Aesthetic Dermatology

MAUI, HAWAII — A number of studies have examined the association of botulinum toxin type A treatment with reduced symptoms of depression, but the connection is still unexplained, Dr. Frederick C. Beddingfield III said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Depressive symptoms commonly occur in patients who have a negative perception about their appearance, and effective treatment often is accompanied by improved psychosocial function, but the limitations and mixed results of the studies that have been conducted leave open the question of how botulinum toxin type A (Botox) is associated with improved psychosocial function, said Dr. Beddingfield of the University of California, Los Angeles. He also is vice president and therapeutic area head of dermatology clinical research at Allergan, which manufactures Botox.

A study of botulinum toxin type A for the treatment of glabellar frown lines in 10 patients with major depressive disorder (MDD) found that 9 patients no longer had MDD after 2 months of treatment (Dermatol. Surg. 2006;32:645–50). But since the study had a small number of patients and was not randomized, blinded, or placebo controlled, the results are interesting but inconclusive, he said.

He also discussed a 4-week study of botulinum toxin type A for focal hyperhidrosis in 70 outpatients (43 female, 27 male). Reductions in depression, anxiety, and social phobia were statistically significant but clinically insignificant because patients were within normal limits at baseline. There was a statistically and clinically significant improvement in "social insecurity" scores (Br. J. Dermatol. 2005;152:342–5).

A study of 289 patients (101 men, 188 women) treated with botulinum toxin type A for cervical dystonia found that treatment was associated with less depression and anxiety, along with an improved quality of life (J. Neurol. Neurosurg. Psychiatry 2002;72:608–14).

A 4-week study of 89 patients with blepharospasm and 131 patients with cervical dystonia (CD) treated with botulinum toxin type A found improvements in clinical symptoms for both blepharospasm and CD patients, accompanied by reduced depression in CD patients (correlated with reduced neck pain) but not in blepharospasm patients, Dr. Beddingfield said.

Quality of life improved minimally for CD patients and not at all for blepharospasm patients (J. Neurol. 2002;249:842–6).

In a study of 51 outpatients (32 female, 19 male) treated for blepharospasm with botulinum toxin type A for 1–7 years, investigators found that all but 1 patient had a positive outcome from treatment (Acta Neurol. Scand. 2001;103:49–52). Twenty-nine patients felt depressed, 19 expressed fear of recurrence of blepharospasm symptoms, 27 expressed fear of increasing doses of botulinum toxin type A, 37 found widespread work improvements from therapy, and 34 said they felt more independent of other people, he said.

Of 32 patients treated for spasmodic dysphonia (SD) in another study, with follow-up for 22 patients after week 1 and 13 after 2 months, those who were depressed before treatment had significant improvements in depression and anxiety measures by 1 week following treatment. But depression and anxiety measures did not improve significantly between week 1 and month 2 after treatment (Arch. Otolaryngol. 1994;120:310–6).

There were statistically significant improvements in measures of depression, anxiety, quality of life, and somatization after 1 month in a different study of 10 patients treated with botulinum toxin type A for SD (Gen. Hosp. Psychiatry 1998;20:255–9).

A study of 26 patients (5 male, 21 female) treated for torticollis found improvements in torticollis symptoms accompanied by a statistically significant improvement in mood and reduced depression (J. Neurol. Neurosurg. Psychiatry 1992;55:229–31).

Investigators who treated 16 patients with botulinum toxin type A for idiopathic torticollis found no significant improvement in patients' or physicians' assessments of head position through five follow-up visits (Mov. Disord. 1995;10:398). There were, however, significant improvements in patients' symptoms of depression, perceived disfigurement, interference with daily activities, experience of pain, and overall impression of their torticollis, he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — A number of studies have examined the association of botulinum toxin type A treatment with reduced symptoms of depression, but the connection is still unexplained, Dr. Frederick C. Beddingfield III said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Depressive symptoms commonly occur in patients who have a negative perception about their appearance, and effective treatment often is accompanied by improved psychosocial function, but the limitations and mixed results of the studies that have been conducted leave open the question of how botulinum toxin type A (Botox) is associated with improved psychosocial function, said Dr. Beddingfield of the University of California, Los Angeles. He also is vice president and therapeutic area head of dermatology clinical research at Allergan, which manufactures Botox.

A study of botulinum toxin type A for the treatment of glabellar frown lines in 10 patients with major depressive disorder (MDD) found that 9 patients no longer had MDD after 2 months of treatment (Dermatol. Surg. 2006;32:645–50). But since the study had a small number of patients and was not randomized, blinded, or placebo controlled, the results are interesting but inconclusive, he said.

He also discussed a 4-week study of botulinum toxin type A for focal hyperhidrosis in 70 outpatients (43 female, 27 male). Reductions in depression, anxiety, and social phobia were statistically significant but clinically insignificant because patients were within normal limits at baseline. There was a statistically and clinically significant improvement in "social insecurity" scores (Br. J. Dermatol. 2005;152:342–5).

A study of 289 patients (101 men, 188 women) treated with botulinum toxin type A for cervical dystonia found that treatment was associated with less depression and anxiety, along with an improved quality of life (J. Neurol. Neurosurg. Psychiatry 2002;72:608–14).

A 4-week study of 89 patients with blepharospasm and 131 patients with cervical dystonia (CD) treated with botulinum toxin type A found improvements in clinical symptoms for both blepharospasm and CD patients, accompanied by reduced depression in CD patients (correlated with reduced neck pain) but not in blepharospasm patients, Dr. Beddingfield said.

Quality of life improved minimally for CD patients and not at all for blepharospasm patients (J. Neurol. 2002;249:842–6).

In a study of 51 outpatients (32 female, 19 male) treated for blepharospasm with botulinum toxin type A for 1–7 years, investigators found that all but 1 patient had a positive outcome from treatment (Acta Neurol. Scand. 2001;103:49–52). Twenty-nine patients felt depressed, 19 expressed fear of recurrence of blepharospasm symptoms, 27 expressed fear of increasing doses of botulinum toxin type A, 37 found widespread work improvements from therapy, and 34 said they felt more independent of other people, he said.

