Face-lifting: an overview

Numerous adaptations of face-lift techniques have been devised, and each surgical approach has its own risks and benefits, as well as proponents and detractors. All of the conventionally accepted techniques achieve removal of redundant skin. However, its the variations in approach to the deeper soft tissue structures that separate the many face-lifting procedures. A skin only face-lift was the earliest form of surgical rhytidectomy, but failed to achieve significant long-term benefit. Cosmetic surgeons of various backgrounds thus sought to achieve a more durable benefit from the surgery. While certain techniques have been classically ascribed to a particular surgeon, innovation does not occur in a vacuum and many surgeons are responsible for our current state of knowledge with regards to facial rhytidectomy surgery.     

A simple technique to reconstruct medium to large scalp defects with exposed bone

Medium to large scalp defects with exposed bone can pose particular challenges to the dermatologic surgeon. Most of the publications pertaining to the repair of such defects are presented in the plastic surgery literature. Dermatologic surgeons may have less experience in this area and be hesitant to pursue surgery when these defects may be encountered. The technique described below is a simple, one‐stage reconstruction, with a short healing period, providing adequate cosmesis, and is within the capability of most dermatologic surgeons.     

Advanced reconstructive techniques for the lip and perioral area

Defects of the lip and perioral area present a significant challenge for reconstructive surgeons. It is important to obtain results that are a success from the functional and aesthetic standpoint. In planning the reconstruction, the surgeon should consider the age and general state of health of the patient and dental status. The surgeon should be well acquainted with the essential principles in planning reconstructive procedures. By becoming familiar with advantages and shortcomings of different cheiloplasty procedures, the surgeon will be able to implement the functionally and cosmetically appropriate technique in each specific case.     

Mohs micrographic surgery: a review of indications,technique, outcomes,and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.     

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.     

Mohs surgery in Australia: a survey of work practices

Background: Mohs micrographic surgery is the preferred treatment for certain skin cancers. It had already been considerably refined prior to its introduction into Australia in 1978, refinement has continued since. Documenting the work practices of Australian Mohs surgeons serves to clarify the current role of Mohs surgery and may help tailor future Mohs fellowship programs. Methods: A survey was conducted to investigate the characteristics and clinical practices of Australian Mohs surgeons, particularly as they relate to skin cancer management and aesthetic dermatology. Results: The typical Australian Mohs surgeon is male (90%), works in a group private practice (70%), and is aged 40–44 years (37%). Mohs surgery is generally reserved for tumours that are located on the head, neck, digits or genitals (98%), and flap reconstructions are the commonest repair types performed (48%). Laser and cosmetic injectable treatments form part of many Mohs surgeon's repertoires. Conclusion: Australian Mohs surgeons make an important contribution to the management of skin cancer in Australia and many are skilled in laser and cosmetic procedures. The increasing number of cases performed annually and the familiarity with laser and cosmetic therapies reinforces Australian dermatologists as leaders in these important areas of dermatology.     

Perioperative management of and recommendations for antithrombotic medications in dermatological surgery

With the ever‐increasing number of patients on anticoagulant or antiplatelet medications presenting for a dermatological surgical procedure, dermatological surgeons are facing the challenge of managing these drugs in order to balance the bleeding complications against the risk of thromboembolic events. The difficulty arises from the scarce available recommendations, the data in the literature that is in part contradictory and the rate of emergence of newer agents that have not been thoroughly studied and widely used. Although the common approach in the past was to stop any antithrombotic medications, including warfarin and aspirin, several days prior to cutaneous surgery, recent data suggest that this practice should be changed as the relatively low risk of bleeding does not justify the life‐threatening nature of a likely thrombosis. For patients on warfarin, surgery should be avoided if the international normalized ratio is > 3·5; aspirin should not be stopped prior to dermatological surgery and in most other circumstances patients taking long‐term antithrombotic medication should not stop this prior to dermatological surgery. In more complicated cases liaison with the prescriber is indispensable even when the therapy should be discontinued for a short period of time. This review studies the available data and presents the dermatological surgeon with up‐to‐date information about all studies concerning the old and new antithrombotic agents in the setting of dermatological surgery procedures. Our aim is to propose our recommendations based on the most recent evidence and our experience and provide a comprehensive approach to the dermatological surgeon without excluding the need for individual assessment of each case.     

