Aesthetic Dermatology

LAS VEGAS —The filler poly-L-lactic acid is indicated for HIV facial atrophy, but in experienced hands it also is safe for volume replenishment of tear troughs and hands, Dr. Neil S. Sadick said at an international symposium on cosmetic and laser surgery.

Before the procedure, instruct patients not to take aspirin, ibuprofen, or platelet inhibitors. Apply a topical anesthetic, such as lidocaine, under occlusion for 30 minutes to the treatment area. "When the S-Caine peel is available, it will replace topical lidocaine," predicted Dr. Sadick, who is in private practice in New York.

Poly-L-lactic acid (Sculptra) is a synthetic filler that requires reconstitution at least 2 hours prior to treatment. Although the instructions for use indicate that the filler can sit reconstituted up to 2 weeks, "it can stay for a couple of months, according to several recent studies," Dr. Sadick said.

Proper dilution and technique are required. For tear troughs or hands, dilute the poly-L-lactic acid in 6 cc of sterile water and 2 cc of 1% lidocaine. For hands, 2 vials of poly-L-lactic acid and prepare eight 1-cc syringes (four for each hand) with 26-gauge half-inch needles. Have ice packs available.

"The most important factor is to tent the skin to minimize the bruising when injecting between each intraosseous space," said Dr. Sadick. "Always aspirate to make sure you are not in a blood vessel," he said.

Once the injections are finished, vigorously massage the area for 10 minutes and then apply ice packs for another 10 minutes. Repeat this regimen for three cycles to avoid the formation of nodules and to minimize pain, said Dr. Sadick, who is a consultant for Dermik Laboratories Inc., the manufacturer of Sculptra.

The volumetric effect goes away in the first few weeks, but collagen remodeling produces a late effect that lasts 6–9 months, Dr. Sadick said. Optimal results are seen after two or three treatment sessions at 3- to 4-week intervals.

Before and after images show the results of injecting a hand with poly-L-lactic acid (Sculptra), a filler approved for the treatment of HIV-associated lipoatrophy. Photos courtesy Dr. Neil S. Sadick

LAS VEGAS —The filler poly-L-lactic acid is indicated for HIV facial atrophy, but in experienced hands it also is safe for volume replenishment of tear troughs and hands, Dr. Neil S. Sadick said at an international symposium on cosmetic and laser surgery.

Before the procedure, instruct patients not to take aspirin, ibuprofen, or platelet inhibitors. Apply a topical anesthetic, such as lidocaine, under occlusion for 30 minutes to the treatment area. "When the S-Caine peel is available, it will replace topical lidocaine," predicted Dr. Sadick, who is in private practice in New York.

Poly-L-lactic acid (Sculptra) is a synthetic filler that requires reconstitution at least 2 hours prior to treatment. Although the instructions for use indicate that the filler can sit reconstituted up to 2 weeks, "it can stay for a couple of months, according to several recent studies," Dr. Sadick said.

Proper dilution and technique are required. For tear troughs or hands, dilute the poly-L-lactic acid in 6 cc of sterile water and 2 cc of 1% lidocaine. For hands, 2 vials of poly-L-lactic acid and prepare eight 1-cc syringes (four for each hand) with 26-gauge half-inch needles. Have ice packs available.

"The most important factor is to tent the skin to minimize the bruising when injecting between each intraosseous space," said Dr. Sadick. "Always aspirate to make sure you are not in a blood vessel," he said.

Once the injections are finished, vigorously massage the area for 10 minutes and then apply ice packs for another 10 minutes. Repeat this regimen for three cycles to avoid the formation of nodules and to minimize pain, said Dr. Sadick, who is a consultant for Dermik Laboratories Inc., the manufacturer of Sculptra.

The volumetric effect goes away in the first few weeks, but collagen remodeling produces a late effect that lasts 6–9 months, Dr. Sadick said. Optimal results are seen after two or three treatment sessions at 3- to 4-week intervals.

Before and after images show the results of injecting a hand with poly-L-lactic acid (Sculptra), a filler approved for the treatment of HIV-associated lipoatrophy. Photos courtesy Dr. Neil S. Sadick

LAS VEGAS —The filler poly-L-lactic acid is indicated for HIV facial atrophy, but in experienced hands it also is safe for volume replenishment of tear troughs and hands, Dr. Neil S. Sadick said at an international symposium on cosmetic and laser surgery.

Before the procedure, instruct patients not to take aspirin, ibuprofen, or platelet inhibitors. Apply a topical anesthetic, such as lidocaine, under occlusion for 30 minutes to the treatment area. "When the S-Caine peel is available, it will replace topical lidocaine," predicted Dr. Sadick, who is in private practice in New York.

Poly-L-lactic acid (Sculptra) is a synthetic filler that requires reconstitution at least 2 hours prior to treatment. Although the instructions for use indicate that the filler can sit reconstituted up to 2 weeks, "it can stay for a couple of months, according to several recent studies," Dr. Sadick said.

Proper dilution and technique are required. For tear troughs or hands, dilute the poly-L-lactic acid in 6 cc of sterile water and 2 cc of 1% lidocaine. For hands, 2 vials of poly-L-lactic acid and prepare eight 1-cc syringes (four for each hand) with 26-gauge half-inch needles. Have ice packs available.

"The most important factor is to tent the skin to minimize the bruising when injecting between each intraosseous space," said Dr. Sadick. "Always aspirate to make sure you are not in a blood vessel," he said.

Once the injections are finished, vigorously massage the area for 10 minutes and then apply ice packs for another 10 minutes. Repeat this regimen for three cycles to avoid the formation of nodules and to minimize pain, said Dr. Sadick, who is a consultant for Dermik Laboratories Inc., the manufacturer of Sculptra.

The volumetric effect goes away in the first few weeks, but collagen remodeling produces a late effect that lasts 6–9 months, Dr. Sadick said. Optimal results are seen after two or three treatment sessions at 3- to 4-week intervals.

Before and after images show the results of injecting a hand with poly-L-lactic acid (Sculptra), a filler approved for the treatment of HIV-associated lipoatrophy. Photos courtesy Dr. Neil S. Sadick

LAS VEGAS — Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.

Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.

"What I am about to tell you some people would call a return to the 20th century. It's a retro method—we are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.

Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.

"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.

"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.

"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.

"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.

