Aesthetic Dermatology

WILLIAMSBURG, VA. — Creating the perfect lip may mean telling a patient to step away from the fillers, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

Following a procedure to increase lip fullness, most patients will want more filler injected. Dr. Mandy tells his patients that if they think they need more, they can come back to him but if he thinks they've had enough, he won't do any additional lip injections. "I just don't want duck lips walking around with my signature on them," he said.

He offered several other tips to create the perfect lip. First, it's important to recognize that there are significant differences in lip shape and size between the races. Even within a racial group, there can be substantial variation. "Look at the patient's lip before you start," said Dr. Mandy, professor of dermatology at the University of Miami.

Be sure to show patients their natural lip asymmetries, if they have any. "If they don't get shown it before hand, they're going to blame it on you," he said.

Sharp definition of the lip margin is critical, so avoid injecting hyaluronic acid there since it blunts or rounds the lip margin. Instead, use collagen injection such as Zyplast or CosmoPlast.

Dr. Mandy uses hyaluronic acid to add fullness to the body of the lip. "If you look at the lip, there is fullness in the lateral portions of the upper lip on each side," he said. These two sites, along with the central tubercle of the top lip and the two medial lower lip protuberances, make up the five sites for hyaluronic acid injection.

Dr. Mandy uses a 0.4-cc syringe. For the lateral portions of the upper lip he injects 0.05 cc on each side. At the central tubercle and at both medial lower lip protuberances, he injects 0.1 cc. Inject along the wet/dry line of the lips in the submucosa to get "a much more natural-looking lip," he said.

In the aging lip, dermatologists may also have to contend with rhytids, volume reduction, elastosis, excess facial hair, and dyspigmentation. For rhytids, he uses botulinum toxin type A in 4–6 injections (1 U total) across the upper lip and about 2 U on the bottom lip. He also uses CosmoDerm to fill rhytids around the lips. He often uses resurfacing as well.

Dr. Mandy disclosed that he has received funding and is a consultant for Surgical Specialties Corp. and Sanofi-Aventis. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

WILLIAMSBURG, VA. — Creating the perfect lip may mean telling a patient to step away from the fillers, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

Following a procedure to increase lip fullness, most patients will want more filler injected. Dr. Mandy tells his patients that if they think they need more, they can come back to him but if he thinks they've had enough, he won't do any additional lip injections. "I just don't want duck lips walking around with my signature on them," he said.

He offered several other tips to create the perfect lip. First, it's important to recognize that there are significant differences in lip shape and size between the races. Even within a racial group, there can be substantial variation. "Look at the patient's lip before you start," said Dr. Mandy, professor of dermatology at the University of Miami.

Be sure to show patients their natural lip asymmetries, if they have any. "If they don't get shown it before hand, they're going to blame it on you," he said.

Sharp definition of the lip margin is critical, so avoid injecting hyaluronic acid there since it blunts or rounds the lip margin. Instead, use collagen injection such as Zyplast or CosmoPlast.

Dr. Mandy uses hyaluronic acid to add fullness to the body of the lip. "If you look at the lip, there is fullness in the lateral portions of the upper lip on each side," he said. These two sites, along with the central tubercle of the top lip and the two medial lower lip protuberances, make up the five sites for hyaluronic acid injection.

Dr. Mandy uses a 0.4-cc syringe. For the lateral portions of the upper lip he injects 0.05 cc on each side. At the central tubercle and at both medial lower lip protuberances, he injects 0.1 cc. Inject along the wet/dry line of the lips in the submucosa to get "a much more natural-looking lip," he said.

In the aging lip, dermatologists may also have to contend with rhytids, volume reduction, elastosis, excess facial hair, and dyspigmentation. For rhytids, he uses botulinum toxin type A in 4–6 injections (1 U total) across the upper lip and about 2 U on the bottom lip. He also uses CosmoDerm to fill rhytids around the lips. He often uses resurfacing as well.

