Aesthetic Dermatology

NASHVILLE, TENN. — Maggots provide a gentle and safe "biological debridement" of refractory wounds and can promote wound healing.

Using maggots to clear infection and dead tissue from a wound is cost effective, usually painless, and well received by patients and their families, Dr. Aletha W. Tippett said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

Since she started using maggot therapy in 2001, Dr. Tippett has treated more than 100 patients.

Perhaps the only drawback to using maggot treatment is that it is time sensitive and requires planning. The single commercial source of medical maggots in the United States is Monarch Labs in Irvine, Calif. Maggots can be ordered on Monday through Thursday for next-day delivery. Each vial contains about 250–500 larvae and costs about $100, explained Dr. Tippett, who serves as medical director of the Hospice of Southwest Ohio in Cincinnati.

Medical maggots are larvae of the green blowfly, Phaenicia sericata. This treatment received approval by the Food and Drug Administration in 2004.

The dosage is 10 larvae for each cubic centimeter of wound. Dr. Tippett constructs a retention dressing out of chiffon and a nylon footie. A cycle of treatment lasts for 48 hours, after which the larvae are rinsed off as they enter the pupal stage of their life cycle.

A typical wound requires one to six cycles of treatment. Sometimes the treatment cycles are applied one after another, while in other cases Dr. Tippett waits a day or so between the cycles.

Dr. Tippett said that she has not had a patient who was not helped by maggot therapy.

In several cases, severe and infected wounds that she did not believe would heal did in fact heal with maggot therapy.

Not only do the maggots remove dead and infected tissue, but they appear to release growth factors that promote wound healing, Dr. Tippett noted.

Dr. Tippett said that she bills for this treatment as surgical debridement under Medicare Part B. Although Medicare and other insurers will pay for the physician's services, they will not yet pay for the maggots. Some hospices have paid for the maggots; sometimes Dr. Tippett pays for them herself.

This wound on the foot of a 93-year-old woman had not healed for over a year.

Medical maggots (Phaenicia sericata) are seen on the wound during treatment.

The wound has healed 6 weeks after the "biological debridement." Photos courtesy Dr. Aletha W. Tippett

NASHVILLE, TENN. — Maggots provide a gentle and safe "biological debridement" of refractory wounds and can promote wound healing.

Using maggots to clear infection and dead tissue from a wound is cost effective, usually painless, and well received by patients and their families, Dr. Aletha W. Tippett said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

Since she started using maggot therapy in 2001, Dr. Tippett has treated more than 100 patients.

Perhaps the only drawback to using maggot treatment is that it is time sensitive and requires planning. The single commercial source of medical maggots in the United States is Monarch Labs in Irvine, Calif. Maggots can be ordered on Monday through Thursday for next-day delivery. Each vial contains about 250–500 larvae and costs about $100, explained Dr. Tippett, who serves as medical director of the Hospice of Southwest Ohio in Cincinnati.

Medical maggots are larvae of the green blowfly, Phaenicia sericata. This treatment received approval by the Food and Drug Administration in 2004.

The dosage is 10 larvae for each cubic centimeter of wound. Dr. Tippett constructs a retention dressing out of chiffon and a nylon footie. A cycle of treatment lasts for 48 hours, after which the larvae are rinsed off as they enter the pupal stage of their life cycle.

A typical wound requires one to six cycles of treatment. Sometimes the treatment cycles are applied one after another, while in other cases Dr. Tippett waits a day or so between the cycles.

Dr. Tippett said that she has not had a patient who was not helped by maggot therapy.

In several cases, severe and infected wounds that she did not believe would heal did in fact heal with maggot therapy.

Not only do the maggots remove dead and infected tissue, but they appear to release growth factors that promote wound healing, Dr. Tippett noted.

Dr. Tippett said that she bills for this treatment as surgical debridement under Medicare Part B. Although Medicare and other insurers will pay for the physician's services, they will not yet pay for the maggots. Some hospices have paid for the maggots; sometimes Dr. Tippett pays for them herself.

This wound on the foot of a 93-year-old woman had not healed for over a year.

Medical maggots (Phaenicia sericata) are seen on the wound during treatment.

The wound has healed 6 weeks after the "biological debridement." Photos courtesy Dr. Aletha W. Tippett

NASHVILLE, TENN. — Maggots provide a gentle and safe "biological debridement" of refractory wounds and can promote wound healing.

