacy is limited but it is real," he said regarding cryolipolysis, a noninvasive cooling and removal of subcutaneous fat.

It is important for dermatologists to assess all emerging noninvasive fat-reduction technologies critically. 

"Patients will ask you about this," Dr. Avram said. "There is a lot of snake-oil salesmanship in this field."

Cryolipolysis (CoolSculpting, Zeltiq Aesthetics) selectively kills fat cells at temperatures above freezing without affecting surrounding tissues. This selective crystallization of fat cells leads to apoptotic death and, ultimately, gradual dissolution of fat over 2-4 months, Dr. Avram said.

In 2009, researchers reported a 22% reduction in "love handles" on the side treated with cryolipolysis, compared with the side with no treatment at 4 months in an unpublished study with 32 participants.

"Whether or not that is clinically relevant is up to you to decide," Dr. Avram said at the meeting.

Results of animal studies are more robust. For example, one study conducted by researchers at the Wellman Center for Photomedicine in Boston demonstrated a 40% decrease in fat layer of pigs over 90 days on ultrasound and gross pathology (Laser Surg. Med. 2008;40:595-604).

Cryolipolysis has been approved by the Food and Drug Administration for various skin cooling applications during dermatology procedures, but the CoolSculpting device is not FDA cleared for marketing as a fat removal device, Dr. Avram said, although regulatory approval for noninvasive fat reduction is pending.

Cryolipolysis is not a weight loss device, nor is it intended as a replacement for liposuction, said Dr. Avram, director of the Massachusetts General Hospital Dermatology Laser and Cosmetic Center.

Cryolipolysis is best suited for local fat removal in areas resistant to exercise, such as love handles or the lower abdomen, Dr. Avram said, and "patient selection is crucial." Relatively thin, weight-stable people who have localized fat areas and realistic expectations are appropriate candidates. "Otherwise, patients will be disappointed. We avoid that with very careful patient selection," he said.

"We got this device at Mass General a few months ago," said Dr. Avram, who tried it himself.

Dr. R. Rox Anderson applied the gel sheet "over my love handle area [and] left it on for an hour," he said, noting that it got a little cold and the area became anesthetized after 7-8 minutes.

He reported a minor urticarial plaque on the area immediately after treatment. Redness for a few minutes to a few hours is a common postprocedure effect, as is bruising for up to a few weeks, although "not all will get it," Dr. Avram said.

A temporary dulling of sensation in the treated area that typically resolves in 1-8 weeks can also occur. No changes in pigmentation have been reported.

Dermatologists are the perfect physicians to perform cryolipolysis, Dr. Avram said. "Subcutaneous fat is a fundamental part of dermatology, and the fact that it has not been claimed by any specialty makes it ours."

Disclosures: Dr. Avram said he owns stock options and is a consultant for Zeltiq Aesthetics, Inc.

Naples, Fla. - Effective, noninvasive fat removal is here, according to Dr. Mathew Avram.

"Efficacy is limited but it is real," he said regarding cryolipolysis, a noninvasive cooling and removal of subcutaneous fat.

It is important for dermatologists to assess all emerging noninvasive fat-reduction technologies critically. 

"Patients will ask you about this," Dr. Avram said. "There is a lot of snake-oil salesmanship in this field."

Cryolipolysis (CoolSculpting, Zeltiq Aesthetics) selectively kills fat cells at temperatures above freezing without affecting surrounding tissues. This selective crystallization of fat cells leads to apoptotic death and, ultimately, gradual dissolution of fat over 2-4 months, Dr. Avram said.

In 2009, researchers reported a 22% reduction in "love handles" on the side treated with cryolipolysis, compared with the side with no treatment at 4 months in an unpublished study with 32 participants.

"Whether or not that is clinically relevant is up to you to decide," Dr. Avram said at the meeting.

Results of animal studies are more robust. For example, one study conducted by researchers at the Wellman Center for Photomedicine in Boston demonstrated a 40% decrease in fat layer of pigs over 90 days on ultrasound and gross pathology (Laser Surg. Med. 2008;40:595-604).

Cryolipolysis has been approved by the Food and Drug Administration for various skin cooling applications during dermatology procedures, but the CoolSculpting device is not FDA cleared for marketing as a fat removal device, Dr. Avram said, although regulatory approval for noninvasive fat reduction is pending.

Cryolipolysis is not a weight loss device, nor is it intended as a replacement for liposuction, said Dr. Avram, director of the Massachusetts General Hospital Dermatology Laser and Cosmetic Center.

Cryolipolysis is best suited for local fat removal in areas resistant to exercise, such as love handles or the lower abdomen, Dr. Avram said, and "patient selection is crucial." Relatively thin, weight-stable people who have localized fat areas and realistic expectations are appropriate candidates. "Otherwise, patients will be disappointed. We avoid that with very careful patient selection," he said.

"We got this device at Mass General a few months ago," said Dr. Avram, who tried it himself.

Dr. R. Rox Anderson applied the gel sheet "over my love handle area [and] left it on for an hour," he said, noting that it got a little cold and the area became anesthetized after 7-8 minutes.

He reported a minor urticarial plaque on the area immediately after treatment. Redness for a few minutes to a few hours is a common postprocedure effect, as is bruising for up to a few weeks, although "not all will get it," Dr. Avram said.

A temporary dulling of sensation in the treated area that typically resolves in 1-8 weeks can also occur. No changes in pigmentation have been reported.

Dermatologists are the perfect physicians to perform cryolipolysis, Dr. Avram said. "Subcutaneous fat is a fundamental part of dermatology, and the fact that it has not been claimed by any specialty makes it ours."

Disclosures: Dr. Avram said he owns stock options and is a consultant for Zeltiq Aesthetics, Inc.

Naples, Fla. - Effective, noninvasive fat removal is here, according to Dr. Mathew Avram.

"Efficacy is limited but it is real," he said regarding cryolipolysis, a noninvasive cooling and removal of subcutaneous fat.

It is important for dermatologists to assess all emerging noninvasive fat-reduction technologies critically. 

"Patients will ask you about this," Dr. Avram said. "There is a lot of snake-oil salesmanship in this field."

Cryolipolysis (CoolSculpting, Zeltiq Aesthetics) selectively kills fat cells at temperatures above freezing without affecting surrounding tissues. This selective crystallization of fat cells leads to apoptotic death and, ultimately, gradual dissolution of fat over 2-4 months, Dr. Avram said.

In 2009, researchers reported a 22% reduction in "love handles" on the side treated with cryolipolysis, compared with the side with no treatment at 4 months in an unpublished study with 32 participants.

"Whether or not that is clinically relevant is up to you to decide," Dr. Avram said at the meeting.

Results of animal studies are more robust. For example, one study conducted by researchers at the Wellman Center for Photomedicine in Boston demonstrated a 40% decrease in fat layer of pigs over 90 days on ultrasound and gross pathology (Laser Surg. Med. 2008;40:595-604).