Dr. Mandy disclosed that he has received funding and is a consultant for Surgical Specialties Corp. and Sanofi-Aventis. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

WILLIAMSBURG, VA. — Creating the perfect lip may mean telling a patient to step away from the fillers, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

Following a procedure to increase lip fullness, most patients will want more filler injected. Dr. Mandy tells his patients that if they think they need more, they can come back to him but if he thinks they've had enough, he won't do any additional lip injections. "I just don't want duck lips walking around with my signature on them," he said.

He offered several other tips to create the perfect lip. First, it's important to recognize that there are significant differences in lip shape and size between the races. Even within a racial group, there can be substantial variation. "Look at the patient's lip before you start," said Dr. Mandy, professor of dermatology at the University of Miami.

Be sure to show patients their natural lip asymmetries, if they have any. "If they don't get shown it before hand, they're going to blame it on you," he said.

Sharp definition of the lip margin is critical, so avoid injecting hyaluronic acid there since it blunts or rounds the lip margin. Instead, use collagen injection such as Zyplast or CosmoPlast.

Dr. Mandy uses hyaluronic acid to add fullness to the body of the lip. "If you look at the lip, there is fullness in the lateral portions of the upper lip on each side," he said. These two sites, along with the central tubercle of the top lip and the two medial lower lip protuberances, make up the five sites for hyaluronic acid injection.

Dr. Mandy uses a 0.4-cc syringe. For the lateral portions of the upper lip he injects 0.05 cc on each side. At the central tubercle and at both medial lower lip protuberances, he injects 0.1 cc. Inject along the wet/dry line of the lips in the submucosa to get "a much more natural-looking lip," he said.

In the aging lip, dermatologists may also have to contend with rhytids, volume reduction, elastosis, excess facial hair, and dyspigmentation. For rhytids, he uses botulinum toxin type A in 4–6 injections (1 U total) across the upper lip and about 2 U on the bottom lip. He also uses CosmoDerm to fill rhytids around the lips. He often uses resurfacing as well.

Dr. Mandy disclosed that he has received funding and is a consultant for Surgical Specialties Corp. and Sanofi-Aventis. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

RHODES, GREECE — Botulinum toxin type A is a safe and effective treatment for crow's feet at doses of 15, 30, and 45 U per eye, Dr. Benjamin Ascher said in a poster presented at the 15th Congress of the European Academy of Dermatology and Venereology.

The 15-U dose appears to be an appropriate starting point for treatment in younger subjects, while the higher doses appear to provide greater benefit in older patients, said Dr. Ascher of the Hospital of St. Cloud, Paris.

A total of 220 adults aged 18–65 years were enrolled in the randomized, multicenter, double-blind, placebo-controlled dose-ranging study of botulinum toxin type A, which is available in Europe as Dysport and is currently in clinical trials under the name Reloxin in the United States. The subjects, who had moderate or severe crow's feet at maximum smile and mild to severe crow's feet at rest, were treated with placebo or 15, 30, or 45 U per eye. Efficacy and safety were evaluated at 2, 4, 8, 12, 16, 20, and 24 weeks following injection.

For all three doses of Dysport, compared with placebo, a highly significant difference in apparent severity of crow's feet at maximum smile was noted after 4 weeks, as determined by independent panel and "live" investigator assessments. At the 2- to 16-week follow-ups, the independent panel assessed the appearance of crow's feet at rest as being statistically significantly improved, compared with placebo, at the two higher doses of Dysport; live investigators assessed their appearance at rest to be significantly improved at all doses, Dr. Ascher said.

When results were considered according to age, those aged 50 years and younger were more likely than older patients to respond to all doses of Dysport. At week 2, between 9 and 12 patients (depending on dose) aged 51 and older were assessed by the independent panel as having significant improvement, compared with 17–20 subjects (depending on dose) aged 50 years and younger. In those aged 51 and older, the higher doses appeared to confer greater benefit, he said.

Patient satisfaction was good in this study, which was funded by Ipsen Ltd., the maker of Dysport.

Self-assessment of satisfaction with the change in crow's feet appearance was significantly greater with Dysport at all doses, compared with placebo, at up to 16 weeks' follow-up. The safety profile of Dysport was also good: 23 treatment-related adverse events were reported by 22 subjects, but none were serious and all resolved without sequelae.

