Aesthetic Dermatology

RHODES, GREECE — A new intralesional cryosurgery technique for targeting dermal skin lesions is safe and effective for the treatment of keloids and hypertrophic scars, Dr. Christos Zouboulis reported at the 15th Congress of the European Academy of Dermatology and Venereology.

The technique is a modified version of one first reported in 1993 and is performed using a novel intralesional cryoprobe (Etgar Group International Ltd., Israel) invented by Dr. Yaron Har-Shai of Berlin, Germany, and his associates. The probe, which is approved by the U.S. Food and Drug Administration, has an elongated, double-lumen, uninsulated needle with a safety cryogen vent and a sharp-cutting, sealed, distal tip designed to easily penetrate hard and dense dermal lesions such as keloids and hypertrophic scars.

In a pilot study of nine patients with recalcitrant auricular keloids, the proximal end of the probe was attached to an adaptor, which was connected to a standard "cryogun" cryogen source. The cryogun was filled with liquid nitrogen about 15 minutes before the procedure to allow adequate pressure to build up.

The patients were placed in the supine position, and the keloid surface was cleaned, disinfected, and draped. The area to be penetrated with the cryoprobe was intralesionally anesthetized with 1% lidocaine, and the sterile cryoprobe was forced into the long axis of the scar, with the sharp tip of the needle penetrating the distal edge of the scar.

Upon activation of the cryogun, the cryogen froze the keloids within 5–30 minutes, depending on scar volume, as iceballs appeared at each penetrating point of the cryoneedle and gradually spread toward one another. When the iceballs met, indicating complete freezing of the keloid, the cryogun was disengaged, and the cryoprobe was allowed to defrost for 1–2 minutes before being carefully withdrawn.

Treatment resulted in an average 67% reduction in scar volume at 6 months, which was maintained for up to 18 months after a single treatment. The average pretreatment scar volume was 2.89 cm

Patients also had significant reductions in scar hardness, scar elevation, and redness (average pre- and posttreatment scores of 2.9 vs. 0.50, 3.0 vs. 1.0, and 2.9 vs. 0.8, respectively). Subjective complaints were also reduced following treatment, with reductions seen in itching, pain, and tenderness (average pre- and posttreatment scores of 2.5 vs. 1.19, 2.0 vs. 0.3, and 2.3 vs. 0.4, respectively). There were no scar recurrences at 18 months' follow-up.

The treatment was generally well tolerated, Dr. Zouboulis said.

Any mild pain or discomfort that occurred during or after the procedure was easily managed. No active bleeding, infection, or adverse reactions such as hypopigmentation occurred, he noted.

The patients, seven women and two men aged 18–55 years, had a total of 10 keloids of 6 months' to 6 years' duration. The keloids, which resulted from piercings in 9 of 10 cases, and from a laceration in 1 case, had failed to respond to excision, laser surgery, surface cryosurgery, intralesional corticosteroid injections, and/or silicone ointment. The findings were reported earlier this year by Dr. Har-Shai, Dr. Zouboulis, and their associates (Wound Rep. Regen. 2006;14:18–27).

Histologic evaluation and studies of swine tissue following ex vivo intralesional cryosurgery—conducted as part of the same study in an effort to explain the mechanism of action of the cryoprobe—showed that the technique destroys the core of the scar with only small effects on surface cells, including melanocytes. The cryodamage caused by the technique is self-limited, and complete cell death is identified in the central cryolesions immediately following treatment; this suggests that direct cryothermic injury is the primary mechanism of action, the investigators explained.

The lack of hypopigmentation in this study—which might be explained by the minimal histologic changes in superficial adjacent areas of the central cryolesion, revealing a limited, demarcated, irreversible cell injury—suggests this technique might be particularly useful in patients with black or pigmented skin, who have a high prevalence of keloids, Dr. Zouboulis noted, adding that this technique and technology can be applied to scars of various shapes and contours at the ear helix and lobule, as well as in other areas of the body, as demonstrated in this and other studies.

In fact, the technology was developed for and will be studied for other indications involving deep skin lesions; keloids served as a "nondangerous proving principle" for efficacy, he explained.

"The major advantage of the intralesional cryoprobe to destroy the deeply localized target tissue with minimal effect on the superficial skin layers may have a significant importance in the future in the clinical application of cryosurgery not only in the treatment of keloids but also of other deeply localized skin lesions and tumors," he concluded.

Auricular keloids are shown at baseline (left) and after the intralesional cryosurgery technique. Photos courtesy Dr. Yaron Har-Shai

RHODES, GREECE — A new intralesional cryosurgery technique for targeting dermal skin lesions is safe and effective for the treatment of keloids and hypertrophic scars, Dr. Christos Zouboulis reported at the 15th Congress of the European Academy of Dermatology and Venereology.

The technique is a modified version of one first reported in 1993 and is performed using a novel intralesional cryoprobe (Etgar Group International Ltd., Israel) invented by Dr. Yaron Har-Shai of Berlin, Germany, and his associates. The probe, which is approved by the U.S. Food and Drug Administration, has an elongated, double-lumen, uninsulated needle with a safety cryogen vent and a sharp-cutting, sealed, distal tip designed to easily penetrate hard and dense dermal lesions such as keloids and hypertrophic scars.

