Aesthetic Dermatology

PALM DESERT, CALIF.—The new, overriding concept in cosmetic procedures is that what the aging face often needs is new volume.

It is the view that the aging face is a "deflated" face, Dr. Gary D. Monheit said at the annual meeting of the American Society for Dermatologic Surgery.

"It is the volume loss as much as the ptosis," said Dr. Monheit, immediate past president of the ASDS. "It is the volume loss in the face that has become the new concept, the volume loss of bone, fat structure, and muscles, and we now have some new handles in order to rejuvenate." Such "handles" include using fillers like hyaluronic acid to enhance hollow cheeks, and barbed sutures used to lift the malar area to smooth out nasolabial folds and create an impression of high cheekbones.

Dr. Monheit, who practices in Birmingham, Ala., said this approach follows the precepts articulated by Dr. Richard Glogau of the University of California, San Francisco. Dr. Glogau said there are four features of the aging face that can be addressed by the cosmetic dermatologist. He calls them the four Rs: rebuild, relax, resurface, and redrape.

For rebuilding, there are fillers. For relaxing, there is botulinum toxin. For resurfacing, there are lasers and cosmeceuticals. And, for redraping, there are the barbed threads. But, all of these options also are making cosmetic dermatology much more complex than it has ever been.

The new challenge for cosmetic dermatology is the number of products now available for rejuvenation, with many more probably coming soon, an almost bewildering array, Dr. Monheit said.

The field will have to be careful in evaluating and embracing these products as they come onto the market, he warned.

PALM DESERT, CALIF.—The new, overriding concept in cosmetic procedures is that what the aging face often needs is new volume.

It is the view that the aging face is a "deflated" face, Dr. Gary D. Monheit said at the annual meeting of the American Society for Dermatologic Surgery.

"It is the volume loss as much as the ptosis," said Dr. Monheit, immediate past president of the ASDS. "It is the volume loss in the face that has become the new concept, the volume loss of bone, fat structure, and muscles, and we now have some new handles in order to rejuvenate." Such "handles" include using fillers like hyaluronic acid to enhance hollow cheeks, and barbed sutures used to lift the malar area to smooth out nasolabial folds and create an impression of high cheekbones.

Dr. Monheit, who practices in Birmingham, Ala., said this approach follows the precepts articulated by Dr. Richard Glogau of the University of California, San Francisco. Dr. Glogau said there are four features of the aging face that can be addressed by the cosmetic dermatologist. He calls them the four Rs: rebuild, relax, resurface, and redrape.

For rebuilding, there are fillers. For relaxing, there is botulinum toxin. For resurfacing, there are lasers and cosmeceuticals. And, for redraping, there are the barbed threads. But, all of these options also are making cosmetic dermatology much more complex than it has ever been.

The new challenge for cosmetic dermatology is the number of products now available for rejuvenation, with many more probably coming soon, an almost bewildering array, Dr. Monheit said.

The field will have to be careful in evaluating and embracing these products as they come onto the market, he warned.

PALM DESERT, CALIF.—The new, overriding concept in cosmetic procedures is that what the aging face often needs is new volume.

It is the view that the aging face is a "deflated" face, Dr. Gary D. Monheit said at the annual meeting of the American Society for Dermatologic Surgery.

"It is the volume loss as much as the ptosis," said Dr. Monheit, immediate past president of the ASDS. "It is the volume loss in the face that has become the new concept, the volume loss of bone, fat structure, and muscles, and we now have some new handles in order to rejuvenate." Such "handles" include using fillers like hyaluronic acid to enhance hollow cheeks, and barbed sutures used to lift the malar area to smooth out nasolabial folds and create an impression of high cheekbones.

Dr. Monheit, who practices in Birmingham, Ala., said this approach follows the precepts articulated by Dr. Richard Glogau of the University of California, San Francisco. Dr. Glogau said there are four features of the aging face that can be addressed by the cosmetic dermatologist. He calls them the four Rs: rebuild, relax, resurface, and redrape.

For rebuilding, there are fillers. For relaxing, there is botulinum toxin. For resurfacing, there are lasers and cosmeceuticals. And, for redraping, there are the barbed threads. But, all of these options also are making cosmetic dermatology much more complex than it has ever been.

The new challenge for cosmetic dermatology is the number of products now available for rejuvenation, with many more probably coming soon, an almost bewildering array, Dr. Monheit said.

The field will have to be careful in evaluating and embracing these products as they come onto the market, he warned.

PALM DESERT, CALIF.—Thermage radiofrequency treatment can be combined with liposuction to shrink loose skin in the abdomen, Dr. Victoria G. Belo said at the annual meeting of the American Society for Dermatologic Surgery.

"By virtue of its noninvasive nature combined with its excellent safety profile, this complementary use of Thermage and liposuction provides an attractive alternative to surgical procedures for patients who want to treat skin laxity," said Dr. Belo, who practices in Manila.

Dr. Belo presented an investigation of 30 patients undergoing liposuction: Ten underwent a Thermage procedure at the time of their liposuction, 10 received a Thermage treatment 1 month after liposuction, and 10 served as controls.

Dr. Belo said that she treated an area of the abdomen that was 20 cm by 14 cm in all the patients, using a 50% overlapping technique, and followed the patients once a month for 6 months.

In all the patients, the area marked out but not treated measured an average of 280 cm

In the group treated immediately with Thermage, however, the area began to contract at about 3 months, and by the fourth month the average size of the area was about 200 cm

The group treated 1 month after liposuction had about half the improvement of the immediate-treatment group. "It is really not until the fourth to sixth month that you can see a difference," Dr. Belo said.

Dr. Belo speculated that those who were treated 1 month after their liposuction might not have had a response because fibrotic tissue from the liposuction procedure had already formed. Alternatively, there may have been a positive interplay between the inflammation stimulated by the liposuction procedure and the Thermage treatment, enhancing the effect, she said.

"It is possible that you have some scar tissue from liposuction at 1 month that is unresponsive to Thermage," she said.

Dr. Belo indicated that she has no financial ties to Thermage Inc.

PALM DESERT, CALIF.—Thermage radiofrequency treatment can be combined with liposuction to shrink loose skin in the abdomen, Dr. Victoria G. Belo said at the annual meeting of the American Society for Dermatologic Surgery.

"By virtue of its noninvasive nature combined with its excellent safety profile, this complementary use of Thermage and liposuction provides an attractive alternative to surgical procedures for patients who want to treat skin laxity," said Dr. Belo, who practices in Manila.