The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.

The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."

Altered pigmentation and scarring are potential disadvantages of the technique.

"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.

"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500–700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.

Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.

Before the process begins, the hair should be cut down to 2–3 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.

Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.

"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.

Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."

The donor site is shown immediately after individual hair follicles were harvested with a punch.

One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.

Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose

LAS VEGAS — Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.

Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.

"What I am about to tell you some people would call a return to the 20th century. It's a retro method—we are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.

Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.

"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.

"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.

"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.

"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.

The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.

The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."

Altered pigmentation and scarring are potential disadvantages of the technique.

"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.

"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500–700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.

Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.

Before the process begins, the hair should be cut down to 2–3 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.

Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.

"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.

Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."

The donor site is shown immediately after individual hair follicles were harvested with a punch.

One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.

Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose

LAS VEGAS — Hair transplantation using follicular isolation is labor intensive and not for everyone, but the technique serves a subset of patients very well, Dr. Paul T. Rose said at an international symposium on cosmetic and laser surgery.

Unlike the more popular follicular unit extraction, in which hair follicles are extracted together from a donor hair strip, the isolation technique involves removal of individual follicles.

"What I am about to tell you some people would call a return to the 20th century. It's a retro method—we are going back to a punch biopsy, a 1-mm punch," Dr. Rose said.

Patients who are younger, want a scar revision, have limited donor hair, or are concerned about a linear scar from a donor strip are candidates. About 15% of Dr. Rose's hair transplantation patients fit one of these categories, he said.

"These days it is not enough to have a great result in the recipient area. The result in the donor area is becoming increasingly important," he noted. Some patients are "very concerned" after seeing donor site scar photos on the Internet, said Dr. Rose, who is in private practice in Tampa, Fla.

"In our practice, it's probably less than 5% of patients," Dr. Marc R. Avram said. The technique is usually reserved for patients who have a specific area with no hair, such as from multiple surgeries.

"Follicular extraction is not always easy," said Dr. Avram, who is in private practice in New York and is with the department of dermatology at New York-Presbyterian Hospital.

"I think this can help for scars, such as through an eyebrow or a beard," said Dr. Ken Washenik, medical director of Bosley and executive vice president of scientific and medical development at the Aderans Research Institute in Beverly Hills, Calif.

The isolation technique allows clinicians to extract donor hair from sites that might otherwise be unavailable. One example is body hair, although "I will tell patients that using body hair at this point is not proven," Dr. Rose said.

The different texture of body hair is one limitation. Dr. Washenik said that "body hair is single-unit extraction, so the number of donor hairs is more limited."

Altered pigmentation and scarring are potential disadvantages of the technique.

"Most of these punches heal wonderfully, but you can end up with hyper- or hypopigmentation," Dr. Rose said. Excessive harvesting in one area can yield a "moth-eaten" appearance and increase risk of scarring, so leave follicles immediately surrounding each graft, he suggested.

"It is an amazingly tedious process for the patient and surgeon," Dr. Rose said. Clinicians can transfer 500–700 grafts per day, compared with up to 2,000 grafts per day from a donor strip harvest. In addition, the isolation technique costs about twice as much as unit extraction.

Use of a modified slit lamp with a chin cushion can expedite the process. "The patient can sit up comfortably and I have better access to areas. I can harvest and place at the same time," Dr. Rose said.

Before the process begins, the hair should be cut down to 2–3 mm. Align the punch with the direction of the hair, which can change across the head. "Sometimes you have to do 10 or 15 of them, and adjust how you are doing. Check for hair transection," he said.

Partially enter the skin with the punch to form a circular rather than an oval defect. Enter to the level of the fat/dermal junction.

"Once you are confident of the level, set the punch depth because this varies from person to person," Dr. Rose said.

Remove the graft with appropriate forceps and free up any attachments. "Recognize that each patient is unique and there is variability with ease of extraction," Dr. Rose said. "A lot of time [the follicle] will just jump out at you, which is great. Sometimes you cannot get it out and you leave it behind."

The donor site is shown immediately after individual hair follicles were harvested with a punch.

One day after the procedure, healthy growth is seen in the hair follicles immediately surrounding the grafts.

Four days after the procedure, the donor site has resumed a normal appearance. Photos courtesy Dr. Paul T. Rose

PALM DESERT, CALIF. — The radiofrequency heating technique Thermage is probably the best studied of the technologies that tighten the skin, said Dr. Roy Geronemus at the annual meeting of the American Society for Dermatologic Surgery.

Even so, proving that the Thermage treatment works has been difficult because the effects are modest and it is hard to measure tightening objectively.

Before and after photos are simply too subjective to be of use in evaluating the effects of treatment, he said.

There have been successful attempts to be as objective as possible, mostly by demonstrating that the treatment can lift eyebrows relative to the eye pupil, said Dr. Geronemus, director of a laser practice in New York.

In a study that he conducted using Fitzpatrick wrinkle scores to make the assessment objective, he and his associates found that 57% of patients at one site and 73% of patients at another had an improvement of 25% or more in their scores at 6 months.

The investigators also used a device that attempts to measure skin tension, and found that it recorded a significant improvement in the areas of skin treated, Dr. Geronemus said.

Techniques have also evolved since Thermage was first introduced, and the better procedures have contributed to dispelling some of the skepticism, he noted. Practitioners now usually use multiple passes at a lower power level, instead of a single pass at a higher power level. The lower-power technique was used in his trial. Many physicians also recommend that a wider device tip be utilized (3 cm instead of 1.5 cm). The wider tip was not used in his trial.

Microscopic data appear to show that radiofrequency heating does result in the denaturing of collagen fibers, said Dr. Brian Zelickson, who practices in Minneapolis and is with the department of dermatology at the University of Minnesota there.

Light microscopy does not show very much effect from the Thermage technology, said Dr. Zelickson, who is a microscopy expert. An electron-microscope view of treated skin, however, shows what he called "islands" of changes in the collagen fibers.

Dr. Zelickson has also reported that one can see additive effects of each pass of the Thermage device, with up to five passes.

"In our patients, we see some modest tightening," Dr. Zelickson said. "We can certainly see some tightening of the skin when you look at the before and after pictures."

What is the most convincing evidence that Thermage works, however, is that patients have the impression that the treatment improves their looks, said Dr. Geronemus.

