C. William Hanke

Safety of tumescent liposuction in 15,336 patients. National survey results.

BACKGROUND Tumescent liposuction is a new method of liposuction under local anesthesia that has been developed by dermatologic surgeons. OBJECTIVE To determine the safety of tumescent liposuction in a large group of patients treated by dermatologic surgeons. METHODS A survey questionnaire was sent to 1,778 Fellows of the American Society for Dermatologic Surgery in February 1994. The comprehensive questionnaire requested information on numbers of patients treated with tumescent liposuction and complications that occurred. RESULTS Sixty‐six dermatologic surgeons provided data on 15,336 patients. The complications that were reported were infrequent and minor. There were no serious complications such as death, embolism (pulmonary or fat), hypovolemic shock, perforation of peritoneum or thorax, or thrombophlebitis. Blood transfusions were not required in any of the 15,336 patients and there were no admissions to the hospital for treatment of complications. CONCLUSIONS Tumescent liposuction is an exceptionally safe method of liposuction under local anesthesia that eliminates the necessity of general anesthesia and blood transfusions. Tumescent liposuction is safer than liposuction under general anesthesia and results in fewer complications.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: A report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Abscess formation and local necrosis after treatment with Zyderm or Zyplast Collagen Implant

The incidence, clinical presentation, pathophysiology, and possible treatment of two rare but clinically meaningful complications of tissue augmentation with Zyderm and Zyplast Collagen Implant are described. Abscesses as a manifestation of hypersensitivity to bovine collagen occur rarely (4 in 10,000 cases) and may persist for days to weeks. Periods of remission and exacerbation may occur from 1 month to more than 24 months. Localized tissue necrosis also occurs rarely (9 in 10,000 cases) after implantation and is probably the result of local vascular interruption and not hypersensitivity. The incidence varies greatly between the anatomic sites of implantation; more than half the reported cases involve the glabella. Evidence strongly suggests that the increased vulnerability of the glabellar region is due to its unique vascular distribution.

Review of fractional photothermolysis: treatment indications and efficacy.

BACKGROUND Fractional photothermolysis (FP) is one of the most significant milestones in laser technology and resurfacing. METHODS Review of the Medline English literature and recent international conferences regarding FP technology, applications, and indications. RESULTS Successful conditions treated with nonablative FP reported in the literature include acne scarring; dyschromia and fine wrinkling of photoaging on the face, chest, neck, and hands; melasma; poikiloderma of Civatte; nevus of Ota; scars; minocycline hyperpigmentation; telangiectatic matting; residual hemangioma; granuloma annulare; colloid milium; and disseminated superficial actinic porokeratosis. An advance in 2007 was the introduction of ablative FP (AFP), which results in significantly greater improvement in skin laxity and textural abnormalities. Most recently, AFP has demonstrated significantly greater improvement than nonablative FP in reducing acne scarring and skin redundancy and laxity associated with photoaging. CONCLUSIONS Through the induction of microthermal zones of injury, FP technology stimulates a robust and rapid wound healing response resulting in improvement in a diversity of aesthetic, inflammatory, and preneoplastic skin disorders. Further investigation into the technology and diverse array of cutaneous conditions that can benefit from FP is highly needed.

Dermal implants: Safety of products injected for soft tissue augmentation

Soft tissue augmentation is a frequently performed outpatient operation. Products available for soft tissue augmentation vary in chemistry, clinical indications, and toxicity. This review examines safety and efficacy data for collagen implants (Zyderm and Zyplast), gelatin matrix implants (Fibrel), and injectable silicone. Soft tissue augmentation requires excellent technique to achieve excellent clinical efficacy. When used appropriately, the available products for soft tissue augmentation have few complications or adverse reactions.

Laser hair removal.