Dr. Belo presented an investigation of 30 patients undergoing liposuction: Ten underwent a Thermage procedure at the time of their liposuction, 10 received a Thermage treatment 1 month after liposuction, and 10 served as controls.

Dr. Belo said that she treated an area of the abdomen that was 20 cm by 14 cm in all the patients, using a 50% overlapping technique, and followed the patients once a month for 6 months.

In all the patients, the area marked out but not treated measured an average of 280 cm

In the group treated immediately with Thermage, however, the area began to contract at about 3 months, and by the fourth month the average size of the area was about 200 cm

The group treated 1 month after liposuction had about half the improvement of the immediate-treatment group. "It is really not until the fourth to sixth month that you can see a difference," Dr. Belo said.

Dr. Belo speculated that those who were treated 1 month after their liposuction might not have had a response because fibrotic tissue from the liposuction procedure had already formed. Alternatively, there may have been a positive interplay between the inflammation stimulated by the liposuction procedure and the Thermage treatment, enhancing the effect, she said.

"It is possible that you have some scar tissue from liposuction at 1 month that is unresponsive to Thermage," she said.

Dr. Belo indicated that she has no financial ties to Thermage Inc.

PALM DESERT, CALIF.—Thermage radiofrequency treatment can be combined with liposuction to shrink loose skin in the abdomen, Dr. Victoria G. Belo said at the annual meeting of the American Society for Dermatologic Surgery.

"By virtue of its noninvasive nature combined with its excellent safety profile, this complementary use of Thermage and liposuction provides an attractive alternative to surgical procedures for patients who want to treat skin laxity," said Dr. Belo, who practices in Manila.

Dr. Belo presented an investigation of 30 patients undergoing liposuction: Ten underwent a Thermage procedure at the time of their liposuction, 10 received a Thermage treatment 1 month after liposuction, and 10 served as controls.

Dr. Belo said that she treated an area of the abdomen that was 20 cm by 14 cm in all the patients, using a 50% overlapping technique, and followed the patients once a month for 6 months.

In all the patients, the area marked out but not treated measured an average of 280 cm

In the group treated immediately with Thermage, however, the area began to contract at about 3 months, and by the fourth month the average size of the area was about 200 cm

The group treated 1 month after liposuction had about half the improvement of the immediate-treatment group. "It is really not until the fourth to sixth month that you can see a difference," Dr. Belo said.

Dr. Belo speculated that those who were treated 1 month after their liposuction might not have had a response because fibrotic tissue from the liposuction procedure had already formed. Alternatively, there may have been a positive interplay between the inflammation stimulated by the liposuction procedure and the Thermage treatment, enhancing the effect, she said.

"It is possible that you have some scar tissue from liposuction at 1 month that is unresponsive to Thermage," she said.

Dr. Belo indicated that she has no financial ties to Thermage Inc.

NEW YORK—The severity of postsurgical complications can be mitigated by knowing the warning signs and best management techniques, Dr. James M. Spencer said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.

Some bruising, for example, is very common after dermatologic surgery. If it's performed in the periocular region, patients can expect to have a black eye. "This can obviously be very alarming to patients, but generally reassurance is all that's necessary," said Dr. Spencer of the department of dermatology at Mount Sinai in New York.

In the case of minor bleeding, advise patients to try direct pressure for 10–15 minutes and apply ice. If the bleeding can't be controlled easily from home, the patient will have to come back in. He advised using lidocaine alone when numbing the wound area because epinephrine causes vasoconstriction and will make it hard to recognize bleeding problems.

A hematoma puts pressure on the wound and is an excellent growth medium for bacteria. Initially, the clot will be gelatinous and generally can be easily evacuated through a small opening, but once it organizes, it will be difficult to remove. Wait 7–10 days for the clot to liquify and reabsorb, Dr. Spencer said.

Like a hematoma, a seroma puts pressure on the wound. This generally can be evacuated with an 18-gauge needle, he said.

A wound infection usually manifests 3–4 days after surgery and the classic signs include pain, redness, and swelling. Although gram-positive infection is most likely in dermatology, there are certain areas of the body where other infections also are likely. Pseudomonas should be considered on the ear and gram-negative infections in the groin and lower leg, Dr. Spencer said.

Contact dermatitis can mimic infection, though if the area is red and itchy, that's a clue that it could be contact dermatitis. Patients may have an allergic reaction to either the topical antibiotic or to the glue of the bandage. Remove the offending agent and put the patient on a short course of topical steroids, he said.

When there is dehiscence, there are two choices—either resuture or allow the wound to heal by second intention. "Second intention, I think, is underutilized. You can get terrific results," he said. If the wound is resutured, wash it, but don't debride the wound edges excessively.

One of the worst postsurgical complications is necrosis. If the flap or graft is blue, then blood is going in but is not getting back out. In that case, try nitroglycerin cream to increase venous return. However, if the flap or graft becomes black, adherent, and crusted, that is necrosis. The physician should do nothing and wait for it to slough on its own. Since it's not apparent how deep the necrosis goes, there could be a viable dermis underneath it. Debriding it just creates a large open wound, Dr. Spencer said.

NEW YORK—The severity of postsurgical complications can be mitigated by knowing the warning signs and best management techniques, Dr. James M. Spencer said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.

Some bruising, for example, is very common after dermatologic surgery. If it's performed in the periocular region, patients can expect to have a black eye. "This can obviously be very alarming to patients, but generally reassurance is all that's necessary," said Dr. Spencer of the department of dermatology at Mount Sinai in New York.

In the case of minor bleeding, advise patients to try direct pressure for 10–15 minutes and apply ice. If the bleeding can't be controlled easily from home, the patient will have to come back in. He advised using lidocaine alone when numbing the wound area because epinephrine causes vasoconstriction and will make it hard to recognize bleeding problems.

A hematoma puts pressure on the wound and is an excellent growth medium for bacteria. Initially, the clot will be gelatinous and generally can be easily evacuated through a small opening, but once it organizes, it will be difficult to remove. Wait 7–10 days for the clot to liquify and reabsorb, Dr. Spencer said.

Like a hematoma, a seroma puts pressure on the wound. This generally can be evacuated with an 18-gauge needle, he said.

A wound infection usually manifests 3–4 days after surgery and the classic signs include pain, redness, and swelling. Although gram-positive infection is most likely in dermatology, there are certain areas of the body where other infections also are likely. Pseudomonas should be considered on the ear and gram-negative infections in the groin and lower leg, Dr. Spencer said.