"Most of the patients I have seen over the last 2 months are people who are coming in for second treatments because of the success they have achieved with their first treatment with Thermage," he said.

Still, even these two experts expressed some reservations about what can actually be accomplished with Thermage's ThermaCool system.

The procedure does not appear to be appropriate for all of his patients, said Dr. Zelickson.

In his experience, selecting the proper patient is crucial to obtaining a good result, but he did not elaborate on his criteria any further except to say that the right patient is one with obvious skin "laxity."

Dr. Geronemus noted that in his research there was some evidence that the benefits of Thermage treatment appeared to be wearing off after a period of about 6 months.

Dr. Zelickson has received research grants from Thermage Inc., and Dr. Geronemus is a company shareholder.

Proving that Thermage works is difficult because the effects are modest and it is hard to measure tightening. DR. GERONEMUS

PALM DESERT, CALIF. — The radiofrequency heating technique Thermage is probably the best studied of the technologies that tighten the skin, said Dr. Roy Geronemus at the annual meeting of the American Society for Dermatologic Surgery.

Even so, proving that the Thermage treatment works has been difficult because the effects are modest and it is hard to measure tightening objectively.

Before and after photos are simply too subjective to be of use in evaluating the effects of treatment, he said.

There have been successful attempts to be as objective as possible, mostly by demonstrating that the treatment can lift eyebrows relative to the eye pupil, said Dr. Geronemus, director of a laser practice in New York.

In a study that he conducted using Fitzpatrick wrinkle scores to make the assessment objective, he and his associates found that 57% of patients at one site and 73% of patients at another had an improvement of 25% or more in their scores at 6 months.

The investigators also used a device that attempts to measure skin tension, and found that it recorded a significant improvement in the areas of skin treated, Dr. Geronemus said.

Techniques have also evolved since Thermage was first introduced, and the better procedures have contributed to dispelling some of the skepticism, he noted. Practitioners now usually use multiple passes at a lower power level, instead of a single pass at a higher power level. The lower-power technique was used in his trial. Many physicians also recommend that a wider device tip be utilized (3 cm instead of 1.5 cm). The wider tip was not used in his trial.

Microscopic data appear to show that radiofrequency heating does result in the denaturing of collagen fibers, said Dr. Brian Zelickson, who practices in Minneapolis and is with the department of dermatology at the University of Minnesota there.

Light microscopy does not show very much effect from the Thermage technology, said Dr. Zelickson, who is a microscopy expert. An electron-microscope view of treated skin, however, shows what he called "islands" of changes in the collagen fibers.

Dr. Zelickson has also reported that one can see additive effects of each pass of the Thermage device, with up to five passes.

"In our patients, we see some modest tightening," Dr. Zelickson said. "We can certainly see some tightening of the skin when you look at the before and after pictures."

What is the most convincing evidence that Thermage works, however, is that patients have the impression that the treatment improves their looks, said Dr. Geronemus.

"Most of the patients I have seen over the last 2 months are people who are coming in for second treatments because of the success they have achieved with their first treatment with Thermage," he said.

Still, even these two experts expressed some reservations about what can actually be accomplished with Thermage's ThermaCool system.

The procedure does not appear to be appropriate for all of his patients, said Dr. Zelickson.

In his experience, selecting the proper patient is crucial to obtaining a good result, but he did not elaborate on his criteria any further except to say that the right patient is one with obvious skin "laxity."

Dr. Geronemus noted that in his research there was some evidence that the benefits of Thermage treatment appeared to be wearing off after a period of about 6 months.

Dr. Zelickson has received research grants from Thermage Inc., and Dr. Geronemus is a company shareholder.

Proving that Thermage works is difficult because the effects are modest and it is hard to measure tightening. DR. GERONEMUS

PALM DESERT, CALIF. — The radiofrequency heating technique Thermage is probably the best studied of the technologies that tighten the skin, said Dr. Roy Geronemus at the annual meeting of the American Society for Dermatologic Surgery.

Even so, proving that the Thermage treatment works has been difficult because the effects are modest and it is hard to measure tightening objectively.

Before and after photos are simply too subjective to be of use in evaluating the effects of treatment, he said.

There have been successful attempts to be as objective as possible, mostly by demonstrating that the treatment can lift eyebrows relative to the eye pupil, said Dr. Geronemus, director of a laser practice in New York.

In a study that he conducted using Fitzpatrick wrinkle scores to make the assessment objective, he and his associates found that 57% of patients at one site and 73% of patients at another had an improvement of 25% or more in their scores at 6 months.

The investigators also used a device that attempts to measure skin tension, and found that it recorded a significant improvement in the areas of skin treated, Dr. Geronemus said.

Techniques have also evolved since Thermage was first introduced, and the better procedures have contributed to dispelling some of the skepticism, he noted. Practitioners now usually use multiple passes at a lower power level, instead of a single pass at a higher power level. The lower-power technique was used in his trial. Many physicians also recommend that a wider device tip be utilized (3 cm instead of 1.5 cm). The wider tip was not used in his trial.

Microscopic data appear to show that radiofrequency heating does result in the denaturing of collagen fibers, said Dr. Brian Zelickson, who practices in Minneapolis and is with the department of dermatology at the University of Minnesota there.

Light microscopy does not show very much effect from the Thermage technology, said Dr. Zelickson, who is a microscopy expert. An electron-microscope view of treated skin, however, shows what he called "islands" of changes in the collagen fibers.

Dr. Zelickson has also reported that one can see additive effects of each pass of the Thermage device, with up to five passes.

"In our patients, we see some modest tightening," Dr. Zelickson said. "We can certainly see some tightening of the skin when you look at the before and after pictures."

What is the most convincing evidence that Thermage works, however, is that patients have the impression that the treatment improves their looks, said Dr. Geronemus.

"Most of the patients I have seen over the last 2 months are people who are coming in for second treatments because of the success they have achieved with their first treatment with Thermage," he said.

Still, even these two experts expressed some reservations about what can actually be accomplished with Thermage's ThermaCool system.

The procedure does not appear to be appropriate for all of his patients, said Dr. Zelickson.

In his experience, selecting the proper patient is crucial to obtaining a good result, but he did not elaborate on his criteria any further except to say that the right patient is one with obvious skin "laxity."

Dr. Geronemus noted that in his research there was some evidence that the benefits of Thermage treatment appeared to be wearing off after a period of about 6 months.

