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.     

A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery

BACKGROUND: Because outpatient surgery is being increasingly scrutinized in the lay press, it is important that dermatologists and dermatologic surgeons accurately characterize the safety of office-based surgery. Although there is abundant anecdotal evidence to support the inherent safety of dermatologic surgery, there are few data that support the safety of Mohs micrographic surgery (MMS) as performed by appropriately trained dermatologic surgeons in outpatient settings. DESIGN: All patients presenting for MMS micrographic surgery during the calendar year 2000 were prospectively enrolled in this study designed to evaluate the incidence of multiple complications associated with scalpel-based cutaneous surgery (postoperative hemorrhage, hematoma formation, wound infection, wound dehiscence, and flap/graft necrosis). SETTING: An academic MMS practice. PATIENTS: A total of ,1052 patients (1,358 MMS cases) were prospectively enrolled. Complete follow-up information was available for 1,343 cases (98.9%). RESULTS: Complications associated with MMS were very infrequent, with an overall complication incidence of 1.64% (22/1,343). Most surgical complications involved difficulties with hemostasis. No complications were significant enough to involve the assistance of another specialist or to require the hospitalization of the patient. CONCLUSIONS: Mohs micrographic surgery is a very safe outpatient procedure when performed by appropriately trained physicians. The types of complications seen in our patients were identical to those seen in hospitalized patients described in previous studies. Our complication rates were equal to or lower than the published complication rates from specialists in other surgical disciplines.     

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.     

Prognosis for cutaneous melanoma according to surgical department: comparative study at a tertiary care hospital

IntroductionSurgical treatment of melanoma is performed by dermatologists and general or plastic surgeons. It is not known whether the type of specialist treating the melanoma results in a different prognosis for these patients.Material and methodsA retrospective study was carried out on the epidemiological, clinical/histological and evolutional characteristics of all patients diagnosed with melanoma at Hospital Gregorio Marañón over a 10-year period (1994--2003). The differences by hospital department where the patients were treated (dermatology, general surgery and plastic surgery) were noted.ResultsOver 90 % of the patients with melanoma were treated by the Dermatology Department. The thickness of the tumors and the presence of histologic ulceration were significantly higher in the melanomas treated by general and plastic surgeons (p < 0.05). The differences in overall average survival (105, 55 and 77 months) and disease-free time (88, 24 and 51.3 months) in the melanomas operated on by dermatologists, general surgeons and plastic surgeons, respectively, were significant (p < 0.001).ConclusionsThis study confirms that there are significant differences in the clinical and histological characteristics and the life prognosis of patients with cutaneous melanoma treated by different specialists. The melanomas treated by general or plastic surgeons have usually been developing for a longer time, and therefore are thicker and more often ulcerated than those treated by dermatologists, resulting in a lower survival period. With appropriate medical and surgical training, dermatologists are the most suitable specialists for early diagnosis and treatment.     

Management of naevus sebaceous: a national survey of UK dermatologists and plastic surgeons

Naevus sebaceous (NS) is a congenital cutaneous hamartoma, which typically occurs on the head and neck. Historically, the treatment of choice was excision in infancy because of the potential for malignant transformation; however, recent studies suggest that this risk is < 1% and unlikely in childhood. We sent a questionnaire to UK dermatologists and plastic surgeons to investigate current management practice of NS. We found that almost a third of dermatologists still recommend excision for malignancy prevention, while over 90% of plastic surgeons consider excision, with 64% citing malignancy prevention as the reason. Plastic surgeons most commonly recommended excision in childhood, whereas dermatologists waited until adulthood. We have shown there is significant variation in practice across the UK in the management of naevus NS. It is important that patients across the UK receive the same standard of care, and therefore we advocate the development of evidence‐based guidance for treatment of naevus NS.     