Contact dermatitis can mimic infection, though if the area is red and itchy, that's a clue that it could be contact dermatitis. Patients may have an allergic reaction to either the topical antibiotic or to the glue of the bandage. Remove the offending agent and put the patient on a short course of topical steroids, he said.

When there is dehiscence, there are two choices—either resuture or allow the wound to heal by second intention. "Second intention, I think, is underutilized. You can get terrific results," he said. If the wound is resutured, wash it, but don't debride the wound edges excessively.

One of the worst postsurgical complications is necrosis. If the flap or graft is blue, then blood is going in but is not getting back out. In that case, try nitroglycerin cream to increase venous return. However, if the flap or graft becomes black, adherent, and crusted, that is necrosis. The physician should do nothing and wait for it to slough on its own. Since it's not apparent how deep the necrosis goes, there could be a viable dermis underneath it. Debriding it just creates a large open wound, Dr. Spencer said.

NEW YORK—The severity of postsurgical complications can be mitigated by knowing the warning signs and best management techniques, Dr. James M. Spencer said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.

Some bruising, for example, is very common after dermatologic surgery. If it's performed in the periocular region, patients can expect to have a black eye. "This can obviously be very alarming to patients, but generally reassurance is all that's necessary," said Dr. Spencer of the department of dermatology at Mount Sinai in New York.

In the case of minor bleeding, advise patients to try direct pressure for 10–15 minutes and apply ice. If the bleeding can't be controlled easily from home, the patient will have to come back in. He advised using lidocaine alone when numbing the wound area because epinephrine causes vasoconstriction and will make it hard to recognize bleeding problems.

A hematoma puts pressure on the wound and is an excellent growth medium for bacteria. Initially, the clot will be gelatinous and generally can be easily evacuated through a small opening, but once it organizes, it will be difficult to remove. Wait 7–10 days for the clot to liquify and reabsorb, Dr. Spencer said.

Like a hematoma, a seroma puts pressure on the wound. This generally can be evacuated with an 18-gauge needle, he said.

A wound infection usually manifests 3–4 days after surgery and the classic signs include pain, redness, and swelling. Although gram-positive infection is most likely in dermatology, there are certain areas of the body where other infections also are likely. Pseudomonas should be considered on the ear and gram-negative infections in the groin and lower leg, Dr. Spencer said.

Contact dermatitis can mimic infection, though if the area is red and itchy, that's a clue that it could be contact dermatitis. Patients may have an allergic reaction to either the topical antibiotic or to the glue of the bandage. Remove the offending agent and put the patient on a short course of topical steroids, he said.

When there is dehiscence, there are two choices—either resuture or allow the wound to heal by second intention. "Second intention, I think, is underutilized. You can get terrific results," he said. If the wound is resutured, wash it, but don't debride the wound edges excessively.

One of the worst postsurgical complications is necrosis. If the flap or graft is blue, then blood is going in but is not getting back out. In that case, try nitroglycerin cream to increase venous return. However, if the flap or graft becomes black, adherent, and crusted, that is necrosis. The physician should do nothing and wait for it to slough on its own. Since it's not apparent how deep the necrosis goes, there could be a viable dermis underneath it. Debriding it just creates a large open wound, Dr. Spencer said.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS—Ablative fractional resurfacing shows promise for skin resurfacing and tightening, according to the first studies conducted on use of the technology.

Considered a more intense treatment than nonablative fractional devices, the ablative fractional laser could hypothetically mitigate the risks that are traditionally associated with ablative laser resurfacing.

"Will this ablative resurfacing really be the middle ground?" Dr. Zakia Rahman asked at an international symposium on cosmetic and laser surgery.

Nonablative fractional resurfacing devices such as Fraxel were developed to produce results similar to those of ablative laser resurfacing with less downtime for patients. With ablative fractional resurfacing, there is more downtime, although it is still less than with ablative laser treatments, noted Dr. Rahman, who is with Stanford (Calif.) University.

Initial ex vivo studies of ablative fractional resurfacing on human skin revealed the degree of skin tightening possible at different energy settings: 20 mJ produced 10% area shrinkage, 32 mJ produced 18% shrinkage, and 40 mJ yielded 23% shrinkage.

"This is really significant to me," Dr. Rahman said. At a high energy setting, 90 mJ, there was a reproducible 37% area shrinkage in the excised human tissue, she added.

Compared with nonablative devices, ablative fractional resurfacing devices increase depth of penetration. The width of the thermal treatment zones increases as the energy of the laser treatment increases. Histologic slides show annular coagulation of dermal collagen and treatment zones that get smaller as they go deeper, Dr. Rahman said.

Results might be comparable to ablative laser outcomes. "At 19 mJ you definitely get immediate tightening, similar to what you would have with a CO₂ laser," Dr. Rahman said.

Dr. Rahman also treated the forearms of 24 patients with an ablative fractional laser at settings that varied from 5 mJ per microablative zone (MAZ) to 40 mJ per MAZ. Two investigators assessed results at 1 week, 1 month, and 3 months after treatment to gauge safety and efficacy.

Further assessment consisted of full face and neck treatments at settings from 5 mJ per MAZ to 20 mJ per MAZ in 30 participants. Ten of these patients were studied at Stanford as part of this multicenter investigation.

All participants in the forearm, face, and neck assessments had subjective and objective improvement of rhytides, pigmentation, and tissue laxity, Dr. Rahman said. Another patient showed significant improvement of the perioral area.

Improvements were sustained at a follow-up assessment at 3 months. Erythema resolved by this time and no adverse effects were reported. Most participants have been followed out to 6 months in this ongoing study.

The wound-healing response that was seen represents a significant improvement over traditional ablative resurfacing, said Dr. Rahman, who is a consultant for Reliant Technologies Inc., developer of the device.

In response to a meeting attendee's question about the next step in development, Dr. Rahman said, "We are going to [a] higher energy setting now, 30 mJ, to see if we can get sustained and greater results."

LAS VEGAS—Ablative fractional resurfacing shows promise for skin resurfacing and tightening, according to the first studies conducted on use of the technology.

Considered a more intense treatment than nonablative fractional devices, the ablative fractional laser could hypothetically mitigate the risks that are traditionally associated with ablative laser resurfacing.

"Will this ablative resurfacing really be the middle ground?" Dr. Zakia Rahman asked at an international symposium on cosmetic and laser surgery.

Nonablative fractional resurfacing devices such as Fraxel were developed to produce results similar to those of ablative laser resurfacing with less downtime for patients. With ablative fractional resurfacing, there is more downtime, although it is still less than with ablative laser treatments, noted Dr. Rahman, who is with Stanford (Calif.) University.