Cryolipolysis has been approved by the Food and Drug Administration for various skin cooling applications during dermatology procedures, but the CoolSculpting device is not FDA cleared for marketing as a fat removal device, Dr. Avram said, although regulatory approval for noninvasive fat reduction is pending.

Cryolipolysis is not a weight loss device, nor is it intended as a replacement for liposuction, said Dr. Avram, director of the Massachusetts General Hospital Dermatology Laser and Cosmetic Center.

Cryolipolysis is best suited for local fat removal in areas resistant to exercise, such as love handles or the lower abdomen, Dr. Avram said, and "patient selection is crucial." Relatively thin, weight-stable people who have localized fat areas and realistic expectations are appropriate candidates. "Otherwise, patients will be disappointed. We avoid that with very careful patient selection," he said.

"We got this device at Mass General a few months ago," said Dr. Avram, who tried it himself.

Dr. R. Rox Anderson applied the gel sheet "over my love handle area [and] left it on for an hour," he said, noting that it got a little cold and the area became anesthetized after 7-8 minutes.

He reported a minor urticarial plaque on the area immediately after treatment. Redness for a few minutes to a few hours is a common postprocedure effect, as is bruising for up to a few weeks, although "not all will get it," Dr. Avram said.

A temporary dulling of sensation in the treated area that typically resolves in 1-8 weeks can also occur. No changes in pigmentation have been reported.

Dermatologists are the perfect physicians to perform cryolipolysis, Dr. Avram said. "Subcutaneous fat is a fundamental part of dermatology, and the fact that it has not been claimed by any specialty makes it ours."

Disclosures: Dr. Avram said he owns stock options and is a consultant for Zeltiq Aesthetics, Inc.

DESTIN, Fla. — It might look easy, but getting a perfect result after dermatologic surgery takes skill and experience, Dr. Christopher J. Miller said.

For dermatologists who are relatively new to incision, excision, and undermining, there are multiple opportunities to assess your expertise during and after surgery. These “quality control checkpoints” include the assessment of incision depth and uniformity of the cut, as well as using your fingers to check for any gaps in your suture line, Dr. Miller said.

Results 1 week after surgery, in particular, provide important feedback on your surgical technique, he said. The goal at 1-week suture removal is wound edges that are sealed and blended together well with minimal inflammation.

“It takes a lot of work to figure out how to do that,” he said.

Recognize that technical errors in the early stages of excision affect subsequent results, said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania, Philadelphia.

-- Incision. Avoid the tendency to bevel edges during incision, because this prevents proper apposition. The goal is for a vertical wound with no internal bevel, so ensure that your scalpel remains perpendicular to the skin.

“If those wound edges cannot come together … you will be forced to have tension on the wound,” which almost guarantees that track marks will develop along the wound, Dr. Miller said.

And make sure you incise all the way through the dermis when you make your ellipse. “This is really your quality control checkpoint.” Applying pressure toward the outward edge of the ellipse is a way to minimize the formation of a bevel, he added.

“No matter what you do, the dermis and epidermis will retract more than the fat. There will always be a little bit of fat popping into the wound,” Dr. Miller said. Take the extra step and remove any excess fat after you undermine; otherwise it will impede your wound edges.

-- Excision. When it is time for excision, remove your ellipse in a uniform plane, Dr. Miller said. The tendency with a scalpel is to go deeper. “What I like to use, which is more reproducible, is scissors at a 45° angle to make a sharp cut. You’ll get a release. Then go across like a plane on a landing strip and you will get a uniform depth of excision.”

Dr. Miller said he generally targets the plane between the upper layer of more organized fat lobules and the less organized lower layer above the fascia. “You are not going to go to the fascia all the time. You might choose to stay just under the dermis—it depends on the size of your incision,” he said. Check for uniform thickness once you excise—this is another quality control checkpoint.

-- Undermining. Which instrument you use to perform your retraction is important for undermining. Forceps, for example, can cause tissue trauma. “I prefer blunt-tip scissors and skin hooks,” Dr. Miller said. Be careful not to place the hooks too superficially or too close to the edge of the wound, he said. Instead, place the hook deeper and apply counterpressure with your finger.

“Understanding the anatomy is really going to drive where you choose to undermine,” Dr. Miller said. For example, remember that the superficial musculoaponeurotic system (SMAS) envelopes the muscles of facial expression. “Your motor nerves are always protected by this SMAS. You cannot cut the motor nerves if you remain above the SMAS. There will still be sensory nerves going to the skin.”

“If you are tentative, stay up higher in the fat on the lateral sides of the face,” Dr. Miller said.

Again, remove any extraneous fat that pops in under the wound edges after you undermine, Dr. Miller suggested. The questions to ask at this point are: Is the dermis clearly visible? Are the wound edges clean and vertical?

When it comes to suturing, Dr. Miller recommended the buried vertical mattress suture. It is a heart-shaped loop, similar to the superficial mattress suture. “The suture ideally is biting your reticular dermis, as far away as possible from the wound edge. This will give you wiggle room,” Dr. Miller said. “If it is too high, up near the epidermal edge, it is harder to adjust.”

Another quality control checkpoint comes after you finish throwing the needle toward the center of wound. Let go of your retracting instrument. “If it snaps back toward your needle, you are at the right depth,” Dr. Miller said.

Finally, “precise, deep sutures are key to the ideal scar,” Dr. Miller said. To confirm the adequacy of your sutures, perform the pull test. “Place your fingers on either side, and if you get a gap [the two wound edges come apart], then you need another deep suture.”

Dr. Miller had no relevant financial disclosures.

DESTIN, Fla. — It might look easy, but getting a perfect result after dermatologic surgery takes skill and experience, Dr. Christopher J. Miller said.

For dermatologists who are relatively new to incision, excision, and undermining, there are multiple opportunities to assess your expertise during and after surgery. These “quality control checkpoints” include the assessment of incision depth and uniformity of the cut, as well as using your fingers to check for any gaps in your suture line, Dr. Miller said.

Results 1 week after surgery, in particular, provide important feedback on your surgical technique, he said. The goal at 1-week suture removal is wound edges that are sealed and blended together well with minimal inflammation.

“It takes a lot of work to figure out how to do that,” he said.

Recognize that technical errors in the early stages of excision affect subsequent results, said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania, Philadelphia.

-- Incision. Avoid the tendency to bevel edges during incision, because this prevents proper apposition. The goal is for a vertical wound with no internal bevel, so ensure that your scalpel remains perpendicular to the skin.

“If those wound edges cannot come together … you will be forced to have tension on the wound,” which almost guarantees that track marks will develop along the wound, Dr. Miller said.