Using maggots to clear infection and dead tissue from a wound is cost effective, usually painless, and well received by patients and their families, Dr. Aletha W. Tippett said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

Since she started using maggot therapy in 2001, Dr. Tippett has treated more than 100 patients.

Perhaps the only drawback to using maggot treatment is that it is time sensitive and requires planning. The single commercial source of medical maggots in the United States is Monarch Labs in Irvine, Calif. Maggots can be ordered on Monday through Thursday for next-day delivery. Each vial contains about 250–500 larvae and costs about $100, explained Dr. Tippett, who serves as medical director of the Hospice of Southwest Ohio in Cincinnati.

Medical maggots are larvae of the green blowfly, Phaenicia sericata. This treatment received approval by the Food and Drug Administration in 2004.

The dosage is 10 larvae for each cubic centimeter of wound. Dr. Tippett constructs a retention dressing out of chiffon and a nylon footie. A cycle of treatment lasts for 48 hours, after which the larvae are rinsed off as they enter the pupal stage of their life cycle.

A typical wound requires one to six cycles of treatment. Sometimes the treatment cycles are applied one after another, while in other cases Dr. Tippett waits a day or so between the cycles.

Dr. Tippett said that she has not had a patient who was not helped by maggot therapy.

In several cases, severe and infected wounds that she did not believe would heal did in fact heal with maggot therapy.

Not only do the maggots remove dead and infected tissue, but they appear to release growth factors that promote wound healing, Dr. Tippett noted.

Dr. Tippett said that she bills for this treatment as surgical debridement under Medicare Part B. Although Medicare and other insurers will pay for the physician's services, they will not yet pay for the maggots. Some hospices have paid for the maggots; sometimes Dr. Tippett pays for them herself.

This wound on the foot of a 93-year-old woman had not healed for over a year.

Medical maggots (Phaenicia sericata) are seen on the wound during treatment.

The wound has healed 6 weeks after the "biological debridement." Photos courtesy Dr. Aletha W. Tippett

ORLANDO — Low-level energy is an effective technique for enhancing wound healing, said Dr. Robert F. Jackson, who offered a few postsurgery tips at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Jackson, a practicing cosmetic surgeon in Marion, Ind., focused on the use of ultrasonic massage, electrical stimulation, and low-level laser therapy.

After liposuction, external ultrasonic massage can correct minor irregularities, decrease edema, and help prevent long-term induration, he said. The therapy also stimulates tissue and wound healing.

Dr. Jackson typically starts this therapy 1 week after surgery and treats patients twice weekly until the induration is gone. He uses a level of 2 W/cm

"If you've got induration that you haven't really treated for a long time, you can still treat it, but at that point you'll also have to mechanically stretch the tissue as you use the ultrasonic therapy," Dr. Jackson said.

"It's a very good marketing tool-my patients enjoy it," he said.

When used after cosmetic surgery procedures, electric stimulation improves blood flow, increases wound tensile strength, reduces edema, inhibits bacterial growth, and reduces pain. The primary purpose, however, is to reduce postoperative pain and edema, Dr. Jackson said. Electric stimulation immediately reduces swelling and improves wound healing. And ultimately, the technique improves the end result of the surgery.

"The Department of Health and Human Services tested all of the adjunctive therapies for pressure sores. … The only [therapy] they recommended for wound care management was the use of electric stimulation," he said.

Dr. Jackson typically starts this therapy the day after surgery and treats patients twice a week in 20-minute sessions until the wounds are satisfactorily healed. He recommends starting with an intensity of 100 pulses per second and increasing the intensity until the patient can feel the pulsation. Use this intensity for a few minutes and then increase the intensity until it just becomes uncomfortable for the patient. Then reduce the intensity gradually.

Low-level laser therapy is a relatively new modality that involves the application of low-power monochromatic and coherent light to injuries and lesions. This therapy is believed to promote blood vessel growth. Dr. Jackson uses low-level laser therapy for wound and ulcer healing. The therapy also reduces pain after surgery.

He uses a 635-nm laser for 8 minutes to enhance wound healing. For incision healing, he treats patients once or twice weekly for 3 weeks. Treatments for ulcers continue until healing is complete.

ORLANDO — Low-level energy is an effective technique for enhancing wound healing, said Dr. Robert F. Jackson, who offered a few postsurgery tips at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Jackson, a practicing cosmetic surgeon in Marion, Ind., focused on the use of ultrasonic massage, electrical stimulation, and low-level laser therapy.