Of 32 patients treated for spasmodic dysphonia (SD) in another study, with follow-up for 22 patients after week 1 and 13 after 2 months, those who were depressed before treatment had significant improvements in depression and anxiety measures by 1 week following treatment. But depression and anxiety measures did not improve significantly between week 1 and month 2 after treatment (Arch. Otolaryngol. 1994;120:310–6).

There were statistically significant improvements in measures of depression, anxiety, quality of life, and somatization after 1 month in a different study of 10 patients treated with botulinum toxin type A for SD (Gen. Hosp. Psychiatry 1998;20:255–9).

A study of 26 patients (5 male, 21 female) treated for torticollis found improvements in torticollis symptoms accompanied by a statistically significant improvement in mood and reduced depression (J. Neurol. Neurosurg. Psychiatry 1992;55:229–31).

Investigators who treated 16 patients with botulinum toxin type A for idiopathic torticollis found no significant improvement in patients' or physicians' assessments of head position through five follow-up visits (Mov. Disord. 1995;10:398). There were, however, significant improvements in patients' symptoms of depression, perceived disfigurement, interference with daily activities, experience of pain, and overall impression of their torticollis, he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MAUI, HAWAII — A number of studies have examined the association of botulinum toxin type A treatment with reduced symptoms of depression, but the connection is still unexplained, Dr. Frederick C. Beddingfield III said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Depressive symptoms commonly occur in patients who have a negative perception about their appearance, and effective treatment often is accompanied by improved psychosocial function, but the limitations and mixed results of the studies that have been conducted leave open the question of how botulinum toxin type A (Botox) is associated with improved psychosocial function, said Dr. Beddingfield of the University of California, Los Angeles. He also is vice president and therapeutic area head of dermatology clinical research at Allergan, which manufactures Botox.

A study of botulinum toxin type A for the treatment of glabellar frown lines in 10 patients with major depressive disorder (MDD) found that 9 patients no longer had MDD after 2 months of treatment (Dermatol. Surg. 2006;32:645–50). But since the study had a small number of patients and was not randomized, blinded, or placebo controlled, the results are interesting but inconclusive, he said.

He also discussed a 4-week study of botulinum toxin type A for focal hyperhidrosis in 70 outpatients (43 female, 27 male). Reductions in depression, anxiety, and social phobia were statistically significant but clinically insignificant because patients were within normal limits at baseline. There was a statistically and clinically significant improvement in "social insecurity" scores (Br. J. Dermatol. 2005;152:342–5).

A study of 289 patients (101 men, 188 women) treated with botulinum toxin type A for cervical dystonia found that treatment was associated with less depression and anxiety, along with an improved quality of life (J. Neurol. Neurosurg. Psychiatry 2002;72:608–14).

A 4-week study of 89 patients with blepharospasm and 131 patients with cervical dystonia (CD) treated with botulinum toxin type A found improvements in clinical symptoms for both blepharospasm and CD patients, accompanied by reduced depression in CD patients (correlated with reduced neck pain) but not in blepharospasm patients, Dr. Beddingfield said.

Quality of life improved minimally for CD patients and not at all for blepharospasm patients (J. Neurol. 2002;249:842–6).

In a study of 51 outpatients (32 female, 19 male) treated for blepharospasm with botulinum toxin type A for 1–7 years, investigators found that all but 1 patient had a positive outcome from treatment (Acta Neurol. Scand. 2001;103:49–52). Twenty-nine patients felt depressed, 19 expressed fear of recurrence of blepharospasm symptoms, 27 expressed fear of increasing doses of botulinum toxin type A, 37 found widespread work improvements from therapy, and 34 said they felt more independent of other people, he said.

Of 32 patients treated for spasmodic dysphonia (SD) in another study, with follow-up for 22 patients after week 1 and 13 after 2 months, those who were depressed before treatment had significant improvements in depression and anxiety measures by 1 week following treatment. But depression and anxiety measures did not improve significantly between week 1 and month 2 after treatment (Arch. Otolaryngol. 1994;120:310–6).

There were statistically significant improvements in measures of depression, anxiety, quality of life, and somatization after 1 month in a different study of 10 patients treated with botulinum toxin type A for SD (Gen. Hosp. Psychiatry 1998;20:255–9).

A study of 26 patients (5 male, 21 female) treated for torticollis found improvements in torticollis symptoms accompanied by a statistically significant improvement in mood and reduced depression (J. Neurol. Neurosurg. Psychiatry 1992;55:229–31).

Investigators who treated 16 patients with botulinum toxin type A for idiopathic torticollis found no significant improvement in patients' or physicians' assessments of head position through five follow-up visits (Mov. Disord. 1995;10:398). There were, however, significant improvements in patients' symptoms of depression, perceived disfigurement, interference with daily activities, experience of pain, and overall impression of their torticollis, he said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

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

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

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

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

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

The Correct Patient

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

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

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

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

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

The Correct Procedure

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

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

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

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

Key Consultation Concepts

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

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

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

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

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

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

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

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

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

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

The Correct Patient

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

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

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

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

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

The Correct Procedure

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

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

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

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

Key Consultation Concepts

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

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

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

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

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

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

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

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

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

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

The Correct Patient

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

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

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

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

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

The Correct Procedure

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

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

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

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

Key Consultation Concepts

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

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

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

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

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

PALM BEACH, FLA. — A new laser with a unique wavelength holds promise for skin rejuvenation and offers advantages over fractional resurfacing, Dr. David J. Goldberg reported at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The Pearl 2790-nm yttrium-scandium-gallium-garnet laser (Cutera Inc.) "is different from a fractional device. The laser treats the whole epidermis, so you don't need multiple treatments," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

Dermatologists will be able to target uneven skin texture and improve fine lines and photodamage with the new laser, and treatment of mild acne scarring is another potential indication, said Dr. Goldberg, who is a researcher for Cutera.