In a pilot study of nine patients with recalcitrant auricular keloids, the proximal end of the probe was attached to an adaptor, which was connected to a standard "cryogun" cryogen source. The cryogun was filled with liquid nitrogen about 15 minutes before the procedure to allow adequate pressure to build up.

The patients were placed in the supine position, and the keloid surface was cleaned, disinfected, and draped. The area to be penetrated with the cryoprobe was intralesionally anesthetized with 1% lidocaine, and the sterile cryoprobe was forced into the long axis of the scar, with the sharp tip of the needle penetrating the distal edge of the scar.

Upon activation of the cryogun, the cryogen froze the keloids within 5–30 minutes, depending on scar volume, as iceballs appeared at each penetrating point of the cryoneedle and gradually spread toward one another. When the iceballs met, indicating complete freezing of the keloid, the cryogun was disengaged, and the cryoprobe was allowed to defrost for 1–2 minutes before being carefully withdrawn.

Treatment resulted in an average 67% reduction in scar volume at 6 months, which was maintained for up to 18 months after a single treatment. The average pretreatment scar volume was 2.89 cm

Patients also had significant reductions in scar hardness, scar elevation, and redness (average pre- and posttreatment scores of 2.9 vs. 0.50, 3.0 vs. 1.0, and 2.9 vs. 0.8, respectively). Subjective complaints were also reduced following treatment, with reductions seen in itching, pain, and tenderness (average pre- and posttreatment scores of 2.5 vs. 1.19, 2.0 vs. 0.3, and 2.3 vs. 0.4, respectively). There were no scar recurrences at 18 months' follow-up.

The treatment was generally well tolerated, Dr. Zouboulis said.

Any mild pain or discomfort that occurred during or after the procedure was easily managed. No active bleeding, infection, or adverse reactions such as hypopigmentation occurred, he noted.

The patients, seven women and two men aged 18–55 years, had a total of 10 keloids of 6 months' to 6 years' duration. The keloids, which resulted from piercings in 9 of 10 cases, and from a laceration in 1 case, had failed to respond to excision, laser surgery, surface cryosurgery, intralesional corticosteroid injections, and/or silicone ointment. The findings were reported earlier this year by Dr. Har-Shai, Dr. Zouboulis, and their associates (Wound Rep. Regen. 2006;14:18–27).

Histologic evaluation and studies of swine tissue following ex vivo intralesional cryosurgery—conducted as part of the same study in an effort to explain the mechanism of action of the cryoprobe—showed that the technique destroys the core of the scar with only small effects on surface cells, including melanocytes. The cryodamage caused by the technique is self-limited, and complete cell death is identified in the central cryolesions immediately following treatment; this suggests that direct cryothermic injury is the primary mechanism of action, the investigators explained.

The lack of hypopigmentation in this study—which might be explained by the minimal histologic changes in superficial adjacent areas of the central cryolesion, revealing a limited, demarcated, irreversible cell injury—suggests this technique might be particularly useful in patients with black or pigmented skin, who have a high prevalence of keloids, Dr. Zouboulis noted, adding that this technique and technology can be applied to scars of various shapes and contours at the ear helix and lobule, as well as in other areas of the body, as demonstrated in this and other studies.

In fact, the technology was developed for and will be studied for other indications involving deep skin lesions; keloids served as a "nondangerous proving principle" for efficacy, he explained.

"The major advantage of the intralesional cryoprobe to destroy the deeply localized target tissue with minimal effect on the superficial skin layers may have a significant importance in the future in the clinical application of cryosurgery not only in the treatment of keloids but also of other deeply localized skin lesions and tumors," he concluded.

Auricular keloids are shown at baseline (left) and after the intralesional cryosurgery technique. Photos courtesy Dr. Yaron Har-Shai

RHODES, GREECE — A new intralesional cryosurgery technique for targeting dermal skin lesions is safe and effective for the treatment of keloids and hypertrophic scars, Dr. Christos Zouboulis reported at the 15th Congress of the European Academy of Dermatology and Venereology.

The technique is a modified version of one first reported in 1993 and is performed using a novel intralesional cryoprobe (Etgar Group International Ltd., Israel) invented by Dr. Yaron Har-Shai of Berlin, Germany, and his associates. The probe, which is approved by the U.S. Food and Drug Administration, has an elongated, double-lumen, uninsulated needle with a safety cryogen vent and a sharp-cutting, sealed, distal tip designed to easily penetrate hard and dense dermal lesions such as keloids and hypertrophic scars.

In a pilot study of nine patients with recalcitrant auricular keloids, the proximal end of the probe was attached to an adaptor, which was connected to a standard "cryogun" cryogen source. The cryogun was filled with liquid nitrogen about 15 minutes before the procedure to allow adequate pressure to build up.

