O to Z flaps in facial reconstructions

Local flaps are the standard procedure to reconstruct facial defects. As it occurs in any surgical procedure, the incision should be planned so that scars are located in the minimum skin tension lines. We report two cases of O to Z flaps in the supra and infraciliary regions. One of them is a hatchet flap.     

Quantitative assessment of epidermal Langerhans cells using automated image analysis

Background/aims: Langerhans cells play a central role In the skin immune system. Quantitative changes have been observed in a variety of dermatological conditions. This paper presents a user-independent automated measurement procedure for Langerhans cells in vertical skin sections. Methods: Frozen sections were stained immunohistochemically with a CD1 monoclonal antibody. Counterstaining was performed with Mayer's hematoxylin. An image analysis procedure was developed, which automatically recognizes the area occupied by the epidermis and the CD1 -positive structures, respectively. Results: The procedure was tested on specimens of normal skin and of chronic cutaneous lupus erythematosus. The results significantly reflect the decrease of Langerhans cells in the latter condition. Conclusion: The proposed image analysis program facilitates a fully automated measurement of immunohistochemically stained epidermal structures in vertical skin sections.     

Confronting the artefact patient with manipulative behavior

Patients with self-inflicted skin disorders form a rather heterogeneous group. Our paper is intended to provide the practitioner with some orientation concerning interaction and therapeutic procedure in patients with artefactual skin diseases. Basically, these patients should be differentiated according to what extent they are aware of their manipulations. This degree of awareness should then be the guideline for a well-dosed and sensitive confrontation with their manipulative behavior. In any case, a positive result of the confrontation largely depends on the confidential relationship between physician and patient.     

Ptosis of submental skin

BACKGROUND/PURPOSE: Sagging of the face skin is a visible and unattractive characteristic of skin ageing. This phenomenon, due to both gravitational force and age-related alterations in the mechanical properties of skin, has never been quantitatively studied. The aim of this paper was, first, to define a method and a precise procedure allowing the objective measurement of this phenomenon and, second,to study how it is related to age. METHODS: We used an electronically controlled bed that allows the comparison of submental skin profiles in both the reclined and the upright positions. A parameter that characterises the sagging amplitude for an individual was defined and the reproducibility of measurement of this parameter was verified. RESULTS: Results, obtained from 66 female volunteers, demonstrated a statistically significant positive correlation between this new parameter and age, and also between this new parameter and the elastic recovery parameter of skin, as measured by torquemeter. CONCLUSION: Age-related changes of the skin's mechanical properties and of the various underlying skin tissues would explain this phenomenon. This new method and procedure should allow objective evaluation of the efficacy of any treatments (cosmetic, medical or surgical) proposed for rendering the appearance of people younger.     

Special considerations for Mohs micrographic surgery on the eyelids, lips, genitalia, and nail unit

Although skin cancers on the eyelids, lips, genitalia, and the nail unit are infrequent, some skin cancers can have higher recurrence rates in these anatomic locations. Intrinsic to Mohs micrographic surgery (MMS) is maximal tissue preservation and high cure rates, making it a worthwhile procedure for these sensitive anatomic areas to ameliorate any functional or aesthetic compromise. The Mohs surgeon can provide a great service to patients by being aware of the anatomy, specialized instruments, unique histology, and potential complications when performing MMS on these areas.     

Evidence of the efficacy of alcohol lavage in the phenolization treatment of ingrown toenails

Background For treatment of ingrown toenails, a phenolization is often chosen. Many reports describe an intra‐operative irrigation or lavage of the wound with various types of alcohol to neutralize any residual phenol from this treatment. There are conflicting reports in the literature as to whether a true neutralization is required or merely effective removal of excess phenol. Objective The aim of our study was to analyse the suitability and effectiveness of the alcohol lavage step during the treatment of ingrown toenails with a phenolization procedure. Methods We performed an in vitro study using human skin and a diffusion cell apparatus to measure the amount of phenol remaining after various lavage washes. The effect of phenol evaporation was also examined. Results There was no measurable amount of phenol collected after each experiment, suggesting that diffusion of phenol through the skin does not exist. The open compartment test had significantly less phenol recovered compared with the occluded compartment test, indicating phenol evaporation. Study limitations None. Conclusions An alcohol lavage step after the phenolization procedure can be a suitable and effective means of diluting and removing any excess or residual phenol from the exposed area.     