Dr. Zelickson has received research grants from Thermage Inc., and Dr. Geronemus is a company shareholder.

Proving that Thermage works is difficult because the effects are modest and it is hard to measure tightening. DR. GERONEMUS

LAS VEGAS — Liposuction can be an effective alternative to breast reduction surgery in select patients, according to a presentation at an international symposium on cosmetic and laser surgery.

Traditional breast reduction can require significant postoperative recovery and cause unnatural-looking breast lift, Dr. Cameron Rokhsar said. In addition, many patients are left with an inverted T scar. In contrast, liposuction with local anesthesia does not lift the breast and often leaves only small scars, said Dr. Rokhsar, a dermatologist in private practice in New York City.

Liposuction is a common cosmetic procedure in the United States. "The procedure has evolved from one under general anesthesia with massive blood loss to an outpatient procedure with minimal blood loss," Dr. Rokhsar said.

The fat removal technique became "extremely safe" with the advent of the tumescent technique, he added. For example, a survey of 66 physician members of the American Society of Dermatologic Surgery found that there were no deaths among 15,336 patients they treated with tumescent liposuction (Dermatol. Surg. 1995;21:459–62).

After baseline mammography, Dr. Rokhsar measures breast size through water displacement and makes radial markings. Cannulas are introduced through two tiny holes to remove the fat from the breast. The process can suction up to 50%–70% of breast fat. In an unpublished study of 30 of Dr. Rokhsar's patients, this procedure reduced breast size by an average of one cup size. A follow-up mammography is performed at 6 months as a new baseline reference.

"The patient can sit up afterward—it is a very simple procedure," said Dr. Rokhsar, who is also on the dermatology faculty at Albert Einstein College of Medicine in New York.

Liposuction is contraindicated for a breast composed primarily of glandular tissue versus fat, Dr. Rokhsar said.

Patients with nipple ptosis, a family history of breast cancer, or patients looking for significant breast lift are generally not candidates for breast liposuction, he added.

LAS VEGAS — Liposuction can be an effective alternative to breast reduction surgery in select patients, according to a presentation at an international symposium on cosmetic and laser surgery.

Traditional breast reduction can require significant postoperative recovery and cause unnatural-looking breast lift, Dr. Cameron Rokhsar said. In addition, many patients are left with an inverted T scar. In contrast, liposuction with local anesthesia does not lift the breast and often leaves only small scars, said Dr. Rokhsar, a dermatologist in private practice in New York City.

Liposuction is a common cosmetic procedure in the United States. "The procedure has evolved from one under general anesthesia with massive blood loss to an outpatient procedure with minimal blood loss," Dr. Rokhsar said.

The fat removal technique became "extremely safe" with the advent of the tumescent technique, he added. For example, a survey of 66 physician members of the American Society of Dermatologic Surgery found that there were no deaths among 15,336 patients they treated with tumescent liposuction (Dermatol. Surg. 1995;21:459–62).

After baseline mammography, Dr. Rokhsar measures breast size through water displacement and makes radial markings. Cannulas are introduced through two tiny holes to remove the fat from the breast. The process can suction up to 50%–70% of breast fat. In an unpublished study of 30 of Dr. Rokhsar's patients, this procedure reduced breast size by an average of one cup size. A follow-up mammography is performed at 6 months as a new baseline reference.

"The patient can sit up afterward—it is a very simple procedure," said Dr. Rokhsar, who is also on the dermatology faculty at Albert Einstein College of Medicine in New York.

Liposuction is contraindicated for a breast composed primarily of glandular tissue versus fat, Dr. Rokhsar said.

Patients with nipple ptosis, a family history of breast cancer, or patients looking for significant breast lift are generally not candidates for breast liposuction, he added.

LAS VEGAS — Liposuction can be an effective alternative to breast reduction surgery in select patients, according to a presentation at an international symposium on cosmetic and laser surgery.

Traditional breast reduction can require significant postoperative recovery and cause unnatural-looking breast lift, Dr. Cameron Rokhsar said. In addition, many patients are left with an inverted T scar. In contrast, liposuction with local anesthesia does not lift the breast and often leaves only small scars, said Dr. Rokhsar, a dermatologist in private practice in New York City.

Liposuction is a common cosmetic procedure in the United States. "The procedure has evolved from one under general anesthesia with massive blood loss to an outpatient procedure with minimal blood loss," Dr. Rokhsar said.

The fat removal technique became "extremely safe" with the advent of the tumescent technique, he added. For example, a survey of 66 physician members of the American Society of Dermatologic Surgery found that there were no deaths among 15,336 patients they treated with tumescent liposuction (Dermatol. Surg. 1995;21:459–62).

After baseline mammography, Dr. Rokhsar measures breast size through water displacement and makes radial markings. Cannulas are introduced through two tiny holes to remove the fat from the breast. The process can suction up to 50%–70% of breast fat. In an unpublished study of 30 of Dr. Rokhsar's patients, this procedure reduced breast size by an average of one cup size. A follow-up mammography is performed at 6 months as a new baseline reference.

"The patient can sit up afterward—it is a very simple procedure," said Dr. Rokhsar, who is also on the dermatology faculty at Albert Einstein College of Medicine in New York.

Liposuction is contraindicated for a breast composed primarily of glandular tissue versus fat, Dr. Rokhsar said.

Patients with nipple ptosis, a family history of breast cancer, or patients looking for significant breast lift are generally not candidates for breast liposuction, he added.

OTTAWA — The smart compression technique using short stretch bandages facilitates healing by extruding edema and lymphedema from a wound, Dr. John MacDonald said at the annual conference of the Canadian Association of Wound Care.

"Lymphedema is a major impediment to wound healing," said Dr. MacDonald, a retired cardiovascular surgeon who is now with the department of dermatology and cutaneous surgery at the University of Miami.

"If you have a bandage that moves as the muscles move, nothing happens," Dr. MacDonald explained. "But if you have a bandage that gives resistance to the motion of the muscle, there is pressure on the tissue that stimulates pressure on the lymphatic fluid and pushes it out of the limb."

"Every chronic wound has a lymphatic pathology," he explained. The lymphatic system accounts for 10%–15% of cardiac output, so be sure to consider what could be wrong with the lymphatic system in any chronic wound.