"It's brand new. I am going to guess no one here has this laser yet," he said at the meeting. The company plans to launch the laser in select cities this summer.

The Pearl 2790-nm laser is indicated for skin types I to III, "with use for skin type IV as a goal," he noted. Fast treatment time is another feature. A full-face treatment takes approximately 30 minutes.

Longer downtime is a tradeoff, however, compared with fractional resurfacing. Patients "are in pain for a while, no question about it. But the results are great," Dr. Goldberg said. "Now more and more people will accept a little downtime if they get a better cosmetic outcome."

In general, flaking begins 2 days after treatment. Peeling starts on day 3 with skin reepithelialization; some erythema will still be seen on day 4. Most patients are ready to return to work and daily activities by this time.

"It is a pretty simple procedure. One pass is required," he said. Apply topical anesthesia for 30–45 minutes beforehand to minimize pain during the procedure.

The energy ranges from about 1 J/cm

The user interface is simple and the 9-ounce hand piece is very lightweight, he said. Also, there are no disposables with this system.

The 2790-nm wavelength is near, but not at, the peak of water absorption in the skin. This allows for a small amount of beneficial thermal effect and controlled ablation of the skin, he explained.

PALM BEACH, FLA. — A new laser with a unique wavelength holds promise for skin rejuvenation and offers advantages over fractional resurfacing, Dr. David J. Goldberg reported at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The Pearl 2790-nm yttrium-scandium-gallium-garnet laser (Cutera Inc.) "is different from a fractional device. The laser treats the whole epidermis, so you don't need multiple treatments," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

Dermatologists will be able to target uneven skin texture and improve fine lines and photodamage with the new laser, and treatment of mild acne scarring is another potential indication, said Dr. Goldberg, who is a researcher for Cutera.

"It's brand new. I am going to guess no one here has this laser yet," he said at the meeting. The company plans to launch the laser in select cities this summer.

The Pearl 2790-nm laser is indicated for skin types I to III, "with use for skin type IV as a goal," he noted. Fast treatment time is another feature. A full-face treatment takes approximately 30 minutes.

Longer downtime is a tradeoff, however, compared with fractional resurfacing. Patients "are in pain for a while, no question about it. But the results are great," Dr. Goldberg said. "Now more and more people will accept a little downtime if they get a better cosmetic outcome."

In general, flaking begins 2 days after treatment. Peeling starts on day 3 with skin reepithelialization; some erythema will still be seen on day 4. Most patients are ready to return to work and daily activities by this time.

"It is a pretty simple procedure. One pass is required," he said. Apply topical anesthesia for 30–45 minutes beforehand to minimize pain during the procedure.

The energy ranges from about 1 J/cm

The user interface is simple and the 9-ounce hand piece is very lightweight, he said. Also, there are no disposables with this system.

The 2790-nm wavelength is near, but not at, the peak of water absorption in the skin. This allows for a small amount of beneficial thermal effect and controlled ablation of the skin, he explained.

PALM BEACH, FLA. — A new laser with a unique wavelength holds promise for skin rejuvenation and offers advantages over fractional resurfacing, Dr. David J. Goldberg reported at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The Pearl 2790-nm yttrium-scandium-gallium-garnet laser (Cutera Inc.) "is different from a fractional device. The laser treats the whole epidermis, so you don't need multiple treatments," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

Dermatologists will be able to target uneven skin texture and improve fine lines and photodamage with the new laser, and treatment of mild acne scarring is another potential indication, said Dr. Goldberg, who is a researcher for Cutera.

"It's brand new. I am going to guess no one here has this laser yet," he said at the meeting. The company plans to launch the laser in select cities this summer.

The Pearl 2790-nm laser is indicated for skin types I to III, "with use for skin type IV as a goal," he noted. Fast treatment time is another feature. A full-face treatment takes approximately 30 minutes.

Longer downtime is a tradeoff, however, compared with fractional resurfacing. Patients "are in pain for a while, no question about it. But the results are great," Dr. Goldberg said. "Now more and more people will accept a little downtime if they get a better cosmetic outcome."

In general, flaking begins 2 days after treatment. Peeling starts on day 3 with skin reepithelialization; some erythema will still be seen on day 4. Most patients are ready to return to work and daily activities by this time.

"It is a pretty simple procedure. One pass is required," he said. Apply topical anesthesia for 30–45 minutes beforehand to minimize pain during the procedure.

The energy ranges from about 1 J/cm

The user interface is simple and the 9-ounce hand piece is very lightweight, he said. Also, there are no disposables with this system.

The 2790-nm wavelength is near, but not at, the peak of water absorption in the skin. This allows for a small amount of beneficial thermal effect and controlled ablation of the skin, he explained.

GRAPEVINE, TEX. — Radio frequency energy treatment of the face and neck led to modest but discernible improvements in rhytids, skin laxity, and photoaging in a small series of patients, Dr. Macrene R. Alexiades-Armenakas said at the annual meeting of the American Society for Laser Medicine and Surgery.

The dual-mode radio frequency device she used was the Accent system made by Alma Lasers. Although the device was not approved by the Food and Drug Administration when Dr. Alexiades-Armenakas did the study, the unit received FDA marketing approval in late April for the treatment of rhytids and wrinkles (SKIN & ALLERGY NEWS, June 2007, p. 9). She disclosed no financial relationship with Alma.

The device produces both unipolar and bipolar radio frequency energy. In unipolar mode, the device creates an alternating electric field that heats tissue at a depth of 2–4 mm by rapidly changing the polarity of charged particles in the skin. The heat produces volumetric changes to a depth of up to 20 mm. In bipolar mode, the device creates an electromagnetic field that heats tissue by causing rapid movement of water molecules, which also produces volumetric changes to a depth of up to 20 mm.

The most discernible effects on facial and neck skin were achieved with a protocol that combined both modes, said Dr. Alexiades-Armenakas, a dermatologist in private practice in New York.