And make sure you incise all the way through the dermis when you make your ellipse. “This is really your quality control checkpoint.” Applying pressure toward the outward edge of the ellipse is a way to minimize the formation of a bevel, he added.

“No matter what you do, the dermis and epidermis will retract more than the fat. There will always be a little bit of fat popping into the wound,” Dr. Miller said. Take the extra step and remove any excess fat after you undermine; otherwise it will impede your wound edges.

-- Excision. When it is time for excision, remove your ellipse in a uniform plane, Dr. Miller said. The tendency with a scalpel is to go deeper. “What I like to use, which is more reproducible, is scissors at a 45° angle to make a sharp cut. You’ll get a release. Then go across like a plane on a landing strip and you will get a uniform depth of excision.”

Dr. Miller said he generally targets the plane between the upper layer of more organized fat lobules and the less organized lower layer above the fascia. “You are not going to go to the fascia all the time. You might choose to stay just under the dermis—it depends on the size of your incision,” he said. Check for uniform thickness once you excise—this is another quality control checkpoint.

-- Undermining. Which instrument you use to perform your retraction is important for undermining. Forceps, for example, can cause tissue trauma. “I prefer blunt-tip scissors and skin hooks,” Dr. Miller said. Be careful not to place the hooks too superficially or too close to the edge of the wound, he said. Instead, place the hook deeper and apply counterpressure with your finger.

“Understanding the anatomy is really going to drive where you choose to undermine,” Dr. Miller said. For example, remember that the superficial musculoaponeurotic system (SMAS) envelopes the muscles of facial expression. “Your motor nerves are always protected by this SMAS. You cannot cut the motor nerves if you remain above the SMAS. There will still be sensory nerves going to the skin.”

“If you are tentative, stay up higher in the fat on the lateral sides of the face,” Dr. Miller said.

Again, remove any extraneous fat that pops in under the wound edges after you undermine, Dr. Miller suggested. The questions to ask at this point are: Is the dermis clearly visible? Are the wound edges clean and vertical?

When it comes to suturing, Dr. Miller recommended the buried vertical mattress suture. It is a heart-shaped loop, similar to the superficial mattress suture. “The suture ideally is biting your reticular dermis, as far away as possible from the wound edge. This will give you wiggle room,” Dr. Miller said. “If it is too high, up near the epidermal edge, it is harder to adjust.”

Another quality control checkpoint comes after you finish throwing the needle toward the center of wound. Let go of your retracting instrument. “If it snaps back toward your needle, you are at the right depth,” Dr. Miller said.

Finally, “precise, deep sutures are key to the ideal scar,” Dr. Miller said. To confirm the adequacy of your sutures, perform the pull test. “Place your fingers on either side, and if you get a gap [the two wound edges come apart], then you need another deep suture.”

Dr. Miller had no relevant financial disclosures.

DESTIN, Fla. — It might look easy, but getting a perfect result after dermatologic surgery takes skill and experience, Dr. Christopher J. Miller said.

For dermatologists who are relatively new to incision, excision, and undermining, there are multiple opportunities to assess your expertise during and after surgery. These “quality control checkpoints” include the assessment of incision depth and uniformity of the cut, as well as using your fingers to check for any gaps in your suture line, Dr. Miller said.

Results 1 week after surgery, in particular, provide important feedback on your surgical technique, he said. The goal at 1-week suture removal is wound edges that are sealed and blended together well with minimal inflammation.

“It takes a lot of work to figure out how to do that,” he said.

Recognize that technical errors in the early stages of excision affect subsequent results, said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania, Philadelphia.

-- Incision. Avoid the tendency to bevel edges during incision, because this prevents proper apposition. The goal is for a vertical wound with no internal bevel, so ensure that your scalpel remains perpendicular to the skin.

“If those wound edges cannot come together … you will be forced to have tension on the wound,” which almost guarantees that track marks will develop along the wound, Dr. Miller said.

And make sure you incise all the way through the dermis when you make your ellipse. “This is really your quality control checkpoint.” Applying pressure toward the outward edge of the ellipse is a way to minimize the formation of a bevel, he added.

“No matter what you do, the dermis and epidermis will retract more than the fat. There will always be a little bit of fat popping into the wound,” Dr. Miller said. Take the extra step and remove any excess fat after you undermine; otherwise it will impede your wound edges.

-- Excision. When it is time for excision, remove your ellipse in a uniform plane, Dr. Miller said. The tendency with a scalpel is to go deeper. “What I like to use, which is more reproducible, is scissors at a 45° angle to make a sharp cut. You’ll get a release. Then go across like a plane on a landing strip and you will get a uniform depth of excision.”

Dr. Miller said he generally targets the plane between the upper layer of more organized fat lobules and the less organized lower layer above the fascia. “You are not going to go to the fascia all the time. You might choose to stay just under the dermis—it depends on the size of your incision,” he said. Check for uniform thickness once you excise—this is another quality control checkpoint.

-- Undermining. Which instrument you use to perform your retraction is important for undermining. Forceps, for example, can cause tissue trauma. “I prefer blunt-tip scissors and skin hooks,” Dr. Miller said. Be careful not to place the hooks too superficially or too close to the edge of the wound, he said. Instead, place the hook deeper and apply counterpressure with your finger.

“Understanding the anatomy is really going to drive where you choose to undermine,” Dr. Miller said. For example, remember that the superficial musculoaponeurotic system (SMAS) envelopes the muscles of facial expression. “Your motor nerves are always protected by this SMAS. You cannot cut the motor nerves if you remain above the SMAS. There will still be sensory nerves going to the skin.”

“If you are tentative, stay up higher in the fat on the lateral sides of the face,” Dr. Miller said.

Again, remove any extraneous fat that pops in under the wound edges after you undermine, Dr. Miller suggested. The questions to ask at this point are: Is the dermis clearly visible? Are the wound edges clean and vertical?

When it comes to suturing, Dr. Miller recommended the buried vertical mattress suture. It is a heart-shaped loop, similar to the superficial mattress suture. “The suture ideally is biting your reticular dermis, as far away as possible from the wound edge. This will give you wiggle room,” Dr. Miller said. “If it is too high, up near the epidermal edge, it is harder to adjust.”

Another quality control checkpoint comes after you finish throwing the needle toward the center of wound. Let go of your retracting instrument. “If it snaps back toward your needle, you are at the right depth,” Dr. Miller said.

Finally, “precise, deep sutures are key to the ideal scar,” Dr. Miller said. To confirm the adequacy of your sutures, perform the pull test. “Place your fingers on either side, and if you get a gap [the two wound edges come apart], then you need another deep suture.”

Dr. Miller had no relevant financial disclosures.

What do you picture when you imagine the future of cosmetic dermatology, a field that aims to erase the skin’s evidence of the past? Dr. Ronald Moy, president-elect of the American Academy of Dermatology, tried his hand at prognostication for the specialty at the annual meeting of the Pacific Dermatologic Association.     

