Aesthetic Dermatology

ORLANDO — For those who are thinking about going into the medical spa business, Dr. Mitchel P. Goldman, a dermatologist in private practice in La Jolla, Calif., named the essential services to offer:

▸ Intense pulsed light. "If you can only buy one machine, intense pulsed light is the machine that you need to purchase because it can do so much," Dr. Goldman said.

Intense pulsed light (IPL) devices can be used for hair removal, dyspigmentation, and photodamage. The device can also be used in conjunction with levulinic acid to treat patients with actinic keratoses. He estimated that IPL machines cost between $40,000 and $100,000.

▸ Laser hair removal. The next procedure to consider adding to a medical spa practice is laser hair removal. "Laser hair removal is also a huge potential business," Dr. Goldman said.

He noted that there are good opportunities to save money on used laser hair removal equipment. New hair removal laser systems range between $60,000 and $150,000.

▸ Long- and short-pulse lasers. "If you want to go to the next level, we still use our erbium: yttrium aluminum garnet (Er:YAG) laser—both long and short pulse—to do full face resurfacing," said Dr. Goldman.

This is a procedure that must be done by a physician and not a nurse or nurse-practitioner, he cautioned. Expect to pay about $60,000 for a long- or short-pulse Er:YAG laser.

▸ Laser cellulite treatment. This procedure is becoming more popular. There are two lasers available for cellulite treatment: the Cynosure TriActive and the Syneron VelaSmooth. The TriActive system costs about $25,000 and the VelaSmooth system about $60,000. "These are incredibly profitable in our practice," Dr. Goldman said.

▸ Pigmentation. "We also have an alexandrite and a long-pulse YAG laser that we use because I believe that if you're going to treat a pigmented population, especially an African American population, you must have a 1,064-nm long-pulse YAG laser," he said. For any other population, a diode or alexandrite laser should work.

Dr. Goldman has financial relationships with STD Pharmaceutical, BTG plc., and CoolTouch.

ORLANDO — For those who are thinking about going into the medical spa business, Dr. Mitchel P. Goldman, a dermatologist in private practice in La Jolla, Calif., named the essential services to offer:

▸ Intense pulsed light. "If you can only buy one machine, intense pulsed light is the machine that you need to purchase because it can do so much," Dr. Goldman said.

Intense pulsed light (IPL) devices can be used for hair removal, dyspigmentation, and photodamage. The device can also be used in conjunction with levulinic acid to treat patients with actinic keratoses. He estimated that IPL machines cost between $40,000 and $100,000.

▸ Laser hair removal. The next procedure to consider adding to a medical spa practice is laser hair removal. "Laser hair removal is also a huge potential business," Dr. Goldman said.

He noted that there are good opportunities to save money on used laser hair removal equipment. New hair removal laser systems range between $60,000 and $150,000.

▸ Long- and short-pulse lasers. "If you want to go to the next level, we still use our erbium: yttrium aluminum garnet (Er:YAG) laser—both long and short pulse—to do full face resurfacing," said Dr. Goldman.

This is a procedure that must be done by a physician and not a nurse or nurse-practitioner, he cautioned. Expect to pay about $60,000 for a long- or short-pulse Er:YAG laser.

▸ Laser cellulite treatment. This procedure is becoming more popular. There are two lasers available for cellulite treatment: the Cynosure TriActive and the Syneron VelaSmooth. The TriActive system costs about $25,000 and the VelaSmooth system about $60,000. "These are incredibly profitable in our practice," Dr. Goldman said.

▸ Pigmentation. "We also have an alexandrite and a long-pulse YAG laser that we use because I believe that if you're going to treat a pigmented population, especially an African American population, you must have a 1,064-nm long-pulse YAG laser," he said. For any other population, a diode or alexandrite laser should work.

Dr. Goldman has financial relationships with STD Pharmaceutical, BTG plc., and CoolTouch.

ORLANDO — For those who are thinking about going into the medical spa business, Dr. Mitchel P. Goldman, a dermatologist in private practice in La Jolla, Calif., named the essential services to offer:

▸ Intense pulsed light. "If you can only buy one machine, intense pulsed light is the machine that you need to purchase because it can do so much," Dr. Goldman said.

Intense pulsed light (IPL) devices can be used for hair removal, dyspigmentation, and photodamage. The device can also be used in conjunction with levulinic acid to treat patients with actinic keratoses. He estimated that IPL machines cost between $40,000 and $100,000.

▸ Laser hair removal. The next procedure to consider adding to a medical spa practice is laser hair removal. "Laser hair removal is also a huge potential business," Dr. Goldman said.

He noted that there are good opportunities to save money on used laser hair removal equipment. New hair removal laser systems range between $60,000 and $150,000.

▸ Long- and short-pulse lasers. "If you want to go to the next level, we still use our erbium: yttrium aluminum garnet (Er:YAG) laser—both long and short pulse—to do full face resurfacing," said Dr. Goldman.

This is a procedure that must be done by a physician and not a nurse or nurse-practitioner, he cautioned. Expect to pay about $60,000 for a long- or short-pulse Er:YAG laser.

▸ Laser cellulite treatment. This procedure is becoming more popular. There are two lasers available for cellulite treatment: the Cynosure TriActive and the Syneron VelaSmooth. The TriActive system costs about $25,000 and the VelaSmooth system about $60,000. "These are incredibly profitable in our practice," Dr. Goldman said.

▸ Pigmentation. "We also have an alexandrite and a long-pulse YAG laser that we use because I believe that if you're going to treat a pigmented population, especially an African American population, you must have a 1,064-nm long-pulse YAG laser," he said. For any other population, a diode or alexandrite laser should work.

Dr. Goldman has financial relationships with STD Pharmaceutical, BTG plc., and CoolTouch.

ORLANDO — One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.

"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.

"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missing—fat.

Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.

For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60–120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.

Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.

Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.

Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.

Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.

The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.

For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 1–5 cc for the upper lid/brow, 3–6 cc for the lower lid/cheek, 4–6 cc for the perioral area, up to 2 cc for the lips, and 3–5 cc for the mandible. "The round contour is really the key to a youthful eye," he said.

He advises physicians to think globally, not focally. Don't think about filling just one or two lines—fill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.

Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.

Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman

ORLANDO — One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.

"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.

"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missing—fat.

Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.

For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60–120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.

Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.

Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.

Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.

Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.

The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.

For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 1–5 cc for the upper lid/brow, 3–6 cc for the lower lid/cheek, 4–6 cc for the perioral area, up to 2 cc for the lips, and 3–5 cc for the mandible. "The round contour is really the key to a youthful eye," he said.

He advises physicians to think globally, not focally. Don't think about filling just one or two lines—fill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.

Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.

Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman

ORLANDO — One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.

"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.

"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missing—fat.

Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.

For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60–120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.

Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.

Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.

Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.

Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.

The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.

For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 1–5 cc for the upper lid/brow, 3–6 cc for the lower lid/cheek, 4–6 cc for the perioral area, up to 2 cc for the lips, and 3–5 cc for the mandible. "The round contour is really the key to a youthful eye," he said.

He advises physicians to think globally, not focally. Don't think about filling just one or two lines—fill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.

Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.

Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman

SAN DIEGO — Tumors travel within the nerve structure, so if a Mohs surgeon has a habit of taking superficial margins, he or she will miss perineural tumors, Dr. Alexander Miller said at a meeting sponsored by the American Society for Mohs Surgery.

The nerve structure includes the endoneurium (nerve fibers), perineurium (mostly collagen), and epineurium (connective tissue). All these components vary with the nerve size, and tumors can travel through all of them.

"A perineural tumor doesn't care which nerve it gets into, and it will go anywhere and in any direction," Dr. Miller said. "It could attack several nerves simultaneously," said Dr. Miller of the University of California, Irvine.

About 60%–70% of perineural tumors are asymptomatic and unknown to the patient. With symptomatic tumors, patients report burning, aching, numbness, or even a complete lack of sensation. The nerves are rarely palpable, although they may be more palpable at points where they cross over bones.

Although most perineural invasion is localized, there are cases in which it travels far beyond the general body of the tumor. "Your challenge is to discriminate between localized and not localized," he said. The majority of perineural tumors are localized to areas within 1 cm or less of the general body of the tumor. That said, some invasions extend several centimeters beyond the general body of the tumor, Dr. Miller said.

"Perineural tumors are hard to see under the microscope, and some people forget to look," he said.