Limited breast reduction by liposuction

Traditionally, dermatologic surgeons have referred women seeking breast reduction to plastic surgeons for excisional mammoplasty. However, with recent advances in small cannula tumescent liposuction surgery, referral for such surgery may be unnecessary in some cases. Breast liposuction can reduce the size of female breasts that have essentially normal architecture with a minimum of visible scarring and an aesthetically pleasing result. We describe a method for liposuction reduction of female breasts that is safe, efficacious, and associated with high levels of patient satisfaction. Liposuction for breast reduction in women is an appropriate addition to the array of liposuction procedures available to the dermatologic surgeon.     

Aesthetic surgery of the face

A large variety of safe and effective surgical procedures to achieve rejuvenation is currently available. If surgery is carefully and properly performed, with an emphasis on a conservative approach, lasting and gratifying results may be realized. Great care must be taken to select appropriate and highly motivated individuals for such procedures, from the standpoint of both psychologic maturity and ideal anatomic configurations. Furthermore, patients seeking aesthetic surgery are generally healthy and well, unlike patients who seek medical care for disease; surgeons must exercise extraordinary care to ensure that rejuventation surgery does not result in an unwell patient. Clearly, the ideal outcome is represented by a patient happy and gratified by his improvement and a surgeon proud of his resultant achievement.     

Lichen planopilaris following hair transplantation and face-lift surgery

Cosmetic surgical procedures, including hair transplantation and face-lift surgery, are becoming increasingly popular. However, there is very little information regarding the associated development of dermatological conditions following these procedures. Lichen planopilaris (LPP) is an uncommon inflammatory hair disorder of unknown aetiology that results in permanent alopecia and replacement of hair follicles with scar-like fibrous tissue. Frontal fibrosing alopecia (FFA), a variant of LPP, involves the frontal hairline and shares similar histological findings with those of LPP. We report 10 patients who developed LPP/FFA following cosmetic scalp surgery. Seven patients developed LPP following hair transplantation, and three patients developed FFA following face-lift surgery. In all cases there was no previous history of LPP or FFA. There is currently a lack of evidence to link the procedures of hair transplantation and cosmetic face-lift surgery to LPP and FFA, respectively. This is the first case series to describe this connection and to postulate the possible pathological processes underlying the clinical observation. Explanations include Koebner phenomenon induced by surgical trauma, an autoimmune process targeting an (as yet, unknown) hair follicle antigen liberated during surgery or perhaps a postsurgery proinflammatory milieu inducing hair follicle immune privilege collapse and follicular damage in susceptible individuals.     

Freestyle perforator flaps: an innovative approach to soft tissue reconstruction

Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery. The technique further evolved with the introduction of the freestyle concept, allowing one to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared with the recipient site in terms of color and texture, on a consistent vascular source and in a tension‐free manner. The authors present their personal approach to the reconstruction of soft tissue defects after excision for a basal cell carcinoma involving the medial tibial region.     

Aktuelle Aspekte der Facelift-Chirurgie

In the care of the aging face, the facelift procedure occupies the center of attention. Of the many techniques available, only a few procedures fulfill the justifiable expectations that both patient and physician should have of such an intervention to reach the four goals of a facelift operation: create a natural, nonoperated appearance, obtain long-term durability, ensure a minimal complication rate, and restore or maintain a youthful vibrancy. This can especially be achieved with the so-called super-extended face lift with SMAS dissection, rotation, and refixation. Besides possessing surgical skill, every surgeon working in the field of aesthetic surgery must have a "concept of beauty" as defined by Connell and Levy, i.e., the surgeon must recognize the entirety of the face as an aesthetic unit and plan each intervention on an individual basis. Thus, in many cases it is not only necessary to correct the cheek and neck area, but also to take the forehead/eyebrow section into consideration.     

