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.     

Transposition island pedicle flaps in the reconstruction of nasal and perinasal defects

Nasal and perinasal defects provide the dermatologic surgeon a challenge. It is necessary that the dermatologic surgeon assess each defect and patient individually for optimal repair. Many reconstructive options exist. This report demonstrates the technique of the transposition island pedicle flap which may be useful for reconstruction of post-Mohs surgery defects on or near the nose.     

Safe and effective conscious sedation administered by dermatologic surgeons

OBJECTIVE: To review the experience with conscious sedation administered by dermatologic surgeons at an academic medical center. DESIGN: Retrospective medical chart review. SETTING: Outpatient dermatologic surgery unit at an academic medical center. PATIENTS: Fifty episodes of conscious sedation in 37 patients undergoing dermatologic surgical procedures. INTERVENTION: Intravenous and inhaled conscious sedation was administered with strict monitoring during procedures. MAIN OUTCOME MEASURES: Efficacy was subjectively recorded by the administering physician and complications were recorded. RESULTS: Administration of conscious sedation by dermatologic surgeons was associated with good to excellent sedation with minimal complications. Extensive preparation and training were necessary, and strict guidelines devised by a conscious sedation task force were followed. Emergency preparedness was high, although it was not used. CONCLUSIONS: Conscious sedation can be safely and effectively administered by dermatologic surgeons in a hospital-based outpatient surgical unit after extensive training. Emergency preparedness is essential, and conservative guidelines should be followed.     

Body Dysmorphic Disorder

Patients with body dysmorphic disorder (BDD) often present to dermatologists and cosmetic surgeons. BDD is a relatively common yet underrecognized disorder that consists of a distressing or impairing preoccupation with an imagined or slight defect in appearance. Although any body area can be the focus of concern, preoccupation with the appearance of the skin, hair, and nose are most common. Typical associated behaviors include skin picking, mirror checking, and camouflaging (e.g., with a hat or makeup). Reassurance seeking is another common behavior that may be enacted with surgeons and dermatologists. BDD is associated with marked impairment in functioning, notably poor quality of life, and a high suicide attempt rate. The disorder appears relatively common in dermatologic and cosmetic surgery settings; in fact, dermatologists may be the type of practitioner most often consulted by patients with BDD. Psychoeducation is an important element in the treatment of BDD. For patients who compulsively pick at their skin, it is generally ineffective to simply advise them to stop picking. Educating them that the picking is a symptom of BDD, and is treatable, can be helpful. For skin pickers, a combination of psychiatric and dermatologic treatment may be best. It is probably best to avoid cosmetic procedures. Although definitive data on the treatment outcome of surgery and dermatologic treatment for BDD are lacking, and although no one can predict how a given patient will respond to such treatment, available data suggest that these treatments are unlikely to be successful and may even make the patient’s condition worse. Rather than referring the patient to another dermatologist or cosmetic surgeon, we recommend attempting to refer the patient to a psychiatrist for cognitive-behavioral therapy or pharmacotherapy. Available data indicate that serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are often effective for BDD. In recent years, BDD has gone from being a neglected psychiatric disorder to one that is becoming better recognized and understood. Nonetheless, research on this disorder is still in its early stages, and much more investigation of BDD is needed, especially in surgical and dermatologic settings. Treatment recommendations will be modified in the future as more research is done. In the meantime, it is important that dermatologists and surgeons screen patients for BDD and accurately diagnose this condition, as available psychiatric treatments are very promising for patients with this distressing and sometimes disabling disorder.     

Cancer of the forehead and temple regions

Several characteristics inherent in tumors of the forehead and temple provide therapeutic challenges for the physician. These include spread along anatomic structures, a propensity toward aggressive growth patterns, the risk of nerve damage, and the preservation of important cosmetic landmarks. As a result of these problems, Mohs micrographic surgery is often indicated in the treatment of skin cancer of the forehead and temple. The high cure rates afforded by micrographic surgery, even for aggressive tumors, and tissue conservation are benefits to the patient. Although most BCCs and SCCs in this region can be handled by a dermatologic surgeon, patients may present with aggressive or neglected tumors exhibiting extensive invasion. These patients may require a cooperative approach between the dermatologic and head and neck surgeon to achieve complete tumor extirpation or appropriate reconstruction. In this article, we have tried to indicate the rationale behind the use of Mohs micrographic surgery for tumors of the forehead and temple. In selected tumors, a team approach between the micrographic and other surgeons will maximize both tumor excision and functional and cosmetic repair for the patient.     