Tumors that are most likely to become perineurally invasive are basal cell carcinoma and squamous cell carcinoma, but microcystic adnexal carcinoma, neurotropic malignant melanoma, and other adnexal tumors, particularly salivary or sweat gland tumors, also are candidates for perineural invasion.

An estimated 1% of basal cell carcinomas have perineural invasion. Those most likely to become perineural are morphealike, micronodular, metatypical, and basal cells invading as long arms of tumor surrounded by concentric fibrous sleeves of collagen.

About 3%–4% of squamous cell carcinomas are perineural, usually those that are moderately to poorly differentiated, and show tumor spreading like a narrow cord.

Squamous cell carcinomas more than 2 cm in diameter or greater than 4-mm thickness are more likely to be perineural than smaller ones; if they are 8 mm in thickness the risk is substantial.

Most microcystic adnexal carcinomas, approximately 80%, invade perineurally and subclinically, and it is crucial for the Mohs surgeon to be aware of this, Dr. Miller said. "Take a wider margin than you would with other tumors, be careful about tracking out the edges, and get good-quality slides."

Regardless of the type of tumor, tumors that are perineurally invasive share a uniform histology and display similar behaviors.

"They all pretty much look the same once they get into the perineural space," Dr. Miller said. The tumor cells can be tightly packed, clustered, or in a line. "In order to tell the tumor of origin, you have to go back to the original histology and look elsewhere on the slide" he said.

The pattern of growth can be spotty or concentric, and perineural tumors tend to be multifocal. "It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve," he said.

"Be aware of multifocality in the subcutaneous layer," Dr. Miller advised. "If you have poor-quality slides that are consistently destroying fat, you may miss crucial structures." Obvious inflammation around a nerve is a helpful indicator of perineural invasion, he added.

Tumor depth has been shown to correlate with perineural invasion, as has tumor recurrence and fibrous sleeve growth. Also, pay attention to nerve orientation on the microscope slides. A tumor may invade concentrically around the nerve, or just crawl along a portion of the nerve circumference. When a tumor invades along only one edge of a nerve, it can easily be missed.

"Multiple Mohs sections and slides must be examined for perineural tumor, or you will miss it," Dr. Miller emphasized.

"When perineural tumors recur, they are unpleasant; they are deep, and they can grow subclinically for a long time," Dr. Miller said. "Meticulous, compulsive evaluation is needed to successfully treat these patients and prevent recurrence."

'It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve.' DR. MILLER

SAN DIEGO — Tumors travel within the nerve structure, so if a Mohs surgeon has a habit of taking superficial margins, he or she will miss perineural tumors, Dr. Alexander Miller said at a meeting sponsored by the American Society for Mohs Surgery.

The nerve structure includes the endoneurium (nerve fibers), perineurium (mostly collagen), and epineurium (connective tissue). All these components vary with the nerve size, and tumors can travel through all of them.

"A perineural tumor doesn't care which nerve it gets into, and it will go anywhere and in any direction," Dr. Miller said. "It could attack several nerves simultaneously," said Dr. Miller of the University of California, Irvine.

About 60%–70% of perineural tumors are asymptomatic and unknown to the patient. With symptomatic tumors, patients report burning, aching, numbness, or even a complete lack of sensation. The nerves are rarely palpable, although they may be more palpable at points where they cross over bones.

Although most perineural invasion is localized, there are cases in which it travels far beyond the general body of the tumor. "Your challenge is to discriminate between localized and not localized," he said. The majority of perineural tumors are localized to areas within 1 cm or less of the general body of the tumor. That said, some invasions extend several centimeters beyond the general body of the tumor, Dr. Miller said.

"Perineural tumors are hard to see under the microscope, and some people forget to look," he said.

Tumors that are most likely to become perineurally invasive are basal cell carcinoma and squamous cell carcinoma, but microcystic adnexal carcinoma, neurotropic malignant melanoma, and other adnexal tumors, particularly salivary or sweat gland tumors, also are candidates for perineural invasion.

An estimated 1% of basal cell carcinomas have perineural invasion. Those most likely to become perineural are morphealike, micronodular, metatypical, and basal cells invading as long arms of tumor surrounded by concentric fibrous sleeves of collagen.

About 3%–4% of squamous cell carcinomas are perineural, usually those that are moderately to poorly differentiated, and show tumor spreading like a narrow cord.

Squamous cell carcinomas more than 2 cm in diameter or greater than 4-mm thickness are more likely to be perineural than smaller ones; if they are 8 mm in thickness the risk is substantial.

Most microcystic adnexal carcinomas, approximately 80%, invade perineurally and subclinically, and it is crucial for the Mohs surgeon to be aware of this, Dr. Miller said. "Take a wider margin than you would with other tumors, be careful about tracking out the edges, and get good-quality slides."

Regardless of the type of tumor, tumors that are perineurally invasive share a uniform histology and display similar behaviors.

"They all pretty much look the same once they get into the perineural space," Dr. Miller said. The tumor cells can be tightly packed, clustered, or in a line. "In order to tell the tumor of origin, you have to go back to the original histology and look elsewhere on the slide" he said.

The pattern of growth can be spotty or concentric, and perineural tumors tend to be multifocal. "It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve," he said.

"Be aware of multifocality in the subcutaneous layer," Dr. Miller advised. "If you have poor-quality slides that are consistently destroying fat, you may miss crucial structures." Obvious inflammation around a nerve is a helpful indicator of perineural invasion, he added.

Tumor depth has been shown to correlate with perineural invasion, as has tumor recurrence and fibrous sleeve growth. Also, pay attention to nerve orientation on the microscope slides. A tumor may invade concentrically around the nerve, or just crawl along a portion of the nerve circumference. When a tumor invades along only one edge of a nerve, it can easily be missed.

"Multiple Mohs sections and slides must be examined for perineural tumor, or you will miss it," Dr. Miller emphasized.

"When perineural tumors recur, they are unpleasant; they are deep, and they can grow subclinically for a long time," Dr. Miller said. "Meticulous, compulsive evaluation is needed to successfully treat these patients and prevent recurrence."

'It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve.' DR. MILLER

SAN DIEGO — Tumors travel within the nerve structure, so if a Mohs surgeon has a habit of taking superficial margins, he or she will miss perineural tumors, Dr. Alexander Miller said at a meeting sponsored by the American Society for Mohs Surgery.

The nerve structure includes the endoneurium (nerve fibers), perineurium (mostly collagen), and epineurium (connective tissue). All these components vary with the nerve size, and tumors can travel through all of them.

"A perineural tumor doesn't care which nerve it gets into, and it will go anywhere and in any direction," Dr. Miller said. "It could attack several nerves simultaneously," said Dr. Miller of the University of California, Irvine.

About 60%–70% of perineural tumors are asymptomatic and unknown to the patient. With symptomatic tumors, patients report burning, aching, numbness, or even a complete lack of sensation. The nerves are rarely palpable, although they may be more palpable at points where they cross over bones.

Although most perineural invasion is localized, there are cases in which it travels far beyond the general body of the tumor. "Your challenge is to discriminate between localized and not localized," he said. The majority of perineural tumors are localized to areas within 1 cm or less of the general body of the tumor. That said, some invasions extend several centimeters beyond the general body of the tumor, Dr. Miller said.

"Perineural tumors are hard to see under the microscope, and some people forget to look," he said.

Tumors that are most likely to become perineurally invasive are basal cell carcinoma and squamous cell carcinoma, but microcystic adnexal carcinoma, neurotropic malignant melanoma, and other adnexal tumors, particularly salivary or sweat gland tumors, also are candidates for perineural invasion.

An estimated 1% of basal cell carcinomas have perineural invasion. Those most likely to become perineural are morphealike, micronodular, metatypical, and basal cells invading as long arms of tumor surrounded by concentric fibrous sleeves of collagen.

About 3%–4% of squamous cell carcinomas are perineural, usually those that are moderately to poorly differentiated, and show tumor spreading like a narrow cord.

Squamous cell carcinomas more than 2 cm in diameter or greater than 4-mm thickness are more likely to be perineural than smaller ones; if they are 8 mm in thickness the risk is substantial.

Most microcystic adnexal carcinomas, approximately 80%, invade perineurally and subclinically, and it is crucial for the Mohs surgeon to be aware of this, Dr. Miller said. "Take a wider margin than you would with other tumors, be careful about tracking out the edges, and get good-quality slides."