Treatment began with four sequential, 30-second unipolar passes over the skin at 100 J/cm

To help maintain the target temperature during treatment, all passes were completed on one side of the face before the other; the neck was done last. No topical anesthesia was used.

In several patients, this regimen produced an immediately discernible skin tightening, she said.

Dr. Alexiades-Armenakas reported results for the first 10 patients in this series after they received one to three treatments (average 1.3) given at monthly intervals. The impact of treatment was rated on a blinded basis by two experienced dermatologists. They judged that treatment produced an average improvement in overall appearance of about 10%.

Treatment was most effective for improving neck laxity, and was noteworthy for being painless and offering rapid treatment and recovery times, with no adverse effects or complications so far, she said.

The assessment of these patients was truly blinded. "I received a stack of photographs of patients, and I did not know what the treatment was or what the outcome was supposed to be. I looked at each picture and rated the appearance from 0 to 4 with 0.5-point increments," said Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass., who was one of the two dermatologists who rated the outcomes.

Although the 47 patients in the study were followed for 1 year after treatment, Dr. Alexiades-Armenakas had not fully tabulated all of the results at the time of her meeting presentation. She stressed that the treatment regimen for this device is still being optimized.

Her preliminary results from the combined treatment protocol showed progress beyond the results she had obtained in an earlier study that used either unipolar or bipolar energy. In that series, 10 patients were treated in a split-face fashion, with the unipolar device used on one side and the bipolar device on the other.

The unipolar treatment involved one or two passes of 20 seconds each at 100 J/cm

Those treatments were also painless and rapid, and caused no adverse effects aside from mild and transient erythema. Blinded assessment of the patients showed an average improvement of about 5% with unipolar energy and about 6% with bipolar energy, Dr. Alexiades-Armenakas said.

Radio frequency energy treatment was most effective for improving neck laxity, and was noteworthy for being painless and offering rapid treatment and recovery times. Photos courtesy Dr. Macrene R. Alexiades-Armenakas

GRAPEVINE, TEX. — Radio frequency energy treatment of the face and neck led to modest but discernible improvements in rhytids, skin laxity, and photoaging in a small series of patients, Dr. Macrene R. Alexiades-Armenakas said at the annual meeting of the American Society for Laser Medicine and Surgery.

The dual-mode radio frequency device she used was the Accent system made by Alma Lasers. Although the device was not approved by the Food and Drug Administration when Dr. Alexiades-Armenakas did the study, the unit received FDA marketing approval in late April for the treatment of rhytids and wrinkles (SKIN & ALLERGY NEWS, June 2007, p. 9). She disclosed no financial relationship with Alma.

The device produces both unipolar and bipolar radio frequency energy. In unipolar mode, the device creates an alternating electric field that heats tissue at a depth of 2–4 mm by rapidly changing the polarity of charged particles in the skin. The heat produces volumetric changes to a depth of up to 20 mm. In bipolar mode, the device creates an electromagnetic field that heats tissue by causing rapid movement of water molecules, which also produces volumetric changes to a depth of up to 20 mm.

The most discernible effects on facial and neck skin were achieved with a protocol that combined both modes, said Dr. Alexiades-Armenakas, a dermatologist in private practice in New York.

Treatment began with four sequential, 30-second unipolar passes over the skin at 100 J/cm

To help maintain the target temperature during treatment, all passes were completed on one side of the face before the other; the neck was done last. No topical anesthesia was used.

In several patients, this regimen produced an immediately discernible skin tightening, she said.

Dr. Alexiades-Armenakas reported results for the first 10 patients in this series after they received one to three treatments (average 1.3) given at monthly intervals. The impact of treatment was rated on a blinded basis by two experienced dermatologists. They judged that treatment produced an average improvement in overall appearance of about 10%.

Treatment was most effective for improving neck laxity, and was noteworthy for being painless and offering rapid treatment and recovery times, with no adverse effects or complications so far, she said.

The assessment of these patients was truly blinded. "I received a stack of photographs of patients, and I did not know what the treatment was or what the outcome was supposed to be. I looked at each picture and rated the appearance from 0 to 4 with 0.5-point increments," said Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass., who was one of the two dermatologists who rated the outcomes.

Although the 47 patients in the study were followed for 1 year after treatment, Dr. Alexiades-Armenakas had not fully tabulated all of the results at the time of her meeting presentation. She stressed that the treatment regimen for this device is still being optimized.

Her preliminary results from the combined treatment protocol showed progress beyond the results she had obtained in an earlier study that used either unipolar or bipolar energy. In that series, 10 patients were treated in a split-face fashion, with the unipolar device used on one side and the bipolar device on the other.

The unipolar treatment involved one or two passes of 20 seconds each at 100 J/cm

Those treatments were also painless and rapid, and caused no adverse effects aside from mild and transient erythema. Blinded assessment of the patients showed an average improvement of about 5% with unipolar energy and about 6% with bipolar energy, Dr. Alexiades-Armenakas said.

Radio frequency energy treatment was most effective for improving neck laxity, and was noteworthy for being painless and offering rapid treatment and recovery times. Photos courtesy Dr. Macrene R. Alexiades-Armenakas

GRAPEVINE, TEX. — Radio frequency energy treatment of the face and neck led to modest but discernible improvements in rhytids, skin laxity, and photoaging in a small series of patients, Dr. Macrene R. Alexiades-Armenakas said at the annual meeting of the American Society for Laser Medicine and Surgery.

The dual-mode radio frequency device she used was the Accent system made by Alma Lasers. Although the device was not approved by the Food and Drug Administration when Dr. Alexiades-Armenakas did the study, the unit received FDA marketing approval in late April for the treatment of rhytids and wrinkles (SKIN & ALLERGY NEWS, June 2007, p. 9). She disclosed no financial relationship with Alma.

The device produces both unipolar and bipolar radio frequency energy. In unipolar mode, the device creates an alternating electric field that heats tissue at a depth of 2–4 mm by rapidly changing the polarity of charged particles in the skin. The heat produces volumetric changes to a depth of up to 20 mm. In bipolar mode, the device creates an electromagnetic field that heats tissue by causing rapid movement of water molecules, which also produces volumetric changes to a depth of up to 20 mm.