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.     

Horizontal advancement flap for lateral dorsal nasal defects

BACKGROUND: Repairing dorsal nasal defects is a frequent challenge for dermatologic surgeons, mainly due to the high frequency of basal cell carcinomas on this site. Obvious scars, mismatched skin and distortion of the nasal contour are the surgical hazards that must be avoided in these cases. AIM: Our aim was to perform surgery involving a simple flap in order to repair medium to large defects on the dorsal side of the nose. METHODS: The dorsal horizontal advancement flap was studied in 12 patients, in order to evaluate the benefits and limits of this surgical procedure. RESULTS: The resulting scars on most of our patients were well-camouflaged among their natural skin lines, and there was neither distortion of the alar contour nor the nostril. CONCLUSIONS: This flap is easy to perform and, in selected cases, provides an outstanding alternative to second-intention healing, full-thickness skin grafts, transposition, rotation and pedicle flaps.     

Ethical dilemmas in dermatologic surgery

Dermatologic surgery presents a unique set of ethical dilemmas not frequently discussed within the medical literature. This contribution presents a few cases commonly encountered by dermatologic surgeons. The case-based discussion follows a principles-based framework for analysis and seeks to identify the central moral conflict and exemplify the development of sound reasoning for subsequent decision making through the consideration of multiple viewpoints and the weighing of potential consequences. Additional cases are provided in concise format to encourage further analysis and discourse on the distinct ethical dilemmas encountered within dermatologic surgery.     

Pioneers of Spanish dermatologic surgery

Even before dermatology was born as a specialty at the beginning of the 19th century, most skin lesions and dermatoses tended to be treated by surgeons rather than physicians. After medicine and surgery were unified into a single discipline and dermatology emerged as a modern specialty, this relationship became blurred and Spanish dermatologists leaned more towards medicine than surgery. Then improvements in surgical techniques, knowledge of antiseptic and aseptic procedures, the development and introduction of anesthesia, and the greater interest in micrographic approaches led to the rediscovery and almost complete rebirth of this old surgical tradition in the second half of the 19th century. In Spain, dermatologic surgery as such did not really exist until the first third of the 20th century, when Enrique Alvarez Sainz de Aja and Vicente Gimeno emerged as the main exponents of this discipline. Of these 2, Alvarez Sainz de Aja drawing on his previous experience as a general surgeon and obstetrician was the better practitioner of the incipient dermatologic surgery. The other, Gimeno, wrote an interesting booklet on dermatologic surgery that was published in 1923 and that formed the basis of his inaugural speech to the Spanish Royal National Academy of Medicine.     

Cera para huesos en la cirugía dermatológica

Bone wax is an inert, malleable material used as a hemostatic agent in treating surgical defects. Healing by secondary intention is an appropriate approach for certain situations in dermatologic surgery. When surgical wounds are deep enough for such tissues as bone or cartilage to be exposed, dressings may adhere to granulation tissue, making removal and subsequent wound care difficult and painful. In such cases bone wax can be molded around deep tissues to create an ideal occlusive, hemostatic microenvironment that facilitates second-intention wound healing.     

Introduction to photodynamic therapy: early experience

Photodynamic therapy (PDT) has become one of the newest and most exciting therapies being used by dermatologic surgeons from all around the world. The earliest uses of PDT can be traced to the early 1900s. This article traces the history of PDT through the discovery of the first topical photosensitizer by Kennedy and his colleagues in 1990 to its uses today in everyday dermatology practices. The two commercially available photosensitizers are reviewed and their primary uses are summarized. PDT is a useful modality that is finding new and exciting niches in today's dermatologic world.     

An approach to patient assessment and preparation in cutaneous oncology

An outline of the many phases of preoperative evaluation of the dermatologic surgery patient is presented. Special emphasis is given to patient assessment and to patient preparation. The purpose of this review is not to create a compendium of steps that one must slavishly perform before each surgical procedure. Instead, it represents an effort to emphasize the importance of adequate preoperative evaluation and to discuss some of the subtleties that may be overlooked by the dermatologic surgeon.     

