Aesthetic Dermatology

LAS VEGAS — When it comes to facial peels, Dr. Devinder S. Mangat has traveled full circle—going from chemical peels to using lasers and back again.

After 16 years of doing chemical facial peels, Dr. Mangat switched to laser peels "because that's what the public was demanding," he recalled at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

About 8 years ago, though, he switched back to using chemicals because they provide more predictable outcomes, cost less than lasers, and produce better results than noninvasive modalities, he said.

Using the more modern Hetter peel solution instead of the traditional Baker-Gordon formula offers greater flexibility in treating different facial areas with less risk of hypopigmentation, added Dr. Mangat, president of the American Board of Facial Plastic and Reconstructive Surgery.

The traditional Baker-Gordon formula contains a 58% concentration of phenol and a 2.1% concentration of croton oil among its ingredients. A few years ago, however, Dr. Greg Hetter of Las Vegas varied the formula's concentrations and discovered that the depth of peel was related to the concentration of croton oil, not the phenol or Septisol, as had been believed.

Dr. Mangat uses different concentrations of the Hetter formula for peels on different facial areas in his practices in Cincinnati and Vail, Colo.

Hetter solutions maintain a lower and constant concentration of phenol—35%—while varying the croton oil concentration in a mixture of water, phenol, Septisol, and croton oil, he explained.

In general, Dr. Mangat prefers a Hetter formula with 0.8%–1.2% croton oil for perioral skin, which is thicker and has deeper rhytids: "Really get into those rhytids either with a Q-tip or the broken end of a Q-tip," he said.

He prefers applying the solution with a cotton-tipped applicator rather than gauze sponges for better control.

For peeling the cheeks and forehead, he usually limits the formula to no more than 0.4% croton oil. Eyelids may require anywhere from 0.1% to 0.4% croton oil, depending on the thickness of the skin and the depth of the rhytids, he said at the meeting.

Dr. Mangat also uses the Hetter formula on the neck, but at nothing stronger than a 0.1% croton oil solution.

Since switching to the Hetter formula, he has not had any cases of hypopigmentation after peels.

With Hetter peels, "once you've selected and prepared patients carefully, they will be, without a doubt, the happiest patients you have in your practice," he predicted.

LAS VEGAS — When it comes to facial peels, Dr. Devinder S. Mangat has traveled full circle—going from chemical peels to using lasers and back again.

After 16 years of doing chemical facial peels, Dr. Mangat switched to laser peels "because that's what the public was demanding," he recalled at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

About 8 years ago, though, he switched back to using chemicals because they provide more predictable outcomes, cost less than lasers, and produce better results than noninvasive modalities, he said.

Using the more modern Hetter peel solution instead of the traditional Baker-Gordon formula offers greater flexibility in treating different facial areas with less risk of hypopigmentation, added Dr. Mangat, president of the American Board of Facial Plastic and Reconstructive Surgery.

The traditional Baker-Gordon formula contains a 58% concentration of phenol and a 2.1% concentration of croton oil among its ingredients. A few years ago, however, Dr. Greg Hetter of Las Vegas varied the formula's concentrations and discovered that the depth of peel was related to the concentration of croton oil, not the phenol or Septisol, as had been believed.

Dr. Mangat uses different concentrations of the Hetter formula for peels on different facial areas in his practices in Cincinnati and Vail, Colo.

Hetter solutions maintain a lower and constant concentration of phenol—35%—while varying the croton oil concentration in a mixture of water, phenol, Septisol, and croton oil, he explained.

In general, Dr. Mangat prefers a Hetter formula with 0.8%–1.2% croton oil for perioral skin, which is thicker and has deeper rhytids: "Really get into those rhytids either with a Q-tip or the broken end of a Q-tip," he said.

He prefers applying the solution with a cotton-tipped applicator rather than gauze sponges for better control.

For peeling the cheeks and forehead, he usually limits the formula to no more than 0.4% croton oil. Eyelids may require anywhere from 0.1% to 0.4% croton oil, depending on the thickness of the skin and the depth of the rhytids, he said at the meeting.

Dr. Mangat also uses the Hetter formula on the neck, but at nothing stronger than a 0.1% croton oil solution.

Since switching to the Hetter formula, he has not had any cases of hypopigmentation after peels.

With Hetter peels, "once you've selected and prepared patients carefully, they will be, without a doubt, the happiest patients you have in your practice," he predicted.

LAS VEGAS — When it comes to facial peels, Dr. Devinder S. Mangat has traveled full circle—going from chemical peels to using lasers and back again.

After 16 years of doing chemical facial peels, Dr. Mangat switched to laser peels "because that's what the public was demanding," he recalled at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

About 8 years ago, though, he switched back to using chemicals because they provide more predictable outcomes, cost less than lasers, and produce better results than noninvasive modalities, he said.

Using the more modern Hetter peel solution instead of the traditional Baker-Gordon formula offers greater flexibility in treating different facial areas with less risk of hypopigmentation, added Dr. Mangat, president of the American Board of Facial Plastic and Reconstructive Surgery.

The traditional Baker-Gordon formula contains a 58% concentration of phenol and a 2.1% concentration of croton oil among its ingredients. A few years ago, however, Dr. Greg Hetter of Las Vegas varied the formula's concentrations and discovered that the depth of peel was related to the concentration of croton oil, not the phenol or Septisol, as had been believed.

Dr. Mangat uses different concentrations of the Hetter formula for peels on different facial areas in his practices in Cincinnati and Vail, Colo.

Hetter solutions maintain a lower and constant concentration of phenol—35%—while varying the croton oil concentration in a mixture of water, phenol, Septisol, and croton oil, he explained.

In general, Dr. Mangat prefers a Hetter formula with 0.8%–1.2% croton oil for perioral skin, which is thicker and has deeper rhytids: "Really get into those rhytids either with a Q-tip or the broken end of a Q-tip," he said.

He prefers applying the solution with a cotton-tipped applicator rather than gauze sponges for better control.

For peeling the cheeks and forehead, he usually limits the formula to no more than 0.4% croton oil. Eyelids may require anywhere from 0.1% to 0.4% croton oil, depending on the thickness of the skin and the depth of the rhytids, he said at the meeting.

Dr. Mangat also uses the Hetter formula on the neck, but at nothing stronger than a 0.1% croton oil solution.

Since switching to the Hetter formula, he has not had any cases of hypopigmentation after peels.

With Hetter peels, "once you've selected and prepared patients carefully, they will be, without a doubt, the happiest patients you have in your practice," he predicted.

LAS VEGAS — Augmenting volume in the midface area can range from rewarding to frustrating, but it's a necessary part of facial rejuvenation, Dr. Suzan Obagi said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

"If we want to accomplish full-face rejuvenation, we have to augment the midface region," said Dr. Obagi, who is director of the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh.

The literature lacks human studies of the best techniques and patient selection, so Dr. Obagi shared tips from her own experience.

She prefers using autologous fat transplantation for the midface area because of its many advantages.

"It's the closest we have to an ideal filler," she said.

Autologous fat is nonallergenic, and there's no risk of transmitting HIV, hepatitis, or other diseases.

Fat usually is available in relative abundance for harvesting, and it takes on the properties of the tissue into which it is injected. Although some clinicians have reported dissatisfaction with the duration of fat injections, the procedure has the potential to last many years, depending on patient selection and on the quality of the fat that is harvested.

In Dr. Obagi's practice, autologous fat augmentation in the midface area lasts about 3 years, she said.

Fat transplantation also is cost effective for patients. "I typically use 20 cc of fat. That much Restylane would be equivalent to the cost of a facelift," she commented.

The best patients are younger—under age 55 years—because they have healthier, better fat. The ideal patient is a nonsmoker with a normal or above-normal body mass index, no prior facial surgery, and good skin tone and skin thickness.

"I'm convinced that patient age is the key factor to decide between one, two, three, or four" sessions of fat transplantation, Dr. Obagi said. In younger patients, one fat transplantation might be sufficient, but older patients could need two or more sessions. Prepare older patients for the possibility of multiple sessions.

Thicker skin is more forgiving and less likely to show lumps after fat transplantation.

Heavier patients tend to have better outcomes after midface fat augmentation than do thinner patients, but the thin ones might be in greater need of the procedure. The best combination might be a patient with a thinner face but more body fat than normal, Dr. Obagi suggested.

Fat will not fill in wrinkles from sun damage, she noted; those are better treated with laser resurfacing.

Assess the facial volume loss to decide where to transfer the fat. Likely sites include the forehead, brow, temples, intraorbital areas, regions of malar atrophy, lateral cheeks, jawline, chin, and perioral areas.

Results may be less satisfactory in patients with prior facelifts, eye lifts, brow lifts, cheek implants, or permanent fillers. Avoid fat augmentation in patients with prior transcutaneous lower blepharoplasty, because the fat injection can cause prolonged edema, she warned.

It's probably also wise to avoid midface fat augmentation in patients with unrealistic expectations, those with malar festoons, and tobacco users, she said, adding that some medications are contraindicated with this procedure.

Prednisone impairs healing. Depression may be triggered in patients on antipsychotic agents, Dr. Obagi said. Aspirin, NSAIDs, or warfarin can cause bleeding that harms the transplanted fat's life span.

LAS VEGAS — Augmenting volume in the midface area can range from rewarding to frustrating, but it's a necessary part of facial rejuvenation, Dr. Suzan Obagi said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

"If we want to accomplish full-face rejuvenation, we have to augment the midface region," said Dr. Obagi, who is director of the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh.

The literature lacks human studies of the best techniques and patient selection, so Dr. Obagi shared tips from her own experience.

She prefers using autologous fat transplantation for the midface area because of its many advantages.

"It's the closest we have to an ideal filler," she said.

Autologous fat is nonallergenic, and there's no risk of transmitting HIV, hepatitis, or other diseases.

Fat usually is available in relative abundance for harvesting, and it takes on the properties of the tissue into which it is injected. Although some clinicians have reported dissatisfaction with the duration of fat injections, the procedure has the potential to last many years, depending on patient selection and on the quality of the fat that is harvested.

In Dr. Obagi's practice, autologous fat augmentation in the midface area lasts about 3 years, she said.

Fat transplantation also is cost effective for patients. "I typically use 20 cc of fat. That much Restylane would be equivalent to the cost of a facelift," she commented.

The best patients are younger—under age 55 years—because they have healthier, better fat. The ideal patient is a nonsmoker with a normal or above-normal body mass index, no prior facial surgery, and good skin tone and skin thickness.

"I'm convinced that patient age is the key factor to decide between one, two, three, or four" sessions of fat transplantation, Dr. Obagi said. In younger patients, one fat transplantation might be sufficient, but older patients could need two or more sessions. Prepare older patients for the possibility of multiple sessions.

Thicker skin is more forgiving and less likely to show lumps after fat transplantation.

Heavier patients tend to have better outcomes after midface fat augmentation than do thinner patients, but the thin ones might be in greater need of the procedure. The best combination might be a patient with a thinner face but more body fat than normal, Dr. Obagi suggested.

Fat will not fill in wrinkles from sun damage, she noted; those are better treated with laser resurfacing.

Assess the facial volume loss to decide where to transfer the fat. Likely sites include the forehead, brow, temples, intraorbital areas, regions of malar atrophy, lateral cheeks, jawline, chin, and perioral areas.

Results may be less satisfactory in patients with prior facelifts, eye lifts, brow lifts, cheek implants, or permanent fillers. Avoid fat augmentation in patients with prior transcutaneous lower blepharoplasty, because the fat injection can cause prolonged edema, she warned.

It's probably also wise to avoid midface fat augmentation in patients with unrealistic expectations, those with malar festoons, and tobacco users, she said, adding that some medications are contraindicated with this procedure.

Prednisone impairs healing. Depression may be triggered in patients on antipsychotic agents, Dr. Obagi said. Aspirin, NSAIDs, or warfarin can cause bleeding that harms the transplanted fat's life span.

LAS VEGAS — Augmenting volume in the midface area can range from rewarding to frustrating, but it's a necessary part of facial rejuvenation, Dr. Suzan Obagi said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

"If we want to accomplish full-face rejuvenation, we have to augment the midface region," said Dr. Obagi, who is director of the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh.

The literature lacks human studies of the best techniques and patient selection, so Dr. Obagi shared tips from her own experience.

She prefers using autologous fat transplantation for the midface area because of its many advantages.

"It's the closest we have to an ideal filler," she said.

Autologous fat is nonallergenic, and there's no risk of transmitting HIV, hepatitis, or other diseases.

Fat usually is available in relative abundance for harvesting, and it takes on the properties of the tissue into which it is injected. Although some clinicians have reported dissatisfaction with the duration of fat injections, the procedure has the potential to last many years, depending on patient selection and on the quality of the fat that is harvested.

In Dr. Obagi's practice, autologous fat augmentation in the midface area lasts about 3 years, she said.

Fat transplantation also is cost effective for patients. "I typically use 20 cc of fat. That much Restylane would be equivalent to the cost of a facelift," she commented.

The best patients are younger—under age 55 years—because they have healthier, better fat. The ideal patient is a nonsmoker with a normal or above-normal body mass index, no prior facial surgery, and good skin tone and skin thickness.

"I'm convinced that patient age is the key factor to decide between one, two, three, or four" sessions of fat transplantation, Dr. Obagi said. In younger patients, one fat transplantation might be sufficient, but older patients could need two or more sessions. Prepare older patients for the possibility of multiple sessions.

Thicker skin is more forgiving and less likely to show lumps after fat transplantation.

Heavier patients tend to have better outcomes after midface fat augmentation than do thinner patients, but the thin ones might be in greater need of the procedure. The best combination might be a patient with a thinner face but more body fat than normal, Dr. Obagi suggested.

Fat will not fill in wrinkles from sun damage, she noted; those are better treated with laser resurfacing.

Assess the facial volume loss to decide where to transfer the fat. Likely sites include the forehead, brow, temples, intraorbital areas, regions of malar atrophy, lateral cheeks, jawline, chin, and perioral areas.

Results may be less satisfactory in patients with prior facelifts, eye lifts, brow lifts, cheek implants, or permanent fillers. Avoid fat augmentation in patients with prior transcutaneous lower blepharoplasty, because the fat injection can cause prolonged edema, she warned.

It's probably also wise to avoid midface fat augmentation in patients with unrealistic expectations, those with malar festoons, and tobacco users, she said, adding that some medications are contraindicated with this procedure.

Prednisone impairs healing. Depression may be triggered in patients on antipsychotic agents, Dr. Obagi said. Aspirin, NSAIDs, or warfarin can cause bleeding that harms the transplanted fat's life span.

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud

BOSTON — Multiple passes of low-fluence radiofrequency delivery can significantly improve overall facial laxity with minimal patient discomfort, Dr. Melissa A. Bogle reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings validate the use of this treatment algorithm over single-pass, high-energy radiofrequency skin tightening, which can be unbearably painful and has been associated with skin changes such as burning and scarring in some patients, she said.

In a study of 66 patients who were an average age of 53, with moderate facial laxity, Dr. Bogle and colleagues evaluated the impact of up to five passes over the lower face and neck with low-energy monopolar radiofrequency. "For all of the patients, we used a device with a 1.5-cm tip and performed two full passes over the entire face, then, based on physician discretion, we performed up to three additional passes in certain areas that needed more attention, such as the jowl region, with a slight delay between passes to allow tissue cooling," said Dr. Bogle of the Laser and Cosmetic Surgery Center in Houston. "In all regions, we treated to a clinical end point of visible tightening and contouring."

The average treatment setting was 62 J/cm

"We used patient discomfort as a guide to energy level. If a patient indicated feeling significant discomfort, we'd turn down the energy settings to minimize the pain experienced with each pulse."

Treatment efficacy was assessed using three measures: the Leal laxity classification system, which evaluates the type and degree of skin laxity on a six-point scale; skin stiffness and energy absorption levels obtained by the BTC-2000 dynamic skin analyzer, which measures the elastic deformation of skin at set points on the face during dynamic stress; and independent photographic review by blinded physicians.

At 4 months, with the skin laxity classification system, "95% of the patients had some degree of visible improvement in skin laxity, and at 6 months this number leveled off to 92%," Dr. Bogle said. In terms of the amount of improvement, "at 4 months 65% of the patients were categorized as having improvement in the good to very good category, with good being between 25% and 50% improvement and very good being 50%–75% improvement. At 6 months, this number dropped to 61%," she said. At 4 months and 6 months, respectively, 5% and 8% of patients had no visible results.

Skin stiffness, as measured by the BTC-2000, showed 75% improvement at 4 months and 35% at 6 months, Dr. Bogle said. "Similarly, in terms of energy absorption, or the amount of energy it takes to deform the skin, at 4 months, we saw 60% improvement. This dropped to about 25% at 6 months, but still was better than at baseline, she said.

Finally, according to the independent physician review, the overall 4-month and 6-month improvements were 75% and 84%, respectively, Dr. Bogle noted. "At 4 months, the middle face and the lower face regions showed similar levels of improvement, while at 6 months, the middle face was generally the most improved region, followed by the lower face." At both time points, the treatment was least effective in the upper neck region, with fewer than half the patients showing visible improvement in that area, she said.

In terms of adverse events, three patients had superficial crusting, which resolved in a few days without sequelae, Dr. Bogle noted. "Also, two patients reported numbness along the jawline at the 1-month follow-up, but it was fully resolved by the 2- and 4-month visits."

Although, for the purposes of this investigation, the multiple passes were limited to five total, "in practice we will usually do as many as 5–10 in addition to the initial full face passes," she said. "This gives the greatest cosmetic improvement, while keeping patient discomfort low because of the lower energy being used."

Dr. Bogle received a research grant for this study from Thermage, maker of the ThermaCool radiofrequency device used in the investigation.

BOSTON — Multiple passes of low-fluence radiofrequency delivery can significantly improve overall facial laxity with minimal patient discomfort, Dr. Melissa A. Bogle reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings validate the use of this treatment algorithm over single-pass, high-energy radiofrequency skin tightening, which can be unbearably painful and has been associated with skin changes such as burning and scarring in some patients, she said.

In a study of 66 patients who were an average age of 53, with moderate facial laxity, Dr. Bogle and colleagues evaluated the impact of up to five passes over the lower face and neck with low-energy monopolar radiofrequency. "For all of the patients, we used a device with a 1.5-cm tip and performed two full passes over the entire face, then, based on physician discretion, we performed up to three additional passes in certain areas that needed more attention, such as the jowl region, with a slight delay between passes to allow tissue cooling," said Dr. Bogle of the Laser and Cosmetic Surgery Center in Houston. "In all regions, we treated to a clinical end point of visible tightening and contouring."

The average treatment setting was 62 J/cm

"We used patient discomfort as a guide to energy level. If a patient indicated feeling significant discomfort, we'd turn down the energy settings to minimize the pain experienced with each pulse."

Treatment efficacy was assessed using three measures: the Leal laxity classification system, which evaluates the type and degree of skin laxity on a six-point scale; skin stiffness and energy absorption levels obtained by the BTC-2000 dynamic skin analyzer, which measures the elastic deformation of skin at set points on the face during dynamic stress; and independent photographic review by blinded physicians.

At 4 months, with the skin laxity classification system, "95% of the patients had some degree of visible improvement in skin laxity, and at 6 months this number leveled off to 92%," Dr. Bogle said. In terms of the amount of improvement, "at 4 months 65% of the patients were categorized as having improvement in the good to very good category, with good being between 25% and 50% improvement and very good being 50%–75% improvement. At 6 months, this number dropped to 61%," she said. At 4 months and 6 months, respectively, 5% and 8% of patients had no visible results.

Skin stiffness, as measured by the BTC-2000, showed 75% improvement at 4 months and 35% at 6 months, Dr. Bogle said. "Similarly, in terms of energy absorption, or the amount of energy it takes to deform the skin, at 4 months, we saw 60% improvement. This dropped to about 25% at 6 months, but still was better than at baseline, she said.

Finally, according to the independent physician review, the overall 4-month and 6-month improvements were 75% and 84%, respectively, Dr. Bogle noted. "At 4 months, the middle face and the lower face regions showed similar levels of improvement, while at 6 months, the middle face was generally the most improved region, followed by the lower face." At both time points, the treatment was least effective in the upper neck region, with fewer than half the patients showing visible improvement in that area, she said.

In terms of adverse events, three patients had superficial crusting, which resolved in a few days without sequelae, Dr. Bogle noted. "Also, two patients reported numbness along the jawline at the 1-month follow-up, but it was fully resolved by the 2- and 4-month visits."

Although, for the purposes of this investigation, the multiple passes were limited to five total, "in practice we will usually do as many as 5–10 in addition to the initial full face passes," she said. "This gives the greatest cosmetic improvement, while keeping patient discomfort low because of the lower energy being used."

Dr. Bogle received a research grant for this study from Thermage, maker of the ThermaCool radiofrequency device used in the investigation.

BOSTON — Multiple passes of low-fluence radiofrequency delivery can significantly improve overall facial laxity with minimal patient discomfort, Dr. Melissa A. Bogle reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings validate the use of this treatment algorithm over single-pass, high-energy radiofrequency skin tightening, which can be unbearably painful and has been associated with skin changes such as burning and scarring in some patients, she said.

In a study of 66 patients who were an average age of 53, with moderate facial laxity, Dr. Bogle and colleagues evaluated the impact of up to five passes over the lower face and neck with low-energy monopolar radiofrequency. "For all of the patients, we used a device with a 1.5-cm tip and performed two full passes over the entire face, then, based on physician discretion, we performed up to three additional passes in certain areas that needed more attention, such as the jowl region, with a slight delay between passes to allow tissue cooling," said Dr. Bogle of the Laser and Cosmetic Surgery Center in Houston. "In all regions, we treated to a clinical end point of visible tightening and contouring."

The average treatment setting was 62 J/cm

"We used patient discomfort as a guide to energy level. If a patient indicated feeling significant discomfort, we'd turn down the energy settings to minimize the pain experienced with each pulse."

Treatment efficacy was assessed using three measures: the Leal laxity classification system, which evaluates the type and degree of skin laxity on a six-point scale; skin stiffness and energy absorption levels obtained by the BTC-2000 dynamic skin analyzer, which measures the elastic deformation of skin at set points on the face during dynamic stress; and independent photographic review by blinded physicians.

At 4 months, with the skin laxity classification system, "95% of the patients had some degree of visible improvement in skin laxity, and at 6 months this number leveled off to 92%," Dr. Bogle said. In terms of the amount of improvement, "at 4 months 65% of the patients were categorized as having improvement in the good to very good category, with good being between 25% and 50% improvement and very good being 50%–75% improvement. At 6 months, this number dropped to 61%," she said. At 4 months and 6 months, respectively, 5% and 8% of patients had no visible results.

Skin stiffness, as measured by the BTC-2000, showed 75% improvement at 4 months and 35% at 6 months, Dr. Bogle said. "Similarly, in terms of energy absorption, or the amount of energy it takes to deform the skin, at 4 months, we saw 60% improvement. This dropped to about 25% at 6 months, but still was better than at baseline, she said.

Finally, according to the independent physician review, the overall 4-month and 6-month improvements were 75% and 84%, respectively, Dr. Bogle noted. "At 4 months, the middle face and the lower face regions showed similar levels of improvement, while at 6 months, the middle face was generally the most improved region, followed by the lower face." At both time points, the treatment was least effective in the upper neck region, with fewer than half the patients showing visible improvement in that area, she said.

In terms of adverse events, three patients had superficial crusting, which resolved in a few days without sequelae, Dr. Bogle noted. "Also, two patients reported numbness along the jawline at the 1-month follow-up, but it was fully resolved by the 2- and 4-month visits."

Although, for the purposes of this investigation, the multiple passes were limited to five total, "in practice we will usually do as many as 5–10 in addition to the initial full face passes," she said. "This gives the greatest cosmetic improvement, while keeping patient discomfort low because of the lower energy being used."

Dr. Bogle received a research grant for this study from Thermage, maker of the ThermaCool radiofrequency device used in the investigation.

BOSTON — A modified, high-energy, variable-pulse-duration, pulsed dye laser safely and effectively treated both vascular and pigmentary changes in patients with photoaged skin, a study has shown.

The findings suggest that what has typically been considered a "vascular" laser can be safely used to treat sun damage and associated pigmentary changes as well, Dr. Nathan Rosen said at the annual meeting of the American Society for Laser Medicine and Surgery.

The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size, so large lesions can be treated quickly, but the resultant high-energy pulses can cause postoperative bruising and transient pigmentary changes.

The device used in this investigation employs a modified pulse structure, whereby each pulse comprises six uniform micropulses that evenly distribute the pulse energy, reducing the likelihood of bruising, compared with earlier devices, Dr. Rosen explained.

"The purpura threshold is increased because pigment more selectively absorbs the individual micropulses," he said.

In addition, the investigational device includes a compression handpiece that, by removing the competing vascular target, prevents the development of purpura. "The handpiece compresses the blood vessels in the region, allowing all of the energy to be concentrated in the pigmented area," said Dr. Rosen, who is in private practice in New York.

To evaluate the impact of the new technology on vascular and pigmentary changes associated with photodamage and long-term sun exposure, Dr. Rosen, along with his colleagues Dr. Arielle N.B. Kauvar and Dr. Tatiana Khrom, who are also in private practice in New York, considered the outcomes of its use on 24 patients with photoaged, phototype I-IV skin.

Of the 24 subjects who were enrolled in the study, 14 were treated for vascular and pigmented lesions and 10 were treated for pigmented lesions alone. All of the subjects received a total of one to three treatments at 4-week intervals, and all underwent follow-up evaluations at 3 and 12 weeks.

To treat background erythema, the dermatologists used a 10-ms pulse width and a 12-mm spot at a fluence of 7 J/cm

Only the vascular lesions were treated with cryogen spray cooling (30-ms spray, 30-ms delay) before each laser pulse, and none of the patients received a topical anesthetic prior to laser treatment, Dr. Rosen noted.

"All of the patients tolerated the treatment well, and there was no purpura with the parameters that we used," Dr. Rosen said.

Three of the patients developed transient hypopigmented macules, and one patient developed a transient atrophic scar as a result of pulse stacking for treating pigmented lesions.

Using blinded comparisons of 35-mm photographs as well as patient self-reports to assess treatment efficacy, the dermatologists observed improvement in the vascular and pigmentary lesions in all of the patients, "and, more importantly, all of the patients were satisfied with their clinical improvement," he said at the meeting.

The clinical implication of these findings "is that we now are able to use one system, rather than multiple systems, to safely treat both the vascular and pigmentary changes associated with sun damage," said Dr. Rosen, who reported receiving a research grant for this investigation from Candela Corp., manufacturer of the laser device that was used in the study.

BOSTON — A modified, high-energy, variable-pulse-duration, pulsed dye laser safely and effectively treated both vascular and pigmentary changes in patients with photoaged skin, a study has shown.

The findings suggest that what has typically been considered a "vascular" laser can be safely used to treat sun damage and associated pigmentary changes as well, Dr. Nathan Rosen said at the annual meeting of the American Society for Laser Medicine and Surgery.

The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size, so large lesions can be treated quickly, but the resultant high-energy pulses can cause postoperative bruising and transient pigmentary changes.

The device used in this investigation employs a modified pulse structure, whereby each pulse comprises six uniform micropulses that evenly distribute the pulse energy, reducing the likelihood of bruising, compared with earlier devices, Dr. Rosen explained.

"The purpura threshold is increased because pigment more selectively absorbs the individual micropulses," he said.

In addition, the investigational device includes a compression handpiece that, by removing the competing vascular target, prevents the development of purpura. "The handpiece compresses the blood vessels in the region, allowing all of the energy to be concentrated in the pigmented area," said Dr. Rosen, who is in private practice in New York.

To evaluate the impact of the new technology on vascular and pigmentary changes associated with photodamage and long-term sun exposure, Dr. Rosen, along with his colleagues Dr. Arielle N.B. Kauvar and Dr. Tatiana Khrom, who are also in private practice in New York, considered the outcomes of its use on 24 patients with photoaged, phototype I-IV skin.

Of the 24 subjects who were enrolled in the study, 14 were treated for vascular and pigmented lesions and 10 were treated for pigmented lesions alone. All of the subjects received a total of one to three treatments at 4-week intervals, and all underwent follow-up evaluations at 3 and 12 weeks.

To treat background erythema, the dermatologists used a 10-ms pulse width and a 12-mm spot at a fluence of 7 J/cm

Only the vascular lesions were treated with cryogen spray cooling (30-ms spray, 30-ms delay) before each laser pulse, and none of the patients received a topical anesthetic prior to laser treatment, Dr. Rosen noted.

"All of the patients tolerated the treatment well, and there was no purpura with the parameters that we used," Dr. Rosen said.

Three of the patients developed transient hypopigmented macules, and one patient developed a transient atrophic scar as a result of pulse stacking for treating pigmented lesions.

Using blinded comparisons of 35-mm photographs as well as patient self-reports to assess treatment efficacy, the dermatologists observed improvement in the vascular and pigmentary lesions in all of the patients, "and, more importantly, all of the patients were satisfied with their clinical improvement," he said at the meeting.

The clinical implication of these findings "is that we now are able to use one system, rather than multiple systems, to safely treat both the vascular and pigmentary changes associated with sun damage," said Dr. Rosen, who reported receiving a research grant for this investigation from Candela Corp., manufacturer of the laser device that was used in the study.

BOSTON — A modified, high-energy, variable-pulse-duration, pulsed dye laser safely and effectively treated both vascular and pigmentary changes in patients with photoaged skin, a study has shown.

The findings suggest that what has typically been considered a "vascular" laser can be safely used to treat sun damage and associated pigmentary changes as well, Dr. Nathan Rosen said at the annual meeting of the American Society for Laser Medicine and Surgery.

The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size, so large lesions can be treated quickly, but the resultant high-energy pulses can cause postoperative bruising and transient pigmentary changes.

The device used in this investigation employs a modified pulse structure, whereby each pulse comprises six uniform micropulses that evenly distribute the pulse energy, reducing the likelihood of bruising, compared with earlier devices, Dr. Rosen explained.

"The purpura threshold is increased because pigment more selectively absorbs the individual micropulses," he said.

In addition, the investigational device includes a compression handpiece that, by removing the competing vascular target, prevents the development of purpura. "The handpiece compresses the blood vessels in the region, allowing all of the energy to be concentrated in the pigmented area," said Dr. Rosen, who is in private practice in New York.

To evaluate the impact of the new technology on vascular and pigmentary changes associated with photodamage and long-term sun exposure, Dr. Rosen, along with his colleagues Dr. Arielle N.B. Kauvar and Dr. Tatiana Khrom, who are also in private practice in New York, considered the outcomes of its use on 24 patients with photoaged, phototype I-IV skin.

Of the 24 subjects who were enrolled in the study, 14 were treated for vascular and pigmented lesions and 10 were treated for pigmented lesions alone. All of the subjects received a total of one to three treatments at 4-week intervals, and all underwent follow-up evaluations at 3 and 12 weeks.

To treat background erythema, the dermatologists used a 10-ms pulse width and a 12-mm spot at a fluence of 7 J/cm

Only the vascular lesions were treated with cryogen spray cooling (30-ms spray, 30-ms delay) before each laser pulse, and none of the patients received a topical anesthetic prior to laser treatment, Dr. Rosen noted.

"All of the patients tolerated the treatment well, and there was no purpura with the parameters that we used," Dr. Rosen said.

Three of the patients developed transient hypopigmented macules, and one patient developed a transient atrophic scar as a result of pulse stacking for treating pigmented lesions.

Using blinded comparisons of 35-mm photographs as well as patient self-reports to assess treatment efficacy, the dermatologists observed improvement in the vascular and pigmentary lesions in all of the patients, "and, more importantly, all of the patients were satisfied with their clinical improvement," he said at the meeting.

The clinical implication of these findings "is that we now are able to use one system, rather than multiple systems, to safely treat both the vascular and pigmentary changes associated with sun damage," said Dr. Rosen, who reported receiving a research grant for this investigation from Candela Corp., manufacturer of the laser device that was used in the study.

BOSTON — Irradiation of benign pigmented nevi with Q-switched laser does not induce malignant transformation of the lesions, said Dr. David J. Goldberg at the annual meeting of the American Society for Laser Medicine and Surgery.

While the use of lasers to treat melanocytic nevi has been the subject of much debate because of concerns about malignant transformation, "to date there has been no study to fully evaluate this theoretical concern," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Toward this end, Dr. Goldberg and colleagues undertook a preliminary study to determine if irradiation with Q-switched laser increases the malignant potential of benign nevi. The investigators analyzed biopsy samples from 10 individuals with laser-treated nevi looking for changes suggestive of malignant transformation.

All participants had multiple benign nevi, one of which was laser irradiated with a Q-switched Nd:Yag laser. "In each patient, the treated nevus was matched with a paired control nevus that was not irradiated," said Dr. Goldberg, who is also in private practice in New York and New Jersey. Twenty-four hours after the laser treatment, both the treated and untreated nevi were excised and biopsy samples were analyzed for three instantaneous markers of malignant transformation: proliferating cell nuclear antigen, pyrimidine dimers, and 8-hydroxydeoxyguanosine. The specimens also were analyzed for p53.

"We didn't find any significant markers for malignant transformation in the laser-treated nevi," said Dr. Goldberg, suggesting not only that Q-switched laser irradiation is a safe option for biopsy-confirmed benign nevi, but also that "any future malignant transformation of such nevi is not the result of the laser treatments."

BOSTON — Irradiation of benign pigmented nevi with Q-switched laser does not induce malignant transformation of the lesions, said Dr. David J. Goldberg at the annual meeting of the American Society for Laser Medicine and Surgery.

While the use of lasers to treat melanocytic nevi has been the subject of much debate because of concerns about malignant transformation, "to date there has been no study to fully evaluate this theoretical concern," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Toward this end, Dr. Goldberg and colleagues undertook a preliminary study to determine if irradiation with Q-switched laser increases the malignant potential of benign nevi. The investigators analyzed biopsy samples from 10 individuals with laser-treated nevi looking for changes suggestive of malignant transformation.

All participants had multiple benign nevi, one of which was laser irradiated with a Q-switched Nd:Yag laser. "In each patient, the treated nevus was matched with a paired control nevus that was not irradiated," said Dr. Goldberg, who is also in private practice in New York and New Jersey. Twenty-four hours after the laser treatment, both the treated and untreated nevi were excised and biopsy samples were analyzed for three instantaneous markers of malignant transformation: proliferating cell nuclear antigen, pyrimidine dimers, and 8-hydroxydeoxyguanosine. The specimens also were analyzed for p53.

"We didn't find any significant markers for malignant transformation in the laser-treated nevi," said Dr. Goldberg, suggesting not only that Q-switched laser irradiation is a safe option for biopsy-confirmed benign nevi, but also that "any future malignant transformation of such nevi is not the result of the laser treatments."

BOSTON — Irradiation of benign pigmented nevi with Q-switched laser does not induce malignant transformation of the lesions, said Dr. David J. Goldberg at the annual meeting of the American Society for Laser Medicine and Surgery.

While the use of lasers to treat melanocytic nevi has been the subject of much debate because of concerns about malignant transformation, "to date there has been no study to fully evaluate this theoretical concern," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Toward this end, Dr. Goldberg and colleagues undertook a preliminary study to determine if irradiation with Q-switched laser increases the malignant potential of benign nevi. The investigators analyzed biopsy samples from 10 individuals with laser-treated nevi looking for changes suggestive of malignant transformation.

All participants had multiple benign nevi, one of which was laser irradiated with a Q-switched Nd:Yag laser. "In each patient, the treated nevus was matched with a paired control nevus that was not irradiated," said Dr. Goldberg, who is also in private practice in New York and New Jersey. Twenty-four hours after the laser treatment, both the treated and untreated nevi were excised and biopsy samples were analyzed for three instantaneous markers of malignant transformation: proliferating cell nuclear antigen, pyrimidine dimers, and 8-hydroxydeoxyguanosine. The specimens also were analyzed for p53.

"We didn't find any significant markers for malignant transformation in the laser-treated nevi," said Dr. Goldberg, suggesting not only that Q-switched laser irradiation is a safe option for biopsy-confirmed benign nevi, but also that "any future malignant transformation of such nevi is not the result of the laser treatments."

LUCAYA, BAHAMAS — Whether atypical fibroxanthoma is an entity unto itself or simply a superficial form of malignant fibrous histiocytoma depends upon whether the observer is a clinician or a dermatopathologist.

While the two nonmelanoma skin cancers behave very differently from a clinical standpoint, "the pathologist can't tell the difference except for the depth," Dr. Henry W. Randle noted at a meeting of the American Society for Mohs Surgery.

Atypical fibroxanthoma (AFX)—also known as "malignant fibrous histiocytoma in situ"—is a rapidly growing and often ulcerated red nodule, typically seen on sun-damaged head and neck areas in elderly men. Although its histology appears ominous, prognosis is usually good. Indeed, of 140 patients, just 6.4% (9) had recurrences after standard excision, usually within the first year. Metastases are rare, usually to a regional node. Mortality is also infrequent, although there have been some recent case reports, he said.

These tumors can be treated with Mohs surgery, after which the recurrence rate is just 6.9%. Malignant fibrous histiocytoma (MFH), in contrast, recurs in 43% following Mohs surgery (J. Am. Acad. Dermatol. 2001;44:656–9).

Moreover, MFH invades the skin from the soft tissue and moves up to the surface rather than the other way around, and it is not associated with sun exposure—it typically appears on extremities, not the face and neck. MFH is a much more aggressive tumor than is AFX, with mortality rates of more than one-third at 3.5 years. "They really behave very differently, even though AFX is considered to be the more superficial form of MFH," noted Dr. Randle of the Mayo Clinic in Jacksonville, Fla.

The treatment of MFH requires staging. Wide excision is the standard, because the depth of these tumors makes the use of Mohs surgery questionable. Node dissection, radiation, and chemotherapy should also be considered, he noted.

Research is now focused on finding immunohistochemical markers that will help to distinguish the two tumors. Most are identical in both, with the only known difference thus far being that AFX has a weak positivity to CD74, while MFH is strongly positive. However, even this isn't absolute. Until better markers are found, pathologists typically consider the lesion to be MFH—and recommend aggressive treatment—if it extends into the subcutis and vascular invasion and tumor necrosis are present.

Dermatologic surgeons who treat these tumors need to take extra care beyond what is involved in minor procedures. In a disturbing case report, a surgeon who accidentally impaled his own hand while removing an MFH developed a genetically identical MFH 5 months later (N. Engl. J. Med. 1996;335:1494–7).

Malignant fibrous histiocytoma (right)is a much more aggressive tumor thanis atypical fibroxanthoma (above), with mortality rates of more than one-third at 3.5 years. Photos courtesy Dr. Henry W. Randle

LUCAYA, BAHAMAS — Whether atypical fibroxanthoma is an entity unto itself or simply a superficial form of malignant fibrous histiocytoma depends upon whether the observer is a clinician or a dermatopathologist.

While the two nonmelanoma skin cancers behave very differently from a clinical standpoint, "the pathologist can't tell the difference except for the depth," Dr. Henry W. Randle noted at a meeting of the American Society for Mohs Surgery.

Atypical fibroxanthoma (AFX)—also known as "malignant fibrous histiocytoma in situ"—is a rapidly growing and often ulcerated red nodule, typically seen on sun-damaged head and neck areas in elderly men. Although its histology appears ominous, prognosis is usually good. Indeed, of 140 patients, just 6.4% (9) had recurrences after standard excision, usually within the first year. Metastases are rare, usually to a regional node. Mortality is also infrequent, although there have been some recent case reports, he said.

These tumors can be treated with Mohs surgery, after which the recurrence rate is just 6.9%. Malignant fibrous histiocytoma (MFH), in contrast, recurs in 43% following Mohs surgery (J. Am. Acad. Dermatol. 2001;44:656–9).

Moreover, MFH invades the skin from the soft tissue and moves up to the surface rather than the other way around, and it is not associated with sun exposure—it typically appears on extremities, not the face and neck. MFH is a much more aggressive tumor than is AFX, with mortality rates of more than one-third at 3.5 years. "They really behave very differently, even though AFX is considered to be the more superficial form of MFH," noted Dr. Randle of the Mayo Clinic in Jacksonville, Fla.

The treatment of MFH requires staging. Wide excision is the standard, because the depth of these tumors makes the use of Mohs surgery questionable. Node dissection, radiation, and chemotherapy should also be considered, he noted.

Research is now focused on finding immunohistochemical markers that will help to distinguish the two tumors. Most are identical in both, with the only known difference thus far being that AFX has a weak positivity to CD74, while MFH is strongly positive. However, even this isn't absolute. Until better markers are found, pathologists typically consider the lesion to be MFH—and recommend aggressive treatment—if it extends into the subcutis and vascular invasion and tumor necrosis are present.

Dermatologic surgeons who treat these tumors need to take extra care beyond what is involved in minor procedures. In a disturbing case report, a surgeon who accidentally impaled his own hand while removing an MFH developed a genetically identical MFH 5 months later (N. Engl. J. Med. 1996;335:1494–7).

Malignant fibrous histiocytoma (right)is a much more aggressive tumor thanis atypical fibroxanthoma (above), with mortality rates of more than one-third at 3.5 years. Photos courtesy Dr. Henry W. Randle

LUCAYA, BAHAMAS — Whether atypical fibroxanthoma is an entity unto itself or simply a superficial form of malignant fibrous histiocytoma depends upon whether the observer is a clinician or a dermatopathologist.

While the two nonmelanoma skin cancers behave very differently from a clinical standpoint, "the pathologist can't tell the difference except for the depth," Dr. Henry W. Randle noted at a meeting of the American Society for Mohs Surgery.

Atypical fibroxanthoma (AFX)—also known as "malignant fibrous histiocytoma in situ"—is a rapidly growing and often ulcerated red nodule, typically seen on sun-damaged head and neck areas in elderly men. Although its histology appears ominous, prognosis is usually good. Indeed, of 140 patients, just 6.4% (9) had recurrences after standard excision, usually within the first year. Metastases are rare, usually to a regional node. Mortality is also infrequent, although there have been some recent case reports, he said.

These tumors can be treated with Mohs surgery, after which the recurrence rate is just 6.9%. Malignant fibrous histiocytoma (MFH), in contrast, recurs in 43% following Mohs surgery (J. Am. Acad. Dermatol. 2001;44:656–9).

Moreover, MFH invades the skin from the soft tissue and moves up to the surface rather than the other way around, and it is not associated with sun exposure—it typically appears on extremities, not the face and neck. MFH is a much more aggressive tumor than is AFX, with mortality rates of more than one-third at 3.5 years. "They really behave very differently, even though AFX is considered to be the more superficial form of MFH," noted Dr. Randle of the Mayo Clinic in Jacksonville, Fla.

The treatment of MFH requires staging. Wide excision is the standard, because the depth of these tumors makes the use of Mohs surgery questionable. Node dissection, radiation, and chemotherapy should also be considered, he noted.

Research is now focused on finding immunohistochemical markers that will help to distinguish the two tumors. Most are identical in both, with the only known difference thus far being that AFX has a weak positivity to CD74, while MFH is strongly positive. However, even this isn't absolute. Until better markers are found, pathologists typically consider the lesion to be MFH—and recommend aggressive treatment—if it extends into the subcutis and vascular invasion and tumor necrosis are present.

Dermatologic surgeons who treat these tumors need to take extra care beyond what is involved in minor procedures. In a disturbing case report, a surgeon who accidentally impaled his own hand while removing an MFH developed a genetically identical MFH 5 months later (N. Engl. J. Med. 1996;335:1494–7).

Malignant fibrous histiocytoma (right)is a much more aggressive tumor thanis atypical fibroxanthoma (above), with mortality rates of more than one-third at 3.5 years. Photos courtesy Dr. Henry W. Randle

LAS VEGAS — Treatment of keloids or hypertrophic scars with surgery alone is almost guaranteed to fail, but there are theories as to which of the many potential adjunctive therapies might be best, and how best to combine treatments, Dr. Jimmy J. Brown said.

Dr. Brown and two other experts described their preferred treatment regimens at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Developing a strong bond between the physician and patient is paramount for successful management of these challenging lesions, especially for giant keloids, said Dr. Brown of Charles R. Drew University of Medicine and Science, Los Angeles.

Dr. Brian J. F. Wong said that most current treatment regimens use some combination of surgery, pressure, silicone gels or sheeting, and steroid injections, based mainly on ad hoc and anecdotal reports. "It's a very confusing body of literature," said Dr. Wong of the University of California, Irvine.

Even with combination therapy, 50% of keloids and hypertrophic scars recur, he noted.

Prevention is the best strategy, Dr. R. James Koch emphasized. Studies show that African Americans and possibly people of Chinese ancestry are at higher risk to develop keloids, compared with whites. Many things can cause keloids, including surgery, burns, skin piercing, lacerations, abrasions, and tattoos. Patient who may be predisposed to keloids should avoid nonessential surgery, said Dr. Koch of Palo Alto, Calif.

After surgery alone, keloids recur in 45%–100% of cases. Adding radiation therapy may reduce the recurrence rate to 10%–20%, the literature suggests, but its use is not standardized. No one knows when best to use it, how much to use, or whether fractionated protocols are beneficial, he pointed out.

Some physicians use a single postoperative dose of radiation in some patients. Dr. Brown cautioned that most radiologists prefer to use low-dose radiation for patients with keloids because it is a benign disease, but this may increase the risk for later development of radiation-related malignancy. He knows of three patients who developed squamous cell carcinoma in a keloid site after postoperative radiation therapy.

His immediate postoperative care comprises topical imiquimod (Aldara) cream 5% once a day and a pressure dressing; the wound is kept tension free. The jury is still out on imiquimod's usefulness for keloids, Dr. Brown said. His anecdotal experience suggests that using positive pressure splints once the surgical wound is healed is important to prevent keloid recurrence. It may be necessary to create pressure devices, such as a clothespin on an earlobe, after keloid removal, he suggested.

"If we can get away with excision, Aldara, and pressure therapy, we may not need radiation," he said.

He generally stops imiquimod after 8 weeks, although he will interrupt therapy earlier if the wound starts to break down where it was applied. This is not a debilitating problem, and the drug can be restarted after the wound heals, he said.

Intralesional corticosteroid injections should be a key part of treatment, Dr. Koch and Dr. Brown agreed.

Dr. Koch typically treats keloids with excision, but one shouldn't compromise anatomic structures to remove all of the keloid at once, he said. It may be done in stages. He avoids wound tension and may add pressure therapy. Intralesional steroids begin at least 2–3 weeks after surgery, and he also may use silicone gel.

For hypertrophic scars, Dr. Koch performs scar revision surgery and will start intralesional steroids at the first sign of hypertrophic scar recurrence. He also said he may use compression or silicone gel.

The most promising upcoming therapies for keloids and hypertrophic scars may be pulsed dye laser and photodynamic therapy (PDT), Dr. Wong said. Keloids are hypervascular lesions, and the pulsed dye laser disrupts blood supply, using a very narrow, local heat effect to trigger apoptotic mechanisms. When he removes a keloid, he sends the patient to a dermatologist for targeted pulsed dye laser therapy.

Studies of PDT for cancer have shown that it does not successfully treat malignancies but seems to decrease scar formation. Since PDT has no ionizing radiation, it can treat the keloid while preserving the normal tissue matrix. Dr. Wong plans to begin using PDT in patients with refractory keloids soon. "It's like a neutron bomb—you can kill the occupants but leave the house intact," he said. "There's no downside in the correct patient."

Dr. Koch was less enthusiastic about flashlamp and pumped pulsed dye laser therapy for keloids. This strategy mainly helps take the red out of the lesions, he said.

A combination of surgery, topical imiquimod, and pressure therapy may stave off the need for radiation. Courtesy Dr. R. James Koch

Metaanalysis Yields Mixed Results in Keloid, Hypertrophic Scar Treatment

Most of the available treatments for keloids or hypertrophic scars offer a minimal likelihood of improvement, a metaanalysis suggests.

The metaanalysis of results from 70 trials found a 70% chance of improvement from treatment. The management regimens improved lesions by a mean of 60%, compared with baseline, and a few therapies were no better than observation alone, Dr. Douglas Leventhal reported in a poster presentation at the international symposium.

There is no universally accepted treatment regimen for keloids or hypertrophic scars and no evidence-based literature to help clinicians choose from among the many treatment options that have already been tried. Management has evolved over the years from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that work on a cellular level, wrote Dr. Leventhal of Jefferson Medical College, Philadelphia.

Some current treatments for keloids or hypertrophic scars may provide clinically significant improvements, but results fall far short of a cure, he concluded.

LAS VEGAS — Treatment of keloids or hypertrophic scars with surgery alone is almost guaranteed to fail, but there are theories as to which of the many potential adjunctive therapies might be best, and how best to combine treatments, Dr. Jimmy J. Brown said.

Dr. Brown and two other experts described their preferred treatment regimens at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Developing a strong bond between the physician and patient is paramount for successful management of these challenging lesions, especially for giant keloids, said Dr. Brown of Charles R. Drew University of Medicine and Science, Los Angeles.

Dr. Brian J. F. Wong said that most current treatment regimens use some combination of surgery, pressure, silicone gels or sheeting, and steroid injections, based mainly on ad hoc and anecdotal reports. "It's a very confusing body of literature," said Dr. Wong of the University of California, Irvine.

Even with combination therapy, 50% of keloids and hypertrophic scars recur, he noted.

Prevention is the best strategy, Dr. R. James Koch emphasized. Studies show that African Americans and possibly people of Chinese ancestry are at higher risk to develop keloids, compared with whites. Many things can cause keloids, including surgery, burns, skin piercing, lacerations, abrasions, and tattoos. Patient who may be predisposed to keloids should avoid nonessential surgery, said Dr. Koch of Palo Alto, Calif.

After surgery alone, keloids recur in 45%–100% of cases. Adding radiation therapy may reduce the recurrence rate to 10%–20%, the literature suggests, but its use is not standardized. No one knows when best to use it, how much to use, or whether fractionated protocols are beneficial, he pointed out.

Some physicians use a single postoperative dose of radiation in some patients. Dr. Brown cautioned that most radiologists prefer to use low-dose radiation for patients with keloids because it is a benign disease, but this may increase the risk for later development of radiation-related malignancy. He knows of three patients who developed squamous cell carcinoma in a keloid site after postoperative radiation therapy.

His immediate postoperative care comprises topical imiquimod (Aldara) cream 5% once a day and a pressure dressing; the wound is kept tension free. The jury is still out on imiquimod's usefulness for keloids, Dr. Brown said. His anecdotal experience suggests that using positive pressure splints once the surgical wound is healed is important to prevent keloid recurrence. It may be necessary to create pressure devices, such as a clothespin on an earlobe, after keloid removal, he suggested.

"If we can get away with excision, Aldara, and pressure therapy, we may not need radiation," he said.

He generally stops imiquimod after 8 weeks, although he will interrupt therapy earlier if the wound starts to break down where it was applied. This is not a debilitating problem, and the drug can be restarted after the wound heals, he said.

Intralesional corticosteroid injections should be a key part of treatment, Dr. Koch and Dr. Brown agreed.

Dr. Koch typically treats keloids with excision, but one shouldn't compromise anatomic structures to remove all of the keloid at once, he said. It may be done in stages. He avoids wound tension and may add pressure therapy. Intralesional steroids begin at least 2–3 weeks after surgery, and he also may use silicone gel.

For hypertrophic scars, Dr. Koch performs scar revision surgery and will start intralesional steroids at the first sign of hypertrophic scar recurrence. He also said he may use compression or silicone gel.

The most promising upcoming therapies for keloids and hypertrophic scars may be pulsed dye laser and photodynamic therapy (PDT), Dr. Wong said. Keloids are hypervascular lesions, and the pulsed dye laser disrupts blood supply, using a very narrow, local heat effect to trigger apoptotic mechanisms. When he removes a keloid, he sends the patient to a dermatologist for targeted pulsed dye laser therapy.

Studies of PDT for cancer have shown that it does not successfully treat malignancies but seems to decrease scar formation. Since PDT has no ionizing radiation, it can treat the keloid while preserving the normal tissue matrix. Dr. Wong plans to begin using PDT in patients with refractory keloids soon. "It's like a neutron bomb—you can kill the occupants but leave the house intact," he said. "There's no downside in the correct patient."

Dr. Koch was less enthusiastic about flashlamp and pumped pulsed dye laser therapy for keloids. This strategy mainly helps take the red out of the lesions, he said.

A combination of surgery, topical imiquimod, and pressure therapy may stave off the need for radiation. Courtesy Dr. R. James Koch

Metaanalysis Yields Mixed Results in Keloid, Hypertrophic Scar Treatment

Most of the available treatments for keloids or hypertrophic scars offer a minimal likelihood of improvement, a metaanalysis suggests.

The metaanalysis of results from 70 trials found a 70% chance of improvement from treatment. The management regimens improved lesions by a mean of 60%, compared with baseline, and a few therapies were no better than observation alone, Dr. Douglas Leventhal reported in a poster presentation at the international symposium.

There is no universally accepted treatment regimen for keloids or hypertrophic scars and no evidence-based literature to help clinicians choose from among the many treatment options that have already been tried. Management has evolved over the years from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that work on a cellular level, wrote Dr. Leventhal of Jefferson Medical College, Philadelphia.

Some current treatments for keloids or hypertrophic scars may provide clinically significant improvements, but results fall far short of a cure, he concluded.

LAS VEGAS — Treatment of keloids or hypertrophic scars with surgery alone is almost guaranteed to fail, but there are theories as to which of the many potential adjunctive therapies might be best, and how best to combine treatments, Dr. Jimmy J. Brown said.

Dr. Brown and two other experts described their preferred treatment regimens at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Developing a strong bond between the physician and patient is paramount for successful management of these challenging lesions, especially for giant keloids, said Dr. Brown of Charles R. Drew University of Medicine and Science, Los Angeles.

Dr. Brian J. F. Wong said that most current treatment regimens use some combination of surgery, pressure, silicone gels or sheeting, and steroid injections, based mainly on ad hoc and anecdotal reports. "It's a very confusing body of literature," said Dr. Wong of the University of California, Irvine.

Even with combination therapy, 50% of keloids and hypertrophic scars recur, he noted.

Prevention is the best strategy, Dr. R. James Koch emphasized. Studies show that African Americans and possibly people of Chinese ancestry are at higher risk to develop keloids, compared with whites. Many things can cause keloids, including surgery, burns, skin piercing, lacerations, abrasions, and tattoos. Patient who may be predisposed to keloids should avoid nonessential surgery, said Dr. Koch of Palo Alto, Calif.

After surgery alone, keloids recur in 45%–100% of cases. Adding radiation therapy may reduce the recurrence rate to 10%–20%, the literature suggests, but its use is not standardized. No one knows when best to use it, how much to use, or whether fractionated protocols are beneficial, he pointed out.

Some physicians use a single postoperative dose of radiation in some patients. Dr. Brown cautioned that most radiologists prefer to use low-dose radiation for patients with keloids because it is a benign disease, but this may increase the risk for later development of radiation-related malignancy. He knows of three patients who developed squamous cell carcinoma in a keloid site after postoperative radiation therapy.

His immediate postoperative care comprises topical imiquimod (Aldara) cream 5% once a day and a pressure dressing; the wound is kept tension free. The jury is still out on imiquimod's usefulness for keloids, Dr. Brown said. His anecdotal experience suggests that using positive pressure splints once the surgical wound is healed is important to prevent keloid recurrence. It may be necessary to create pressure devices, such as a clothespin on an earlobe, after keloid removal, he suggested.

"If we can get away with excision, Aldara, and pressure therapy, we may not need radiation," he said.

He generally stops imiquimod after 8 weeks, although he will interrupt therapy earlier if the wound starts to break down where it was applied. This is not a debilitating problem, and the drug can be restarted after the wound heals, he said.

Intralesional corticosteroid injections should be a key part of treatment, Dr. Koch and Dr. Brown agreed.

Dr. Koch typically treats keloids with excision, but one shouldn't compromise anatomic structures to remove all of the keloid at once, he said. It may be done in stages. He avoids wound tension and may add pressure therapy. Intralesional steroids begin at least 2–3 weeks after surgery, and he also may use silicone gel.

For hypertrophic scars, Dr. Koch performs scar revision surgery and will start intralesional steroids at the first sign of hypertrophic scar recurrence. He also said he may use compression or silicone gel.

The most promising upcoming therapies for keloids and hypertrophic scars may be pulsed dye laser and photodynamic therapy (PDT), Dr. Wong said. Keloids are hypervascular lesions, and the pulsed dye laser disrupts blood supply, using a very narrow, local heat effect to trigger apoptotic mechanisms. When he removes a keloid, he sends the patient to a dermatologist for targeted pulsed dye laser therapy.

Studies of PDT for cancer have shown that it does not successfully treat malignancies but seems to decrease scar formation. Since PDT has no ionizing radiation, it can treat the keloid while preserving the normal tissue matrix. Dr. Wong plans to begin using PDT in patients with refractory keloids soon. "It's like a neutron bomb—you can kill the occupants but leave the house intact," he said. "There's no downside in the correct patient."

Dr. Koch was less enthusiastic about flashlamp and pumped pulsed dye laser therapy for keloids. This strategy mainly helps take the red out of the lesions, he said.

A combination of surgery, topical imiquimod, and pressure therapy may stave off the need for radiation. Courtesy Dr. R. James Koch

Metaanalysis Yields Mixed Results in Keloid, Hypertrophic Scar Treatment

Most of the available treatments for keloids or hypertrophic scars offer a minimal likelihood of improvement, a metaanalysis suggests.

The metaanalysis of results from 70 trials found a 70% chance of improvement from treatment. The management regimens improved lesions by a mean of 60%, compared with baseline, and a few therapies were no better than observation alone, Dr. Douglas Leventhal reported in a poster presentation at the international symposium.

There is no universally accepted treatment regimen for keloids or hypertrophic scars and no evidence-based literature to help clinicians choose from among the many treatment options that have already been tried. Management has evolved over the years from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that work on a cellular level, wrote Dr. Leventhal of Jefferson Medical College, Philadelphia.

Some current treatments for keloids or hypertrophic scars may provide clinically significant improvements, but results fall far short of a cure, he concluded.