RHODES, GREECE — Botulinum toxin type A is a safe and effective treatment for crow's feet at doses of 15, 30, and 45 U per eye, Dr. Benjamin Ascher said in a poster presented at the 15th Congress of the European Academy of Dermatology and Venereology.

The 15-U dose appears to be an appropriate starting point for treatment in younger subjects, while the higher doses appear to provide greater benefit in older patients, said Dr. Ascher of the Hospital of St. Cloud, Paris.

A total of 220 adults aged 18–65 years were enrolled in the randomized, multicenter, double-blind, placebo-controlled dose-ranging study of botulinum toxin type A, which is available in Europe as Dysport and is currently in clinical trials under the name Reloxin in the United States. The subjects, who had moderate or severe crow's feet at maximum smile and mild to severe crow's feet at rest, were treated with placebo or 15, 30, or 45 U per eye. Efficacy and safety were evaluated at 2, 4, 8, 12, 16, 20, and 24 weeks following injection.

For all three doses of Dysport, compared with placebo, a highly significant difference in apparent severity of crow's feet at maximum smile was noted after 4 weeks, as determined by independent panel and "live" investigator assessments. At the 2- to 16-week follow-ups, the independent panel assessed the appearance of crow's feet at rest as being statistically significantly improved, compared with placebo, at the two higher doses of Dysport; live investigators assessed their appearance at rest to be significantly improved at all doses, Dr. Ascher said.

When results were considered according to age, those aged 50 years and younger were more likely than older patients to respond to all doses of Dysport. At week 2, between 9 and 12 patients (depending on dose) aged 51 and older were assessed by the independent panel as having significant improvement, compared with 17–20 subjects (depending on dose) aged 50 years and younger. In those aged 51 and older, the higher doses appeared to confer greater benefit, he said.

Patient satisfaction was good in this study, which was funded by Ipsen Ltd., the maker of Dysport.

Self-assessment of satisfaction with the change in crow's feet appearance was significantly greater with Dysport at all doses, compared with placebo, at up to 16 weeks' follow-up. The safety profile of Dysport was also good: 23 treatment-related adverse events were reported by 22 subjects, but none were serious and all resolved without sequelae.

RHODES, GREECE — Botulinum toxin type A is a safe and effective treatment for crow's feet at doses of 15, 30, and 45 U per eye, Dr. Benjamin Ascher said in a poster presented at the 15th Congress of the European Academy of Dermatology and Venereology.

The 15-U dose appears to be an appropriate starting point for treatment in younger subjects, while the higher doses appear to provide greater benefit in older patients, said Dr. Ascher of the Hospital of St. Cloud, Paris.

A total of 220 adults aged 18–65 years were enrolled in the randomized, multicenter, double-blind, placebo-controlled dose-ranging study of botulinum toxin type A, which is available in Europe as Dysport and is currently in clinical trials under the name Reloxin in the United States. The subjects, who had moderate or severe crow's feet at maximum smile and mild to severe crow's feet at rest, were treated with placebo or 15, 30, or 45 U per eye. Efficacy and safety were evaluated at 2, 4, 8, 12, 16, 20, and 24 weeks following injection.

For all three doses of Dysport, compared with placebo, a highly significant difference in apparent severity of crow's feet at maximum smile was noted after 4 weeks, as determined by independent panel and "live" investigator assessments. At the 2- to 16-week follow-ups, the independent panel assessed the appearance of crow's feet at rest as being statistically significantly improved, compared with placebo, at the two higher doses of Dysport; live investigators assessed their appearance at rest to be significantly improved at all doses, Dr. Ascher said.

When results were considered according to age, those aged 50 years and younger were more likely than older patients to respond to all doses of Dysport. At week 2, between 9 and 12 patients (depending on dose) aged 51 and older were assessed by the independent panel as having significant improvement, compared with 17–20 subjects (depending on dose) aged 50 years and younger. In those aged 51 and older, the higher doses appeared to confer greater benefit, he said.