Regardless of the type of tumor, tumors that are perineurally invasive share a uniform histology and display similar behaviors.

"They all pretty much look the same once they get into the perineural space," Dr. Miller said. The tumor cells can be tightly packed, clustered, or in a line. "In order to tell the tumor of origin, you have to go back to the original histology and look elsewhere on the slide" he said.

The pattern of growth can be spotty or concentric, and perineural tumors tend to be multifocal. "It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve," he said.

"Be aware of multifocality in the subcutaneous layer," Dr. Miller advised. "If you have poor-quality slides that are consistently destroying fat, you may miss crucial structures." Obvious inflammation around a nerve is a helpful indicator of perineural invasion, he added.

Tumor depth has been shown to correlate with perineural invasion, as has tumor recurrence and fibrous sleeve growth. Also, pay attention to nerve orientation on the microscope slides. A tumor may invade concentrically around the nerve, or just crawl along a portion of the nerve circumference. When a tumor invades along only one edge of a nerve, it can easily be missed.

"Multiple Mohs sections and slides must be examined for perineural tumor, or you will miss it," Dr. Miller emphasized.

"When perineural tumors recur, they are unpleasant; they are deep, and they can grow subclinically for a long time," Dr. Miller said. "Meticulous, compulsive evaluation is needed to successfully treat these patients and prevent recurrence."

'It's crucial to realize that perineural tumors can affect more than one nerve or multiple branches of the same nerve.' DR. MILLER

SAN DIEGO — The use of zinc chloride fixative paste may be controversial, but its judicious application can increase the melanoma-clearing properties of Mohs surgery, Dr. Norman A. Brooks said at a meeting sponsored by the American Society for Mohs Surgery.

"Zinc chloride fixative paste is an amazing substance; it has the ability to cure cancer right out of the bone," said Dr. Brooks, a Mohs surgeon in private practice in Encino, Calif.

Application of the paste has been shown to freeze melanomatous tissue in place. This process kills the tissue, which can then be removed using Mohs surgery.

Dr. Frederic Mohs did not invent the paste, but he did fine-tune the standard formula, which is still in use today.

The use of zinc chloride fixative paste for the treatment of skin conditions has not been approved by the Food and Drug Administration, and patients should not apply it themselves or buy it online. The paste is powerful, toxic, and potentially scar causing, and it must be handled carefully, Dr. Brooks said.

It does, however, appear to work. Studies have shown higher cure rates in melanoma patients when the paste was used prior to excision of the cancer with Mohs surgery, he noted.

The application of zinc chloride fixative paste is a two-step process. The paste can't penetrate the outer keratin layer of the skin, so it's necessary to apply a saturated dichloroacetic or trichloroacetic acid solution to the area. When the area turns white, that means the acid has dissolved the keratin and the paste can be applied. The paste is applied in a layer 1- to 2-mm thick, with a narrow margin around the clinical melanoma that includes subclinical extensions. A dry, sterile cotton ball is then applied with clear plastic adhesive tape as an occlusive dressing to hold the paste in place.

Approximately 24 hours later, the killed tissue is excised and a wall of white, fixed tissue will be visible, Dr. Brooks said. The excised specimen can be preserved in formaldehyde, embedded in paraffin, and sectioned for examination.

The use of zinc chloride paste is not a substitution for Mohs surgery, but it can be a supplement to it. "If used preoperatively, after a biopsy, it can cure patients even more effectively than surgery alone," Dr. Brooks said.

Zinc chloride paste does not get the publicity of cancer treatments such as interferon because it is not FDA approved, Dr. Brooks noted. Companies that might consider seeking FDA approval balk at the multimillion-dollar cost of a toxicity study. Although the paste is made of naturally occurring ingredients, the toxicity study is cost prohibitive and no company has been willing to put up the money.

"I don't blame them. That would be financially insane," Dr. Brooks said. But that doesn't mean Mohs surgeons can't use the paste if they get informed consent from patients.

"You need to tell the patient that this is not an FDA-approved drug; it is a naturally occurring substance, and it can improve the outcome of the surgery by reducing the risk of recurrence," Dr. Brooks said.

The formula for zinc paste perfected by Dr. Mohs has been published and can be found in the Mohs surgery literature.

Many patients with cancer are now receiving preoperative treatments such as chemotherapy, and the use of zinc chloride fixative paste prior to excision of the cancer can be another effective strategy when properly applied, Dr. Brooks said.

A biopsy was performed on a 1.8-mm-thick amelanotic melanoma of the left arm.

Zinc chloride fixative paste was applied to the fresh tissue site with a 2- to 3-mm margin.

A dressing held the zinc chloride paste in place for 24 hours before Mohs excision.

Conventional excision of a deep wide margin was done a week after applying paste.

No sentinel node involvement was seen on this patient at time of fresh tissue excision. Photos courtesy Dr. Norman A. Brooks

SAN DIEGO — The use of zinc chloride fixative paste may be controversial, but its judicious application can increase the melanoma-clearing properties of Mohs surgery, Dr. Norman A. Brooks said at a meeting sponsored by the American Society for Mohs Surgery.

"Zinc chloride fixative paste is an amazing substance; it has the ability to cure cancer right out of the bone," said Dr. Brooks, a Mohs surgeon in private practice in Encino, Calif.

Application of the paste has been shown to freeze melanomatous tissue in place. This process kills the tissue, which can then be removed using Mohs surgery.

Dr. Frederic Mohs did not invent the paste, but he did fine-tune the standard formula, which is still in use today.

The use of zinc chloride fixative paste for the treatment of skin conditions has not been approved by the Food and Drug Administration, and patients should not apply it themselves or buy it online. The paste is powerful, toxic, and potentially scar causing, and it must be handled carefully, Dr. Brooks said.

It does, however, appear to work. Studies have shown higher cure rates in melanoma patients when the paste was used prior to excision of the cancer with Mohs surgery, he noted.

The application of zinc chloride fixative paste is a two-step process. The paste can't penetrate the outer keratin layer of the skin, so it's necessary to apply a saturated dichloroacetic or trichloroacetic acid solution to the area. When the area turns white, that means the acid has dissolved the keratin and the paste can be applied. The paste is applied in a layer 1- to 2-mm thick, with a narrow margin around the clinical melanoma that includes subclinical extensions. A dry, sterile cotton ball is then applied with clear plastic adhesive tape as an occlusive dressing to hold the paste in place.

Approximately 24 hours later, the killed tissue is excised and a wall of white, fixed tissue will be visible, Dr. Brooks said. The excised specimen can be preserved in formaldehyde, embedded in paraffin, and sectioned for examination.

The use of zinc chloride paste is not a substitution for Mohs surgery, but it can be a supplement to it. "If used preoperatively, after a biopsy, it can cure patients even more effectively than surgery alone," Dr. Brooks said.

Zinc chloride paste does not get the publicity of cancer treatments such as interferon because it is not FDA approved, Dr. Brooks noted. Companies that might consider seeking FDA approval balk at the multimillion-dollar cost of a toxicity study. Although the paste is made of naturally occurring ingredients, the toxicity study is cost prohibitive and no company has been willing to put up the money.

"I don't blame them. That would be financially insane," Dr. Brooks said. But that doesn't mean Mohs surgeons can't use the paste if they get informed consent from patients.

"You need to tell the patient that this is not an FDA-approved drug; it is a naturally occurring substance, and it can improve the outcome of the surgery by reducing the risk of recurrence," Dr. Brooks said.

The formula for zinc paste perfected by Dr. Mohs has been published and can be found in the Mohs surgery literature.

Many patients with cancer are now receiving preoperative treatments such as chemotherapy, and the use of zinc chloride fixative paste prior to excision of the cancer can be another effective strategy when properly applied, Dr. Brooks said.

A biopsy was performed on a 1.8-mm-thick amelanotic melanoma of the left arm.

Zinc chloride fixative paste was applied to the fresh tissue site with a 2- to 3-mm margin.

A dressing held the zinc chloride paste in place for 24 hours before Mohs excision.

Conventional excision of a deep wide margin was done a week after applying paste.

No sentinel node involvement was seen on this patient at time of fresh tissue excision. Photos courtesy Dr. Norman A. Brooks

SAN DIEGO — The use of zinc chloride fixative paste may be controversial, but its judicious application can increase the melanoma-clearing properties of Mohs surgery, Dr. Norman A. Brooks said at a meeting sponsored by the American Society for Mohs Surgery.