Modulated dual mode erbium/CO2 lasers for the treatment of acne scars

BACKGROUND: Treatment of acne scarring is a challenging problem for dermatologists and cosmetic surgeons. Combining skin resurfacing with other procedures, especially the use of filling agents, has proven to be superior to the use of a single modality. Carbon dioxide laser resurfacing has been popularized for the treatment of acne scarring, but post operative morbidity with stimulation of active acne has been problematic. Conventional erbium resurfacing is effective when sufficient fluences are used, particularly when treating relatively superficial acne scars. Deeper resurfacing for acne scars is difficult with erbium lasers, owing to bleeding and heavy exudation, which decreases ablation efficiency and makes 'end points' difficult to visualize. The newer modulated hybrid erbium/CO2 lasers (Derma K, ESC Sharplan, Yokneam, Israel) produce efficient ablation by the reduction of bleeding, yet at the same time incur little post operative morbidity. This is suitable for treating deeper acne scars, and may be combined with other procedures, e.g. fat grafting. Of particular importance is the lack of acne stimulation associated with the use of the erbium/CO2 hybrid lasers. RESULTS: In my series of 78 patients, improvement in acne scarring was > 70% in the majority of patients. Post operative morbidity and complications were minor compared to conventional CO2 laser resurfacing.     

Preliminary results following treatment of vascular lesions of the skin using a continuous wave tunable dye laser which emits at 577 nm

A continuous wave tunable dye laser which emits orange light at 577 nm was used to treat a wide variety of vascular lesions of the skin. Most superficial vascular lesions responded well, and in particular the effect of treatment on the purple, mature port wine stain was impressive. The pink, easily compressible port wine stain responded less well. The incidence of frank scarring using the tunable dye laser is low and overall is less than 4%. This figure is much less than even the most conservative estimates which use either the neodymium-YAG, carbon dioxide or argon lasers. Pigmentary change following tunable dye laser therapy is also unusual.     

Melanoma

A retrospective review of 182 cutaneous melanomas seen at King's College Hospital from 1970 to 1987 showed that surgeons saw much thicker melanomas (median 3.64 mm) when compared to dermatologists (median 1.14 mm). Surgeons saw a greater proportion of nodular melanomas, less superficial spreading melanomas, were less likely to make the correct clinical diagnosis, and were more likely to perform wide excisions for thin melanomas (less than 2 mm) when compared to dermatologists. General surgeons see a different group of melanoma patients compared to dermatologists and manage them differently from dermatologists working with plastic surgeons. There is a need for a combined approach for the diagnosis and management of cutaneous melanoma between specialists.     

The treatment of multiple angiokeratomata with the argon laser

Two patients with multiple angiokeratomata of the thigh and knee were treated with the argon laser. There was successful ablation of the lesions with no scarring. We believe the argon laser to be worthy of a therapeutic trial in patients with multiple cutaneous angiokeratomata.     

Proceedings of the Facial Aesthetics Conference and Exhibition,Royal College of Physicians,London, 24–25 June 2006

BACKGROUND: Treatment of acne scarring is a challenging problem for dermatologists and cosmetic surgeons. Combining skin resurfacing with other procedures, especially the use of filling agents, has proven to be superior to the use of a single modality. Carbon dioxide laser resurfacing has been popularized for the treatment of acne scarring, but post operative morbidity with stimulation of active acne has been problematic. Conventional erbium resurfacing is effective when sufficient fluences are used, particularly when treating relatively superficial acne scars. Deeper resurfacing for acne scars is difficult with erbium lasers, owing to bleeding and heavy exudation, which decreases ablation efficiency and makes 'end points' difficult to visualize. The newer modulated hybrid erbium/CO 2 lasers (Derma K, ESC Sharplan, Yokneam, Israel) produce efficient ablation by the reduction of bleeding, yet at the same time incur little post operative morbidity. This is suitable for treating deeper acne scars, and may be combined with other procedures, e.g. fat grafting. Of particular importance is the lack of acne stimulation associated with the use of the erbium/CO 2 hybrid lasers. RESULTS: In my series of 78 patients, improvement in acne scarring was >70% in the majority of patients. Post operative morbidity and complications were minor compared to conventional CO 2 laser resurfacing.     