The extended theory of selective photothermolysis enables the laser surgeon to target and destroy hair follicles, thereby leading to hair removal. Today, laser hair removal (LHR) is the most commonly requested cosmetic procedure in the world and is routinely performed by dermatologists, other physicians, and non‐physician personnel with variable efficacy. The ideal candidate for LHR is fair skinned with dark terminal hair; however, LHR can today be successfully performed in all skin types. Knowledge of hair follicle anatomy and physiology, proper patient selection and preoperative preparation, principles of laser safety, familiarity with the various laser/light devices, and a thorough understanding of laser–tissue interactions are vital to optimizing treatment efficacy while minimizing complications and side effects.

Skin cancer in patients with chronic radiation dermatitis

The cases of 76 patients with chronic radiation dermatitis resulting from low-dose ionizing radiation for benign disease were reviewed retrospectively for risk factors leading to the development of neoplasia. The patients were studied with respect to original hair color, eye color, sun reactive skin type, benign disease treated, area treated, age at treatment, and age at development of first skin cancer. Analysis of data showed 37% of patients had sun-reactive skin type I, 27% had type II, and 36% had type III. Types IV through VI were not represented. There appeared to be an overrepresentation of types I and II. Increased melanin pigmentation may therefore be either directly or indirectly protective against the development of skin cancers in patients who have received low-dose superficial ionizing radiation for benign disease. The sun-reactive skin type of patients with chronic radiation dermatitis may be used as a predictor of skin cancer risk when the total dose of ionizing radiation is not known.

Fractionated CO2 laser skin rejuvenation

Fractional photothermolysis has been reported in the literature to improve both the pigmentary and textural changes associated with photoaging. The objective of the study was to review the literature of non‐ablative fractional laser (NAFL) and ablative fractional laser (AFL) resurfacing for the treatment of photoaging. This is a review of the Medline literature evaluating NAFL and AFL for photoaging. Review of the literature supports the use of NAFL and AFL as safe and effective treatments for photoaging. It is likely that the controlled, limited dermal heating of fractional resurfacing initiates a cascade of events in which normalization of the collagenesis/collagenolysis cycle occurs. The advent of fractionated resurfacing for the treatment of photoaging is a significant advance over ablative laser resurfacing treatments, which were complicated by prolonged erythema, delayed onset hypopigmentation, and scarring.

Electrosurgical treatment of rhinophyma

Thirteen patients with moderate to severe rhinophyma were treated with electrosurgery. All patients achieved cosmetic improvement with minimal postoperative complications. Six of 13 patients noted an improvement in nasal breathing after treatment. Patients with a predominantly lobular rhinophyma achieved the best overall results whereas younger patients with generalized nasal hypertrophy were at the highest risk for scarring. This low-cost treatment was associated with few complications and gave excellent cosmetic results. A new clinical classification of rhinophyma has been developed on the basis of the patients in this series.

Current status of tumescent liposuction in the United States. National survey results.

background Tumescent liposuction is an extremely safe method of liposuction that can be performed entirely under local anesthesia. objective To determine evolving trends in the current practice of tumescent liposuction in 15,336 patients treated by 66 dermatologic surgeons. methods A survey questionnaire was sent to 1,778 Fellows of the American Society for Dermatologic Surgery in February 1994. The comprehensive questionnaire requested information on the number of patients treated with tumescent liposuction, complications, and various practice issues. result Sixty‐six dermatologic surgeons provided data on 15,336 patients; 44,014 body areas were treated. The complications that developed were infrequent and minor and have been reported previously. The average amount of fat removed per patient was 1,276 cc. An average of 33 cc of blood was lost per patient per procedure. Cannulas of 4.0 mm or less in diameter were commonly used. The abdomen and outer thighs were the most common areas treated in women. The flanks/love handles and abdomen were the most common areas treated in men. Intraoperative monitoring of vital signs was common. conclusions Tumescent liposuction is an evolving technique that has virtually eliminated blood transfusions and the major complications of liposuction under general anesthesia. Large amounts of fat can be removed using small diameter cannulas. The fat can be safely removed with a minimum risk of minor complications.