The current status of curettage and electrodesiccation

Curettage and electrodesiccation (CE) is a technique widely used in the destruction of benign and selected malignant cutaneous neoplasms. CE is used mainly by dermatologists and family practice physicians, whereas plastic surgeons and other surgeons excise most benign and malignant lesions. The use of CE for the treatment of skin cancer has been widely extolled and also fervently criticized. Some practitioners treat most non-melanoma skin cancers (NMSC) with CE, and others have called for abandoning the technique in the treatment of such lesions. A thorough review of the literature reveals that CE has both virtues and flaws. In taking a rational approach to the treatment of benign and malignant cutaneous lesions it is essential to learn the basis for CE, the likely cure rates for given lesions, the proper technique, and the expected level of cosmesis. As the surgical treatment of skin cancer has become firmly entrenched in the field of dermatology, it is valuable to examine this technique in depth and to come to some thoughtful conclusions about its use for patients with skin cancer and assorted benign skin lesions. Last year a remarkably complete and exhaustive favorable review of curettage, electrosurgery, and skin cancer was published by Sheridan and Dawber. This article is a must read for anyone performing curettage; however, the author is writing with a slightly different perspective, that of a dermatologic surgeon. Although the author believes that CE has value and he uses this technique frequently, he disagrees with some of the truisms expressed in the literature about CE and attempts to define carefully what he believes are the strengths and limitations of this technique.     

Differences in biopsy techniques of actinic keratoses by plastic surgeons and dermatologists: a histologically controlled pilot study

OBJECTIVE: To compare differences in biopsy techniques of actinic keratoses between dermatologists and plastic surgeons. DESIGN: Blinded, comparative, retrospective study. SETTING: Dermatopathology laboratory at a major academic medical center with referral of outside cases.Intervention We reexamined the histopathologic slides of 405 actinic keratosis biopsy specimens obtained by plastic surgeons and dermatologists from January 1, 1992, through May 31, 2002. We were specifically interested in the type of biopsy technique (shave, punch, or excisional biopsy) used for the surgical management of actinic keratoses by both groups of physicians. We also recorded the clinical diagnoses rendered on the dermatopathology request form and compared them with the histopathologic diagnoses. RESULTS: Excisional biopsies were performed by plastic surgeons in 50.0% of the cases, compared with only 1.4% by dermatologists. In contrast, shave biopsies of actinic keratoses were performed by plastic surgeons in only 32.4% of the cases, compared with 89.4% by dermatologists. Only 1 (0.5%) of the 198 dermatopathology request forms submitted by the plastic surgeons mentioned actinic keratosis, compared with 82 (39.6%) of 207 histopathologic evaluation requests submitted by dermatologists. CONCLUSIONS: The predominance of excisional biopsies of actinic keratoses by plastic surgeons may be related to a different ability in the clinical recognition of actinic keratoses compared with that of dermatologists. The surgical approach of dermatologists to shave diagnostically uncertain cutaneous lesions is less invasive than that of plastic surgeons and is more likely to achieve a better cosmetic outcome.     

Standards for aseptic techniques in medical aesthetic practices in the Benelux: Consensus recommendations

Introduction

While the demand for aesthetic procedures is rising, complications are rising alongside. Infection is a frequent complication, there is therefore an increased need for strict aseptic technique, particularly in procedures breaching the skin. The level of training of practitioners carrying out these procedures varies and there are no comprehensive guidelines on aseptic aesthetic practice in the Benelux region.

Objective

Developing a step-by-step procedure for achieving and maintaining a high standard of aseptic conditions in a standard aesthetic practice in the Benelux region.