New facial rejuvenation techniques

The popularity of cutaneous laser resurfacing has soared in recent years. For optimal clinical improvement, patients have been limited to the carbon dioxide and erbium:yttrium aluminum garnet lasers. With these systems, tissue can effectively be ablated to induce collagen shrinkage and remodeling that result in an improved clinical appearance. The prolonged recovery periods associated with traditional cutaneous laser resurfacing have sparked an immense interest in devices that rejuvenate the skin while minimizing adverse effects. Both physicians and patients seem willing to accept more gradual improvement if it is associated with fewer complications such as prolonged erythema or delayed-onset hypopigmentation. The following review discusses the newest devices in development or currently available for skin rejuvenation.     

Pulsed dye laser treatment of telangiectases with and without subtherapeutic sclerotherapy. Clinical and histologic examination in the rabbit ear vein model

The treatment of leg telangiectases with the carbon dioxide or argon laser results in a low success rate and an unacceptable risk of scarring. Sclerotherapy is effective; however, pigmentation and telangiectatic matting induced by extravasation of RBCs and excessive posttreatment inflammation are common. We conducted a clinical and histologic study of therapy with the 585 nm pulsed dye laser alone and in combination with subtherapeutic sclerotherapy in the rabbit ear vein model. The pulsed dye laser alone was effective when 10 joule/cm2 was used. In combination with immediate injection of the sclerosant, effective endosclerosis occurred with all tested laser energies (8 to 10 joule/cm2).     

Argon Laser Treatment of Small Keratoacanthomas in Difficult Locations

Seventeen patients (mean age, 64.7 years) with solitary keratoacanthomas (KA) located on the face and auricles were treated with the argon laser. All lesions were less than 10 mm in diameter and had been present for 2-10 weeks (mean, 3.8 weeks). The diagnosis was made clinically and was confirmed by histology. The lesions were treated with the argon laser using the continuous exposure technique with a power setting of 4.5 watts (W) and a beam diameter of 1 mm. Complete re-epithelialization occurred within 14-21 days. Excellent treatment results were achieved in 65% of the patients. Thirty-five percent healed with mild scarring. During a follow-up period of 2 years no recurrences were noted. The use of the argon laser for removal of small KAs in difficult locations, which would often require invasive surgery, appears to be an effective additional treatment modality.     

Full-face laser resurfacing using a supplemented topical anesthesia protocol

BACKGROUND: Laser resurfacing has become a popular modality for the treatment of photodamaged skin, rhytids, and acne scarring. In many cases, this procedure is performed under general anesthesia or intravenous sedation in conjunction with nerve blocks and local infiltration. OBJECTIVE: To evaluate the safety and efficacy of facial carbon dioxide laser resurfacing using a supplemented topical anesthesia protocol. DESIGN: Nonrandomized case series of patients observed for 1 year. SETTING: Outpatient surgery center. PATIENTS: Two hundred consecutive patients undergoing treatment for facial rhytids or acne scarring.Intervention Full-face carbon dioxide laser resurfacing procedures were performed using a supplemented topical anesthesia protocol. Pretreatment medications included diazepam, oral analgesics, and intramuscular ketorolac tromethamine. MAIN OUTCOME MEASURES: Tolerability of procedure, healing times, and adverse effects. RESULTS: Topical anesthesia provided effective and sufficient anesthesia in most cases. Only 10 of 200 patients required additional anesthesia (regional nerve blocks and/or local infiltration). Substantial improvement of rhytids, photodamage, and acne scarring was observed. Posttreatment hypopigmentation was seen in 1 patient. Scarring was not observed.Conclusion A supplemented topical anesthesia protocol for full-face laser resurfacing is a safe and effective alternative to traditional anesthesia strategies.     

The effect of wavelength, power and treatment pattern on the outcome of laser treatment of port-wine stains

The argon laser was used to treat 220 patients with port-wine stains with moderate efficacy and few complications although perfect cosmetic results were rarely achieved. Primary failure of the argon laser to produce permanent blanching graded good or excellent was the most important factor limiting the final cosmetic results whilst severe scarring was rare (less than 2%). In order to improve the efficacy of this treatment, a randomized controlled study of different parameters of laser treatment was undertaken in test patches of port-wine stains in 50 patients. A treatment pattern with contiguous or overlapping laser spots was significantly superior to treatment with spots of 1 or 2 mm separation. Increasing the power level to twice the minimum blanching power did not improve efficacy or significantly increase scarring. A randomized study of selective absorption using a neodymium (Nd) YAG laser showed similar efficacy for the different wavelengths although scarring was greater with the Nd-YAG laser. This study has shown that laser treatment can offer a moderately effective treatment for port-wine stains. For best results spot separation needs to be carefully controlled, whilst wavelength and power level appear to be less important than previously reported.     