Lymphatic vessels are easily injured, and they can't move fluid to and from a chronic wound without help; but if the external pressure from a compression bandage is high enough, the lymphatic capillaries start to fill with fluid and the fluid moves away from the wound and back toward the heart. "It is external pressure from the compression bandage that is moving this fluid," Dr. MacDonald said. The steady, constant pressure (5–10 mm Hg) on the delicate lymphatic vessels can propel the fluid back into the cardiovascular system.

Smart compression takes into account both resting pressure and working pressure on the affected area. Resting pressure is the pressure applied by a bandage to a body part, such as a leg, when that part is at rest. Working pressure develops when the muscles contract and push against the compressing bandage; there is a dynamic pulsation between the muscles and the bandage. Working pressure develops internally and has a positive effect on the deeper muscles when the bandage restrains muscle expansion, he said.

Smart compression is uniform, not like squeezing a tube of toothpaste, and short stretch bandages are the best way to achieve it.

The short bandage creates a lower resting pressure and a higher working pressure, which is the safest treatment option for a compromised limb, Dr. MacDonald noted. External compression is extremely important in controlling edema and lymphedema because it promotes fluid absorption, which is critical to the healing of any chronic wound.

To treat a patient with smart compression, Dr. MacDonald recommends using inelastic short stretch bandages that are left on 24 hours a day, 7 days a week. Although the bandages on the wound itself are to be changed regularly, the patient doesn't get a break from the compression for more than the time needed to change the dressing. The steady, constant compression helps move the lymphatic fluid out of the swollen, wounded area.

Padding is needed underneath the bandage to fill in crevices and to equalize pressure over the area to be treated, he added.

Adding smart compression does not detract from the principles of basic wound care. "It was the missing link," Dr. MacDonald said. Healing is restricted when debris in a wound can't drain via the lymphatic system. Smart compression is "like sending your patient home with their own massage therapist 24 hours a day," he said.

Smart compression with short stretch bandages also can be used to treat lymphedema in patients with metastatic lesions, as well as wounds in obese patients or patients with cellulitis or diabetes.

"There has never been a study to show that using compression will shorten the life of someone with metastatic disease," said Dr. MacDonald.

Smart compression should be used to treat lymphedema in obese patients with wounds below the knee, which is the site of most wounds in these patients. "You can't do anything about their weight, but if you use continuous sustained compression, you will stop that drainage and heal the wounds," he explained.

This wound in patient with grade three lymphedema is shown before treatment.

The patient is shown approximately 21/2 months after treatment. Photos courtesy Dr. John MacDonald

OTTAWA — The smart compression technique using short stretch bandages facilitates healing by extruding edema and lymphedema from a wound, Dr. John MacDonald said at the annual conference of the Canadian Association of Wound Care.

"Lymphedema is a major impediment to wound healing," said Dr. MacDonald, a retired cardiovascular surgeon who is now with the department of dermatology and cutaneous surgery at the University of Miami.

"If you have a bandage that moves as the muscles move, nothing happens," Dr. MacDonald explained. "But if you have a bandage that gives resistance to the motion of the muscle, there is pressure on the tissue that stimulates pressure on the lymphatic fluid and pushes it out of the limb."

"Every chronic wound has a lymphatic pathology," he explained. The lymphatic system accounts for 10%–15% of cardiac output, so be sure to consider what could be wrong with the lymphatic system in any chronic wound.

Lymphatic vessels are easily injured, and they can't move fluid to and from a chronic wound without help; but if the external pressure from a compression bandage is high enough, the lymphatic capillaries start to fill with fluid and the fluid moves away from the wound and back toward the heart. "It is external pressure from the compression bandage that is moving this fluid," Dr. MacDonald said. The steady, constant pressure (5–10 mm Hg) on the delicate lymphatic vessels can propel the fluid back into the cardiovascular system.

Smart compression takes into account both resting pressure and working pressure on the affected area. Resting pressure is the pressure applied by a bandage to a body part, such as a leg, when that part is at rest. Working pressure develops when the muscles contract and push against the compressing bandage; there is a dynamic pulsation between the muscles and the bandage. Working pressure develops internally and has a positive effect on the deeper muscles when the bandage restrains muscle expansion, he said.

Smart compression is uniform, not like squeezing a tube of toothpaste, and short stretch bandages are the best way to achieve it.

The short bandage creates a lower resting pressure and a higher working pressure, which is the safest treatment option for a compromised limb, Dr. MacDonald noted. External compression is extremely important in controlling edema and lymphedema because it promotes fluid absorption, which is critical to the healing of any chronic wound.

To treat a patient with smart compression, Dr. MacDonald recommends using inelastic short stretch bandages that are left on 24 hours a day, 7 days a week. Although the bandages on the wound itself are to be changed regularly, the patient doesn't get a break from the compression for more than the time needed to change the dressing. The steady, constant compression helps move the lymphatic fluid out of the swollen, wounded area.

Padding is needed underneath the bandage to fill in crevices and to equalize pressure over the area to be treated, he added.

Adding smart compression does not detract from the principles of basic wound care. "It was the missing link," Dr. MacDonald said. Healing is restricted when debris in a wound can't drain via the lymphatic system. Smart compression is "like sending your patient home with their own massage therapist 24 hours a day," he said.

Smart compression with short stretch bandages also can be used to treat lymphedema in patients with metastatic lesions, as well as wounds in obese patients or patients with cellulitis or diabetes.

"There has never been a study to show that using compression will shorten the life of someone with metastatic disease," said Dr. MacDonald.

Smart compression should be used to treat lymphedema in obese patients with wounds below the knee, which is the site of most wounds in these patients. "You can't do anything about their weight, but if you use continuous sustained compression, you will stop that drainage and heal the wounds," he explained.

This wound in patient with grade three lymphedema is shown before treatment.

The patient is shown approximately 21/2 months after treatment. Photos courtesy Dr. John MacDonald

OTTAWA — The smart compression technique using short stretch bandages facilitates healing by extruding edema and lymphedema from a wound, Dr. John MacDonald said at the annual conference of the Canadian Association of Wound Care.

"Lymphedema is a major impediment to wound healing," said Dr. MacDonald, a retired cardiovascular surgeon who is now with the department of dermatology and cutaneous surgery at the University of Miami.

