Brent R. Moody

Electrosurgical modification of orbicularis oculi hypertrophy.

Purpose To assess two electrosurgical approaches for the modification of orbicularis hypertrophy that may be used in conjunction with, or separate from, lower lid blepharoplasty. The hypothesis to be tested is that purely electrosurgical nonexcisional techniques may be used to modify orbicularis oculi muscle. Methods Electrosurgical techniques to treat orbicularis hypertrophy with an “open” and a “closed” technique are described. The open technique is performed in conjunction with transconjunctival blepharoplasty. The closed technique requires a 1-mm to 2-mm dermal incision, 2 minutes of surgical time per eyelid, and a specially insulated and formed electrosurgical needle. A review and case series are presented to illustrate and describe the techniques and results. Results Results for both techniques were rated by both patients and surgeons using the categories of poor, fair, good, or excellent. The open technique was performed in conjunction with transconjunctival blepharoplasty on 23 patients during 2 years with a minimum follow-up of 6 months. Results for the open technique were considered “excellent” by 14 patients and “good” by 9 patients. The operating surgeons evaluated the improvement as “excellent” in 4, “good” in 11, and “fair” in 8 patients. The closed technique was performed on eight patients. Results for patient satisfaction for the closed technique were considered “good” by 4, “excellent” by 2, “fair” by 1, and the final patient abstained from categorization. Operating surgeon evaluation of the closed technique revealed “excellent” outcomes in 3, “good” in 3, and “fair” for 2 patients. Conclusion Electrosurgical techniques may be used to modify orbicularis hypertrophy. Drawbacks include a significant learning curve, potential cutaneous ulceration, and occasional temporary anatomic distortion as manifested by scleral show. Complications are minimal, and the technique was safe in all patients studied.

Properly Selected Skin Cancer Treatments Are Very Effective

The lower amounts of Ki-67 staining when p16INK4A expression is high suggests that downregulation of proliferation is occurring. This decrease is likely a consequence of its increased inhibitory effects on CDK4/6 and the retinoblastoma pathway, resulting in cell cycle arrest (Ortega et al., 2002) and increased senescence (Alcorta et al., 1996). Unexpectedly, we observed that the level of endogenous p16INK4A expression appeared higher in the p16INK4A overexpression model. We speculate that the presence of recombinant p16INK4A protein might indirectly upregulate endogenous p16INK4A protein through various detrimental factors excreted from an increased number of senescent cells. On the basis of these observations, we decided to explore the biological consequences of silencing p16INK4A in the aged donor LSE model. Here, we saw a dramatic improvement in the morphology of the aged donor LSE, which now resembled that of a much younger donor (Figure 2c and d). A striking difference between these LSEs and the atrophic, non–silenced controls was the substantial increase of Ki-67positive cells in the p16INK4A-silenced cultures with a consequent normalization of terminal differentiation, as detected by the restoration of filaggrin, loricrin, and caspase expression. This was repeated in at least three other aged donor models with similar results. In accordance with the conditional knockout model of Baker et al. (2011), in which senescent p16INK4A-expressing cells were selectively eliminated, and as evidenced by this model’s morphology and biomarkers, our results indicate that the atrophic phenotype can be significantly improved in vitro by selectively silencing the expression of p16INK4A. Collectively, these results further substantiate p16INK4A as a major regulator of aging in the epidermis, thus lending strong support for furthering our knowledge on the function and appearance of aged skin. For human cells obtained from donors, the Declaration of Helsinki protocols were followed; donors gave written, informed consent; and the Stony Brook University IRB approved of the study.

Mohs Tissue Mapping and Processing

BACKGROUND Mohs micrographic surgery (MMS) is the most reliable, conservative, and tissue-sparing approach to the management of cutaneous malignancies. The concept of MMS is simple, but its technique, which involves a series of suboperations, is complex. OBJECTIVE To define which techniques of Mohs tissue mapping and processing are presently employed by members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. METHODS Five hundred eighty surveys of eight questions regarding different techniques used in Mohs tissue mapping and processing were mailed out to Mohs micrographic surgeons registered with the American College of Mohs Micrographic Surgery and Cutaneous Oncology. A total of 310 responses (53%) were collected between October and December 2002. The results were tabulated and analyzed. RESULTS Most Mohs micrographic surgeons personally prepare the map of the tissue in relationship to the patient (66.5%). A hand-drawn picture with standard orientations is most frequently used to map and orient a tissue specimen (69.4%). Histotechnicians usually prepare the tissue specimen for cryostat processing (63.5%). A heat extractor and/or tissue cuts or “slits” are the preferred methods used to flatten tissue by 52.9% of respondents. Hematoxylin and eosin is the stain that is most commonly used (82.6%). Approximately 50% of Mohs micrographic surgeons cut the excised specimen from the first stage into two separate pieces. Each tissue piece is then commonly processed into three to six representative serial sections per glass slide (68.1%). These sections are most commonly cut at 5 to 6 μm (53.9%) and less frequently at 4 μm (21.9%). CONCLUSION There is variability in mapping and processing techniques employed Mohs micrographic surgeons and their histotechnicians. As long as the integrity of each step of Mohs tissue mapping and processing is preserved, the high cure rate of the technique should be maintained.