Congenital melanocytic nevi. Evaluation and management

This article discusses the care of patients with CMN, who often require a multidisciplinary approach involving pediatricians, family physicians, internists, dermatologists, psychologists, plastic surgeons, neurologists, and radiologists. The cosmetic and psychosocial issues, combined with the knowledge of the increased risk of developing melanoma or NCM, is a huge burden that many of these patients and their families have to carry. This article describes the importance for physicians to help these patients and families come to terms with these issues, as well as remind their patients and their family members that although melanoma, NCM, or other complications can develop, most affected individuals do not develop any complications. The article mentions that there are many healthy, happy, functional adults with large, small, and multiple CMN alive today.     

Flashlamp-pumped pulsed dye laser treatment for pyogenic granuloma.

Pyogenic granuloma is a frequently diagnosed, benign vascular lesion common in children and young adults. Treatment of pyogenic granuloma consists of removal of the lesion for therapeutic as well as diagnostic purposes. Current treatment modalities include curettage with electrodesiccation, cryosurgery, chemical cauterization, and argon laser therapy. However, these methods are not without the risk of complications such as scarring and pigmentary changes. The recently reported success of the flashlamp-pumped pulsed dye laser for treating telangiectasias, hemangiomas, and port-wine stains led us to hypothesize that this same device, using different variables, such as multiple overlapping pulses, would be of benefit in the treatment of pyogenic granuloma. We describe three patients with pyogenic granuloma treated with the pulsed dye laser, with the total number of treatments and energy densities varying according to the size of the initial lesion. All three patients demonstrated complete resolution of lesions with no evidence of scarring, atrophy, or pigment changes. This preliminary report suggests that pulsed laser therapy should be considered in the treatment of pyogenic granuloma, especially in cosmetically sensitive areas.     

Histologic responses of port-wine stains treated by argon, carbon dioxide, and tunable dye lasers. A preliminary report

Although the blue-green argon laser light has been used successfully to treat port-wine stains (PWSs) for many years, it produces substantial epidermal damage. We have previously shown in normal human skin that pulsed yellow tunable dye lasers (577-nm wavelength) can cause highly selective damage to cutaneous microvessels with minimal injury to the overlying epidermis. Pulsed tunable dye lasers also produce selective vascular injury in the abnormal vessels of PWSs, with clinically apparent lightening of the lesions. Both epidermal injury and fibrosis are less severe with this laser treatment than with argon and carbon dioxide laser treatments. Clinical and histologic responses of PWSs treated by argon, CO2, and pulsed yellow dye lasers were compared and followed up for one month in three patients. Although larger and longer-term clinical trials are necessary to fully evaluate this new treatment modality, it appears that pulsed yellow laser radiation offers a more selective, less traumatic, and probably superior form of treatment for PWSs.     

Hexascan: a new robotized scanning laser handpiece

A variety of treatment techniques are used with both argon and tunable dye lasers. Each method has its unique advantages: however, all appear to share common limitations such as poor reproducibility, lack of homogeneous energy delivery, and inability to treat rapidly large cutaneous vascular disorders such as port-wine stains. These problems have recently been addressed with a new scanning device designed to automate or speed treatment and provide improved consistency in cosmetic results. Hexascan is a computerized, automated scanning device that allows for the rapid and easily reproducible treatment of large areas of skin using either the dye or argon laser. The scanning pattern is designed to promote uniform energy fluence and minimize unwanted thermal damage to nontarget tissue. Clinical trials using Hexascan with 577 nm and 585 nm wavelengths have shown good results with cutaneous vascular disorders. Utilizing blue-green argon wavelengths, markedly reduced scarring has been observed compared to traditional argon techniques. Use with 514 nm green only argon light has successfully removed a variety of benign brown pigmented cutaneous lesions.