"If you have a bandage that moves as the muscles move, nothing happens," Dr. MacDonald explained. "But if you have a bandage that gives resistance to the motion of the muscle, there is pressure on the tissue that stimulates pressure on the lymphatic fluid and pushes it out of the limb."

"Every chronic wound has a lymphatic pathology," he explained. The lymphatic system accounts for 10%–15% of cardiac output, so be sure to consider what could be wrong with the lymphatic system in any chronic wound.

Lymphatic vessels are easily injured, and they can't move fluid to and from a chronic wound without help; but if the external pressure from a compression bandage is high enough, the lymphatic capillaries start to fill with fluid and the fluid moves away from the wound and back toward the heart. "It is external pressure from the compression bandage that is moving this fluid," Dr. MacDonald said. The steady, constant pressure (5–10 mm Hg) on the delicate lymphatic vessels can propel the fluid back into the cardiovascular system.

Smart compression takes into account both resting pressure and working pressure on the affected area. Resting pressure is the pressure applied by a bandage to a body part, such as a leg, when that part is at rest. Working pressure develops when the muscles contract and push against the compressing bandage; there is a dynamic pulsation between the muscles and the bandage. Working pressure develops internally and has a positive effect on the deeper muscles when the bandage restrains muscle expansion, he said.

Smart compression is uniform, not like squeezing a tube of toothpaste, and short stretch bandages are the best way to achieve it.

The short bandage creates a lower resting pressure and a higher working pressure, which is the safest treatment option for a compromised limb, Dr. MacDonald noted. External compression is extremely important in controlling edema and lymphedema because it promotes fluid absorption, which is critical to the healing of any chronic wound.

To treat a patient with smart compression, Dr. MacDonald recommends using inelastic short stretch bandages that are left on 24 hours a day, 7 days a week. Although the bandages on the wound itself are to be changed regularly, the patient doesn't get a break from the compression for more than the time needed to change the dressing. The steady, constant compression helps move the lymphatic fluid out of the swollen, wounded area.

Padding is needed underneath the bandage to fill in crevices and to equalize pressure over the area to be treated, he added.

Adding smart compression does not detract from the principles of basic wound care. "It was the missing link," Dr. MacDonald said. Healing is restricted when debris in a wound can't drain via the lymphatic system. Smart compression is "like sending your patient home with their own massage therapist 24 hours a day," he said.

Smart compression with short stretch bandages also can be used to treat lymphedema in patients with metastatic lesions, as well as wounds in obese patients or patients with cellulitis or diabetes.

"There has never been a study to show that using compression will shorten the life of someone with metastatic disease," said Dr. MacDonald.

Smart compression should be used to treat lymphedema in obese patients with wounds below the knee, which is the site of most wounds in these patients. "You can't do anything about their weight, but if you use continuous sustained compression, you will stop that drainage and heal the wounds," he explained.

This wound in patient with grade three lymphedema is shown before treatment.

The patient is shown approximately 21/2 months after treatment. Photos courtesy Dr. John MacDonald

SAN DIEGO — Since most Mohs surgeons want at least a 1-mm clear margin around a basal cell or squamous cell carcinoma, it is crucial to know how many slices were taken between frozen sections mounted for review, Dr. John Campbell said at a meeting sponsored by the American Society for Mohs Surgery.

Dr. Campbell, a San Diego pathologist with an interest in Mohs surgery, said that planning and consistency in how a block of tissue is sectioned by the cryostat's microtome is of the utmost importance to performing good Mohs surgery.

By averaging out the amount of tissue that disappears when the microtome slices a block of tissue, it appears that about 3 mum of tissue are lost for every 10 mum in most microtomes, Dr. Campbell said at the meeting.

Therefore, he recommends that the microtome be set to make slices every 7 mum, and that every 20th section get mounted on the slide. When the mounting is that consistent, then it is easy to know exactly how many clear sections one must see before declaring a margin clear—in this case, five to six sections.

Dr. Campbell instructs the cryostat technicians he works with that he wants to see the first mounted tissue section within the first 100 mum of tissue whenever possible.

To be considered a proper and countable section, a section should have epithelium visible around 90% of the section edge.

Sometimes, though, when it is not possible to get a section without a hole in the middle, or skin all the way around the edge, it does not hurt to have incomplete sections mounted for the physician to at least see, he noted.

Although some surgeons claim to need less than a 1-mm clear margin around a tumor and that the amount of clear tissue necessary depends on the tumor type, 1 mm of clear tissue is a good, fairly conservative option for margins, Dr. Campbell said.

SAN DIEGO — Since most Mohs surgeons want at least a 1-mm clear margin around a basal cell or squamous cell carcinoma, it is crucial to know how many slices were taken between frozen sections mounted for review, Dr. John Campbell said at a meeting sponsored by the American Society for Mohs Surgery.

Dr. Campbell, a San Diego pathologist with an interest in Mohs surgery, said that planning and consistency in how a block of tissue is sectioned by the cryostat's microtome is of the utmost importance to performing good Mohs surgery.

By averaging out the amount of tissue that disappears when the microtome slices a block of tissue, it appears that about 3 mum of tissue are lost for every 10 mum in most microtomes, Dr. Campbell said at the meeting.

Therefore, he recommends that the microtome be set to make slices every 7 mum, and that every 20th section get mounted on the slide. When the mounting is that consistent, then it is easy to know exactly how many clear sections one must see before declaring a margin clear—in this case, five to six sections.

Dr. Campbell instructs the cryostat technicians he works with that he wants to see the first mounted tissue section within the first 100 mum of tissue whenever possible.

To be considered a proper and countable section, a section should have epithelium visible around 90% of the section edge.

Sometimes, though, when it is not possible to get a section without a hole in the middle, or skin all the way around the edge, it does not hurt to have incomplete sections mounted for the physician to at least see, he noted.

Although some surgeons claim to need less than a 1-mm clear margin around a tumor and that the amount of clear tissue necessary depends on the tumor type, 1 mm of clear tissue is a good, fairly conservative option for margins, Dr. Campbell said.

SAN DIEGO — Since most Mohs surgeons want at least a 1-mm clear margin around a basal cell or squamous cell carcinoma, it is crucial to know how many slices were taken between frozen sections mounted for review, Dr. John Campbell said at a meeting sponsored by the American Society for Mohs Surgery.