Methods

A consensus group of 10 aesthetic medical practitioners (dermatologists, plastic surgeons, and cosmetic physicians) representing the Benelux region convened to discuss best practice for aseptic techniques in medical aesthetics. Step-by-step procedures were recommended to achieve optimal aseptic practice in private facilities and define important considerations for reducing infection risk. Recommendations were based on current evidence and extensive clinical experience.

Results

Recommendations were made to achieve and maintain a high standard of asepsis and infection control. Guidance included maintaining high standard aseptic conditions of the injecting room, the injecting area on the patient, the injection procedure, the materials, and procedures commonly used to achieve aseptic conditions.

Conclusions

This expert consensus summary publication recommends aseptic procedures, setting a standard with the goal of minimizing rates of complications in aesthetic clinical practice in the Benelux region.     

Aesthetics and reconstruction--seeing before cutting

In order to restore a specific form during aesthetic surgery it is self-evident that the surgeon needs to know the form exists. But more than this simple form restoration, the development of aesthetic restoration suggests a specific restoration in the context of the whole form. Developing a disciplined method of visualizing the problem is the first step toward being able to start an aesthetic sense or eye. Careful study of master artists drawings often forces the surgeon to simplify and concentrate not on parts, but parts as they relate to the whole face. Often the artist, as with the successful surgeon, must continually alternate consideration of a specific part with consideration of the whole. This discussion is meant to provide a few relationships and constructs so that the surgeon may start on the journey to development of the aesthetic eye.     

Principles of liposuction

There has been a dramatic increase in liposuction procedures during the last decade by both dermatologic and plastic surgeons. It is one of the most commonly performed cosmetic surgery procedures. Since its inception in 1976, numerous major advances have made the procedure more successful for both the surgeon and patient alike. This article reviews the current principles of liposuction and serves as a comprehensive overview of recent innovations in this field.     

MOHS micrographic surgery for head and neck nonmelanoma skin cancer: An approach for ENT surgeons

Surgery is the main approach for skin cancer, with Mohs micrographic surgery (MMS) allowing the highest cure rates, best esthetics and superior functional outcomes. Ear, nose, and throat (ENT) surgeons are often challenged with patients presenting skin cancer, needing appropriate expertise to its adequate management. This paper highlights the most important aspects of MMS, enabling ENT surgeons to become familiar with its fundamental aspects. A review of the literature was performed, concomitantly presenting the author's outcomes as an ENT surgeon. A total of 51 MMSs were performed in 41 patients, and 78.4% of the tumors were cutaneous basal cell carcinomas (cBCCs), 19.6% were cutaneous squamous cell carcinomas (cSCCs), and one case was a microcystic adnexal carcinoma. Most tumors were located in high‐risk areas (88.2%), and 84.3% of them were ≥10 mm in diameter. Most tumors (90.2%) required no more than two MMS excision steps to be completely removed. All cases were managed by reconstruction either using flaps or grafts. Recurrence occurred in only 2% of the cases. This study addressed the main issues of MMS, which may be important in ENT surgeons' daily practice.     

Interpretation of Mohs micrographic frozen sections: a peer review comparison study

The ability of the Mohs surgeon to interpret frozen sections generated during Mohs surgery has been questioned recently. In this study 1000 Mohs micrographic slides were interpreted by a Mohs surgeon and subsequently by a general pathologist. The disputed slides were then reviewed independently by two Mohs surgeons, two pathologists, and a dermatopathologist. Overall, there was a 98.9% agreement in interpretation among the Mohs surgeons, the pathologists, and the dermatopathologist. Results would indicate that a well-trained and experienced Mohs surgeon is competent to interpret slides prepared under his or her supervision during Mohs surgery.     

Cutaneous surgery in the elderly: ensuring comfort and safety

Increasingly, cutaneous surgeons are asked to treat cancers and the visible signs of aging in extremely elderly patients. While many elderly patients have functional status similar to that of younger patients, some older patients may have co-morbities and special needs that must be monitored and accommodated by the skin surgeon. A rational approach to surgery can increase the comfort and safety of surgery in such patients. Overall, cutaneous surgery is well-tolerated in even the oldest patients.