The patients were placed in the supine position, and the keloid surface was cleaned, disinfected, and draped. The area to be penetrated with the cryoprobe was intralesionally anesthetized with 1% lidocaine, and the sterile cryoprobe was forced into the long axis of the scar, with the sharp tip of the needle penetrating the distal edge of the scar.

Upon activation of the cryogun, the cryogen froze the keloids within 5–30 minutes, depending on scar volume, as iceballs appeared at each penetrating point of the cryoneedle and gradually spread toward one another. When the iceballs met, indicating complete freezing of the keloid, the cryogun was disengaged, and the cryoprobe was allowed to defrost for 1–2 minutes before being carefully withdrawn.

Treatment resulted in an average 67% reduction in scar volume at 6 months, which was maintained for up to 18 months after a single treatment. The average pretreatment scar volume was 2.89 cm

Patients also had significant reductions in scar hardness, scar elevation, and redness (average pre- and posttreatment scores of 2.9 vs. 0.50, 3.0 vs. 1.0, and 2.9 vs. 0.8, respectively). Subjective complaints were also reduced following treatment, with reductions seen in itching, pain, and tenderness (average pre- and posttreatment scores of 2.5 vs. 1.19, 2.0 vs. 0.3, and 2.3 vs. 0.4, respectively). There were no scar recurrences at 18 months' follow-up.

The treatment was generally well tolerated, Dr. Zouboulis said.

Any mild pain or discomfort that occurred during or after the procedure was easily managed. No active bleeding, infection, or adverse reactions such as hypopigmentation occurred, he noted.

The patients, seven women and two men aged 18–55 years, had a total of 10 keloids of 6 months' to 6 years' duration. The keloids, which resulted from piercings in 9 of 10 cases, and from a laceration in 1 case, had failed to respond to excision, laser surgery, surface cryosurgery, intralesional corticosteroid injections, and/or silicone ointment. The findings were reported earlier this year by Dr. Har-Shai, Dr. Zouboulis, and their associates (Wound Rep. Regen. 2006;14:18–27).

Histologic evaluation and studies of swine tissue following ex vivo intralesional cryosurgery—conducted as part of the same study in an effort to explain the mechanism of action of the cryoprobe—showed that the technique destroys the core of the scar with only small effects on surface cells, including melanocytes. The cryodamage caused by the technique is self-limited, and complete cell death is identified in the central cryolesions immediately following treatment; this suggests that direct cryothermic injury is the primary mechanism of action, the investigators explained.

The lack of hypopigmentation in this study—which might be explained by the minimal histologic changes in superficial adjacent areas of the central cryolesion, revealing a limited, demarcated, irreversible cell injury—suggests this technique might be particularly useful in patients with black or pigmented skin, who have a high prevalence of keloids, Dr. Zouboulis noted, adding that this technique and technology can be applied to scars of various shapes and contours at the ear helix and lobule, as well as in other areas of the body, as demonstrated in this and other studies.

In fact, the technology was developed for and will be studied for other indications involving deep skin lesions; keloids served as a "nondangerous proving principle" for efficacy, he explained.

"The major advantage of the intralesional cryoprobe to destroy the deeply localized target tissue with minimal effect on the superficial skin layers may have a significant importance in the future in the clinical application of cryosurgery not only in the treatment of keloids but also of other deeply localized skin lesions and tumors," he concluded.

Auricular keloids are shown at baseline (left) and after the intralesional cryosurgery technique. Photos courtesy Dr. Yaron Har-Shai

LAS VEGAS — Chemoprevention with photodynamic therapy is encouraging—the therapy increases the time it takes actinic keratoses to develop into skin cancer, according to anecdotal data and preliminary results of larger trials.

Chemoprevention is the most important indication for photodynamic therapy (PDT), Dr. Michael H. Gold said at an international symposium on cosmetic and laser surgery.

Initial reports indicate efficacy for basal cell carcinoma, especially superficial lesions, and researchers have reported improvements to nodular basal cell and ulcerative basal cell lesions.

"PDT is wonderful for basal cell carcinoma on the ear. Mohs surgeons don't want to touch it, and my only other option is radiation," said Dr. Gold, who is in private practice in Nashville, Tenn., and is also with Vanderbilt University, Nashville.

Methyl-aminolevulinic HCl (Metvixia/PhotoCure, Galderma) and 5-aminolevulinic acid (ALA) (Levulan Kerastick, Dusa Pharmaceuticals) are the two photosensitizers generally studied for use with photodynamic therapy. Dr. Gold is a researcher, speaker, and consultant for Dusa.

ALA is approved for the treatment of precancerous actinic keratoses on the face and scalp. The product is being developed for the treatment of acne and photodamage, according to the manufacturer's Web site. Methyl-aminolevulinic HCl (methyl-ALA) is approved in the United States for treatment of nonhyperkeratotic actinic keratoses. The product is marketed in Europe as Metvix and carries an additional indication for basal cell carcinoma unsuitable for conventional therapy.

"What is interesting is what has been done with Metvix," Dr. Gold said. There has been a great deal of "very good work done in Europe with Metvix for actinic keratoses and Bowen's disease. It is now the treatment of choice in Europe for Bowen's disease."