Side effects and complications of laser therapy

Laser skin surgery is not without risk and some degree of downtime in most situations. Patient satisfaction is key to the perceived success of the procedure. Therefore, the physician must fully explain all risks, potential complications, and expected morbidity associated with any laser treatment to be performed. Although many side effects can be avoided by use of appropriate intraoperative technique and adequate postoperative management, untoward effects may still occur and must be promptly identified and addressed. An informed patient is an important factor in the healing process and contributes to the success of the procedure.     

Mucinosis follicularis provoked by light exposure.

The present paper reports a study on a case of follicular mucinosis exacerbated by sunlight exposure. Provocation with standardized light testing was carried out on both normally pigmented skin and on areas of hypopigmentation representing a residual state after earlier skin lesions but without any signs of active mucinosis follicularis. Typical clinical and histologically verified lesions were provoked by the light test procedure, best seen in hypopigmented areas but with similar changes in normally pigmented skin. Characteristic findings developed gradually, assuming an appearance identical with that of the observed spontaneously elicited lesions after 3--4 weeks. Treatment with carotenoids periodically over several years has provided a proper light protective effect, as only minimal lesions have been noted during these periods, compared with extensive changes during similar periods without treatment.     

Use of Raman spectroscopy for the early detection of filaggrin‐related atopic dermatitis

Background: Filaggrin (FLG) gene mutations, which result in complete or incomplete loss of proFLG/FLG peptides, have been reported as an important predisposing factor for atopic dermatitis (AD) and secondary atopic phenotypes such as atopic asthma. Method: The presence of the protein FLG in the skin was evaluated at birth on 12 infants using Raman spectroscopy; these 12 infants were monitored for 1 year to see whether they developed AD. Three different statistical analysis procedures, two of which involved principal component analysis (PCA), were performed on the Raman spectra in order to determine the FLG content. Results: The infants who had a lower FLG content, determined using any of the three statistical analysis procedures proposed, were also the ones that clinically developed AD. Conclusion: The results suggest that Raman spectroscopy and statistical analysis such as PCA could be used as an early detection procedure for FLG ‐related AD and as a possible quantitative marker for FLG gene mutations.     

Patient satisfaction after removal of skin lesions

BACKGROUND: Removal of skin lesions is one of the most common surgical procedures, with the number increasing progressively since the 1980s. OBJECTIVE: We tried to evaluate the satisfaction level of patients after removal of skin lesions and to identify the factors influencing it. STUDY DESIGN: The study group consisted of 138 patients who had skin lesions removed by shaving or primary excision and closure. They were evaluated 1 year after the procedure. Two questionnaires were completed independently by the patient and the surgeon. RESULTS: The main indication for the procedure was suspicion of malignancy, functional disturbance, or aesthetic reason. The satisfaction level (general and specific areas) for patients who had a malignant tumour removed was similar to those who had a benign tumour removed. Females were less satisfied than males (P = 0.05). Younger people were less satisfied with the aesthetic results (P = 0.007). Patients who had at least one significant side-effect were less satisfied than those who did not mention any side-effects (P = 0.038). The higher the level of patient satisfaction, the higher the level of surgeon satisfaction (P = 0.012). CONCLUSION: Skin lesion removal, although considered to be a minor procedure, leaves scars that sometimes disturb the patient. According to our study, the most prevalent population for dissatisfaction is females and young males.     

