Ming H. Jih

Fractional photothermolysis: a review and update.

Fractional resurfacing is a new laser treatment modality that creates numerous microscopic thermal injury zones of controlled width, depth, and density that are surrounded by a reservoir of spared epidermal and dermal tissue, allowing for rapid repair of laser-induced thermal injury. This unique modality, if implemented with proper laser-delivery systems, enables high-energy treatments while minimizing risks. In this article, we review the various fractional laser devices, including the new fractional ablative devices, as well as the results of studies on the clinical efficacy of fractional photothermolysis. This technology offers patients significant clinical improvement in photodamage, melasma, and scarring with modest treatment-related downtime and minimal risk of complications.

The 20-Minute Rapid MART-1 Immunostain for Malignant Melanoma Frozen Sections

BACKGROUND Immunohistochemical staining has been used to help detect malignant melanoma on Mohs surgery frozen sections. Previous investigators have developed protocols for reliable MART-1 immunostaining of frozen sections, but these protocols are time-consuming. OBJECTIVE The objective was to report a rapid 20-minute MART-1 immunostaining protocol for frozen sections. METHODS The protocol was utilized on 30 melanomas treated with Mohs micrographic surgery. RESULTS The stain clearly highlighted normal background melanocytes, as well as melanocytic hyperplasia and malignant melanoma. CONCLUSIONS The 20-minute protocol provides a rapid and reliable method for immunostaining of malignant melanoma. The availability of more rapid immunostaining methods improves efficiency of the Mohs laboratory and significantly reduces patient and physician waiting time.

Laser Treatment of Acne Vulgaris

Traditional medical treatments for acne vulgaris include a variety of topical and oral medications. The combination of poor compliance, lack of durable remission, and potential side effects are common drawbacks to these treatments. The use of lasers and light devices has increased dramatically in recent years due to the overall ease of treatment, predictable clinical efficacy, and minimal adverse effects. A variety of light and laser devices has been used for the treatment of acne, including the potassium titanyl phosphate (KTP) laser, the 585- and 595-nm pulsed dye lasers, the 1450-nm diode laser, radiofrequency devices, intense pulsed light sources, low-intensity light treatment, and photodynamic therapy using 5-aminolevulinic acid and indocyanine green. These devices are thought to target underlying pathogenic factors such as Propionibacterium acnes colonization, increased sebaceous gland activity, and the cutaneous inflammatory response. Lasers in particular also have a central role in the management of acne scarring, which tends to be refractory to medical therapies. Fractional photothermolysis, the 1450-nm diode laser, and pulsed dye lasers have been used in the nonablative treatment of acne scars with significant success. In this article, we review the current status of light- and laser-based treatment of acne and related conditions and briefly review the use of lasers for the treatment of acne scarring.

Increased burden of melanoma and nonmelanoma skin cancer in young women.

BACKGROUND A higher and increasing incidence of skin cancer has been noted in younger women as compared with men. OBJECTIVE To assess the relative gender burden of basal cell carcinoma, squamous cell carcinoma, and malignant melanoma in various age groups, particularly in young adult women. MATERIALS AND METHODS A total of 16,994 biopsy-proven skin cancers in 9,376 patients in a single private dermatologic surgery practice was included in this study. RESULTS Men constituted the majority (63.7%, p < .0001) of patients, accounting for 68.7% of squamous cell carcinomas (p < .0001), 60.8% of basal cell carcinomas (p < .0001), and 57.5% of malignant melanomas (p < .0001). However, a statistically significant majority of melanomas (67.3%, p < .0001) and basal cell carcinomas (60.4%, p < .0001) were seen in women in patients aged 10 to 49 years. There was also a statistically significant increase in the female representation in patients aged 10 to 49 years as compared with those aged 50 to 99 years with respect to squamous cell carcinoma. CONCLUSION Women comprise a statistically significant majority of patients with melanoma and basal cell carcinoma in the younger (10–49 years) age groups. This raises a concern regarding an increased future incidence of skin cancer in this population group and a demographic shift to increased female representation among patients with skin cancer.