There are two very interesting studies in Europe looking at immunosuppressed organ transplant patients treated with methyl-ALA, Dr. Gold said.

In one study, a single treatment with methyl-ALA/PDT delayed development of actinic keratoses for 9.6 months, versus 6.8 months in untreated patients (Acta. Derm. Venereol. 2006;86:25–8). The second study is an ongoing multicenter trial with 81 transplant patients enrolled to date who were treated with either methyl-ALA/PDT or cryotherapy. There was a significantly lower number of actinic keratoses in the areas treated with methyl-ALA/PDT, according to preliminary findings presented at the 10th World Congress on Cancers of the Skin in Vienna in 2005.

European research includes reports of two patients who had an allergic contact dermatitis reaction to methyl-ALA but not ALA (Br. J. Dermatol. 2004;150:143–5). "So keep this in mind in the United States," Dr. Gold said.

In a study of 69 patients with multiple actinic keratoses on their faces, patients receiving PDT with methyl-ALA reported less pain on a 0–10 scale compared with a PDT/ALA combination (J. Drugs Dermatol. 2006;5:353–6).

A second investigation compared PDT with ALA or methyl-ALA for inflammatory acne vulgaris (J. Am. Acad. Dermatol. 2006;54:647–51). This split-face study with 15 participants found no differences in response rates but more prolonged and severe adverse effects on the ALA-treated side. The treatment protocol was not a fair comparison, Dr. Gold said, which "is important to understand. The authors stated the ALA side will give you as much, if not more, adverse events than the methyl-ALA. But you cannot compare apples to oranges as they did this in the study.

"My response to both of these articles is, basically, you cannot compare short-term application of ALA, where we have no problems, to long-term methyl-ALA under occlusion, where we have problems," Dr. Gold said.

LAS VEGAS — Chemoprevention with photodynamic therapy is encouraging—the therapy increases the time it takes actinic keratoses to develop into skin cancer, according to anecdotal data and preliminary results of larger trials.

Chemoprevention is the most important indication for photodynamic therapy (PDT), Dr. Michael H. Gold said at an international symposium on cosmetic and laser surgery.

Initial reports indicate efficacy for basal cell carcinoma, especially superficial lesions, and researchers have reported improvements to nodular basal cell and ulcerative basal cell lesions.

"PDT is wonderful for basal cell carcinoma on the ear. Mohs surgeons don't want to touch it, and my only other option is radiation," said Dr. Gold, who is in private practice in Nashville, Tenn., and is also with Vanderbilt University, Nashville.

Methyl-aminolevulinic HCl (Metvixia/PhotoCure, Galderma) and 5-aminolevulinic acid (ALA) (Levulan Kerastick, Dusa Pharmaceuticals) are the two photosensitizers generally studied for use with photodynamic therapy. Dr. Gold is a researcher, speaker, and consultant for Dusa.

ALA is approved for the treatment of precancerous actinic keratoses on the face and scalp. The product is being developed for the treatment of acne and photodamage, according to the manufacturer's Web site. Methyl-aminolevulinic HCl (methyl-ALA) is approved in the United States for treatment of nonhyperkeratotic actinic keratoses. The product is marketed in Europe as Metvix and carries an additional indication for basal cell carcinoma unsuitable for conventional therapy.

"What is interesting is what has been done with Metvix," Dr. Gold said. There has been a great deal of "very good work done in Europe with Metvix for actinic keratoses and Bowen's disease. It is now the treatment of choice in Europe for Bowen's disease."

There are two very interesting studies in Europe looking at immunosuppressed organ transplant patients treated with methyl-ALA, Dr. Gold said.

In one study, a single treatment with methyl-ALA/PDT delayed development of actinic keratoses for 9.6 months, versus 6.8 months in untreated patients (Acta. Derm. Venereol. 2006;86:25–8). The second study is an ongoing multicenter trial with 81 transplant patients enrolled to date who were treated with either methyl-ALA/PDT or cryotherapy. There was a significantly lower number of actinic keratoses in the areas treated with methyl-ALA/PDT, according to preliminary findings presented at the 10th World Congress on Cancers of the Skin in Vienna in 2005.

European research includes reports of two patients who had an allergic contact dermatitis reaction to methyl-ALA but not ALA (Br. J. Dermatol. 2004;150:143–5). "So keep this in mind in the United States," Dr. Gold said.

In a study of 69 patients with multiple actinic keratoses on their faces, patients receiving PDT with methyl-ALA reported less pain on a 0–10 scale compared with a PDT/ALA combination (J. Drugs Dermatol. 2006;5:353–6).

A second investigation compared PDT with ALA or methyl-ALA for inflammatory acne vulgaris (J. Am. Acad. Dermatol. 2006;54:647–51). This split-face study with 15 participants found no differences in response rates but more prolonged and severe adverse effects on the ALA-treated side. The treatment protocol was not a fair comparison, Dr. Gold said, which "is important to understand. The authors stated the ALA side will give you as much, if not more, adverse events than the methyl-ALA. But you cannot compare apples to oranges as they did this in the study.

