Thomas E. Rohrer

Adverse Events Associated With Mohs Micrographic Surgery Multicenter Prospective Cohort Study of 20 821 Cases at 23 Centers

IMPORTANCE Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Angiolymphoid Hyperplasia with Eosinophilia Successfully Treated with a Long‐Pulsed Tunable Dye Laser

Background. To date, both surgical excision and laser treatments for angiolymphoid hyperplasia with eosinophilia (ALHE) have resulted in scarring. Objective. Based on the principle of selective photothermolysis, we considered employing the newer long‐pulsed tunable dye laser in the treatment of ALHE, as less scarring would be expected and deeper blood vessels could be ablated. Methods. After punch biopsy specimens confirmed the diagnosis, the patient was treated on two separate occasions, 2 months apart with a long‐pulsed tunable dye laser. Results. The lesions flattened after the initial treatment and resolved after a second treatment. No scarring was detectable and no recurrence was noted in follow‐up after 1 year. Conclusion. We conclude that the long‐pulsed tunable dye laser can be employed successfully to treat superficial lesions of ALHE, particularly in cosmetically sensitive areas.

Novel cutaneous uses for botulinum toxin type A

Botulinum toxin type A is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It has been used extensively in the field of dermatology for the treatment of dynamic rhytides and in the treatment of hyperhidrosis. Botulinum toxin has an excellent safety profile and few side effects when used for these purposes. Recently, botulinum toxin has also been used experimentally in a number of other dermatologic conditions with good results. These conditions include: persistent facial flushing, gustatory sweating and epiphora, anal fissures, familial benign pemphigus (Hailey‐Hailey disease), dyshidrotic eczema, and following surgical wound closures. While randomized, controlled prospective trials are still needed to further understand the efficacy and safety of botulinum toxin in these conditions, anecdotal and case report data suggest that botulinum toxin is both safe and efficacious in these and many other procedures.

Multicenter prospective cohort study of the incidence of adverse events associated with cosmetic dermatologic procedures: Lasers, energy devices, and injectable neurotoxins and fillers

IMPORTANCE Common noninvasive to minimally invasive cosmetic dermatologic procedures are widely believed to be safe given the low incidence of reported adverse events, but reliable incidence data regarding adverse event rates are unavailable to date. OBJECTIVE To assess the incidence of adverse events associated with noninvasive to minimally invasive cosmetic dermatologic procedures, including those involving laser and energy devices, as well as injectable neurotoxins and fillers. DESIGN, SETTING, AND PARTICIPANTS A multicenter prospective cohort study (March 28, 2011, to December 30, 2011) of procedures performed using laser and energy devices, as well as injectable neurotoxins and soft-tissue augmentation materials, among 8 geographically dispersed US private and institutional dermatology outpatient clinical practices focused on cosmetic dermatology, with a total of 23 dermatologists. Participants represented a consecutive sample of 20 399 cosmetic procedures. Data acquisition was for 3 months (13 weeks) per center, with staggered start dates to account for seasonal variation. EXPOSURES Web-based data collection daily at each center to record relevant procedures, by category type and subtype. Adverse events were detected by (1) initial observation by participating physicians or staff; (2) active ascertainment from patients, who were encouraged to self-report after their procedure; and (3) follow-up postprocedural phone calls to patients by staff, if appropriate. When adverse events were not observed by physicians but were suspected, follow-up visits were scheduled within 24 hours to characterize these events. Detailed information regarding each adverse event was entered into an online form. MAIN OUTCOMES AND MEASURES The main outcome was the total incidence of procedure-related adverse events (total adverse events divided by total procedures performed), as verified by clinical examination. RESULTS Forty-eight adverse events were reported, for a rate of 0.24% (95% CI, 0.18%-0.31%). Overall, 36 procedures resulted in at least 1 adverse event, for a rate of 0.18% (95% CI, 0.13%-0.25%). No serious adverse events were reported. Adverse events were infrequently associated with known risk factors. CONCLUSIONS AND RELEVANCE Noninvasive to minimally invasive cosmetic dermatologic procedures, including energy, neurotoxin, and filler procedures, are safe when performed by experienced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and transient.