Determination of the in vivo bioavailability of iontophoretically delivered diclofenac using a methyl nicotinate skin inflammation assay

BACKGROUND/AIMS: In this study, we investigated the bioavailability of iontophoretically delivered diclofenac with the methylnicotinate (MN) test. The inhibition of an erythema provoked by MN is proportional to the bioavailability of diclofenac in the skin. It was our aim to use this procedure in the determination of the contribution of, respectively, passive diffusion, occlusion and electrically assisted delivery during an iontophoretic procedure as used in physiotherapy. METHOD: A total of six application sites were marked on the volar forearms of each volunteer (n=12), for the following treatment and/or control modes: A=cathodal iontophoresis of 12 mg/cm(2) Voltaren Emulgel (diethylammonii diclofenac 1%) for 20 min; B=passive diffusion under a contact sponge; C=passive diffusion without any covering; D=current alone; E=standard MN response; and F=blanco site. Tristimulus surface colorimetry and Laser Doppler flowmetry were used to measure, respectively, the skin color and the perfusion of the microcirculation. Bioavailability was assessed by quantification of an MN-induced erythema under the different conditions. RESULTS: A significant reduction of the MN-induced erythema was observed with the Chromameter and Laser Doppler measurements for the following treatment modalities: (1) electrically assisted delivery: respectively, 65% and 100%, (2) application under a contact sponge: 66% and 97% and (3) passive diffusion without any covering: 32% and 65%. A significant reduction was equally observed for the site treated with the current alone: 19% and 42%. There was no significant difference between the response after iontophoretic-delivered diclofenac (mode A) and application of diclofenac under a contact sponge (mode B). CONCLUSION: The procedure used enabled us to evaluate the bioavailability of a non-steroidal anti-inflammatory drug in the skin. Under the conditions used, we did not find an increased bioavailability after electrically assisted delivery of diclofenac compared with the passive percutaneous penetration under the contact sponge.     

Assessment of aging and actinic damages by cyanoacrylate skin surface strippings

Cyanoacrylate skin surface stripping is a simple noninvasive approach that is useful in the evaluation of a number of changes affecting the skin during aging and chronic sun exposure. The procedure has proved to be especially valuable in the diagnosis of some inflammatory, xerotic, neoplastic, and dermal atrophic changes. It can also be used to monitor therapy. The technique of computerized image analysis is also conveniently applied to such material.     

What is nonablative photorejuvenation of human skin?

Nonablative photorejuvenation has become an integral procedure in the emerging discipline of laser dermatologic surgery. The objective is to confine selectively, without any epidermal damage, thermal injury to the papillary, and upper reticular dermis leading to fibroblast activation and synthesis of new collagen and extracellular matrix material. The procedure results in minimal patient morbidity, no interference with lifestyle, and a low risk of complications, while providing a satisfying degree of rhytides reduction. Multiple devices have been studied and marketed for nonablative photorejuvenation of human skin. However, currently, nonablative photorejuvenation should not be considered an alternative to laser skin resurfacing. The skin surface is not removed or modified. What really occurs may be more accurately referred to as dermal "remodeling" or "toning" as a wound healing response is initiated and collagen regenerated. The narrow "therapeutic window" of laser-induced dermal heating and epidermal cooling must still be optimized so that effective treatments can be obtained routinely. Clinical verification of effective treatment parameters (irradiation wavelength, pulse structure, radiant exposure, cooling time) will be obtained through further human studies. Most importantly, understanding the relationship between the degree of dermal thermal injury and synthesis of new collagen and extracellular matrix material will be fundamental to predicting the clinical efficacy and limitations of nonablative photorejuvenation.     

Study of carcinoembryonic antigen (CEA) in the epidermis of psoriasis vulgaris

By immunohistochemical methods, we detected CEA in the epidermis of psoriatic skin in 10 out of 20 cases with the plaque type of psoriasis vulgaris. The CEA detected in the psoriatic skin was limited in area to the intra-squamous cell cytoplasm, cell membranes, and intercellular space just beneath the markedly parakeratotic layer. It was not found in the orthokeratotic layer. At the same time, serum CEA value was measured in 7 cases. No increased CEA value was found in any case with or without positive CEA in the epidermis. The origin of CEA in the psoriatic skin might be: 1) squamous cell just below the rapidly proliferating parakeratotic cells. 2) CEA contained in eccrine sweat and deposited by dishidotic procedure. It can not involve permeation of CEA in serum into the epidermis. Of the 1) and 2) theories we prefer the first, but further study is needed. This is the first report of the existence of CEA in the psoriatic epidermis.     