The most discernible effects on facial and neck skin were achieved with a protocol that combined both modes, said Dr. Alexiades-Armenakas, a dermatologist in private practice in New York.

Treatment began with four sequential, 30-second unipolar passes over the skin at 100 J/cm

To help maintain the target temperature during treatment, all passes were completed on one side of the face before the other; the neck was done last. No topical anesthesia was used.

In several patients, this regimen produced an immediately discernible skin tightening, she said.

Dr. Alexiades-Armenakas reported results for the first 10 patients in this series after they received one to three treatments (average 1.3) given at monthly intervals. The impact of treatment was rated on a blinded basis by two experienced dermatologists. They judged that treatment produced an average improvement in overall appearance of about 10%.

Treatment was most effective for improving neck laxity, and was noteworthy for being painless and offering rapid treatment and recovery times, with no adverse effects or complications so far, she said.

The assessment of these patients was truly blinded. "I received a stack of photographs of patients, and I did not know what the treatment was or what the outcome was supposed to be. I looked at each picture and rated the appearance from 0 to 4 with 0.5-point increments," said Dr. Jeffrey S. Dover, a dermatologist in private practice in Chestnut Hill, Mass., who was one of the two dermatologists who rated the outcomes.

Although the 47 patients in the study were followed for 1 year after treatment, Dr. Alexiades-Armenakas had not fully tabulated all of the results at the time of her meeting presentation. She stressed that the treatment regimen for this device is still being optimized.

Her preliminary results from the combined treatment protocol showed progress beyond the results she had obtained in an earlier study that used either unipolar or bipolar energy. In that series, 10 patients were treated in a split-face fashion, with the unipolar device used on one side and the bipolar device on the other.

The unipolar treatment involved one or two passes of 20 seconds each at 100 J/cm

Those treatments were also painless and rapid, and caused no adverse effects aside from mild and transient erythema. Blinded assessment of the patients showed an average improvement of about 5% with unipolar energy and about 6% with bipolar energy, Dr. Alexiades-Armenakas said.

Radio frequency energy treatment was most effective for improving neck laxity, and was noteworthy for being painless and offering rapid treatment and recovery times. Photos courtesy Dr. Macrene R. Alexiades-Armenakas

SANTA ANA PUEBLO, N.M. — The first step in considering Mohs surgery for melanoma is a detailed informed consent, Dr. Kenneth G. Gross advised at a meeting of the American Society for Mohs Surgery.

He uses the consent form "to counsel the patient, tell them about the tumor, and what I expect to do," said Dr. Gross, a dermatologic surgeon practicing in San Diego.

For example, his standard Mohs consent form is modified to include the possibility of taking an additional rim of tissue beyond the ostensibly clear Mohs margin, the possible need for immunohistochemistry, and the inclusion of postoperative therapy with imiquimod.

Dr. Gross photographs the melanoma lesions prior to surgery and also documents cross-measurements from adjacent anatomical areas to localize the melanoma. "I have had patients referred to me for a melanoma, but neither the patient, nor the referring doctor, nor I could find the site," he said. "That's a very embarrassing thing."

At the time of biopsy and/or when the patient is first seen for preoperative evaluation, and again on the day of surgery, the clinical status of the regional nodes should be evaluated and documented. "My note includes a statement such as: 'The regional nodes were negative or bilaterally negative to palpation.'"

He went on to share his clinical approach to Mohs surgery for melanoma:

▸ Outline the melanoma using magnification with and without a Wood's lamp, plus an additional margin of 3–5 mm. Dermoscopy "may be helpful in delineating the margins," he said.

▸ Excise the lesion using standard Mohs technique to below the hair follicles, if possible.

Dr. Gross uses Dr. John A. Zitelli's criteria to determine positive margins, defined as nests of three or more atypical melanocytes, melanocytes above the dermal-epidermal junction, or nonuniform contiguous melanocytic hyperplasia at the dermal-epidermal junction.

Other suspicious findings include confluent atypical melanocytes down the adnexa, increased numbers of melanophages, brisk inflammation, and dermal scarring.

He noted that one recent study found that about 25% of in situ melanomas on biopsy are upstaged to invasive melanoma if step cross-sections were done. "So I think cross-sectioning has to be part of your overall way of doing things," he said. "In our office, after the Mohs margins are assessed using standard Mohs technique, then the blocks are partially thawed and cross-sectioned by frozen section processing. This allows both assessment of invasion and another look at how closely the tumor approaches the 'clear' margins. It influences whether we take an additional rim of tissue—processed by permanent section technique—past our Mohs margin."

▸ Be capable of producing high-quality Mohs slides. "You want 2- to 4-mcm wafers of high quality," said Dr. Gross, who is also with the department of medicine at the University of California, San Diego.

▸ Consider double-reading the slides with a pathologist. "I'm not completely comfortable reading these slides myself," he said. "If you're a dermatopathologist, you may be comfortable reading these slides on your own. But for the rest of us, if you have an association with a dermatopathologist or pathologist, double-reading the slides gives you a tremendous advantage."

Dr. Gross uses hematoxylin and eosin (H&E) staining for his frozen section slides, and every second or third slide is left unstained for immunohistochemistry (IHC) if needed.

▸ When clear margins are achieved, close the wound. Starting on postoperative day 25, Dr. Gross begins imiquimod cream b.i.d. for 6 weeks, titering the effect to produce a brisk immune response.

Dr. Gross said there is now a consensus among leading surgical oncologists that sentinel node biopsy is the standard of care for primary cutaneous melanoma measuring 1.0–3.5 mm thick.

'I have had patients referred to me for a melanoma, but [no one] could find the site.' DR. GROSS

SANTA ANA PUEBLO, N.M. — The first step in considering Mohs surgery for melanoma is a detailed informed consent, Dr. Kenneth G. Gross advised at a meeting of the American Society for Mohs Surgery.