After liposuction, external ultrasonic massage can correct minor irregularities, decrease edema, and help prevent long-term induration, he said. The therapy also stimulates tissue and wound healing.

Dr. Jackson typically starts this therapy 1 week after surgery and treats patients twice weekly until the induration is gone. He uses a level of 2 W/cm

"If you've got induration that you haven't really treated for a long time, you can still treat it, but at that point you'll also have to mechanically stretch the tissue as you use the ultrasonic therapy," Dr. Jackson said.

"It's a very good marketing tool-my patients enjoy it," he said.

When used after cosmetic surgery procedures, electric stimulation improves blood flow, increases wound tensile strength, reduces edema, inhibits bacterial growth, and reduces pain. The primary purpose, however, is to reduce postoperative pain and edema, Dr. Jackson said. Electric stimulation immediately reduces swelling and improves wound healing. And ultimately, the technique improves the end result of the surgery.

"The Department of Health and Human Services tested all of the adjunctive therapies for pressure sores. … The only [therapy] they recommended for wound care management was the use of electric stimulation," he said.

Dr. Jackson typically starts this therapy the day after surgery and treats patients twice a week in 20-minute sessions until the wounds are satisfactorily healed. He recommends starting with an intensity of 100 pulses per second and increasing the intensity until the patient can feel the pulsation. Use this intensity for a few minutes and then increase the intensity until it just becomes uncomfortable for the patient. Then reduce the intensity gradually.

Low-level laser therapy is a relatively new modality that involves the application of low-power monochromatic and coherent light to injuries and lesions. This therapy is believed to promote blood vessel growth. Dr. Jackson uses low-level laser therapy for wound and ulcer healing. The therapy also reduces pain after surgery.

He uses a 635-nm laser for 8 minutes to enhance wound healing. For incision healing, he treats patients once or twice weekly for 3 weeks. Treatments for ulcers continue until healing is complete.

ORLANDO — Low-level energy is an effective technique for enhancing wound healing, said Dr. Robert F. Jackson, who offered a few postsurgery tips at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Jackson, a practicing cosmetic surgeon in Marion, Ind., focused on the use of ultrasonic massage, electrical stimulation, and low-level laser therapy.

After liposuction, external ultrasonic massage can correct minor irregularities, decrease edema, and help prevent long-term induration, he said. The therapy also stimulates tissue and wound healing.

Dr. Jackson typically starts this therapy 1 week after surgery and treats patients twice weekly until the induration is gone. He uses a level of 2 W/cm

"If you've got induration that you haven't really treated for a long time, you can still treat it, but at that point you'll also have to mechanically stretch the tissue as you use the ultrasonic therapy," Dr. Jackson said.

"It's a very good marketing tool-my patients enjoy it," he said.

When used after cosmetic surgery procedures, electric stimulation improves blood flow, increases wound tensile strength, reduces edema, inhibits bacterial growth, and reduces pain. The primary purpose, however, is to reduce postoperative pain and edema, Dr. Jackson said. Electric stimulation immediately reduces swelling and improves wound healing. And ultimately, the technique improves the end result of the surgery.

"The Department of Health and Human Services tested all of the adjunctive therapies for pressure sores. … The only [therapy] they recommended for wound care management was the use of electric stimulation," he said.

Dr. Jackson typically starts this therapy the day after surgery and treats patients twice a week in 20-minute sessions until the wounds are satisfactorily healed. He recommends starting with an intensity of 100 pulses per second and increasing the intensity until the patient can feel the pulsation. Use this intensity for a few minutes and then increase the intensity until it just becomes uncomfortable for the patient. Then reduce the intensity gradually.

Low-level laser therapy is a relatively new modality that involves the application of low-power monochromatic and coherent light to injuries and lesions. This therapy is believed to promote blood vessel growth. Dr. Jackson uses low-level laser therapy for wound and ulcer healing. The therapy also reduces pain after surgery.

He uses a 635-nm laser for 8 minutes to enhance wound healing. For incision healing, he treats patients once or twice weekly for 3 weeks. Treatments for ulcers continue until healing is complete.

LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Older studies that support the leave-it-alone approach defined "acceptable" cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.

Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.

In the half of children with hemangiomas who show significant ("early") involution before age 5, 38% had "imperfect" cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant ("late") involution by 5 years of age, 80% had imperfect cosmetic outcomes.

Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.

Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion. All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.

There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.

Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.

Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.

Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.

There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.

PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.

For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.

Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.

"You don't have to get every bit of tissue out. These are benign tumors in young children, and we have plenty of opportunity in ensuing years to clean things up," Dr. Hochman said.

Hemangiomas: Fact vs. Fiction

Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:

Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.

Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.

Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.

Reality: Hemangiomas typically have one feeder vessel that's easily isolated. "This is very low-tech surgery," Dr. Hochman said.

Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.

Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.

Dr. Hochman cautioned that while these myths don't apply to apply to hemangiomas, they may apply to malformations like port wine stains.

LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Older studies that support the leave-it-alone approach defined "acceptable" cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.

Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.

In the half of children with hemangiomas who show significant ("early") involution before age 5, 38% had "imperfect" cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant ("late") involution by 5 years of age, 80% had imperfect cosmetic outcomes.

Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.

Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion. All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.

There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.

Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.

Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.

Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.

There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.

PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.

For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.

Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.

"You don't have to get every bit of tissue out. These are benign tumors in young children, and we have plenty of opportunity in ensuing years to clean things up," Dr. Hochman said.

Hemangiomas: Fact vs. Fiction

Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:

Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.

Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.

Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.

Reality: Hemangiomas typically have one feeder vessel that's easily isolated. "This is very low-tech surgery," Dr. Hochman said.

Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.

Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.

Dr. Hochman cautioned that while these myths don't apply to apply to hemangiomas, they may apply to malformations like port wine stains.

LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Older studies that support the leave-it-alone approach defined "acceptable" cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.

Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.

In the half of children with hemangiomas who show significant ("early") involution before age 5, 38% had "imperfect" cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant ("late") involution by 5 years of age, 80% had imperfect cosmetic outcomes.

Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.

Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion. All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.

There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.

Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.

Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.

Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.

There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.

PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.

For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.

Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.

"You don't have to get every bit of tissue out. These are benign tumors in young children, and we have plenty of opportunity in ensuing years to clean things up," Dr. Hochman said.

Hemangiomas: Fact vs. Fiction

Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:

Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.

Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.

Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.

Reality: Hemangiomas typically have one feeder vessel that's easily isolated. "This is very low-tech surgery," Dr. Hochman said.

Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.

Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.

Dr. Hochman cautioned that while these myths don't apply to apply to hemangiomas, they may apply to malformations like port wine stains.

NEW YORK — Plastic surgeons' approach to nevi in challenging anatomical locations may differ from that of dermatologists, said Dr. Barry Zide at a dermatology conference sponsored by New York University.

"When I look at nevi, I have questions that have to be asked: Can it be shaved? What residual or abnormal pigment will occur, and why? How many aesthetic units are involved? What ancillary methods can be used? How many steps will it take?" said Dr. Zide, professor of plastic surgery at New York University, New York.

One thing to avoid is scab formation after shaving. This can be prevented by not allowing the shaved area to dry out. "Patients have to keep [an adhesive bandage] on for 7–10 days postop," Dr. Zide said.

"A bulky nevus of the nose has a minimal tendency to be malignant, so you can leave some nevus without taking the whole thing off," said Dr. Zide, referring to a case in which he did not have to biopsy the whole lesion but worked with shaving, abrasion, and electrolysis to manage the lesion. The advantage to this approach is that it leaves no reconstructive defect.

For dark lesions located above the tip of the nose, skin grafting is an option. "It is important to think in terms of aesthetic units," he said, adding, "The best place for a graft of the nose is the forehead. It has good color." A patch and edges are not perfect, so sanding the units post dermabrasion over a wide area that is not just limited to the actual skin graft is important. "Think big on dermabrasion, even though the graft can be small."

When confronted with a big nevus in a very young child, remember that in babies younger than 4 months old, there is a lot of skin to work with because their skin on the head hasn't yet firmly bound to the scalp. "You can take a lot of skin and do a straight excision in some cases, or a W-plasty," Dr. Zide explained.

Sometimes multiple steps are needed. Patients should always be informed of and prepared for the biopsy of a nevus to entail several steps.

NEW YORK — Plastic surgeons' approach to nevi in challenging anatomical locations may differ from that of dermatologists, said Dr. Barry Zide at a dermatology conference sponsored by New York University.

"When I look at nevi, I have questions that have to be asked: Can it be shaved? What residual or abnormal pigment will occur, and why? How many aesthetic units are involved? What ancillary methods can be used? How many steps will it take?" said Dr. Zide, professor of plastic surgery at New York University, New York.

