Roberta D. Sengelmann

New advances in liposuction technology.

Although suction-assisted liposuction under tumescent anesthesia remains the traditional method for body sculpting, newer technologies promise to increase efficiency, decrease surgeon fatigue, and minimize complication. Power-, ultrasound-, and laser-assisted devices are ideal in large volume cases and in areas of fibrous tissues as an adjunct to traditional liposuction. Although skepticism remains chemical lipolysis, more commonly termed mesotherapy or lipodissolve may be an alternative to surgical treatment of localized fat. This article reviews the recent advancements in the field of liposuction and the current literature which support their use.

Nonsurgical Treatment Modalities for Primary Cutaneous Malignancies

BACKGROUND Various modalities have been available to treat primary cutaneous malignancies. Although not indicated for certain aggressive tumors, many of the newest regimens involve noninvasive techniques. It behooves both the nonsurgeon and the surgeon alike to be apprised of all treatment options, their indications, and their efficacy. OBJECTIVE The objective was to review the indications and published data on various nonsurgical treatment options for primary cutaneous malignancy. METHODS AND MATERIALS This study is a literature review. CONCLUSIONS Many nonsurgical treatment options exist for primary cutaneous malignancies. In determining which modalities to implement, consideration must be given to careful patient selection, tumor type, and appropriate expectations. Additionally, adjunctive/combination therapy may be used before or after surgery.

The Flipped Island Pedicle Flap: A New Twist on an Old Favorite

Island pedicle flaps (IPFs), also known as ‘‘V-to-Y’’ or ‘‘kite’’ flaps, are commonly used in cutaneous reconstruction, typically offering a hearty blood supply and good match of skin color, texture, and quality. The IPFs most commonly used by dermatologic surgeons are random pattern flaps, without incorporation of a named artery. They have proven particularly useful in areas with predictable underlying musculature that provides reliable vascularity, such as the superior cutaneous lip, eyebrows, and nose. An IPF is freed at its peripheral borders from its dermal and epidermal restraints and remains attached only by an underlying pedicle, thus creating an ‘‘island.’’ Their vascular pedicle, which acts as a ‘‘leash’’ connecting the overlying flap to subcutaneous tissues at its donor site, limits the linear motion of traditional IPFs. We describe a modification of the IPF, which we term the flipped IPF, that further extends its versatility.

Iatrogenic Parotid Sialocele After Excision of Malignant Melanoma of the Cheek

A 79-year-old white female presented for excision of a biopsy-proven malignant melanoma on the right cheek. Initial biopsy performed 3 months earlier by her primary care physician showed a melanocytic nevus with severe architectural disorder and severe cytological atypia. Re-biopsy of this ill-defined brown patch 1 month later by her primary care physician showed a lentiginous malignant melanoma, Breslow depth of 0.42 mm, Clark level II, extending to the lateral surgical margins. The delay of 3 months between initial biopsy and referral was due to both patient factors and confirmation of the diagnosis by the dermatopathologist. Physical examination revealed a 1.0 1.7 cm brown patch with central erythema and scar consistent with a prior biopsy. No evidence of lymphadenopathy was noted. The patient underwent staged excision of the melanoma using slow Mohs technique, with 8-mm margins for permanent en face histologic evaluation. Pathological examination of the excised margins showed residual melanoma in situ with negative peripheral margins. Reconstruction was delayed because of the patient’s scheduling conflicts. Fourteen days after the initial excision, the patient underwent reconstruction with complex closure without any apparent intraoperative complications. Three days after the reconstructive procedure, she presented with a complaint of increasing swelling at the surgical site (Figure 1). Examination revealed a large, nonindurated fluctuant mass on the right cheek with no evidence of drainage and minimal erythema. She had intact sensation throughout and no motor deficits. The swelling was aspirated with an 18-gauge needle, and 35 mL of serous fluid was obtained and sent for culture. She was started on oral antibiotics and a compressive head wrap. Three days later, she returned to the clinic complaining of increasing swelling in the area and minimal drainage from the suture line, especially with chewing and after eating. Because of strong suspicion of sialocele, the area was reaspirated, and fluid was sent for amylase levels, which were high at 109,850 U/L. Bacterial cultures were negative. The patient was started on low-dose glycopyrrolate at 1 mg orally twice a day and instructed to continue with compressive dressings. Otolaryngology service was consulted to discuss possible surgical intervention, but they recommended continuing conservative management with higher doses of glycopyrrolate (2 mg orally twice a day) and daily pressure wraps. Four weeks after the reconstruction and 3 weeks after initiation of glycopyrrolate and pressure dressings, the patient noticed less swelling and no drainage. Conservative management was continued, with complete resolution of her symptoms.

Cotton Dental Rolls for Effective and Cost-Efficient Hemostasis

Continuous visualization of the surgical field is a key component of good surgical technique. Removing blood from the field ensures that the surgical dissection remains in the appropriate plane and decreases the risk for inadvertent injury to vital structures. Maintaining a clear surgical field also allows for identification of individual bleeding vessels so that they may be cauterized precisely or ligated. This decreases the need for excessive thermal damage. Standard 6’’ cotton-tipped swabs may be used to more precisely absorb blood from the surgical field, but in all but the most limited of procedures, these small swabs quickly become saturated and ineffective. Two alternatives for precise hemostasis include cotton dental rolls and large cotton rectal swabs (Figure 1). The dental roll can be used by clamping it with a hemostat or placing it at the end of a cotton swab and can even be used to retract tissues within the surgical field (Figures 2 and 3).