Initial ex vivo studies of ablative fractional resurfacing on human skin revealed the degree of skin tightening possible at different energy settings: 20 mJ produced 10% area shrinkage, 32 mJ produced 18% shrinkage, and 40 mJ yielded 23% shrinkage.

"This is really significant to me," Dr. Rahman said. At a high energy setting, 90 mJ, there was a reproducible 37% area shrinkage in the excised human tissue, she added.

Compared with nonablative devices, ablative fractional resurfacing devices increase depth of penetration. The width of the thermal treatment zones increases as the energy of the laser treatment increases. Histologic slides show annular coagulation of dermal collagen and treatment zones that get smaller as they go deeper, Dr. Rahman said.

Results might be comparable to ablative laser outcomes. "At 19 mJ you definitely get immediate tightening, similar to what you would have with a CO₂ laser," Dr. Rahman said.

Dr. Rahman also treated the forearms of 24 patients with an ablative fractional laser at settings that varied from 5 mJ per microablative zone (MAZ) to 40 mJ per MAZ. Two investigators assessed results at 1 week, 1 month, and 3 months after treatment to gauge safety and efficacy.

Further assessment consisted of full face and neck treatments at settings from 5 mJ per MAZ to 20 mJ per MAZ in 30 participants. Ten of these patients were studied at Stanford as part of this multicenter investigation.

All participants in the forearm, face, and neck assessments had subjective and objective improvement of rhytides, pigmentation, and tissue laxity, Dr. Rahman said. Another patient showed significant improvement of the perioral area.

Improvements were sustained at a follow-up assessment at 3 months. Erythema resolved by this time and no adverse effects were reported. Most participants have been followed out to 6 months in this ongoing study.

The wound-healing response that was seen represents a significant improvement over traditional ablative resurfacing, said Dr. Rahman, who is a consultant for Reliant Technologies Inc., developer of the device.

In response to a meeting attendee's question about the next step in development, Dr. Rahman said, "We are going to [a] higher energy setting now, 30 mJ, to see if we can get sustained and greater results."

LAS VEGAS—Ablative fractional resurfacing shows promise for skin resurfacing and tightening, according to the first studies conducted on use of the technology.

Considered a more intense treatment than nonablative fractional devices, the ablative fractional laser could hypothetically mitigate the risks that are traditionally associated with ablative laser resurfacing.

"Will this ablative resurfacing really be the middle ground?" Dr. Zakia Rahman asked at an international symposium on cosmetic and laser surgery.

Nonablative fractional resurfacing devices such as Fraxel were developed to produce results similar to those of ablative laser resurfacing with less downtime for patients. With ablative fractional resurfacing, there is more downtime, although it is still less than with ablative laser treatments, noted Dr. Rahman, who is with Stanford (Calif.) University.

Initial ex vivo studies of ablative fractional resurfacing on human skin revealed the degree of skin tightening possible at different energy settings: 20 mJ produced 10% area shrinkage, 32 mJ produced 18% shrinkage, and 40 mJ yielded 23% shrinkage.

"This is really significant to me," Dr. Rahman said. At a high energy setting, 90 mJ, there was a reproducible 37% area shrinkage in the excised human tissue, she added.

Compared with nonablative devices, ablative fractional resurfacing devices increase depth of penetration. The width of the thermal treatment zones increases as the energy of the laser treatment increases. Histologic slides show annular coagulation of dermal collagen and treatment zones that get smaller as they go deeper, Dr. Rahman said.

Results might be comparable to ablative laser outcomes. "At 19 mJ you definitely get immediate tightening, similar to what you would have with a CO₂ laser," Dr. Rahman said.

Dr. Rahman also treated the forearms of 24 patients with an ablative fractional laser at settings that varied from 5 mJ per microablative zone (MAZ) to 40 mJ per MAZ. Two investigators assessed results at 1 week, 1 month, and 3 months after treatment to gauge safety and efficacy.

Further assessment consisted of full face and neck treatments at settings from 5 mJ per MAZ to 20 mJ per MAZ in 30 participants. Ten of these patients were studied at Stanford as part of this multicenter investigation.

All participants in the forearm, face, and neck assessments had subjective and objective improvement of rhytides, pigmentation, and tissue laxity, Dr. Rahman said. Another patient showed significant improvement of the perioral area.

Improvements were sustained at a follow-up assessment at 3 months. Erythema resolved by this time and no adverse effects were reported. Most participants have been followed out to 6 months in this ongoing study.

The wound-healing response that was seen represents a significant improvement over traditional ablative resurfacing, said Dr. Rahman, who is a consultant for Reliant Technologies Inc., developer of the device.

In response to a meeting attendee's question about the next step in development, Dr. Rahman said, "We are going to [a] higher energy setting now, 30 mJ, to see if we can get sustained and greater results."

TORONTO—Available data suggest that light-emitting diode devices are of questionable utility for skin rejuvenation, Dr. Ranella Hirsch said at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

Light-emitting diode (LED) photomodulation devices use nonablative technology—low-intensity light therapy—to nonthermally modulate the activity of living cells, said Dr. Hirsch, who is in private practice in Cambridge, Mass. The devices are used primarily to treat wrinkles, hyperpigmentation, redness, roughness, and pore size, she said.

The most prevalent unit, which has been approved by the Food and Drug Administration, is the GentleWaves LED photomodulation device from Light BioScience.

There is histologic evidence that LED devices stimulate collagen growth and do so without harming the skin's surface, but most of that data have been generated by Light BioScience or investigators with close ties to that manufacturer or other LED makers, Dr. Hirsch said.

The company also submitted data to the FDA that showed some potential clinical benefit after eight patient visits, she said.

LEDs offer an advantage over higher-powered lasers in that they can treat larger areas with lower energy.

It's not certain, however, that there is no benefit at all. Some studies have indicated that LED technology may be useful for wound healing. A literature review published in 2005 found some studies showing improvements in surgical wound healing with low-level laser therapy, but those studies involved a rodent model and would need to be duplicated in pigs and then humans, the authors said (Dermatol. Surg. 2005;31:334–40).

The technology appears to be safe, said Dr. Hirsch, but is "by no definition a home run. I would put it in the same basket as microdermabrasion—by and large, there is no huge benefit, but there is no harm."

Dr. Hirsch expressed other doubts about the technology, including the fact that a physician is not required to administer the therapy. Patients generally sit in front of the units for 10–15 minutes, once a week, for 8–10 weeks.

Dr. Hirsch is a clinical investigator for Candela Corp., Palomar, Cynosure, and Hoya ConBio.