One thing to avoid is scab formation after shaving. This can be prevented by not allowing the shaved area to dry out. "Patients have to keep [an adhesive bandage] on for 7–10 days postop," Dr. Zide said.

"A bulky nevus of the nose has a minimal tendency to be malignant, so you can leave some nevus without taking the whole thing off," said Dr. Zide, referring to a case in which he did not have to biopsy the whole lesion but worked with shaving, abrasion, and electrolysis to manage the lesion. The advantage to this approach is that it leaves no reconstructive defect.

For dark lesions located above the tip of the nose, skin grafting is an option. "It is important to think in terms of aesthetic units," he said, adding, "The best place for a graft of the nose is the forehead. It has good color." A patch and edges are not perfect, so sanding the units post dermabrasion over a wide area that is not just limited to the actual skin graft is important. "Think big on dermabrasion, even though the graft can be small."

When confronted with a big nevus in a very young child, remember that in babies younger than 4 months old, there is a lot of skin to work with because their skin on the head hasn't yet firmly bound to the scalp. "You can take a lot of skin and do a straight excision in some cases, or a W-plasty," Dr. Zide explained.

Sometimes multiple steps are needed. Patients should always be informed of and prepared for the biopsy of a nevus to entail several steps.

NEW YORK — Plastic surgeons' approach to nevi in challenging anatomical locations may differ from that of dermatologists, said Dr. Barry Zide at a dermatology conference sponsored by New York University.

"When I look at nevi, I have questions that have to be asked: Can it be shaved? What residual or abnormal pigment will occur, and why? How many aesthetic units are involved? What ancillary methods can be used? How many steps will it take?" said Dr. Zide, professor of plastic surgery at New York University, New York.

One thing to avoid is scab formation after shaving. This can be prevented by not allowing the shaved area to dry out. "Patients have to keep [an adhesive bandage] on for 7–10 days postop," Dr. Zide said.

"A bulky nevus of the nose has a minimal tendency to be malignant, so you can leave some nevus without taking the whole thing off," said Dr. Zide, referring to a case in which he did not have to biopsy the whole lesion but worked with shaving, abrasion, and electrolysis to manage the lesion. The advantage to this approach is that it leaves no reconstructive defect.

For dark lesions located above the tip of the nose, skin grafting is an option. "It is important to think in terms of aesthetic units," he said, adding, "The best place for a graft of the nose is the forehead. It has good color." A patch and edges are not perfect, so sanding the units post dermabrasion over a wide area that is not just limited to the actual skin graft is important. "Think big on dermabrasion, even though the graft can be small."

When confronted with a big nevus in a very young child, remember that in babies younger than 4 months old, there is a lot of skin to work with because their skin on the head hasn't yet firmly bound to the scalp. "You can take a lot of skin and do a straight excision in some cases, or a W-plasty," Dr. Zide explained.

Sometimes multiple steps are needed. Patients should always be informed of and prepared for the biopsy of a nevus to entail several steps.

LUCAYA, BAHAMAS — Partial closure is an underutilized technique that can improve the outcome of surgical reconstruction after Mohs surgery for many patients, Dr. J. Robert Hamill Jr. said at a meeting of the American Society for Mohs Surgery.

Indeed, closing only part of the wound and leaving the rest to granulate on its own is advantageous in a wide variety of situations. Surgical sites to consider for partial closure include:

▸ Tumor sites that need to be monitored for recurrence.

▸ Surgical sites under high tension, including the leg, scalp, and fingers.

▸ Sites where function may become compromised, especially the eyelid, lip, nose, and finger.

▸ Sites where complete closure may cause ischemia or necrosis.

"You don't have to close every defect," said Dr. Hamill of the department of dermatology at the University of South Florida, Tampa, who also has a private dermatology practice in Hudson, Fla.

Many areas granulate well without any closure, especially in the concave areas on the nose, eyelid, ear, and temple—the so-called NEET areas (J. Am. Acad. Dermatol. 1983;9:407–15).

Surgical scars will have the best results when they are kept within anatomical units (especially the eyelids, nose, lips, and ears), and are best hidden within the lines of relaxed tension. Indeed, an overriding principle is that "the best surgical scar is the one you don't need to extend," he said.

Partial closures allow you to shorten a scar and to decrease overall surgery time, a particularly important consideration in elderly patients.