^{photo by flickr user benleto (CC).}

Much of it will be based on a molecular approach to aging. Dr. Moy’s training  back in the day relied more on medical dermatology, but looking at the textbooks now used by a daughter who is in medical school, there’s much more of a genetic and molecular emphasis, he said.     

Among other changes ahead: “Collagen as we know it will be taken off the market very soon,” so we’ll soon see some changes in procedures using collagen, he noted.     

New technology means expensive machines, “so unless you’re practicing as a group, it’s going to be very difficult” to offer the most modern services, Dr. Moy added. The roles of robots, computers, and teledermatology also likely will increase.     

Synthetic medicines will be individualized to patients. Skin cancer will be treated nonsurgically with cocktails of immunostimulants. Hair transplants will disappear like the hair that went missing, and hair cloning will fill the void.     

Lasers will evolve like other modern mobile devices, becoming hand-held and used by patients to remove hair, fat, wrinkles, lentigos, and more. Stem cell research will lead to lipoinjection of stem cells to generate volume-filling effects. If radiofrequency devices continue to improve, they might replace facelifts for less invasive cosmetic surgery. We’re already seeing a strong trend toward very small incisions for brow lifts, fat redistribution, and facelifts, and the less-invasive theme will only grow stronger, he predicted.     

If you were to put a face on the future of cosmetic dermatology, would it look like the one Dr. Moy describes? Do you see something he doesn’t? Look for my full story soon for greater details on Dr. Moy’s predictions.     

–Sherry Boschert (@sherryboschert on Twitter)

What do you picture when you imagine the future of cosmetic dermatology, a field that aims to erase the skin’s evidence of the past? Dr. Ronald Moy, president-elect of the American Academy of Dermatology, tried his hand at prognostication for the specialty at the annual meeting of the Pacific Dermatologic Association.     

^{photo by flickr user benleto (CC).}

Much of it will be based on a molecular approach to aging. Dr. Moy’s training  back in the day relied more on medical dermatology, but looking at the textbooks now used by a daughter who is in medical school, there’s much more of a genetic and molecular emphasis, he said.     

Among other changes ahead: “Collagen as we know it will be taken off the market very soon,” so we’ll soon see some changes in procedures using collagen, he noted.     

New technology means expensive machines, “so unless you’re practicing as a group, it’s going to be very difficult” to offer the most modern services, Dr. Moy added. The roles of robots, computers, and teledermatology also likely will increase.     

Synthetic medicines will be individualized to patients. Skin cancer will be treated nonsurgically with cocktails of immunostimulants. Hair transplants will disappear like the hair that went missing, and hair cloning will fill the void.     

Lasers will evolve like other modern mobile devices, becoming hand-held and used by patients to remove hair, fat, wrinkles, lentigos, and more. Stem cell research will lead to lipoinjection of stem cells to generate volume-filling effects. If radiofrequency devices continue to improve, they might replace facelifts for less invasive cosmetic surgery. We’re already seeing a strong trend toward very small incisions for brow lifts, fat redistribution, and facelifts, and the less-invasive theme will only grow stronger, he predicted.     

If you were to put a face on the future of cosmetic dermatology, would it look like the one Dr. Moy describes? Do you see something he doesn’t? Look for my full story soon for greater details on Dr. Moy’s predictions.     

–Sherry Boschert (@sherryboschert on Twitter)

What do you picture when you imagine the future of cosmetic dermatology, a field that aims to erase the skin’s evidence of the past? Dr. Ronald Moy, president-elect of the American Academy of Dermatology, tried his hand at prognostication for the specialty at the annual meeting of the Pacific Dermatologic Association.     

^{photo by flickr user benleto (CC).}

Much of it will be based on a molecular approach to aging. Dr. Moy’s training  back in the day relied more on medical dermatology, but looking at the textbooks now used by a daughter who is in medical school, there’s much more of a genetic and molecular emphasis, he said.     

Among other changes ahead: “Collagen as we know it will be taken off the market very soon,” so we’ll soon see some changes in procedures using collagen, he noted.     

New technology means expensive machines, “so unless you’re practicing as a group, it’s going to be very difficult” to offer the most modern services, Dr. Moy added. The roles of robots, computers, and teledermatology also likely will increase.     

Synthetic medicines will be individualized to patients. Skin cancer will be treated nonsurgically with cocktails of immunostimulants. Hair transplants will disappear like the hair that went missing, and hair cloning will fill the void.     

Lasers will evolve like other modern mobile devices, becoming hand-held and used by patients to remove hair, fat, wrinkles, lentigos, and more. Stem cell research will lead to lipoinjection of stem cells to generate volume-filling effects. If radiofrequency devices continue to improve, they might replace facelifts for less invasive cosmetic surgery. We’re already seeing a strong trend toward very small incisions for brow lifts, fat redistribution, and facelifts, and the less-invasive theme will only grow stronger, he predicted.     

If you were to put a face on the future of cosmetic dermatology, would it look like the one Dr. Moy describes? Do you see something he doesn’t? Look for my full story soon for greater details on Dr. Moy’s predictions.     

–Sherry Boschert (@sherryboschert on Twitter)

Single treatment with a carbon dioxide fractional laser was as effective for acne scars as a nonablative fractional system, according to results of a randomized split-face study.

Fractional lasers are well tolerated and widely used to treat scarring, but patients often need multiple sessions to achieve clinical improvement, reported Dr. S.B. Cho of Yonsei University College of Medicine in Seoul, Korea, and colleagues.

However, previous studies have shown that carbon dioxide fractional laser systems can improve scars in as few as three treatments.

In this study, the researchers directly compared improvements in acne scarring after half of a patient’s face underwent a single treatment with a nonablative 1550-nm erbium-doped fractional photothermolysis system (FPS) and the other half underwent a single treatment with an ablative 10,600-nm carbon dioxide fractional laser system (CO₂ FS).

The eight patients in the study were Asian males (Fitzpatrick skin type IV) aged 20 to 23 years with mild to severe atrophic acne scars.

At follow-up 3 months after FPS treatment, six of the eight patients showed clinical improvements of 26%-50% from baseline, one patient showed a clinical improvement of 51%-75%, and one showed no clinical improvement (J. Eur. Acad. Dermatol. Venereol. 2010;24:921-5). As for CO₂ FS results at 3 months, five of the eight patients had a 26%-50% clinical improvement from baseline, two patients had a 51%-75% improvement, and one had an improvement of over 76%.

The level of clinical improvement was not affected by the type of acne scar (boxcar, icepick, or rolling).

