Naomi Lawrence

Fat transplantation for treatment of the senescent face.

ABSTRACT:u2002 For more than a century, clinicians have attempted to utilize fat for the treatment of tissue deficiencies and contour abnormalities. Autologous fat transplantation for soft tissue augmentation has become increasingly popular in recent years. This has occurred as a result of the present authors’ comprehension that the aging face is not simply as a result of gravity‐induced ptosis, but also as a result of volume loss secondary to the atrophy of tissues. The popularity of tumescent liposuction has brought renewed interest and accessibility of fat for transplantation. Newer techniques and approaches to augmentation have provided more predictable and reproducible results. Fat augmentation has become an effective, safe, and reliable method for restoring volume and correcting the atrophy that accompanies senescence. In this review, the present authors describe their approach and technique of fat transplantation for the aging face.

Site identification challenges in dermatologic surgery: A physician survey

BACKGROUNDnPrevious single-institution studies have shown that patients and physicians struggle to identify biopsy sites requiring surgery on the day of treatment. To date no studies have been done to assess if this is a widespread challenge faced by many dermatologic surgeons.nnnOBJECTIVEnWe sought to determine if site identification is an issue among Mohs surgeons, and to determine which practice environments have the best supplementary data available to surgeons for site localization.nnnMETHODSnWe conducted an online survey of 722 members of the American College of Mohs Surgery inquiring about site identification and documentation typically received from referring physicians.nnnRESULTSnOf 325 surveys completed (45% response rate), 71% reported that more than 5% of their patients have difficulty identifying their surgery site. The majority (89%) responded that a photograph is most useful for identifying biopsy sites. Surgeons in academic centers and multispecialty group practices were more likely to receive a photograph versus those in private practice.nnnLIMITATIONSnIndividual survey responses may be subject to recall bias.nnnCONCLUSIONnDifficulty identifying biopsy sites needing surgery is a common challenge faced by Mohs surgeons. The majority of Mohs surgeons surveyed find photographs the most useful documentation for decreasing the risk of wrong-site dermatologic surgery.

Difficulty with surgical site identification: What role does it play in dermatology?

BACKGROUNDnThe potential for wrong-site surgery is a growing concern in dermatology.nnnOBJECTIVEnThe purpose of this study was to determine the incidence of difficulty with surgical site identification and possible confounding factors.nnnMETHODSnThis was a prospective study on 333 Mohs cases performed between April 1, 2009, and February 9, 2010. Data collection forms were used on the day of surgery to record the difficulty associated with surgical site identification and potential confounding factors.nnnRESULTSnOf the 333 patients evaluated, 9% were unable to identify their surgical sites. The majority of cases (88.5%) were located on the head and neck. When comparing patients who were able to identify their site and those who were not, there was a statistically significant difference (P = .035) in the percentage of lesions residing in a location visible to the patient. Those who were able to see their biopsy sites were 3.5 times more likely to identify their surgical site. Of the 47.6% of patients with chart notes, only 5% of these cases were photographs and 23% had high-quality diagrams. Although a delay in treatment of greater than 3 months from the original biopsy site was higher among those with difficulty in identifying their surgical site, this was not found to be statistically significant.nnnLIMITATIONSnWe believe our sample size was not large enough to show a significant link between difficulty with surgical site identification and several likely confounding factors.nnnCONCLUSIONnWe have shown that at least 9% of patients presenting for Mohs micrographic surgery are unable to confidently identify their surgical sites.

Collagenase-Assisted Fat Dissociation for Autologous Fat Transfer

BACKGROUND The quality of fat for autologous transfer procedures has been a major focus of research in the past few years. The primary goal of these efforts is to improve the viability and longevity of the graft in human subjects. One possible factor in the permanence of theses transplants is the size of the adipose tissue grafts. OBJECTIVE This study evaluated the effects of collagenase digestion on the viability of human adipose tissue. MATERIALS AND METHODS Samples of fat were obtained from subjects undergoing tumescent liposuction. The tissue was digested in a variety of concentrations of collagenase using optimized methods of processing. The digested fat was also subjected to mock injections through small bore needles. RESULTS Eight subjects completed the study. The viability of the fat using the optimized methods of collagenase digestion was consistently higher than 79%. During the mock injection trials, the viability of fat was improved from approximately 17% to 84% by collagenase digestion. CONCLUSIONS Our results show increased viability of human adipose tissue when digested by collagenase. These techniques can be applied to human autologous lipoaugmentation procedures in an effort to improve longevity of the transplanted tissue.