Some preliminary data even suggest that partial closures—by not creating a dead space—may be associated with a reduced risk of postsurgical infection. Avoiding infection is becoming especially critical in this era of methicillin-resistant Staphylococcus aureus, Dr. Hamill said.

It's important to warn patients that there will be a small hole or wound in the area you've partially closed, which may take up to 2–3 weeks to completely heal. During this time, there may be crusting or oozing that may require cleaning. Depending on their comfort level, patients can either clean the wound themselves or come back to your office.

"Patients are very receptive to partial closures as long as you tell them up front what to expect," said Dr. Hamill.

Partial closure is also the best option any time there is a risk for ectropion. "If a closure results in pulling, I always adjust the flap by placing the patient in a seated position and removing sutures, [thereby] creating a partial closure so there is no ectropion immediately after suturing," he noted.

In some cases, it may even make sense to consider a partial closure after a complete one in areas of high tension, such as the leg or scalp. If you've done a complete closure in such an area, try waiting 5 minutes, he advised.

If the area looks white and ischemic, you may want to take out a few sutures to create a partial closure. This will allow the flap to completely take and is always better than partial necrosis. A clinical pearl is to debride the new partial defect every 2 weeks so that the defect heals from within, thus preventing a depressed scar, he said.

And another clinical pearl: When using a simple transposition flap, it may be possible to subdivide the defect to create two separate but smaller areas of granulation, rather than one larger area. Doing so may reduce the healing time and produce a smaller scar. This technique is especially useful on the nose if a complete closure pulls the tip and results in congested breathing.

"You can make a very complex closure simple and prevent functional deficit," Dr. Hamill said.

Overall, the aim is to "keep it simple and work with nature," he said.

This patient had ectropion that resulted from the closure of a lateral advancement flap used to repair a defect on her lower eyelid.

The partial closure was created by removing the medial superior sutures until the ectropion was no longer present.

One month after surgery, there is no ectropion with only minimal swelling, which eventually resolved over the next few months. Photos courtesy Dr. J. Robert Hamill Jr.

LUCAYA, BAHAMAS — Partial closure is an underutilized technique that can improve the outcome of surgical reconstruction after Mohs surgery for many patients, Dr. J. Robert Hamill Jr. said at a meeting of the American Society for Mohs Surgery.

Indeed, closing only part of the wound and leaving the rest to granulate on its own is advantageous in a wide variety of situations. Surgical sites to consider for partial closure include:

▸ Tumor sites that need to be monitored for recurrence.

▸ Surgical sites under high tension, including the leg, scalp, and fingers.

▸ Sites where function may become compromised, especially the eyelid, lip, nose, and finger.

▸ Sites where complete closure may cause ischemia or necrosis.

"You don't have to close every defect," said Dr. Hamill of the department of dermatology at the University of South Florida, Tampa, who also has a private dermatology practice in Hudson, Fla.

Many areas granulate well without any closure, especially in the concave areas on the nose, eyelid, ear, and temple—the so-called NEET areas (J. Am. Acad. Dermatol. 1983;9:407–15).

Surgical scars will have the best results when they are kept within anatomical units (especially the eyelids, nose, lips, and ears), and are best hidden within the lines of relaxed tension. Indeed, an overriding principle is that "the best surgical scar is the one you don't need to extend," he said.

Partial closures allow you to shorten a scar and to decrease overall surgery time, a particularly important consideration in elderly patients.

Some preliminary data even suggest that partial closures—by not creating a dead space—may be associated with a reduced risk of postsurgical infection. Avoiding infection is becoming especially critical in this era of methicillin-resistant Staphylococcus aureus, Dr. Hamill said.

It's important to warn patients that there will be a small hole or wound in the area you've partially closed, which may take up to 2–3 weeks to completely heal. During this time, there may be crusting or oozing that may require cleaning. Depending on their comfort level, patients can either clean the wound themselves or come back to your office.

"Patients are very receptive to partial closures as long as you tell them up front what to expect," said Dr. Hamill.

Partial closure is also the best option any time there is a risk for ectropion. "If a closure results in pulling, I always adjust the flap by placing the patient in a seated position and removing sutures, [thereby] creating a partial closure so there is no ectropion immediately after suturing," he noted.

In some cases, it may even make sense to consider a partial closure after a complete one in areas of high tension, such as the leg or scalp. If you've done a complete closure in such an area, try waiting 5 minutes, he advised.