"Zinc chloride fixative paste is an amazing substance; it has the ability to cure cancer right out of the bone," said Dr. Brooks, a Mohs surgeon in private practice in Encino, Calif.

Application of the paste has been shown to freeze melanomatous tissue in place. This process kills the tissue, which can then be removed using Mohs surgery.

Dr. Frederic Mohs did not invent the paste, but he did fine-tune the standard formula, which is still in use today.

The use of zinc chloride fixative paste for the treatment of skin conditions has not been approved by the Food and Drug Administration, and patients should not apply it themselves or buy it online. The paste is powerful, toxic, and potentially scar causing, and it must be handled carefully, Dr. Brooks said.

It does, however, appear to work. Studies have shown higher cure rates in melanoma patients when the paste was used prior to excision of the cancer with Mohs surgery, he noted.

The application of zinc chloride fixative paste is a two-step process. The paste can't penetrate the outer keratin layer of the skin, so it's necessary to apply a saturated dichloroacetic or trichloroacetic acid solution to the area. When the area turns white, that means the acid has dissolved the keratin and the paste can be applied. The paste is applied in a layer 1- to 2-mm thick, with a narrow margin around the clinical melanoma that includes subclinical extensions. A dry, sterile cotton ball is then applied with clear plastic adhesive tape as an occlusive dressing to hold the paste in place.

Approximately 24 hours later, the killed tissue is excised and a wall of white, fixed tissue will be visible, Dr. Brooks said. The excised specimen can be preserved in formaldehyde, embedded in paraffin, and sectioned for examination.

The use of zinc chloride paste is not a substitution for Mohs surgery, but it can be a supplement to it. "If used preoperatively, after a biopsy, it can cure patients even more effectively than surgery alone," Dr. Brooks said.

Zinc chloride paste does not get the publicity of cancer treatments such as interferon because it is not FDA approved, Dr. Brooks noted. Companies that might consider seeking FDA approval balk at the multimillion-dollar cost of a toxicity study. Although the paste is made of naturally occurring ingredients, the toxicity study is cost prohibitive and no company has been willing to put up the money.

"I don't blame them. That would be financially insane," Dr. Brooks said. But that doesn't mean Mohs surgeons can't use the paste if they get informed consent from patients.

"You need to tell the patient that this is not an FDA-approved drug; it is a naturally occurring substance, and it can improve the outcome of the surgery by reducing the risk of recurrence," Dr. Brooks said.

The formula for zinc paste perfected by Dr. Mohs has been published and can be found in the Mohs surgery literature.

Many patients with cancer are now receiving preoperative treatments such as chemotherapy, and the use of zinc chloride fixative paste prior to excision of the cancer can be another effective strategy when properly applied, Dr. Brooks said.

A biopsy was performed on a 1.8-mm-thick amelanotic melanoma of the left arm.

Zinc chloride fixative paste was applied to the fresh tissue site with a 2- to 3-mm margin.

A dressing held the zinc chloride paste in place for 24 hours before Mohs excision.

Conventional excision of a deep wide margin was done a week after applying paste.

No sentinel node involvement was seen on this patient at time of fresh tissue excision. Photos courtesy Dr. Norman A. Brooks

SAN DIEGO — Some closures may be too complex for inexperienced Mohs surgeons, but even novices can successfully close most of their cases if they have an understanding of how skin flaps move and a willingness to see the possibilities in the two simple skin movements—the fusiform and the z-plasty—that underlie all flap closures, Dr. Kenneth G. Gross said at a meeting sponsored by the American Society for Mohs Surgery.

It helps to think of flap movement as occurring in two dimensions.

"The majority of skin flaps can be explained simply by exploring what makes a fusiform work," Dr. Gross said.

Fusiform flaps generally have 30-degree angles at their tips, based on principles of plane geometry, but the skin is not a flat plane, and whether a lesion will close with 30-degree angles depends on the anatomic location.

"The purpose of making 30-degree angles at the ends of the fusiform is to allow closure without a standing cone," said Dr. Gross, a dermatologic surgeon in private practice in San Diego.

The fusiform consists of three components: the central defect to be closed (depicted as a circle) and two Burow's triangles.

The short axis of the defect usually forms the short axis of the fusiform. The surgeon uses the Burow's triangles at each end of the fusiform to bring the defect to 30-degree angles or to the angles necessary to close the wound without creating a standing cone at the ends of the excision.

The Burow's triangles also can be rotated at the ends of the fusiform as needed to achieve the best cosmetic result. "The Burow's triangle can even be rotated 90 degrees," Dr. Gross pointed out. "You should do whatever type of Burow's triangle is needed to make the best possible closure."

If the location of the defect prevents the use of a Burow's triangle at one or both ends of the fusiform, the surgeon can offset the Burow's triangles, Dr. Gross explained.

"This will result in the creation of what we call an advancement or a rotation flap. If the Burow's triangle is offset to two sides, the result will be a bilateral flap, such as the bilateral advancement or the A to T flap," he commented.

"If the surgeon is in doubt about how to close a wound, he or she may start by drawing a fusiform and then [assessing] whether the fusiform lies in the relaxed skin tension lines and whether it causes distortion of surrounding important anatomic structures," Dr. Gross advised.

If the fusiform does interfere with important anatomy, the surgeon must decide where to offset the Burow's triangles at one or both ends of the fusiform—thereby creating an advancement or rotation flap that doesn't interfere with important anatomy or degrade the cosmetic result.

He noted that about 90% of his Mohs closures are variations of rotation flaps.

Although rotation flaps are generally larger than other types of flaps, Dr. Gross believes that they yield better cosmetic results than transposition flaps because the resulting scar lines can usually be placed in junctions between anatomic units.

Transposition flaps are based primarily on z-plasty movement.

"If you understand the movement of a z-plasty, you will understand how all transposition flaps move and why they move the way they do," Dr. Gross said at the meeting.

Think of a z-plasty as two Burow's triangles sharing a common side, called the central limb. When planning a z-plasty, think about using imaginary skin hooks to pull the central limb longer, Dr. Gross said.

While the central limb lengthens and rotates, there is concomitant shortening of tissue approximately 90 degrees from the axis of the central limb.

The amount of central limb lengthening, and the amount of rotation and shortening in the other axis, is determined by the total of both angles of the Burow's triangles in the z-plasty.

"You can combine 45-degree and 90-degree angles in the same z-plasty, and in fact the Burow's triangles of transposition flaps never have the same-sized angles," Dr. Gross said.

This is the reason some surgeons don't recognize the z-plasties that lie at the heart of all transposition flaps: They are accustomed to seeing z-plasties in textbooks that are drawn with equal angles.

As long as there is sufficient tissue in the opposite direction to allow for shortening without disrupting the surrounding anatomy, as well as enough skin laxity, the surgeon can use whatever size z-plasty angles are needed to produce the amount of central limb lengthening that will close the defect.

The three transposition flaps most often discussed and used by dermatologic surgeons are the Limberg, Webster, and Dufourmentel flaps.

The only difference among them is the total angle of the z-plasties used to create the flaps. The larger the sum of the total angles of the z-plasty of the transposition flap, the greater the lengthening and degree of rotation of the central limb and the greater the shortening of tissue in the opposite axis.

These actions result in the movement of tissue into the defect known as a transposition flap closure. Overall, the amount of tissue that is "wasted" is similar in both a z-plasty and a rotation flap, Dr. Gross said.

SAN DIEGO — Some closures may be too complex for inexperienced Mohs surgeons, but even novices can successfully close most of their cases if they have an understanding of how skin flaps move and a willingness to see the possibilities in the two simple skin movements—the fusiform and the z-plasty—that underlie all flap closures, Dr. Kenneth G. Gross said at a meeting sponsored by the American Society for Mohs Surgery.

It helps to think of flap movement as occurring in two dimensions.

"The majority of skin flaps can be explained simply by exploring what makes a fusiform work," Dr. Gross said.

Fusiform flaps generally have 30-degree angles at their tips, based on principles of plane geometry, but the skin is not a flat plane, and whether a lesion will close with 30-degree angles depends on the anatomic location.

"The purpose of making 30-degree angles at the ends of the fusiform is to allow closure without a standing cone," said Dr. Gross, a dermatologic surgeon in private practice in San Diego.

The fusiform consists of three components: the central defect to be closed (depicted as a circle) and two Burow's triangles.