Electrosurgical suspension apparatus.

Background. Dermatologic surgeons commonly employ electrosurgery. Objective. We describe a novel, yet simple, electrosurgical suspension apparatus and variations that facilitate the performance of excision and repair, Mohs micrographic surgery, cosmetic surgery, and other forms of dermatologic surgery. Methods. The described techniques result from more than a decade of use and refinements in electrosurgical suspension apparatuses. Results. The use of an electrosurgical suspension device has eliminated electrosurgical needle stick injuries, facilitated surgery, and reduced the risk of surgical field contamination via the electrosurgical handpiece or wiring. Conclusion. The use of a suspended electrosurgical handpiece results in reduced surgical time, eliminates many of the inconveniences associated with the current use of electrosurgery, and facilitates the use of electrosurgery as a tool of the dermatologic surgeon.

Health Care Overutilization in the United States

In Reply: Dr Sinnott and Mr Joseph have listed additional measures a physician could take to remove his or her Web presence and to anonymize Web surfing habits. Some of these suggestions are straightforward to implement, such as using a post office box and blocking caller ID, but others require advanced knowledge of server configuration and are cumbersome to execute. Although these tools may be useful for some physicians, cultivating an awareness of a person’s Internet presence may be more broadly useful than executing specific countermeasure strategies. In addition to the nearly impossible technical challenges associated with total removal of an individual’s digital information, focusing on such measures may result in a missed opportunity to shape and enhance a physician’s Web identity. Given the vastness and increasing ubiquity of personal data online, it is important to have a strategy for moving forward. We offer these steps as general guidelines for clinicians: 1. Know your Web presence. Every physician should search for data about herself or himself to have an idea of what patients may find. 2. Remove slanderous information. Be aggressive in removing slanderous information posted about you or about someone who might be confused for you. 3. Isolate personal data. Use the privacy settings on social network sites such as Facebook. 4. Build your professional Web identity. By creating a Web page or blog, a physician has the ability to put forth the kind of professional identity that he or she would want a patient to see. By making available on the Web appropriate contact information, practice information, curriculum vitae, licensing and board certification information, and academic interests, a physician can use the Internet in a constructive manner and embrace it as a tool to enhance digital identity.

Flap minimization via peripheral recruitment.

Purpose To describe tissue-conserving modifications to traditional flap design such as the use of beveled incisions and the pattern of the incisions. These techniques should maintain flap viability and enhance cosmesis. Methods We describe the techniques of peripheral flap recruitment. Results Flaps conformed to reduced geometry, beveled incisions and bases, and tapered ends maximize vascularity. Peripheral tissues are recruited to fill primary defects; smaller flaps thus can be used to fill larger defects. Additionally, this flap design enhances cosmetic results and maintains a high probability for flap survival. Conclusion The described novel flap design has many potential advantages over traditional designs. Correctly applied, these flap techniques spare tissue, decrease scarification, trauma and bleeding, and reduce the need for secondary procedures. Potential drawbacks of this flap design include temporary anatomic distortion especially over rounded structures such as the nose. Complications are minimal.

Anesthesia for In-Office Oculoplastic Surgery: How We Do It

The effective use of local anesthesia combined with minimal oral sedation can obviate the need for intravenous sedation or general anesthesia in many common oculoplastic procedures. We routinely perform upper and lower blepharoplasty, fat pad repositioning, ptosis correction, tumor removal and reconstruction, and entropion and ectropion repair without the use of intravenous or general anesthesia.

Evaluation of Skin Lesions in the Cosmetic Patient Made Simple: Actinic Keratosis

Actinic keratoses (AKs) are the earliest form of malignant transformation in the skin. The primary initiator of this malignant transformation is exposure to ultraviolet radiation, which explains their clinical predilection for the head and neck, dorsal hands, and extremities. Many times, patients with AKs will present chiefly with what they perceive to be a cosmetic complaint, such a dry or rough skin. In the context of an aesthetic practice, recognition of AKs has important medical implications for the patient. Left untreated, AKs can progress into invasive squamous cell carcinoma.

Dual Use of Monofilament Poliglecaprone in Layered Closure: Buried and Cuticular

The perfect suture would be easy to handle, tie reliably, and be applicable to a wide variety of applications. Although not perfect, monofilament poliglecaprone suture was found to result in excellent scars with use in combined buried and cuticular fashion.

Evaluation Documentation in Cosmetic Oculoplastic Surgery

Cosmetic surgeons frequently spend considerable time dictating and formulating a surgical plan. Unfortunately, time constraints can limit the amount of information transferred to the actual medical record. This can have medical and medicolegal implications. Accurate documentation may also aid in cases of medical insurability. This article helps facilitate transcription or notation in ophthalmic plastic surgery in a complete, concise, and useful manner. The individual elements of the evaluation document are explained and its use with respect to each item.