The average VAS pain score on a scale of 0, no pain, to 10, severe pain, was significantly higher after the CO₂ FS treatment, compared with the FPS treatment (7.0 vs. 3.9, respectively). However, patient-reported satisfaction was higher after the CO₂ FS treatment. Two patients (25%) were “very satisfied,” four (50%) were “satisfied,” one (12.5%) was “slightly satisfied,” and one (12.5%) was “unsatisfied.” After the FPS treatment, none of the patients were very satisfied, two (25%) were satisfied, five (62.5%) were slightly satisfied, and one (12.5%) was unsatisfied.

Common side effects associated with both treatments included crusting, scaling, and erythema. The average duration of crusting or scaling was significantly longer in the CO₂ FS group, compared with the FPS group (7.4 days vs. 2.3 days, respectively). However, the difference in post-therapy erythema was not significantly different between the two groups (11.5 days vs. 7.5 days, respectively).

“We could not completely eliminate the possibility of subject bias as the participants experienced different posttreatment responses with FPS and CO₂ FS,” the researchers wrote. But the results suggest that a single treatment with CO₂ FS might be more effective than a single treatment with FPS.

Although the findings are not conclusive, given the study’s small size, they could serve as a reference for clinicians choosing among laser options for acne scar treatment, the researchers added.

Dr. Cho and colleagues had no financial conflicts to disclose.

Single treatment with a carbon dioxide fractional laser was as effective for acne scars as a nonablative fractional system, according to results of a randomized split-face study.

Fractional lasers are well tolerated and widely used to treat scarring, but patients often need multiple sessions to achieve clinical improvement, reported Dr. S.B. Cho of Yonsei University College of Medicine in Seoul, Korea, and colleagues.

However, previous studies have shown that carbon dioxide fractional laser systems can improve scars in as few as three treatments.

In this study, the researchers directly compared improvements in acne scarring after half of a patient’s face underwent a single treatment with a nonablative 1550-nm erbium-doped fractional photothermolysis system (FPS) and the other half underwent a single treatment with an ablative 10,600-nm carbon dioxide fractional laser system (CO₂ FS).

The eight patients in the study were Asian males (Fitzpatrick skin type IV) aged 20 to 23 years with mild to severe atrophic acne scars.

At follow-up 3 months after FPS treatment, six of the eight patients showed clinical improvements of 26%-50% from baseline, one patient showed a clinical improvement of 51%-75%, and one showed no clinical improvement (J. Eur. Acad. Dermatol. Venereol. 2010;24:921-5). As for CO₂ FS results at 3 months, five of the eight patients had a 26%-50% clinical improvement from baseline, two patients had a 51%-75% improvement, and one had an improvement of over 76%.

The level of clinical improvement was not affected by the type of acne scar (boxcar, icepick, or rolling).

The average VAS pain score on a scale of 0, no pain, to 10, severe pain, was significantly higher after the CO₂ FS treatment, compared with the FPS treatment (7.0 vs. 3.9, respectively). However, patient-reported satisfaction was higher after the CO₂ FS treatment. Two patients (25%) were “very satisfied,” four (50%) were “satisfied,” one (12.5%) was “slightly satisfied,” and one (12.5%) was “unsatisfied.” After the FPS treatment, none of the patients were very satisfied, two (25%) were satisfied, five (62.5%) were slightly satisfied, and one (12.5%) was unsatisfied.

Common side effects associated with both treatments included crusting, scaling, and erythema. The average duration of crusting or scaling was significantly longer in the CO₂ FS group, compared with the FPS group (7.4 days vs. 2.3 days, respectively). However, the difference in post-therapy erythema was not significantly different between the two groups (11.5 days vs. 7.5 days, respectively).

“We could not completely eliminate the possibility of subject bias as the participants experienced different posttreatment responses with FPS and CO₂ FS,” the researchers wrote. But the results suggest that a single treatment with CO₂ FS might be more effective than a single treatment with FPS.

Although the findings are not conclusive, given the study’s small size, they could serve as a reference for clinicians choosing among laser options for acne scar treatment, the researchers added.

Dr. Cho and colleagues had no financial conflicts to disclose.

Single treatment with a carbon dioxide fractional laser was as effective for acne scars as a nonablative fractional system, according to results of a randomized split-face study.

Fractional lasers are well tolerated and widely used to treat scarring, but patients often need multiple sessions to achieve clinical improvement, reported Dr. S.B. Cho of Yonsei University College of Medicine in Seoul, Korea, and colleagues.

However, previous studies have shown that carbon dioxide fractional laser systems can improve scars in as few as three treatments.

In this study, the researchers directly compared improvements in acne scarring after half of a patient’s face underwent a single treatment with a nonablative 1550-nm erbium-doped fractional photothermolysis system (FPS) and the other half underwent a single treatment with an ablative 10,600-nm carbon dioxide fractional laser system (CO₂ FS).

The eight patients in the study were Asian males (Fitzpatrick skin type IV) aged 20 to 23 years with mild to severe atrophic acne scars.

At follow-up 3 months after FPS treatment, six of the eight patients showed clinical improvements of 26%-50% from baseline, one patient showed a clinical improvement of 51%-75%, and one showed no clinical improvement (J. Eur. Acad. Dermatol. Venereol. 2010;24:921-5). As for CO₂ FS results at 3 months, five of the eight patients had a 26%-50% clinical improvement from baseline, two patients had a 51%-75% improvement, and one had an improvement of over 76%.

The level of clinical improvement was not affected by the type of acne scar (boxcar, icepick, or rolling).

The average VAS pain score on a scale of 0, no pain, to 10, severe pain, was significantly higher after the CO₂ FS treatment, compared with the FPS treatment (7.0 vs. 3.9, respectively). However, patient-reported satisfaction was higher after the CO₂ FS treatment. Two patients (25%) were “very satisfied,” four (50%) were “satisfied,” one (12.5%) was “slightly satisfied,” and one (12.5%) was “unsatisfied.” After the FPS treatment, none of the patients were very satisfied, two (25%) were satisfied, five (62.5%) were slightly satisfied, and one (12.5%) was unsatisfied.

Common side effects associated with both treatments included crusting, scaling, and erythema. The average duration of crusting or scaling was significantly longer in the CO₂ FS group, compared with the FPS group (7.4 days vs. 2.3 days, respectively). However, the difference in post-therapy erythema was not significantly different between the two groups (11.5 days vs. 7.5 days, respectively).

“We could not completely eliminate the possibility of subject bias as the participants experienced different posttreatment responses with FPS and CO₂ FS,” the researchers wrote. But the results suggest that a single treatment with CO₂ FS might be more effective than a single treatment with FPS.

Although the findings are not conclusive, given the study’s small size, they could serve as a reference for clinicians choosing among laser options for acne scar treatment, the researchers added.

Dr. Cho and colleagues had no financial conflicts to disclose.

Ablative fractional resurfacing appears to be safe and effective in Asians with mild to moderate atrophic acne scarring, according to a study of 13 patients.

While 12 of the 13 patients experienced some postinflammatory hyperpigmentation, this resolved in all patients in an average of 5 weeks.