He uses the consent form "to counsel the patient, tell them about the tumor, and what I expect to do," said Dr. Gross, a dermatologic surgeon practicing in San Diego.

For example, his standard Mohs consent form is modified to include the possibility of taking an additional rim of tissue beyond the ostensibly clear Mohs margin, the possible need for immunohistochemistry, and the inclusion of postoperative therapy with imiquimod.

Dr. Gross photographs the melanoma lesions prior to surgery and also documents cross-measurements from adjacent anatomical areas to localize the melanoma. "I have had patients referred to me for a melanoma, but neither the patient, nor the referring doctor, nor I could find the site," he said. "That's a very embarrassing thing."

At the time of biopsy and/or when the patient is first seen for preoperative evaluation, and again on the day of surgery, the clinical status of the regional nodes should be evaluated and documented. "My note includes a statement such as: 'The regional nodes were negative or bilaterally negative to palpation.'"

He went on to share his clinical approach to Mohs surgery for melanoma:

▸ Outline the melanoma using magnification with and without a Wood's lamp, plus an additional margin of 3–5 mm. Dermoscopy "may be helpful in delineating the margins," he said.

▸ Excise the lesion using standard Mohs technique to below the hair follicles, if possible.

Dr. Gross uses Dr. John A. Zitelli's criteria to determine positive margins, defined as nests of three or more atypical melanocytes, melanocytes above the dermal-epidermal junction, or nonuniform contiguous melanocytic hyperplasia at the dermal-epidermal junction.

Other suspicious findings include confluent atypical melanocytes down the adnexa, increased numbers of melanophages, brisk inflammation, and dermal scarring.

He noted that one recent study found that about 25% of in situ melanomas on biopsy are upstaged to invasive melanoma if step cross-sections were done. "So I think cross-sectioning has to be part of your overall way of doing things," he said. "In our office, after the Mohs margins are assessed using standard Mohs technique, then the blocks are partially thawed and cross-sectioned by frozen section processing. This allows both assessment of invasion and another look at how closely the tumor approaches the 'clear' margins. It influences whether we take an additional rim of tissue—processed by permanent section technique—past our Mohs margin."

▸ Be capable of producing high-quality Mohs slides. "You want 2- to 4-mcm wafers of high quality," said Dr. Gross, who is also with the department of medicine at the University of California, San Diego.

▸ Consider double-reading the slides with a pathologist. "I'm not completely comfortable reading these slides myself," he said. "If you're a dermatopathologist, you may be comfortable reading these slides on your own. But for the rest of us, if you have an association with a dermatopathologist or pathologist, double-reading the slides gives you a tremendous advantage."

Dr. Gross uses hematoxylin and eosin (H&E) staining for his frozen section slides, and every second or third slide is left unstained for immunohistochemistry (IHC) if needed.

▸ When clear margins are achieved, close the wound. Starting on postoperative day 25, Dr. Gross begins imiquimod cream b.i.d. for 6 weeks, titering the effect to produce a brisk immune response.

Dr. Gross said there is now a consensus among leading surgical oncologists that sentinel node biopsy is the standard of care for primary cutaneous melanoma measuring 1.0–3.5 mm thick.

'I have had patients referred to me for a melanoma, but [no one] could find the site.' DR. GROSS

SANTA ANA PUEBLO, N.M. — The first step in considering Mohs surgery for melanoma is a detailed informed consent, Dr. Kenneth G. Gross advised at a meeting of the American Society for Mohs Surgery.

He uses the consent form "to counsel the patient, tell them about the tumor, and what I expect to do," said Dr. Gross, a dermatologic surgeon practicing in San Diego.

For example, his standard Mohs consent form is modified to include the possibility of taking an additional rim of tissue beyond the ostensibly clear Mohs margin, the possible need for immunohistochemistry, and the inclusion of postoperative therapy with imiquimod.

Dr. Gross photographs the melanoma lesions prior to surgery and also documents cross-measurements from adjacent anatomical areas to localize the melanoma. "I have had patients referred to me for a melanoma, but neither the patient, nor the referring doctor, nor I could find the site," he said. "That's a very embarrassing thing."

At the time of biopsy and/or when the patient is first seen for preoperative evaluation, and again on the day of surgery, the clinical status of the regional nodes should be evaluated and documented. "My note includes a statement such as: 'The regional nodes were negative or bilaterally negative to palpation.'"

He went on to share his clinical approach to Mohs surgery for melanoma:

▸ Outline the melanoma using magnification with and without a Wood's lamp, plus an additional margin of 3–5 mm. Dermoscopy "may be helpful in delineating the margins," he said.

▸ Excise the lesion using standard Mohs technique to below the hair follicles, if possible.

Dr. Gross uses Dr. John A. Zitelli's criteria to determine positive margins, defined as nests of three or more atypical melanocytes, melanocytes above the dermal-epidermal junction, or nonuniform contiguous melanocytic hyperplasia at the dermal-epidermal junction.

Other suspicious findings include confluent atypical melanocytes down the adnexa, increased numbers of melanophages, brisk inflammation, and dermal scarring.

He noted that one recent study found that about 25% of in situ melanomas on biopsy are upstaged to invasive melanoma if step cross-sections were done. "So I think cross-sectioning has to be part of your overall way of doing things," he said. "In our office, after the Mohs margins are assessed using standard Mohs technique, then the blocks are partially thawed and cross-sectioned by frozen section processing. This allows both assessment of invasion and another look at how closely the tumor approaches the 'clear' margins. It influences whether we take an additional rim of tissue—processed by permanent section technique—past our Mohs margin."

▸ Be capable of producing high-quality Mohs slides. "You want 2- to 4-mcm wafers of high quality," said Dr. Gross, who is also with the department of medicine at the University of California, San Diego.

▸ Consider double-reading the slides with a pathologist. "I'm not completely comfortable reading these slides myself," he said. "If you're a dermatopathologist, you may be comfortable reading these slides on your own. But for the rest of us, if you have an association with a dermatopathologist or pathologist, double-reading the slides gives you a tremendous advantage."