The short axis of the defect usually forms the short axis of the fusiform. The surgeon uses the Burow's triangles at each end of the fusiform to bring the defect to 30-degree angles or to the angles necessary to close the wound without creating a standing cone at the ends of the excision.

The Burow's triangles also can be rotated at the ends of the fusiform as needed to achieve the best cosmetic result. "The Burow's triangle can even be rotated 90 degrees," Dr. Gross pointed out. "You should do whatever type of Burow's triangle is needed to make the best possible closure."

If the location of the defect prevents the use of a Burow's triangle at one or both ends of the fusiform, the surgeon can offset the Burow's triangles, Dr. Gross explained.

"This will result in the creation of what we call an advancement or a rotation flap. If the Burow's triangle is offset to two sides, the result will be a bilateral flap, such as the bilateral advancement or the A to T flap," he commented.

"If the surgeon is in doubt about how to close a wound, he or she may start by drawing a fusiform and then [assessing] whether the fusiform lies in the relaxed skin tension lines and whether it causes distortion of surrounding important anatomic structures," Dr. Gross advised.

If the fusiform does interfere with important anatomy, the surgeon must decide where to offset the Burow's triangles at one or both ends of the fusiform—thereby creating an advancement or rotation flap that doesn't interfere with important anatomy or degrade the cosmetic result.

He noted that about 90% of his Mohs closures are variations of rotation flaps.

Although rotation flaps are generally larger than other types of flaps, Dr. Gross believes that they yield better cosmetic results than transposition flaps because the resulting scar lines can usually be placed in junctions between anatomic units.

Transposition flaps are based primarily on z-plasty movement.

"If you understand the movement of a z-plasty, you will understand how all transposition flaps move and why they move the way they do," Dr. Gross said at the meeting.

Think of a z-plasty as two Burow's triangles sharing a common side, called the central limb. When planning a z-plasty, think about using imaginary skin hooks to pull the central limb longer, Dr. Gross said.

While the central limb lengthens and rotates, there is concomitant shortening of tissue approximately 90 degrees from the axis of the central limb.

The amount of central limb lengthening, and the amount of rotation and shortening in the other axis, is determined by the total of both angles of the Burow's triangles in the z-plasty.

"You can combine 45-degree and 90-degree angles in the same z-plasty, and in fact the Burow's triangles of transposition flaps never have the same-sized angles," Dr. Gross said.

This is the reason some surgeons don't recognize the z-plasties that lie at the heart of all transposition flaps: They are accustomed to seeing z-plasties in textbooks that are drawn with equal angles.

As long as there is sufficient tissue in the opposite direction to allow for shortening without disrupting the surrounding anatomy, as well as enough skin laxity, the surgeon can use whatever size z-plasty angles are needed to produce the amount of central limb lengthening that will close the defect.

The three transposition flaps most often discussed and used by dermatologic surgeons are the Limberg, Webster, and Dufourmentel flaps.

The only difference among them is the total angle of the z-plasties used to create the flaps. The larger the sum of the total angles of the z-plasty of the transposition flap, the greater the lengthening and degree of rotation of the central limb and the greater the shortening of tissue in the opposite axis.

These actions result in the movement of tissue into the defect known as a transposition flap closure. Overall, the amount of tissue that is "wasted" is similar in both a z-plasty and a rotation flap, Dr. Gross said.

SAN DIEGO — Some closures may be too complex for inexperienced Mohs surgeons, but even novices can successfully close most of their cases if they have an understanding of how skin flaps move and a willingness to see the possibilities in the two simple skin movements—the fusiform and the z-plasty—that underlie all flap closures, Dr. Kenneth G. Gross said at a meeting sponsored by the American Society for Mohs Surgery.

It helps to think of flap movement as occurring in two dimensions.

"The majority of skin flaps can be explained simply by exploring what makes a fusiform work," Dr. Gross said.

Fusiform flaps generally have 30-degree angles at their tips, based on principles of plane geometry, but the skin is not a flat plane, and whether a lesion will close with 30-degree angles depends on the anatomic location.

"The purpose of making 30-degree angles at the ends of the fusiform is to allow closure without a standing cone," said Dr. Gross, a dermatologic surgeon in private practice in San Diego.

The fusiform consists of three components: the central defect to be closed (depicted as a circle) and two Burow's triangles.

The short axis of the defect usually forms the short axis of the fusiform. The surgeon uses the Burow's triangles at each end of the fusiform to bring the defect to 30-degree angles or to the angles necessary to close the wound without creating a standing cone at the ends of the excision.

The Burow's triangles also can be rotated at the ends of the fusiform as needed to achieve the best cosmetic result. "The Burow's triangle can even be rotated 90 degrees," Dr. Gross pointed out. "You should do whatever type of Burow's triangle is needed to make the best possible closure."

If the location of the defect prevents the use of a Burow's triangle at one or both ends of the fusiform, the surgeon can offset the Burow's triangles, Dr. Gross explained.

"This will result in the creation of what we call an advancement or a rotation flap. If the Burow's triangle is offset to two sides, the result will be a bilateral flap, such as the bilateral advancement or the A to T flap," he commented.

"If the surgeon is in doubt about how to close a wound, he or she may start by drawing a fusiform and then [assessing] whether the fusiform lies in the relaxed skin tension lines and whether it causes distortion of surrounding important anatomic structures," Dr. Gross advised.

If the fusiform does interfere with important anatomy, the surgeon must decide where to offset the Burow's triangles at one or both ends of the fusiform—thereby creating an advancement or rotation flap that doesn't interfere with important anatomy or degrade the cosmetic result.

He noted that about 90% of his Mohs closures are variations of rotation flaps.

Although rotation flaps are generally larger than other types of flaps, Dr. Gross believes that they yield better cosmetic results than transposition flaps because the resulting scar lines can usually be placed in junctions between anatomic units.

Transposition flaps are based primarily on z-plasty movement.

"If you understand the movement of a z-plasty, you will understand how all transposition flaps move and why they move the way they do," Dr. Gross said at the meeting.

Think of a z-plasty as two Burow's triangles sharing a common side, called the central limb. When planning a z-plasty, think about using imaginary skin hooks to pull the central limb longer, Dr. Gross said.

While the central limb lengthens and rotates, there is concomitant shortening of tissue approximately 90 degrees from the axis of the central limb.

The amount of central limb lengthening, and the amount of rotation and shortening in the other axis, is determined by the total of both angles of the Burow's triangles in the z-plasty.

"You can combine 45-degree and 90-degree angles in the same z-plasty, and in fact the Burow's triangles of transposition flaps never have the same-sized angles," Dr. Gross said.

This is the reason some surgeons don't recognize the z-plasties that lie at the heart of all transposition flaps: They are accustomed to seeing z-plasties in textbooks that are drawn with equal angles.

As long as there is sufficient tissue in the opposite direction to allow for shortening without disrupting the surrounding anatomy, as well as enough skin laxity, the surgeon can use whatever size z-plasty angles are needed to produce the amount of central limb lengthening that will close the defect.

The three transposition flaps most often discussed and used by dermatologic surgeons are the Limberg, Webster, and Dufourmentel flaps.

The only difference among them is the total angle of the z-plasties used to create the flaps. The larger the sum of the total angles of the z-plasty of the transposition flap, the greater the lengthening and degree of rotation of the central limb and the greater the shortening of tissue in the opposite axis.

These actions result in the movement of tissue into the defect known as a transposition flap closure. Overall, the amount of tissue that is "wasted" is similar in both a z-plasty and a rotation flap, Dr. Gross said.

The duration of anesthesia does not correlate with morbidity or mortality in facial plastic surgery performed in an office-based facility, reported Dr. Neil A. Gordon of Yale University, New Haven, and Dr. Marc E. Koch of the State University of New York at Stony Brook.

The investigators conducted what they described as the first study to quantify morbidity and mortality in in-office procedures lasting longer than 4 hours, because no study to date has presented specific outcomes data on such surgery. Despite this lack of data, "state medical boards and government agencies have rushed to regulate office-based surgery" in response to reports of six patient deaths in Florida, they said (Arch. Facial Plast. Surg. 2006;8:47–53).

Their study included a retrospective analysis of 492 cases of facial plastic surgery performed at a single private-practice surgical facility from July 1995 through March 2000 and a prospective analysis of 708 cases performed from April 2000 through February 2005. The cases were divided into those lasting less than 4 hours (168 cases) and those lasting longer (1,032 cases).