Perioperative antibiotic prophylaxis in skin surgery – Position paper of the Antibiotic Stewardship working group of the German Society for Dermatologic Surgery (DGDC), Part 1: Procedure- and patient-related risk factors

The aim of perioperative antibiotic prophylaxis (PAP) is to prevent the occurrence of surgical site infections (SSIs) or other infectious complications (especially bacterial endocarditis or septic arthritis). PAP is effective in surgeries where overall infection rates are high even without considering patient-related risk factors (such as orthopedic surgery or fracture repair). Surgery on airways, gastrointestinal, genital, or urinary tract is also considered to be associated with a risk of infection and may require PAP. Overall, SSIs in skin surgery are relatively rare and vary between 1% and 11% depending on the localization, complexity of the wound closure and patient cohort. Therefore, the general surgical recommendations regarding PAP only partially reflect the needs of dermatologic surgery. In contrast to the USA, where recommendations on the use of PAP in skin surgery already exist, there are currently no guidelines for the use of PAP specifically designed for dermatologic surgery in Germany. In the absence of an evidence-based recommendation, the use of PAP is guided by the experience of the surgeons and leads to a heterogeneous use of antimicrobial substances. In this work, we summarize the current scientific literature on the use of PAP and make a recommendation depending on procedure- and patient-related risk factors.     

Bedeutung und Prävention postoperativer Wundkomplikationen

Although surgical site infections (SSI) in dermatologic operative procedures are extremely rare, it is important to understand risks and etiological factors to initiate risk assessment and specific preventive measures. SSI commonly are associated with a complicated, long-term and expensive outcome. Typical wound pathogens of these infections include a variety of multiresistant organisms along with Staphylococcus aureus, Staphylococcus epidermidis, hemolytic streptococci and the gram-negative bacilli Escherichia coli and Pseudomonas aeruginosa. Effective hygienic measures as part of an adequate quality management system should consider the critical points in the development of SSI, particularly in the setting of an outpatient dermatologic unit, such as preparation of the operative area, preoperative skin antisepsis, hand hygiene, safe and skilled technique by surgeons, and barrier nursing to prevent spread of pathogens. The baseline infection incidence in dermatologic surgery inherently is low; nevertheless significant improvements can be achieved by implementation of risk-adapted infection control measures.     

Repair of nasal tip and alar defects using cheek-based 2-stage flaps: an alternative to the median forehead flap

OBJECTIVE: To describe our use of cheek-based 2-stage transposition flaps for repairing Mohs surgery defects of the lower third of the nose. DESIGN: Retrospective case series. SETTING: Private dermatologic day surgery facility.Patients Twenty-eight patients with defects of the lower third of the nose after Mohs surgery.Intervention Ten alar and 18 nasal tip defects repaired using cheek-based 2-stage transposition flaps. MAIN OUTCOME MEASURES: Acceptability of procedure to patient, complications, and appearance from photographic records. RESULTS: The procedures were well tolerated and achieved good cosmetic results without major complications. CONCLUSIONS: These flaps allow repair of extensive defects of the nasal tip and ala with the patient under local anesthesia. This approach provides an alternative to the median forehead flap for nasal tip repairs.     

Surgical techniques for scar revision

Patients frequently seek cosmetic improvement for existing scars. While no scar can be completely erased, dermatologic surgeons can employ a variety of approaches to achieve more esthetically pleasing scars. Classification of a scar abnormality guides the choice of treatment technique. Lasers and injectables are useful tools; however, for certain scar abnormalities, scalpel-based surgery remains the mainstay. This review focuses on common incisional surgical methods for scar revision.     

Reconstrucción de un defecto en mejilla tras la exéresis de un carcinoma basocelular extenso mediante la combinación de un colgajo romboidal y un injerto de Burow

Reconstruction of large surgical defects on the cheek can be challenging for dermatologic surgeons. We describe using a modified rhomboid flap and Burow's advancement flap to close a surgical defect resulting from the excision of a basal cell carcinoma measuring 10 × 10 cm in the buccomandibular area of the cheek.     

The history of dermatologic liposuction

Dermatologists have been involved in liposuction even before its introduction into the United States. Liposuction has rapidly become part of the dermatologic surgeon's armamentarium. Dermatologic surgeons have been innovators in teaching and research in liposuction. They have been largely responsible for developments in fat transfer surgery.     

Operative Therapie in Problemlokalisationen

The term "problem site" is based on a constellation of factors including the disease itself, the anatomic site, the resulting excision defect and choice of the most appropriate wound closure technique. Typical problem sites are the nose, eyelids, hands (fingers and nails) and the anogenital region, each of which is a functional-aesthetic entity. As dermatologic surgeons become even more experienced in plastic and reconstructive surgery, the term"problem sites" will be used less often.     

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.