Repair of scalp defects using an H-plasty type of bilateral advancement flap.

BACKGROUND Defects of the scalp often pose a reconstructive challenge in dermatologic surgery. OBJECTIVE We report our experience with the H‐plasty type of bilateral advancement flap for the closure of small to medium‐sized scalp defects that cannot be closed primarily. METHODS In this case series study, 69 scalp defects 1.5 to 3.0 cm in diameter that could not be closed primarily were repaired using the H‐plasty type of bilateral advancement flap. RESULTS Sixty‐nine 1.5‐ to 3.0‐cm‐diameter scalp defects resulting from Mohs micrographic surgery that could not be closed primarily were identified over the 2‐year study period. All 69 defects were closed entirely with the bilateral advancement flap, and there were no significant complications. CONCLUSIONS The H‐plasty type of bilateral advancement flap allows appropriately selected scalp defects that might not be readily closed primarily to be repaired easily using local skin, providing an attractive alternative to other flap techniques, skin grafting, and healing via secondary intention. The limitations of this study are that the results are based on a retrospective single‐surgeon experience and that there was no long‐term follow‐up scheduled to evaluate the final cosmetic outcome of the repair. &NA; The authors have indicated no significant interest with commercial supporters.

Superior Helical Rim Advancement Flap for the Repair of Ear Defects

Surgical defects of the auricular helix generally require reconstruction to maintain the contiguous border of the helical rim. Whereas the traditional helical advancement flap (Figure 1A) provides an excellent repair for defects along the lateral helix, this flap is not ideally suited for repair of defects of the superior helix. We report a superior helical advancement flap that utilizes donor skin from the laxity of the superior preauricular area to repair defects of the superior helical rim (Figure 1B).

Cellular, Atypical, and Indeterminate Dermatofibromas: Benign or Malignant?

A number of clinical and histologic variants of dermatofibroma have been described. Cellular dermatofibromas account for approximately 5% of cutaneous dermatofibromas. Like common dermatofibromas, lesions tend to occur on the extremities of young or middle-aged adults, although they have been reported in children and adolescents as well. In comparison to classic dermatofibromas, cellular dermatofibromas tend to be larger in size, with a significant proportion of tumors having a diameter greater than 2 cm. Moreover, cellular dermatofibromas have a higher recurrence rate after initial surgical excision.

Plication of the superficial musculoaponeurotic system in reconstruction of cheek defects.

The cheek is a common site for skin tumors requiring surgical intervention. In our Mohs surgery practice, approximately 7% of tumors are located on the cheek. Usually, this facial area has the potential to provide an abundance of tissue for reconstruction. Undermining and a primary layered linear closure is preferred if it can be accomplished without distortions, including ectropion, eclabium, and contour changes on the cheek, as well as excessive wound tension that would result in scar spread, hypertrophic scarring, indented scarlines, and necrosis of the wound edge. If primary linear closure is not possible, a number of flap designs can be used, including a variety of advancement, rotation, and transposition flaps. We rarely use secondintention healing for full-thickness cutaneous defects on the cheek because of the risk of visible scarring on this convex surface. Although skin grafting is an option for larger defects, it is rarely used because color and texture match is difficult to attain.

Striated palmoplantar keratoderma of Brunauer-Fohs-Siemens.

A 67‐year‐old African American man presented with callosities of his hands (which he had since adolescence) that were exacerbated by manual labor. His father suffered severe callosities of his feet, but no other family member was afflicted. Physical examination revealed symmetrically distributed linear hyperkeratotic plaques on the palms extending onto the full length of the volar aspect of his digits ( Fig. 1 ). There was no personal or family history of hair, nail, or dental abnormalities. Histologic evaluation showed marked acanthosis, hypergranulosis, and hyperkeratosis of the lesions ( Fig. 2 ). There was no evidence of epidermolytic hyperkeratosis.