Most of the latter group underwent combined procedures for facial rejuvenation, such as rhytidectomies, blepharoplasties, brow lifts, and laser surgery to resurface the skin. The procedures required an average of 306 minutes. Combined procedures that take a relatively long time often are necessary "to appropriately treat the aging face as a unit, thereby preventing the disharmonious appearance produced when portions of the aging face are treated and portions are left untreated," the investigators said.

The shorter procedures were mostly isolated rhinoplasties. The average patient age was 55.7 years. Just over half the patients were older than 51 years, and almost 12% were older than 65.

There were no deaths, no myocardial infarctions, no cardiac arrhythmias, and no pulmonary embolisms.

Three cases of major morbidity occurred (a 0.25% rate), none of which were directly related to procedure duration. A 59-year-old man developed aspiration pneumonia secondary to an obstruction event on extubation, a 53-year-old woman had a cerebral hemorrhage for unknown reasons, and a 52-year-old woman had an anaphylactic reaction to cephalosporin.

"We had no cases … in which inpatient care would have prevented these major morbidity events from occurring or being treated optimally," the researchers said. In fact, it can be argued that receiving intubation for general anesthesia rather than local anesthesia in the office setting actually helped the latter two patients. Because they had secure airways at the time of the events, the surgical team was able to immediately and continuously oxygenate these patients while resuscitating and treating them. "This directly maximized their outcomes and prevented further morbidity, if not mortality," Dr. Gordon and Dr. Koch noted.

"Contrary to reports that longer procedure duration causes a higher incidence of intractable postoperative nausea, vomiting, and pain, thus necessitating higher precautionary hospitalization rates if performed in the office-based environment, we had no cases with any of these complications," they said.

According to the researchers, guidelines including "arbitrary" 4-hour cutoffs for in-office surgery duration—which have been adopted in Pennsylvania and Tennessee—are imposing "inappropriate, non-data-driven regulation" on office-based plastic surgeons.

The duration of anesthesia does not correlate with morbidity or mortality in facial plastic surgery performed in an office-based facility, reported Dr. Neil A. Gordon of Yale University, New Haven, and Dr. Marc E. Koch of the State University of New York at Stony Brook.

The investigators conducted what they described as the first study to quantify morbidity and mortality in in-office procedures lasting longer than 4 hours, because no study to date has presented specific outcomes data on such surgery. Despite this lack of data, "state medical boards and government agencies have rushed to regulate office-based surgery" in response to reports of six patient deaths in Florida, they said (Arch. Facial Plast. Surg. 2006;8:47–53).

Their study included a retrospective analysis of 492 cases of facial plastic surgery performed at a single private-practice surgical facility from July 1995 through March 2000 and a prospective analysis of 708 cases performed from April 2000 through February 2005. The cases were divided into those lasting less than 4 hours (168 cases) and those lasting longer (1,032 cases).

Most of the latter group underwent combined procedures for facial rejuvenation, such as rhytidectomies, blepharoplasties, brow lifts, and laser surgery to resurface the skin. The procedures required an average of 306 minutes. Combined procedures that take a relatively long time often are necessary "to appropriately treat the aging face as a unit, thereby preventing the disharmonious appearance produced when portions of the aging face are treated and portions are left untreated," the investigators said.

The shorter procedures were mostly isolated rhinoplasties. The average patient age was 55.7 years. Just over half the patients were older than 51 years, and almost 12% were older than 65.

There were no deaths, no myocardial infarctions, no cardiac arrhythmias, and no pulmonary embolisms.

Three cases of major morbidity occurred (a 0.25% rate), none of which were directly related to procedure duration. A 59-year-old man developed aspiration pneumonia secondary to an obstruction event on extubation, a 53-year-old woman had a cerebral hemorrhage for unknown reasons, and a 52-year-old woman had an anaphylactic reaction to cephalosporin.

"We had no cases … in which inpatient care would have prevented these major morbidity events from occurring or being treated optimally," the researchers said. In fact, it can be argued that receiving intubation for general anesthesia rather than local anesthesia in the office setting actually helped the latter two patients. Because they had secure airways at the time of the events, the surgical team was able to immediately and continuously oxygenate these patients while resuscitating and treating them. "This directly maximized their outcomes and prevented further morbidity, if not mortality," Dr. Gordon and Dr. Koch noted.

"Contrary to reports that longer procedure duration causes a higher incidence of intractable postoperative nausea, vomiting, and pain, thus necessitating higher precautionary hospitalization rates if performed in the office-based environment, we had no cases with any of these complications," they said.

According to the researchers, guidelines including "arbitrary" 4-hour cutoffs for in-office surgery duration—which have been adopted in Pennsylvania and Tennessee—are imposing "inappropriate, non-data-driven regulation" on office-based plastic surgeons.

The duration of anesthesia does not correlate with morbidity or mortality in facial plastic surgery performed in an office-based facility, reported Dr. Neil A. Gordon of Yale University, New Haven, and Dr. Marc E. Koch of the State University of New York at Stony Brook.

The investigators conducted what they described as the first study to quantify morbidity and mortality in in-office procedures lasting longer than 4 hours, because no study to date has presented specific outcomes data on such surgery. Despite this lack of data, "state medical boards and government agencies have rushed to regulate office-based surgery" in response to reports of six patient deaths in Florida, they said (Arch. Facial Plast. Surg. 2006;8:47–53).

Their study included a retrospective analysis of 492 cases of facial plastic surgery performed at a single private-practice surgical facility from July 1995 through March 2000 and a prospective analysis of 708 cases performed from April 2000 through February 2005. The cases were divided into those lasting less than 4 hours (168 cases) and those lasting longer (1,032 cases).

Most of the latter group underwent combined procedures for facial rejuvenation, such as rhytidectomies, blepharoplasties, brow lifts, and laser surgery to resurface the skin. The procedures required an average of 306 minutes. Combined procedures that take a relatively long time often are necessary "to appropriately treat the aging face as a unit, thereby preventing the disharmonious appearance produced when portions of the aging face are treated and portions are left untreated," the investigators said.

The shorter procedures were mostly isolated rhinoplasties. The average patient age was 55.7 years. Just over half the patients were older than 51 years, and almost 12% were older than 65.

There were no deaths, no myocardial infarctions, no cardiac arrhythmias, and no pulmonary embolisms.

Three cases of major morbidity occurred (a 0.25% rate), none of which were directly related to procedure duration. A 59-year-old man developed aspiration pneumonia secondary to an obstruction event on extubation, a 53-year-old woman had a cerebral hemorrhage for unknown reasons, and a 52-year-old woman had an anaphylactic reaction to cephalosporin.

"We had no cases … in which inpatient care would have prevented these major morbidity events from occurring or being treated optimally," the researchers said. In fact, it can be argued that receiving intubation for general anesthesia rather than local anesthesia in the office setting actually helped the latter two patients. Because they had secure airways at the time of the events, the surgical team was able to immediately and continuously oxygenate these patients while resuscitating and treating them. "This directly maximized their outcomes and prevented further morbidity, if not mortality," Dr. Gordon and Dr. Koch noted.

"Contrary to reports that longer procedure duration causes a higher incidence of intractable postoperative nausea, vomiting, and pain, thus necessitating higher precautionary hospitalization rates if performed in the office-based environment, we had no cases with any of these complications," they said.

According to the researchers, guidelines including "arbitrary" 4-hour cutoffs for in-office surgery duration—which have been adopted in Pennsylvania and Tennessee—are imposing "inappropriate, non-data-driven regulation" on office-based plastic surgeons.

NAPLES, FLA. — Proper technique is paramount to optimize outcome and avoid complications with either calcium hydroxyapatite or poly-L-lactic acid fillers, according to a presentation at a Dermatology Foundation-sponsored symposium.

Infiltration of local anesthesia, needle size, injection technique, multiple treatment sessions, and tips to avoid complications are among clinical pearls for optimal use of calcium hydroxyapatite (Radiesse, BioForm Medical) and poly-L-lactic acid (Sculptra, Sanofi-Aventis).

"Radiesse is for structure and support and Sculptra is for diffuse volume," said Dr. Ken K. Lee, director of dermatologic surgery at Oregon Health and Science University in Portland. The two fillers are not mutually exclusive, he added. "I use these two together all the time."