Laser peel: facial rejuvenation with a superficial erbium:YAG laser treatment

BACKGROUND : Facial rejuvenation is a popular procedure to temporarily mask the effects of aging. Most patients desiring this treatment are younger and want improvement without any down time. This study was conducted to evaluate the use of Er:YAG laser as a facial rejuvenation tool. METHODS : The full faces of 18 volunteers were treated with an Er:YAG laser using a fluence of either 5 or 10 J/cm 2 . All volunteers applied EMLA ® cream (lidocaine 2.5% and prilocaine 2.5%) two hours before the procedure and were treated with a single pass using a pulse duration of about 300µs. Follow-up visits were made in order to evaluate the degree of discomfort, erythema, swelling and improvement in skin aging. Skin biopsy was performed in one volunteer before and two hours after EMLA ® application, although preceding laser treatment. RESULTS : Most volunteers experienced moderate discomfort during the treatment. There was mild to moderate erythema and mild swelling. The improvement in general skin appearance, actinic bronzing and photo-damage was mild to moderate. The microscopic evaluation of pre-laser treated skin two hours after EMLA ® application was suggestive of increased water content in the dermis. CONCLUSION : The Er:YAG laser is an effective and safe tool for facial rejuvenation. With a superficial treatment, resolution of intense erythema is fairly rapid, averaging two to three days. The improvement, however, is mild compared to full laser skin resurfacing (LSR).     

Tissue counter analysis of tissue components in skin biopsies: evaluation using CART (Classification and Regression Trees)

In tissue counter analysis, complex histologic sections are overlaid with regularly distributed measuring masks of equal size and shape, and the digital contents of each mask (or tissue element) are evaluated by gray level, color, and texture parameters. In this study, the feasibility of tissue counter analysis and classification and regression trees for the quantitative evaluation of skin biopsies was assessed. From 100 randomly selected skin biopsies, a learning set of tissue elements was created, differentiating between cellular elements, collagenous elements of the reticular dermis, fatty elements and other tissue components. Classification and regression trees based on the learning set were used to automatically classify tissue elements in samples of normal skin, benign common nevi, malignant melanoma, molluscum contagiosum, seborrheic keratosis, epidermoid cysts, basal cell carcinoma, and scleroderma. The procedure yielded reproducible assessments of the relative amounts of tissue components in various diagnostic groups. Furthermore, a reliable diagnostic separation of molluscum contagiosum versus normal skin and epidermal cysts, benign common nevi versus malignant melanoma, and seborrheic keratosis versus basal cell carcinoma was possible. Tissue counter analysis combined with classification and regression trees may be a suitable approach to the fully automated analysis of histologic sections of skin biopsies.     

Antenatal diagnosis of genodermatoses

The technics of fetoscopy and fetal skin biopsy have expanded our capabilities for antenatal diagnosis of certain hereditary skin disorders (genodermatoses). The fetus and placenta can be visualized directly and skin biopsy specimens can be obtained for light and electron microscopic studies, tissue culture, and biochemical analysis. These technics have been utilized successfully in the prenatal diagnosis or exclusion of epidermolysis bullosa, epidermolytic hyperkeratosis, and harlequin ichthyosis in fetuses known to be at risk for these disorders, and they offer tremendous potential for prenatal diagnosis in a variety of other genodermatoses. Studies of tissue obtained by this procedure will undoubtedly expand our knowledge of the morphogenesis and biochemistry of fetal skin and will provide needed baseline data for the further development of these technics.     

Steroid hormone receptors in normal skin

Hormonal influences modulate various skin functions. Despite of skin manifestations indicative of increased androgenic influence, many cases show normal hormone serum levels. The target organ sensitivity of skin may be figured out by hormone receptor analysis. Our study presents data from 60 volunteer patients regarding estrogen (ER), androgen (AR), and gestagen (PgR) receptor analysis in normal skin. The highest percentages of AR and ER were found in the face of male and female patients followed by the lower extremities. Equal AR levels in both sexes indicate equal androgenic stimulability at the cellular level in both sexes. ER levels were higher in female than in male patients. PgR was negative in 14 cases. Nor could we prove any receptors in the youngest group of patients. Our results correspond with the clinical observation of different hormonal stimulability in various skin regions.