Patient satisfaction was good in this study, which was funded by Ipsen Ltd., the maker of Dysport.

Self-assessment of satisfaction with the change in crow's feet appearance was significantly greater with Dysport at all doses, compared with placebo, at up to 16 weeks' follow-up. The safety profile of Dysport was also good: 23 treatment-related adverse events were reported by 22 subjects, but none were serious and all resolved without sequelae.

LAS VEGAS — Using three light forms to hit three targets effectively tightens skin and can add facial volume without fillers, Dr. Javier Ruiz-Esparza said at an international symposium on cosmetic and laser surgery.

"This is an entirely light-based procedure without any mechanical or medical improvement to heat multiple targets in multiple layers, with three energies in succession," Dr. Ruiz-Esparza said. "We call this approach 3-D rejuvenation."

The 3-D skin rejuvenation system from Cutera (Brisbane, Calif.) targets the deep dermis with infrared light for skin tightening; mid-dermal fibroblasts, melanin, and hemoglobin with a 1064-nm Nd:YAG laser to promote new collagen formation; and superficial melanin and hemoglobin with a 560-nm intense pulsed light to treat surface dyspigmentation.

This triple combination improves natural skin quality and fine wrinkles. "You can get quick improvement in a matter of 6 weeks without downtime and without pain," said Dr. Ruiz-Esparza of the University of California, San Diego. "So far, everything we have done with Nd:YAG has been aimed at improving planar, bidimensional signs of photodamage, such as solar lentigo and telangiectasias," said Dr. Ruiz-Esparza, who is a consultant for Cutera.

Now, this system—laser and pulsed light in combination with the Titan infrared light source—can also add volume. With this approach, new collagen forms and adds uniform volume to the face and neck "never seen before with any other technology," he said.

Maximum volume effects are observed at 3 months as the healing process promotes collagen creation. Some volume augmentation for lips might be possible too, although this is a work in progress, he said.

A meeting attendee asked about the end point for the Titan treatment. "I have found the last passes are the ones that count the most," Dr. Ruiz-Esparza said. There is more tightening after initial heating of the skin. "If you quit too soon, you will not get the same results," he noted.

Stop periodically and check for contracture of the skin. "You can continue treatment until it starts to hurt the patient. You don't want to go overboard and end up with erythema and edema," Dr. Ruiz-Esparza said.

For a patient who is skeptical about Titan treatment, treat one side and have the patient sit up and look in a mirror. The benefits of treatment will become even more pronounced when the patient smiles. "You can see it in every race—the dramatic difference between the treated and untreated sides," he said.

If patients remain unconvinced, send them home with just one side treated and tell them to come back if they see a difference, he said. This approach usually works because contraction on one side will persist and be visible for days or even weeks later.

The best tightening with Titan is often seen in what Dr. Ruiz-Esparza calls "area 1"—the cheek and either side of the mouth. "If I can get contraction in area 1, I can do a lot for the patient." Area 2 is the lateral aspects of the neck. Area 3—the forehead and temples—"is the one that gives me the least reliable result," he said.

Although dermatologists are well versed in the benefits of showing patient progress with photographs, Dr. Ruiz-Esparza said there are limitations. "We should stop trying to show results with still pictures. It's a pain in the neck because you need the same lighting, room, and expression." Instead, he proposed showing results with a postoperative video taken from every angle around the patient's face. "This hides nothing," he asserted.

Photos before (left) and after the procedure show some progress. But often, a postoperative video taken from different angles can show results more clearly. Photos courtesy Dr. Javier Ruiz-Esparza

LAS VEGAS — Using three light forms to hit three targets effectively tightens skin and can add facial volume without fillers, Dr. Javier Ruiz-Esparza said at an international symposium on cosmetic and laser surgery.

"This is an entirely light-based procedure without any mechanical or medical improvement to heat multiple targets in multiple layers, with three energies in succession," Dr. Ruiz-Esparza said. "We call this approach 3-D rejuvenation."