"My response to both of these articles is, basically, you cannot compare short-term application of ALA, where we have no problems, to long-term methyl-ALA under occlusion, where we have problems," Dr. Gold said.

LAS VEGAS — Chemoprevention with photodynamic therapy is encouraging—the therapy increases the time it takes actinic keratoses to develop into skin cancer, according to anecdotal data and preliminary results of larger trials.

Chemoprevention is the most important indication for photodynamic therapy (PDT), Dr. Michael H. Gold said at an international symposium on cosmetic and laser surgery.

Initial reports indicate efficacy for basal cell carcinoma, especially superficial lesions, and researchers have reported improvements to nodular basal cell and ulcerative basal cell lesions.

"PDT is wonderful for basal cell carcinoma on the ear. Mohs surgeons don't want to touch it, and my only other option is radiation," said Dr. Gold, who is in private practice in Nashville, Tenn., and is also with Vanderbilt University, Nashville.

Methyl-aminolevulinic HCl (Metvixia/PhotoCure, Galderma) and 5-aminolevulinic acid (ALA) (Levulan Kerastick, Dusa Pharmaceuticals) are the two photosensitizers generally studied for use with photodynamic therapy. Dr. Gold is a researcher, speaker, and consultant for Dusa.

ALA is approved for the treatment of precancerous actinic keratoses on the face and scalp. The product is being developed for the treatment of acne and photodamage, according to the manufacturer's Web site. Methyl-aminolevulinic HCl (methyl-ALA) is approved in the United States for treatment of nonhyperkeratotic actinic keratoses. The product is marketed in Europe as Metvix and carries an additional indication for basal cell carcinoma unsuitable for conventional therapy.

"What is interesting is what has been done with Metvix," Dr. Gold said. There has been a great deal of "very good work done in Europe with Metvix for actinic keratoses and Bowen's disease. It is now the treatment of choice in Europe for Bowen's disease."

There are two very interesting studies in Europe looking at immunosuppressed organ transplant patients treated with methyl-ALA, Dr. Gold said.

In one study, a single treatment with methyl-ALA/PDT delayed development of actinic keratoses for 9.6 months, versus 6.8 months in untreated patients (Acta. Derm. Venereol. 2006;86:25–8). The second study is an ongoing multicenter trial with 81 transplant patients enrolled to date who were treated with either methyl-ALA/PDT or cryotherapy. There was a significantly lower number of actinic keratoses in the areas treated with methyl-ALA/PDT, according to preliminary findings presented at the 10th World Congress on Cancers of the Skin in Vienna in 2005.

European research includes reports of two patients who had an allergic contact dermatitis reaction to methyl-ALA but not ALA (Br. J. Dermatol. 2004;150:143–5). "So keep this in mind in the United States," Dr. Gold said.

In a study of 69 patients with multiple actinic keratoses on their faces, patients receiving PDT with methyl-ALA reported less pain on a 0–10 scale compared with a PDT/ALA combination (J. Drugs Dermatol. 2006;5:353–6).

A second investigation compared PDT with ALA or methyl-ALA for inflammatory acne vulgaris (J. Am. Acad. Dermatol. 2006;54:647–51). This split-face study with 15 participants found no differences in response rates but more prolonged and severe adverse effects on the ALA-treated side. The treatment protocol was not a fair comparison, Dr. Gold said, which "is important to understand. The authors stated the ALA side will give you as much, if not more, adverse events than the methyl-ALA. But you cannot compare apples to oranges as they did this in the study.

"My response to both of these articles is, basically, you cannot compare short-term application of ALA, where we have no problems, to long-term methyl-ALA under occlusion, where we have problems," Dr. Gold said.

SAN DIEGO — Physicians should think outside the liposuction box when it comes to using tumescent anesthesia in dermatologic surgery practices, Dr. Jeffrey A. Klein said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Excisions, Mohs surgery, lipoma removal, breast reduction, and intravascular vein ablation all lend themselves well to the use of tumescent anesthesia, according to the discoverer of the technique.

Besides providing long-lasting and profound local anesthesia, bactericidal protection, and elevation of tissues for delicate procedures, the tumescent technique offers "exquisite hemostasis," said Dr. Klein, a dermatologic surgeon in San Juan Capistrano, Calif., who is credited with revolutionizing the safety of liposuction anesthesia by pioneering the use of dilute concentrations of lidocaine and epinephrine in saline with sodium bicarbonate.

"I'm really impressed at how little blood loss there is," he said.

In laser and radiofrequency procedures, tumescent liposuction acts as a heat sink. For excisions or Mohs surgery on the neck or face, it can lift lesions safely away from superficial nerve branches, he pointed out.

It can be used in conjunction with dissection with blunt liposuction cannulas to separate fibrous, multilobular lipomas from surrounding tissue so they can be easily excised. In Germany, it is being used to perform sentinel lymph node biopsies on melanoma patients.

Dr. Klein outlined examples of numerous dermatologic procedures he has performed with tumescent liposuction, from the extraction of excess glandular tissue through the nipple of a patient with male gynecomastia to the excision of a large melanoma down to fascia.