Dr. Campbell, a San Diego pathologist with an interest in Mohs surgery, said that planning and consistency in how a block of tissue is sectioned by the cryostat's microtome is of the utmost importance to performing good Mohs surgery.

By averaging out the amount of tissue that disappears when the microtome slices a block of tissue, it appears that about 3 mum of tissue are lost for every 10 mum in most microtomes, Dr. Campbell said at the meeting.

Therefore, he recommends that the microtome be set to make slices every 7 mum, and that every 20th section get mounted on the slide. When the mounting is that consistent, then it is easy to know exactly how many clear sections one must see before declaring a margin clear—in this case, five to six sections.

Dr. Campbell instructs the cryostat technicians he works with that he wants to see the first mounted tissue section within the first 100 mum of tissue whenever possible.

To be considered a proper and countable section, a section should have epithelium visible around 90% of the section edge.

Sometimes, though, when it is not possible to get a section without a hole in the middle, or skin all the way around the edge, it does not hurt to have incomplete sections mounted for the physician to at least see, he noted.

Although some surgeons claim to need less than a 1-mm clear margin around a tumor and that the amount of clear tissue necessary depends on the tumor type, 1 mm of clear tissue is a good, fairly conservative option for margins, Dr. Campbell said.

SAN DIEGO — Neophyte Mohs surgeons should start with an easy case, ideally with a lesion located anywhere other than on the face, and, if possible, give the case an entire day on the schedule.

That was just one bit of advice given by Dr. Howard K. Steinman at a meeting sponsored by the American Society for Mohs Surgery.

Another tip provided by Dr. Steinman, one of the meeting's organizers, was that one should photograph the lesion on the day one first sees the patient, at the time of the evaluation.

Sometimes, a lesion readily apparent on the day of the evaluation is not so obvious on the day of surgery, and to illustrate his point, Dr. Steinman showed a picture of a biopsy-confirmed lesion that had almost completely disappeared when the patient showed up for surgery. It would have been difficult to find that lesion again if not for the picture, Dr. Steinman noted.

Some surgeons curette a lesion before taking the first Mohs stage, and some surgeons do not, Dr. Steinman pointed out, but he said it can be helpful in planning the procedure, particularly because it can give the surgeon a better idea of tumor depth.

In Mohs, when the surgeon takes the first stage, the blade should be angled at 45 degrees, not so much so the lesion can be removed easily as so it will lay flat when being sectioned. And, the stage should be taken at a depth one tissue layer below the expected margin of the lesion.

The key to removing the lesion is marking it with reference marks before it is removed from the patient and with the different colors appropriately after it is removed.

Otherwise, it is too easy for the specimen to fall to the floor, or be turned inadvertently, or even flipped while being sliced in the cryostat, with the result that the surgeon becomes uncertain where the proper margin is, explained Dr. Steinman, who practices in Chula Vista, Calif.

The making of the reference marks around the lesion to be removed is, of course, up to the surgeon but a common practice is to use five, one at what is decided will be the 12 o'clock mark on the specimen, and one each at 9, 6, and 3 o'clock. The fifth mark goes immediately next to the 12 o'clock reference mark, usually, so that mark can be distinguished, he added.

Reasons for a second stage, in the absence of tumor that clearly crosses the edge of the section, include a hole in the section, misorientation because the section is not clearly marked, and/or dense inflammation at the edge of the section, which can indicate tumor, Dr. Steinman said.

SAN DIEGO — Neophyte Mohs surgeons should start with an easy case, ideally with a lesion located anywhere other than on the face, and, if possible, give the case an entire day on the schedule.

That was just one bit of advice given by Dr. Howard K. Steinman at a meeting sponsored by the American Society for Mohs Surgery.

Another tip provided by Dr. Steinman, one of the meeting's organizers, was that one should photograph the lesion on the day one first sees the patient, at the time of the evaluation.

Sometimes, a lesion readily apparent on the day of the evaluation is not so obvious on the day of surgery, and to illustrate his point, Dr. Steinman showed a picture of a biopsy-confirmed lesion that had almost completely disappeared when the patient showed up for surgery. It would have been difficult to find that lesion again if not for the picture, Dr. Steinman noted.

Some surgeons curette a lesion before taking the first Mohs stage, and some surgeons do not, Dr. Steinman pointed out, but he said it can be helpful in planning the procedure, particularly because it can give the surgeon a better idea of tumor depth.

In Mohs, when the surgeon takes the first stage, the blade should be angled at 45 degrees, not so much so the lesion can be removed easily as so it will lay flat when being sectioned. And, the stage should be taken at a depth one tissue layer below the expected margin of the lesion.

The key to removing the lesion is marking it with reference marks before it is removed from the patient and with the different colors appropriately after it is removed.

Otherwise, it is too easy for the specimen to fall to the floor, or be turned inadvertently, or even flipped while being sliced in the cryostat, with the result that the surgeon becomes uncertain where the proper margin is, explained Dr. Steinman, who practices in Chula Vista, Calif.

The making of the reference marks around the lesion to be removed is, of course, up to the surgeon but a common practice is to use five, one at what is decided will be the 12 o'clock mark on the specimen, and one each at 9, 6, and 3 o'clock. The fifth mark goes immediately next to the 12 o'clock reference mark, usually, so that mark can be distinguished, he added.

Reasons for a second stage, in the absence of tumor that clearly crosses the edge of the section, include a hole in the section, misorientation because the section is not clearly marked, and/or dense inflammation at the edge of the section, which can indicate tumor, Dr. Steinman said.

SAN DIEGO — Neophyte Mohs surgeons should start with an easy case, ideally with a lesion located anywhere other than on the face, and, if possible, give the case an entire day on the schedule.

That was just one bit of advice given by Dr. Howard K. Steinman at a meeting sponsored by the American Society for Mohs Surgery.

Another tip provided by Dr. Steinman, one of the meeting's organizers, was that one should photograph the lesion on the day one first sees the patient, at the time of the evaluation.

Sometimes, a lesion readily apparent on the day of the evaluation is not so obvious on the day of surgery, and to illustrate his point, Dr. Steinman showed a picture of a biopsy-confirmed lesion that had almost completely disappeared when the patient showed up for surgery. It would have been difficult to find that lesion again if not for the picture, Dr. Steinman noted.