The 3-D skin rejuvenation system from Cutera (Brisbane, Calif.) targets the deep dermis with infrared light for skin tightening; mid-dermal fibroblasts, melanin, and hemoglobin with a 1064-nm Nd:YAG laser to promote new collagen formation; and superficial melanin and hemoglobin with a 560-nm intense pulsed light to treat surface dyspigmentation.

This triple combination improves natural skin quality and fine wrinkles. "You can get quick improvement in a matter of 6 weeks without downtime and without pain," said Dr. Ruiz-Esparza of the University of California, San Diego. "So far, everything we have done with Nd:YAG has been aimed at improving planar, bidimensional signs of photodamage, such as solar lentigo and telangiectasias," said Dr. Ruiz-Esparza, who is a consultant for Cutera.

Now, this system—laser and pulsed light in combination with the Titan infrared light source—can also add volume. With this approach, new collagen forms and adds uniform volume to the face and neck "never seen before with any other technology," he said.

Maximum volume effects are observed at 3 months as the healing process promotes collagen creation. Some volume augmentation for lips might be possible too, although this is a work in progress, he said.

A meeting attendee asked about the end point for the Titan treatment. "I have found the last passes are the ones that count the most," Dr. Ruiz-Esparza said. There is more tightening after initial heating of the skin. "If you quit too soon, you will not get the same results," he noted.

Stop periodically and check for contracture of the skin. "You can continue treatment until it starts to hurt the patient. You don't want to go overboard and end up with erythema and edema," Dr. Ruiz-Esparza said.

For a patient who is skeptical about Titan treatment, treat one side and have the patient sit up and look in a mirror. The benefits of treatment will become even more pronounced when the patient smiles. "You can see it in every race—the dramatic difference between the treated and untreated sides," he said.

If patients remain unconvinced, send them home with just one side treated and tell them to come back if they see a difference, he said. This approach usually works because contraction on one side will persist and be visible for days or even weeks later.

The best tightening with Titan is often seen in what Dr. Ruiz-Esparza calls "area 1"—the cheek and either side of the mouth. "If I can get contraction in area 1, I can do a lot for the patient." Area 2 is the lateral aspects of the neck. Area 3—the forehead and temples—"is the one that gives me the least reliable result," he said.

Although dermatologists are well versed in the benefits of showing patient progress with photographs, Dr. Ruiz-Esparza said there are limitations. "We should stop trying to show results with still pictures. It's a pain in the neck because you need the same lighting, room, and expression." Instead, he proposed showing results with a postoperative video taken from every angle around the patient's face. "This hides nothing," he asserted.

Photos before (left) and after the procedure show some progress. But often, a postoperative video taken from different angles can show results more clearly. Photos courtesy Dr. Javier Ruiz-Esparza

LAS VEGAS — Using three light forms to hit three targets effectively tightens skin and can add facial volume without fillers, Dr. Javier Ruiz-Esparza said at an international symposium on cosmetic and laser surgery.

"This is an entirely light-based procedure without any mechanical or medical improvement to heat multiple targets in multiple layers, with three energies in succession," Dr. Ruiz-Esparza said. "We call this approach 3-D rejuvenation."

The 3-D skin rejuvenation system from Cutera (Brisbane, Calif.) targets the deep dermis with infrared light for skin tightening; mid-dermal fibroblasts, melanin, and hemoglobin with a 1064-nm Nd:YAG laser to promote new collagen formation; and superficial melanin and hemoglobin with a 560-nm intense pulsed light to treat surface dyspigmentation.

This triple combination improves natural skin quality and fine wrinkles. "You can get quick improvement in a matter of 6 weeks without downtime and without pain," said Dr. Ruiz-Esparza of the University of California, San Diego. "So far, everything we have done with Nd:YAG has been aimed at improving planar, bidimensional signs of photodamage, such as solar lentigo and telangiectasias," said Dr. Ruiz-Esparza, who is a consultant for Cutera.

Now, this system—laser and pulsed light in combination with the Titan infrared light source—can also add volume. With this approach, new collagen forms and adds uniform volume to the face and neck "never seen before with any other technology," he said.