If the area looks white and ischemic, you may want to take out a few sutures to create a partial closure. This will allow the flap to completely take and is always better than partial necrosis. A clinical pearl is to debride the new partial defect every 2 weeks so that the defect heals from within, thus preventing a depressed scar, he said.

And another clinical pearl: When using a simple transposition flap, it may be possible to subdivide the defect to create two separate but smaller areas of granulation, rather than one larger area. Doing so may reduce the healing time and produce a smaller scar. This technique is especially useful on the nose if a complete closure pulls the tip and results in congested breathing.

"You can make a very complex closure simple and prevent functional deficit," Dr. Hamill said.

Overall, the aim is to "keep it simple and work with nature," he said.

This patient had ectropion that resulted from the closure of a lateral advancement flap used to repair a defect on her lower eyelid.

The partial closure was created by removing the medial superior sutures until the ectropion was no longer present.

One month after surgery, there is no ectropion with only minimal swelling, which eventually resolved over the next few months. Photos courtesy Dr. J. Robert Hamill Jr.

LUCAYA, BAHAMAS — Partial closure is an underutilized technique that can improve the outcome of surgical reconstruction after Mohs surgery for many patients, Dr. J. Robert Hamill Jr. said at a meeting of the American Society for Mohs Surgery.

Indeed, closing only part of the wound and leaving the rest to granulate on its own is advantageous in a wide variety of situations. Surgical sites to consider for partial closure include:

▸ Tumor sites that need to be monitored for recurrence.

▸ Surgical sites under high tension, including the leg, scalp, and fingers.

▸ Sites where function may become compromised, especially the eyelid, lip, nose, and finger.

▸ Sites where complete closure may cause ischemia or necrosis.

"You don't have to close every defect," said Dr. Hamill of the department of dermatology at the University of South Florida, Tampa, who also has a private dermatology practice in Hudson, Fla.

Many areas granulate well without any closure, especially in the concave areas on the nose, eyelid, ear, and temple—the so-called NEET areas (J. Am. Acad. Dermatol. 1983;9:407–15).

Surgical scars will have the best results when they are kept within anatomical units (especially the eyelids, nose, lips, and ears), and are best hidden within the lines of relaxed tension. Indeed, an overriding principle is that "the best surgical scar is the one you don't need to extend," he said.

Partial closures allow you to shorten a scar and to decrease overall surgery time, a particularly important consideration in elderly patients.

Some preliminary data even suggest that partial closures—by not creating a dead space—may be associated with a reduced risk of postsurgical infection. Avoiding infection is becoming especially critical in this era of methicillin-resistant Staphylococcus aureus, Dr. Hamill said.

It's important to warn patients that there will be a small hole or wound in the area you've partially closed, which may take up to 2–3 weeks to completely heal. During this time, there may be crusting or oozing that may require cleaning. Depending on their comfort level, patients can either clean the wound themselves or come back to your office.

"Patients are very receptive to partial closures as long as you tell them up front what to expect," said Dr. Hamill.

Partial closure is also the best option any time there is a risk for ectropion. "If a closure results in pulling, I always adjust the flap by placing the patient in a seated position and removing sutures, [thereby] creating a partial closure so there is no ectropion immediately after suturing," he noted.

In some cases, it may even make sense to consider a partial closure after a complete one in areas of high tension, such as the leg or scalp. If you've done a complete closure in such an area, try waiting 5 minutes, he advised.

If the area looks white and ischemic, you may want to take out a few sutures to create a partial closure. This will allow the flap to completely take and is always better than partial necrosis. A clinical pearl is to debride the new partial defect every 2 weeks so that the defect heals from within, thus preventing a depressed scar, he said.

And another clinical pearl: When using a simple transposition flap, it may be possible to subdivide the defect to create two separate but smaller areas of granulation, rather than one larger area. Doing so may reduce the healing time and produce a smaller scar. This technique is especially useful on the nose if a complete closure pulls the tip and results in congested breathing.

"You can make a very complex closure simple and prevent functional deficit," Dr. Hamill said.

Overall, the aim is to "keep it simple and work with nature," he said.

This patient had ectropion that resulted from the closure of a lateral advancement flap used to repair a defect on her lower eyelid.

The partial closure was created by removing the medial superior sutures until the ectropion was no longer present.

One month after surgery, there is no ectropion with only minimal swelling, which eventually resolved over the next few months. Photos courtesy Dr. J. Robert Hamill Jr.