Some surgeons curette a lesion before taking the first Mohs stage, and some surgeons do not, Dr. Steinman pointed out, but he said it can be helpful in planning the procedure, particularly because it can give the surgeon a better idea of tumor depth.

In Mohs, when the surgeon takes the first stage, the blade should be angled at 45 degrees, not so much so the lesion can be removed easily as so it will lay flat when being sectioned. And, the stage should be taken at a depth one tissue layer below the expected margin of the lesion.

The key to removing the lesion is marking it with reference marks before it is removed from the patient and with the different colors appropriately after it is removed.

Otherwise, it is too easy for the specimen to fall to the floor, or be turned inadvertently, or even flipped while being sliced in the cryostat, with the result that the surgeon becomes uncertain where the proper margin is, explained Dr. Steinman, who practices in Chula Vista, Calif.

The making of the reference marks around the lesion to be removed is, of course, up to the surgeon but a common practice is to use five, one at what is decided will be the 12 o'clock mark on the specimen, and one each at 9, 6, and 3 o'clock. The fifth mark goes immediately next to the 12 o'clock reference mark, usually, so that mark can be distinguished, he added.

Reasons for a second stage, in the absence of tumor that clearly crosses the edge of the section, include a hole in the section, misorientation because the section is not clearly marked, and/or dense inflammation at the edge of the section, which can indicate tumor, Dr. Steinman said.

SAN DIEGO — When Dr. Edward Yob moved to Oklahoma 16 years ago, he became the first physician in that state to perform Mohs surgery. The dermatologists in Oklahoma, however, were not impressed.

They saw no need for such a fancy approach, Dr. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

As a result, he learned to woo a constituency. One practice he has adopted is to take before and after pictures of his cases, and he sends them to the referring physician when he sends the patient back after Mohs, said Dr. Yob, who practices in Tulsa.

He sends the pictures along with a letter and his preprocedure and postprocedure reports. Dr. Yob uses a Nikon CoolPix 990 digital camera because it has a pivot hinge that lets one take pictures at any angle.

One purpose of the pictures is to advertise his skills, but another is to let the referring physicians know that a case does not have to be a huge tumor or be in an intricate location for Mohs referral. Those obviously are not the only cases a Mohs surgeon wants to have to do, Dr. Yob noted.

"It's really just a marketing gimmick, even though that is not all it is," he said. "Show them how you can do small tumors and intricate locations."

The patient records should include a preprocedure report with a diagnosis and location. The postprocedure report should include mention of any special techniques used, anything such as actinic keratoses in the region but left behind, and a histology report.

The operative report should include the Mohs map used during the procedure with a code for the symbols depicting the inking colors used.

When physicians start a Mohs practice, they also need to keep in mind that referrals actually can drop off a little as one becomes established. That is not because one is doing anything wrong. Instead, many areas without a Mohs surgeon can have something of a backlog of cases, and once that backlog gets taken care of, business can drop off a bit, Dr. Yob said.

"Show [referring physicians] how you can do small tumors and intricate locations." DR. YOB

SAN DIEGO — When Dr. Edward Yob moved to Oklahoma 16 years ago, he became the first physician in that state to perform Mohs surgery. The dermatologists in Oklahoma, however, were not impressed.

They saw no need for such a fancy approach, Dr. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

As a result, he learned to woo a constituency. One practice he has adopted is to take before and after pictures of his cases, and he sends them to the referring physician when he sends the patient back after Mohs, said Dr. Yob, who practices in Tulsa.

He sends the pictures along with a letter and his preprocedure and postprocedure reports. Dr. Yob uses a Nikon CoolPix 990 digital camera because it has a pivot hinge that lets one take pictures at any angle.

One purpose of the pictures is to advertise his skills, but another is to let the referring physicians know that a case does not have to be a huge tumor or be in an intricate location for Mohs referral. Those obviously are not the only cases a Mohs surgeon wants to have to do, Dr. Yob noted.

"It's really just a marketing gimmick, even though that is not all it is," he said. "Show them how you can do small tumors and intricate locations."

The patient records should include a preprocedure report with a diagnosis and location. The postprocedure report should include mention of any special techniques used, anything such as actinic keratoses in the region but left behind, and a histology report.

The operative report should include the Mohs map used during the procedure with a code for the symbols depicting the inking colors used.

When physicians start a Mohs practice, they also need to keep in mind that referrals actually can drop off a little as one becomes established. That is not because one is doing anything wrong. Instead, many areas without a Mohs surgeon can have something of a backlog of cases, and once that backlog gets taken care of, business can drop off a bit, Dr. Yob said.

"Show [referring physicians] how you can do small tumors and intricate locations." DR. YOB

SAN DIEGO — When Dr. Edward Yob moved to Oklahoma 16 years ago, he became the first physician in that state to perform Mohs surgery. The dermatologists in Oklahoma, however, were not impressed.

They saw no need for such a fancy approach, Dr. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

As a result, he learned to woo a constituency. One practice he has adopted is to take before and after pictures of his cases, and he sends them to the referring physician when he sends the patient back after Mohs, said Dr. Yob, who practices in Tulsa.

He sends the pictures along with a letter and his preprocedure and postprocedure reports. Dr. Yob uses a Nikon CoolPix 990 digital camera because it has a pivot hinge that lets one take pictures at any angle.

One purpose of the pictures is to advertise his skills, but another is to let the referring physicians know that a case does not have to be a huge tumor or be in an intricate location for Mohs referral. Those obviously are not the only cases a Mohs surgeon wants to have to do, Dr. Yob noted.

"It's really just a marketing gimmick, even though that is not all it is," he said. "Show them how you can do small tumors and intricate locations."

The patient records should include a preprocedure report with a diagnosis and location. The postprocedure report should include mention of any special techniques used, anything such as actinic keratoses in the region but left behind, and a histology report.

The operative report should include the Mohs map used during the procedure with a code for the symbols depicting the inking colors used.

When physicians start a Mohs practice, they also need to keep in mind that referrals actually can drop off a little as one becomes established. That is not because one is doing anything wrong. Instead, many areas without a Mohs surgeon can have something of a backlog of cases, and once that backlog gets taken care of, business can drop off a bit, Dr. Yob said.

"Show [referring physicians] how you can do small tumors and intricate locations." DR. YOB

PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper

PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper

PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper