Aesthetic Dermatology

PARK CITY, UTAH — Facial reconstruction after tumor removal should be guided by the surgical defect rather than presurgical clinical appearance, Dr. Andrew J. Kaufman advised at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Reconstruction is successful "when the aesthetic and functional goals are met," said Dr. Kaufman, a Mohs surgeon in Thousand Oaks, Calif.

Before proceeding, the surgeon should set functional goals for the patient, said Dr. Kaufman, also of the University of California, Los Angeles. To choose the "correct" repair for meeting those goals, he recommended doing a thorough preoperative evaluation.

This would include consideration of patient characteristics such as age, anxiety level, concurrent medical problems, and type of cancer. Older patients, for example, generally have more loose skin available for repairs.

Other factors to consider beyond size, depth, and location of the wound are whether the function, surface, and structure are intact, Dr. Kaufman said.

The surgeon should determine whether the wound is concave or convex and whether the skin is sebaceous or thin. Concave areas heal well with a graft, and convex areas do better with a flap. Sebaceous skin does not hide a scar as well as thin skin, he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Adjacent loose tissue also should be taken into account. "Adjacent tissue is the bank or reserve from which to borrow for repairs," he said, adding that surgeons should "avoid distortion or deviation of free margins and anatomic margins at all costs."

Dr. Kaufman recommended trying to reconstruct within cosmetic units or subunits. "Consider closing multiunit defects in individual defects," he said, suggesting that incision lines be placed at junctions between units/subunits or rhytids/furrows.

When it is appropriate, the wound should be allowed to heal by secondary intention. For big defects, consider three options: secondary intention, graft, or making the defect smaller (closing it in subunits or using combination repairs).

Consider all options for repair. "A lot of time people get locked into an idea," he said, warning that the first choice may not be the best. Assess what is missing and where its replacement is going to come from. "Look to see: Where is the loose skin, and where are the relaxed skin tension lines?" said Dr. Kaufman.

"Don't get in over your head," he cautioned. Each surgeon should build on experience, starting with complex repairs, going on to small flaps and grafts, and later attempting more advanced flaps. If uncomfortable with a reconstruction, refer it to another surgeon.

He went on to offer the following advice:

▸ Distorting an anatomic landmark is worse than having a longer scar.

▸ Keeping incision lines between cosmetic units or subunits wherever possible will help, he said, "to hide scar in shadows caused by concavities and convexities."

▸ Flaps usually are better than grafts for matching color, texture, and thickness, but grafts "work well in thin, shiny skin and in reconstruction of complete units or subunits," he noted.

▸ When doing a repair, always make sure the margins are clean before starting.

Surgeons can enhance patients' experience by playing classical music, sending them home with wound supplies, and calling to see how they are recovering. "Patients love it. They don't expect doctors to call them at home," he said. "By doing those kinds of things, you put in their mind that they are going to have good results."

'Don't get in over your head.' If you're uncomfortable with a reconstruction, refer it to another surgeon. DR. KAUFMAN

PARK CITY, UTAH — Facial reconstruction after tumor removal should be guided by the surgical defect rather than presurgical clinical appearance, Dr. Andrew J. Kaufman advised at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Reconstruction is successful "when the aesthetic and functional goals are met," said Dr. Kaufman, a Mohs surgeon in Thousand Oaks, Calif.

Before proceeding, the surgeon should set functional goals for the patient, said Dr. Kaufman, also of the University of California, Los Angeles. To choose the "correct" repair for meeting those goals, he recommended doing a thorough preoperative evaluation.

This would include consideration of patient characteristics such as age, anxiety level, concurrent medical problems, and type of cancer. Older patients, for example, generally have more loose skin available for repairs.

Other factors to consider beyond size, depth, and location of the wound are whether the function, surface, and structure are intact, Dr. Kaufman said.

The surgeon should determine whether the wound is concave or convex and whether the skin is sebaceous or thin. Concave areas heal well with a graft, and convex areas do better with a flap. Sebaceous skin does not hide a scar as well as thin skin, he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Adjacent loose tissue also should be taken into account. "Adjacent tissue is the bank or reserve from which to borrow for repairs," he said, adding that surgeons should "avoid distortion or deviation of free margins and anatomic margins at all costs."

Dr. Kaufman recommended trying to reconstruct within cosmetic units or subunits. "Consider closing multiunit defects in individual defects," he said, suggesting that incision lines be placed at junctions between units/subunits or rhytids/furrows.

When it is appropriate, the wound should be allowed to heal by secondary intention. For big defects, consider three options: secondary intention, graft, or making the defect smaller (closing it in subunits or using combination repairs).

Consider all options for repair. "A lot of time people get locked into an idea," he said, warning that the first choice may not be the best. Assess what is missing and where its replacement is going to come from. "Look to see: Where is the loose skin, and where are the relaxed skin tension lines?" said Dr. Kaufman.

"Don't get in over your head," he cautioned. Each surgeon should build on experience, starting with complex repairs, going on to small flaps and grafts, and later attempting more advanced flaps. If uncomfortable with a reconstruction, refer it to another surgeon.

He went on to offer the following advice:

▸ Distorting an anatomic landmark is worse than having a longer scar.

▸ Keeping incision lines between cosmetic units or subunits wherever possible will help, he said, "to hide scar in shadows caused by concavities and convexities."

▸ Flaps usually are better than grafts for matching color, texture, and thickness, but grafts "work well in thin, shiny skin and in reconstruction of complete units or subunits," he noted.

▸ When doing a repair, always make sure the margins are clean before starting.

Surgeons can enhance patients' experience by playing classical music, sending them home with wound supplies, and calling to see how they are recovering. "Patients love it. They don't expect doctors to call them at home," he said. "By doing those kinds of things, you put in their mind that they are going to have good results."

'Don't get in over your head.' If you're uncomfortable with a reconstruction, refer it to another surgeon. DR. KAUFMAN

PARK CITY, UTAH — Facial reconstruction after tumor removal should be guided by the surgical defect rather than presurgical clinical appearance, Dr. Andrew J. Kaufman advised at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Reconstruction is successful "when the aesthetic and functional goals are met," said Dr. Kaufman, a Mohs surgeon in Thousand Oaks, Calif.

Before proceeding, the surgeon should set functional goals for the patient, said Dr. Kaufman, also of the University of California, Los Angeles. To choose the "correct" repair for meeting those goals, he recommended doing a thorough preoperative evaluation.

This would include consideration of patient characteristics such as age, anxiety level, concurrent medical problems, and type of cancer. Older patients, for example, generally have more loose skin available for repairs.

Other factors to consider beyond size, depth, and location of the wound are whether the function, surface, and structure are intact, Dr. Kaufman said.

The surgeon should determine whether the wound is concave or convex and whether the skin is sebaceous or thin. Concave areas heal well with a graft, and convex areas do better with a flap. Sebaceous skin does not hide a scar as well as thin skin, he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Adjacent loose tissue also should be taken into account. "Adjacent tissue is the bank or reserve from which to borrow for repairs," he said, adding that surgeons should "avoid distortion or deviation of free margins and anatomic margins at all costs."

Dr. Kaufman recommended trying to reconstruct within cosmetic units or subunits. "Consider closing multiunit defects in individual defects," he said, suggesting that incision lines be placed at junctions between units/subunits or rhytids/furrows.

When it is appropriate, the wound should be allowed to heal by secondary intention. For big defects, consider three options: secondary intention, graft, or making the defect smaller (closing it in subunits or using combination repairs).

Consider all options for repair. "A lot of time people get locked into an idea," he said, warning that the first choice may not be the best. Assess what is missing and where its replacement is going to come from. "Look to see: Where is the loose skin, and where are the relaxed skin tension lines?" said Dr. Kaufman.

"Don't get in over your head," he cautioned. Each surgeon should build on experience, starting with complex repairs, going on to small flaps and grafts, and later attempting more advanced flaps. If uncomfortable with a reconstruction, refer it to another surgeon.

He went on to offer the following advice:

▸ Distorting an anatomic landmark is worse than having a longer scar.

▸ Keeping incision lines between cosmetic units or subunits wherever possible will help, he said, "to hide scar in shadows caused by concavities and convexities."

▸ Flaps usually are better than grafts for matching color, texture, and thickness, but grafts "work well in thin, shiny skin and in reconstruction of complete units or subunits," he noted.

▸ When doing a repair, always make sure the margins are clean before starting.

Surgeons can enhance patients' experience by playing classical music, sending them home with wound supplies, and calling to see how they are recovering. "Patients love it. They don't expect doctors to call them at home," he said. "By doing those kinds of things, you put in their mind that they are going to have good results."

'Don't get in over your head.' If you're uncomfortable with a reconstruction, refer it to another surgeon. DR. KAUFMAN

STOWE, VT. — Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.

Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.

"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.

On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.

For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.

"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."

Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."

Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.

After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.

In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.

"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.

STOWE, VT. — Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.

Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.

"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.

On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.

For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.

"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."

Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."

Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.

After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.

In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.

"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.

STOWE, VT. — Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.

Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.

"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.

On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.

For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.

"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."

Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."

Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.

After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.

In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.

"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.

PARK CITY, UTAH — Treat Merkel cell carcinoma aggressively—recurrences are always fatal, Dr. Mary E. Maloney told physicians at a clinical dermatology seminar sponsored by Medicis.

"You have one chance to cure this disease. When treating a primary tumor, you use whatever you can to get a cure," counseled Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester.

While stage I disease has a 100% survival rate, she said mortality is 11% for stage II disease. Should there be distant metastasis, the hallmark of stage III disease, mortality climbs to 100% (J. Clin. Oncol. 1988;6:1863–73).

By the time a recurrence is diagnosed, the disease has already spread, according to Dr. Maloney. "We don't have the luxury of recurrence," she said, describing this rare skin cancer as "a very difficult tumor to diagnose and to cure."

Merkel cell carcinoma strikes men and women equally, she said, putting the incidence at 500 cases per year. Though the age range is 15–97 years, the average is 69 years, as most patients are older.

Most tumors occur in sun-exposed areas, according to Dr. Maloney. Immunosuppression also appears to play a role, as Merkel cell carcinoma is more common in transplant patients and people with chronic lymphocytic leukemia than in the general population.

Because they can appear benign when small, these rare tumors are often 2 cm at presentation, said Dr. Maloney. They range from pink to red, and 20% have palpable nodes at presentation.

Ruling out other carcinomas is the clinician's first step, she said, recommending that the physical examination include a lymph node exam with careful palpitation of the entire area for deep nodules and a careful exam for satellitosis.

Electron microscopy and immunohistochemistry are important in making the diagnosis, she added. Positive staining for cytokeratins 8, 18, 19, and 20 would be a key marker, along with neuron-specific enolase, synaptophysin, chromogranin, and neurofilaments.

Neither size nor duration is a prognostic factor, according to Dr. Maloney, but lymph node involvement and tumor location are predictive. She estimated survival as 70%–80% for those with lymph node-negative tumors and less than 48% for those that are lymph node-positive. Survival is higher for lesions on a limb than on the trunk.

Increasingly, Mohs surgery is being used for Merkel cell carcinoma, according to Dr. Maloney. She said the standard Mohs technique allows for true margin control and removal of all inflammation. She advocated removing an additional margin, usually about 1 cm, after all clear sections are obtained.

Dr. Maloney also recommended adjunctive radiation treatment to improve local and regional control. Retrospective studies have not shown it to reduce mortality, but she predicted that when prospective studies are done, they will show improved survival.

With truncal lesions, she advocated adjunctive radiation therapy whether a sentinel node biopsy shows the patient's lymph nodes to be positive or negative. If the nodes are positive, she said to do full node dissection as well.

When lesions are not on the trunk, her advice is the same. She disagreed with physicians who advocate no further therapy if biopsy shows sentinel nodes to be negative. "We have one chance to cure this disease," she reiterated. "Therefore, I believe radiating … is the best shot at curing the patient."

Chemotherapy is also an option, but she cautioned that it is not life-saving. Dr. Maloney said 42 different regimens have been tried, with response rates ranging from 50% to 65%. Yet survival with chemotherapy is only 9 months for patients with metastatic disease.

"While Merkel cell appears chemosensitive, it is seldom cured with chemotherapy," she said.

PARK CITY, UTAH — Treat Merkel cell carcinoma aggressively—recurrences are always fatal, Dr. Mary E. Maloney told physicians at a clinical dermatology seminar sponsored by Medicis.

"You have one chance to cure this disease. When treating a primary tumor, you use whatever you can to get a cure," counseled Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester.

While stage I disease has a 100% survival rate, she said mortality is 11% for stage II disease. Should there be distant metastasis, the hallmark of stage III disease, mortality climbs to 100% (J. Clin. Oncol. 1988;6:1863–73).

By the time a recurrence is diagnosed, the disease has already spread, according to Dr. Maloney. "We don't have the luxury of recurrence," she said, describing this rare skin cancer as "a very difficult tumor to diagnose and to cure."

Merkel cell carcinoma strikes men and women equally, she said, putting the incidence at 500 cases per year. Though the age range is 15–97 years, the average is 69 years, as most patients are older.

Most tumors occur in sun-exposed areas, according to Dr. Maloney. Immunosuppression also appears to play a role, as Merkel cell carcinoma is more common in transplant patients and people with chronic lymphocytic leukemia than in the general population.

Because they can appear benign when small, these rare tumors are often 2 cm at presentation, said Dr. Maloney. They range from pink to red, and 20% have palpable nodes at presentation.

Ruling out other carcinomas is the clinician's first step, she said, recommending that the physical examination include a lymph node exam with careful palpitation of the entire area for deep nodules and a careful exam for satellitosis.

Electron microscopy and immunohistochemistry are important in making the diagnosis, she added. Positive staining for cytokeratins 8, 18, 19, and 20 would be a key marker, along with neuron-specific enolase, synaptophysin, chromogranin, and neurofilaments.

Neither size nor duration is a prognostic factor, according to Dr. Maloney, but lymph node involvement and tumor location are predictive. She estimated survival as 70%–80% for those with lymph node-negative tumors and less than 48% for those that are lymph node-positive. Survival is higher for lesions on a limb than on the trunk.

Increasingly, Mohs surgery is being used for Merkel cell carcinoma, according to Dr. Maloney. She said the standard Mohs technique allows for true margin control and removal of all inflammation. She advocated removing an additional margin, usually about 1 cm, after all clear sections are obtained.

Dr. Maloney also recommended adjunctive radiation treatment to improve local and regional control. Retrospective studies have not shown it to reduce mortality, but she predicted that when prospective studies are done, they will show improved survival.

With truncal lesions, she advocated adjunctive radiation therapy whether a sentinel node biopsy shows the patient's lymph nodes to be positive or negative. If the nodes are positive, she said to do full node dissection as well.

When lesions are not on the trunk, her advice is the same. She disagreed with physicians who advocate no further therapy if biopsy shows sentinel nodes to be negative. "We have one chance to cure this disease," she reiterated. "Therefore, I believe radiating … is the best shot at curing the patient."

Chemotherapy is also an option, but she cautioned that it is not life-saving. Dr. Maloney said 42 different regimens have been tried, with response rates ranging from 50% to 65%. Yet survival with chemotherapy is only 9 months for patients with metastatic disease.

"While Merkel cell appears chemosensitive, it is seldom cured with chemotherapy," she said.

PARK CITY, UTAH — Treat Merkel cell carcinoma aggressively—recurrences are always fatal, Dr. Mary E. Maloney told physicians at a clinical dermatology seminar sponsored by Medicis.

"You have one chance to cure this disease. When treating a primary tumor, you use whatever you can to get a cure," counseled Dr. Maloney, director of dermatologic surgery at the University of Massachusetts, Worcester.

While stage I disease has a 100% survival rate, she said mortality is 11% for stage II disease. Should there be distant metastasis, the hallmark of stage III disease, mortality climbs to 100% (J. Clin. Oncol. 1988;6:1863–73).

By the time a recurrence is diagnosed, the disease has already spread, according to Dr. Maloney. "We don't have the luxury of recurrence," she said, describing this rare skin cancer as "a very difficult tumor to diagnose and to cure."

Merkel cell carcinoma strikes men and women equally, she said, putting the incidence at 500 cases per year. Though the age range is 15–97 years, the average is 69 years, as most patients are older.

Most tumors occur in sun-exposed areas, according to Dr. Maloney. Immunosuppression also appears to play a role, as Merkel cell carcinoma is more common in transplant patients and people with chronic lymphocytic leukemia than in the general population.

Because they can appear benign when small, these rare tumors are often 2 cm at presentation, said Dr. Maloney. They range from pink to red, and 20% have palpable nodes at presentation.

Ruling out other carcinomas is the clinician's first step, she said, recommending that the physical examination include a lymph node exam with careful palpitation of the entire area for deep nodules and a careful exam for satellitosis.

Electron microscopy and immunohistochemistry are important in making the diagnosis, she added. Positive staining for cytokeratins 8, 18, 19, and 20 would be a key marker, along with neuron-specific enolase, synaptophysin, chromogranin, and neurofilaments.

Neither size nor duration is a prognostic factor, according to Dr. Maloney, but lymph node involvement and tumor location are predictive. She estimated survival as 70%–80% for those with lymph node-negative tumors and less than 48% for those that are lymph node-positive. Survival is higher for lesions on a limb than on the trunk.

Increasingly, Mohs surgery is being used for Merkel cell carcinoma, according to Dr. Maloney. She said the standard Mohs technique allows for true margin control and removal of all inflammation. She advocated removing an additional margin, usually about 1 cm, after all clear sections are obtained.

Dr. Maloney also recommended adjunctive radiation treatment to improve local and regional control. Retrospective studies have not shown it to reduce mortality, but she predicted that when prospective studies are done, they will show improved survival.

With truncal lesions, she advocated adjunctive radiation therapy whether a sentinel node biopsy shows the patient's lymph nodes to be positive or negative. If the nodes are positive, she said to do full node dissection as well.

When lesions are not on the trunk, her advice is the same. She disagreed with physicians who advocate no further therapy if biopsy shows sentinel nodes to be negative. "We have one chance to cure this disease," she reiterated. "Therefore, I believe radiating … is the best shot at curing the patient."

Chemotherapy is also an option, but she cautioned that it is not life-saving. Dr. Maloney said 42 different regimens have been tried, with response rates ranging from 50% to 65%. Yet survival with chemotherapy is only 9 months for patients with metastatic disease.

"While Merkel cell appears chemosensitive, it is seldom cured with chemotherapy," she said.

PARK CITY, UTAH — Contour threads offer a minimally invasive alternative to plastic surgery for patients who cannot opt for a full facelift, Dr. William H. Truswell said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Surgery is the standard "to rejuvenate the face, but there are people who, for money or time restraints, can't have a facelift. This is an alternative I can offer them," said Dr. Truswell, a facial plastic surgeon in Northampton, Mass.

The Food and Drug Administration approved the barbed sutures for midface, brow, and neck suspension in September 2004.

Dr. Truswell estimated the subjective improvement as 60%–70% of that provided by a facelift. He suggested that the threads are well suited for minimal repairs on the "early" aging face and for a postfacelift "tune-up."

"Virtually anybody with an aging face is a candidate," he said, adding that the widely publicized procedure has drawn patients to his practice. "I have gotten more facelifts out of advertising this," he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Truswell described his first 2 months' experience with the patented, trademarked product, which is made of polypropylene. He said that he found the thread lift procedure easy to learn, and that he could do an entire face in 40 minutes.

How long the improvements will last is an open question, he noted, as the procedure is too new for him to say with certainty. The process causes some patient discomfort and requires about a week of downtime.

Two weeks before the thread lift, Dr. Truswell advises patients to stop nonsteroidal anti-inflammatory drugs. For preoperative medications, he suggests prescribing diazepam (Valium) 5 mg, oxycodone/acetaminophen (Percocet), and dimenhydrinate (Dramamine) 25 mg.

"With oral medications they tolerate it very well," he said, noting that patients must be driven to and from the office.

For 2 weeks following the procedure, patients are told not to pull down on the skin, drink from straws, strain, talk a lot, or touch the face (splashing with water is okay, but the face should be patted dry). If patients cry, cough, or sneeze, they should hold the brow area up, added Dr. Truswell.

"Men should shave upward only," he said.

All patients are told to use cold compresses to reduce swelling and to keep the head elevated above the heart for the first 48 hours. Dr. Truswell also tells them to use two pillows when resting, and he recommends that they use a donut or travel pillow at night to keep the face straight up—a precaution against pressing on the threads.

Dr. Truswell warns patients that they will look "overcorrected" for 7–14 days, but advises that most of this will resolve in the first week. "There will be some "bunching" near the incision site that usually resolves in 1 week," he said, adding that he schedules follow-up appointments 2, 7, and 14 days post procedure.

As for possible complications, Dr. Truswell listed thread failure, migration, exposure, and palpable threads. Abrupt changes in suture depth will appear as lumps and depressions once the tissue has been telescoped during contouring, he said.

"The skin should progress from smooth and tight where the suture exits to corrugated and lax at the hairline," he said.

He warned against placing a suture too deep in the forehead; gathering of the skin will be inhibited. "Avoid 'V' placement of sutures, as 'U' placement distributes the tension more broadly," he said.

Dr. Truswell said that his talk was supported by Surgical Specialties Corp., the manufacturer of Contour Threads.

PARK CITY, UTAH — Contour threads offer a minimally invasive alternative to plastic surgery for patients who cannot opt for a full facelift, Dr. William H. Truswell said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Surgery is the standard "to rejuvenate the face, but there are people who, for money or time restraints, can't have a facelift. This is an alternative I can offer them," said Dr. Truswell, a facial plastic surgeon in Northampton, Mass.

The Food and Drug Administration approved the barbed sutures for midface, brow, and neck suspension in September 2004.

Dr. Truswell estimated the subjective improvement as 60%–70% of that provided by a facelift. He suggested that the threads are well suited for minimal repairs on the "early" aging face and for a postfacelift "tune-up."

"Virtually anybody with an aging face is a candidate," he said, adding that the widely publicized procedure has drawn patients to his practice. "I have gotten more facelifts out of advertising this," he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Truswell described his first 2 months' experience with the patented, trademarked product, which is made of polypropylene. He said that he found the thread lift procedure easy to learn, and that he could do an entire face in 40 minutes.

How long the improvements will last is an open question, he noted, as the procedure is too new for him to say with certainty. The process causes some patient discomfort and requires about a week of downtime.

Two weeks before the thread lift, Dr. Truswell advises patients to stop nonsteroidal anti-inflammatory drugs. For preoperative medications, he suggests prescribing diazepam (Valium) 5 mg, oxycodone/acetaminophen (Percocet), and dimenhydrinate (Dramamine) 25 mg.

"With oral medications they tolerate it very well," he said, noting that patients must be driven to and from the office.

For 2 weeks following the procedure, patients are told not to pull down on the skin, drink from straws, strain, talk a lot, or touch the face (splashing with water is okay, but the face should be patted dry). If patients cry, cough, or sneeze, they should hold the brow area up, added Dr. Truswell.

"Men should shave upward only," he said.

All patients are told to use cold compresses to reduce swelling and to keep the head elevated above the heart for the first 48 hours. Dr. Truswell also tells them to use two pillows when resting, and he recommends that they use a donut or travel pillow at night to keep the face straight up—a precaution against pressing on the threads.

Dr. Truswell warns patients that they will look "overcorrected" for 7–14 days, but advises that most of this will resolve in the first week. "There will be some "bunching" near the incision site that usually resolves in 1 week," he said, adding that he schedules follow-up appointments 2, 7, and 14 days post procedure.

As for possible complications, Dr. Truswell listed thread failure, migration, exposure, and palpable threads. Abrupt changes in suture depth will appear as lumps and depressions once the tissue has been telescoped during contouring, he said.

"The skin should progress from smooth and tight where the suture exits to corrugated and lax at the hairline," he said.

He warned against placing a suture too deep in the forehead; gathering of the skin will be inhibited. "Avoid 'V' placement of sutures, as 'U' placement distributes the tension more broadly," he said.

Dr. Truswell said that his talk was supported by Surgical Specialties Corp., the manufacturer of Contour Threads.

PARK CITY, UTAH — Contour threads offer a minimally invasive alternative to plastic surgery for patients who cannot opt for a full facelift, Dr. William H. Truswell said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Surgery is the standard "to rejuvenate the face, but there are people who, for money or time restraints, can't have a facelift. This is an alternative I can offer them," said Dr. Truswell, a facial plastic surgeon in Northampton, Mass.

The Food and Drug Administration approved the barbed sutures for midface, brow, and neck suspension in September 2004.

Dr. Truswell estimated the subjective improvement as 60%–70% of that provided by a facelift. He suggested that the threads are well suited for minimal repairs on the "early" aging face and for a postfacelift "tune-up."

"Virtually anybody with an aging face is a candidate," he said, adding that the widely publicized procedure has drawn patients to his practice. "I have gotten more facelifts out of advertising this," he said at the meeting, which also was sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Dr. Truswell described his first 2 months' experience with the patented, trademarked product, which is made of polypropylene. He said that he found the thread lift procedure easy to learn, and that he could do an entire face in 40 minutes.

How long the improvements will last is an open question, he noted, as the procedure is too new for him to say with certainty. The process causes some patient discomfort and requires about a week of downtime.

Two weeks before the thread lift, Dr. Truswell advises patients to stop nonsteroidal anti-inflammatory drugs. For preoperative medications, he suggests prescribing diazepam (Valium) 5 mg, oxycodone/acetaminophen (Percocet), and dimenhydrinate (Dramamine) 25 mg.

"With oral medications they tolerate it very well," he said, noting that patients must be driven to and from the office.

For 2 weeks following the procedure, patients are told not to pull down on the skin, drink from straws, strain, talk a lot, or touch the face (splashing with water is okay, but the face should be patted dry). If patients cry, cough, or sneeze, they should hold the brow area up, added Dr. Truswell.

"Men should shave upward only," he said.

All patients are told to use cold compresses to reduce swelling and to keep the head elevated above the heart for the first 48 hours. Dr. Truswell also tells them to use two pillows when resting, and he recommends that they use a donut or travel pillow at night to keep the face straight up—a precaution against pressing on the threads.

Dr. Truswell warns patients that they will look "overcorrected" for 7–14 days, but advises that most of this will resolve in the first week. "There will be some "bunching" near the incision site that usually resolves in 1 week," he said, adding that he schedules follow-up appointments 2, 7, and 14 days post procedure.

As for possible complications, Dr. Truswell listed thread failure, migration, exposure, and palpable threads. Abrupt changes in suture depth will appear as lumps and depressions once the tissue has been telescoped during contouring, he said.

"The skin should progress from smooth and tight where the suture exits to corrugated and lax at the hairline," he said.

He warned against placing a suture too deep in the forehead; gathering of the skin will be inhibited. "Avoid 'V' placement of sutures, as 'U' placement distributes the tension more broadly," he said.

Dr. Truswell said that his talk was supported by Surgical Specialties Corp., the manufacturer of Contour Threads.