Mohs surgery of a large, recurrent basal cell carcinoma can be accomplished as "essentially a painless procedure" during which the patient remains awake, he said.

The lack of infections seen following liposuction—just 1 in more than 6,000 procedures performed by Dr. Klein—suggests that "there must be a very substantial bacteriocidal effect" of tumescent solution, he said.

Obviously, much smaller volumes of tumescent fluid are utilized in these other procedures than are needed in large liposuction cases, but the ratio of the ingredients in the formula remains the same. (See box.)

Once the area is infiltrated, "you need to allow time for detumescence to occur," said Dr. Klein.

In large abdominal liposuction cases, this process ideally should occur over the course of an hour. For smaller dermatologic surgery cases, the procedure should be delayed for at least 15–30 minutes for fluids to drain away and the architecture of the lesion to be restored.

Recovery following cases in which tumescent anesthesia is used is remarkably quick, with patients most likely able to return to work within a day, even following large excisions.

Dr. Klein noted that tumescent anesthesia has been widely adopted by other specialties and is commonly used in stem cell harvesting and vein, breast, burn, craniofacial, and rectal surgery.

Small-Volume Tumescent Recipe

A 100-mL formulation of tumescent local anesthesia (TLA) consists of approximately 0.25% lidocaine and epinephrine 1:400,000. To prepare this formulation, use:

▸ 100-mL bag of sodium chloride 0.9%.

▸ 300 mg lidocaine and 0.3 mg epinephrine (30 mL of 1% lidocaine with epinephrine 1:100,000).

▸ 3 mEq sodium bicarbonate (3 mL of 8.4% sodium bicarbonate).

On the day of surgery, a nurse prepares and labels the bag of TLA immediately after the patient arrives. For safety reasons, TLA should never be mixed 1 or more days before the day of surgery. Every bag of TLA should be well labeled at the time of its preparation.

Source: Dr. Klein

SAN DIEGO — Physicians should think outside the liposuction box when it comes to using tumescent anesthesia in dermatologic surgery practices, Dr. Jeffrey A. Klein said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Excisions, Mohs surgery, lipoma removal, breast reduction, and intravascular vein ablation all lend themselves well to the use of tumescent anesthesia, according to the discoverer of the technique.

Besides providing long-lasting and profound local anesthesia, bactericidal protection, and elevation of tissues for delicate procedures, the tumescent technique offers "exquisite hemostasis," said Dr. Klein, a dermatologic surgeon in San Juan Capistrano, Calif., who is credited with revolutionizing the safety of liposuction anesthesia by pioneering the use of dilute concentrations of lidocaine and epinephrine in saline with sodium bicarbonate.

"I'm really impressed at how little blood loss there is," he said.

In laser and radiofrequency procedures, tumescent liposuction acts as a heat sink. For excisions or Mohs surgery on the neck or face, it can lift lesions safely away from superficial nerve branches, he pointed out.

It can be used in conjunction with dissection with blunt liposuction cannulas to separate fibrous, multilobular lipomas from surrounding tissue so they can be easily excised. In Germany, it is being used to perform sentinel lymph node biopsies on melanoma patients.

Dr. Klein outlined examples of numerous dermatologic procedures he has performed with tumescent liposuction, from the extraction of excess glandular tissue through the nipple of a patient with male gynecomastia to the excision of a large melanoma down to fascia.

Mohs surgery of a large, recurrent basal cell carcinoma can be accomplished as "essentially a painless procedure" during which the patient remains awake, he said.

The lack of infections seen following liposuction—just 1 in more than 6,000 procedures performed by Dr. Klein—suggests that "there must be a very substantial bacteriocidal effect" of tumescent solution, he said.

Obviously, much smaller volumes of tumescent fluid are utilized in these other procedures than are needed in large liposuction cases, but the ratio of the ingredients in the formula remains the same. (See box.)

Once the area is infiltrated, "you need to allow time for detumescence to occur," said Dr. Klein.

In large abdominal liposuction cases, this process ideally should occur over the course of an hour. For smaller dermatologic surgery cases, the procedure should be delayed for at least 15–30 minutes for fluids to drain away and the architecture of the lesion to be restored.

Recovery following cases in which tumescent anesthesia is used is remarkably quick, with patients most likely able to return to work within a day, even following large excisions.

Dr. Klein noted that tumescent anesthesia has been widely adopted by other specialties and is commonly used in stem cell harvesting and vein, breast, burn, craniofacial, and rectal surgery.

Small-Volume Tumescent Recipe

A 100-mL formulation of tumescent local anesthesia (TLA) consists of approximately 0.25% lidocaine and epinephrine 1:400,000. To prepare this formulation, use:

▸ 100-mL bag of sodium chloride 0.9%.

▸ 300 mg lidocaine and 0.3 mg epinephrine (30 mL of 1% lidocaine with epinephrine 1:100,000).

▸ 3 mEq sodium bicarbonate (3 mL of 8.4% sodium bicarbonate).