Lasers and cosmetic dermatologic surgery for aging skin

Many topical agents and physical modalities have been used throughout the years to give the face a more youthful appearance. The goal has always been to effectively and consistently rejuvenate the face while minimizing the time of recovery and risk for complications. Because each person is unique, there is no one modality that is best for everyone. This article reviews some of the options available for treating photoaged skin in 2001. Various lasers (e.g., vascular lesion, pigmented lesion, hair removal, and resurfacing), botulinum A toxin, chemical peels, and various dermal and subcutaneous filler substances all are discussed.

A Randomized, Controlled Trial of Four Ablative Fractionated Lasers for Photoaging: A Quadrant Study

BACKGROUND Fractionated technology has revolutionized laser therapy. With the success of initial devices, several fractionated lasers have appeared on the market. Claims of superiority have made device choice difficult for physicians and patients. MATERIALS AND METHODS Twelve subjects were treated with fractionated ablative lasers (10,600‐nm carbon dioxide and 2790‐nm yttrium scandium gallium garnet) in this institutional review board–approved trial. Each face was divided into four quadrants, and each quadrant was randomly treated using one of four lasers. Clinical experience was used to optimize settings. Two patients submitted biopsies from each quadrant immediately after treatment. Patients and blinded investigators assessed pain during treatment and post‐treatment improvement in photoaging (measured by rhytides, lentigines, texture, and pore size) using a five‐point scale. RESULTS All devices resulted in statistical improvement in photoaging in all patients, but no device was statistically significantly superior. No statistically significant difference was found in pain scores. All patients reported satisfaction 1 month after treatment. Three patients experienced adverse reactions. Histologically, there were no statistically significant differences between devices. CONCLUSIONS Fractionated ablative lasers reliably result in improvement in photoaging. Despite marketing claims, no statistically significant differences were found in outcomes, pain during treatment, or histologic findings. Even with experienced users, significant adverse reactions are possible.

Planning the closure.

Consistently achieving aesthetically pleasing closures of the skin requires a significant amount of forethought and planning. In addition to understanding the regional anatomy, recognizing and respecting free margins, cosmetic unit junctions, and skin tension lines are all of critical importance.

Asds Guidelines Task Force: Consensus Recommendations Regarding the Safety of Lasers, Dermabrasion, Chemical Peels, Energy Devices, and Skin Surgery During and After Isotretinoin Use

BACKGROUND Currently, the isotretinoin (13-cis-retinoic acid) package insert contains language advising the discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. It is common practice to follow this standard because of concerns regarding reports of sporadic adverse events and increased risk of scarring. OBJECTIVE To develop expert consensus regarding the safety of skin procedures, including resurfacing, energy device treatments, and incisional and excisional procedures, in the setting of concurrent or recent isotretinoin use. MATERIALS AND METHODS The American Society for Dermatologic Surgery authorized a task force of content experts to review the evidence and provide guidance. First, data were extracted from the literature. This was followed by a clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS The task force concluded that there is insufficient evidence to justify delaying treatment with superficial chemical peels and nonablative lasers, including hair removal lasers and lights, vascular lasers, and nonablative fractional devices for patients currently or recently exposed to isotretinoin. Superficial and focal dermabrasion may also be safe when performed by a well-trained clinician.

Introduction to the Laser Journal.