The Asian patients underwent three sessions of ablative fractional resurfacing (AFR) with the Ellipse Juvia 15-W CO2 laser, wrote Dr. Woraphong Manuskiatti and colleagues of Mahidol University, Bangkok. All patients had skin phototype IV. Intervals between treatments averaged 7 weeks. All patients were followed for 6 months after the third treatment.

Independent physicians blinded to the order in which clinical photos had been taken judged the improvement in scarring to be excellent in 8% of the patients, good in 38.5% of them, fair in 38.5%, and slight in 15%. None of the patients worsened (J. Am. Acad. Dermatol. 2010;63:274-83).

By the patients’ own evaluations, 46% judged their overall improvement to be fair, 23% judged it to be good, and 31% judged it to be excellent. In both physician and patient evaluations, “slight” was defined as less than 25% improvement, “fair” as 25%-50% improvement, good as 51%-75% improvement, and excellent as 76%-100% improvement.

Postinflammatory hyperpigmentation (PIH) was the most common side effect, seen in 12 of the 13 (92%) patients and after 20 of the 39 (51%) treatment sessions. All cases of PIH were graded as mild except for one that was graded as moderate. After treatment with 4% hydroquinone cream once daily, PIH resolved in all patients within 2-16 weeks (average 5 weeks).

Other adverse events were acneiform eruptions in four patients, allergic contact dermatitis in two patients, and herpes simplex infection in one patient.

Each treatment consisted of a full-face single-pass treatment with a 5-7 ms pulse width. Investigators adjusted the laser to deliver 49 microthermal zones (MTZs) per square centimeter, with each individual MTZ 500 mcm in diameter. The average percent coverage was 9.6%, and the investigators set the laser to deliver energies between 75-105 mJ/MTZ depending on the severity of scarring.

Although physicians prepared the patients for 1 hour before each treatment with a topical anesthetic applied to the full face with occlusion, on average patients rated their pain as 8.1 on a scale of 1-10. Pain scores tended to decrease for the second and third treatments.

The investigators described AFR as offering a treatment alternative midway between nonablative fractional resurfacing (NAFR) and fractional photothermolysis (FP). “Although NAFR has a patient-friendly advantage,” the investigators wrote, “the outcomes of most NAFR lasers still leave much to be desired in the treatment of photodamaged skin, rhytides, and atrophic scars. ... By depositing a pixelated pattern of microscopic ablative wounds surrounded by healthy tissue in a manner similar to that of [the] NAFR method, AFR combines the increased efficacy of ablative techniques with the safety and reduced downtime associated with FP.”

The investigators declared that they had no conflicts of interest. The study was supported by a research grant from Ellipse A/S, which manufactures the laser used in the study.

Ablative fractional resurfacing appears to be safe and effective in Asians with mild to moderate atrophic acne scarring, according to a study of 13 patients.

While 12 of the 13 patients experienced some postinflammatory hyperpigmentation, this resolved in all patients in an average of 5 weeks.

The Asian patients underwent three sessions of ablative fractional resurfacing (AFR) with the Ellipse Juvia 15-W CO2 laser, wrote Dr. Woraphong Manuskiatti and colleagues of Mahidol University, Bangkok. All patients had skin phototype IV. Intervals between treatments averaged 7 weeks. All patients were followed for 6 months after the third treatment.

Independent physicians blinded to the order in which clinical photos had been taken judged the improvement in scarring to be excellent in 8% of the patients, good in 38.5% of them, fair in 38.5%, and slight in 15%. None of the patients worsened (J. Am. Acad. Dermatol. 2010;63:274-83).

By the patients’ own evaluations, 46% judged their overall improvement to be fair, 23% judged it to be good, and 31% judged it to be excellent. In both physician and patient evaluations, “slight” was defined as less than 25% improvement, “fair” as 25%-50% improvement, good as 51%-75% improvement, and excellent as 76%-100% improvement.

Postinflammatory hyperpigmentation (PIH) was the most common side effect, seen in 12 of the 13 (92%) patients and after 20 of the 39 (51%) treatment sessions. All cases of PIH were graded as mild except for one that was graded as moderate. After treatment with 4% hydroquinone cream once daily, PIH resolved in all patients within 2-16 weeks (average 5 weeks).

Other adverse events were acneiform eruptions in four patients, allergic contact dermatitis in two patients, and herpes simplex infection in one patient.

Each treatment consisted of a full-face single-pass treatment with a 5-7 ms pulse width. Investigators adjusted the laser to deliver 49 microthermal zones (MTZs) per square centimeter, with each individual MTZ 500 mcm in diameter. The average percent coverage was 9.6%, and the investigators set the laser to deliver energies between 75-105 mJ/MTZ depending on the severity of scarring.

Although physicians prepared the patients for 1 hour before each treatment with a topical anesthetic applied to the full face with occlusion, on average patients rated their pain as 8.1 on a scale of 1-10. Pain scores tended to decrease for the second and third treatments.

The investigators described AFR as offering a treatment alternative midway between nonablative fractional resurfacing (NAFR) and fractional photothermolysis (FP). “Although NAFR has a patient-friendly advantage,” the investigators wrote, “the outcomes of most NAFR lasers still leave much to be desired in the treatment of photodamaged skin, rhytides, and atrophic scars. ... By depositing a pixelated pattern of microscopic ablative wounds surrounded by healthy tissue in a manner similar to that of [the] NAFR method, AFR combines the increased efficacy of ablative techniques with the safety and reduced downtime associated with FP.”

The investigators declared that they had no conflicts of interest. The study was supported by a research grant from Ellipse A/S, which manufactures the laser used in the study.

Ablative fractional resurfacing appears to be safe and effective in Asians with mild to moderate atrophic acne scarring, according to a study of 13 patients.

While 12 of the 13 patients experienced some postinflammatory hyperpigmentation, this resolved in all patients in an average of 5 weeks.

The Asian patients underwent three sessions of ablative fractional resurfacing (AFR) with the Ellipse Juvia 15-W CO2 laser, wrote Dr. Woraphong Manuskiatti and colleagues of Mahidol University, Bangkok. All patients had skin phototype IV. Intervals between treatments averaged 7 weeks. All patients were followed for 6 months after the third treatment.

Independent physicians blinded to the order in which clinical photos had been taken judged the improvement in scarring to be excellent in 8% of the patients, good in 38.5% of them, fair in 38.5%, and slight in 15%. None of the patients worsened (J. Am. Acad. Dermatol. 2010;63:274-83).

By the patients’ own evaluations, 46% judged their overall improvement to be fair, 23% judged it to be good, and 31% judged it to be excellent. In both physician and patient evaluations, “slight” was defined as less than 25% improvement, “fair” as 25%-50% improvement, good as 51%-75% improvement, and excellent as 76%-100% improvement.