Focal treatment is the goal with these fillers, Dr. Lee said. "There is a paradigm shift from filling to contouring. Contouring really was only available before with fat transfer." The gauge of needles typically used to inject calcium hydroxyapatite (27G) or poly-L-lactic acid (25G or 26G) can hurt, Dr. Lee said. He recommended local infiltration with lidocaine with epinephrine prior to injection to reduce pain and bruising. Dr. Lee does not have a disclosure regarding either filler product.

The goal with calcium hydroxyapatite is not to fill in fine lines, but to give more structure, Dr. Lee explained. The synthetic particles form scaffolding for tissue in-growth. "It is off label for cosmetic use—I do tell patients that."

Radiesse is packaged in 1.3-cc and 0.3-cc syringes. Inject into "deep dermis and a little bit into subcutaneous fat," Dr. Lee said. He recommended a threading and fanning technique, injecting only a small amount at each pass, such as 0.05 cc. Stop injection before exiting the skin and knead or mold any firm nodules after injection, he suggested.

"I don't just thread the material along the nasolabial line, I also crisscross to enhance the volume effect," Dr. Lee said. "This stuff is really thick and hard to get out of the needle, which is good. You don't want a lot of material in any one area."

Dr. Lee informs patients in advance that if they have prominent nasolabial lines or marionette lines they will likely need three syringes over two treatment sessions. "Then it doesn't look like you've failed them."

Volume from a single injection typically lasts about 9 months, Dr. Lee said. The double session strategy extends duration of effect to 1 year or longer. "Somehow getting it to last up to a year is much more appealing to patients. The downside is that complications last a long time, too."

Avoid filling thin eyelids and lips with calcium hydroxyapatite, Dr. Lee advised. Deposits can be seen in these areas. Dr. Lee said, "I really recommend collagen or hyaluronic acid for lips."

Poly-L-lactic acid, similar to calcium hydroxyapatite, is injected into the deep dermis or subcutaneous layer. Do not inject this filler superficially, Dr. Lee cautioned. "I aim for the subcutaneous layer. It is more difficult to consistently place in deep dermis and there are more complications." Inject a small amount on withdrawal.

Poly-L-lactic acid is a synthetic, biodegradable, biocompatible polymer that stimulates a patient's own collagen. Dr. Lee reconstitutes the filler with sterile water and 2% lidocaine. It is stable up to 72 hours after reconstitution. The vial is stored at room temperature but should be warmed prior to use, Dr. Lee suggested. "I have the patient hold the vial prior to injection. It helps to avoid clogging of the needle."

Massaging right after injections is very important, Dr. Lee said. "I tell patients to massage five times a day for 5 minutes for 5 days for distribution of the Sculptra."

Up to six treatment sessions may be necessary for full effect. Schedule treatment sessions about 4–6 weeks apart, Dr. Lee suggested. Volume enhancement with poly-L-lactic acid can last 2 years or more.

Hematoma is the most commonly reported complication in studies, Dr. Lee said. Subcutaneous papules are another potential problem. "You really have to be careful," he said. "Sculptra in cosmetic patients has really shown me how much volume affects the drooping of the skin."

NAPLES, FLA. — Proper technique is paramount to optimize outcome and avoid complications with either calcium hydroxyapatite or poly-L-lactic acid fillers, according to a presentation at a Dermatology Foundation-sponsored symposium.

Infiltration of local anesthesia, needle size, injection technique, multiple treatment sessions, and tips to avoid complications are among clinical pearls for optimal use of calcium hydroxyapatite (Radiesse, BioForm Medical) and poly-L-lactic acid (Sculptra, Sanofi-Aventis).

"Radiesse is for structure and support and Sculptra is for diffuse volume," said Dr. Ken K. Lee, director of dermatologic surgery at Oregon Health and Science University in Portland. The two fillers are not mutually exclusive, he added. "I use these two together all the time."

Focal treatment is the goal with these fillers, Dr. Lee said. "There is a paradigm shift from filling to contouring. Contouring really was only available before with fat transfer." The gauge of needles typically used to inject calcium hydroxyapatite (27G) or poly-L-lactic acid (25G or 26G) can hurt, Dr. Lee said. He recommended local infiltration with lidocaine with epinephrine prior to injection to reduce pain and bruising. Dr. Lee does not have a disclosure regarding either filler product.

The goal with calcium hydroxyapatite is not to fill in fine lines, but to give more structure, Dr. Lee explained. The synthetic particles form scaffolding for tissue in-growth. "It is off label for cosmetic use—I do tell patients that."

Radiesse is packaged in 1.3-cc and 0.3-cc syringes. Inject into "deep dermis and a little bit into subcutaneous fat," Dr. Lee said. He recommended a threading and fanning technique, injecting only a small amount at each pass, such as 0.05 cc. Stop injection before exiting the skin and knead or mold any firm nodules after injection, he suggested.

"I don't just thread the material along the nasolabial line, I also crisscross to enhance the volume effect," Dr. Lee said. "This stuff is really thick and hard to get out of the needle, which is good. You don't want a lot of material in any one area."

Dr. Lee informs patients in advance that if they have prominent nasolabial lines or marionette lines they will likely need three syringes over two treatment sessions. "Then it doesn't look like you've failed them."

Volume from a single injection typically lasts about 9 months, Dr. Lee said. The double session strategy extends duration of effect to 1 year or longer. "Somehow getting it to last up to a year is much more appealing to patients. The downside is that complications last a long time, too."

Avoid filling thin eyelids and lips with calcium hydroxyapatite, Dr. Lee advised. Deposits can be seen in these areas. Dr. Lee said, "I really recommend collagen or hyaluronic acid for lips."

Poly-L-lactic acid, similar to calcium hydroxyapatite, is injected into the deep dermis or subcutaneous layer. Do not inject this filler superficially, Dr. Lee cautioned. "I aim for the subcutaneous layer. It is more difficult to consistently place in deep dermis and there are more complications." Inject a small amount on withdrawal.

Poly-L-lactic acid is a synthetic, biodegradable, biocompatible polymer that stimulates a patient's own collagen. Dr. Lee reconstitutes the filler with sterile water and 2% lidocaine. It is stable up to 72 hours after reconstitution. The vial is stored at room temperature but should be warmed prior to use, Dr. Lee suggested. "I have the patient hold the vial prior to injection. It helps to avoid clogging of the needle."

Massaging right after injections is very important, Dr. Lee said. "I tell patients to massage five times a day for 5 minutes for 5 days for distribution of the Sculptra."

Up to six treatment sessions may be necessary for full effect. Schedule treatment sessions about 4–6 weeks apart, Dr. Lee suggested. Volume enhancement with poly-L-lactic acid can last 2 years or more.

Hematoma is the most commonly reported complication in studies, Dr. Lee said. Subcutaneous papules are another potential problem. "You really have to be careful," he said. "Sculptra in cosmetic patients has really shown me how much volume affects the drooping of the skin."

NAPLES, FLA. — Proper technique is paramount to optimize outcome and avoid complications with either calcium hydroxyapatite or poly-L-lactic acid fillers, according to a presentation at a Dermatology Foundation-sponsored symposium.

Infiltration of local anesthesia, needle size, injection technique, multiple treatment sessions, and tips to avoid complications are among clinical pearls for optimal use of calcium hydroxyapatite (Radiesse, BioForm Medical) and poly-L-lactic acid (Sculptra, Sanofi-Aventis).

"Radiesse is for structure and support and Sculptra is for diffuse volume," said Dr. Ken K. Lee, director of dermatologic surgery at Oregon Health and Science University in Portland. The two fillers are not mutually exclusive, he added. "I use these two together all the time."

Focal treatment is the goal with these fillers, Dr. Lee said. "There is a paradigm shift from filling to contouring. Contouring really was only available before with fat transfer." The gauge of needles typically used to inject calcium hydroxyapatite (27G) or poly-L-lactic acid (25G or 26G) can hurt, Dr. Lee said. He recommended local infiltration with lidocaine with epinephrine prior to injection to reduce pain and bruising. Dr. Lee does not have a disclosure regarding either filler product.

The goal with calcium hydroxyapatite is not to fill in fine lines, but to give more structure, Dr. Lee explained. The synthetic particles form scaffolding for tissue in-growth. "It is off label for cosmetic use—I do tell patients that."