On the day of surgery, a nurse prepares and labels the bag of TLA immediately after the patient arrives. For safety reasons, TLA should never be mixed 1 or more days before the day of surgery. Every bag of TLA should be well labeled at the time of its preparation.

Source: Dr. Klein

SAN DIEGO — Physicians should think outside the liposuction box when it comes to using tumescent anesthesia in dermatologic surgery practices, Dr. Jeffrey A. Klein said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Excisions, Mohs surgery, lipoma removal, breast reduction, and intravascular vein ablation all lend themselves well to the use of tumescent anesthesia, according to the discoverer of the technique.

Besides providing long-lasting and profound local anesthesia, bactericidal protection, and elevation of tissues for delicate procedures, the tumescent technique offers "exquisite hemostasis," said Dr. Klein, a dermatologic surgeon in San Juan Capistrano, Calif., who is credited with revolutionizing the safety of liposuction anesthesia by pioneering the use of dilute concentrations of lidocaine and epinephrine in saline with sodium bicarbonate.

"I'm really impressed at how little blood loss there is," he said.

In laser and radiofrequency procedures, tumescent liposuction acts as a heat sink. For excisions or Mohs surgery on the neck or face, it can lift lesions safely away from superficial nerve branches, he pointed out.

It can be used in conjunction with dissection with blunt liposuction cannulas to separate fibrous, multilobular lipomas from surrounding tissue so they can be easily excised. In Germany, it is being used to perform sentinel lymph node biopsies on melanoma patients.

Dr. Klein outlined examples of numerous dermatologic procedures he has performed with tumescent liposuction, from the extraction of excess glandular tissue through the nipple of a patient with male gynecomastia to the excision of a large melanoma down to fascia.

Mohs surgery of a large, recurrent basal cell carcinoma can be accomplished as "essentially a painless procedure" during which the patient remains awake, he said.

The lack of infections seen following liposuction—just 1 in more than 6,000 procedures performed by Dr. Klein—suggests that "there must be a very substantial bacteriocidal effect" of tumescent solution, he said.

Obviously, much smaller volumes of tumescent fluid are utilized in these other procedures than are needed in large liposuction cases, but the ratio of the ingredients in the formula remains the same. (See box.)

Once the area is infiltrated, "you need to allow time for detumescence to occur," said Dr. Klein.

In large abdominal liposuction cases, this process ideally should occur over the course of an hour. For smaller dermatologic surgery cases, the procedure should be delayed for at least 15–30 minutes for fluids to drain away and the architecture of the lesion to be restored.

Recovery following cases in which tumescent anesthesia is used is remarkably quick, with patients most likely able to return to work within a day, even following large excisions.

Dr. Klein noted that tumescent anesthesia has been widely adopted by other specialties and is commonly used in stem cell harvesting and vein, breast, burn, craniofacial, and rectal surgery.

Small-Volume Tumescent Recipe

A 100-mL formulation of tumescent local anesthesia (TLA) consists of approximately 0.25% lidocaine and epinephrine 1:400,000. To prepare this formulation, use:

▸ 100-mL bag of sodium chloride 0.9%.

▸ 300 mg lidocaine and 0.3 mg epinephrine (30 mL of 1% lidocaine with epinephrine 1:100,000).

▸ 3 mEq sodium bicarbonate (3 mL of 8.4% sodium bicarbonate).

On the day of surgery, a nurse prepares and labels the bag of TLA immediately after the patient arrives. For safety reasons, TLA should never be mixed 1 or more days before the day of surgery. Every bag of TLA should be well labeled at the time of its preparation.

Source: Dr. Klein

SAN DIEGO — A novel pneumatic skin-flattening device may reduce the pain associated with laser or light-source hair removal treatments, although comprehensive data are not yet available to verify the results, said Dr. Gary Lask at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The device generates negative pressure of 600 mm Hg when the skin surface is elevated using compression and suction, which flattens the skin surface and causes expulsion of blood into surrounding tissues. This allows for less absorption of laser or light energy by competing chromophores during hair removal procedures, as well as the potential for less erythema, he explained. It appears to reduce pain "by way of the gate theory: afferent inhibition of sensory nerves of the dorsal horn," said Dr. Lask, director of dermatologic surgery and the dermatology laser center at the University of California, Los Angeles.

Patients treated with various hair removal sources and the adjunctive skin-flattening device had "no pain whatsoever" in Dr. Lask's practice, even though no topical anesthetic was used, he said. Early results from Israeli researchers suggest that the device may produce "a little more efficacious" reduction of hair growth, less pain, and less erythema than hair removal devices can achieve on their own, he said.

Other surgeons at the conference expressed interest in the device's mechanism of action, which they said makes more scientific sense than some explanations for how various light and energy sources and devices can supposedly plump, compress, and tighten skin; erase wrinkles; and remove cellulite. In a general overview of such devices, Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, scoffed, "There is far too much sucking and blowing going on here."

Dr. Lask good-naturedly encouraged Dr. Zachary to keep an open mind about the pneumatic skin-flattening device: "Just because a machine sucks doesn't mean it doesn't work."