Postinflammatory hyperpigmentation (PIH) was the most common side effect, seen in 12 of the 13 (92%) patients and after 20 of the 39 (51%) treatment sessions. All cases of PIH were graded as mild except for one that was graded as moderate. After treatment with 4% hydroquinone cream once daily, PIH resolved in all patients within 2-16 weeks (average 5 weeks).

Other adverse events were acneiform eruptions in four patients, allergic contact dermatitis in two patients, and herpes simplex infection in one patient.

Each treatment consisted of a full-face single-pass treatment with a 5-7 ms pulse width. Investigators adjusted the laser to deliver 49 microthermal zones (MTZs) per square centimeter, with each individual MTZ 500 mcm in diameter. The average percent coverage was 9.6%, and the investigators set the laser to deliver energies between 75-105 mJ/MTZ depending on the severity of scarring.

Although physicians prepared the patients for 1 hour before each treatment with a topical anesthetic applied to the full face with occlusion, on average patients rated their pain as 8.1 on a scale of 1-10. Pain scores tended to decrease for the second and third treatments.

The investigators described AFR as offering a treatment alternative midway between nonablative fractional resurfacing (NAFR) and fractional photothermolysis (FP). “Although NAFR has a patient-friendly advantage,” the investigators wrote, “the outcomes of most NAFR lasers still leave much to be desired in the treatment of photodamaged skin, rhytides, and atrophic scars. ... By depositing a pixelated pattern of microscopic ablative wounds surrounded by healthy tissue in a manner similar to that of [the] NAFR method, AFR combines the increased efficacy of ablative techniques with the safety and reduced downtime associated with FP.”

The investigators declared that they had no conflicts of interest. The study was supported by a research grant from Ellipse A/S, which manufactures the laser used in the study.

DESTIN, Fla. - When it comes to melanoma treatment, one of the most effective strategies - excision - is what dermatologists do best, Dr. Christopher J. Miller said.

"Getting the tumor out is the one thing we are good at [with melanoma]. And we have tools to be better at it," he emphasized.

Histostains, including melanoma antigen recognized by T cells 1 (MART-1), are one such tool. "These stains have revolutionized our ability to treat melanoma using frozen sections," said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania in Philadelphia.

Dr. Miller said he hopes MART-1 staining will change a belief in dermatology that detection of residual disease is less accurate with use of frozen sections after Mohs surgery, compared with use of permanent sections after staged excision, also known as "slow Mohs."

"That is a dogma that is holding back the transition to using frozen sections," Dr. Miller noted at the annual meeting of the Alabama Dermatology Society.

There are data to indicate this is a safe practice, Dr. Miller said, including a large study of 625 patients with melanoma in the head and neck area, "an anatomic location with historically high recurrence and metastasis rates and poor survival rates." Mohs surgery using frozen sections resulted in complete melanoma removal in 97%, with 5-year local recurrence and metastasis rates, and disease-specific survival rates comparable to or better than those for historical controls (J. Am. Acad. Dermatol. 2005;52:92-100).

"And the proof is in the high cure rates all of us are getting with Mohs surgery using frozen sections and immunostains," he said.

"If you compare the frozen sections with MART-1 to the permanent sections with MART-1, we’re making the same calls," emphasized Dr. Miller.

Several studies support a finding that MART-1 imparts equivalence in terms of residual disease detection between frozen sections and permanent sections (Dermatol. Surg. 2009;35:207-13; J. Am. Acad. Dermatol. 2002;46:78-84).

With frozen sections, the Mohs surgeon (not a pathologist) checks for evidence of residual disease, results are immediate, and multiple stages of surgery can be performed on the same day. In contrast, slow Mohs requires that permanent sections processed in formalin be sent to a pathologist for evaluation. "And you have to coordinate a lot of logistics because you have to make sure the pathologist is ready to read these slides when they are available, and the patient is ready to come back right when you know your answer," Dr. Miller said. Typical turnaround time for pathology results is 24-48 hours.

Both Mohs with frozen sections and slow Mohs with permanent sections demonstrate excellent cure rates in studies, Dr. Miller said. Recurrences were in the range of 0%-2.6% in a review study (Cancer Control 2008;15:216-24).

"So they are both reliable methods in experienced hands," he noted. Importantly, both Mohs techniques permit examination of 100% of the excised margin for residual disease, Dr. Miller said. "That is what determines how certain you will be that the cancer is removed."

There are dermatologists who remain unconvinced about the benefits of frozen sections, Dr. Miller said. "I’d invite anybody to spend time with me treating these melanomas in my clinic. I’m sure I can convince them that with high-quality sections and attentive [histotechnicians] who are true experts in these stains, we can have stains that are of excellent quality that can give our patients the highest cure rates," he said in a follow-up interview.

Recognition that melanoma is a microscopic disease is important, Dr. Miller noted. "Let's accept we cannot see subclinical spread in every case. Twenty percent of the time we don’t get it all with what we think is an appropriate margin. Surgeons are having to go back for a second stage to remove tumor that wasn’t visible to them."

Dr. Miller's surgical approach to melanoma is Mohs with frozen sections. He supplements a standard hematoxylin and eosin (H&E) stain with a MART-1 immunostain for each patient. This strategy "has allowed me in multiple cases to detect melanocytes I probably would have missed had I used hematoxylin and eosin alone."

Dr. Miller also recommended an online tool that calculates the likelihood for survival from localized melanoma or regional metastatic disease based on clinical and patient characteristics. A blog posting on this easy-to-use tool is available.

For advice from Dr. Miller on the management of patients with thin melanomas, including why sentinel lymph node biopsies remain controversial in this population, watch a video interview.

Dr. Miller said he had no relevant financial disclosures.

DESTIN, Fla. - When it comes to melanoma treatment, one of the most effective strategies - excision - is what dermatologists do best, Dr. Christopher J. Miller said.

"Getting the tumor out is the one thing we are good at [with melanoma]. And we have tools to be better at it," he emphasized.

Histostains, including melanoma antigen recognized by T cells 1 (MART-1), are one such tool. "These stains have revolutionized our ability to treat melanoma using frozen sections," said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania in Philadelphia.

Dr. Miller said he hopes MART-1 staining will change a belief in dermatology that detection of residual disease is less accurate with use of frozen sections after Mohs surgery, compared with use of permanent sections after staged excision, also known as "slow Mohs."

"That is a dogma that is holding back the transition to using frozen sections," Dr. Miller noted at the annual meeting of the Alabama Dermatology Society.

There are data to indicate this is a safe practice, Dr. Miller said, including a large study of 625 patients with melanoma in the head and neck area, "an anatomic location with historically high recurrence and metastasis rates and poor survival rates." Mohs surgery using frozen sections resulted in complete melanoma removal in 97%, with 5-year local recurrence and metastasis rates, and disease-specific survival rates comparable to or better than those for historical controls (J. Am. Acad. Dermatol. 2005;52:92-100).