Research on cutaneous laser surgery is alive and well. There were many submissions to Laser and Surgery Medicine concerning clinical, preclinical, and basic science aspects of this rapidly evolving field, some with immediate clinical application and others with interesting implications for future investigation and application. Treatment of atrophic and hyperpigmented scarring in darker skin types has long represented a great challenge, particularly when treating large areas of the face such as scars from cystic acne. A study by Badawi and colleagues using a submilisecond 1064Nd:YAG laser found this treatment to be safe and quite effective, inducing significant improvement among 22 patients treated on 6 occasions using this painless and non-invasive approach. The before and after photographs on the cover of this issue show a dramatic improvement in both the color and texture of the treated skin. Fractional C02 laser treatment has been shown to bring about striking clinical improvement of scarred and photodamaged facial skin. While most histologic studies are performed on abdominal skin, the vast majority of patients are treated on facial skin. A study of 15 subjects by Bailey and colleagues compared the histologic effects of treatment on the abdomen to that on the face. There is considerable variation in anatomy and biomechanical properties of these two areas, and this was reflected in the dimunition by 28% of the laser energy and the column depth of laser penetration into skin on the face compared to that abdominal tissue. As the authors point, it is important for readers to understand which part of the body a device was used on for any given study before extrapolating the data to other areas of the body. Photodynamic therapy is a successful and often very effective treatment for photodamage and actinic keratoses. Intense pulse light (IPL) sources are frequently used to activate the ALA, but they appear not to be uniformly useful. Maisch and colleagues assessed the spectra of 5 different intense pulsed light systems and found that considerably different radiant exposures were necessary to achieve a photodynamic effect. Although IPL’s may be useful with the clinical photodynamic therapy, each intense pulsed light system must be separately evaluated for its effectiveness in activating the ALA. Non-ablative fractional lasers have now been used for several years with considerable success in facial rejuvenation. Zelickson and colleagues evaluated an innovative hand piece device, which when used with a 1540 nm laser, provided skin compression during treatment in order to reach deeper reticular dermis while minimizing epidermal damage. They found that energy from this new device did indeed reach deeper into the dermis without having to increase the energy or enlarge the total size and area of the tip. Efforts continue to optimize successful treatment of port wine stains with the pulsed dye laser. Current treatment often involves the use of this laser with sequential cryogen spray cooling. Milanic and colleagues hypothesize that altering the parameters of sequential spray cooling and laser radiation might both improve photocoagulation of blood vessels and minimize epidermal thermal damage. They evaluated light and heat transport in a mathematical model and concluded that the application of specific cooling and laser sequences may improve the therapeutic outcome in resistant port wine stains. Basal cell carcinomas have previously been shown to respond to treatment with the pulsed dye laser, and an article in this issue by the same authors further confirms that observation. The authors optimized treatment parameters, repeated their original study, and found improved clearance. In a case report on a patient with basal cell nevus syndrome, an alexandrite laser was used successfully to treat 15 of 18 lesions. While both of these lasers may be used to target vascular structures, the extremely high fluences used in each of the studies induces a significant ablative/ destructive effect. It will be interesting to determine with further studies what the actual mechanism of action is for these lasers and tumor clearance. Vascular abnormalities in cutaneous blood flow play a crucial role in multiple dermatologic entities such as a psoriasis, vascular malformations, and skin cancers. Noninvasive imaging capable of assessing microcirculation might well help understand vascular involvement in these conditions and may lead to new approaches to therapy. Wang and colleagues evaluated the microcirculation of psoriasis using optical microangiography and found considerably higher blood vessel density. This tool may well be useful for both diagnosis and treatment of other cutaneous diseases.

Introduction to Special Issue on Hypertrophic Scars and Keloids

Our patients do not want scars. Even when all goes well and a surgical procedure produces an “acceptable” scar, there are quality of life measures that decline significantly as a result of the physical and psychological impact of having a scar. Problems can occur in any of the 3 stages of wound healing (inflammation phase, proliferation phase, or remodeling phase) and when a hypertrophic or keloidal scar is formed, the situation becomes even worse. Minimizing scars from our surgical procedures and those produced by other forms of trauma or disease weighs heavily on dermatologists. Good surgical technique and proper wound care go a long way in minimizing the risk of abnormal scar formation. Topical treatments, injectables, lasers, other energy sources, and physical modalities such as subcision, microneedling, and dermabrasion have all been used to improve the appearance of scars. This issue examines how normal and abnormal scars form and presents a wide variety of treatment options available today to treat scars. Drs. Berman, Maderal, and Raphael review the pathophysiology, classification, and treatment of hypertrophic and keloidal scars. They describe how the ratio of various subtypes of interleukins and growth factors play an important role in the formation of scars and howa small imbalance can have dramatic effects. They go on to present a comprehensive overview of the various treatment options available for hypertrophic andkeloidal scars anddiscuss themechanismof action of each. Drs. Cohen, Geronemus, McDaniel, and Brauer performed a literature reviewon the role elastin fibers play in scar formation and discuss how laser treatments help normalize the disorganization of the elastin fibers typically found in scars. In another article in this issue, Dr. Yang compares the gene expression of hypertrophic scar markers after being injected with a steroid, a calcium channel blocker (verapamil), and interferon.