Dr. Gross uses hematoxylin and eosin (H&E) staining for his frozen section slides, and every second or third slide is left unstained for immunohistochemistry (IHC) if needed.

▸ When clear margins are achieved, close the wound. Starting on postoperative day 25, Dr. Gross begins imiquimod cream b.i.d. for 6 weeks, titering the effect to produce a brisk immune response.

Dr. Gross said there is now a consensus among leading surgical oncologists that sentinel node biopsy is the standard of care for primary cutaneous melanoma measuring 1.0–3.5 mm thick.

'I have had patients referred to me for a melanoma, but [no one] could find the site.' DR. GROSS

SANTA ANA PUEBLO, N.M. — The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.

"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.

Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.

"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."

There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.

He offered four questions to keep in mind before and after every dermatologic procedure involving the face:

▸ What is the blood supply to the area?

▸ What motor and sensory nerves are involved?

▸ What layers of tissue will I cut through?

▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.

He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."

Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.

"The best tool is real patients," he said.

Summer Reading Recommendations

Dr. Feldman suggested several anatomy books:

"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)

"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)

"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)

"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)

"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)

"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)

"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)

SANTA ANA PUEBLO, N.M. — The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.

"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.

Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.

"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."

There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.

He offered four questions to keep in mind before and after every dermatologic procedure involving the face:

▸ What is the blood supply to the area?

▸ What motor and sensory nerves are involved?

▸ What layers of tissue will I cut through?

▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.

He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."

Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.

"The best tool is real patients," he said.

Summer Reading Recommendations

Dr. Feldman suggested several anatomy books:

"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)

"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)

"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)

"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)

"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)

"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)

"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)

SANTA ANA PUEBLO, N.M. — The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.

"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.

Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.

"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."

There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.

He offered four questions to keep in mind before and after every dermatologic procedure involving the face:

▸ What is the blood supply to the area?

▸ What motor and sensory nerves are involved?

▸ What layers of tissue will I cut through?

▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.

He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."

Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.

"The best tool is real patients," he said.

Summer Reading Recommendations

Dr. Feldman suggested several anatomy books:

"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)

"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)

"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)

"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)

"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)

"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)

"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

▸ Avoid postoperative hot soaks.

▸ Look out for vasospastic patients.

▸ Consider having nitroglycerin or phentolamine on hand.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

▸ Avoid postoperative hot soaks.

▸ Look out for vasospastic patients.

▸ Consider having nitroglycerin or phentolamine on hand.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

▸ Avoid postoperative hot soaks.

▸ Look out for vasospastic patients.

▸ Consider having nitroglycerin or phentolamine on hand.

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

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

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

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

MAUI, HAWAII — A conservative and highly selective approach to pulsed dye laser therapy is appropriate for treating infantile hemangiomas, Dr. Ilona J. Frieden reported at the annual Hawaii Dermatology seminar sponsored by Skin Disease Education Foundation.

Pulsed dye laser (PDL) therapy of infantile hemangiomas has not been nearly as well established as it has for port-wine stains.

It has become clear that experience derived from PDL of port-wine stains in infants can't be generalized to infantile hemangiomas, she said.

Early enthusiasm in many quarters has faded.

"Infantile hemangiomas are much more complicated lesions than port-wine stains," cautioned Dr. Frieden, professor of clinical dermatology at the University of California, San Francisco.

Superficial-appearing infantile hemangiomas can run much deeper than is evident upon physical examination.

The growth characteristics of hemangiomas of infancy are less predictable than those of port-wine stains, and the lesions feature a very fragile epidermal layer that's prone to ulceration.

"I think there's growing recognition that the risk of scarring due to laser therapy is definitely greater than with port-wine stains," she continued.

Dr. Frieden was coauthor of a report detailing such complications in a dozen patients following PDL treatment of superficial infantile hemangiomas.

Eight of the children experienced severe ulceration with scarring and pain—and in one case, there was a life-threatening hemorrhage.

The other four had permanent atrophic scarring with no ulceration (Lasers Surg. Med. 2006;38:116–23).

Other downsides of PDL for infantile hemangiomas include its expense and the distinct possibility that the treatment will delay the use of more effective therapies, such as corticosteroids, she said.

The literature on PDL for infantile hemangiomas is best assessed with an especially critical eye, according to Dr. Frieden.

Uncontrolled case series by laser enthusiasts are the norm.

There has been only a single randomized controlled trial of PDL treatment of infantile hemangiomas.

In this 121-patient study, dermatologists at Birmingham (England) Children's Hospital found that the rate of cleared lesions or only minimal residual signs at age 1 year was 42% in the PDL group and 44% in observation-only controls.

Moreover, both skin atrophy and hypopigmentation were at least threefold more common in the PDL-treated children (Lancet 2002;360:521–7).

Consensus exists among pediatric dermatologists that a reasonable use of PDL in infantile hemangiomas is to mop up residual telangiectasias once a lesion has undergone involution.

Beyond this limited application, however, the field is fraught with controversy.

Dr. Frieden believes laser therapy isn't appropriate for lesions in the early proliferative phase because of limited efficacy coupled with the potential for serious complications.

Furthermore, although PDL therapy for infantile hemangiomas that undergo ulceration has its advocates, Dr. Frieden considers it merely a third-line treatment, behind local wound care—the first-line therapy—and corticosteroids.

There are no comparative studies involving PDL for ulceration in infantile hemangiomas, a serious complication that occurs in roughly 10% of the lesions, she noted.

Indeed, the use of laser therapy in clinical practice for vascular birthmarks of all types has far outstripped the supporting science, according to Dr. Frieden.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'The risk of scarring due to laser therapy is definitely greater than with port-wine stains.' DR. FRIEDEN

MAUI, HAWAII — A conservative and highly selective approach to pulsed dye laser therapy is appropriate for treating infantile hemangiomas, Dr. Ilona J. Frieden reported at the annual Hawaii Dermatology seminar sponsored by Skin Disease Education Foundation.