"And the proof is in the high cure rates all of us are getting with Mohs surgery using frozen sections and immunostains," he said.

"If you compare the frozen sections with MART-1 to the permanent sections with MART-1, we’re making the same calls," emphasized Dr. Miller.

Several studies support a finding that MART-1 imparts equivalence in terms of residual disease detection between frozen sections and permanent sections (Dermatol. Surg. 2009;35:207-13; J. Am. Acad. Dermatol. 2002;46:78-84).

With frozen sections, the Mohs surgeon (not a pathologist) checks for evidence of residual disease, results are immediate, and multiple stages of surgery can be performed on the same day. In contrast, slow Mohs requires that permanent sections processed in formalin be sent to a pathologist for evaluation. "And you have to coordinate a lot of logistics because you have to make sure the pathologist is ready to read these slides when they are available, and the patient is ready to come back right when you know your answer," Dr. Miller said. Typical turnaround time for pathology results is 24-48 hours.

Both Mohs with frozen sections and slow Mohs with permanent sections demonstrate excellent cure rates in studies, Dr. Miller said. Recurrences were in the range of 0%-2.6% in a review study (Cancer Control 2008;15:216-24).

"So they are both reliable methods in experienced hands," he noted. Importantly, both Mohs techniques permit examination of 100% of the excised margin for residual disease, Dr. Miller said. "That is what determines how certain you will be that the cancer is removed."

There are dermatologists who remain unconvinced about the benefits of frozen sections, Dr. Miller said. "I’d invite anybody to spend time with me treating these melanomas in my clinic. I’m sure I can convince them that with high-quality sections and attentive [histotechnicians] who are true experts in these stains, we can have stains that are of excellent quality that can give our patients the highest cure rates," he said in a follow-up interview.

Recognition that melanoma is a microscopic disease is important, Dr. Miller noted. "Let's accept we cannot see subclinical spread in every case. Twenty percent of the time we don’t get it all with what we think is an appropriate margin. Surgeons are having to go back for a second stage to remove tumor that wasn’t visible to them."

Dr. Miller's surgical approach to melanoma is Mohs with frozen sections. He supplements a standard hematoxylin and eosin (H&E) stain with a MART-1 immunostain for each patient. This strategy "has allowed me in multiple cases to detect melanocytes I probably would have missed had I used hematoxylin and eosin alone."

Dr. Miller also recommended an online tool that calculates the likelihood for survival from localized melanoma or regional metastatic disease based on clinical and patient characteristics. A blog posting on this easy-to-use tool is available.

For advice from Dr. Miller on the management of patients with thin melanomas, including why sentinel lymph node biopsies remain controversial in this population, watch a video interview.

Dr. Miller said he had no relevant financial disclosures.

DESTIN, Fla. - When it comes to melanoma treatment, one of the most effective strategies - excision - is what dermatologists do best, Dr. Christopher J. Miller said.

"Getting the tumor out is the one thing we are good at [with melanoma]. And we have tools to be better at it," he emphasized.

Histostains, including melanoma antigen recognized by T cells 1 (MART-1), are one such tool. "These stains have revolutionized our ability to treat melanoma using frozen sections," said Dr. Miller, director of dermatologic surgery at the University of Pennsylvania in Philadelphia.

Dr. Miller said he hopes MART-1 staining will change a belief in dermatology that detection of residual disease is less accurate with use of frozen sections after Mohs surgery, compared with use of permanent sections after staged excision, also known as "slow Mohs."

"That is a dogma that is holding back the transition to using frozen sections," Dr. Miller noted at the annual meeting of the Alabama Dermatology Society.

There are data to indicate this is a safe practice, Dr. Miller said, including a large study of 625 patients with melanoma in the head and neck area, "an anatomic location with historically high recurrence and metastasis rates and poor survival rates." Mohs surgery using frozen sections resulted in complete melanoma removal in 97%, with 5-year local recurrence and metastasis rates, and disease-specific survival rates comparable to or better than those for historical controls (J. Am. Acad. Dermatol. 2005;52:92-100).

"And the proof is in the high cure rates all of us are getting with Mohs surgery using frozen sections and immunostains," he said.

"If you compare the frozen sections with MART-1 to the permanent sections with MART-1, we’re making the same calls," emphasized Dr. Miller.

Several studies support a finding that MART-1 imparts equivalence in terms of residual disease detection between frozen sections and permanent sections (Dermatol. Surg. 2009;35:207-13; J. Am. Acad. Dermatol. 2002;46:78-84).

With frozen sections, the Mohs surgeon (not a pathologist) checks for evidence of residual disease, results are immediate, and multiple stages of surgery can be performed on the same day. In contrast, slow Mohs requires that permanent sections processed in formalin be sent to a pathologist for evaluation. "And you have to coordinate a lot of logistics because you have to make sure the pathologist is ready to read these slides when they are available, and the patient is ready to come back right when you know your answer," Dr. Miller said. Typical turnaround time for pathology results is 24-48 hours.

Both Mohs with frozen sections and slow Mohs with permanent sections demonstrate excellent cure rates in studies, Dr. Miller said. Recurrences were in the range of 0%-2.6% in a review study (Cancer Control 2008;15:216-24).

"So they are both reliable methods in experienced hands," he noted. Importantly, both Mohs techniques permit examination of 100% of the excised margin for residual disease, Dr. Miller said. "That is what determines how certain you will be that the cancer is removed."

There are dermatologists who remain unconvinced about the benefits of frozen sections, Dr. Miller said. "I’d invite anybody to spend time with me treating these melanomas in my clinic. I’m sure I can convince them that with high-quality sections and attentive [histotechnicians] who are true experts in these stains, we can have stains that are of excellent quality that can give our patients the highest cure rates," he said in a follow-up interview.

Recognition that melanoma is a microscopic disease is important, Dr. Miller noted. "Let's accept we cannot see subclinical spread in every case. Twenty percent of the time we don’t get it all with what we think is an appropriate margin. Surgeons are having to go back for a second stage to remove tumor that wasn’t visible to them."

Dr. Miller's surgical approach to melanoma is Mohs with frozen sections. He supplements a standard hematoxylin and eosin (H&E) stain with a MART-1 immunostain for each patient. This strategy "has allowed me in multiple cases to detect melanocytes I probably would have missed had I used hematoxylin and eosin alone."

Dr. Miller also recommended an online tool that calculates the likelihood for survival from localized melanoma or regional metastatic disease based on clinical and patient characteristics. A blog posting on this easy-to-use tool is available.

For advice from Dr. Miller on the management of patients with thin melanomas, including why sentinel lymph node biopsies remain controversial in this population, watch a video interview.

Dr. Miller said he had no relevant financial disclosures.