The Purse‐String Lockdown

Over the last few decades, the purse-string closure has become a popular technique for reducing the size or even completely closing wounds resulting from cutaneous surgery. Since its initial description as a method of partially closing wounds there have been numerous modifications and enhancements of the technique in the field of dermasurgery. Most of the descriptions of the technique focus on its uses for closure of various larger defects resulting from Mohs surgery. There is also emphasis on various methods of suture placement, inside, outside, or a combination of inside and outside the wound, to assist with tissue recruitment based on the tissue type and defect location. Other enhancements to the closure have included suture type, absorbable versus nonabsorbable suture, and placement of guiding stitches to enhance wound approximation. In reviewing the literature, it became clear that a more detailed description of its execution would be of benefit to those less familiar with the technique.

Incidence of infection after Mohs micrographic and dermatologic surgery before and after implementation of new sterilization guidelines.

BACKGROUNDnClinical guidelines regarding surgical instrument sterilization established by accrediting organizations should be based on peer-reviewed scientific literature. Few data exist in the scientific literature to support the changes in sterilization protocols imposed by accrediting organizations.nnnOBJECTIVEnWe sought to determine whether recently established guidelines for the sterilization of surgical instruments have had any clinical impact on postsurgical infection rates.nnnMETHODSnInfections rates after excisional and Mohs micrographic surgery before and after implementation of new Joint Commission on the Accreditation of Healthcare Organizations sterilization guidelines were examined retrospectively. All surgeries were performed at an academic outpatient office.nnnRESULTSnIn all, 1415 patients underwent a total of 1688 surgeries. No significant differences were observed in mean patient age (P = .113), mean number of Mohs micrographic surgical levels (P = .067), final defect size (P = .305), patient gender (P = .072), repair type (P = .691), or infection rate (P = .453). No major differences in predisposing factors were identified in patients who developed postsurgical infections.nnnLIMITATIONSnThis was a retrospective study conducted at a single academic institution.nnnCONCLUSIONSnIn our practice, recent changes in surgical instrument sterilization protocols have had no impact on postsurgical infection rates. The implementation of such guidelines places an additional burden on the health care system without providing any improvement in patient outcomes.

Delayed Migration of Hyaluronic Acid Fillers: A New Complication?

(right thigh and left chest wall) and normal wholebody MRI in the interim, a metastatic lesion is unlikely. We conducted an electronic literature search for cases of two primary DFSP lesions occurring in the same patient. We were able to find only one case report of a patient noting two separate DFSP lesions occurring in separate pregnancies. The reason for the rarity of reported second primary tumors is unknown but could be because of the mathematical probability of a second rare acquired disease occurring in the same patient. Furthermore, this case demonstrates features of the Bednar and fibrosarcomatous subtypes, which is an uncommon occurrence that has not been reported in a second primary DFSP.

Letter: regarding lentigo maligna: outcomes of treatment with q-switched neodymium-doped yttrium aluminum garnet and alexandrite lasers.

The study included 22 patients, eight (36%) of whom failed treatment with laser. Twenty-five percent of those who failed treatment (n = 2) progressed to invasive melanoma. Previous estimates of the percentage of LM cases that progress to lentigo malignant melanoma (LMM) vary from 5% to 19% of LM harboring foci of invasion. Recurrence rates for superficial destructive methods range from 20% to 100% at 5 years. As is all too familiar, prior treatment interventions that may cause depigmentation and mask an amelanotic recurrence may complicate the clinical examination of LM. Furthermore, absence of these characteristic features that herald progression to LMM may be eliminated.

Error Avoidance in Dermatologic Surgery

Surgical errors pose a significant source of morbidity, mortality, and expense within the health care system. While rates of errors within dermatologic surgery are low, there are certain areas of dermatologic surgery that are more prone to errors than others. These include site identification, specimen labeling, triage, lidocaine toxicity, needle sticks, electrosurgery, and laser surgery. Within these areas, continued research is being done to identify the source of the errors and establish protocols to minimize the risk.

Proliferating Pilar Tumor of the Scalp

A previously healthy 47-year-old AfricanAmerican man presented to the dermatology clinic complaining of a 30-year history of an asymptomatic, progressively enlarging mass on his forehead. The initial biopsy was read as a squamous cell carcinoma, and the patient was referred to our office for Mohs micrographic surgery. The patient denied any antecedent trauma, weight loss, night sweats, fevers, headache, or gastrointestinal symptoms. His medical and family history were unremarkable, although his social history revealed that he had recently emigrated from Nigeria. On physical examination, the patient had a fixed, solid 11by 5-cm multilobular subcutaneous mass on the right lower forehead and frontal scalp (Figure 1). A full-body skin examination failed to demonstrate other similar lesions, and there was no palpable lymphadenopathy. Given the unusual clinical presentation, a deeper wedge incisional biopsy was obtained. Acid-fast, Grocott’s methenamine silver, and periodic acid-Schiff stain were negative for fungal and mycobacterial organisms.