Pulsed dye laser (PDL) therapy of infantile hemangiomas has not been nearly as well established as it has for port-wine stains.

It has become clear that experience derived from PDL of port-wine stains in infants can't be generalized to infantile hemangiomas, she said.

Early enthusiasm in many quarters has faded.

"Infantile hemangiomas are much more complicated lesions than port-wine stains," cautioned Dr. Frieden, professor of clinical dermatology at the University of California, San Francisco.

Superficial-appearing infantile hemangiomas can run much deeper than is evident upon physical examination.

The growth characteristics of hemangiomas of infancy are less predictable than those of port-wine stains, and the lesions feature a very fragile epidermal layer that's prone to ulceration.

"I think there's growing recognition that the risk of scarring due to laser therapy is definitely greater than with port-wine stains," she continued.

Dr. Frieden was coauthor of a report detailing such complications in a dozen patients following PDL treatment of superficial infantile hemangiomas.

Eight of the children experienced severe ulceration with scarring and pain—and in one case, there was a life-threatening hemorrhage.

The other four had permanent atrophic scarring with no ulceration (Lasers Surg. Med. 2006;38:116–23).

Other downsides of PDL for infantile hemangiomas include its expense and the distinct possibility that the treatment will delay the use of more effective therapies, such as corticosteroids, she said.

The literature on PDL for infantile hemangiomas is best assessed with an especially critical eye, according to Dr. Frieden.

Uncontrolled case series by laser enthusiasts are the norm.

There has been only a single randomized controlled trial of PDL treatment of infantile hemangiomas.

In this 121-patient study, dermatologists at Birmingham (England) Children's Hospital found that the rate of cleared lesions or only minimal residual signs at age 1 year was 42% in the PDL group and 44% in observation-only controls.

Moreover, both skin atrophy and hypopigmentation were at least threefold more common in the PDL-treated children (Lancet 2002;360:521–7).

Consensus exists among pediatric dermatologists that a reasonable use of PDL in infantile hemangiomas is to mop up residual telangiectasias once a lesion has undergone involution.

Beyond this limited application, however, the field is fraught with controversy.

Dr. Frieden believes laser therapy isn't appropriate for lesions in the early proliferative phase because of limited efficacy coupled with the potential for serious complications.

Furthermore, although PDL therapy for infantile hemangiomas that undergo ulceration has its advocates, Dr. Frieden considers it merely a third-line treatment, behind local wound care—the first-line therapy—and corticosteroids.

There are no comparative studies involving PDL for ulceration in infantile hemangiomas, a serious complication that occurs in roughly 10% of the lesions, she noted.

Indeed, the use of laser therapy in clinical practice for vascular birthmarks of all types has far outstripped the supporting science, according to Dr. Frieden.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'The risk of scarring due to laser therapy is definitely greater than with port-wine stains.' DR. FRIEDEN

MAUI, HAWAII — A conservative and highly selective approach to pulsed dye laser therapy is appropriate for treating infantile hemangiomas, Dr. Ilona J. Frieden reported at the annual Hawaii Dermatology seminar sponsored by Skin Disease Education Foundation.

Pulsed dye laser (PDL) therapy of infantile hemangiomas has not been nearly as well established as it has for port-wine stains.

It has become clear that experience derived from PDL of port-wine stains in infants can't be generalized to infantile hemangiomas, she said.

Early enthusiasm in many quarters has faded.

"Infantile hemangiomas are much more complicated lesions than port-wine stains," cautioned Dr. Frieden, professor of clinical dermatology at the University of California, San Francisco.

Superficial-appearing infantile hemangiomas can run much deeper than is evident upon physical examination.

The growth characteristics of hemangiomas of infancy are less predictable than those of port-wine stains, and the lesions feature a very fragile epidermal layer that's prone to ulceration.

"I think there's growing recognition that the risk of scarring due to laser therapy is definitely greater than with port-wine stains," she continued.

Dr. Frieden was coauthor of a report detailing such complications in a dozen patients following PDL treatment of superficial infantile hemangiomas.

Eight of the children experienced severe ulceration with scarring and pain—and in one case, there was a life-threatening hemorrhage.

The other four had permanent atrophic scarring with no ulceration (Lasers Surg. Med. 2006;38:116–23).

Other downsides of PDL for infantile hemangiomas include its expense and the distinct possibility that the treatment will delay the use of more effective therapies, such as corticosteroids, she said.

The literature on PDL for infantile hemangiomas is best assessed with an especially critical eye, according to Dr. Frieden.

Uncontrolled case series by laser enthusiasts are the norm.

There has been only a single randomized controlled trial of PDL treatment of infantile hemangiomas.

In this 121-patient study, dermatologists at Birmingham (England) Children's Hospital found that the rate of cleared lesions or only minimal residual signs at age 1 year was 42% in the PDL group and 44% in observation-only controls.

Moreover, both skin atrophy and hypopigmentation were at least threefold more common in the PDL-treated children (Lancet 2002;360:521–7).

Consensus exists among pediatric dermatologists that a reasonable use of PDL in infantile hemangiomas is to mop up residual telangiectasias once a lesion has undergone involution.

Beyond this limited application, however, the field is fraught with controversy.

Dr. Frieden believes laser therapy isn't appropriate for lesions in the early proliferative phase because of limited efficacy coupled with the potential for serious complications.

Furthermore, although PDL therapy for infantile hemangiomas that undergo ulceration has its advocates, Dr. Frieden considers it merely a third-line treatment, behind local wound care—the first-line therapy—and corticosteroids.

There are no comparative studies involving PDL for ulceration in infantile hemangiomas, a serious complication that occurs in roughly 10% of the lesions, she noted.

Indeed, the use of laser therapy in clinical practice for vascular birthmarks of all types has far outstripped the supporting science, according to Dr. Frieden.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'The risk of scarring due to laser therapy is definitely greater than with port-wine stains.' DR. FRIEDEN

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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