Radiesse is packaged in 1.3-cc and 0.3-cc syringes. Inject into "deep dermis and a little bit into subcutaneous fat," Dr. Lee said. He recommended a threading and fanning technique, injecting only a small amount at each pass, such as 0.05 cc. Stop injection before exiting the skin and knead or mold any firm nodules after injection, he suggested.

"I don't just thread the material along the nasolabial line, I also crisscross to enhance the volume effect," Dr. Lee said. "This stuff is really thick and hard to get out of the needle, which is good. You don't want a lot of material in any one area."

Dr. Lee informs patients in advance that if they have prominent nasolabial lines or marionette lines they will likely need three syringes over two treatment sessions. "Then it doesn't look like you've failed them."

Volume from a single injection typically lasts about 9 months, Dr. Lee said. The double session strategy extends duration of effect to 1 year or longer. "Somehow getting it to last up to a year is much more appealing to patients. The downside is that complications last a long time, too."

Avoid filling thin eyelids and lips with calcium hydroxyapatite, Dr. Lee advised. Deposits can be seen in these areas. Dr. Lee said, "I really recommend collagen or hyaluronic acid for lips."

Poly-L-lactic acid, similar to calcium hydroxyapatite, is injected into the deep dermis or subcutaneous layer. Do not inject this filler superficially, Dr. Lee cautioned. "I aim for the subcutaneous layer. It is more difficult to consistently place in deep dermis and there are more complications." Inject a small amount on withdrawal.

Poly-L-lactic acid is a synthetic, biodegradable, biocompatible polymer that stimulates a patient's own collagen. Dr. Lee reconstitutes the filler with sterile water and 2% lidocaine. It is stable up to 72 hours after reconstitution. The vial is stored at room temperature but should be warmed prior to use, Dr. Lee suggested. "I have the patient hold the vial prior to injection. It helps to avoid clogging of the needle."

Massaging right after injections is very important, Dr. Lee said. "I tell patients to massage five times a day for 5 minutes for 5 days for distribution of the Sculptra."

Up to six treatment sessions may be necessary for full effect. Schedule treatment sessions about 4–6 weeks apart, Dr. Lee suggested. Volume enhancement with poly-L-lactic acid can last 2 years or more.

Hematoma is the most commonly reported complication in studies, Dr. Lee said. Subcutaneous papules are another potential problem. "You really have to be careful," he said. "Sculptra in cosmetic patients has really shown me how much volume affects the drooping of the skin."

ATLANTA — Lateral orbital fullness noted during upper blepharoplasty is usually caused by orbital fat that can be resected, but the finding can be a result of lacrimal gland prolapse, Dr. Hanspaul Makkar said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Resection of prolapsed lacrimal gland tissue will cause decreased tear production and could compromise aesthetic outcome, so it is important to be aware of this potential finding, said Dr. Makkar of the University of California, San Francisco.

A preoperative examination is imperative. Lacrimal gland prolapse—which results from dehiscence of ligaments that connect the gland to the orbital rim fossa, and which can occur as a result of trauma or the normal aging process—should be suspected if the tissue feels firmer and is more circumscribed than surrounding tissue. Palpation will reveal a nontender, sharply bordered, and easily reducible mass, he explained. However, a nonreducible or tender mass merits work-up for a lacrimal gland tumor or inflammatory process.

Keep in mind that in patients with marked herniation of fat, lacrimal gland prolapse might not be detectable except during surgical exploration.

Correction of lacrimal gland prolapse can be achieved easily by resuspending the lacrimal gland to the orbital rim during the upper blepharoplasty procedure. This step is necessary for a good cosmetic outcome.

Dr. Makkar described two of his own patients whose unexpected lacrimal gland prolapse was detected perioperatively. The patients were treated with the resuspension procedure, and outcomes at 6 months were excellent with no signs of recurrent lacrimal gland ptosis, he said.

ATLANTA — Lateral orbital fullness noted during upper blepharoplasty is usually caused by orbital fat that can be resected, but the finding can be a result of lacrimal gland prolapse, Dr. Hanspaul Makkar said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Resection of prolapsed lacrimal gland tissue will cause decreased tear production and could compromise aesthetic outcome, so it is important to be aware of this potential finding, said Dr. Makkar of the University of California, San Francisco.

A preoperative examination is imperative. Lacrimal gland prolapse—which results from dehiscence of ligaments that connect the gland to the orbital rim fossa, and which can occur as a result of trauma or the normal aging process—should be suspected if the tissue feels firmer and is more circumscribed than surrounding tissue. Palpation will reveal a nontender, sharply bordered, and easily reducible mass, he explained. However, a nonreducible or tender mass merits work-up for a lacrimal gland tumor or inflammatory process.

Keep in mind that in patients with marked herniation of fat, lacrimal gland prolapse might not be detectable except during surgical exploration.

Correction of lacrimal gland prolapse can be achieved easily by resuspending the lacrimal gland to the orbital rim during the upper blepharoplasty procedure. This step is necessary for a good cosmetic outcome.

Dr. Makkar described two of his own patients whose unexpected lacrimal gland prolapse was detected perioperatively. The patients were treated with the resuspension procedure, and outcomes at 6 months were excellent with no signs of recurrent lacrimal gland ptosis, he said.

ATLANTA — Lateral orbital fullness noted during upper blepharoplasty is usually caused by orbital fat that can be resected, but the finding can be a result of lacrimal gland prolapse, Dr. Hanspaul Makkar said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Resection of prolapsed lacrimal gland tissue will cause decreased tear production and could compromise aesthetic outcome, so it is important to be aware of this potential finding, said Dr. Makkar of the University of California, San Francisco.

A preoperative examination is imperative. Lacrimal gland prolapse—which results from dehiscence of ligaments that connect the gland to the orbital rim fossa, and which can occur as a result of trauma or the normal aging process—should be suspected if the tissue feels firmer and is more circumscribed than surrounding tissue. Palpation will reveal a nontender, sharply bordered, and easily reducible mass, he explained. However, a nonreducible or tender mass merits work-up for a lacrimal gland tumor or inflammatory process.

Keep in mind that in patients with marked herniation of fat, lacrimal gland prolapse might not be detectable except during surgical exploration.

Correction of lacrimal gland prolapse can be achieved easily by resuspending the lacrimal gland to the orbital rim during the upper blepharoplasty procedure. This step is necessary for a good cosmetic outcome.

Dr. Makkar described two of his own patients whose unexpected lacrimal gland prolapse was detected perioperatively. The patients were treated with the resuspension procedure, and outcomes at 6 months were excellent with no signs of recurrent lacrimal gland ptosis, he said.

SAN DIEGO — The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.

The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.

"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.

OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.

In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.

The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.

The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.

In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.

Quality control in a Mohs practice—defined as the monitoring of testing procedures to achieve accurate, consistent results—also falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.

SAN DIEGO — The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.

The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.

"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.

OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.

In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.

The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.

The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.

In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.

Quality control in a Mohs practice—defined as the monitoring of testing procedures to achieve accurate, consistent results—also falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.

SAN DIEGO — The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.

The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.

"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.

OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.

In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.

The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.

The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.

In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.

Quality control in a Mohs practice—defined as the monitoring of testing procedures to achieve accurate, consistent results—also falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.

SAN DIEGO — Most Mohs surgeons don't have the luxury of designing an ideal office from scratch—they must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.

Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.

▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.

▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.

Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.

▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick buckets—buckets on wheels that can be moved with the feet while the surgeon is gloved during a procedure—are extremely helpful in a Mohs surgical suite.

▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.

▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratory—with its unique processing of specimens and methods of record keeping—is one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.

"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.

Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.

His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.

Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.

SAN DIEGO — Most Mohs surgeons don't have the luxury of designing an ideal office from scratch—they must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.

Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.

▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.

▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.

Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.

▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick buckets—buckets on wheels that can be moved with the feet while the surgeon is gloved during a procedure—are extremely helpful in a Mohs surgical suite.

▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.

▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratory—with its unique processing of specimens and methods of record keeping—is one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.

"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.

Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.

His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.

Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.

SAN DIEGO — Most Mohs surgeons don't have the luxury of designing an ideal office from scratch—they must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.

Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.

▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.

▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.

Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.

▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick buckets—buckets on wheels that can be moved with the feet while the surgeon is gloved during a procedure—are extremely helpful in a Mohs surgical suite.

▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.

▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratory—with its unique processing of specimens and methods of record keeping—is one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.

"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.

Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.

His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.

Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.