Dr. Lask disclosed that he has a commercial interest in the device's manufacturer, Inolase Ltd. of Netanya, Israel. He chairs the company's advisory board.

Hair removal remains a highly popular in-office cosmetic procedure, but it is not without drawbacks, including pain that can be considerable. Despite a generally safe track record, hair removal procedures constitute a sizable proportion of the medicolegal cases Dr. Lask reviews each year. "Most of your complications are at higher energy levels. If you can theoretically get the same results with lower power, you should minimize your complications," he said.

The pneumatic device, by better targeting hair follicles, might have the potential to accomplish this goal, he said.

'There is far too much sucking and blowing going on' with the various light and energy devices. DR. ZACHARY

SAN DIEGO — A novel pneumatic skin-flattening device may reduce the pain associated with laser or light-source hair removal treatments, although comprehensive data are not yet available to verify the results, said Dr. Gary Lask at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The device generates negative pressure of 600 mm Hg when the skin surface is elevated using compression and suction, which flattens the skin surface and causes expulsion of blood into surrounding tissues. This allows for less absorption of laser or light energy by competing chromophores during hair removal procedures, as well as the potential for less erythema, he explained. It appears to reduce pain "by way of the gate theory: afferent inhibition of sensory nerves of the dorsal horn," said Dr. Lask, director of dermatologic surgery and the dermatology laser center at the University of California, Los Angeles.

Patients treated with various hair removal sources and the adjunctive skin-flattening device had "no pain whatsoever" in Dr. Lask's practice, even though no topical anesthetic was used, he said. Early results from Israeli researchers suggest that the device may produce "a little more efficacious" reduction of hair growth, less pain, and less erythema than hair removal devices can achieve on their own, he said.

Other surgeons at the conference expressed interest in the device's mechanism of action, which they said makes more scientific sense than some explanations for how various light and energy sources and devices can supposedly plump, compress, and tighten skin; erase wrinkles; and remove cellulite. In a general overview of such devices, Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, scoffed, "There is far too much sucking and blowing going on here."

Dr. Lask good-naturedly encouraged Dr. Zachary to keep an open mind about the pneumatic skin-flattening device: "Just because a machine sucks doesn't mean it doesn't work."

Dr. Lask disclosed that he has a commercial interest in the device's manufacturer, Inolase Ltd. of Netanya, Israel. He chairs the company's advisory board.

Hair removal remains a highly popular in-office cosmetic procedure, but it is not without drawbacks, including pain that can be considerable. Despite a generally safe track record, hair removal procedures constitute a sizable proportion of the medicolegal cases Dr. Lask reviews each year. "Most of your complications are at higher energy levels. If you can theoretically get the same results with lower power, you should minimize your complications," he said.

The pneumatic device, by better targeting hair follicles, might have the potential to accomplish this goal, he said.

'There is far too much sucking and blowing going on' with the various light and energy devices. DR. ZACHARY

SAN DIEGO — A novel pneumatic skin-flattening device may reduce the pain associated with laser or light-source hair removal treatments, although comprehensive data are not yet available to verify the results, said Dr. Gary Lask at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The device generates negative pressure of 600 mm Hg when the skin surface is elevated using compression and suction, which flattens the skin surface and causes expulsion of blood into surrounding tissues. This allows for less absorption of laser or light energy by competing chromophores during hair removal procedures, as well as the potential for less erythema, he explained. It appears to reduce pain "by way of the gate theory: afferent inhibition of sensory nerves of the dorsal horn," said Dr. Lask, director of dermatologic surgery and the dermatology laser center at the University of California, Los Angeles.

Patients treated with various hair removal sources and the adjunctive skin-flattening device had "no pain whatsoever" in Dr. Lask's practice, even though no topical anesthetic was used, he said. Early results from Israeli researchers suggest that the device may produce "a little more efficacious" reduction of hair growth, less pain, and less erythema than hair removal devices can achieve on their own, he said.

Other surgeons at the conference expressed interest in the device's mechanism of action, which they said makes more scientific sense than some explanations for how various light and energy sources and devices can supposedly plump, compress, and tighten skin; erase wrinkles; and remove cellulite. In a general overview of such devices, Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, scoffed, "There is far too much sucking and blowing going on here."

Dr. Lask good-naturedly encouraged Dr. Zachary to keep an open mind about the pneumatic skin-flattening device: "Just because a machine sucks doesn't mean it doesn't work."

Dr. Lask disclosed that he has a commercial interest in the device's manufacturer, Inolase Ltd. of Netanya, Israel. He chairs the company's advisory board.

Hair removal remains a highly popular in-office cosmetic procedure, but it is not without drawbacks, including pain that can be considerable. Despite a generally safe track record, hair removal procedures constitute a sizable proportion of the medicolegal cases Dr. Lask reviews each year. "Most of your complications are at higher energy levels. If you can theoretically get the same results with lower power, you should minimize your complications," he said.

The pneumatic device, by better targeting hair follicles, might have the potential to accomplish this goal, he said.

'There is far too much sucking and blowing going on' with the various light and energy devices. DR. ZACHARY