TORONTO—Available data suggest that light-emitting diode devices are of questionable utility for skin rejuvenation, Dr. Ranella Hirsch said at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

Light-emitting diode (LED) photomodulation devices use nonablative technology—low-intensity light therapy—to nonthermally modulate the activity of living cells, said Dr. Hirsch, who is in private practice in Cambridge, Mass. The devices are used primarily to treat wrinkles, hyperpigmentation, redness, roughness, and pore size, she said.

The most prevalent unit, which has been approved by the Food and Drug Administration, is the GentleWaves LED photomodulation device from Light BioScience.

There is histologic evidence that LED devices stimulate collagen growth and do so without harming the skin's surface, but most of that data have been generated by Light BioScience or investigators with close ties to that manufacturer or other LED makers, Dr. Hirsch said.

The company also submitted data to the FDA that showed some potential clinical benefit after eight patient visits, she said.

LEDs offer an advantage over higher-powered lasers in that they can treat larger areas with lower energy.

It's not certain, however, that there is no benefit at all. Some studies have indicated that LED technology may be useful for wound healing. A literature review published in 2005 found some studies showing improvements in surgical wound healing with low-level laser therapy, but those studies involved a rodent model and would need to be duplicated in pigs and then humans, the authors said (Dermatol. Surg. 2005;31:334–40).

The technology appears to be safe, said Dr. Hirsch, but is "by no definition a home run. I would put it in the same basket as microdermabrasion—by and large, there is no huge benefit, but there is no harm."

Dr. Hirsch expressed other doubts about the technology, including the fact that a physician is not required to administer the therapy. Patients generally sit in front of the units for 10–15 minutes, once a week, for 8–10 weeks.

Dr. Hirsch is a clinical investigator for Candela Corp., Palomar, Cynosure, and Hoya ConBio.

TORONTO—Available data suggest that light-emitting diode devices are of questionable utility for skin rejuvenation, Dr. Ranella Hirsch said at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

Light-emitting diode (LED) photomodulation devices use nonablative technology—low-intensity light therapy—to nonthermally modulate the activity of living cells, said Dr. Hirsch, who is in private practice in Cambridge, Mass. The devices are used primarily to treat wrinkles, hyperpigmentation, redness, roughness, and pore size, she said.

The most prevalent unit, which has been approved by the Food and Drug Administration, is the GentleWaves LED photomodulation device from Light BioScience.

There is histologic evidence that LED devices stimulate collagen growth and do so without harming the skin's surface, but most of that data have been generated by Light BioScience or investigators with close ties to that manufacturer or other LED makers, Dr. Hirsch said.

The company also submitted data to the FDA that showed some potential clinical benefit after eight patient visits, she said.

LEDs offer an advantage over higher-powered lasers in that they can treat larger areas with lower energy.

It's not certain, however, that there is no benefit at all. Some studies have indicated that LED technology may be useful for wound healing. A literature review published in 2005 found some studies showing improvements in surgical wound healing with low-level laser therapy, but those studies involved a rodent model and would need to be duplicated in pigs and then humans, the authors said (Dermatol. Surg. 2005;31:334–40).

The technology appears to be safe, said Dr. Hirsch, but is "by no definition a home run. I would put it in the same basket as microdermabrasion—by and large, there is no huge benefit, but there is no harm."

Dr. Hirsch expressed other doubts about the technology, including the fact that a physician is not required to administer the therapy. Patients generally sit in front of the units for 10–15 minutes, once a week, for 8–10 weeks.

Dr. Hirsch is a clinical investigator for Candela Corp., Palomar, Cynosure, and Hoya ConBio.

PALM DESERT, CALIF.—An immunoperoxidase stain for cytokeratin 7 can be extremely helpful for reducing recurrences when performing Mohs surgery on patients with extramammary Paget's disease, Dr. John Zitelli said at the annual meeting of the American Society for Dermatologic Surgery.

"Although I don't have enough patients in the last 2 years to give you long-term follow-up, there is no doubt in my mind that this is the way to go," Dr. Zitelli said.

Without the stain, a review that included his own patients treated over a period of 20 years showed a recurrence rate of about 20%, said Dr. Zitelli, a former president of the American College of Mohs Micrographic Surgery and Cutaneous Oncology who practices in Pittsburgh.

Although all of the patients who had recurrences did well eventually, the recurrence rate probably indicates that he was missing individual Paget cells around the nests of tumor of the main lesion. The stain makes those individual cells in a frozen section easy to see without extra magnification, he said.

Cytokeratin 7 is a filament protein expressed by cancers in the epithelia.

"My kids could see it," he said of stained, individual cells in a section.

The staining technique using the cytokeratin 7 stain requires only 1 hour, so a case requiring multiple stages can be done in a single day, he added.

To remove Paget's disease using the Mohs technique, Dr. Zitelli uses the exact same method he helped develop for MART(melanoma antigen recognized by T cells)-1 staining of melanoma (Dermatol. Surg. 2004;30:403–8).

He also uses a "strip technique" in part because the lesions tend to be rather large (20–30 mm in diameter), which can make them difficult to section. With this technique, he outlines the lesion before cutting. His first stage is to take the margin around where he has marked. Once the margins are clear, he goes back and takes the central island of tissue, and all tissue is taken down to the fat.

PALM DESERT, CALIF.—An immunoperoxidase stain for cytokeratin 7 can be extremely helpful for reducing recurrences when performing Mohs surgery on patients with extramammary Paget's disease, Dr. John Zitelli said at the annual meeting of the American Society for Dermatologic Surgery.

"Although I don't have enough patients in the last 2 years to give you long-term follow-up, there is no doubt in my mind that this is the way to go," Dr. Zitelli said.

Without the stain, a review that included his own patients treated over a period of 20 years showed a recurrence rate of about 20%, said Dr. Zitelli, a former president of the American College of Mohs Micrographic Surgery and Cutaneous Oncology who practices in Pittsburgh.

Although all of the patients who had recurrences did well eventually, the recurrence rate probably indicates that he was missing individual Paget cells around the nests of tumor of the main lesion. The stain makes those individual cells in a frozen section easy to see without extra magnification, he said.

Cytokeratin 7 is a filament protein expressed by cancers in the epithelia.

"My kids could see it," he said of stained, individual cells in a section.

The staining technique using the cytokeratin 7 stain requires only 1 hour, so a case requiring multiple stages can be done in a single day, he added.

To remove Paget's disease using the Mohs technique, Dr. Zitelli uses the exact same method he helped develop for MART(melanoma antigen recognized by T cells)-1 staining of melanoma (Dermatol. Surg. 2004;30:403–8).

He also uses a "strip technique" in part because the lesions tend to be rather large (20–30 mm in diameter), which can make them difficult to section. With this technique, he outlines the lesion before cutting. His first stage is to take the margin around where he has marked. Once the margins are clear, he goes back and takes the central island of tissue, and all tissue is taken down to the fat.

PALM DESERT, CALIF.—An immunoperoxidase stain for cytokeratin 7 can be extremely helpful for reducing recurrences when performing Mohs surgery on patients with extramammary Paget's disease, Dr. John Zitelli said at the annual meeting of the American Society for Dermatologic Surgery.

"Although I don't have enough patients in the last 2 years to give you long-term follow-up, there is no doubt in my mind that this is the way to go," Dr. Zitelli said.

Without the stain, a review that included his own patients treated over a period of 20 years showed a recurrence rate of about 20%, said Dr. Zitelli, a former president of the American College of Mohs Micrographic Surgery and Cutaneous Oncology who practices in Pittsburgh.

Although all of the patients who had recurrences did well eventually, the recurrence rate probably indicates that he was missing individual Paget cells around the nests of tumor of the main lesion. The stain makes those individual cells in a frozen section easy to see without extra magnification, he said.

Cytokeratin 7 is a filament protein expressed by cancers in the epithelia.

"My kids could see it," he said of stained, individual cells in a section.

The staining technique using the cytokeratin 7 stain requires only 1 hour, so a case requiring multiple stages can be done in a single day, he added.

To remove Paget's disease using the Mohs technique, Dr. Zitelli uses the exact same method he helped develop for MART(melanoma antigen recognized by T cells)-1 staining of melanoma (Dermatol. Surg. 2004;30:403–8).

He also uses a "strip technique" in part because the lesions tend to be rather large (20–30 mm in diameter), which can make them difficult to section. With this technique, he outlines the lesion before cutting. His first stage is to take the margin around where he has marked. Once the margins are clear, he goes back and takes the central island of tissue, and all tissue is taken down to the fat.

SAN DIEGO—Dr. Daniel Siegel applies the zinc chloride paste developed by Dr. Frederic E. Mohs to melanomas the day before he removes them as a kind of insurance policy to reduce the risk of recurrence.

"The paste is wonderful stuff," Dr. Siegel said at a course on Mohs surgery during a meeting sponsored by the American Society for Mohs Surgery.

The paste is not commercially available, but it can be compounded by a pharmacy. Dr. Mohs himself eventually abandoned its use in favor of the fresh tissue technique in the 1950s. In addition to zinc chloride, the paste contains bloodroot (Sanguinaria canadensis) and stibnite, and a little bit lasts a long time. A single jar has lasted about 10 years, he said.

It has not been possible to get a clinical trial of the paste organized because there is no commercial interest, but there is some evidence to suggest its efficacy, said Dr. Siegel, a dermatologist practicing in Smithtown, N.Y.

Dr. Mohs reported better 5-year survival rates for melanoma than are usually reported, even better than those reported by Dr. Wallace H. Clark, originator of the Clark's levels of invasion. He reported 5-year survival of 57% for melanoma patients with a Clark's level III tumor, but Dr. Mohs reported 92%, Dr. Siegel said.

In an experiment with mice that Dr. Siegel was involved in, the investigators reported a markedly positive effect when mice were treated with the paste and then injected with melanoma cells. The mice had melanomas treated with the zinc oxide paste then removed 24 hours later. A second group of mice simply had melanomas excised. Then all the mice were injected in a second site with melanoma cells. Melanomas developed at the challenge site in 69% of the mice treated with excision only, but just 32% of the mice treated with paste (Dermatol. Surg. 1998;24:1021–5). The researchers concluded that the paste was enhancing some kind of immune response.

When Dr. Siegel uses the paste in his practice, he said he is careful to fully inform patients that the treatment is not proven. He also lets them know it is very uncomfortable, and he often uses anesthetic.

Dr. Siegel applies a 50% trichloroacetic acid solution to the lesion before applying the paste, which is painful. Patients often come in the next day complaining that they have a temperature and that their lymph nodes are sore. He then does a wide excision despite the paste, he said.

It is important to warn patients not to touch the lesion and get the paste in an eye. "You have to be very careful and fearful," he said. "Paste can be dangerous."

Despite that, it may be advantageous to use the paste for patients who may be infectious, such as those who are HIV positive, because it probably minimizes infectious agent "splatter," he added.

Most importantly, there is no reason to believe that the use of the paste may be harmful, since the tumor is being removed anyway, Dr. Siegel said.

In fact, he is not the only Mohs surgeon who uses the paste for melanoma cases.

Dr. Kenneth Gross of San Diego, one of the organizers of the Mohs course, said that he has used it for patients who are having a sentinel node procedure.

"Do I know this is helping? I absolutely do not. [But] we are killing and immobilizing cells and I don't see how that could be any problem," he said.

SAN DIEGO—Dr. Daniel Siegel applies the zinc chloride paste developed by Dr. Frederic E. Mohs to melanomas the day before he removes them as a kind of insurance policy to reduce the risk of recurrence.

"The paste is wonderful stuff," Dr. Siegel said at a course on Mohs surgery during a meeting sponsored by the American Society for Mohs Surgery.

The paste is not commercially available, but it can be compounded by a pharmacy. Dr. Mohs himself eventually abandoned its use in favor of the fresh tissue technique in the 1950s. In addition to zinc chloride, the paste contains bloodroot (Sanguinaria canadensis) and stibnite, and a little bit lasts a long time. A single jar has lasted about 10 years, he said.

It has not been possible to get a clinical trial of the paste organized because there is no commercial interest, but there is some evidence to suggest its efficacy, said Dr. Siegel, a dermatologist practicing in Smithtown, N.Y.

Dr. Mohs reported better 5-year survival rates for melanoma than are usually reported, even better than those reported by Dr. Wallace H. Clark, originator of the Clark's levels of invasion. He reported 5-year survival of 57% for melanoma patients with a Clark's level III tumor, but Dr. Mohs reported 92%, Dr. Siegel said.

In an experiment with mice that Dr. Siegel was involved in, the investigators reported a markedly positive effect when mice were treated with the paste and then injected with melanoma cells. The mice had melanomas treated with the zinc oxide paste then removed 24 hours later. A second group of mice simply had melanomas excised. Then all the mice were injected in a second site with melanoma cells. Melanomas developed at the challenge site in 69% of the mice treated with excision only, but just 32% of the mice treated with paste (Dermatol. Surg. 1998;24:1021–5). The researchers concluded that the paste was enhancing some kind of immune response.

When Dr. Siegel uses the paste in his practice, he said he is careful to fully inform patients that the treatment is not proven. He also lets them know it is very uncomfortable, and he often uses anesthetic.

Dr. Siegel applies a 50% trichloroacetic acid solution to the lesion before applying the paste, which is painful. Patients often come in the next day complaining that they have a temperature and that their lymph nodes are sore. He then does a wide excision despite the paste, he said.

It is important to warn patients not to touch the lesion and get the paste in an eye. "You have to be very careful and fearful," he said. "Paste can be dangerous."

Despite that, it may be advantageous to use the paste for patients who may be infectious, such as those who are HIV positive, because it probably minimizes infectious agent "splatter," he added.

Most importantly, there is no reason to believe that the use of the paste may be harmful, since the tumor is being removed anyway, Dr. Siegel said.

In fact, he is not the only Mohs surgeon who uses the paste for melanoma cases.

Dr. Kenneth Gross of San Diego, one of the organizers of the Mohs course, said that he has used it for patients who are having a sentinel node procedure.

"Do I know this is helping? I absolutely do not. [But] we are killing and immobilizing cells and I don't see how that could be any problem," he said.

SAN DIEGO—Dr. Daniel Siegel applies the zinc chloride paste developed by Dr. Frederic E. Mohs to melanomas the day before he removes them as a kind of insurance policy to reduce the risk of recurrence.

"The paste is wonderful stuff," Dr. Siegel said at a course on Mohs surgery during a meeting sponsored by the American Society for Mohs Surgery.

The paste is not commercially available, but it can be compounded by a pharmacy. Dr. Mohs himself eventually abandoned its use in favor of the fresh tissue technique in the 1950s. In addition to zinc chloride, the paste contains bloodroot (Sanguinaria canadensis) and stibnite, and a little bit lasts a long time. A single jar has lasted about 10 years, he said.

It has not been possible to get a clinical trial of the paste organized because there is no commercial interest, but there is some evidence to suggest its efficacy, said Dr. Siegel, a dermatologist practicing in Smithtown, N.Y.

Dr. Mohs reported better 5-year survival rates for melanoma than are usually reported, even better than those reported by Dr. Wallace H. Clark, originator of the Clark's levels of invasion. He reported 5-year survival of 57% for melanoma patients with a Clark's level III tumor, but Dr. Mohs reported 92%, Dr. Siegel said.

In an experiment with mice that Dr. Siegel was involved in, the investigators reported a markedly positive effect when mice were treated with the paste and then injected with melanoma cells. The mice had melanomas treated with the zinc oxide paste then removed 24 hours later. A second group of mice simply had melanomas excised. Then all the mice were injected in a second site with melanoma cells. Melanomas developed at the challenge site in 69% of the mice treated with excision only, but just 32% of the mice treated with paste (Dermatol. Surg. 1998;24:1021–5). The researchers concluded that the paste was enhancing some kind of immune response.

When Dr. Siegel uses the paste in his practice, he said he is careful to fully inform patients that the treatment is not proven. He also lets them know it is very uncomfortable, and he often uses anesthetic.

Dr. Siegel applies a 50% trichloroacetic acid solution to the lesion before applying the paste, which is painful. Patients often come in the next day complaining that they have a temperature and that their lymph nodes are sore. He then does a wide excision despite the paste, he said.

It is important to warn patients not to touch the lesion and get the paste in an eye. "You have to be very careful and fearful," he said. "Paste can be dangerous."

Despite that, it may be advantageous to use the paste for patients who may be infectious, such as those who are HIV positive, because it probably minimizes infectious agent "splatter," he added.

Most importantly, there is no reason to believe that the use of the paste may be harmful, since the tumor is being removed anyway, Dr. Siegel said.

In fact, he is not the only Mohs surgeon who uses the paste for melanoma cases.

Dr. Kenneth Gross of San Diego, one of the organizers of the Mohs course, said that he has used it for patients who are having a sentinel node procedure.

"Do I know this is helping? I absolutely do not. [But] we are killing and immobilizing cells and I don't see how that could be any problem," he said.

PALM DESERT, CALIF.—Use of the "nested" M-plasty technique makes it possible to further shorten round wounds when closing Mohs defects, Dr. Ravi Krishnan said at the annual meeting of the American Society for Dermatologic Surgery.

The technique involves making two Ms, instead of one, in the M portion of the closure. Dr. Krishnan, director of dermatologic surgery at Indiana University, Indianapolis, said he uses a No. 11 blade to remove the Burow's triangles because that blade gives better precision.

"The M portion closes as a broken line, which, as we know, is less noticeable than a straight line," he said.

Dr. Krishnan said he uses the technique primarily when he does not want the closure excisions to extend into an adjacent cosmetic unit, or when he does not want to interrupt a structure such as the eyebrow or the nose.

Dr. Krishnan said he did not know whether his technique was unique, but it has not been described in the dermatology literature.

"It is extremely easy to execute and involves cutting out less skin," Dr. Krishnan added.

PALM DESERT, CALIF.—Use of the "nested" M-plasty technique makes it possible to further shorten round wounds when closing Mohs defects, Dr. Ravi Krishnan said at the annual meeting of the American Society for Dermatologic Surgery.

The technique involves making two Ms, instead of one, in the M portion of the closure. Dr. Krishnan, director of dermatologic surgery at Indiana University, Indianapolis, said he uses a No. 11 blade to remove the Burow's triangles because that blade gives better precision.

"The M portion closes as a broken line, which, as we know, is less noticeable than a straight line," he said.

Dr. Krishnan said he uses the technique primarily when he does not want the closure excisions to extend into an adjacent cosmetic unit, or when he does not want to interrupt a structure such as the eyebrow or the nose.

Dr. Krishnan said he did not know whether his technique was unique, but it has not been described in the dermatology literature.

"It is extremely easy to execute and involves cutting out less skin," Dr. Krishnan added.

PALM DESERT, CALIF.—Use of the "nested" M-plasty technique makes it possible to further shorten round wounds when closing Mohs defects, Dr. Ravi Krishnan said at the annual meeting of the American Society for Dermatologic Surgery.

The technique involves making two Ms, instead of one, in the M portion of the closure. Dr. Krishnan, director of dermatologic surgery at Indiana University, Indianapolis, said he uses a No. 11 blade to remove the Burow's triangles because that blade gives better precision.

"The M portion closes as a broken line, which, as we know, is less noticeable than a straight line," he said.

Dr. Krishnan said he uses the technique primarily when he does not want the closure excisions to extend into an adjacent cosmetic unit, or when he does not want to interrupt a structure such as the eyebrow or the nose.

Dr. Krishnan said he did not know whether his technique was unique, but it has not been described in the dermatology literature.

"It is extremely easy to execute and involves cutting out less skin," Dr. Krishnan added.

NEW YORK—Every dermatologist should be able to perform excisional surgery and leave only a fine line scar on the patient's face, Dr. C. William Hanke said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.

Dermatologists who are not able to leave only a fine line scar are falling behind some of the family physicians who are doing excisional surgery, he said. And a scar that is long and noticeable is poor marketing for the physician.

Dr. Hanke, a dermatologic surgeon in Carmel, Ind., who founded the Mohs Micrographic Surgery Unit at Indiana University, Indianapolis, offered several techniques for achieving superior results with excisional surgery.

Make incisions in normal anatomic boundary lines or relaxed skin tension lines to hide scars. "That's where you want your scars to be so that they don't look like scars," he said.

Handle tissue atraumatically by avoiding touching the skin surface with forceps; instead, grab tissue from the bottom.

Make scars as short as possible. A scar longer than 2 cm will be much more noticeable than will shorter scars. By using an M-plasty, the incision can be shortened by about a third.

Don't bury unnecessary suture material. Tying the appropriate number of knots on buried sutures allows you to keep the amount of buried foreign material to a minimum. "The wound doesn't have to work as hard to heal with that smaller volume of foreign material," he said.

Use fine-caliber suture material to reduce trauma and choose simple closures over complex ones. "If you do a complex closure in a case where you could have done a simple closure and there's a complication, you've got a big complication."

Undermine appropriately to relieve wound tension and facilitate wound-edge eversion. Some dermatologists do a lot of unnecessary undermining and others never do it, but the right balance is likely somewhere in between, he said.

Use appropriate methods of hemostasis. Dr. Hanke said he does some suture ligature and uses a lot of electrocoagulation. Electrocautery is needed sometimes for patients with pacemakers. Pressure also is important, he said.

Use "tie-over" sutures to relieve tension and don't tie sutures tightly. Doing so can result in strangulated tissue that won't be evident until suture removal.

Be a student of dog-ear repair and close wounds rapidly. The medical literature shows that wounds that stay open for more than an hour or 2 have a higher rate of infection.

NEW YORK—Every dermatologist should be able to perform excisional surgery and leave only a fine line scar on the patient's face, Dr. C. William Hanke said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.

Dermatologists who are not able to leave only a fine line scar are falling behind some of the family physicians who are doing excisional surgery, he said. And a scar that is long and noticeable is poor marketing for the physician.

Dr. Hanke, a dermatologic surgeon in Carmel, Ind., who founded the Mohs Micrographic Surgery Unit at Indiana University, Indianapolis, offered several techniques for achieving superior results with excisional surgery.

Make incisions in normal anatomic boundary lines or relaxed skin tension lines to hide scars. "That's where you want your scars to be so that they don't look like scars," he said.

Handle tissue atraumatically by avoiding touching the skin surface with forceps; instead, grab tissue from the bottom.

Make scars as short as possible. A scar longer than 2 cm will be much more noticeable than will shorter scars. By using an M-plasty, the incision can be shortened by about a third.

Don't bury unnecessary suture material. Tying the appropriate number of knots on buried sutures allows you to keep the amount of buried foreign material to a minimum. "The wound doesn't have to work as hard to heal with that smaller volume of foreign material," he said.

Use fine-caliber suture material to reduce trauma and choose simple closures over complex ones. "If you do a complex closure in a case where you could have done a simple closure and there's a complication, you've got a big complication."

Undermine appropriately to relieve wound tension and facilitate wound-edge eversion. Some dermatologists do a lot of unnecessary undermining and others never do it, but the right balance is likely somewhere in between, he said.

Use appropriate methods of hemostasis. Dr. Hanke said he does some suture ligature and uses a lot of electrocoagulation. Electrocautery is needed sometimes for patients with pacemakers. Pressure also is important, he said.

Use "tie-over" sutures to relieve tension and don't tie sutures tightly. Doing so can result in strangulated tissue that won't be evident until suture removal.

Be a student of dog-ear repair and close wounds rapidly. The medical literature shows that wounds that stay open for more than an hour or 2 have a higher rate of infection.

NEW YORK—Every dermatologist should be able to perform excisional surgery and leave only a fine line scar on the patient's face, Dr. C. William Hanke said at a meeting on medical and surgical dermatology sponsored by Mount Sinai School of Medicine.

Dermatologists who are not able to leave only a fine line scar are falling behind some of the family physicians who are doing excisional surgery, he said. And a scar that is long and noticeable is poor marketing for the physician.

Dr. Hanke, a dermatologic surgeon in Carmel, Ind., who founded the Mohs Micrographic Surgery Unit at Indiana University, Indianapolis, offered several techniques for achieving superior results with excisional surgery.

Make incisions in normal anatomic boundary lines or relaxed skin tension lines to hide scars. "That's where you want your scars to be so that they don't look like scars," he said.

Handle tissue atraumatically by avoiding touching the skin surface with forceps; instead, grab tissue from the bottom.

Make scars as short as possible. A scar longer than 2 cm will be much more noticeable than will shorter scars. By using an M-plasty, the incision can be shortened by about a third.

Don't bury unnecessary suture material. Tying the appropriate number of knots on buried sutures allows you to keep the amount of buried foreign material to a minimum. "The wound doesn't have to work as hard to heal with that smaller volume of foreign material," he said.

Use fine-caliber suture material to reduce trauma and choose simple closures over complex ones. "If you do a complex closure in a case where you could have done a simple closure and there's a complication, you've got a big complication."

Undermine appropriately to relieve wound tension and facilitate wound-edge eversion. Some dermatologists do a lot of unnecessary undermining and others never do it, but the right balance is likely somewhere in between, he said.

Use appropriate methods of hemostasis. Dr. Hanke said he does some suture ligature and uses a lot of electrocoagulation. Electrocautery is needed sometimes for patients with pacemakers. Pressure also is important, he said.

Use "tie-over" sutures to relieve tension and don't tie sutures tightly. Doing so can result in strangulated tissue that won't be evident until suture removal.

Be a student of dog-ear repair and close wounds rapidly. The medical literature shows that wounds that stay open for more than an hour or 2 have a higher rate of infection.