Maximum volume effects are observed at 3 months as the healing process promotes collagen creation. Some volume augmentation for lips might be possible too, although this is a work in progress, he said.

A meeting attendee asked about the end point for the Titan treatment. "I have found the last passes are the ones that count the most," Dr. Ruiz-Esparza said. There is more tightening after initial heating of the skin. "If you quit too soon, you will not get the same results," he noted.

Stop periodically and check for contracture of the skin. "You can continue treatment until it starts to hurt the patient. You don't want to go overboard and end up with erythema and edema," Dr. Ruiz-Esparza said.

For a patient who is skeptical about Titan treatment, treat one side and have the patient sit up and look in a mirror. The benefits of treatment will become even more pronounced when the patient smiles. "You can see it in every race—the dramatic difference between the treated and untreated sides," he said.

If patients remain unconvinced, send them home with just one side treated and tell them to come back if they see a difference, he said. This approach usually works because contraction on one side will persist and be visible for days or even weeks later.

The best tightening with Titan is often seen in what Dr. Ruiz-Esparza calls "area 1"—the cheek and either side of the mouth. "If I can get contraction in area 1, I can do a lot for the patient." Area 2 is the lateral aspects of the neck. Area 3—the forehead and temples—"is the one that gives me the least reliable result," he said.

Although dermatologists are well versed in the benefits of showing patient progress with photographs, Dr. Ruiz-Esparza said there are limitations. "We should stop trying to show results with still pictures. It's a pain in the neck because you need the same lighting, room, and expression." Instead, he proposed showing results with a postoperative video taken from every angle around the patient's face. "This hides nothing," he asserted.

Photos before (left) and after the procedure show some progress. But often, a postoperative video taken from different angles can show results more clearly. Photos courtesy Dr. Javier Ruiz-Esparza

The Agency for Healthcare Research and Quality and the nonprofit National Business Group on Health offer "A Purchaser's Guide to Clinical Preventive Services: Moving Science Into Coverage." Developed in collaboration with the Centers for Disease Control and Prevention, the guide contains preventive services recommended by the U.S. Preventive Services Task Force and the CDC. For more information, visit www.businessgrouphealth.org/prevention/purchasers

The Agency for Healthcare Research and Quality and the nonprofit National Business Group on Health offer "A Purchaser's Guide to Clinical Preventive Services: Moving Science Into Coverage." Developed in collaboration with the Centers for Disease Control and Prevention, the guide contains preventive services recommended by the U.S. Preventive Services Task Force and the CDC. For more information, visit www.businessgrouphealth.org/prevention/purchasers

The Agency for Healthcare Research and Quality and the nonprofit National Business Group on Health offer "A Purchaser's Guide to Clinical Preventive Services: Moving Science Into Coverage." Developed in collaboration with the Centers for Disease Control and Prevention, the guide contains preventive services recommended by the U.S. Preventive Services Task Force and the CDC. For more information, visit www.businessgrouphealth.org/prevention/purchasers

PALM DESERT, CALIF. — An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.

The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.

It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.

In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.

Elongating the taper also can make the defect easier to close, with less tension, he added.

In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.

Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.

This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.

It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.

He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.

The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.

He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.

"It is a very vascular area, so you don't need a large pedicle," he said.

Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.

The flap is threaded from the posterior ear through a slit in the cartilage.

The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi

PALM DESERT, CALIF. — An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.

The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.

It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.

In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.

Elongating the taper also can make the defect easier to close, with less tension, he added.

In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.

Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.

This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.

It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.

He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.

The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.

He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.

"It is a very vascular area, so you don't need a large pedicle," he said.

Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.

The flap is threaded from the posterior ear through a slit in the cartilage.

The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi

PALM DESERT, CALIF. — An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.

The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.

It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.

In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.

Elongating the taper also can make the defect easier to close, with less tension, he added.

In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.

Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.

This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.

It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.

He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.

The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.

He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.

"It is a very vascular area, so you don't need a large pedicle," he said.

Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.

The flap is threaded from the posterior ear through a slit in the cartilage.

The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi