Pro edur l

Derm tology
 N
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy are required. T e authors and the publisher o this work have
checked with sources believed to be reliable in their e orts to provide in ormation that is complete
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 Pro edur l
Derm tology
EDITORS
Ma Rc R. a v Ra M, MD
Clinical Pro essor o Dermatology
Weill Cornell Medical School
New York, New York
Private Practice
New York, New York

MaTh Ew M. a v Ra M, MD, JD
Director, MGH Dermatology Laser & Cosmetic Center, Massachusetts General Hospital
Faculty Director or Dermatology Laser and Cosmetic Training, Harvard Medical School
Assistant Pro essor o Dermatology, Harvard Medical School Af liate Faculty, Wellman Center or Photomedicine
Boston, Massachusetts

Dé SIRé E RaTn ER, MD

Director o Comprehensive Skin Cancer Program
Continuum Cancer Centers o New York (CCCNY)
Director, Dermatologic Surgery, Department o Dermatology
Mount Sinai Beth Israel Medical Center and St. Luke’s and Roosevelt Hospitals
New York, New York

New York Chicago San Francisco Athens London Madrid Mexico City
New Delhi San Juan Singapore Sydney Toronto
Copyright © 2015 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may
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 M r R. a r m, MD
I would like to dedicate this book to my loving parents Morrell and Maria Avram.
T ey have always given me and my amily unconditional support and love.
T ank you!
o my wi e Robin or all o her love and being my best riend. o my sons
Robert and Jacob, thank you or always bringing joy, love, and wonder to my li e.
I am very proud o you both.

M t ew M. a r m, MD, JD
I would like to dedicate this textbook to my parents, Morrell and Maria Avram,
who have provided me with their love and support my entire li e. o my beauti ul
wi e, Alison. T ank you or your love, understanding and support. o my
wonder ul children Rachel, Alexander and Noah. T ank you or inspiring me
with your love, joy and accomplishments.

Désirée R t er, MD
o my parents, Marion and Paul Ratner, or always being there,
to my children, Xanthe and Evan T omas, or their love and support, and
to Paul Heller, or his kindness, love, and understanding.
This page intentionally left blank
 Co n t e n t s

C i ix 13 Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Wilfred A. Lumbang, Meghan Scharf, &
P fac xv
T oma s Sta sko
Ack wl dgm xvii
14 Electrosurgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Jo Martin & imothy S. Wang

Sec t io N 1 Su r g ic a l Pr iNc iPl eS 15 Cryosurgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

James M. Spencer & Summer D. Moon
1 Super cial Head and Neck Anatomy . . . . . . . . . . . . . . 1
Hugh . Greenway, Vineet Mishra , Lee M. Miller, & 16 Suture Closure Materials and echniques . . . . . . . . 165
Salman Alsaad Ian A. Maher, James D. Russell, T uzar Shin,
Margaret Mann, & Jeremy Bordeaux
2 Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . .14
Bichchau M. Nguyen & Chrysalyne D. Schmults 17 T e Elliptical Excision and its Variations . . . . . . . . . 177
Joseph F. Sobanko & Christopher J. Miller
3 In ormed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
anya Nino, Rachel Epstein, Andrea Smith, & 18 Random Pattern Flaps. . . . . . . . . . . . . . . . . . . . . . . . . . 193
Abel orres Margaret Mann, Jeremy Bordeaux, &
Roberta Sengelmann
4 Anesthesia and Analgesia. . . . . . . . . . . . . . . . . . . . . . . . 33
Nima M. Gharavi & Gary P. La sk 19 Axial Pattern and Interpolation Flaps . . . . . . . . . . . . 221
Christopher J. Miller, Joseph F. Sobanko, &
5 Aseptic echnique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 John G. Albertini
Jill Henley & Jerry D. Brewer
20 Skin Gra ting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
6 Digital Imaging in Dermatologic Surgery. . . . . . . . . . 63 Hillary Johnson-Jahangir & Kira Minkis
Andrea M. Hui, Neil Brody, & Daniel M. Siegel
21 Surgical Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . 261
7 T e Surgical Suite: Equipment and Accreditation . . .72 Lee M. Miller & Seaver L. Soon
Riley McLean & Mary E. Maloney
22 Nail Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
8 Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Joshua W. rufant, John A. Carucci,
Zena Pinnella , Kerri Robbins, & Aaron K. Joseph Nathaniel Jellinek, & Chris G. Adigun

9 Preoperative and Postoperative Antibiotics . . . . . . . . 89 23 Ear Piercing and Ear Lobe Repairs . . . . . . . . . . . . . . . 295
Michael M. Wolz & Christopher J. Arpey Steven S. Greenbaum, Charles H. Greenbaum, &
Joshua M. Greenbaum
10 Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Katherine A. Nolan, Liza Braun, & Robert S. Kirsner 24 Surgical Complications and T eir
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
11 Dressings and Postoperative Care . . . . . . . . . . . . . . . 110 Milène K. Crispin, Erik S. Cabral, & Sumaira Z. Aa si
Daniel A. Davis

Sec t io N 3 Sk iN t u mo r S
Sec t io N 2 Su r g ic a l Sk il l S
25 Benign Subcutaneous umors . . . . . . . . . . . . . . . . . . 323
12 Biopsy echniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Paul X. Benedetto & Allison . Vidimos
Anthony M. Rossi, Erica H. Lee, & Kishwer S. Nehal
 26 Mohs Micrographic Surgery: Indications 43 Special Considerations for Hair
and echnique 329 Restoration Surgery 504
Nichola s B. Countryman & C. William Hanke Marc R. Avram & Meena Singh

27 Practical Management of Atypical Nevi 338 44 Sclerotherapy 520

June J. Park, Clara Curiel-Lewandrowski, & Karen L. Bea sley & Robert A. Weiss
Caroline C. Kim
45 Minimally Invasive reatment of Varicose Veins 527
28 Surgical Management of Melanoma 344 Karen L. Bea sley & Robert A. Weiss
Peter L. Mattei, Elizabeth K. Jones, & Hensin Tsao
46 Phototherapy and Photodynamic T erapy for
29 Management of Advanced the reatment of Acne Vulgaris 537
Nonmelanoma Skin Cancer 353 Michael H. Gold
Catherine Lee Tran, Mark M. Tran, & Timothy S. Wang
C
47 Acne Scarring 549
o
n
30 Skin Cancer in the Organ ransplant Patient 370 Snehal Amin
t
e
Sa sha Jenkins, Maren Cotes, & Fiona Zwald
n
t
48 Management of Dyschromias 563
s
Claire Marie Reyes-Habito & Molly Wanner

Sec t io n 4 AeSt h et ic An d LASer 49 Laser and Light reatment of Pigmented

Lesions 578
Pr o c ed u r eS Mussarrat Hussain, Suzanne L. Kilmer, &
Omar A. Ibrahimi
31 Cosmeceuticals and opical Agents 381
Zoe Diana Draelos

32 Chemical Peels 388

Christopher B. Harmon & Tarek M. Fakhouri
Sec t io n 5 AeSt h et ic Pr o bLemS

33 Photodynamic T erapy for Nonmelanoma 50 attoos 589

Skin Cancer and Precursor Lesions 398 Mussarrat Hussain, Suzanne L. Kilmer, &
Katrine Togsverd-Bo & Merete Haedersdal Omar A. Ibrahimi

34 Noninvasive Skin ightening echnology 410 51 Noninvasive Scar reatment 603

Andrew A. Nelson Anna Chacon, Katlein Franca , Jenni er Ledon,
Jessica Sava s, & Keyvan Nouri
35 Ablative and Fractional Ablative Resurfacing 419
Arisa E. Ortiz, Mitchel P. Goldman, & 52 Laser and Light-Based reatment
Richard E. Fitzpatrick of Vascular Lesions 614
Kathryn Serowka & Kristen M. Kelly
36 Nonablative Dermal Remodeling 429
Yoon-Soo Cindy Bae & David J. Goldberg 53 Laser Hair Removal 627
Omar A. Ibrahimi & Suzanne L. Kilmer
37 Fillers 438
Ja son Emer & Heidi A. Waldor 54 Eyelid Rejuvenation 640
Robyn Sackeyf o, Robert Silich, & Henry M. Spinelli
38 Injectables 453
Karen L. Connolly, David M. Ozog, & Joel L. Cohen 55 Facial Rejuvenation 654
Jenny C. Hu & Jenny Kim
39 Non-Invasive Fat Removal 467
H. Ray Jalian 56 Hand Rejuvenation 672
Nils Krueger & Neil S. Sadick
40 Non-Invasive Body Contouring 472
Andrew A. Nelson & Mathew M. Avram 57 Laser reatment of Asian Skin 676
Samantha Yee Nam Shek & Henry Hin Lee Chan
41 Liposuction 479
Daniel P. Friedmann, Kimberly J. Butterwick, & 58 African Skin 684
Arisa E. Ortiz Valerie D. Callender, Cherie M. Young, &
Susan C. Taylor
42 Hair ransplantation for Men and Women 495
Nicole E. Rogers & Marc R. Avram Index 695
viii
 Co n t r Ib u t o r s

Sum ir Z. a si, MD M r R. a r m, MD Kimberly J. Butterwi k, MD

Dermatologic Surgery Clinical Pro essor o Dermatology Private Practice
Stan ord Department o Dermatology Weill Cornell Medical School San Diego, Cali ornia
Redwood City, Cali ornia New York, New York
Private Practice Erik S. c br l, MD
c ris G. a digu , MD New York, New York Bennett Surgical Center
Clinical Instructor o Dermatology Santa Monica, Cali ornia
Ronald O. Perelman Department o K re L. Be sley, MD
Dermatology Clinical Assistant Pro essor o v lerie D. c lle der, MD
New York University School o Medicine Dermatology Callender Dermatology and Cosmetic
New York, New York University o Maryland School o Center
Medicine Glenn Dale, Maryland
Jo G. a lberti i, MD T e Maryland Laser Skin and Vein
Vice President and Laboratory Director Institute Jo a . c ru i, MD, P D
T e Skin Surgery Center Baltimore, Maryland Associate Pro essor; Chie , Mohs
Winston Salem, North Carolina Micrographic and Dermatologic
P ul X. Be edetto, MD Surgery
S lm a ls d, MD Procedural Dermatology Fellow, Director, Procedural Dermatology
Division o Mohs Surgery and Department o Dermatology Fellowship raining Program
Procedural Dermatology Dermatology and Plastic Surgery Director o Dermatologic Surgery,
Scripps Clinic orrey Pines Institute Ronald O. Perelman Department o
La Jolla, Cali ornia Cleveland Clinic Foundation Dermatology
Cleveland, Ohio New York University School o
S e l a mi , MD Medicine
Surgical Director Jeremy Borde ux, MD, MPh New York, New York
Manhattan Dermatology and Assistant Pro essor, Director o
Cosmetic Surgery Dermatologic Surgery a c o , MD
Clinical Assistant Pro essor o Department o Dermatology Post-Doctoral Clinical Research Fellow
Dermatology University Hospitals Sylvester Comprehensive Cancer
Weill Cornell Medical College Case Medical Center Center
Attending, Department o Case Western Reserve University Mohs/Laser Unit
Dermatology Cleveland, Ohio Miami, Florida
New York Presbyterian Hospital
New York, New York Liz Br u , Ba Yoo -Soo c i dy B e, MD
Department o Dermatology and Department o Dermatology
c ristop er J. a rpey, MD Cutaneous Surgery Boston University Medical Center
Mayo Clinic, Department o University o Miami Miller School o Boston, Massachusetts
Dermatology Medicine
Rochester, Minnesota Miami, Florida Joel L. c o e , MD
AboutSkin Dermatology and
M t ew M. a r m, MD, JD Jerry D. Brewer, MD DermSurgery
Director, MGH Dermatology Division o Dermatologic Surgery Englewood, Colorado
Laser and Cosmetic Center, Department o Dermatology
Massachusetts General Hospital Mayo Clinic College o Medicine K re L. c o olly, MD
Faculty Director or Dermatology Rochester, Minnesota Henry Ford Hospital Department o
Laser and Cosmetic raining, Dermatology
Harvard Medical School n eil Brody, MD, P D Detroit, Michigan
Assistant Pro essor o Dermatology, Department o Dermatology
Harvard Medical School Af liate State University o New York
Faculty, Wellman Center or Downstate Medical Center
Photomedicine Brooklyn, New York
Boston, Massachusetts
 Nicholas B. Countryman, Daniel P. Friedmann, MD David J. Goldberg, MD
MD, MBA Private Practice Skin Laser and Surgery Specialists
T e Laser and Skin Surgery Center o Westlake Dermatology Clinical Department o Dermatology
Indiana Research Center Mount Sinai School o Medicine
St. Vincent Carmel Hospital, Carmel, Austin, exas New York, New York
Indiana
Volunteer Assistant Pro essor o Nima M. Gharavi, MD, PhD Mitchel P. Goldman, MD
Clinical Dermatology Department o Medicine, Division o Private Practice, Cosmetic Laser
Indiana University School o Medicine Dermatology Dermatology
Indianapolis, Indiana University o Cali ornia Volunteer Clinical Pro essor
Los Angeles, Cali ornia University o Cali ornia
Milène K. Crispin, MD San Diego, Cali ornia
Dermatologic Surgery Charles H. Greenbaum, MD
Stan ord Department o Dermatology Emeritus Clinical Pro essor o
Redwood City, Cali ornia Dermatology Merete Haedersdal, MD, PhD
Bispebjerg University Hospital
C
T omas Jef erson University School o
o
Department o Dermatology
n
Clara Curiel-Lewandrowski, MD Medicine
t
Copenhagen, Denmark
r
Philadelphia, Pennsylvania
i
Associate Pro essor, University o
b
u
Arizona
t
o
Director, Pigmented Lesion and Joshua M. Greenbaum C. William Hanke, MD, MPH,
r
s
Cutaneous Oncology Clinic Vanderbilt University FACP
Arizona Cancer Center and Section o Nashville, ennessee T e Laser and Skin Surgery Center o
Dermatology Indiana, St. Vincent Hospital
ucson, Arizona Steven S. Greenbaum, MD Carmel, Indiana
Director o Skin and Laser Surgery Visiting Pro essor o Dermatology
Daniel A. Davis, MD Center o Pennsylvania University o Iowa-Carver College o
Departments o Dermatology and Clinical Pro essor o Dermatology Medicine
Pathology Drexel University School o Iowa City, Iowa
University o Arkansas or Medical Medicine Clinical Pro essor o Otolaryngology-
Science Clinical Associate Pro essor o Head and Neck Surgery
Little Rock, Arkansas Head and Neck Surgery T omas Indiana University School o
Jef erson Medicine
Zoe Diana Draelos, MD University School o Medicine Indianapolis, Indiana
Consulting Pro essor Philadelphia, Pennsylvania
Department o Dermatology Christopher B. Harmon, MD
Duke University School o Medicine Hugh T. Greenway, MD Surgical Dermatology Group
Durham, North Carolina Division o Mohs Surgery and Birmingham, Alabama
Procedural Dermatology
Jason Emer, MD Scripps Clinic orrey Pines
La Jolla, Cali ornia Jill Henley, BA
University o Cali ornia at San
Midwestern University
Francisco
College o Osteopathic Medicine
Dermatologic Surgery and Laser Center Michael H. Gold, MD Scottsdale, Arizona
San Francisco, Cali ornia Medical Director
Gold Skin Care Center
Rachel Epstein, DO Advanced Aesthetics Medical Spa Jenny C. Hu, MD, MPH
Loma Linda University ennessee Clinical Research Center Division o Dermatology
Department o Dermatology T e Laser and Rejuvenation Center David Gef en School o Medicine
Loma Linda, Cali ornia Clinical Assistant Pro essor University o Cali ornia
Vanderbilt University School Los Angeles, Cali ornia
Tarek M. Fakhouri, MD o Medicine, Department o
Dermatology
Surgical Dermatology Group
Vanderbilt University School o
Andrea M. Hui, MD
Birmingham, Alabama Department o Dermatology
Nursing
State University o New York
Nashville, ennessee
Richard E. Fitzpatrick, MD Visiting Pro essor o Dermatology
Downstate Medical Center
Private Practice, Cosmetic Laser Brooklyn, New York
Huashan Hospital, Fudan University
Dermatology Shanghai, China
Volunteer Clinical Pro essor Hospital o China Medical University Mussarrat Hussain, MD, MS
University o Cali ornia San Diego Shenyang, China Manhattan Dermatology and
San Diego, Cali ornia Visiting Pro essor o Plastic Surgery Cosmetic Surgery
First People’s Hospital o Foshan New York, New York
Katlein Franca, MD, MSc Guangzhou, China
Post-Doctoral Research Associate
Sylvester Comprehensive Cancer Center
Mohs/Laser Unit
Miami, Florida
x
Omar A. Ibrahimi, MD, PhD Caroline C. Kim, MD Catherine Lee Tran, MD
Director, Connecticut Skin Institute Assistant Pro essor, Department o Procedural Dermatology Fellow
Stam ord, Connecticut Dermatology, Harvard Medical Cutaneous Surgery and Oncology Unit
Visiting Assistant Pro essor o School Department o Dermatology, Johns
Dermatology Director, Pigmented Lesion Clinic Hopkins Medical Center
Massachusetts General Hospital Associate Director, Cutaneous Baltimore, Maryland
Harvard Medical School Oncology Program, Department o
Boston, Massachusetts Dermatology Wilfred A. Lumbang, MD
Beth Israel Deaconess Medical Center Assistant Pro essor o Medicine
Boston, Massachusetts (Dermatology)
H. Ray Jalian, MD
Clinical Instructor Division o Dermatology
Division o Dermatology Jenny Kim, MD, PhD Department o Medicine
University o Cali ornia, Division o Dermatology Vanderbilt University Medical Center
Los Angeles David Ge en School o Medicine Nashville, ennessee
Visiting Scientist University o Cali ornia

C
Wellman Center or Photomedicine Los Angeles, Cali ornia Ian A. Maher, MD

o
n
Massachusetts General Hospital Assistant Pro essor, Department o

t
r
Robert S. Kirsner, MD, PhD Dermatology

i
Santa Monica, Cali ornia

b
u
Department o Dermatology and Virginia Commonwealth University

t
o
Cutaneous Surgery Richmond, Virginia

r
Nathaniel Jellinek, MD

s
University o Miami Miller School o
Clinical Assistant Pro essor o Medicine
Dermatology Mary E. Maloney, MD
Miami, Florida Division o Dermatology
Brown University Department o
Dermatology University o Massachusetts
East Greenwich, Rhode Island Nils Krueger, PhD Medical School
Chie Operating Of cer Worcester, Massachusetts
Rosenpark Research
Sasha Jenkins, MD, MPH Wilhelminenstrasse Margaret Mann, MD
Emory Department o Dermatology Darmstadt, Germany Assistant Pro essor, Department o
Atlanta, Georgia Dermatology
Gary P. Lask, MD Director o Aesthetic Dermatology
Hillary Johnson-Jahangir, MD, Department o Medicine, Division o University Hospitals
PhD Dermatology Case Medical Center
Assistant Pro essor University o Cali ornia Case Western Reserve University
Director o Dermatologic Surgery Los Angeles, Cali ornia Cleveland, Ohio
Weill Cornell Medical College
Department o Dermatology Jennifer Ledon, BSc Jo Martin, MD
New York, New York Clinical Research Fellow Johns Hopkins Department o
Sylvester Comprehensive Cancer Dermatology
Center Baltimore, Maryland
Elizabeth K. Jones, BS Mohs/Laser Unit
Je erson Medical College Miami, Florida
Philadelphia, Pennsylvania
Peter L. Mattei, MD
Johns Hopkins Department o
Erica H. Lee, MD Dermatology
Aaron K. Joseph, MD Assistant Attending Physician Baltimore, Maryland
Skin and Laser Surgery Associates Memorial Sloan-Kettering Cancer
Pasadena, exas Center Riley McLean, MD
Instructor, Weill Medical College o Division o Dermatology
Cornell University University o Massachusetts
Kristen M. Kelly, MD New York, New York
Department o Dermatology Medical School
Beckman Laser Institute and Medical Worcester, Massachusetts
Clinic Henry Hin Lee Chan, MBBS,
University o Cali ornia MD, PhD, FRCP, FHKCP, FHKAM Bichchau M. Nguyen, MD
Irvine, Cali ornia Honorary Clinical Pro essor Procedural Dermatology Fellow
Division o Dermatology, Department Brigham and Women’s Faulkner
o Medicine Hospital
Suzanne L. Kilmer, MD Li Ka Shing Faculty o Medicine Jamaica Plain, Massachusetts
Founding Director T e University o Hong Kong
Laser and Skin Surgery Center o Hong Kong, China
Northern Cali ornia Christopher J. Miller, MD
Visiting Scientist, Wellman Center or Hospital o the University o
Clinical Associate Pro essor o Photomedicine
dermatology Pennsylvania
Massachusetts General Hospital Perelman Center or Advanced
University o Cali ornia Harvard Medical School
Sacramento, Cali ornia Medicine
Boston, Massachusetts Division o Dermatologic Surgery and
Cutaneous Oncology
Philadelphia, Pennsylvania xi
 Lee M. Miller, MD David M. Ozog, MD Meghan Schar , MD
Division of Mohs Surgery and Henry Ford Hospital Department of Dermatology Resident
Procedural Dermatology Dermatology Division of Dermatology
Scripps Clinic Torrey Pines Detroit, Michigan Department of Medicine
La Jolla, California Vanderbilt University Medical Center
June J. Park, BS Nashville, Tennessee
Kira Minkis, MD, PhD University of Illinois College of
Assistant Professor, Director of Mohs Medicine Chrysalyne D. Schmults, MD,
and Dermatologic Surgery Chicago, Illinois MSCE
Weill Cornell Medical College Assistant Professor of Dermatology,
Department of Dermatology Zena Pinnella, MD Harvard Medical School
New York, New York Baylor College of Medicine Director, Brigham and Women’s Mohs
Fourth-Year Medical Student and Dermatologic Surgery Center
Vineet Mishra, MD Houston, Texas Director, Dana Farber High-Risk Skin
Division of Mohs Surgery and Cancer Clinic
C
Procedural Dermatology Claire Marie Reyes-Habito, MD Jamaica Plain, Massachusetts
o
n
Scripps Clinic Torrey Pines Los Banos Doctors Hospital and
t
r
La Jolla, California Roberta Sengelmann, MD
i
Medical Center
b
u
Laguna, Philippines Associate Clinical Professor
t
o
Summer D. Moon, BS Irvine Department of Dermatology
r
s
Fourth Year Medical Student Kerri Robbins, MD University of California
Lake Erie College of Osteopathic Baylor College of Medicine (President and Owner) Santa Barbara
Medicine Dermatology Resident Skin Institute
Saint Petersburg, Florida Houston, Texas Santa Barbara, California

Kishwer S. Nehal, MD Nicole E. Rogers, MD Kathryn Serowka, MD

Associate Attending Physician Assistant Clinical Professor Department of Dermatology
Memorial Sloan-Kettering Cancer Dermatology University of California
Center Tulane University School of Irvine, California
Associate Professor of Dermatology Medicine
Weill Medical College of Cornell Private Practice Thuzar Shin, MD
University Metairie, Louisiana Resident Department of Dermatology
New York, New York University Hospitals
Anthony Rossi, MD Case Medical Center
Andrew A. Nelson, MD Procedural Dermatology Fellow Case Western Reserve University
Assistant Clinical Professor of Memorial-Sloan Kettering Cancer Cleveland, Ohio
Dermatology Center
Tufts University School of Medicine Weill Medical College of Cornell Daniel M. Siegel, MD
Boston, Massachusetts University Department of Dermatology
Nelson Dermatology New York, New York State University of New York
Saint Petersburg, Florida Downstate Medical Center
James D. Russell, MD Brooklyn, New York
Tanya Nino, MD Resident, Department of Dermatology
Loma Linda University Virginia Commonwealth University Robert Silich, MD
Department of Dermatology Richmond, Virginia Assistant Clinical Professor of Surgery
Loma Linda, California New York Presbyterian Hospital
Robyn Sackeyf o, MD New York, New York
Katherine A. Nolan, BA Plastic Surgery Resident
Mount Sinai School of Medicine New York Presbyterian Hospital Meena Singh, MD
New York, New York New York, New York Private Practice
Kansas City, Missouri
Keyvan Nouri, MD Neil S. Sadick, MD
Professor of Dermatology, Clinical Professor Andrea Smith, MD
Ophthalmology and Otolaryngology Weill Cornell Medical College Loma Linda University
Louis C. Skinner, Jr. M.D. Endowed Cornell University Department of Dermatology
Chair in Dermatology New York, New York Loma Linda, California
University of Miami
Miami, Florida Jessica Savas, BSc Maren Cotes, MD
Clinical Research Fellow Emory Department of Dermatology
Arisa E. Ortiz, MD Sylvester Comprehensive Cancer Atlanta, Georgia
Assistant Clinical Professor Center
University of California Mohs/Laser Unit
San Diego, California Miami, Florida

xii
James M. Spencer, MD, MS Mark M. Tran, MD Molly Wanner, MD
Professor of Clinical Dermatology Dermatopathology Fellow Harvard Medical School and
Mount Sinai School of Medicine, Stanford Dermatopathology Service Department of Dermatology
New York Department of Pathology Stanford Massachusetts General Hospital
Carillon Outpatient Center University Medical Center Boston, Massachusetts
Saint Petersburg, Florida Stanford, California
Robert A. Weiss, MD
Henry M. Spinelli, MD Joshua W. Trufant, MD Clinical Associate Professor of
Clinical Professor of Surgery Dermatology Resident, Ronald Dermatology
Clinical Professor of Neurological O. Perelman Department of University of Maryland School of
Surgery Dermatology Medicine
New York Presbyterian Hospital New York University School of Medicine Director, T e Maryland Laser Skin and
New York, New York New York, New York Vein Institute
Baltimore, Maryland
Thomas Stasko, MD Hensin Tsao, MD, PhD

C
Professor and Chair of Dermatology Massachusetts General Hospital Michael M. Wolz, BMBCh, JD

o
n
University of Oklahoma Medical Department of Dermatology and Mayo Clinic, Department of

t
r
Center Wellman Center for Photomedicine Dermatology

i
b
u
Oklahoma City, Oklahoma Boston, Massachusetts Rochester, Minnesota

t
o
r
s
Joseph F. Sobanko, MD Allison T. Vidimos, MD, RPh Samantha Yee Nam Shek,
Hospital of the University of Chairman, Department of MBBS, DipClinDerm
Pennsylvania Dermatology Honorary Research Associate
Perelman Center for Advanced Vice-Chairman, Dermatology and Division of Dermatology, Department
Medicine Plastic Surgery Institute of Medicine
Division of Dermatologic Surgery and Cleveland Clinic Foundation Li Ka Shing Faculty of Medicine
Cutaneous Oncology Cleveland, Ohio T e University of Hong Kong
Philadelphia, Pennsylvania Hong Kong, China
Heidi A. Waldorf, MD
Seaver L. Soon, MD Associate Clinical Professor of Cherie M. Young, MD
Division of Dermatology and Dermatology Callender Dermatology and Cosmetic
Dermatologic Surgery Icahn School of Medicine Center
Scripps Clinic Director of Laser and Cosmetic Glenn Dale, Maryland
La Jolla, California Dermatology
Mount Sinai Medical Center Fiona Zwald, MD, MRCP
Susan C. Taylor, MD New York, New York Emory Department of Dermatology
Society Hill Dermatology Mount SinaiWaldorf Dermatology and Emory ransplant Dermatology Clinic
Philadelphia, Pennsylvania Laser Associates, PC Mohs Micrographic surgery
Nanuet, New York Atlanta, Georgia
Katrine Togsverd-Bo, MD, PhD
Bispebjerg University Hospital Timothy S. Wang, MD
Department of Dermatology Associate Professor of Dermatology
Copenhagen, Denmark Director, Cutaneous Surgery and
Oncology Unit
Abel Torres, MD Department of Dermatology
Loma Linda University Johns Hopkins Medical Center
Department of Dermatology Baltimore, Maryland
Loma Linda, California

xiii
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 Pr eFACe

Dermatologic surgery is a discipline that has evolved part o all dermatology residencies, while postgraduate
dramatically rom the mid-20th century to the present day. ellowship training in procedural dermatology is an
Dermabrasion, chemical peels, hair transplantation, Mohs ACGME accredited subspecialty.
chemosurgery, and excisional surgery were per ormed Developing knowledge and expertise in any eld requires
principally by a select group o NYU dermatologists in the starting with the basics, and building upon them. o that
1950s, while cutaneous laser surgery was rst per ormed at end, we have organized this text into the ollowing sections:
the University o Cincinnati in the 1960s. Over the years, surgical principles, surgical skills, skin tumors, aesthetic
the number o dermatologists per orming these procedures and laser procedures, and aesthetic problems. We have
increased signi cantly. Our knowledge o basic science endeavored to develop a consistent ormat or each chapter,
has also advanced, as has our clinical expertise in wound with high-quality photographic images and graphics to
healing and postoperative care. Dermatologic surgeons have enhance the presentation o each topic. T e reader may
become experts in Mohs micrographic surgery and de ect choose to progress sequentially through the book, or to
reconstruction, while our cosmetic armamentarium has ocus individually on the topics o interest to them.
grown to include botulinum toxins, a variety o so t tissue Our goal in developing this textbook was to compile the
llers, sclerotherapy, ambulatory phlebectomy, nonablative current, state o the art in ormation concerning all aspects
and ablative lasers, ractional resur acing, lasers or the o procedural dermatology. T e authors o this text are
treatment o tattoos, pigmented and vascular lesions, and without exception leaders in their elds with a passion or
liposuction. Standards o training, patient sa ety, in ormed teaching, and we eel ortunate to have enlisted them to
consent, anesthesia and analgesia, preoperative evaluation, assist us in this endeavor. Our hope is that this book will
and of ce accreditation are now recognized to be o vital become a resource or all practitioners o dermatologic
importance, and have become disciplines o their own. surgery, rom the novice to the seasoned surgeon looking
Now, decades a ter a small group o dermatologists ounded to re ne his or her skills in a particular area. We hope you
the American Society or Dermatologic Surgery in 1970, enjoy reading this book as much as we have enjoyed putting
surgical training has become a undamental and required it together.

Marc R. Avram, MD
Mathew M. Avram, MD, JD
Désirée Ratner, MD
2014
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 ACKn o WLeDGMen t s

We extend our heart elt thanks to the sta at McGraw Hill, most notably Christine Barcellona,
Christie Naglieri, and Anne Sydor, or making this book possible and helping us see it through to
completion.
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 Sect ion
Surgical Principles
1
ch a pt er

1 Superf cial Head and Neck Anatomy

Hugh T. Greenway, Vineet Mishra, Lee M. Miller, &Salman Alsaad

INTRODUCTION vestibules. T ey are divided by the nasal septum medially

and bounded by the nasal alae laterally. T e columella is
the reely movable portion o the nasal septum (Fig. 1-1).2
Mastering surgical anatomy is crucial or the dermatologic
T e skeleton o the nose includes both bone and carti-
surgeon, not only to obtain the best cosmetic outcome but
lage. T e two nasal bones lie adjacent to the maxilla lat-
also to avoid complications related to injury o underlying
erally and the rontal bone superiorly. T ere are also ve
anatomic structures. Since a signi cant number o der-
major cartilages o the nose which provide the remainder
matologic surgeries are per ormed on the head and neck,
o the nasal ramework: two lateral cartilages, two greater
the dermatologic surgeon ought to have ull knowledge o
alar cartilages, and the single septal cartilage. In the mid-
the acial nerve and its branches, blood supply, sensory
line, the septal cartilage joins each o the lateral cartilages.
nerves, underlying musculature, and specialized struc-
T e lateral aspect o the lateral cartilage articulates with
tures such as the parotid duct. With a ull understanding
the rontal process o the maxilla whereas the superior
o the super cial anatomy o this complex region, the phy-
aspect o the lateral nasal cartilage articulates with the
sician will have the con dence to per orm a wide range
in erior aspect o the nasal bone. T e greater alar carti-
o super cial surgical procedures while keeping possible
lages are C-shaped. Each o the medial crura joins at the
risks and complications in mind.
midline with the septal cartilage to orm the nasal septum.
T e lateral crura articulate with the in erior aspects o the
lateral nasal cartilages.1
NOSE T ere are several muscles associated with the nose: the
nasalis, the depressor septi, the levator labii superioris
T e external nose is shaped like a pear or pyramid with alaeque nasi, and the procerus muscles. T e transverse
several key divisions: dorsum, tip, ala, and lateral sidewalls.
T e dorsum o the nose extends rom the tip, the lower- S upra tip a re a
most aspect o the nose, to the nasal root. In contrast to
the dorsum o the nose where the skin is quite mobile, the Root of
nos e
skin overlying the tip o the nose is adherent to the under-
lying brous tissue and cartilage. T e nasal bridge is the Dors um
portion o the nose overlying the nasal bones. T e lateral Ala r
sides o the nose encompass the area rom the nasal dor- groove S upra tip
sum to the cheeks. T e naso acial sulcus, or margin o the a re a
Exte rna l
nose, is the transition rom the lateral aspects o the nose na re s
to the cheeks.1 Tip
Na s ola bia l
T e ala, a distinct cosmetic subunit, is demarcated rom fold
Tip
Colume lla Colume lla
the lateral sidewalls o the nose by the alar crease and
separated rom the lip by the nasolabial crease. T e root Na s ola bia l
a ngle
o the nose is the region o attachment o the nose to the
glabella. T e nares are the openings into the anterior nasal Figure 1-1 Cutaneous anatomy o the nose.
1 S upe r cia l te mpora l ve s s e ls
Proce rus m. S upra orbita l
Occipita l ve s s e ls
ve s s e ls
S upra trochle a r
Leva tor la bii ve s s e ls
s upe rior a la e que Infra orbita l
na s i m. a rte ry
Angula r
Na s a lis m. De pre s s or ve s s e ls
s e pti m.
Dors a l
na s a l
a rte ry

Figure 1-2 Musculature o the nose. La te ra l

na s a l
a rte ry
S
S upe rior
e
portion o the nasalis muscle originates rom the body o
c
Tra nsve rs e la bia l
t
i
the maxilla on each side and inserts into the aponeurosis fa cia l a rte ry a rte ry
o
n
that overlies the bridge o the nose. A small portion o the Infe rior
1
nasalis, the alar component, inserts into the lateral crus De e p la bia l
fa cia l ve in a rte ry
:
o the alar cartilage. Contraction o the transverse portion
:
o the nasalis muscle compresses the nares; meanwhile, Me nta l a rte ry
S
Exte rna l
u
activation o the alar portion causes dilation o the nares. Fa cia l a rte ry
r
jugula r ve in
g
i
Innervation o the nasalis muscle occurs via the buccal
c
Fa cia l re troma ndibula r
a
branch o the acial nerve. T e depressor septi muscle ve ins
l
P
r
unctions to narrow the nares. It originates rom the inci-
i
Figure 1-3 Vasculature o the ace.
n
c
sive ossa o the maxilla and inserts into the columella and
i
p
nasal septum. T e buccal branches o the acial nerve also
l
e
s
innervate this muscle.3 T e levator labii superioris alae-
que nasi muscle originates rom the rontal process o PERIORAL REGION
the maxilla and courses in eriorly with a portion o the
muscle inserting into the ala be ore the main body inserts T e labial area o the ace is demarcated by the mental
into the skin o the upper lip. T e alar portion dilates the region in eriorly, the nose superiorly, and the buccal areas
nares and is innervated by the buccal branches o the acial o the cheeks laterally. T e lips are two structures de ning
nerve. T e procerus muscle arises rom the nasal bones the entrance to the mouth. T e upper and lower lips are
and inserts into the skin overlying the glabella. Contrac- joined laterally at the labial commissures. T e upper lip is
tion o this muscle leads to downward pulling o the skin separated rom the cheek by the melolabial crease, which
while creating horizontal olds over the bridge o the nose. extends rom the ala o the nose in eriorly and obliquely,
Unlike the other nasal muscles, the procerus is innervated and is divided into two halves by the philtrum. T e phil-
by the temporal branch o the acial nerve (Fig. 1-2).1 trum is a depression in the central upper lip bounded by
Sensory innervation to the nose is provided by the the two prominences (philtral ridges) laterally, the ver-
terminal branches o the ophthalmic and maxillary divi- milion border o the upper lip in eriorly, and the nasal
sions o the trigeminal nerve. T e supra- and in ratroch- septum superiorly. T e crossing o the muscle insertions
lear branches innervate the nasal root, bridge, and upper within the super cial portion o the orbicularis oris muscle
sidewall. T e dorsal external nasal branch o the anterior is hypothesized to lead to the ormation o the philtrum.2
ethmoidal nerve innervates the lower dorsum and nasal Each lip also has a vermilion border, a region o transi-
tip. T e in raorbital nerve provides sensation to the lat- tion rom normal skin to modi ed epithelium without
eral sidewall and ala whereas the depressor septi branch is hair, sweat glands, and sebaceous glands. T e junction
responsible or the columella.4 o the vermilion border with the philtrum is known as
T e vasculature supply to the nose is quite robust. T e “Cupid’s bow.”1
arterial supply to the external nose primarily arises rom T e oral musculature arises rom dif erent regions on
the lateral nasal and septal branches o the superior labial the ace. For purposes o simpli cation, these can be
artery, which emanates rom the acial artery. T ere are divided into our major groups: the muscles o the lower
also secondary branches rom the in raorbital artery, nasal lip (depressors), the muscles o the upper lip (elevators),
branches rom the in ratrochlear artery via the ophthal- the buccinator, and the orbicularis oris. T e muscles o the
mic artery, and the dorsal nasal branch o the anterior eth- lower lip are comprised o the depressor anguli oris, the
moidal artery, also rom the ophthalmic artery (Fig. 1-3). depressor labii in erioris, and the mentalis. T e depressor
T e veins o the external nose are tributaries o the ante- anguli oris depresses the corners o the mouth. It arises
rior acial vein. T e nose lies in the “danger area” o the rom the anterolateral aspect o the body o the mandible
ace given the open communication between the anterior and inserts into the skin and mucosa at the labial commis-
acial vein and ophthalmic veins, which drain into the cav- sure (Fig. 1-4). Similarly, the depressor labii in erioris origi-
ernous sinus.1 T e lymphatic drainage o the nose ows nates rom the mandible deep to the depressor anguli oris
into the buccal nodes o the acial lymphatic chain and muscle and inserts into the skin and mucosa o the lower
2 then subsequently into the submandibular nodes.4 lip, thereby depressing the lips. T e mentalis originates
 Leva tor la bii
s upe rioris a la e que
1
na s i m.
Leva tor a nguli
Zygoma ticus oris m.
minor m. Leva tor la bii Ma s s e te r m.
s upe rioris m.

Buccina tor m.
Zygoma ticus Leva tor
ma jor m. a nguli oris m.

Buccina tor m.
Ris orius m.

Orbicula ris
De pre s s or oris m. Figure 1-6 Deeper musculature o the perioral area.
a nguli oris m.

C
h
Figure 1-4 Musculature o the perioral area and medial nares. T e levator anguli oris originates rom the maxilla

a
p
cheek. below the in raorbital oramen and inserts into the skin

t
e
and mucosa at the labial commissure, thus elevating the

r
1
corners o the mouth. T ese muscles are innervated by the
rom the body o the mandible medial to the depressor labii buccal branches o the acial nerve with secondary inner-

:
:
in erioris and inserts into the skin overlying the tip o the vation rom the zygomatic branches o the acial nerve.2

S
chin. Upon contraction, it leads to protrusion o the lower

u
T e buccinator, also known as the cheek bulk muscle, is

p
lip and dimpling o the skin. T ese muscles are innervated

e
the key muscle o the cheek (Fig. 1-6). It originates rom

r
by the marginal mandibular branch o the acial nerve with

f
the posterolateral aspect o the maxilla, the medial aspect

c
i
secondary innervation rom the buccal branches o the

a
o the mandible near the last molar, and the pterygoman-

l
acial nerve.5

H
dibular raphe. Its insertion is into the skin and mucosa o

e
T e muscles o the upper lip consist o the risorius, zygo-

a
the labial commissure as well as the upper and lower lips.

d
maticus major and minor, levator labii superioris, levator

a
It serves to press the lips and cheeks against the teeth. Its

n
labii superioris alaeque nasi, and levator anguli oris mus-

d
innervation is rom the buccal branches o the acial nerve.

N
cles (Fig. 1-5). T e risorius arises rom the parotid ascia O note, this is the only muscle o acial expression that

e
and inserts into the skin and mucosa at the corner o the

c
receives its innervation rom the super cial aspect o the

k
mouth. T is leads to pulling o the labial commissure lat-

A
acial nerve.5

n
erally. T e zygomaticus major muscle arises rom the pos-

a
Finally, the orbicularis oris consists o concentrically

t
o
terolateral aspect o the zygomatic bone; it inserts into the arranged bers providing a sphincteric unction, which

m
skin and mucosa o the lateral upper lip and elevates the

y
allows or pursing and protrusion o the lips. It is mostly
labial commissure. T e zygomaticus minor muscle arises innervated by the buccal branches o the acial nerve.2
medial to the zygomaticus major and inserts into the skin T e sensory supply to the lips is provided by the
and mucosa o the upper lip, thus elevating the upper lip. branches o the trigeminal nerve. T e maxillary division
T e levator labii superioris originates rom the maxilla just o the trigeminal nerve gives of the in raorbital branch,
above the in raorbital oramen and inserts into the skin which innervates the upper lip, lower eyelid, in raorbital
and mucosa o the medial upper lip, thereby elevating the cheek, parts o the buccal cheek, malar cheek, and lateral
upper lip. T e levator labii superioris alaeque nasi arises aspect o the nose. T e mandibular division o the trigemi-
rom the medial origin rom the orbit, gives of bers to nal nerve branches into the mental nerve, which provides
the nasal ala, and proceeds in eriorly to insert into the sensation to the lower lip. o identi y these nerves, one
skin and mucosa o the medial aspect o the upper lip. T is may visualize an imaginary vertical line dropping in eri-
muscle not only elevates the upper lip but also dilates the orly rom the supraorbital notch. T e in raorbital oramen
and nerve are ound approximately 5 mm below the in e-
rior margin o the orbit. T e mental oramen and nerve
Leva tor la bii are intersected by this imaginary line and are located mid-
s upe rioris m.
Orbicula ris way along the height o the body o the mandible.5
oculi m. T e vascular supply to the lips arises rom the acial
artery via the in erior and superior labial arteries. T ese
tortuous vessels meander through the muscle bers and
Zygoma ticus
ma jor m. Zygoma ticus anastomose across the midline; there ore, i needed, the
minor m. acial artery may be ligated at its point o entry into the ace
without ear o ischemia to the ipsilateral ace. T e venous
Ris orius m. drainage rom the lips occurs through the superior and
in erior labial veins, which eventually join the anterior
P la tys ma m. acial vein. T e lymphatic drainage rom the lips is multi-
aceted. T e central and ipsilateral regions o the upper lip
drain into the ipsilateral submandibular nodes. T e lateral
regions o the lower lip ow into the ipsilateral subman-
Figure 1-5 Superf cial musculature o the perioral area. dibular nodes; however, the central portion o the lower 3
1 lip ows into both ipsilateral and contralateral subman-
dibular and submental nodes. T is is o great importance
T e conjunctiva covers the globe and lines the inner
sur ace o the eyelids to orm the conjunctival sac. T e tar-
when there is concern or possible metastasis o tumors in sal plates o the upper and lower lids give orm and shape
this location.1 to the eyelids. On average, the height o the tarsal plate in
the upper lid varies between 9 and 11 mm whereas that o
the lower lid is about 4 to 5 mm. T e medial palpebral liga-
ment secures the tarsal plates to the anterior lacrimal crest
PERIORBITAL REGION at the medial orbital rim. T e upper and lower tarsal plates
are also secured via the lateral palpebral ligament to the
T e orbital rim is composed o the ollowing bones: ron- lateral orbital tubercle, also known as Whitnall’s tubercle.3
tal, zygomatic, maxillary, and lacrimal. Key landmarks T e key muscles o the eyelid are the orbicularis oculi
include the supraorbital margin, supraorbital notch, and and levator palpebrae superioris. T e orbicularis oculi
in raorbital margin. T e supraorbital notch, rom which allows or closure o the eye whereas the levator palpebrae
the supraorbital nerve exits, is ound 2 cm rom the mid- superioris opens the eye. T e orbicularis oculi muscle
line. T e lateral orbital tubercle, also known as Whitnall’s bers encircle the eyelids, orehead, temple, and cheeks.
S
e
tubercle, is a small bony prominence located 10 mm T is muscle unctions as a sphincter and can be divided
c
t
i
below the zygomatico rontal suture and 4 mm behind the into palpebral and orbital portions, whose primary and
o
n
anterolateral orbital rim. T is is the site o attachment or secondary innervation are provided by the zygomatic
1
the lateral palpebral ligament. In the area o the medial and temporal branch o the acial nerve, respectively.
:
:
orbital rim is the anterior lacrimal crest, to which the Upon contraction, the muscle allows or protection o the
medial palpebral ligament is attached. T e lacrimal sac is globe and even spreading o tears across the sur ace o the
S
u
located posterior to the medial palpebral ligament.3 eye. Damage to the muscle or its innervation may lead to
r
g
i
T e eyelids orm a protective covering or the underly- ectropion o the lower eyelid. T e second eyelid muscle
c
a
l
ing globe. T e upper eyelid is larger than the lower eyelid o note is the levator palpebrae superioris muscle, which
P
r
and provides the bulk o protection to the underlying eye- is innervated by the third cranial nerve (the oculomo-
i
n
c
ball. T e skin o the eyelids is quite thin and continuous tor nerve).5 T is muscle originates rom the orbital apex
i
p
with the conjunctiva at the ree margins. T e palpebral and then ans out, molding itsel around the globe be ore
l
e
s
ssure is the space between the open eyelids. T e com- inserting onto the anterior sur ace o the tarsus. It also has
missure or canthus is the site where the upper and lower bers above the superior border o the tarsus between the
eyelids join. T e medial canthus is separated rom the sur- orbicularis oculi and the skin, which orms the supratarsal
ace o the eyeball by the lacrimal caruncle, which appears eyelid crease.
as an erythematous structure. T e space occupied by the T e orbital septum is a brous sheath lying beneath the
lacrimal caruncle is the lacrimal lake. T e plica semiluna- orbicularis oculi muscle. T is structure marks the anterior
ris is the portion o the olded conjunctiva lateral to the border o the orbit and encases the orbital at. T e orbital
lacrimal caruncle. Along the ree margins o the medial septum originates rom the bony margins o the orbit and
eyelids are small elevations at the base o the eyelashes lies anterior to the tarsal plates. T e septum is thinnest at
known as lacrimal papillae. Each papilla encircles a punc- its medial aspect (Fig. 1-8). T ere are two at pads poste-
tum, which marks the opening to the lacrimal canalicular rior to the orbital septum in the upper eyelid and three at
system through which the uid drains into the lacrimal
sac. From there, the nasolacrimal duct, which typically
runs or approximately 18 mm, empties its contents into
the in erior meatus o the nose. T e lacrimal gland, located
behind the orbital margin o the zygomatic process o the
rontal bone, consists o a larger orbital portion and a
smaller palpebral portion and provides lubrication or the Leva tor
Orbita l pa lpe bra e
eye (Fig. 1-7).4 mus cle
s e ptum

Me dia l ca nthus
Pe riphe ra l Conjunctiva
La crima l s a c a rca de
La crima l
gla nd
Orbicula ris
oculi mus cle
La te ra l ca nthus

La crima l pa pilla Ta rs us
Na s ola crima l
La crima l duct
ca runcle Ma rgina l
a rca de

La crima l
duct

4 Figure 1-7 Anatomy o the lacrimal system. Figure 1-8 Sagittal view o the upper eyelid.
pads posterior to the orbital septum in the lower eyelid.
In addition, in the upper eyelid, posterosuperior to the
separated by the coronal, sagittal, lambdoid, and squamo-
sal sutures. T e so t tissues above it include ve distinct
1
orbital septum, is the lacrimal gland.1 layers which are easily remembered using the ollowing
T e nerve supply to the eyelids consists o both motor mnemonic:
and sensory components. T e zygomatic and temporal
Skin
branches o the acial nerve supply motor innervation to
Connective tissue (subcutaneous tissue)
the orbicularis oculi. T e oculomotor nerve innervates Aponeurosis (galea aponeurotica)
the levator palpebrae superioris. Sensory innervation Loose areolar connective tissue
is provided by the ophthalmic division o the trigeminal Periosteum
nerve. T e ophthalmic division o the trigeminal nerve
gives rise to the supraorbital, supratrochlear, and lacrimal On the scalp, the skin extends rom the supraorbital
nerves, which provide sensation to the upper eyelid. T e ridges o the rontal bone posteriorly to the superior
lower eyelid is innervated by the in raorbital nerve, which nuchal lines o the occipital bone. T e lateral portions
arises rom the maxillary division o the trigeminal nerve. cover the parietal bones and temporalis muscle. T e ore-
O note, visual acuity should be documented prior to any head may be considered a subsection o the scalp extend-

C
h
surgical procedure in the periorbital region. A ter surgery, ing rom the supraorbital ridges to the highest wrinkle

a
p
i the eye needs to be patched, extra care should be exer- overlying the rontal bone. T e at portion o the orehead

t
e
is due to the underlying squamous portion o the rontal

r
cised to ensure that it is patched in the closed position to

1
avoid corneal abrasions and injury to other structures o bone. Posteriorly, the inion is a protuberance which may
be palpated at the midline o the occipital bone. Extending

:
the eye.4

:
T e vascular supply to the eyelids is derived rom the laterally rom the inion are two ridges orming the supe-

S
u
rich arterial supply rom both the internal and external rior nuchal lines (Fig. 1-9).1

p
e
carotid arteries. T e ophthalmic artery arises rom the T e bones o the calvarium consist o an inner table

r
f
internal carotid artery and gives rise to the supraorbital, and an outer table o cortical bone separated by a spongy

c
i
a
supratrochlear, medial palpebral, dorsal nasal, and lacri- diploe layer o trabecular bone. T ese bones receive

l
H
mal arteries. T e medial palpebral arteries include both their blood supply rom both the interior and exterior

e
a
superior and in erior components that dive through the sur aces. On occasion, the dermatologic surgeon may

d
a
orbital septum medially and then traverse laterally over need to sample the outer table to evaluate or invasion

n
d
the eyelid. O note, the superior palpebral artery supplies o tumor, or may remove portions o the outer table to

N
both the peripheral and marginal arcades. T e peripheral stimulate the ormation o granulation tissue. Care must

e
c
be taken to avoid penetrating the inner table i sampling

k
arcade is located in the upper body o the tarsus whereas

A
the marginal arcade is ound in the lower portion o the is done with the osteotome and mallet. T e surgeon

n
a
tarsus just superior to the eyelashes in the pretarsal space. should also avoid using an osteotome across suture lines

t
o
o the calvarium or on a site which has been irradiated

m
Meanwhile, the external carotid artery gives of the max-

y
illary and super cial temporal arteries. T e maxillary previously.5
artery gives rise to the in raorbital artery, which exits Under the skin o the scalp lies the connective tissue
the in raorbital oramen and supplies the lower eyelid. layer (subcutaneous tissue), which contains most o the
T e super cial temporal artery branches into the trans- vascular and nerve supply or the scalp. T e scalp vas-
verse acial artery, the zygomatico-orbital artery, and the culature consists o many anastomosing branches which
rontal artery. T ese supply the lateral orbit and orehead. originate rom both the internal and external carotid
T ere are two key sites or anastomosis: rst in the lateral
eyelid, between the super cial temporal artery and the lat-
eral distribution o the in raorbital artery, and second in Crown
the medial eyelid, between the in erior medial palpebral S upe rior
artery and the in raorbital artery.1 te mpora l
T e venous network o the eyelid is also quite exten- line
sive, and parallels the arterial system. T e veins drain into
the ophthalmic venous system, the super cial temporal
vein, or the angular vein. O note, the ophthalmic venous
system ows into the dural venous sinus. T e lymphatic
drainage o the periorbital area is divided into lateral
and medial components. T e lateral aspects o the upper
and lower eyelids drain into the preauricular nodal basin Inion
whereas the medial aspects drain to the central acial and
submandibular nodes.3 S upe rior
nucha l
line
SCALP
T e scalp consists o the skin and multiple layers o so t
tissue overlying bone. T e calvarium, which is composed
o the rontal, occipital, and two paired parietal bones,
serves as the oundation or the scalp. T e scalp bones are Figure 1-9 Landmarks o the scalp. 5
1 Occipita l a . Le a s t
occipita l n.
Pos ta uricula r a .

Gre a te r
occipita l n.

Le s s e r
occipita l n.

Auriculo-
te mpora l n.
S
e
c
t
i
o
n
Zygoma tico-
1
te mpora l n.
S upe r cia l
:
te mpora l a .
:
S
S upra orbita l a .
u
r
S upra trochle a r n.
g
S upra trochle a r a .
i
c
a
l
Figure 1-10 Vasculature o the scalp. Figure 1-11 Sensory innervation o the scalp.
P
r
i
n
c
i
p
arteries. T e occipital artery and posterior auricular artery and posteriorly along the top o the scalp to innervate the
l
e
s
are branches rom the external carotid which supply the crown.1 T e auriculotemporal nerve originates rom the
occipital and retroauricular scalp. T e external carotid mandibular division o the th cranial nerve. It courses
artery eventually branches into the super cial temporal posterior to the ramus o the mandible and ollows the
artery, which is palpable at the superior pole o the parotid course o the super cial temporal artery. It supplies sensa-
gland, supplying the temporal scalp. T e internal carotid tion or most o the temporal and parietal scalp as well as
artery, via the ophthalmic artery, divides into the supra- the anterolateral auricle and anterior hal o the external
orbital, supratrochlear, and lacrimal arterial branches. auditory canal.6 T e lesser occipital nerve originates rom
A ter traversing the orbit, the supraorbital artery exits the cervical plexus and ollows the posterior edge o the
the supraorbital oramen as part o a neurovascular bun- sternocleidomastoid muscle to supply the skin over the
dle approximately 2 to 2.5 cm lateral to the nasion along mastoid and lateral occipital region o the scalp. T e greater
the superior orbital margin.4 T is oramen is palpable as occipital nerve is the dorsal ramus o the second cervical
the supraorbital notch. T e supratrochlear artery also tra- spinal nerve. It penetrates the trapezius muscle to provide
verses the orbit and wraps around the supraorbital rim sensation to the occipital and parietal regions o the scalp
approximately 1 cm medial to the supraorbital notch to extending anteriorly as ar as the vertex (Fig. 1-11).1
supply the medial orehead. T e supraorbital and supra- Deep to the subcutaneous connective tissue o the scalp
trochlear arteries supply the orehead and anterior scalp. lies the galea aponeurotica which, along with the occipital
T e remainder o the scalp is per used via anastomos- and rontalis muscles, orms the most important ascio-
ing branches o the occipital, postauricular, super cial muscular unit o the scalp. T e small muscular belly o
temporal, and supraorbital arteries (Fig. 1-10).2 O note, the occipital muscle originates rom the posterior mastoid
the connective tissue o the scalp contains brous reti- process and the posterior nuchal line o the occipital bone.
nacula which restrain vascular spasm, potentially leading It inserts into the galea aponeurotica and serves to pull
to increased surgical bleeding as vessels are transected.1 the entire scalp posteriorly. T e rontalis muscle originates
T e venous circulation o the scalp generally parallels rom the galea aponeurosis and inserts into the skin o the
arterial supply.6 Veins o the head and neck are devoid o orehead and eyebrows, contiguous with the super cial
valves and ow is, there ore, determined strictly by pres- muscular aponeurotic system (SMAS) consists o brous
sure gradients. Emissary veins pass through the calvarium, and muscle tissues ensheathing and connecting acial
allowing or communication between the extracranial and muscles which allow coordinated acial expressions. T e
intracranial vessels. T is may serve as a potential route or occipitalis muscle is innervated by the posterior auricular
spread o either in ectious or neoplastic processes. branch o the acial nerve whereas the rontalis receives its
T e sensory innervation o the scalp is provided by the innervation rom the temporal branch o the acial nerve.
terminal branches o cranial nerve V, the cervical plexus, I the temporal branch o the acial nerve is damaged, this
and dorsal rami. T e supratrochlear nerve parallels the may result in drooping o the eyebrow or ptosis o the
artery as a neurovascular bundle and innervates the medial upper eyelid. I paralysis o the temporalis muscle occurs,
orehead. T e supraorbital nerve passes through the supra- the surgeon may try to correct the damage by doing a brow
orbital oramen/notch and innervates the lateral orehead. li t, a coronal li t, a blepharoplasty, or a combination o
6 T ese two nerves course superiorly across the rontal bone these procedures. T e galea is a thick brous layer and as
such serves as a barrier against tumor spread.6 It may also
impede tissue movement when considering reconstructive
1
approaches. Galeal resection or relaxing incisions may be Crura of
necessary to allow adequate motion o aps in order to a ntihe lix
optimize reconstruction o scalp de ects. Tria ngula r fos s a
A layer o relatively avascular loose areolar connective
S ca pha
tissue lies below the occipito rontalis muscle and the brous Crus of he lix
galea aponeurotica. T e loose and avascular nature o this Concha
tissue creates an ideal plane or undermining the overlying
Ante rior
skin, connective tissue, and galea, allowing or increased incis ure He lix
tissue mobility. T is area is also sometimes re erred to as
Antihe lix
the “danger zone,” due to its potential or accumulation o
Me a tus
large volumes o blood or other uids and the possibility o Pos te rior
in ection spreading intracranially via emissary veins.1 s ulcus
T e lymphatic drainage o the scalp closely ollows Tra gus

C
h
the vascular supply. T e occipital scalp drains into scat- Antitra gus

a
p
tered occipital nodes along the superior nuchal lines. T e

t
e
Lobe Inte rtra gic

r
postauricular nodes located around the mastoid process incis ure

1
receive drainage rom the occipital, parietal, and temporal

:
scalp. T e orehead and temporal regions drain into the

:
preauricular or super cial parotid nodes.4,5

S
u
p
e
Figure 1-12 Cutaneous anatomy o the ear.

r
EAR

f
c
i
a
temporal artery, whereas the medial sur ace receives its

l
H
In general, the ear may be divided into three portions: the supply rom the posterior auricular and occipital arter-

e
a
inner ear, the middle ear, and the external ear. T e external ies. Its venous drainage parallels the arterial supply and

d
a
ear consists o the auricle and external auditory meatus, its lymphatic drainage ows to the preauricular, post-

n
d
which terminates at the tympanic membrane. T e auricle auricular, and super cial cervical nodes.1 T e sensory

N
is composed o irregularly shaped elastic cartilage and innervation o the ear includes the auriculotemporal

e
c
adipose tissue suspended below in the orm o the lobule. nerve, which originates rom the mandibular branch o

k
A
T is cartilaginous support is lined with perichondrium cranial nerve V. It innervates the anterosuperior quadrant

n
a
and draped with skin. T e skin o the anterior auricular o the anteriomedial hal o the auricle, the anterior hal

t
o
sur ace is tightly adherent to the underlying structure as o the external auditory meatus, the tympanic membrane,

m
y
compared to the posterior sur ace which is rather loose. a small portion o the superior auricle on the posterosu-
T ere are several anatomic landmarks which prove use ul perior sur ace, and most o the temporal scalp.2,5,6 Cranial
when describing the location o lesions on the ear, includ- nerves VII, IX, and X supply the concha, the posterior
ing the helix, scaphoid ossa, antihelix, triangular ossa, hal o the external auditory meatus, and a small patch o
crus o the helix, crura o the antihelix, concha (conchal skin on the posterior auricle. T e remainder o the auricle
bowl), tragus, antitragus, incisure (intertragal notch), and is innervated by the greater auricular nerve and the lesser
lobule (Fig. 1-12). T e entire auricle is xed to the cranium occipital nerve, which originate rom the cervical plexus.
by auricular ligaments.1 T e greater auricular nerve appears at the posterior edge
T e external auditory meatus consists o cartilage and o the junction o the middle and upper thirds o the ster-
bone lined with skin, which terminates at the tympanic nocleidomastoid muscle. It ascends across the sternoclei-
membrane. T e anterior and in erior lateral third o the domastoid directly toward the in erior auricle to supply
meatus is composed o cartilage, whereas the posterior and the anterolateral sur ace o the auricle, as well as most
superior portions o the lateral third and the entire medial o its posteromedial sur ace. T e lesser occipital nerve
two-thirds are composed o temporal bone. T e cartilagi- parallels the posterior edge o the sternocleidomastoid to
nous portion o the lateral third o the meatus is requently supply a small portion o the posteromedial auricle and
per orated by ssures called the ssures o Santorini. It is the skin overlying the mastoid.1
important to note that the superior pole o the parotid gland
lies immediately anterior and in erior to these ssures,
which may, there ore, represent a potential direct route or
tumor invasion o the parotid rom the external meatus.4 CHEEK
T e musculature o the ear consists o the anterior, supe-
rior, and posterior auricular muscles. T ey arise rom the T e cheek is a loosely de ned area which extends ante-
scalp and insert into the skin and auricle in areas named riorly rom the tragus o the ear to the oral commissure,
according to their location. T ey are innervated by pos- and rom the in erior orbital margin and the zygomatic
terior and temporal branches o the acial nerve, but are arch in eriorly to the mandible. T e nasolabial old
o minimal clinical signi cance i their unction is lost.2,5 extends in erolaterally rom the alar groove and separates
T e vascular supply o the ear originates rom the the cheek rom the perioral region, extending downward
external carotid artery. T e lateral sur ace receives its to become the melolabial old. T e cheek can be divided
supply rom the auricular branches o the super cial into our subsections: malar, in raorbital, masseteric, and 7
1
S upra orbita l
Infra orbita l

Zygoma tic
(ma la r)

Ma s s e te ric

Infra orbita l
S
Bucca l
e
c
t
i
o
n
1
Figure 1-13 Divisions o the cheek.
:
:
S
u
buccal (Fig. 1-13). T e malar portion o the cheek overlies
r
g
Me nta l
i
the malar prominence o the zygomatic bone. T e in raor-
c
a
bital cheek consists o the small area just below the in erior
l
P
r
orbit. T e tissue overlying the masseter muscle constitutes
i
n
Figure 1-14 Foramina o the ace.
c
the masseteric cheek. T e buccal cheek is the largest area
i
p
and extends rom the anterior edge o the masseter muscle
l
e
s
to the oral commissure and rom the in raorbital area to it courses through the gland and divides into its various
the mandible.3 branches.
T e underlying bony structure o the cheek includes T e sensory innervation or the cheek is derived rom
portions o the maxilla, the zygoma, and the mandible. multiple nerves, including the in raorbital and zygomati-
T e temporal process o the zygoma extends posteriorly co acial branches rom the maxillary division o cranial
to join the zygomatic process o the temporal bone, orm- nerve V and the auriculotemporal and buccal nerves rom
ing the zygomatic arch, and marking the superior aspect the mandibular branch o cranial nerve V. T e maxilla
o the cheek.2 While the malar prominence and zygomatic contains the in raorbital oramen, through which travels
arch o the zygomatic bone contribute to the overall shape the in raorbital nerve, which supplies the in raorbital,
o the cheek, the maxilla is the predominant bony support buccal, and portions o the malar cheek, as well as the
o the cheek and lower ace. Deep to the skin o the cheek lower eyelid, lateral nose, and upper lip. I a vertical line
lies the subcutaneous tissue. T e at o the cheek is thick- is drawn on the ace passing through the supraorbital
est in an area o the buccal cheek re erred to as the buccal oramen and the pupil, the in raorbital oramen would be
at pad. It is positioned between the buccinator mus- ound approximately 0.5 to 1.5 cm rom the in erior mar-
cle and the masseter muscle. It continues deep into the gin o the orbit along that line.1 T e mental oramen is also
ace between these two muscles and then superiorly into located approximately 1 cm above the in erior margin o
the temporal and in ratemporal ossae. T is space may the mandible along this same line (Fig. 1-14). T e zygo-
serve as a possible route or deep tumor extension, pos- matico acial nerve penetrates the zygoma through small
sibly even as ar as the maxilla or maxillary sinus, rom the oramina in the malar prominence to supply the overly-
mid cheek.1 ing skin o the malar cheek. As mentioned previously, the
While not palpable, the parotid gland is an important auriculotemporal nerve courses superiorly just anterior
structure which lies directly over the masseter muscle. to the auricle and supplies the masseteric cheek, a por-
T e posterior edge o the parotid gland begins at the tion o the ear, and the temporal scalp. T e buccal nerve
posterior edge o the mandibular ramus. Its superior leaves the in ratemporal ossa and descends medial to the
pole extends nearly to the zygomatic arch and its in erior mandible into the cheek along the super cial sur ace o
margin extends to the angle o the mandible. T e ante- the buccinator muscle. It innervates the overlying skin
rior margin o the gland extends a variable distance over and buccal mucosa. T e greater auricular nerve, which
the masseter. T e parotid gland is encapsulated in a thin originates rom the cervical plexus and ascends across the
layer o ascia. T e parotid duct, Stensen’s duct, is palpable sur ace o the sternocleidomastoid muscle, provides the
hal way between the zygomatic arch and the oral commis- sensory innervation or the lower portion o the masse-
sure along the anterior edge o the masseter as the teeth teric cheek (Fig. 1-15).
are clenched.5 T is duct pierces the buccinator muscle T e musculature o the cheek can be divided into
and empties onto the mucosal cheek opposite the second super cial and deep components. T e super cial mus-
upper molar. Should the duct be damaged during surgery, culature includes the zygomaticus major and minor, the
immediate repair is indicated.4– 6 In addition to its salivary orbicularis oculi, the risorius, the levator labii superioris,
8 unction, this gland serves to protect the acial nerve as and the platysma. T e deeper muscle group includes the
 La crima l n.
Zygoma ticote mpora l n.
1
S upra orbita l n.

S upra trochle a r n.

Infra trochle a r n.

Infra orbita l n.

C
h
a
Exte rna l

p
t
Te mpora l na s a l n.

e
r
bra nch

1
:
Zygoma tic

:
bra nch

S
u
p
Me nta l n.

e
r
Gre a te r

f
Bucca l

c
bra nch a uricula r n.

i
a
l
H
Zygoma ticofa cia l n.
Ma ndibula r

e
Ce rvica l

a
bra nch

d
A bra nch B Bucca l n.

a
n
Figure 1-15 Sensory and motor nerves o the ace (A) motor acial nerve and branches (B) sensory nerves.

d
N
e
c
k
A
levator anguli oris and the buccinator muscle. T e zygo- muscle, except the buccinator which receives its motor

n
a
maticus major and minor originate rom the zygoma and innervation rom its super cial sur ace.6

t
o
insert into the skin o the upper lip, serving to elevate T e acial nerve exits the stylomastoid oramen,

m
y
the lip. T e orbicularis oculi is a muscle which af ects courses in eriorly, gives of the posterior auricular nerve,
primarily the orbital and periorbital region, but some o and enters the posterior aspect o the parotid gland as
its bers extend onto the in raorbital cheek. Its circum- a single nerve trunk which arborizes into ve branches:
erential course around the orbit serves to close the eye temporal, zygomatic, buccal, marginal mandibular, and
tightly. T e risorius arises rom the parotid ascia and cervical (Figs. 1-15 and 1-16). T ese branches exit the
inserts into the skin at the corner o the mouth, serv- parotid along its anterior edge, arborize in either one or
ing to pull the oral commissure laterally. T e levator labii two stages, and an across the ace. T e temporal branch
superioris originates rom the maxilla just above the
in raorbital oramen. It inserts into the skin o the upper
lip and elevates the lip. T e platysma originates rom
the super cial ascia o the upper thoracic region and the
neck. It extends over the mandible and inserts into the
Fronta lis
skin o the oral commissures and pulls them in eriorly. Le s s e r
T e levator anguli oris arises rom the maxilla below the zygoma tic Orbicula ris
occuli
in raorbital oramen and inserts into the corner o the Gre a te r
mouth. It elevates the oral commissures. T e buccinator zygoma tic Proce rus
muscle plays a key role in the musculature o the cheek.
Pa rotid Na s a lis
It originates rom the pterygomandibular raphe, the pos- gla nd
terolateral aspect o the maxilla, and the medial aspect a nd duct
o the mandible. It inserts into the skin and mucosa o 1
2 Leva tor la bii
the upper and lower lips, and this muscular wall keeps 3 s upe rioris
the cheek pressed against the dentition and assists in 5 4
Ma s s e te r Orbicula ris
mastication.3
oris
T e muscles o the cheek all receive their motor inner-
De pre s s or
vation rom the acial nerve with the exception o the pla- Buccina tor la bii
tysma, which is innervated by the cervical plexus, and the Ris orius infe rioris
masseter, which is innervated by the mandibular division De pre s s or Me nta lis
a nguli oris
o the th cranial nerve. T e muscles o acial expression
all receive their innervation rom the deep sur ace o the Figure 1-16 Branches o the acial nerve. 9
1 innervates the rontalis muscle. T e marginal mandibu-
lar nerve innervates muscles in the perioral area and the
o the mandible, is drawn. Within the area delineated by
these lines, the branches o the acial nerve are at risk or
cervical branch innervates the neck. T e zygomatic and injury as they have not arborized extensively.2,4– 6 It may,
buccal branches o the acial nerve are, there ore, the only there ore, be wise to avoid vertical incisions overlying the
branches which provide innervation to the cheek area. in erior masseter and mandible as well as deep incisions
T e buccal branch exits the anterior edge o the parotid parallel to the zygomatic arch, so as to avoid injury to
and parallels the course o the parotid duct. It provides the marginal mandibular and temporal branches o the
innervation to the zygomaticus major and minor, levator acial nerve. T e danger zone is an area in which the sur-
labii superioris, risorius, levator anguli oris, and buccina- geon may pre er to place incisions parallel to the course
tor muscles. T e zygomatic branch provides secondary o the nerve regardless o the relaxed skin tension lines to
innervation to the zygomaticus major and minor mus- minimize the chance o nerve injury. It may also be use-
cles. While the temporal branch o the acial nerve does ul to use larger volumes o local anesthesia or saline or
not innervate anything in the cheek, it is at risk in the “hydrodissection” to li t the super cial tissues away rom
superior malar cheek area.1 As it exits the superior pole these deeper structures.
o the parotid, it travels a short distance over the zygo- T e vascular supply o the cheek originates rom the
S
e
matic arch be ore it enters the temporal region o the external carotid artery which gives of the acial artery in
c
t
i
scalp.2,4 For this short time, it is only protected by skin the neck and crosses the mandible at the anterior edge o
o
n
and a variable amount o adipose tissue and is, there ore, the masseter muscle. It courses across the ace directly
1
subject to injury. Loss o unction o the temporal branch super cial to the buccinator muscle and deep to the pla-
:
:
o the acial nerve results in ptosis o the brow and eyelid tysma, risorius, zygomaticus major and minor, and the
as well as inability to wrinkle the orehead. T e marginal levator labii superioris muscles. As it approaches the oral
S
u
mandibular nerve courses along the in erior edge o the commissure, it gives of the in erior and then the supe-
r
g
i
mandible through the parotid in the masseteric cheek. rior labial arteries be ore continuing along the naso-
c
a
l
Once it exits, it is also at risk or injury as it too is only acial sulcus as the angular artery. T e maxillary artery
P
r
covered by skin and a variable amount o subcutaneous also contributes to the vascular supply o the cheek. It is
i
n
c
tissue. T e marginal mandibular branch also remains as another branch o the external carotid artery which ulti-
i
p
a trunk and ails to arborize until it nearly reaches its mately branches into the in raorbital and buccal arteries.
l
e
s
intended target. T is means that surgical injury to this T e in raorbital artery passes through the in raorbital
nerve may result in a more complete motor de cit.1 It oramen to supply the overlying area o the cheek. T e
is also important to note that in the elderly, the mar- buccal artery originates medial to the mandible, descends
ginal mandibular nerve may descend up to 2 cm below in eriorly onto the super cial aspect o the buccinator,
the margin o the mandible. Due to the risk o injury to and supplies the skin and buccal mucosa. T e super cial
branches o the acial nerve as they exit the parotid, a temporal artery yields the transverse acial artery which
schematic “danger zone” has been devised (Fig. 1-17). passes through the superior pole o the parotid gland and
o create this zone, a line is drawn parallel to and 1 cm parallels the parotid duct to supply the malar region o
above the zygomatic arch rom the tragus to Whitnall’s the cheek (Fig. 1-18). T e venous circulation ollows the
tubercle o the lateral margin o the orbit. A vertical line same pattern as the arterial circulation, including the buc-
is drawn rom the lateral margin o the orbit to the in e- cal, in raorbital, super cial temporal, and anterior acial
rior margin o the mandible at the insertion o the masse- veins. T e anterior acial vein is the most important col-
ter muscle. Finally, a line curving 2 cm below the in erior lecting vein or venous drainage o the ace. O note, due
margin o the mandible, coursing posteriorly to the angle to the valveless nature o veins in the head and neck as
well as the numerous anastomotic connections between
them, it is possible or veins o the ace to communicate
with the cavernous sinus, most notably via the buccal or
Da nge r zone
in raorbital veins.1
Lymphatic drainage rom the cheek ows predomi-
nantly to the preauricular/parotid nodes. T is nodal basin
drains the masseteric cheek, the posterior hal o the buc-
Zygoma tic
cal cheek, and the lateral hal o the in raorbital cheek.
T e acial nodes which ollow the course o the acial vein
Te mpora l drain the remainder o the anterior cheek. From there, the
lymph ows into the submandibular and submental nodes
(Fig. 1-19).

Ce rvica l
Bucca l
NECK
T e neck can be divided into two triangles: anterior and
posterior. T e anterior triangle borders are de ned by the
anterior border o the sternocleidomastoid muscle, the
Ma rgina l in erior margin o the mandible, and the midline border
ma ndibula r
rom the tip o the chin to the jugular notch. T e posterior
10 Figure 1-17 Danger zones o the ace. triangle borders are composed o the sternocleidomastoid
 S upra orbita l ne rve s
1
S upra trochle a r
a rte ry

S upra trochle a r
S upra orbita l ne rve
a rte ry

S upe r cia l Auriculote mpora l

te mpora l ne rve s
a rte ry
Zygoma ticote mpora l
Angula r a rte ry ne rve s

C
Infra orbita l a rte ry

h
a
p
t
e
Tra nsve rs e fa cia l

r
a rte ry

1
:
:
Pa rotid gla nd Infra orbita l ne rve

S
u
p
Fa cia l ve in

e
r
f
c
Fa cia l a rte ry

i
a
Me nta l ne rve

l
H
e
a
d
Figure 1-18 Vasculature and sensory innervation o the cheek.

a
n
d
N
e
c
muscle, the clavicle in eriorly, and the anterior edge o the triangle are the sternocleidomastoid muscle, the posterior

k
A
trapezius muscle (Fig. 1-20). border o digastric muscle, and the superior belly o the

n
a
Each triangle can be divided into smaller triangles or omohyoid muscle. T e borders o the muscular triangle

t
o
more precise localization o skin lesions and better under- are the sternocleidomastoid muscle, the superior belly o

m
y
standing o neck anatomy. T e anterior triangle can be the omohyoid muscle, and the midline o the neck.3
subdivided into submental, submandibular, carotid, and T e posterior triangle o the neck can also be divided
muscular triangles. T e borders o the submental triangle into two smaller triangles: the subclavian and the occipi-
are the anterior belly o the digastric muscle, the hyoid tal. T e subclavian triangle’s borders are composed o the
bone body, and the midline o the neck. T e borders o clavicle, the sternocleidomastoid muscle and the in erior
the submandibular triangle are the two bellies o the digas- belly o the omohyoid muscle. T e occipital triangle’s bor-
tric muscle and the mandible. T e borders o the carotid ders are demarcated by the in erior belly o the omohyoid
muscle, the sternocleidomastoid muscle, and the trapezius
muscle.4
T e skin o the neck exhibits various unique proper-
ties. First o , it is very delicate and thin. It also contains
Re troa uricula r numerous hair ollicles, sweat glands, and some sebaceous
node s glands. T e super cial cervical ascia, a thin layer o loose
areolar connective tissue, allows or the skin o the neck
to be pliable and mobile. O note, the ascia is continuous
Fa cia l with the super cial ascia o the ace. T e platysma, located
node s
within the anterior triangle, is the only super cial muscle
in this area. It originates rom the ascia o the upper chest
Occipita l and continues superiorly over the mandible to insert into
node s the skin and super cial tissue o the lower ace. T e pla-
tysma muscle tenses the skin o the neck and depresses
the mouth. T e cervical branch o the acial nerve pro-
vides innervation to the platysma. Although the platysma
S ubme nta l
node s
is super cial to the sternocleidomastoid and reaches the
most in erior aspect o the occipital triangle, it does not
S ubma ndibula r provide coverage or protection to the spinal accessory
S upe r cia l node s nerve in the posterior triangle. T e sternocleidomastoid
pa rotid node s
muscle arises rom the sternum and the clavicle and passes
Figure 1-19 Lymphatics o the head and neck. obliquely across the neck to end at the mastoid process.3 11
1

Ma s toid
proce s s
S
e
c
t
i
o
n
Pos te rior
1
ce rvica l Pos te rola te ra l be lly of
S ubme nta l
:
tria ngle s te rnocle idoma s toid
:
tria ngle Ante rior
S
ce rvica l
u
La rynge a l
r
tria ngle
g
promine nce
i
c
S upra clavicula r
a
l
fos s a
P
r
i
Le s s e r Gre a te r
n
c
Clavicle
i
p
l
e
Figure 1-20 Anatomy o the neck. The neck can be urther divided into the anterior
s
and posterior cervical triangles.

Gre a te r a uricula r
ne rve

Ma rgina l ma ndibula r
bra nch of the
fa cia l ne rve
Le s s e r
occipita l
ne rve Ce rvica l bra nch of
the fa cia l ne rve

Tra nsve rs e ce rvica l

ne rve
Acce s s ory
ne rve

Tra pe zius
mus cle
Ante rior
Pos te rior tria ngle of
tria ngle of the ne ck
the ne ck

S te rnocle idoma s toid

S upra clavicula r mus cle
ne rve s

12 Figure 1-21 Sensory and motor supply o the neck and associated regions.
 T e hyoid bone is located in the anterior triangle o
the neck at the second cervical vertebral level. It can be
triangle, as it is covered only by skin and super cial ascia
at this location (Fig. 1-21). Damage to the spinal accessory
1
palpated just in erior to the chin within the midline o nerve can lead to a permanent loss o ability to elevate the
the neck. T e prominence o the thyroid cartilage is also shoulder on the ipsilateral side.1
palpable just below the hyoid bone. T e anterior lamina
o the cricoid cartilage, along with tracheal rings and the
isthmus o the thyroid gland, is located below the thyroid
cartilage.1 CONCLUSION
T e branches o the external carotid artery and the thy-
rocervical trunk, a branch o the subclavian artery, provide T e head and neck region contains many important ana-
the arterial supply to the neck skin. T e venous drainage tomic structures that every dermatologic surgeon must
o the neck occurs through the anterior super cial venous be amiliar with to provide the highest level o patient
system deep to the platysma muscle. It then drains into care. Preoperative anatomic knowledge and planning,
the anterior jugular vein, which may be connected to the along with intraoperative awareness and precision, are
common acial vein via a small communicating vein. T e necessary to provide the best cosmetic result with the

C
h
super cial veins o the posterior cervical triangle drain least possible unctional disturbance. With a ull under-

a
p
into the external jugular vein.6 standing o this anatomically complex region, the physi-

t
e
r
T e cervical plexus provides sensory innervation to the cian will have the con dence to per orm a wide range

1
skin o the neck. T e transverse cervical nerves cross the o super cial surgical procedures and the knowledge

:
sternocleidomastoid muscle at the midpoint horizontally required to minimize the likelihood o complications and

:
to provide sensory innervation to the mid-anterior cervi- adverse outcomes.

S
u
cal triangle. A series o supraclavicular nerves pass in e-

p
e
rior to the transverse cervical nerves to supply the skin

r
f
o the anterior and posterior cervical triangles as well

c
REFERENCES

i
a
as the upper pectoral area. T e lesser occipital nerve is

l
H
ound at the posterior border o the sternocleidomastoid

e
1. Greenway H , Breisch EA. Anatomy o the head and neck.

a
muscle near its midpoint. It travels superiorly, paralleling

d
In: Mikhail GR, ed. Practice of Mohs Micrographic Surgery.

a
the posterior border o the sternocleidomastoid muscle, Philadelphia, PA: W.B. Saunders; 1991:150– 166.

n
d
to innervate the posterior ear and mastoid area. Similarly, 2. Breisch EA, Greenway H . Surgical anatomy. In: Moy RL,

N
the greater auricular nerve arises rom the midpoint o the Lask GP, eds. Principles and Techniques of Cutaneous Surgery.

e
c
New York, NY: McGraw-Hill; 1996:35– 46.

k
sternocleidomastoid muscle with a superior trajectory to 3. Breisch EA, Greenway H . Cutaneous Surgical Anatomy

A
provide sensory innervation to the lower portion o the ear.

n
of the Head and Neck. New York, NY: Livingstone Inc.;

a
Understanding the location o the nerves in the neck is

t
1991:1– 133.

o
m
key or every surgeon so as to avoid complications. T e 4. Greenway H , Breisch EA. Super cial cutaneous anatomy.

y
marginal mandibular branch o the acial nerve descends In: Robinson JK, Arndt KA, Leboit PE, Wintroub BU, eds.
Atla s of Cutaneous Surgery. Philadelphia, PA: W.B. Saunders
into the anterior triangle o the neck along the mandible Co; 1996:5–19.
be ore innervating the muscles o the lower lip. T e mar- 5. Breisch EA, Greenway H . Fundamental anatomy or the
ginal mandibular nerve is at risk during surgery in this practice o cutaneous surgery. In: Arndt KA, Leboit PE,
area. T e spinal accessory nerve, which supplies the ster- Robinson JK, Wintroub BU, eds. Cutaneous Medicine and
nocleidomastoid and trapezius muscles, is at risk in the Surgery. Philadelphia, PA: W.B. Saunders Co; 1996:111– 119.
6. Breisch EA, Greenway H . Super cial anatomy o the head
posterior triangle during surgery. T is is especially true as and neck. In: Greenway H , Barrett L, eds. Preoperative and
it exits rom the junction o the upper and middle thirds Postoperative Dermatologic Surgical Care. New York, NY:
o the sternocleidomastoid muscle to enter the posterior Igaku-Shoin Medical Publishers; 1994:71– 92.

13
 Ch a p t e r

2 Preoperative Evaluation
Bichchau M. Nguyen & Chrysalyne D. Schmults

in t r Od u c t iOn Gen er a l Ov er v iew

Preoperative evaluation o patients undergoing cutaneous A thorough preoperative evaluation provides a global
surgery serves multiple purposes: (1) it provides patients overview o patient actors that can complicate the planned
and physicians with the opportunity to discuss pertinent surgical procedure: past medical and surgical history,
risks, bene ts, and alternatives or the planned procedure; medications, allergies, and social history and habits ( able
(2) to identi y signi cant patient, lesion, or surgical actors 2-1). Diabetes, cardiovascular heart disease, immunosup-
that could increase the risk o complications; and (3) to pression, blood-borne in ections, bleeding disorders, and
plan care so as to mitigate identi ed risk actors. neuropsychiatric conditions are medical conditions that
T e extent o preoperative evaluation depends in part may in uence operative planning. All prior surgeries, sur-
on the type o procedure, the duration and degree o inva- gical complications and outcomes, and the presence o
siveness o the procedure, and the use o topical, local, prosthetic joints or implantable cardiac devices should be
or general anesthesia. T e vast majority o dermatologic speci cally elicited rom the patient.
surgeries are conducted under local anesthesia. A brie Obtaining an accurate medication record is crucial but
questionnaire addressing major risk actors or bleeding, challenging, especially in the elderly population, whose
in ection, allergies, and implantable cardiac devices that medication lists can be extensive. It can be help ul to con-
may limit the use o electrocautery devices, will typically rm the medication list on record with the patient and
suf ce or super cial procedures such as biopsies and his or her caregiver, given the varying degrees o compli-
curettage. Surgical excisions and Mohs micrographic sur- ance and to inquire speci cally about over-the-counter
gery require a more thorough investigation o the patient’s medications and herbal supplements as these are o ten
past medical history and lesion(s) o interest to identi y underreported. In ormation on allergies should contain
and appropriately mitigate possible complications. Preop- agent name and type o reaction. Patients may sometime
erative evaluation or elective cosmetic procedures such as con use an adverse e ect or vasovagal response with a
laser therapies, liposuction, hair transplant, sclerotherapy, true allergy. Allergic reactions can be anaphylactic (type
injections o llers, and botulinum toxins varies signi - I) or delayed hypersensitivity (type IV) reactions. Facial
cantly depending on the procedure and will, there ore, be edema and respiratory distress are important type I reac-
covered in their corresponding speci c chapters. tions that should be asked about, especially with respect

TABLE 2-1
P op a ss ssm of S g P s
Past medical history Medical: cardiovascular disease, hypertension, diabetes, bleeding disorders, malignancy,
immunosuppression, blood borne in ection (HIV, hepatitis C)
Neuropsychiatric: claustrophobia, anxiety, panic attacks, dementia
Past surgical history Prosthetic joints, coronary artery stents, implantable cardiac devices
Prior surgical complications and outcomes
Medications Prescribed medications: antiplatelet, anticoagulant, antibiotics, analgesics
Over the counter medications (herbal supplements and vitamins)
Allergies Medications: agent and type o reaction (adverse ef ects vs. true allergy; delayed hypersensitivity vs.
anaphylactic response)
Topical preparations: cleansing antiseptics, dressings, adhesives
Social history Alcohol consumption: servings per week
Smoking: pack years
Illegal drug use
Social situation: caregiver, transportation, type o job, access to medical care
to antibiotic and latex allergies. Aside rom medications,
patients can also develop allergies (mostly allergic con-
aged 65 years or older a ected.3 Diabetic patients have an
increased risk o in ection a ter general and cardiac sur-
1
tact dermatitis) to antiseptic agents, topical antibiotics, geries. However, con icting data exist regarding the risk
and surgical dressings. o postoperative complications in diabetics undergoing
Social habits such as smoking, consumption o alcohol, dermatologic surgery. In the absence o prophylactic anti-
and use o illicit drugs should be noted, although data on biotics, the risk o perioperative in ection in these patients
the true impact o these actors on surgical risks are mixed. ranges rom 1.1%4 to 10%.5 Some studies have ound an
Finally, dif cult social situations including lack o social increased risk o in ections in patients with diabetes com-
support, caregivers, or stable housing can make postopera- pared to those without,6 whereas others have noted no
tive wound care challenging. Long-distance travel, lack o di erence between the two groups.5 Patients with diabe-
transportation, and limited access to local medical care tes do not appear to have an increased risk o dehiscence,
may delay detection and treatment o postoperative com- bleeding, or other nonin ectious complications.6 Little
plications. T ese actors should be considered in choosing data exist on the e ects o insulin dependence or periop-
appropriate surgical repairs and ollow-up care. erative glycemic control on the risk o dermatologic surgi-
A ocused physical examination should be per ormed to cal complications. T e variable prevalence o diabetics in

C
h
assess the overall health status o the patient and charac- study cohorts, along with di erent de nitions o in ection,

a
p
teristics o lesion(s) being treated. T e correct procedure, inconsistent use o cultures, and the observational nature

t
e
r
diagnosis, and site should be con rmed with patients (via o these studies contribute to the dif culty o translating

2
a mirror i needed) and/or caregivers and veri ed with the available data into management guidelines. One may,

:
available medical records, ideally including photographs. there ore, advise patients with diabetes that they may have

:
Use o prebiopsy photographs to identi y the correct an increased risk o surgical site in ection, but, as addressed

P
r
lesion is highly recommended because studies have shown later in this chapter, standard use o prophylactic antibiot-

e
o
that both patients and physicians are prone to identi y- ics in this patient group is not warranted.

p
e
ing incorrect sites in a signi cant percentage o surgical

r
a
t
cases—16% and 6%, respectively, in a prospective cohort

i
v
HyPer t en SiOn

e
study involving patients undergoing Mohs micrographic

E
v
surgery.1 When a lesion cannot be de nitively identi ed

a
l
T e main concern in patients with uncontrolled hyperten-

u
using the available resources, rozen biopsy o the sus-

a
t
pected site can be per ormed with continuation to surgery sion is an increased risk o intra- and postoperative bleed-

i
o
ing. Studies rom the 1970s showed that patients with a

n
i biopsy is positive or malignancy, or 3 month clinical
ollow-up i the biopsy is negative.2 blood pressure o 150/100 mm Hg had twice the risk o
Once the correct lesion has been identi ed, the physi- postoperative hematoma ollowing rhytidectomy com-
cian can proceed to assess the extent o spread, evidence pared to normotensive counterparts.7 More recent meta-
o local or metastatic spread, proximity to unctionally analysis has shown that patients with blood pressures as
or aesthetically critical structures, easibility o obtaining high as 180/100 mm Hg do not have an increased risk
adequate surgical margins, and any potential neurologic o perioperative cardiac complications such as myocar-
or vascular complications. Depending on these actors, a dial in arction, arrhythmia, and stroke when undergoing
nodal examination, imaging studies or consultation with general anesthesia or planned surgeries.8 Concerns exist
other specialists might be warranted. T e patient should that blood pressure lability during cutaneous surgery may
be made aware o potential risks that may pertain to be signi cant, raising the question o whether intraop-
their procedure (such as in ection, bleeding, hematoma, erative monitoring is warranted or baseline hypertensive
seroma, numbness, paralysis, asymmetry, and scarring) patients. However, studies have ound little uctuation in
prior to surgery. A comprehensive discussion o these blood pressure be ore, during, or a ter cutaneous surgery
risks as well as the bene ts o the proposed treatment and in both normotensive and hypertensive patients.9 Cuta-
possible alternatives is needed in order or the patient to neous surgery may be sa ely conducted in patients with
make a ully in ormed choice to proceed. Expectations a baseline blood pressure o 180/100 mm Hg or less. For
regarding the anticipated extent o surgery and the length patients with blood pressures >180/100 mm Hg, the pro-
o recovery should be addressed preoperatively as well. cedure, i not urgent or emergent in nature, should be
rescheduled so that urther evaluation by a primary care
physician or hypertension specialist may take place. A
Med ic a l c OMOr bid it ieS component o observed hypertension could be secondary
to anxiety as well as the “white coat phenomenon” which
Patients with certain medical comorbidities deserve addi- can be e ectively mitigated with use o low dose anxiolyt-
tional preoperative consideration due to their suspected ics and nonmedical interventions such as music and main-
or proven impact on the surgical risks o in ection, bleed- taining a calm surgical environment. Patients should also
ing, or wound healing. T ese special patient populations be reminded to continue taking their prescribed antihy-
are discussed in more detail subsequently. pertensive medications on the day o surgery.

d ia be t eS c a r d iOva Sc u l a r d iSea Se
As o 2012, 9.3% o all children and adults in the United T ree main considerations in patients with cardiovascular
States were shown to have diabetes, with 25.9% o patients disease undergoing dermatologic surgery are anticoagulation, 15
1 implantable cardiac devices, and prophylactic antibiot-
ics or endocarditis. T ese patients are o ten prescribed
to the patient’s cardiac tissue and a pulse generator that
discharges electrical signals to treat detected arrhythmias.
antiplatelet agents, or example, aspirin and clopidogrel, Electromagnetic inter erence rom electrosurgical devices
or primary and secondary prevention o coronary artery can either impair the sensing capabilities o the leads or
disease, or to prevent stenosis o coronary artery stents. trigger inappropriate electrical discharges rom the pulse
Patients with atrial brillation or prosthetic valves may generator.
receive anticoagulation with war arin to prevent clot or- T e most commonly used electrosurgical device in
mation, thromboembolic events, and valve ailure. In gen- dermatologic surgery is the hy recator, which generates
eral, all o these agents should be continued, since their low power, high requency alternating current through
discontinuation in patients undergoing dermatologic sur- an electrode that can either be monoterminal or biter-
gery has been associated with catastrophic thrombotic minal. T e hy recator itsel can transmit current through
adverse events such as myocardial in arctions and stent the tissue through one or two prongs, that is, monopo-
restenosis (see Anticoagulants section under medications). lar or bipolar, respectively. Less electrical current passes
Discontinuation o any prescribed anticoagulants should through the patient with a bipolar hy recator. As a result,
be discussed with and cleared by the patient’s primary recommendations or patients with implantable cardiac
S
e
care physician or cardiologist. Although these agents devices have included use o handheld bipolar electro-
c
t
i
may increase the risk o bleeding, the reported complica- cautery, short bursts o current, temporary deactivation
o
n
tions are o ten localized and not li e threatening. T us, o cardiac devices with magnets, intraoperative cardiac
1
the risks o stopping anticoagulants usually outweigh monitoring, and postoperative device unction testing to
:
:
potential bene ts. Rare exceptions may include patients reduce the risk o electromagnetic inter erence.
undergoing major reconstructions such as ree aps. In Recent experimental data, however, suggest that the
S
u
such cases, decisions regarding perioperative anticoagu- hy recator is sa e to use in patients with implantable cardiac
r
g
i
lation can be made with input rom the entire physician devices. Weyer et al. tested the electromagnetic inter er-
c
a
l
team. More detailed in ormation on the speci c agent and ence o two commonly used hy recators on six Medtronic
P
r
recommended management can be ound in the “Antico- devices (three pacemakers and three de brillators) using
i
n
c
agulants” section. Appropriate endocarditis prophylaxis is an industry standard saline–collagen gel model that simu-
i
p
discussed in the section on prophylactic antibiotics. lates human so t-tissue conduction. ested settings include
l
e
s
monoterminal and biterminal con gurations, typical and
maximum power (10 and 30 W, respectively), intermittent
St en t S on/o and continuous on modes, with various distances
between the hy recators and the cardiac devices. T ere
Dual antiplatelet therapy with aspirin and typically clopi- was no electromagnetic inter erence at any o the tested
dogrel is recommended or patients with recently placed settings or the de brillators and no accidental discharge
bare metal or drug eluting stents as treatment or coro- o electrical currents. Inhibition o ventricular pacing was
nary arterial disease. Patients with bare metal stents noted at a distance o 1 cm, and o atrial pacing at 3 cm.
should continue taking aspirin and clopidogrel or at least T e authors prospectively used hy recators or hemostasis
1 month a ter stent placement, while those with drug elut- in 40 patients with cardiac devices and noted no adverse
ing stents should be on these agents or at least 1 year a ter events.14
the procedure to prevent stent thrombosis.10 Current pub- Based on these data, hy recators may be sa ely used
lished guidelines recommend continuation o dual anti- within 2 in o cardiac devices without the need or biter-
platelet therapy or all dermatologic procedures, including minal con guration, intraoperative cardiac monitoring or
Mohs micrographic surgery with extensive reconstruc- postoperative testing o device unction. Routine derma-
tion.11– 13 Elective procedures can be delayed until the tologic surgery utilizing only the hy recator or hemosta-
patient has nished the recommended course o dual sis and electrodesiccation is generally sa e or all patients
antiplatelet therapy. I medically necessary procedures in with pacemakers and de brillators when the surgical site
highly vascularized areas are required, one might consult is more than 2 in away rom the cardiac devices.
the managing cardiologist to consider holding clopidogrel
therapy or 1 week or ticlopidine or 2 weeks prior to the
procedure. bl eed in G d iSOr d er S
T e three most common congenital coagulation disor-
iMPl a n t a bl e c a r d ia c d ev ic eS ders are von Willebrand disease, actor VIII de ciency
(hemophilia A), and actor IX (hemophilia B).15 A bleed-
Implantable cardiac devices include pacemakers, de bril- ing diathesis o ten presents as slow but persistent oozing
lators, and cardiac synchronization therapy devices. Indi- rom multiple operative sites rather than as localized rapid
cations or pacemakers include heart blocks, bradycardia, bleeding. Patients with von Willebrand disease have a 10%
and atrial brillation. De brillators are indicated or pri- risk o clinically signi cant bleeding rom a decreased
mary prevention o arrhythmias in patients with heart quantity or quality o von Willebrand actor, which pro-
ailure, and secondary prevention or ventricular arrhyth- vides binding sites or platelets and actor VIII. reatment
mias. Cardiac resynchronization therapy devices are with desmopressin, 1-desamino-8-arginine vasopressin
designed to improve symptoms in patients with advanced (DDAVP), or select actor VIII concentrates is typically
heart ailure through the use o ventricular synchroniza- indicated or 1 day be ore and 3 to 5 days a ter minor sur-
16 tion. T ese devices contain sensing leads that connect gery and up to 10 days a ter major surgery. T e patient’s
bleeding time should be corrected to 100% o normal or
the perioperative period. For hemophilia A and B, ac-
since depending on the clinical setting and patient popu-
lation, the rate o undiagnosed HIV or hepatitis in ection
1
tor VIII and actor IX concentrates, respectively, can be can be as high as 10%.19
in used to raise actor levels to 100% o normal preopera-
tively and 30% to 50% postoperatively during the wound
healing phase.15 Preoperative evaluation should elicit a
hemostasis history a ter prior surgical procedures since Med ic a t iOn S
laboratory studies such as bleeding time, P , and P
cannot reliably predict intra- and postoperative bleeding. Polypharmacy, de ned as using ve or more prescription
Consultation with hematology services is highly recom- medications, is especially prevalent in the elderly popu-
mended or appropriate clinical and laboratory preopera- lation, with 29% o patients over the age o 65 taking 10
tive evaluation, as well as or management o trans usion or more medications in a week.20 Polypharmacy increases
products during the perioperative period. Meticulous the risks o drug adverse events; one-third o these events
hemostasis, minimizing undermining, and requent post- relate to the use o insulin, digoxin, or war arin.21 Hemor-
operative ollow-up are also help ul in reducing the risks o rhagic complications account or nearly one in ve adverse

C
h
serious bleeding complications in this patient population. events. T e remaining adverse e ects result rom electro-

a
p
lyte, metabolic, and gastrointestinal disturbances.22 E orts

t
e
should be made to obtain an accurate and complete

r
2
medication list rom patients undergoing dermatologic
bl OOd -bOr n e in ec t iOn —HePa t it iS surgery to ensure appropriate medication monitoring.

:
:
a n d Hiv Adjustments to certain medications to reduce the risks o

P
r
bleeding, blood pressure lability, poor glycemic control,

e
o
With continuing improvements in antiretroviral therapies and altered mental status may be indicated. Speci c ques-

p
e
and supportive care, patients with HIV now have a sig- tions regarding the use o anticoagulants and antiplatelet

r
a
t
ni cantly longer li e expectancy and are there ore more agents, corticosteroids, immunosuppressants, over the

i
v
e
commonly encountered in the outpatient and surgical counter medications, and herbal supplements should be

E
included in any preoperative questionnaire. Management

v
settings. Higher risks o postoperative surgical site in ec-

a
l
tions in patients with HIV are o ten assumed but there o these classes o medications is detailed below.

u
a
is little available data to con rm this hypothesis. A mul- Anticoa gula nts. Management o anticoagulants in the

t
i
o
ticenter prospective cohort study in Italy examining the perioperative period has changed signi cantly in the past

n
incidence o surgical site in ection in HIV patients under- several years. In the past, withholding these agents be ore
going a variety o inpatient surgical procedures revealed a and a ter the procedure was common. Now, consensus
10% rate o in ection overall and a 12.5% rate o in ection guidelines recommend continuation o these agents in the
ollowing plastic/dermatologic surgical procedures. Anti- vast majority o patients undergoing dermatologic sur-
biotic prophylaxis use varied widely among the surgical geries, since the risks o catastrophic thrombotic events
subspecialties, ranging rom 50% o patients undergoing associated with their discontinuation ar outweigh the
plastic/dermatologic surgical interventions, up to nearly increased risk o bleeding complications.
100% in patients undergoing cesarean sections or thoracic T e list o medications that a ect platelet unction and
surgeries.16 However, there were no data on in ection rates the coagulation cascade continues to grow ( able 2-2).
in non-HIV patients or outpatient surgical procedures in Aspirin and thienopyridines (e.g., clopidogrel, ticlopidine,
this study, which precludes extrapolation o these data and prasugrel) inhibit platelet unction or the li espan o
to outpatient dermatologic surgery. A meta-analysis o the platelets. Heparin, low–molecular-weight heparin (e.g.,
orthopedic surgery studies showed no statistically signi - enoxaparin and dalteparin), direct thrombin inhibitors
cant di erences in the incidence o surgical site in ection (e.g., dabigatran, argatroban, and lepirudin), and war arin
between HIV and non-HIV patients.17 Given the paucity all target speci c components o the coagulation pathway.23
o data supporting an increased risk o in ection in HIV Indications or these agents include primary and secondary
patients, antibiotic prophylaxis or this patient population prevention o cardiac and neurologic thrombotic events,
in the setting o routine outpatient dermatologic surgery is pulmonary embolism, and deep vein thrombosis. T e most
not currently recommended. commonly encountered agents in dermatologic surgery are
Aside rom patient sa ety, one must also consider per- aspirin, clopidogrel, and war arin.24
sonnel sa ety when per orming surgical procedures on Patients on anticoagulants are at increased risk o
patients with HIV, hepatitis B or hepatitis C in ections. bleeding complications although the overall absolute risk
A survey o Mohs micrographic surgeons revealed an or these events remains low and none o the reported
astonishingly high 65% rate o needlestick and other complications have been li e threatening. T e risk o
exposure injury within the past year, with 5% reporting severe complications, de ned as considerable intra- or
exposure to patients with HIV or hepatitis. Strategies postoperative bleeding, acute hematoma, ap or gra t
such as use o double gloves or surgeons, assistants, necrosis, and dehiscence, was 1.3% or patients taking
and laboratory technicians, ormal training o labora- aspirin, and 5.7% or those taking war arin based on a
tory personnel, and warning labels on surgical trays are meta-analysis o six published studies encompassing
associated with lower relative risk o exposure injuries. approximately 1400 patients.25 Clopidogrel-containing
Warning labels on the patient’s chart, though used by regimens have a higher risk o severe complications (3%)
almost hal o surveyed surgeons, did not impact the risk than aspirin alone (0.5%).26 A large prospective study
o injuries.18 Universal precautions are recommended on 1900 patients undergoing dermatologic surgeries 17
1 TABLE 2-2
a o g se o O p S g

r s o S
c omp o
d o c o s
a o g M h sm o a o o a o S g Mo o g
Aspirin Irreversible inhibition o 7–10 d 0.5%–1.3%25,26 None
cyclooxygenase
Clopidogrela Irreversible inhibition o adenosine 7–10 d 3%a26 None
Ticlopidine diphosphate
Prasugrel
5.7%25
S
War arin Vitamin K antagonist, inhibition o 2–5 d PT, INR
e
c
synthesis o actors II, VII, IX, and X
t
i
o
LMWH—enoxaparin and dalteparin Selective inhibition o actor Xa 24 h N/A aPTT
n
1
Dabigatran, argatroban a , lepirudin a Selective reversible direct thrombin 24 h N/A aPTT
:
inhibitor
:
S
a
Cook Norris RH, JAAD, 2011—Table 3.
u
r
g
showed that clopidogrel increased bleeding risk by 4.7 T e management o new antiplatelet agents, prasug-
i
c
a
old, war arin by 10 old, and both agents by 40 old.24 rel and ticagrelor, is similarly based on comparative data
l
P
A signi cantly increased risk o bleeding in patients on against clopidogrel. Prasugrel unctions in a manner
r
i
n
two or more anticoagulants compared to those on one similar to that o clopidogrel but has higher potency. In
c
i
p
or no anticoagulant was con rmed by Shimizu et al.27 in animal models, prasugrel inhibition o platelet aggre-
l
e
s
a large retrospective study involving 1000 patients. No gation was 10 and 100 times more potent than that o
di erence in in ection rates attributable to use o antico- clopidogrel and ticlopidine, respectively.32 Clinically,
agulants was noted. this agent has a higher documented risk o atal bleeding
Several new anticoagulants and antiplatelet agents have and the need or trans usion in a study o 13,608 patients
entered the market in the last 5 years. T ree new oral undergoing percutaneous cardiac inter vention or acute
anticoagulants, designed to replace war arin, have been coronary syndrome.33 On the other hand, ticagrelor, a
approved or stroke and systemic embolism prevention reversible antiplatelet aggregation agent, has demon-
in patients with atrial brillation: dabigatran, rivaroxaban, strated a risk o severe bleeding equivalent to that o
and apixaban. No data exist on the e ects o these agents clopidogrel, 2.9% versus 3.2%, in an RC study o 13,408
on bleeding risk during or a ter cutaneous surgery. How- patients.34 Consultation with cardiology regarding the
ever, Healey et al. compared the periprocedural bleed- perioperative management o these two agents is pru-
ing rates in 4591 patients on dabigatran (110 mg or 150 dent, particularly in the case o patients taking prasugrel
mg) or war arin undergoing at least one invasive proce- who may have a higher bleeding risk than those taking
dure, including pacemaker/de brillator insertion, den- clopidogrel.
tal procedures, diagnostic procedures, cataract removal, Heparin and low– molecular-weight heparin prepara-
colonoscopy, and joint replacement. T ey ound no sta- tions, such as enoxaparin and dalteparin, are associated
tistically signi cant di erences in bleeding rates among with higher risks o bleeding in patients undergoing car-
those taking dabigatran 110 mg po daily, 150 mg po daily diac and gynecological surgeries. However, because o
or war arin (3.8%, 5.1%, and 4.6%, respectively).28 Simi- their intramuscular and intravenous administration, these
larly, rivaroxaban appears to have a statistically equiva- agents are relatively rarely seen in the outpatient setting
lent risk o major bleeding to war arin, 3.6% versus 3.4%, where dermatologic surgeries are conducted.
in a multicenter randomized controlled trial (RC ) with Although anticoagulants increase the risks o bleeding
over 14,000 patients.29 Apixaban, the latest approved oral and severe complications, discontinuation o these agents
anticoagulant, has a slightly lower reported risk o major can result in catastrophic li e-threatening thromboem-
bleeding compared to war arin, 2.1% versus 3.09% in an bolic events. T ere have been case reports o stroke, IA,
RC study o over 18,000 patients30 and a risk o major pulmonary embolism, DV , MI, clotted prosthetic aortic
and clinically relevant nonmajor bleeding events compa- valve, and retinal artery occlusion occurring shortly a ter
rable to that o aspirin (4.5% vs. 3.8%) in a randomized discontinuation o anticoagulants or dermatologic sur-
study o stroke prevention with 5599 patients.31 On the gery.35– 37 T ese events are thought to be secondary to a
basis o these data, management o these three new oral rebound hypercoagulable state due to more rapid deple-
anticoagulants should mirror that o war arin or cutane- tion o antithrombotic protein C and S relative to clotting
ous surgeries, namely, continuation o the agents i they actors during the rst ew days o anticoagulant reinitia-
are prescribed as monotherapy, unless patient comorbidi- tion.38 Given that the risk o thromboembolic events out-
ties and extent o planned surgery warrant discussion with weighs the risk o bleeding rom dermatologic surgery,
the prescribing physician regarding consideration o a prescribed monotherapy aspirin, clopidogrel, and war a-
18 brie interruption in therapy. rin should be continued in the perioperative period. For
patients taking both aspirin and clopidogrel, or aspirin
and war arin, or clopidogrel and war arin, elective proce- r e t in Oid S
1
dures should be delayed until one or both o the agents
are no longer medically indicated. For medically neces- Chemoprophylaxis with acitretin does not appear to
sary procedures, the surgeon should discuss the situation increase the risks o in ection, hypertrophic granulation
with the prescribing physician to determine whether one tissue, scars, or dehiscence in organ transplant recipients
o the agents can be sa ely discontinued. For monitoring undergoing Mohs or surgical excisions or nonmelanoma
o war arin, older studies suggested that checking INR skin cancers.44 T ere ore, or nonelective surgeries, there-
within 24 hours o surgery and use o a target INR goal o ore, patients may continue taking acitretin in the peri-
<3.5 could minimize the risks o intra- and postoperative operative period. For ablative resur acing, the standard
bleeding.39 However, even with an INR <3.5, patients on o care is discontinuation o isotretinoin or 6 months’
war arin still have an increased risk o bleeding compared preprocedure to avoid the risks o delayed healing and
to patients not taking anticoagulants.40 Appropriate surgi- excessive granulation tissue based on the manu acturer’s
cal techniques should be employed to minimize intra- and recommendations.45 Acitretin can be withheld or 20 days
postoperative bleeding in these cases. prior to the procedure i concerns o similar complications

C
exist, although none have been reported in the literature or

h
In summar y, all prescribed monotherapy anticoagu-

a
by the manu acturer. In our practice, patients on low-dose

p
lants and antiplatelets should be continued or derma-

t
e
(25 mg daily or less) acitretin or skin cancer prevention

r
tologic surgeries. Aspirin may only be discontinued i it

2
is sel -prescribed by the patient or used solely or pain continue on this medication in the pre- and postoperative
period surrounding Mohs surgery and reconstruction.

:
relie . For patients on combination therapy with two or

:
more agents, discussion with the managing physicians

P
r
is warranted to determine whether any o those agents biOl OGic r eSPOn Se MOd i ier S

e
o
can be sa ely discontinued. Appropriate laborator y

p
e
monitoring, meticulous surgical techniques, and close

r
Biologic response modi ers or tumor necrosis actor

a
t
ollow-up will minimize complications in this patient

i
( NF) antagonists such as in iximab, etanercept, and

v
e
population. adalimumab are most commonly encountered in patients

E
v
In our practice, nonprescribed aspirin is discontinued 7 with psoriasis, in ammatory bowel disease, or in amma-

a
l
u
days be ore and 3 days a ter the procedure, and a preoper- tory arthropathies. T ese medications may increase the

a
t
ative INR is checked within 24 hours with a target o <3.0.

i
risks o opportunistic bacterial, mycobacterial, and ungal

o
n
Consultation with the managing physician is standard in ections. However, available data have shown no signi -
or patients on two or more anticoagulants to determine cant increase in perioperative in ections or dehiscence with
whether discontinuation o one or more agents is easible NF antagonists in rheumatoid arthritis and in amma-
to reduce the risk o bleeding. tory bowel disease patients undergoing elective ankle and
oot surgeries, joint replacements, and, abdominal surger-
ies.46,47 Use o NF antagonists in patients with in amma-
c Or t ic OSt er Oid S tory bowel disease actually improved healing o surgical
wounds, stulas, and mucosal ulcerations. A paucity o
Chronic corticosteroid use carries two particular con-
data exists on the perioperative risks o psoriatic patients
cerns relating to dermatologic surgery: (1) hypothalamus–
on biologic response modi ers. Perioperative manage-
pituitary axis (HPA) suppression requiring supplement
ment options include continuing these agents with close
stresses dose o steroids and (2) poor wound healing. HPA
postoperative ollow-up, or discontinuing them 1 week
suppression can occur in patients receiving prednisone
be ore and 1 to 2 weeks a ter the surgery.41,48 Consultation
20 mg po or higher dosing daily or more than 3 weeks.
with the managing physician has been recommended or
T ese patients should be continued on their normal daily
other immunosuppressive agents such as methotrexate,
prednisone dose and should receive additional corticoste-
cyclosporine, tacrolimus, azathioprine, and mycopheno-
roid or anticipated surgical stress, the dosing o which
late mo etil since usage, dosing, and perioperative man-
depends on the extent o the surgery. Super cial proce-
agement vary depending on disease under treatment and
dures such as skin biopsies and short procedures <1 hour
other medical comorbidities. However, skin cancer is com-
in duration under local anesthesia typically do not require
mon in organ transplant patients who are o ten on such
supplementation. For minor procedures or those that last
medications, and dermatologic surgical procedures are
longer than 1 hour, supplemental hydrocortisone 25 mg
per ormed routinely in such patients without reports o
po once should be considered on the day o the surgery.41
increased complications. T us, in our practice, no special
T ese recommendations are based on general surgery data
perioperative considerations are made or patients taking
since little data exist in the dermatologic surgery literature
these drugs (other than discussions with the treating team
regarding perioperative steroid management. Chronic
regarding dose reductions to boost immunity in patients
glucocorticoid use also inter eres with multiple phases o
who are developing multiple cancers and may, there ore, be
healing, leading to delayed wound healing and an increased
overly immunosuppressed).
risk o in ection.42 Even mid- to high-strength uorinated
topical steroids can delay wound healing through impair-
ment o reepithelialization, collagen ormation, and angio- Her ba l Su PPl eMen t a t iOn
genesis.43 Patients should be made aware o these potential
complications prior to surgery so that nonessential topical Use o herbal supplements has increased dramatically in
steroid use may be discontinued. the United States, accounting or more than $5 billion 19
1 TABLE 2-3
50
c ommo H S pp m s e s o Op r s

H
S pp m Poss ef so S g r s
Garlic Increased bleeding due to direct antithrombotic e ects and increased e ects o war arin, ASA/NSAIDs
Hypotension due to increased e ects o antihypertensive drugs
Ginseng Increased bleeding due to direct anticoagulant e ects and increased e ects o war arin, ASA/NSAIDs
Increased blood pressure and heart rate
Ginkgo Increased bleeding due to direct anticoagulant e ects and increased e ects o war arin, ASA/NSAIDs
Hypotension due to vasodilator e ects
Ma Huang Increased bleeding due to inhibition o complement cascade
S
e
c
Vitamin E Increased bleeding due to inhibition o platelet unction and vitamin K dependent clotting actors
t
i
o
Echinacea Possible poor wound healing in chronic users
n
1
:
:
S
in sales every year. T ere are more than 20,000 herbal smokers have an approximately our times higher risk
u
r
medicines available on the market, with echinacea, gar- o tissue necrosis, and a two times higher risk o surgi-
g
i
c
lic, goldenseal, ginseng, ginkgo, aloe, ma huang, St John’s cal site in ection, dehiscence, and healing delay. Former
a
l
wort, valerian, and cranberry as the top selling products. smokers have a signi cantly lower risk o surgical com-
P
r
i
Up to 85% patients with skin diseases report using com- plications compared to current smokers but still higher
n
c
than that o nonsmokers.53 However, prospective 5 year
i
plementary and alternative medicines, most commonly
p
l
e
vitamins and herbal supplements, yet only a raction o data on surgical excisions o over 7000 skin lesions
s
these patients report their use to physicians.49,50 T e physi- in 4100 patients revealed no di erence in the rates o
ological e ects are not ully understood or the majority o in ection, bleeding, dehiscence, or ap/ gra t necrosis
the herbal supplements. Studies on the more commonly between smokers and nonsmokers. T e same conclu-
prescribed agents have shown inter erence with hepatic sions held when the two groups were matched or age,
cytochrome P450 enzymes, and interactions with many gender, geographic location, and outdoor occupational
prescribed medications including anticoagulants, antihy- exposure. T e total complication rate was approximately
pertensives and antidepressants, and clinical e ects on 4% or both groups.54 Although smoking has deleteri-
the cardiovascular, neurologic, and coagulation systems. ous e ects on the overall health o the patient, it does
T ese e ects may result in prolonged anesthesia, bleed- not de nitively increase complication rates in patients
ing, cardiovascular, and neurologic instability in the peri- undergoing dermatologic surger y. Perioperative smok-
operative period ( able 2-3).50,51 Given these potential ing cessation has produced mixed results in terms o
complications, the American Society o Anesthesiologists reducing complications in smokers undergoing general
recommends discontinuation o all herbal medications surgery. Patients who stopped smoking 4 to 8 weeks
or 2 weeks prior to surgery under general anesthesia. be ore and 2 to 4 weeks a ter the surgical procedure had
Although no consensus recommendations exist regarding a reduction in surgical site in ections but not in healing
dermatologic surgery, advising patients to discontinue all complications.53
herbal supplements 1 to 2 weeks be ore procedures such
as excisions and Mohs micrographic surgery would be
reasonable. a n t ibiOt ic Pr OPHyl a x iS
SOc ia l Ha bit S: a l c OHOl Prophylactic antibiotics serve two purposes: (1) to prevent
local surgical site in ection and (2) to reduce bacteremia
a n d SMOk in G resulting in endocarditis and prosthetic joint in ections.
Recent years have seen a shi t away rom routine prescrip-
Alcohol may increase bleeding tendencies through inhi- tion o prophylactic antibiotics, given that the risks o
bition o platelet aggregation, decreasing clotting actors, adverse e ects rom antibiotics outweigh their bene ts in
and increasing brinolysis and vasodilation.52 Patients most cases based on available data. I a decision is made to
may there ore be instructed to stop or reduce alcohol provide antibiotic prophylaxis, it must be given within 1
intake 48 hours be ore and a ter surgery. hour o the procedure to ensure biologic availability at the
Smoking has not been de nitively shown to increase time o incision. opical antiseptics, surgical eld prepa-
the risk o surgical complications in patients undergoing ration and maintenance, sterile equipment during wound
routine dermatologic surgery. Large scale meta-analyses closure, and surgical technique have a greater in uence on
comparing complication rates between smokers and risk o surgical site in ection than the presence or absence
nonsmokers undergoing general surger y have ound that o antibiotic prophylaxis.
20
 TABLE 2-4
involve the oral mucosa. Patients with penicillin allergy
may take levo oxacin or surgeries in the groin or on the
1
d m o og P o s w h H gh r s lower extremities, and clindamycin or azithromycin or
a
o S g S i o surgeries in other sites.57 When local surgical site in ection
is suspected, a clinical evaluation should be per ormed and
Any procedure breaching oral mucosa
a culture should be obtained, ollowed by empiric treat-
Any procedure involving in ected skin or musculoskeletal tissue ment with penicillin- or cephalosporin-based antibiotics
High risk o local surgical site in ection based on unless there is a high clinical index o suspicion or in ection
Anatomical site: lower legs, groin with methicillin-resistant Staphylococcus aureus (MRSA).
Reconstruction: gra ts, wedge excision on the ear or lip T e incidence o hospital and community acquired MRSA
skin and so t-tissue in ections has increased in recent
a
Based on published guidelines rom American Board o Dermatology years, especially in elderly, A rican–American, and male
and American Society o Dermatologic Surgeons.57,58
patients, and those with a history o hospitalization or
surgeries in the previous year.59 Rates o MRSA in ection
also vary between geographic locations and communities.

C
h
For patients with a history o MRSA in ection or coloniza-

a
p
Pr OPHyl a x iS a Ga in St l Oc a l tion, clindamycin or trimethoprim-sul amethoxazole may

t
e
Su r Gic a l Sit e in ec t iOn

r
be used or empiric coverage or MRSA pending culture

2
sensitivity results.57

:
:
T e risk o surgical site in ection in dermatologic surgery
is quite low, ranging rom 1% to 2% or excisions and Mohs

P
Pr OPHyl a x iS a Ga in St

r
e
micrographic surgery in multiple studies.55 Medical comor-

o
en d Oc a r d it iS

p
bidities, smoking status, alcohol consumption, location

e
r
and extent o tumor, and reconstruction techniques have

a
t
i
been examined as potential actors in uencing the risk o Bacteremia rom surgical procedures can lead to endocar-

v
e
surgical site in ection. Con icting data on the degree o ditis in high-risk patients with speci c valvular or cardiac

E
v
risk attributable to these actors make establishing consen- de ects. T e American Heart Association narrowed its

a
l
u
sus guidelines challenging. Diabetic patients and smokers de nition o patients at high risk or in ective endocar-

a
t
i
do not necessarily have higher in ection risks, as previ- ditis in 2007 to include only those with prosthetic heart

o
n
ously discussed. Surgeries on the lower legs or in the groin, valves, cardiac transplantation with valvulopathy, cyanotic
wedge excisions o the lip and ear, and reconstruction with congenital heart de ects that are unrepaired or repaired in
gra ts carry a > 5% risk o in ection based on prospec- the previous 6 months, or history o in ective endocarditis
tive data rom 5000 lesions in 2400 patients rom a single ( able 2-6). Patients with mitral valve prolapse, rheumatic
practice in Australia.4 However, prospective cohort data heart disease, bicuspid valve disease, calci ed aortic ste-
rom the United States on 1000 patients undergoing Mohs nosis, septal de ects, and hypertrophic cardiomyopathy
micrographic surgery showed a culture proven in ection are no longer considered high risk. Furthermore, high-
rate o only 0.7% overall, and 3.1% or nose aps.56 Anti- risk patients should only receive in ective endocarditis
biotic prophylaxis to reduce local surgical site in ections prophylaxis when undergoing high-risk surgical proce-
may be considered on an individual basis or surgeries on dures, namely surgeries involving the oral mucosa or clini-
the lower legs and in the groin, wedge excisions, and gra ts cally in ected skin and musculoskeletal tissue.60 T e vast
based on the overall clinical assessment o the patient majority o dermatologic surgeries do not require in ec-
and procedure ( able 2-4). Universal prophylaxis or all tive endocarditis antibiotic prophylaxis even or high-risk
patients under these circumstances is not currently sup- patients. Immunocompetent patients undergoing exci-
ported by available data. sions and Mohs micrographic surgery have a 1% to 3%
T e choice o antibiotic depends on the organisms that risk o transient bacteremia,61 a signi cantly lower risk
need to be covered, which varies with body location ( able than that rom routine activities such as brushing teeth
2-5). Most skin ora, such as Staphylococcus and Strepto- and eating.62 Antibiotic prophylaxis has not been shown
coccus species, can be treated adequately with cephalexin. to protect patients rom endocarditis resulting rom these
Amoxicillin is the pre erred agent or procedures that rare transient bacteremias. Moreover, antibiotics have a

TABLE 2-5
a o P oph s o P o o lo S g S i o

S g S a o
Groin and lower legs Cephalexin 2 g po
If penicillin a llergic: TMP SMX DS 1 tablet po OR Levof oxacin 500 mg po
Wedge excisions o ear or lip, Cephalexin 2 g po OR Dicloxacillin 2 g po
gra ts, nose f aps If penicillin a llergic: Clindamycin 600 mg po, OR Azithromycin or Clarithromycin 500 mg po

Source: Data rom published guidelines rom American Board o Dermatology, 2008.
21
1 TABLE 2-6
immunosuppressive medications, radiation, HIV in ec-
tion, poor nutritional status, and hemophilia ( able 2-7).
c o d o s w h H gh r sk o i v Patients at high risk o prosthetic joint in ection require
e do d s antibiotic prophylaxis when undergoing surgeries involv-
ing oral mucosa, in ected skin and tissues, or procedures
Prosthetic cardiac valves
with high risk o local surgical site in ections.64 Assess-
History o in ective endocarditis ment o surgical site in ection risk was previously dis-
Cardiac transplant recipients who develop valvulopathy cussed in detail, but mainly takes into account anatomical
sites such as legs and groin, and reconstruction with
Cyanotic congenital heart de ects that are unrepaired, repaired gra ts. Routine antibiotic prophylaxis or all patients with
within last 6 mo, or with residual de ects at or near prostheses
prosthetic joints is not recommended or any other pro-
Source: Data rom American Heart Association consensus guidelines, cedures including Mohs micrographic surgery. Patients
2007.60 with orthopedic pins, plates, or screws also do not require
antibiotic prophylaxis.57 At postoperative ollow-up, both
the surgical site and the area with joint prosthesis should
S
e
be inspected or redness, pain, swelling, and warmth as
c
t
i
long list o potential side ef ects including gastrointestinal signs o in ection. Suspected local surgical site in ection
o
n
disturbance, drug interactions, cutaneous eruptions, ana- in patients with a prosthetic joint must be aggressively
1
phylactic reactions, and drug resistance. Adherence to the treated with initial empiric therapy designed to cover S.
:
:
published guidelines will reduce the number o patients aureus and beta-hemolytic streptococci. T e de nitive
receiving unnecessary antibiotics without compromising antibiotic choice should ultimately be guided by sensitiv-
S
u
overall protection against in ective endocarditis. ity results rom cultures.
r
g
i
c
a
l
P
Pr OPHyl a x iS a Ga in St
r
i
n
c On Sen Su S St a t eMen t :
c
HeMa t OGen Ou S j Oin t in f ec t iOn
i
p
Pr OPHyl a c t ic a n t ibiOt ic S
l
e
s
otal prosthetic joint in ection may result rom transient
bacteremia during surgery, or more commonly rom late An advisory statement published by the Journal o the
onset bacteremia secondary to local surgical site in ec- American Academy o Dermatology in 2008 recom-
tion.63 T e occurrence o either scenario may be reduced mended prophylactic antibiotics or high-risk patients
with preoperative antibiotic prophylaxis. T e same prin- with surgical sites that are in ected or involving oral
ciple guides antibiotic prophylaxis or joint in ection as mucosa. Antibiotics may also be considered in patients
or in ective endocarditis: prophylaxis is indicated only with severe in ammatory dermatoses, gra ts, aps on the
in high-risk patients undergoing high-risk procedures. nose, wedge excisions o the ear or lip, and surgeries on
Patients with an increased risk o prosthetic joint in ec- the lower extremities or in the groin, to decrease the risk
tion are generally those with prior joint in ections, or a o surgical site in ection.57
history o insulin-dependent diabetes, malignancy, or At our procedural dermatology and Mohs micrographic
immunosuppression. Recognized causes o immuno- surgery center in a tertiary care academic institution,
suppression include in ammatory arthropathies such as prophylactic antibiotics to prevent surgical site in ection
systemic lupus erythematosus and rheumatoid arthritis, are routinely used only in patients with in ected wounds
(although surgery is usually delayed in such cases until
in ection has resolved), patients with extensive in am-
matory skin diseases, or oral aps/gra ts. Saline irrigation
is used prior to closure o all wounds. For prevention o
TABLE 2-7 in ective endocarditis and hematogenous total joint in ec-
P s H gh r sk o P os h jo tion, antibiotics are prescribed only or high-risk patients
i o undergoing surgery involving the oral mucosa, groin,
lower legs, or in ected skin. Cephalexin 2 g po is the pre-
All patients soon a ter prosthetic joint surgery
erred antibiotic or cutaneous cases, and amoxicillin 2 g
History o prosthetic joint in ection po or mucosal cases. Clindamycin 600 mg po or levo ox-
Insulin dependent diabetes acin 500 mg po are alternatives or patients with penicillin
allergies ( able 2-8).
HIV in ection Given that the guidelines or antibiotic prophylaxis or
Malignancy in ective endocarditis and hematogenous prosthetic joint
in ection have undergone signi cant changes in recent
Inf ammatory arthropathies (lupus, rheumatoid arthritis)
years, patients may have come to expect antibiotic pro-
Drug or radiation induced immunosuppression phylaxis even when it is no longer indicated. Consultation
Hemophilia with the patient’s managing cardiologist or orthopedic
surgeon to determine whether extenuating circumstances
Poor nutritional status
exist, as well as discussion o the treatment guidelines
Source: Data rom American Association o Orthopedic Surgeons and patient education will help to clari y the appropriate
22 consensus guidelines, 2009. course o action.
 TABLE 2-8
1
a o P oph s o P o o i e o s o to P os h jo i o

S g S a o
Skin Cephalexin 2 g po
If penicillin a llergic: Azithromycin or Clarithromycin 500 mg po OR Clindamycin 600 mg po
Oral mucosa Amoxicillin 2 g po
If penicillin a llergic: Azithromycin or Clarithromycin 500 mg po OR Clindamycin 600 mg po

Source: Data rom published guidelines rom American Board o Dermatology, 2008.

c On c l u SiOn 11. Chu MB, urner RB, Kriegel DA. Patients with drug-eluting

C
stents and management o their anticoagulant therapy in cu-

h
a
taneous surgery. J Am Acad Dermatol. 2011;64(3):553– 558.

p
T is chapter has reviewed the major preoperative con- 12. Douketis JD, Berger PB, Dunn AS, et al; American College

t
e
o Chest Physicians. T e perioperative management o anti-

r
siderations o which surgeons should be aware prior to

2
thrombotic therapy: American College o Chest Physicians
per orming dermatologic surgical procedures, as well Evidence-Based Clinical Practice Guidelines (8th Edition).

:
:
as current data and recommendations regarding antibi- Chest. 2008;133(6 Suppl):299S– 339S.
otic prophylaxis. Standardized checklists summarizing

P
13. Korte W, Cattaneo M, Chassot PG, et al. Peri-operative man-

r
e
this in ormation can be help ul in alerting physicians to agement o antiplatelet therapy in patients with coronary ar-

o
tery disease: joint position paper by members o the working

p
their patients’ medical conditions preoperatively, so that

e
group on Perioperative Haemostasis o the Society on T rom-

r
appropriate evaluation and/or action can be taken, and

a
bosis and Haemostasis Research (G H), the working group

t
i
complications can be avoided. Physicians can use this pre-

v
on Perioperative Coagulation o the Austrian Society or An-

e
operative screening to adjust care as needed in accordance esthesiology, Resuscitation and Intensive Care (OGARI) and

E
v
with each individual patient’s needs, thereby optimizing the Working Group T rombosis o the European Society or

a
l
u
both patient sa ety and outcomes in the dermatologic sur- Cardiology (ESC). T romb Haemost. 2011;105(5):743– 749.

a
14. Weyer C, Siegle RJ, Eng GG. Investigation o hy recators and

t
gical setting.

i
o
their in vitro inter erence with implantable cardiac devices.

n
Dermatol Surg. 2012;38(11):1843– 1848.
15. Peterson SR, Joseph AK. Inherited bleeding disorders in der-
r e er en c eS matologic surgery. Dermatol Surg. 2001;27(10):885– 889.
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2011. 2011. http://www.cdc.gov/diabetes/pubs/estimates14. 18. LoPiccolo MC, Balle MR, Kouba DJ. Sa ety precautions in
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9. Larson MJ, aylor RS. Monitoring vital signs during outpa- 23. Callahan S, Goldsberry A, Kim G, Yoo S. T e management
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under local anesthesia. Dermatol Surg. 2004;30(5):777– 783. 2012;38(9):1417– 1426.
10. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/ 24. Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, Fu P, Ma-
AHA/SCAI Guideline or Percutaneous Coronary Interven- loney ME. Prospective evaluation o dermatologic surgery
tion: executive summary: a report o the American College complications including patients on multiple antiplatelet
o Cardiology Foundation/American Heart Association ask and anticoagulant medications. J Am Acad Dermatol. 2011;
Force on Practice Guidelines and the Society or Cardio- 65(3):576– 583.
vascular Angiography and Interventions. Circulation. 2011; 25. Lewis KG, Du resne RG Jr. A meta-analysis o complica-
124(23):2574– 25609. tions attributed to anticoagulation among patients ollowing 23
1 cutaneous surgery. Dermatol Surg. 2008;34(2):160– 164; dis-
cussion 164– 165.
43. Hengge UR, Ruzicka , Schwartz RA, Cork MJ. Adverse
e ects o topical glucocorticosteroids. J Am Acad Dermatol.
26. Cook-Norris RH, Michaels JD, Weaver AL, et al. Complica- 2006;54(1):1– 15; quiz 16– 18.
tions o cutaneous surgery in patients taking clopidogrel- 44. an SR, ope WD. E ect o acitretin on wound healing in
containing anticoagulation. J Am Acad Dermatol. 2011; organ transplant recipients. Dermatol Surg. 2004;30(4 Pt 2):
65(3):584– 591. 667– 673.
27. Shimizu I, Jellinek NJ, Du resne RG, Li , Devarajan K, Perlis 45. Abdelmalek M, Spencer J. Retinoids and wound healing. Der-
C. Multiple antithrombotic agents increase the risk o post- matol Surg. 2006;32(10):1219– 1230.
operative hemorrhage in dermatologic surgery. J Am Acad 46. Bibbo C, Goldberg JW. In ectious and healing complica-
Dermatol. 2008;58(5):810– 816. tions a ter elective orthopaedic oot and ankle surgery during
28. Healey JS, Eikelboom J, Douketis J, et al. Periprocedural tumor necrosis actor-alpha inhibition therapy. Foot Ankle
bleeding and thromboembolic events with dabigatran com- Int. 2004;25(5):331– 335.
pared with war arin: results rom the Randomized Evaluation 47. Colombel JF, Lo tus EV Jr, remaine WJ, et al. Early postoper-
o Long- erm Anticoagulation T erapy (RE-LY) randomized ative complications are not increased in patients with Crohn’s
trial. Circulation. 2012;126(3):343– 348. disease treated perioperatively with in iximab or immuno-
29. Patel MR, Maha ey KW, Garg J, et al; ROCKE AF Investiga- suppressive therapy. Am J Ga stroenterol. 2004;99(5):878– 883.
tors. Rivaroxaban versus war arin in nonvalvular atrial bril- 48. Rosandich PA, Kelley J III, Conn DL. Perioperative man-
S
lation. N Engl J Med. 2011;365(10):883– 891. agement o patients with rheumatoid arthritis in the era o
e
30. Granger CB, Alexander JH, McMurray JJ, et al; ARIS- biologic response modi ers. Curr Opin Rheumatol. 2004;
c
t
i
O LE Committees and Investigators. Apixaban versus 16(3):192– 198.
o
n
war arin in patients with atrial brillation. N Engl J Med. 49. Fuhrmann , Smith N, ausk F. Use o complementary and
1
2011;365(11):981– 992. alternative medicine among adults with skin disease: up-
31. Flaker GC, Eikelboom JW, Shestakovska O, et al. Bleeding dated results rom a national survey. J Am Acad Dermatol.
:
:
during treatment with aspirin versus apixaban in patients 2010;63(6):1000– 1005.
with atrial brillation unsuitable or war arin: the apixaban 50. Broughton G II, Crosby MA, Coleman J, Rohrich RJ. Use o
S
u
versus acetylsalicylic acid to prevent stroke in atrial brilla- herbal supplements and vitamins in plastic surgery: a practi-
r
g
tion patients who have ailed or are unsuitable or vitamin K cal review. Pla st Reconstr Surg. 2007;119(3):48e– 66e.
i
c
a
antagonist treatment (AVERROES) trial. Stroke. 2012;43(12): 51. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and periop-
l
P
3291– 3297. erative care. JAMA. 2001;286(2):208– 216.
r
i
32. Niitsu Y, Jakubowski JA, Sugidachi A, Asai F. Pharmacology 52. Salem RO, Laposata M. E ects o alcohol on hemostasis. Am
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c
o CS-747 (prasugrel, LY640315), a novel, potent antiplatelet J Clin Pathol. 2005;123(Suppl):S96–S105.
i
p
agent with in vivo P2Y12 receptor antagonist activity. Semin 53. Sorensen L . Wound healing and in ection in surgery. T e
l
e
T romb Hemost. 2005;31(2):184– 194. clinical impact o smoking and smoking cessation: a systematic
s
33. Hochholzer W, Wiviott SD, Antman EM, et al. Predictors review and meta-analysis. Arch Surg. 2012;147(4):373–383.
o bleeding and time dependence o association o bleed- 54. Dixon AJ, Dixon MP, Dixon JB, Del Mar CB. Prospective study
ing with mortality: insights rom the rial to Assess Im- o skin surgery in smokers vs. nonsmokers. Br J Dermatol.
provement in T erapeutic Outcomes by Optimizing Plate- 2009;160(2):365– 367.
let Inhibition With Prasugrel–T rombolysis in Myocar- 55. Shurman DL, Benedetto AV. Antimicrobials in dermato-
dial In arction 38 ( RI ON- IMI 38). Circula tion. 2011; logic surgery: acts and controversies. Clin Dermatol. 2010;
123(23):2681– 2689. 28(5):505– 510.
34. Cannon CP, Harrington RA, James S, et al. Comparison o 56. Maragh SL, Brown MD. Prospective evaluation o surgical
ticagrelor with clopidogrel in patients with a planned in- site in ection rate among patients with Mohs micrographic
vasive strategy or acute coronary syndromes (PLA O): a surgery without the use o prophylactic antibiotics. J Am
randomised double-blind study. Lancet. 2010;375(9711): Acad Dermatol. 2008;59(2):275– 278.
283– 293. 57. Wright I, Baddour LM, Berbari EF, et al. Antibiotic prophy-
35. Khali eh MR, Redett RJ. T e management o patients on laxis in dermatologic surgery: advisory statement 2008. J Am
anticoagulants prior to cutaneous surgery: case report o Acad Dermatol. 2008;59(3):464– 473.
a thromboembolic complication, review o the literature, 58. Rossi AM, Mariwalla K. Prophylactic and empiric use o antibi-
and evidence-based recommendations. Pla st Reconstr Surg. otics in dermatologic surgery: a review o the literature and prac-
2006;118(5):110e– 117e. tical considerations. Dermatol Surg. 2012;38(12):1898–1921.
36. Kovich O, Otley CC. T rombotic complications related to 59. Awad SS, Ehabash SI, Lee L, Farrow B, Berger DH. Increasing
discontinuation o war arin and aspirin therapy periopera- incidence o methicillin-resistant Staphylococcus aureus skin
tively or cutaneous operation. J Am Acad Dermatol. 2003; and so t-tissue in ections: reconsideration o empiric antimi-
48(2):233– 237. crobial therapy. Am J Surg. 2007;194(5):606– 610.
37. Alam M, Goldberg LH. Serious adverse vascular events as- 60. Wilson W, aubert KA, Gewitz M, et al. Prevention o in-
sociated with perioperative interruption o antiplatelet and ective endocarditis: guidelines rom the American Heart
anticoagulant therapy. Dermatol Surg. 2002;28(11):992– 998; Association: a guideline rom the American Heart Associa-
discussion 998. tion Rheumatic Fever, Endocarditis, and Kawasaki Disease
38. Grip L, Blomback M, Schulman S. Hypercoagulable state and Committee, Council on Cardiovascular Disease in the Young,
thromboembolism ollowing war arin withdrawal in post- and the Council on Clinical Cardiology, Council on Cardio-
myocardial-in arction patients. Eur Heart J. 1991;12(11): vascular Surgery and Anesthesia, and the Quality o Care and
1225– 1233. Outcomes Research Interdisciplinary Working Group. Circu-
39. Ah-Weng A, Natarajan S, Velangi S, Langtry JA. Preoperative lation. 2007;116(15):1736– 1754.
monitoring o war arin in cutaneous surgery. Br J Dermatol. 61. Carmichael AJ, Flanagan PG, Holt PJ, Duerden BI. T e
2003;149(2):386– 389. occurrence o bacteraemia with skin surgery. Br J Dermatol.
40. Blasdale C, Lawrence CM. Perioperative international nor- 1996;134(1):120– 122.
malized ratio level is a poor predictor o postoperative bleed- 62. Everett ED, Hirschmann JV. ransient bacteremia and endo-
ing complications in dermatological surgery patients taking carditis prophylaxis. A review. Medicine (Baltimore). 1977;
war arin. Br J Dermatol. 2008;158(3):522– 526. 56(1):61–77.
41. Hernandez C, Emer J, Robinson JK. Perioperative management 63. Berbari EF, Hanssen AD, Du y MC, et al. Risk actors or
o medications or psoriasis and psoriatic arthritis: a review or prosthetic joint in ection: case-control study. Clin Infect Dis.
the dermasurgeon. Dermatol Surg. 2008;34(4):446–459. 1998;27(5):1247– 1254.
42. Karukonda SR, Flynn C, Boh EE, McBurney EI, Russo GG, 64. American Academy o Orthopaedic Surgeons, American Den-
Millikan LE. T e e ects o drugs on wound healing– part II. tal Association. Prevention of Orthopaedic Implant Infection in
24 Speci c classes o drugs and their e ect on healing wounds. Patients Undergoing Dental Procedures Guideline. Rosemont,
Int J Dermatol. 2000;39(5):321– 333. IL: American Academy o Orthopaedic Surgeons; 2012.
 Ch a p t e r

3 Informed Consent
Tanya Nino, Rache Epstein, Andrea Smith, & A e Torres

In t r o d u c t Io n be an in erred acceptance o a proposed medical interven-

tion. Examples include the ollowing:
A physician's duty has been succinctly described in medi- ■ A patient does not withdraw or object when the medical
cine's amous oath “ o Do No Harm.” Although this con- assistant obtains the vital signs.
cept may seem straight orward, de ning harm can be ■ A patient removes his or her shirt to show a skin lesion
more complex. A physician is in a unique position, pos- prior to the examination o the area.
sessing knowledge o the possible harm that may occur as ■ A patient applies sun block when advised to protect the
a result o a procedure, which must then be communicated skin rom ultraviolet light.
to the patient. T ere are many types o in ormed consent,
which are generally based on the risk o the procedure to In these situations, the patient's agreement is assumed
be per ormed. raditional in ormed consent depends on by his or her conduct in response to the proposed inter-
the patient's capacity to comprehend and appreciate the vention. T is type o implied consent, otherwise known
nature and consequences o a decision regarding medi- as simple consent, is appropriate or low-risk decisions.
cal treatment; however, even routine situations can be Accordingly, it is an accepted practice or the dermato-
complicated when they involve patients with individual logic surgeon to explain the low-risk intervention in sim-
needs and challenges. Our ultimate goal as physicians is ple terms and to accept the patient's implied consent.1
to have open communication with in ormed and engaged As circumstances become more complex, however,
patients. We will address how physicians can do their it becomes more precarious to rely on implied consent
utmost to appropriately in orm every patient in their prac- alone. T is is because the burden o proo usually lies with
tice about the risks inherent in the procedures that have the physician to show that the patient consented through
been recommended or them, with emphasis on ways to his or her conduct.2 Even in some low-risk situations, it
improve the in ormed consent process. may be wise to obtain express consent. Examples include
the ollowing:
u n d er s t a n d In g c o n s en t : ■ Per orming a physical examination o a sensitive area.
t h e Ba s Ic s ■ Low-risk procedures that are potentially pain ul (i.e.,
cryotherapy, intralesional injection).
■ Prescription medications that pose some risk o an
Obtaining proper consent is o paramount importance in undesirable result (i.e., topical chemotherapy).
dermatologic surgery. By obtaining consent or treatment,
a physician invites the patient to take part in medical deci- In the a orementioned examples, it is prudent at mini-
sion-making. Consent can all into the categories shown mum to obtain verbal consent as well as verbalization o
in Figure 3-1. understanding rom the patient.
Implied consent is typically employed in basic o ce As circumstances begin to involve a greater degree o
situations, where a patient's conduct can be considered to risk to the patient, in ormed consent with shared deci-
sion-making comes to the ore ront. Examples include the
ollowing:
Implie d Cons e nt Expre s s Cons e nt
■ Using isotretinoin to treat severe acne in a ertile woman.1
■ Surgical excision versus topical imiquimod or the treat-
ment o a super cial basal-cell carcinoma on the arm.
■ T e option o a sentinel lymph node biopsy or a Stage II
Conduct Ve rba l melanoma.

O ten, it is best to obtain written consent rom the

patient. It is important to remember that in ormed con-
sent is more than a patient's signature on a orm; rather,
Circums ta nce s Writte n
it encompasses a process during which the physician can
explore the patient's needs, values, and belie s and invite
patients to participate in their own healthcare decisions.
Figure 3-1 Types o consent. During this process, physicians should discuss the nature
1 o the medical intervention at length, including the pur-
pose, risks, bene ts, and alternatives, a ter which the
brings a claim that in ormed consent was absent or de ec-
tive, it must be shown that the de endant (physician) did
patient should explicitly agree to or re use the proposed not con orm to the standard o care when disclosing the
intervention.1 pertinent risks, bene ts, and alternatives o a procedure.3,4
In other words, one must determine what a reasonably pru-
dent physician in a similar situation would have disclosed
d ev el o pmen t o f t h e In f o r med regarding the given procedure.3,4 But what determines the
c o n s en t pr In c Ipl e: l eg a l standard against which a de endant may be measured?
Many jurisdictions will consider the community standard
Ba c kg r o u n d to be that prevailing within a physician's local geographic
area; however, with advances in communication, tech-
In ormed consent law derives rom the principles o nology, and electronic documentation, the scope o the
human autonomy and sel -determination.3 T ese basic duty has expanded. T us, a physician's “community” may
human rights are undamental to medical ethics and pro- include a national and even an international level.
vide a basis or in ormed consent and shared decision- In addition to determining what a reasonable physician
S
e
making. In addition, the concept o in ormed consent would disclose to a patient, in most jurisdictions it is impor-
c
t
i
tant to assess what a reasonably prudent patient would have
o
derives rom the intentional torts o a ssault and battery.
n
Assault is a volitional act intended to cause another per- expected in order to make a decision in a given situation,
1
son to ear harm ul or o ensive contact.3,4 Battery takes based on the in ormation presented to that patient. Inad-
:
:
place when there is intentional physical contact to a per- equate in ormation could lead a patient to choose an option
that results in an un avorable outcome. T is approach
S
son against his or her wishes, which a reasonable person
u
would consider harm ul or o ensive.3,4 In medical battery means that in most jurisdictions the dermatologic surgeon
r
g
i
should disclose all in ormation that a patient would con-
c
cases, the patient (plainti ) must prove that the unauthor-
a
ized contact resulted in harm.3,4 In surgical dermatology, sider material to his or her decision-making.6
P
r
a physician may be subject to allegations o battery under What makes a risk material? T e answer lies in the risk's
i
n
c
the ollowing circumstances4,5: requency o occurrence, as well as its severity.6 It may not
i
p
be relevant to ocus on risks that are remote or unlikely
e
s
■ T e surgeon per orms a procedure without a patient's to arise; however, i such risks could have severe conse-
consent. quences, they could become pertinent to the patient.
■ T e surgeon per orms a procedure that is signi cantly It is important to keep in mind that damages must
di erent rom the one to which the patient consented. also be incurred in order or an action or medical neg-
■ T e surgeon surpasses the scope o the consent. ligence to be present. In other words, even i in ormed
consent was lacking or de ective, the other elements o
As such, obtaining proper consent and acting accord- medical negligence must be satis ed in order or a patient
ingly are o paramount importance in dermatologic surgery. to recover damages. T is means that the actual injury
T e law also recognizes the concept o negligence as must have arisen as a result o occurrence o the nondis-
a completely separate distinct cause o action rom bat- closed risk.6
tery law. Medical negligence takes place when a breach o
duty occurs that compromises the standard o care and
results in unintended harm to the patient. T e compo-
nents required to prove medical negligence are listed in a d eq u a t e In f o r med
able 3-1.
Each o these components must be present in order to
c o n s en t : el emen t s
prove a case o medical negligence. First, physicians have
a duty o reasonable care to patients to avoid oreseeable Shared decision-making and respect or patient autonomy
risks o harm. Medical malpractice may take place when a are the key concepts behind the doctrine o in ormed con-
treatment alls below the accepted standard o care (breach sent. T e basis or having appropriate in ormed consent is
of duty), which results in injury to the patient (causation to promote a patient's sel -determination in deciding what
and damages). can be done to his or her body.5 In order or consent to be
Central to the theory o medical negligence is the term adequate, the ollowing elements must be ul lled:
standard of care, which re ers to the conduct and degree ■ Patient's capacity
o prudence expected o a similarly situated physician in ■ Adequate in ormation
a particular (similar) circumstance. I a plainti (patient) ■ Freedom to consent (noncoercion)

Capacity re ers to the patient's ability to understand his

TAbl E 3-1 or her medical problem and the need or treatment. T e
c n i patient should be able to process the in ormation at hand
Duty
and be able to weigh the risks, bene ts, and alternatives
o the proposed treatment.5– 7 T e patient should have
breach o Duty the mental aculty to rationalize the in ormation given
Causation and communicate a meaning ul acceptance or re usal o
that treatment. T is hinges on the requirement that the
Damages
26 patient be without cognitive impairment. Speci cally, a
patient's reasoning should not be impaired by medica-
tions, substance abuse, psychiatric conditions (i.e., depres-
s pec Ia l c Ir c u ms t a n c es
1
sion, anxiety), or external pressures (such as rom amily
Central to the spirit o in ormed consent is the concept
members).5 Accordingly, patients who have been deemed
that a patient should be able to participate ully. Ideally,
incompetent secondary to dementia should have their
patients are able to appreciate their current condition,
decision-making rights trans erred to an authorized sur-
how the procedural intervention (or lack thereo ) will
rogate, as is discussed later in this chapter.
a ect their uture, the likelihood o expected and unex-
When it comes to the actual medical consent docu-
pected outcomes, and alternatives to the o ered treat-
ment, certain requisites should be present to show that
ment that they may consider;8 however, in the eld o
the patient was presented with adequate in ormation.
medicine, there are circumstances in which the patient is
First, there should be an acceptable description o the
unable to participate in this manner. T ese circumstances
proposed procedure in terms that are easily understood
may include occasions when the patient does not have
by the patient. T e nature o the patient's illness or injury
the intellectual capacity to participate, when the patient
should be addressed, along with the purpose o the pro-
is a minor, or when the patient re uses the surgical inter-
posed medical intervention. T e orm should contain

C
vention.8 In these circumstances, much thought and con-

h
the risks and bene ts o the proposed procedure with

a
sideration must be devoted to balancing the needs o the

p
the probability o success. Documentation o alternative

t
e
patient, respecting the patient's autonomy, and under-

r
treatment options (including the option o no treatment)

3
standing the patient's belie s and values, so as to guide the
should be included with the respective advantages and
decisions that are made.8

:
disadvantages. A checklist or an in ormed consent docu-

:
ment is shown in able 3-2.2,4– 7

I
n
In order or an in ormed consent to be valid, the patient's pa t Ien t s Wh o r ef u s e s u r g er y

o
r
consent must be voluntary.5– 7 T is means that the consent

m
e
must be given by ree will, without any undue persuasion

d
When a patient re uses a recommended intervention, it
or duress. T e patient must not be coerced, meaning that

C
can be di cult or the physician not to take personal

o
there must be no threats or intimidation involved. While

n
umbrage or question the validity o the patient's deci-

s
e
this may seem obvious, it may be considered coercive i sion; nevertheless, the patient should be supported

n
t
one were to exaggerate the risks o harm rom oregoing a and questioned in order to elicit the reasoning or the
given treatment, or to mislead the patient through misrep- decision in a nonthreatening and pro essional man-
resentation o the acts.7 ner.8 Common reasons or re usal o the procedure can
During the in ormed consent process, a meaning ul dia- include a “state o indecision” where the patient eels
logue should take place, and the physician should assess unprepared to make a decision in an immediate time
the patient's values and belie s. Subject to HIPAA regula- rame, a lack o understanding, consideration o alterna-
tions, it may also be appropriate to include amily members tive treatments, mistrust o the surgeon, or eelings o
and healthcare surrogates in the decision-making pro- anxiety or depression.8
cess so that patients can lean on their support network.5 For example, when a patient is o ered Mohs surgery or
Obtaining proper in ormed consent and ensuring patient a basal-cell carcinoma o the nose, reasons or declining
comprehension can be an important way to avoid uture may include: wishing to discuss the diagnosis with amily,
litigation. Most importantly, the in ormed consent pro- not understanding the concept o Mohs surgery, wanting
cess is a unique opportunity to build trust between the to try less invasive treatments such as topical prepara-
physician and the patient. tions, being concerned about the surgical skills o the phy-
sician, or being concerned about the potential impact o
the surgery on physical appearance.
TAbl E 3-2 I the physician is able to maintain a nonthreatening and
c i I c d supportive atmosphere, he or she may be able to address
the patient's speci c concerns in a way that results in a
Nature o i ness or injury reasonable treatment solution and preserves the best
Description and purpose o procedure interest o the patient.
In the a orementioned example, the ollowing could be
Common, even i not serious, risks
options:
Uncommon ut serious risks
■ Allowing the patient to return with a amily member to
benef ts discuss the surgery urther.
Pro a i ity o success ■ Drawing diagrams and providing written in ormation
detailing what will be expected on the day o Mohs
A ternative strategies surgery.
Risks o oregoing treatment ■ Considering a trial o topical therapy such as 5-f uoro-
uracil or imiquimod with a date set or the lesion to be
Patient's signature
reevaluated.
Physician's signature ■ Consideration o re erral to another surgical specialist
Witness' signature or assistance in the repair o the Mohs surgical de ect.
■ Discussion o likely repair options so that the patient
Date o signatures
has a reasonable expectation o possible nal results. 27
1 With many dermatologic conditions, the outcome o
delaying surgery is not li e-threatening; there ore, these
be ree rom any cognitive impairment. In most cases,
this is clear, but in some cases it is di cult to determine
may be appropriate and acceptable treatment options. whether or not a patient has decision-making capacity.
However, there are a ew circumstances in which delay- Legally, every patient is considered competent or to have
ing surgery can be li e-threatening, such as when patients the capacity to make autonomous decisions until there is
present with a diagnosis o invasive melanoma, Merkel clear evidence that they do not.9 I a patient is determined
cell carcinoma, or squamous cell carcinoma in high-risk not to have the capacity, then a surrogate decision-maker
areas. In these circumstances, it is imperative that patients should be sought.
understand the rami cations o their decision to delay In general, the more high-risk a surgical intervention,
or decline treatment. In addition, the physician needs the more important it is or the patient to have a high
to make a concerted e ort to understand the underlying level o capacity;9 or example, when treating a patient or
system o values guiding the patient's decision-making an actinic keratosis with liquid nitrogen, receiving con-
process. For certain patients, discussing how a proposed rmation rom the patient that he or she has a spot that
surgical intervention will or will not a ect them in the needs treatment may be su cient. I Mohs surgery or a
context o their belie system may be essential in deter- skin cancer o the temple is planned, however, the patient
S
e
mining whether they will accept or decline treatment. should have the capacity to understand that there is a risk
c
t
i
All patients have a value system that drives them toward o nerve damage in addition to other surgical risks in this
o
n
the goals they have or their lives. Physicians need to make anatomical area. It is important, there ore, that clinicians
1
an e ort to understand these values so that they can dis- assess the patient's capacity or at least recognize signs that
:
:
cuss how the surgical intervention does or does not a ect warrant urther evaluation by someone more experienced.
them. While physicians usually recommend the “gold Be ore determining that a patient lacks the capacity, the
S
u
standard” or treatment, whether this is the best option physician must have given su cient in ormation to the
r
g
i
or the patient must be considered within the context o patient in a way that is considered “reasonably” under-
c
a
the patient's individual circumstances. In declining the standable,9 such as the ollowing:
P
r
procedure, patients may be choosing the option that helps
i
n
Describing things in simple terms that are easy to
c
them achieve their values best, even i the cancer poses a ■
i
p
signi cant risk to their health. understand.
e
s
Examples where declining the o ered treatment may ■ Using drawings, diagrams, and other visual aids.
be the most appropriate choice or the patient include the ■ Discussing the procedure at a time when the patient is
ollowing: most lucid.
■ Assuring that there are no language barriers, using
■ T e patient has other li e-threatening conditions that translators when necessary.
preclude him or her rom any li e-lengthening bene t
rom the procedure; or example, a patient who has A study published by Sessums et al.10 in the Journal of
metastatic colon cancer may reasonably decline treat- the American Medical Association describes our aspects
ment or the Merkel cell carcinoma on the scalp in o capacity. T ese include the ollowing:
avor o com ort care. ■ Recognizing your current situation.
■ T e patient has had multiple previous treatments o the ■ Identi ying the consequences o your choices.
same type; or example, a patient who has had multiple ■ Identi ying the important in ormation with relation to
resections o a melanoma with requent recurrences
important risks, bene ts, and alternatives.
therea ter may appropriately decide that he/she does ■ Communicating a choice.
not wish to have urther surgeries, even i that decision
ultimately results in death. T e most common reasons in the United States or a
■ T ere is an alternative treatment that may be adequate patient's capacity to be questioned include being elderly,
even though not rst line; or example, a patient with a mentally ill, or objecting to recommended treatment.9 All
basal-cell carcinoma on the nose may elect or a trial o o these groups have unique and complicated needs.
topical imiquimod rather than Mohs surgery. I the patient is determined to lack the capacity or
medical decision-making, it is then appropriate to nd a
I the physician is not able to determine a reasonable person to be the surrogate or giving consent. O ten this
basis or the patient's re usal to consent, it may be reason- is an individual who has been legally empowered with ull
able to consider whether the patient has adequate cogni- authority or medical decision-making ahead o time. T is
tive understanding to decline the procedure.8 T is may is usually called Durable Power o Attorney or healthcare.
prompt the physician to consider a Surrogate Consent or T e physician should rst determine whether the patient
at least an evaluation to determine whether that might be has appointed such a designated person. Another legal
appropriate. alternative is called the Living Will, in which the patient
has created a document outlining pre erences regarding
treatment, should the patient lose the capacity to make
s u r r o g a t e c o n s en t these medical decisions.9 I these arrangements have not
been previously made, then a person should be sought out
As reviewed earlier, the elements o In ormed Consent to help make decisions in accordance with the patient's
include Patient's Capacity, Adequate In ormation, and wishes, pre erably someone who is intimately amiliar with
Freedom to Consent; there ore, in order or any patient the patient's values. T e order in which these individuals
28 to participate ully in in ormed consent, he or she must usually have priority has been documented in able 3-3.9
 TAbl E 3-3 TAbl E 3-4
1
p i i s d ii -m c b p x
1. Guardian 1. Step parent
2. Spouse 2. Grandparent o a Minor
3. Adu t Chi dren 3. Adu t brother/Sister
4. Parents 4. Adu t Unc e/Aunt
5. Adu t Si ings 5. Power o Attorney/Court Appointed
6. Other C ose Adu ts
7. Court Appointed
the LAR is not available, then most states requently have
a predetermined hierarchy concerning who will be next in

C
line to give in ormed consent. An example o this hierar-

h
a
It is important to remember that while patients may des- chy is illustrated in able 3-4.12,13

p
t
ignate a surrogate to help make their medical decisions, an

e
Adolescents are another unique population as they are

r
e ort should still be made to develop a joint decision and

3
beginning to unction independently and learning to make
explain and obtain consent rom patients themselves to decisions that a ect their personal health. All states have

:
:
the degree that they are able.11 recognized this by writing unique legislation or this age

I
n
group. Physicians should be aware o the ollowing special

o
circumstances in which the minors are entitled to con -
ped Ia t r Ic pa t Ien t s :

r
m
dentiality and may legally give their own consent. T ese

e
c o n s Id er a t Io n s

d
include minors who are married or considered eman-

C
cipated and situations where their reproductive health,

o
n
mental health, or substance use is concerned.12 It is impor-

s
In most states, an individual is considered a Minor until

e
n
the age o 18 years. Until this threshold is reached, in tant to note that the age at which a patient is considered

t
general the parents or the Legally Authorized Repre- an adolescent may vary rom state to state. Finally, ado-
sentative (LAR) must give consent or any treatment or lescents may also consent to their own treatment when a
procedure.12,13 parent has agreed to con dentiality between the physician
T ere are some legal exceptions or emergent care and and the adolescent.
special circumstances such as religious actors where there T ere is also substantial common law supporting a
is precedent or treatment without consent rom an LAR. practice known as the “mature minor law.” I an adolescent
However, these exceptions aside, any treatment or proce- has been living in a proven responsible manner, he or she
dure that is done on a minor usually requires in ormed is entitled to give his or her own consent; however, this
consent rom the LAR with the same requirements as or should be care ully scrutinized on a case-by-case basis.12
adults.12 T is does not mean, however, that there should
not be an e ort to gain the minor's engagement in the pa r t Ic Ipa t Io n o f s u per v Is ed
decision-making. In act, every e ort should be made on
the part o the clinician to include the minor in decision- t r a In ees
making appropriate to his or her level o understanding
and ability to participate. As in every patient population, T e process o obtaining consent or procedures in which
care should be taken to approach the consent at a level a trainee will be involved presents a unique conundrum
that can be reasonably understood and not cause undue or the medical community. It is well established that
concern. In the case o a child, this requently involves the common reasonable risks o a procedure should be
employing analogies and very simple language. reviewed with the patient as a part o in ormed consent.
For example, i a young child requires a biopsy, in ormed However, the common risks are based on the per ormance
consent should be obtained rom the LAR with the stan- o an experienced and competent practitioner. rainees
dard in ormation regarding scar, bleeding, and in ection. present a possible additional risk in that they have not per-
However, cooperation may be obtained rom the child ormed the procedure numerous times and have not yet
with terms such as “bee sting” or the injection and “owie” been declared competent to practice without supervision.
to describe the biopsy site. Clearly, the level o involve- Nevertheless, society as a whole has been amenable to
ment o children should increase with their age and ability allowing trainees to learn with supervision because physi-
to participate. cians must be trained or the uture o healthcare.
Minors present a unique challenge in that they o ten T e question then becomes: to what extent should
present or evaluation and treatment without their LAR. patients be in ormed that a trainee might be involved in
Children are o ten brought in by other amily members, their procedure? Pallin et al. proposed that this question
caretakers, and noncustodial parents. Care ul attention should be examined starting with how much patients want
should be paid by the clinician in those circumstances, to know about the involvement o trainees. T ese authors
because i the LAR has not given in ormed consent, the per ormed a study interviewing patients waiting to be seen
physician may be held accountable legally or assault as in the emergency room. T e study ound that most patients
described earlier.12 I emergent treatment is required or do not understand the hierarchy o training. Only 30% o 29
1 patients were able to correctly identi y the de nition o a
Medical Student, an Intern, and a Resident.14 Once patients
this section), avoiding guarantees about procedures, and
documenting discussions thoroughly.17,20
become in ormed, they are even less willing to have a Several studies have demonstrated that patients' in or-
trainee participate in their care;14 there ore, the study dem- mation retention rates are approximately 25% to 57%.21– 25
onstrates that patients want to know whether a trainee Patients undergoing elective Mohs micrographic surgery
will be involved, and physicians should consider includ- had an overall retention rate o 26.5% only 20 minutes
ing this in their in ormed consent. T e American Medical a ter being in ormed o 10 possible complications, with
Association Council on Ethical and Judicial A airs agrees no signi cant di erences in recall based on age, gender,
and in their position statement states: “Patients should be source o re erral, or education.20
in ormed o the identity and training status o individuals Hence, methods must be developed to aid in com-
involved in their care, and all healthcare pro essionals share munication and retention. One model or more e ective
the responsibility or properly identi ying themselves.”8 communication is the “teach-back” approach in which
In an Editorial regarding in orming patients o surgeon- the physician identi es the principal messages o the dis-
speci c outcomes, Dr. Margaret Schwarze states that it cussion and then asks the patient to paraphrase them.18
is the job o the medical specialty to ensure that all sur- Patients should be encouraged to actively ask questions
S
e
geons per orm at an acceptable standard. I this standard and restate in ormation in their own words. Some physi-
c
t
i
is upheld by the medical specialty, patients should be able cians even have the patients ll in the procedure and risks
o
n
to trust that every certi ed surgeon meets that standard. discussed on the in ormed consent orm. Other improve-
1
T is would preclude the necessity to provide patients with ments could include the use o technology, such as videos
:
:
a surgeon's personal “sa ety and complication record.”15 or photos, to demonstrate potential risks or complica-
Dr. Schwarze, however, also clearly states that every tions. T e use o technology and its role in in ormed con-
S
u
patient has a right to know his or her options and be given sent will be addressed urther in the next section.
r
g
i
a chance to “opt out” should he or she eel uncom ortable Staying up-to-date with the medical literature as well
c
a
with the situation.15 T ese principles should apply to pro- as the risks and bene ts o all treatment alternatives is
P
r
cedures involving trainees as well. rainees should not be imperative. T e goal is to present patients with enough
i
n
c
allowed to participate in procedures during which they are data to be able to understand and better strati y the risks
i
p
not adequately trained or supervised. T e burden lies with o their treatment options. T e need or laboratory and
e
s
the training institutions to ensure that these standards are radiographic studies should also be discussed including
upheld, or patients to be assured that an acceptable stan- their advantages, disadvantages, and limitations. It is also
dard o care will be met even when trainees are involved. important to discuss how test results can be communi-
Should patients be hesitant to proceed, they should be cated to reduce error and liability. Physicians should make
given the option o obtaining care where trainees are not no presumptive conclusions and should also consider a
involved. patient's nancial situation in the shared decision-making
process. It is important to customize the discussion with
patients as it relates to their occupation, restrictions on
Impr o v In g In f o r med c o n s en t li estyle, physical appearance, and so on. One can also
provide patients with medical literature and contact in or-
In ormed consent orms the ethical oundation or the mation or support groups so that they can make a more
modern practices o shared decision-making and patient- educated decision.
centered care.16 It should be viewed as an ongoing pro- T e ABCDEF mnemonic is use ul or guiding physician
cess o communication, education, question answering, discussion and documentation. It is as ollows: Alternative
and listening to the patient or the surrogate that proceeds therapies available, Bene ts o the therapy proposed, Com-
through the continuum o care.7 It has been well estab- mon but not devastating risks, Devastating but not com-
lished that e ective communication reduces the likeli- mon risks, Extra considerations speci c to this patient, and
hood o litigation and that the level o rapport between Facial expressions, body language, and questions.17
a physician and a patient is a better predictor o the risk A discussion o risks, bene ts, and alternatives or
o litigation than the actual documented content o any any procedure, whether elective or not, is critical to
particular discussion.17,18 in ormed consent. T e discussion should include any
Legally and ethically, physicians have an obligation to associated risks o medication and anesthesia. No guar-
strive to establish a strong patient– physician relationship. antees should be made regarding any procedure, since
T eoretically, improvements in health outcomes occur guarantees are nearly impossible in li e and can some-
when patients are better in ormed and more engaged in times be the impetus or legal action (breach o war-
treatment decisions because they select treatments that ranty claim) should the promised outcome not occur. It
better t their values and li estyle.19 It is a physician's duty is important to remember that one can re er a patient
to educate patients and improve in ormed consent. o or another opinion i a patient's expectations are out o
make improvements, one must evaluate the pit alls, antic- line or i the procedure is outside one's realm o exper-
ipate complications, and use various tools to implement tise. T e physician should be open and honest about all
change. quali cations and representations, and should make sure
Some practical suggestions to improve the in ormed these representations are accurate, so as not to under-
consent process include: improving in ormation retention mine the validity o the in ormed consent.
and communication with the patient and/or surrogates, Finally, it is essential to document well. While documen-
discussing all treatment options regardless o insurance tation is o the utmost importance, there are no clear-cut
30 coverage, using an ABCDEF mnemonic (detailed later in laws dictating what represents adequate documentation.
With the advent o electronic medical records, patient
charts have become more legible and easier to store. Phy-
indications, alternatives, and complications o any proce-
dure they may need to undergo. Physicians can make deci-
1
sician o ces must keep up-to-date with the documenta- sion aids especially e ective by being culturally sensitive
tion requirements rom the various insurance companies, to their target population.
as well as with ederal and state legislation. In conclusion, decision aids such as videos, photo-
Improving in ormed consent not only protects the phy- graphs, diagrams, and pamphlets are e ective tools that
sician but also enhances the doctor– patient relationship. can strengthen the in ormed consent process. T ey pro-
raditional in ormed consent methods have o ten proven vide highly reproducible dissemination o in ormation
inadequate in this day and age. As educators, physicians with a high degree o patient satis action.26 Decision aids
also have an ethical obligation to continue to optimize can also potentially help patients with their retention and
in ormed consent or all patients. comprehension, which has been associated with improved
clinical outcomes.34 It is use ul to document the secondary
sources that are used, suggested, or given to a patient.
f u t u r e o f In f o r med c o n s en t Another important topic to address here concerns the
ethical and legal aspects o in ormed consent with respect

C
h
Re orm is required in order to adapt to the ever-changing to photography. T e use o photography is an integral part

a
p
medical and social environment. T is section will ocus o multiple specialties including dermatology and plas-

t
e
r
on the use o technology or advancement o in ormed tic surgery. Photographs are part o the patient's medical

3
consent. It is vital to be prudent and knowledgeable about record and thus are covered both by ederal and state pri-

:
common law, medical ethics, and statutory law. Be sure vacy laws. Some states have speci c requirements as to the

:
to check with the state in which you practice medicine, manner in which these photographs are taken and what

I
n
as some state laws regarding in ormed consent may vary. claims may appear as text with the photographs.35 Prior to

o
r
T e traditional process o in ormed consent can be taking a photograph, one should obtain and record con-

m
e
inadequate, inconsistent among physicians obtaining con- sent adequately.36 T e photography consent orm should

d
sent, and variably comprehensible among patients with include the name o the individual, subject matter (i.e.,

C
o
di erent educational levels.26 Decision aids such as pam- so t-tissue augmentation, scar revision, etc.), and nature o

n
s
e
phlets, videos, and photographs may signi cantly improve use and distribution (i.e., patient care, lecture, manuscript

n
t
retention rates, comprehension, and ultimately patients' or publication, brochure, etc.). Patients have the right to
decision-making. T ere are multiple bene ts to utilizing review photographs or accuracy and have the right to
decision aids during the in ormed consent process, which revoke their consent at any time be ore publication. Once
aid in improving two major pit alls that have been iden- the in ormation has been committed to publication, how-
ti ed in surgical consent: lack o time or dialogue with ever, it may not be possible to revoke the consent.35 It is
a patient and poor timing o the consent.27 Decision aids paramount to respect the patient's autonomy, privacy,
o er patients the opportunity to learn about their disease and con dentiality by de-identi ying all photographs and
or condition and their treatment options in the com ort o images. Patients should be aware that there are no cur-
their home at a less stress ul time. Patients can also review rent e cient controls once an image is electronically pub-
the in ormation multiple times on their own or with am- lished.37 One should respect ethical principles and use
ily and riends. Furthermore, patients can have more time images with anonymous in ormation to avoid uture legal
to think about personal pre erences and values or di er- consequences.
ent risks/bene ts and can be more prepared to discuss
options with their physician.19 A Cochrane review con-
ducted in 2009 concluded that shared decision-making c o n c l u s Io n
with decision aids improves patient knowledge o the risks
and bene ts o treatment, the accuracy o risk percep- T e eld o dermatology, like medicine in general, is
tions, patient com ort with decisions, and participation constantly changing and becoming more vulnerable to
in decision-making and lessens the number o patients medical– legal implications. Dermatologists are per orm-
remaining undecided concerning their treatment.28 ing more cosmetic and surgical procedures which add to
A newer concept using portable video media or pre- the inherent risks. In ormed consent and the concept o
senting in ormed consent has recently come into the shared decision-making should be implemented, not only
spotlight. Several prior studies suggest that video-based to help protect against lawsuits but also to strengthen
patient education may lead to greater patient compre- the dynamic physician– patient relationship. Patients
hension and satis action as well as a signi cant reduction are more likely to take legal action i they perceive their
in patient anxiety.29– 33 Dermatologists routinely obtain doctors to be lacking in empathy and communication
in ormed consent and provide pre- and postprocedure skills.38 Physicians should be cognizant o patient values
instructions or patients undergoing biopsies and other and pre erences and view in ormed consent as a shared
procedures. Armstrong et al.26 demonstrated a statistically therapeutic alliance that is ongoing.
signi cant increase in knowledge and satis action ollow- T e physician is ultimately responsible or obtaining
ing video education on in ormed consent and wound care in ormed consent. T e consent should be individual-
instruction or skin biopsies, as opposed to ollowing tra- ized and can be written, verbal, and/or mani ested by
ditional verbal education. T ese decision aid modalities, conduct. Decision aids can be a very use ul tool or both
however, do not necessarily replace verbal discussions parties involved such that physicians can provide repro-
between the physician and the patient. Patients should ducible in ormation to their patients in more e ective
have the opportunity to ask questions regarding the ways. Patients can also use these aids to improve retention 31
1 and comprehension. echnology will continue to be an
integral tool in evolution o the in ormed consent process.
20. Fleishman M, Garcia C. In ormed consent in dermatologic
surgery. Dermatol Surg. 2003;29:952– 955.
21. Godwin Y. Do they Listen? A review o in ormation retained
Remember that in ormed consent varies rom state to
by patients ollowing consent or reduction mammoplasty.
state and country to county. I you are interested in learn- Br J Pla st Surg. 2000;53:121– 125.
ing more about in ormed consent, it would be wise to 22. Hekkenberg RJ, Irish JC, Rotstein LE, Brown DH, Gullane PJ.
contact your state medical board and/or your attorney or In ormed consent in head and neck surgery: how much do
additional in ormation. patients actually remember? J Otolaryngol. 1997;26:155– 159.
23. Herz DA, Looman JE, Lewis SK. In ormed consent: is it a
myth? Neurosurgery. 1992;30:453– 458.
24. Kriwanek S, Armbuster C, Beckerhinn P, Blauensteier W,
r ef er en c es Gschwantler M. Patients' assessment and recall o surgical
in ormation a ter laparoscopic cholecystectomy. Dig Surg.
1. Whitney SN, McGuire AL, McCullough LB. A typology 1998;15:669– 673.
o shared decision making, in ormed consent, and simple 25. Priluck IA, Robertson DM, Buettner H. What patients recall
consent. Ann Intern Med. 2003;140:54– 59. o the preoperative discussion a ter retinal detachment sur-
2. orres A, et al. Medical and legal aspects o skin cancer gery. Am J Opthalmol. 1979;87:620– 623.
patients. In: Rigel D, ed. Cancer of the Skin. 2nd ed. China:
S
26. Armstrong AW, Alikhan A, Cheng LS, Schupp C, Kurlinkus
e
Elsevier Saunders; 2011. C, Eisen DB. Portable video media or presenting in ormed
c
t
3. Dobbs DB. T e Law of orts. St. Paul, MN: West Group; 2000.
i
consent and wound care instructions or skin biopsies: a
o
n
4. Pape . Legal and ethical considerations o in ormed consent. randomized controlled trial. Br J Dermatol. 2010;163:1014–
1
AORN J. 1997;65(6):1122– 1127. 1019.
5. Paterick J, Carson GV, Allen MC, Paterick E. Medical in- 27. Edwards WS, Yahne C, T omas G. Orr Memorial Lecture:
:
:
ormed consent: general considerations or physicians. Mayo surgical in ormed consent: what it is and is not. Am J Surg.
Clin Proc. 2008;83(3):313– 319. 1987;154:574– 578.
S
u
6. Sprung CL, Winick BJ. In ormed consent in theory and prac- 28. O'Connor AM, Bennett CL, Stacey D, et al. Decision aids
r
g
tice: legal and medical perspectives on the in ormed consent or people acing health treatment or screening decisions.
i
c
doctrine and a proposed reconceptualization. Crit Care Med.
a
Cochrane Databa se Syst Rev. 2009;(3). http://decisionaid.
1989;17:1346– 1354.
P
ohri.ca/cochsystem.html.
r
i
7. Bernat J, Peterson L. Patient-centered in ormed consent in 29. Idriss NZ, Alikhan A, Baba K, Armstrong AW. Online video-
n
c
surgical practice. Arch Surg. 2006;141:86– 92. based patient education improves melanoma awareness:
i
p
8. Jones JW, McCullough LB, Richman BW. A comprehensive a randomized controlled trial. elemed J E Health. 2009;
e
primer o surgical in ormed consent. Surg Clin North Am. 15:992– 997.
s
2007;87:903– 918. 30. Miller JS, Litva A, Gabby M. Motivating patients with shoul-
9. Venesy BA. A clinician's guide to decision making capacity der and back pain to sel -care: can a videotape o exercise sup-
and ethically sound medical decisions. Am J Phys Med Rehabil. port physiotherapy? Physiotherapy. 2009;95:29– 35.
1994;73:219–226. 31. Hill AM, McPhail S, Ho man , et al. A randomized trial
10. Sessums LL, Zembrzuska H, Jackson JL. Does this patient have comparing digital video disc with written delivery o all
medical decision-making capacity? JAMA. 2011;306(4):420–427. prevention education or the older patients in hospital. J Am
11. Whitely L, Kuwahara R , Garcia C. Dermatologic surgery in Geriatr Soc. 2009;57:1458– 1463.
the demented patient. Dermatol Surg. 2003;29:241– 244. 32. Ong J, Miller PS, Appleby R, Allegretto R, Gawlinski A. E ect
12. Berlan ED, Bravender . Con dentiality, consent and caring or o a preoperative instructional digital video disc on patient
the adolescent patient. Curr Opin Pediatr. 2009;21:450– 456. knowledge and preparedness or engaging in postoperative
13 McAbee GN; Committee on Medical Liability and Risk Man- care activities. Nurs Clin North Am. 2009;44:103– 115.
agement American Academy o Pediatrics. Consent by proxy 33. Jlala Ha, French JL, Foxall GL, et al. E ect o preoperative
or nonurgent pediatric care. Pediatrics. 2010;126:1022– 1031. multimedia in ormation on perioperative anxiety in patients
14. Pallin DJ, Harris R, Johnson CI, Giraldez E. Is consent “in- undergoing procedures under regional anesthesia, Br J Anaesth.
ormed” when patients receive care rom medical trainees? 2010;104:369– 374.
Acad Emerg Med. 2008;15:1304– 1308. 34. Schillinger D, Piette J, Grumback K, et al. Closing the loop:
15. Schwarze ML. T e process o in ormed consent: neither the physician communication with diabetic patients who have
time nor the place or disclosure o surgeon-speci c out- low health literacy. Arch Intern Med. 2003;163:83– 90.
comes. Ann Surg. 2007;245:514– 515. 35. Segal J, Sacopulos MJ. Photography consent and related le-
16. Laine C, Davido F. Patient-centered medicine: a pro essional gal issue. Facial Pla st Surg Clin North Am. 2007; 18(2):237–
evolution. JAMA. 1996;275:152– 156. 244.
17. Kaibara P. 8 ways to improve the in ormed consent process. 36. Hill K. Consent, con dentiality and record keeping or the
J Fam Pract. 2010;59(7):373–375. recording and usage o medical images. J Vis Commun Med.
18. National Quality Forum. Implementing a National Voluntary 2006;29(2):76– 79.
Consensus Standard for Informed Consent: A Users Guide for 37. Mavro orou A, Antoniou G, Giannoukas AD. Ethical and legal
Healthcare Professionals. Washington, DC: National Quality aspects on the use o images and photographs in medical
Forum; 2005:13,15,27. teaching and publication. Int Angiol. 2010;29(4):376–379.
19. King J, Eckman M, Moulton B. T e potential o shared deci- 38. Farmer ER, Gonin R, Hanna MP. Discordance in the histopath-
sion making to reduce health disparities. J Law Med Ethics. ologic diagnosis o melanoma and melanocytic nevi between
2011;39(Suppl 1):30– 33. expert pathologists. Human Pathol. 1996;27:528–531.

32
 Ch a p t e r

4 Anesthesia and Analgesia

Nim M. Gh r vi & G ry P. L sk

In t r o d u c t Io n and Lundqvist synthesized lidocaine, an amide deriva-

tive o diethylaminoacetic acid.1,2 T is new anesthetic
displayed superior sa ety and e cacy, which has since
Local anesthesia is an essential part o surgical derma-
led to its widespread use in cutaneous surger y, as well as
tology. A proper understanding o the selection and
its claim as the prototype o local anesthetics. Following
administration o anesthesia, including indications, con-
the introduction o lidocaine, additional amide deriva-
traindications, potential side e ects, and toxicities, is nec-
tives were developed.
essary to maximize patient sa ety and com ort.
Currently, there are multiple local anesthetics and
modes o delivery available or cutaneous surgery. A com-
prehensive understanding o the pharmacological prop-
HIs t o r y erties, as well as techniques or administration o local
anesthesia, is necessary in order to maximize patient
T e biologic e ects o local anesthestics were rst de- sa ety, minimize pain and discom ort, and improve the
scribed in the ninteenth century, when Albert Niemann, a ease with which surgical procedures are per ormed.
graduate student in pharmacology in Gottingen, Germany,
extracted cocaine rom the leaves o the coca plant (Eryth-
roxylum coca) and noted numbness a ter application to s t r u c t u r e a n d PHys Io l o g y
his tongue.1 Niemann, however, did not consider cocaine’s
utility as an anesthetic during surgery. Approximately Local anesthetics have similar chemical structures. T e
25 years later, Sigmund Freud, then a graduate student three major components include an aromatic ring, an
in Vienna who had read Niemann’s work, began experi- intermediate chain, and an amine portion. T ese three
menting with cocaine. In the 1880s, he published a amous components and their modi cation determine the phar-
paper “Uber Coca,” in which he advocated this agent as a macological properties o anesthetic agents. T e aromatic
means o treating patients with morphine addiction, dys- ring, which is lipophilic, acilitates di usion o the anes-
pepsia, atigue, hysteria, and headaches, as well as a num- thetic through membranes and nerve sheaths, and corre-
ber o mental disorders.1 In 1884, Karl Koller, a resident lates with both the onset o action as well as the potency
in ophthalmology and a colleague o Freud, introduced o the anesthetic.3,4 In contrast, the terminal amine por-
cocaine into the clinical arena by publishing a paper on tion may exist in a tertiary orm (3 bonds) that is lipid
its use in ophthalmologic surgery.1 Although the medical soluble or as a quaternary orm (4 bonds) that is positively
establishment was slow to accept this new anesthetic and charged and renders the molecule water soluble.5 While
its vast potential, most practitioners eventually began to the aromatic ring determines the actual degree o lipid
adopt the use o cocaine as an aid in preventing pain dur- solubility, the terminal amine portion acts as an “on– o
ing a variety o operations. As its use or local anesthe- switch” allowing the local anesthetic to exist in either a
sia expanded, however, reports o potential toxicities and lipid-soluble or a water-soluble con ormation.5 T e amine
addictive e ects also began to emerge. portion is also postulated to bind to the sodium channel
In the twentieth century, a number o sa er anesthet- and determine the anesthetic’s duration o action.6 Con-
ics were identi ed. In 1904, Al red Einhorn synthesized necting these two chemical residues is an intermediate
procaine hydrochloride, an ester o para-aminobenzoic chain, which biochemically is either an amide or an ester.
acid (PABA).2 In 1905, Heinrich Braun became the rst Disruption o the intermediate chain mediates the metab-
to use this new anesthetic in surgery.1 Soon, Höechst olism o anesthetics and determines the reversible nature
and Company marketed procaine under the trade name o these drugs (Fig. 4-1).
Novocain. However, it was soon learned that procaine, a Local anesthetics can be classi ed into two groups,
vasodilator, caused a pro ound drop in blood pressure, esters or amides, as determined by the structure o the
by allowing the anesthetic to travel widely rom the site intermediate chain ( able 4-1). T ese two groups behave
o injection. In act, a number o deaths were reported di erently in several ways, namely their duration o action,
a ter in ltration o procaine. Fortunately, this was over- metabolism, and potential or sensitization.3,4 In general,
come by combining procaine with epinephrine, initially ester anesthetics have a shorter duration o action due
at a ratio o 1 to 20,000, which shortly became 1 to to rapid hydrolysis by plasma pseudocholinesterase and
200,000. In 1930, tetracaine, a more potent PABA ester, excretion via the kidneys.5 T e potential or toxicity as a
was introduced. Additional side e ects such as allergic side e ect may, there ore, be higher in individuals with
reactions were noted in some patients. In 1943, Lo gren low levels o pseudocholinesterase. In addition, a major
1 O
Ta bLe 4-2
n v f ib
R1 R2
O N
t p M i f i
R3 A f bers
a lph Ys Motor impuls
Aminoe s te r b t Ys Pr ssur nd light touch
G mm Ys Proprioc ption
D lt Ys P in nd t mp r tur
H
R1 R2 B f bers Ys Pr g nglionic symp th tic
N
N C f bers No P in nd t mp r tur

O R3
S
c
allowing or entry o sodium ions across the cell mem-
t
i
o
Aminoa mide brane into the cell to generate an action potential. Local
n
1
Figure 4-1 Ch mic l structur o mid nd st r anesthetics prevent this depolarization and subsequent
n sth tics. nerve activation by inter ering with the inf ux o sodium
:
:
ions into the cell.9 T e exact mechanism by which local
S
anesthetics inhibit this sodium transport remains unclear,
u
r
g
metabolic byproduct o ester anesthetics (and amides to a but one hypothesis is that it occurs through direct binding
i
c
much lesser degree) is PABA, which in turn is responsible o the local anesthetic to a receptor in the sodium channel,
l
P
or a higher incidence o allergic reactions.5,7 In addition, which in turn undergoes con ormational changes, render-
r
i
ing the sodium channel inactive.10 T is receptor site is
n
cross-reaction may occur with other agents, including
c
i
thought to be located at the cytoplasmic (inner) portion
p
thiazide diuretics, sul a drugs, and azo dyes.
l
In contrast, amide anesthetics are not readily hydro- o the sodium channel. Local anesthetic drugs bind more
s
lyzed. T ey are metabolized in the liver by the P450 system readily to sodium channels in an activated state, leading to
o microsomal enzymes (namely CYP 3A4), and subse- the more rapid onset o neuronal blockade in neurons that
quently excreted via the kidneys.5 Caution is warranted in are rapidly ring. T is is re erred to as state-dependent
individuals with compromised liver unction, who may be blockade.11,12
more susceptible to potential toxicities.8 T ere are three main categories o nerve bers: A, B,
and C bers ( able 4-2).7 A and B bers are myelinated,
whereas C bers are unmyelinated. A bers have the larg-
Mec Ha n Is M o f a c t Io n est diameter and the highest conduction velocities, and
are divided into our subtypes: alpha, beta, gamma, and
Local anesthetics reversibly block nerve propagation and delta. A-alpha bers conduct motor impulses, A-beta
depolarization.9 In a resting cell, the intracellular electric bers conduct pressure and light touch, A-gamma bers
potential is negative relative to the extracellular space, mainly conduct proprioception, and A-delta bers, which are
as a result o an ionic gradient o sodium and potassium the smallest A bers, conduct pain and temperature. B
ions. T e cell membrane and the Na+/K+ adenosine tri- bers are preganglionic sympathetic bers. C bers are
phosphatase (A Pase) pump help maintain this gradient.10 the smallest bers, and similar to A-delta bers, conduct
During depolarization o a neuron, sodium channels open, pain and temperature. As a general rule, larger myelinated
bers are more di cult to block than smaller myelinated
bers. T ere ore, the sensations o pain and temperature
are eliminated be ore loss o vibration, pressure, and pro-
Ta bLe 4-1 prioception.7 Clinically translated, this means that while a
a h i c ii i patient may be locally anesthetized to pain and tempera-
ture, he or she may continue to eel a pressure sensation
c g i n m t n m during the surgical procedure.
est r b nzoc in HurriC in
Chloroproc in
Proc in
N s c in
Novoc in
a d d It Io n s t o l o c a l
T tr c in Pontoc in a n es t He t Ic s
a mid bupivic in M rc in
Di uc in Nup rc in l In order to improve and enhance the duration, ease, and
etidoc in Dur n st sa ety o local anesthetics, various substances may be
L vo upiv c in Chiroc in admixed. It is important or the dermatologist to have
Lidoc in Xyloc in a good understanding o the concentration at which
M pivic in C r oc in these substances may be added, as well as the physiologic
Priloc in Cit n st properties o these additives, including their impact
Ropiv c in N ropin
34 on anesthesia.
 ePIn ePHr In e Ta bLe 4-4
1
c i i i epi ph i
Local anesthetics, with the exception o cocaine, promote
relaxation o vascular smooth muscle. T e resulting vaso- ab r iv
dilation can in turn lead to undesired side e ects, such c i i i c i i i
as increased operative site bleeding, as well as increased
di usion o the anesthetic away rom the site o injection. Uncontroll d Pr gn ncy
Agents that promote vasoconstriction, such as epineph- hyp rthyroidism
rine, may be added to local anesthetics, acilitating the Ph ochromocytom Hyp rt nsion
ease o surgery through the ollowing mechanisms. First,
Coron ry rt ry dis s
through vasoconstriction, these agents help to decrease
operative bleeding. It should be noted however, that while T chyc rdi /a rrhythmi s
the anesthetic may have an immediate onset o action, ull Gl ucom
vasoconstriction with epinephrine typically requires 7 to

C
15 minutes.7 Second, vasoconstrictors decrease di usion Known ll rgy to pin phrin

h
and absorption o local anesthetics, allowing the surgeon

p
t
to minimize the amount o anesthetic injected and

r
4
the potential or systemic toxicity. T ird, by decreasing the
relative and absolute contraindications to epinephrine is
di usion o local anesthetics and any associated systemic

:
:
provided in able 4-4.
toxicity, the addition o vasoconstrictors raises the maxi-
Commercially prepared lidocaine with epinephrine

a
mum concentration o anesthetic that can be used dur-

n
contains acidic preservatives to prevent the degradation o
ing the surgical procedure. T e maximum concentration

s
t
epinephrine. Such preservatives include sodium metabi-

h
o lidocaine without epinephrine, or example, is 4.5 to
sul te and citric acid.18 Given that the resulting solution

s
5.0 mg/kg; with epinephrine, the maximum concentration

i
is more acidic, it tends to cause more pain on injection.
is 7.0 mg/kg ( able 4-3).

n
However, i epinephrine is added reshly to lidocaine, the
Epinephrine is the most common vasoconstrictor

d
solution will be less acidic and in turn, cause less discom-

a
added to local anesthetics, and is commercially available

n
ort with injection.19 Preparation o resh lidocaine with
premixed with lidocaine at concentrations o 1:100,000 to

l
g
epinephrine at a concentration o 1:100,000 and 1:200,000
1:200,000.13,14 Although the optimal dose o epinephrine

s
can be made by adding 0.5 mL or 0.25 mL o 1:1000 epi-

i
has been debated, concentrations higher than 1:100,000
nephrine respectively to 50 mL o lidocaine. In the ollow-
have been reported to have a higher incidence o serious
ing section, we will describe the use o sodium bicarbonate
adverse e ects.5 T e maximum dose o epinephrine or
as another means o decreasing the pain o injection o
local anesthesia injected in healthy individuals should not
lidocaine with epinephrine.
exceed 1 mg (100 mL o 1:100,000 solution) over approxi-
mately 8 to 10 hours (roughly equivalent to ve hal -lives).
Care ul attention must also be paid to the patient’s age s o d Iu M BIc a r Bo n a t e
and any concomitant health issues which may a ect the
metabolism o and/or sensitivity to epinephrine. Lidocaine without epinephrine is slightly acidic with a pH
Although epinephrine at recommended doses is a sa e ranging rom 5.0 to 7.0. Commercially available lidocaine
additive, studies on its sa ety during pregnancy have shown with epinephrine has acidic preservatives, as previously
reduction o uterine blood f ow in animal models.15 Given described, which lower the solution’s pH to around 3.3
that decreased placental per usion can theoretically inter- to 5.5, in turn leading to more pain and discom ort with
ere with etal organogenesis, epinephrine has been labeled injection. Sodium bicarbonate is a weak basic compound
as a pregnancy category C drug. Decreased uterine blood with the ormula, NaHCO 3. When added to commercially
f ow in the later months o pregnancy may also induce available lidocaine with epinephrine, NaHCO 3 renders the
premature labor. T ere ore, while not an absolute contra- solution less acidic and, there ore, less pain ul on in ltra-
indication, pregnancy is considered a relative contraindica- tion.20 ypically, an 8.4% solution o NaHCO 3 is used to
tion to the use o epinephrine, and nonurgent procedures bu er commercially available lidocaine with epinephrine
requiring epinephrine should be postponed until a ter and added at a ratio o 1:10 (1 part NaHCO 3 to 10 parts
delivery.16,17 It should be noted that the only absolute con- 1:100,000 epinephrine) or 1:15 (1 part NaHCO 3 to 15 parts
traindications to epinephrine are uncontrolled hyperthy- 1:200,000 epinephrine). Although the resulting solution
roidism and pheochromocytoma. A complete list o the has a pH closer to physiologic range and is less pain ul,
adjusting the pH o the solution a ects other pharmaco-
logic properties o the anesthetic as well.21,22
Ta bLe 4-3
Epinephrine is less chemically stable in solutions with
M xim m r mm d li i a neutral pH. T e addition o NaHCO 3 to anesthetic solu-
tions containing epinephrine decreases the epinephrine’s
M xim d
duration o action as well as the shel li e o the mixture,
li i t p 70
and the mixture cannot, there ore, be stored or more than
Pl in 4.5 mg/kg or 300 mg 24 hours.21,22 Furthermore, addition o NaHCO 3 to anes-
thetics containing epinephrine renders the solution more
With pin phrin 7.0 mg/kg or 500 mg
neutrally charged and lipid soluble, allowing it to cross the 35
1 nerve membrane more rapidly, leading to a aster onset o
action.21,22 T is in turn leads to more rapid nerve blockade.
have been developed to allow or increased absorption and
e cacy o topical anesthesia. Given the potential or sys-
Animal studies have also suggested that the addition o temic absorption and toxicity, care ul attention must be
NaHCO 3 to anesthesia containing epinephrine increases paid to the anatomic location to which the agent is applied,
the duration o action.6 the total sur ace area covered, and the duration o skin con-
tact with the anesthetic.
Hya l u r o n Id a s e
Ben z o c a In e
Hyaluronidase is an enzyme that breaks down hyaluronic
acid, one o the major natural acid mucopolysaccharides Benzocaine is an ester anesthetic. It is available at con-
present in the extracellular matrix. It is commercially centrations ranging rom 5% to 20%, and in a variety o
available and marketed under the trade name Vitrase. vehicles, including gels, ointments, and solutions. Benzo-
When added to local anesthetics, hyaluronidase acilitates caine is commonly used on mucosal sur aces, and is the
di usion o the local anesthetic through tissue, thereby active ingredient in many over-the-counter anesthetic
S
increasing the area o anesthesia and minimizing the tis- ointments, such as products or oral ulcers. T e 20% gel,
c
t
sue distortion caused by any potential f uid retention.23 It
i
marketed as HurriCaine gel, can be applied with a dry
o
n
may also acilitate undermining o the subcutaneous plane gauze or 30 to 60 seconds or as a spray or less than 2
1
by hydrodissection o tissue.24 Clinical uses or hyaluroni- seconds to achieve anesthesia within 30 seconds.26 Benzo-
dase have been well documented in ophthalmologic sur-
:
:
caine is also commonly combined with other anesthetics,
gery, where this enzyme has been shown to minimize the such as lidocaine and tetracaine, or more e ective topical
S
u
number o anesthetic injection sites, decrease the volume anesthesia. Since it is derived rom PABA, cases o aller-
r
g
o anesthesia used, decrease the extent o bruising, and
i
gic contact dermatitis have been reported.27 In addition to
c
improve the onset o anesthesia. Although the precise dose
l
possible allergic reactions, benzocaine can also increase
P
o hyaluronidase to be used in cutaneous surgery remains
r
the risk o methemoglobinemia and, there ore, should be
i
n
unclear, most studies recommend a concentration o
c
avoided in in ants.28
i
p
7.5 IU/mL or 150 units in 20 to 30 mL o anesthetic.24
l
T is enzyme does, however, have disadvantages that limit
s
its use in cutaneous surgery. It decreases the duration o l Id o c a In e
anesthesia and potentially increases the risk o toxicity due to
greater di usion and systemic absorption.24 It also contains Lidocaine is an amide anesthetic which is available at con-
the preservative thimerosal, a known contact allergen. Rare centrations ranging rom 2% to 5%, and in a variety o vehi-
allergic reactions to hyaluronidase have been documented cles, including gel, ointment, and solution. A 5% topical
and preoperative skin testing is, there ore, recommended.24 patch is also commercially available, primarily marketed
to treat postherpetic neuralgia.26 Recently, newer prepa-
t o PIc a l a n es t Hes Ia rations o lidocaine, including those with higher concen-
trations, as well as combination anesthetics, in which it is
opical anesthesia may be used to alleviate pain associated mixed with tetracaine or with benzocaine and tetracaine,
with various inf ammatory disorders, as well as a number o have been manu actured to provide more e ective anes-
surgical, cosmetic, and laser procedures. T e major barrier thesia. o acilitate penetration, newer delivery systems
to the delivery o topical anesthesia is di usion through the using microemulsion or liposomal vehicles have also
stratum corneum.25 T us, topical anesthesia is particularly been developed.
e ective on mucosal sur aces and areas with a relatively
thin stratum corneum ( able 4-5). Novel delivery systems
t et r a c a In e
etracaine is a long-acting ester anesthetic. It is available
Ta bLe 4-5 as a topical cream and gel as well as a 0.5% solution. T e
t pi a h i solution is most commonly employed during ophthal-
mologic procedures, since one to two drops instilled into
g i n m t n m c i the eye provide anesthesia or up to 1 hour.26 etracaine
solution has also been combined with 1:2000 epinephrine
b nzoc in a m ric n Otic 20% (Liquid, g l,
spr y) and 11.8% cocaine, a mixture termed AC, and used over
the past ew decades as anesthesia or repair o super -
b nzoc in HurriC in 20% cial wounds, especially in children.28 Although this solu-
b nzoc in / C t c in 14%/2% tion has limited absorption, concern regarding potential
T tr c in systemic toxicities o cocaine, have limited its use.29 Fur-
thermore, newer anesthetic mixtures, including LE (4%
Coc in 2%–10%
lidocaine, 1:2000 epinephrine, 0.5% tetracaine), BL (20%
Lidoc in Xyloc in 2% viscous benzocaine, 6% lidocaine, 4% tetracaine), and EMLA
solution; 5% (eutectic mixture o lidocaine anesthesia) (2.5% lidocaine
liquid; 5% with 2.5% prilocaine) have demonstrated similar to supe-
ointm nt
36 rior e cacy compared to AC or topical anesthesia.30,31
 etracaine 4% gel (Amethocaine gel) comes in a leci-
thin based microemulsion vehicle. Lecithin is a mix-
due to increased absorption and potential toxicity, as well
as the potential or direct irritation o the cornea.26
1
ture o phospholipids in oil; its hydrophobic properties
provide enhanced penetration o tetracaine. In a recent
study, Amethocaine 4% gel was demonstrated to be eMl a
superior to EMLA a ter a 60 minute application time in
a group o 29 patients prior to pulsed dye laser (PDL) EMLA is a 5% eutectic mixture o lidocaine (2.5 mg/mL)
treatments, as determined by visual analog and verbal and prilocaine (2.5 mg/mL) in an oil-in-water emulsion
rating scores.32 cream. It is also available as a patch. A eutectic mixture
is one whose constituents melt at room temperature and
are present in liquid phase. Broberg and colleagues37
t o PIc a In e discovered this property serendipitously, observing that
when lidocaine and prilocaine bases in crystalline orm
opicaine (4% Lidocaine & 5% Lidocaine) is an amide were mixed together, they became f uid at room tem-
anesthetic, ound in a hydroethanolic translucent gel perature. In EMLA, the concentration o lidocaine and

C
h
microemulsion vehicle. Each gram o opicaine con- prilocaine achieved in the oil droplet is 80% though the

p
tains lidocaine 40 mg in a gel composed o water, etha- overall concentration o both the active drugs is as low

t
nol (35% w/w), glycerin, jojoba oil, aloe vera oil, glyceryl as 5% in the mixture. EMLA contains emulsi ers that

r
4
monolaurate, benzyl alcohol, carbomer 940, and ED A. enhance skin penetration and decrease the overall con-
T e 4% preparation is applied under occlusion whereas centration and potential or systemic toxicity.26 In addi-

:
:
the 5% preparation may or may not be applied under tion to lidocaine and prilocaine, EMLA is composed o

a
n
occlusion. T e recommended duration o application is polyoxyethylene atty acid esters to serve as emulsi ers,

s
30 to 60 minutes under occlusion or intact skin and 30 carboxypolymethylene as a thickening agent, distilled

t
h
minutes on mucosal sur aces. One study with opicaine water, and no preservatives. Several studies have shown

s
i
noted e ective anesthesia against 1064 nm Q-switched the e cacy o EMLA in alleviating pain during various
Nd:YAG laser induced pain a ter 30 minutes o applica- dermatologic procedures, including laser surgery, chemi-

n
d
tion under occlusion.30 T e anesthetic’s highest level o cal peels, harvesting split-thickness skin gra ts (S SG),

a
e cacy was achieved 30 minutes a ter removal o the skin biopsies, curettage and electrosurgery, and applica-

n
tion o liquid nitrogen.26,32

l
anesthetic. In a separate study, EMLA and ELA-Max

g
provided analgesia superior to that o topicaine at the EMLA cream has to be applied under occlusion. he

s
i
60 and 90 minute measurement periods.32 onset o anesthesia depends on the anatomic location
and the duration o application. On the ace, anesthe-
sia can occur in less than 25 minutes or needlestick
l MX purposes.32 On mucous membranes, given its rapid
penetration, onset o anesthesia is within 5 to 15 min-
LMX (originally called ELA-Max; Ferndale, Michigan) utes.32 EMLA does not provide e ective anesthesia on
is a topical anesthetic, which contains lidocaine encap- thick glabrous skin such as the palms and soles and is
sulated in a liposomal delivery system. A liposome is an not recommended or procedures in these areas. he
arti cially prepared vesicle composed o a phospholipid recommended application time or adequate analgesia
bilayer that can be used as a vehicle or administration is at least 1 hour. For pain ul procedures, the recom-
o pharmaceutical agents. T e liposomal delivery system mended application time is 2 hours.32 Maximum e ect
enhances the penetration o lidocaine, and increases its is reached 2 to 3 hours a ter application and lasts or at
duration o action by protecting it rom metabolic break- least 1 to 2 hours a ter removal. he depth o analgesia
down.32 LMX is available at concentrations o 4% and 5%, is 3.0 mm a ter 60 minutes o application and 5.0 mm
is available over the counter, and does not require a pre- a ter 120 minutes.26
scription. T e 5% cream is labeled as an anorectal cream, EMLA is contraindicated in patients with a positive
and provides temporary relie or discom ort associated histor y o amide hypersensitivity, liver disease, and skin
with anorectal disorders. LMX has a relatively ast onset diseases such as atopic dermatitis or psoriasis.29 In the
o action; a 30 minute application time prior to procedures latter conditions, EMLA is contraindicated secondar y to
is recommended. Studies comparing LMX 5% to EMLA higher rates o absorption rom inf amed areas. Alkaline
have shown that both are e ective in reducing pain, but injur y to the cornea has also been reported with EMLA,
that LMX 5% has a longer duration o action.33 Regarding and it should, there ore, not be used in this area.38 Finally,
sa ety, a study demonstrated that application o moderate EMLA should be used with caution in in ants less than
amounts (30 to 60 g) o occluded LMX 4% in eight healthy 12 months o age, in patients with glucose-6-phosphate
patients had no signs o clinical or serum toxicity.34 LMX dehydrogenase (G6PD) de ciency and those with con-
can also be used in children but special consideration genital or idiopathic methemoglobinemia, given the
must be paid to the sur ace area o application. In a child increased risk o methemoglobenemia secondar y to
weighing less than 20 kg, a single application o LMX prilocaine. A maximum o 1 g or an hour o applica-
should be limited to an area less than 100 cm 2.32 LMX has tion is sa e on intact skin o term neonates younger than
been used without occlusion to decrease the level o pain 3 months ( able 4-6).29 Central ner vous system (CNS)
induced during cosmetic procedures such as medium- toxicity was reported in a toddler a ter excessive EMLA
depth chemical peels and laser hair removal.35,36 Its use on was applied over an extensive area prior to molluscum
mucosal sur aces and the conjunctiva is not recommended treatment.37 37
1 Ta bLe 4-6 Ta bLe 4-7
r mm eMl a u b a B Wi h c mp t pi a h i

a M xim m M xim m a h i
B M xim m a a pp i i P p i c mm
W i h d m2 t im h
Lidocaine Laser Ointment: 60 min pplic tion provid s
1–3 mo 1 10 1 30% Lidoc in susp nsion ctiv n sth si or most
or <5 kg in propri t ry mulsion l s r proc dur s
ointm nt
4–12 mo nd 2 20 4
<5–10 kg 23% Lidoc in : 7% T tr c in 30–60 min pplic tion tim

1–6 yr nd 10 100 4 20% b t c in : 8% Lidoc in : 30–60 min pplic tion tim

<10–20 kg 4% T tr c in (bLT)
S
7–12 yr 20 200 4 7% Lidoc in : 7% T tr c in 60 min pplic tion tim
c
nd >20 kg
t
Photocaine: 6% Lidoc in : 30 min pplic tion ( c )
i
o
n
For in nts nd childr n s d on pplic tion to int ct skin. 6% T tr c in in lotion lik M ximum tr tm nt r =
1
I p ti nt gr t r th n 3 months old do s not m t th minimum v hicl 600 cm 2 ov r 2 h p riod
:
w ight r quir m nt, th m ximum tot l dos o eMLa Cr m should
:
4% T tr c in in l cithin g l 30 minut pplic tion tim
r strict d to corr spond to th p ti nt’s w ight. s und r occlusion
S
u
r
g
i
l Id o c a In e/t e t r a c a In e Peel
c
topical anesthetics. Clinical trials are not required to
l
P
approve compounded topical anesthetics, as they do not
r
i
Lidocaine/tetracaine (L ) peel is a 1:1 eutectic mixture
n
all under FDA regulation. As a result, great variability
c
o 7% lidocaine and 7% tetracaine. It is delivered in a
i
p
may exist among available preparations and no consen-
l
sel -occlusive membrane, whereby the cream is applied
s
sus guidelines on maximum dosages or maximum sur ace
to the treatment area and allowed to air dry into a f ex-
areas exist. Given this, and because o the narrow thera-
ible membrane. T e thin membrane is then peeled rom
peutic window that exists with most topical anesthetics,
the skin prior to the procedure. Recommended durations
it is essential that the clinician develop a working relation-
or e ective anesthesia are approximately 20, 30, and 60
ship with a reputable compounding pharmacy. Maximum
minutes or 585 to 595 nm PDL, 30 minutes or collagen
doses should not exceed those established or injectable
injection, cryotherapy, laser hair removal, and 1450 nm
preparations. Compounded topical anesthetics should
diode nonablative acial laser rejuvenation, and 60 min-
only be used under direct physician supervision.
utes or 1064 nm Nd:YAG leg vein treatment and 1064 nm
Q-switched Nd:YAG laser assisted tattoo removal.39 One
study demonstrated that when compared to a placebo c r yo a n es t Hes Ia
peel, L peel was more e ective or local anesthesia in
patients undergoing cryotherapy or acial actinic kerato- Application o cold agents to the skin can reduce the level
ses (30 minute application), collagen injections (30 min- o pain associated with dermatologic procedures. T is
ute application), PDL treatment o acial telangiectasia technique, using ice cubes or example, is rapid, inexpen-
or port wine stains (20, 30, 60 minute applications), laser sive, and relatively convenient to minimize discom ort dur-
hair removal (30 minute application), nonablative acial ing needle injections.41 Various topical reezing agents or
laser resur acing (30 minute application), 1064 nm long vapocoolants can also be used or brie surgical procedures
pulsed Nd:YAG leg vein treatment (60 minute applica- ( able 4-8). Caution should be taken to protect the eyes and
tion), and laser-assisted tattoo removal (60 minute appli- avoid inhalation o vapor when using these agents. Poten-
cation).40 T e L peel also provided greater anesthesia tial risks associated with using these agents include scar-
or cutaneous carbon dioxide laser skin resur acing o ring and pigment alteration. Some vapocoolants, such as
the cheek when compared to EMLA cream under occlu-
sion a ter a 30 minute application time or both. O note,
serum lidocaine and tetracaine concentrations a ter 30, Ta bLe 4-8
60, and 90 minute applications to areas ranging rom 50 Vp
to 200 cm 2 were below the lower limit o quantitation
values.39 n m I i
1) ethyl chlorid a,b (G u r 50% dichlorodi uorom th n ,
o t Her t o PIc a l a g en t s Comp ny, Cl v l nd, OH) 50% trichloromono uorom th n

opical anesthetics may be compounded by pharmacies 2) Inst nt cold spr ya (HL 10% isop nt n , 90% ut n
or use in dermatologic procedures. Although any phar- Moor , N w brit in, CT)
macy may compound topical medications, most mixtures a
Ozon S , bFl mm l
are custom prepared by specialized compounding phar- Source: D t rom Plotkin S. Clinic l comp rison o pr inj ction
38 macies. able 4-7 lists the most commonly compounded n sth tics. J Am Podiatr Med Assoc. 1998;88:73–79.
ethyl chloride, are also f ammable,42,43 while others have
raised concern over potential harm ul e ects to the ozone.42 Ta bLe 4-9
1
Cooling methods are particularly e ective during cos- o p imi i P i exp i
metic and laser procedures. Prior to injection o botuli-
Th ollowing t chniqu s c n improv p ti nt xp ri nc
num toxin and/or dermal llers, application o icepacks nd minimiz discom ort during dministr tion o loc l
may reduce pain. During laser procedures, application o n sth si :
cooled gels, cold glass windows, and other contact cool- D scri th proc dur nd r ssur th p ti nt.
ing devices have also been employed. Devices, such as the Provid c lm, cool nd qui t nvironm nt.
Zimmer air cooling device, which delivers re rigerated air Position p ti nt with h d support d to nh nc com ort.
onto the skin, have been used success ully during many Minimiz p ti nt vi wing o th n dl .
dermatologic procedures including ractional photother- Us sm ll di m t r (30 or 31 g ug ) n dl s.
molysis and PDL. Some lasers are even equipped with Distr ct p ti nt during dministr tion using count rirrit tion
dichlorodif uoromethane and tetraf uoroethane cryogen o dj c nt skin.
sprays that deliver transient cooling to the epidermis.43 In a dd sodium ic r on t to n sth tics cont ining
addition to providing anesthesia during laser procedures,

C
pin phrin .

h
these cooling methods also protect against laser-induced Us n sth tic solution w rm d to room t mp r tur .

p
epidermal thermal injury.

t
R tr ct nd str tch skin nd g ntly ins rt n dl .

r
Inj ct nd inf ltr t n sth tic slowly.

4
Minimiz th num r o skin punctur s.
Io n t o PHo r es Is

:
:
For r p t skin punctur s, dv nc n dl initi lly into
r s pr viously n sth tiz d.

a
Iontophoresis is a method o enhancing the transport o top-

n
Consid r using topic l n sth si in childr n nd xtr m ly
ically applied drugs using a mild electric current to increase

s
nxious p ti nts.

t
h
the permeability o charged drugs through the skin. T is For l rg r r s, us n rv locks.

s
method has been used to deliver solutions o drugs such

i
For p ti nts with history o l ding or on lood
as lidocaine into the skin without the pain o needle injec- thinn rs, us n sth tic with pin phrin nd w it 7 to

n
d
tions. With this system, an electrical current draws ionically 15 minut s or st rting surg ry.

a
charged drugs into the skin.44,45 Iontophoresis was ound to

n
For sm ll childr n, consid r conscious s d tion nd/or
enhance the penetration o lidocaine by 20 to 60 old when g n r l n sth si .

l
g
compared with topical application.46 Lidocaine iontophore-

s
i
sis has been ound to be 80% to 100% e ective in provid-
ing anesthetic action prior to procedures such as needle
injections, laser surgery, and electrosurgery, especially in Common methods employed to improve patient com-
the pediatric population. With lidocaine iontophoresis, the ort are providing a calm environment, having the patient
onset o action is within 10 minutes and the anesthetic e ect recline, providing reassurance, and explaining what to
lasts or 15 minutes.47 T e depth o anesthesia was ound to expect so that the patient is not surprised when the injec-
be 1 to 2 cm and plasma levels o lidocaine were less than tion occurs. Patients o ten describe eeling sensations o a
1 µg/mL a ter 10 minutes o iontophoresis application.44,46 “stick and a burn,” with entry o the needle into the skin and
A study comparing iontophoresis o lidocaine versus EMLA in ltration o anesthesia. A discussion o such anticipated
ound iontophoresis more e ective in achieving anesthesia.44 sensations prior to the planned procedure may help allevi-
However, two disadvantages to using this method are the ate anxiety. In addition, using a small-diameter needle (i.e.,
limited depth o penetration o the anesthetic, as well as the 30 gauge or 31 gauge) will signi cantly reduce pain and
need or additional equipment. discom ort as compared to larger-diameter needles. Some
argue that slow injection into the skin is also associated
with decreased pain and discom ort. T e application o
In f Il t r a t Io n t ec Hn Iq u es topical anesthesia, ice, or other cooling devices be ore the
initial injection is also use ul to alleviate pain, especially
l o c a l In f Il t r a t Io n in children and highly anxious patients.41 Neutralizing the
pH o lidocaine with NaHCO 3, along with warming lido-
T e most common technique or local in ltration o anes- caine to body temperature, have also been shown to help
thesia is through direct injection o anesthesia into the pro- attenuate the pain o in ltration.28 Methods o distraction,
cedural site. Injection o anesthesia can be administered such as rubbing a distant site, or providing counterirrita-
either intradermally or subcutaneously, each o which has tion by pinching or stretching the skin around the needle
certain advantages and disadvantages. Intradermal injec- entry point, can also di use any associated pain.17 I mul-
tion, which is more super cial than subcutaneous injec- tiple injections are needed, initial re-entry o the needle
tion, provides a more immediate onset o anesthesia and should be into areas previously anesthetized to reduce the
a longer duration o action, but may be more pain ul and level o discom ort rom repeat needle punctures. Finally,
may cause more tissue distortion. T e deeper subcutane- recently developed computer-controlled injection devices
ous injection may be less pain ul and cause less tissue dis- such as the Wand®or CompuDent®,as well as needle- ree
tortion, but has a slower onset and duration o anesthesia. devices, have been developed, which control the rate o
A number o techniques can be employed to improve the injection and limit patient discom ort. T ese systems have
level o pain associated with local in ltration and optimize been marketed primarily or dentistry, and their use in
patient experience and com ort ( able 4-9). dermatologic procedures remains to be determined. 39
1 Ta bLe 4-10
k i t m a h i

am a
fi 1l n m
c mp c i s i
Lidoc in 500 mg/L 50 mL o 1% lidoc in
epin phrin 0.5 mg/L 0.5 mL o 1:1,000,000
pin phrin
Sodium 10 meq/L 10 mL o 8.5%
ic r on t sodium ic r on t

Source: D t rom Kl in Ja . a n sth tic ormul tion o tum sc nt solu

S
tions. Dermatol Clin. 1999;17:751–759. R produc d with p rmission
c
rom Ro inson JK, H nk CW, Si g l DM, Fr tli a , ds. Surgery of the
t
i
o
Skin, 2nd d. Mos y els vi r; 2010. Copyright els vi r.
n
1
:
:
S
areas to be anesthetized, such as endovenous laser abla-
u
r
tion, ambulatory phlebectomy and ace li ts.
g
i
Figure 4-2 During ring (or f ld) lock, n sth si is
c
l
inj ct d circum r nti lly round th surgic l sit .
P
r eg Io n a l (n er Ve) Bl o c k
r
i
n
c
i
p
Regional blocks (or nerve blocks) involve injecting anes-
l
s
r In g (f Iel d ) Bl o c k thesia adjacent to a sensory nerve to block the entire
region served by that nerve. A detailed understanding
A ring block (or f eld block) is the injection and placement o the anatomic distribution o the sensory nerves o the
o local anesthetic circum erentially around the operative head, neck, hands, and eet, is essential to optimize e ec-
site (Fig. 4-2). It is particularly e ective in surgical cases tive anesthesia as well as patient com ort. T ese techniques
or which direct inf ltration into the surgical site should are particularly e ective in reducing the toxicity o anes-
be avoided, that is, excisional procedures o cysts whereby thetic by using smaller volumes, and also decrease tissue
direct inf ltration into the cyst may cause rupture o con- distortion at the operative site. In cases where hemostasis
tents.4 When properly per ormed, entry o the needle is needed, local inf ltration o lidocaine with epinephrine
around the surgical site occurs only in areas previously into the perioperative site may be added. Nerve blocks are
anesthetized, which reduces discom ort rom repeat nee- particularly e ective or surgical or cosmetic procedures
dle punctures. T e anesthetic should be injected into both involving the ace, especially the nose and lips, as well as
the superf cial and deep planes to optimize anesthesia. the digits. Additional locations in which nerve blocks are
commonly employed include the ears, hands, eet, lateral
thigh, and perineum.
t u Mes c en t a n es t Hes Ia T e most common type o anesthetic used or nerve
blocks is amide anesthetic. ypically, a higher concentra-
umescent anesthesia involves the delivery o large vol- tion o the anesthetic (i.e., 2% lidocaine) is used to enhance
umes o dilute anesthesia into the subcutaneous at until di usion o the anesthetic around the nerve, while using
the tissue distends. It is commonly used during liposuc- a small volume.52 Epinephrine may be added to the anes-
tion, appropriately named tumescent liposuction. During thetic to help prolong its duration by decreasing its di -
tumescent liposuction, the anesthetic is typically delivered usion and absorption, and to help improve hemostasis.53
through 0.5 to 1.5 mm multiport inf ltration cannulas or 18 T e use o epinephrine with digital blocks is not recom-
to 20 gauge blunt-tipped spinal needles. T e basic tumes- mended given the potential risk or vasoconstrictor-
cent solution described by Klein 48 contains 0.05% to 0.1% induced ischemia. T at being said, some argue that this
lidocaine with 1:1,000,000 epinephrine ( able 4-10). A risk is only theoretical and does not occur when proper
special pumping device is typically used to aid inf ltration technique is used.53,54
o such large volumes o anesthetic. T e upper dose limit In addition to recognizing the anatomic distribution o
o lidocaine which may be sa ely used with this technique sensory nerves, a care ul understanding o proper tech-
is estimated at 55 mg/kg.49 umescent anesthesia is a sa e niques or inf ltration o nerve blocks is necessary to maxi-
and e ective technique or providing e ective anesthesia mize patient com ort and minimize adverse e ects. Proper
with minimal blood loss, and without the risks o general technique involves injecting anesthesia adjacent to a nerve
anesthesia. Its prolonged duration o action also provides or within the same ascial compartment as the nerve to be
a level o postoperative analgesia.50,51 Although its use has anesthetized. ypically, a small, 1 inch 30 gauge, needle is
been best documented during liposuction, it can also be used; this helps minimize pain and allows or a slow, con-
40 used in a number o other procedures requiring larger trolled delivery o anesthesia.54,55 A ter the needle is placed
into the desired location, a small volume o anesthetic is
injected and allowed to di use locally. T e ensuing anes-
1
thesia allows or additional insertion o the needle with-
out signi cant pain or discom ort. Care ul attention must
be paid not to inject the nerve itsel , which can cause a
neuropraxia, with resulting paresthesias; rarely, this can
be permanent.55 Furthermore, as vessels typically travel
with nerves, care must also be taken to avoid intravascu-
lar injection; aspirating prior to injection may be use ul
in this instance. T e most common potential risks asso-
ciated with nerve blocks include direct nerve injury sec-
ondary to improper advancement o the needle, leading to
paresis and dysesthesias, as well as vessel trauma, causing
ecchymoses and potential hematomas.52 Peripheral nerve
blocks require di usion into larger-sized nerve trunks,

C
h
and as a result, these blocks have a longer onset o action

p
than local in ltration, usually becoming e ective a ter 5

t
r
to 10 minutes.

4
:
:
n er Ve Bl o c k s o n t He f a c e

a
n
T e trigeminal nerve (cranial nerve V) and branches o the

s
t
= Optha mic ne rve

h
cervical plexus provide the majority o the sensory inner-
= Ma xilla ry ne rve

s
vation or the ace ( able 4-11). T e trigeminal nerve has

i
= Ma ndibula r ne rve
three main branches: the ophthalmic (V1), maxillary (V2),

n
= Ce rvica l ne rve (pos te rior divis ions )

d
and mandibular (V3) (Fig. 4-3). T ese nerves relay sen-
= S upe rficia l ce rvica l plexus

a
sory innervation rom the ace, rontal scalp, conjunctiva,

n
and oral cavity. T ree distinct oramina serve as the bony

l
g
landmarks or in ltration o trigeminal nerve blocks. In Figure 4-3 S nsory inn rv tion to th h d, showing th

s
i
addition, the cervical plexus, a network arising rom the g n r l distri ution o th thr divisions o th trig min l
anterior rami o the our superior cervical nerves, inner- n rv , s w ll s r s inn rv t d y r nch s rom th
vates the neck and jaw, as well as segments o the ear and c rvic l pl xus.
occipital scalp (Fig. 4-3).54

o PHt Ha l MIc (V1) n er Ve Br a n c Hes T e supratrochlear nerve is located approximately 1.2 to

1.7 cm medial to the supraorbital notch at the upper medial
T e ophthalmic (V1) nerve gives rise to the rontal nerve, corner o the orbit. Blocking these nerves will provide anes-
which subsequently branches into the supraorbital and thesia rom the ipsilateral orehead, including the glabella,
supratrochlear nerves (Fig. 4-4). T ese two nerves provide extending to the vertex o the scalp. Both nerves can be
sensory innervation to the ipsilateral orehead and the ron- blocked through a similar approach: palpating the supraor-
tal scalp extending to the vertex. T e supraorbital nerve bital notch, entering just lateral to the notch in the midpu-
emerges rom the supraorbital oramen or notch, which is pillary line, and injecting 1 to 2 mL o anesthetic toward
located on the superior orbital rim in the midpupillary line. the midline.56

Ta bLe 4-11
s mi a v r i

a i r i si /s mp m t m
Typ I Mild–Moderate Mild–Moderate
(Ige m di t d) Pruritus, urtic ri Or l ntihist min s nd corticost roids
Severe Severe
Wh zing, ronchosp sm, ngio d m , dyspn , Institut bLS protocol, l rt 911, giv suppl m nt l
cy nosis, t chyc rdi , hypot nsion oxyg n, monitor vit l signs, IM ntihist min s,
0.3–0.5 mg pin phrin su cut n ously (1:1000)
Also consider: IV cc ss nd uids, ronchodil tors,
PO/IV corticost roids
Typ 4 Allergic Contact Dermatitis Topic l corticost roids
(D l y d typ ) eryth m , pruritus, p pulov sicul r ruption within a ntihist min s
ound ri s o pplic tion sit
41
1 S upra trochle a r
ne rve Ma XIl l a r y (V2) n er Ve Br a n c Hes
S upra orbita l
ne rve T e maxillary (V2) nerve gives rise to the in raorbital
nerve, which emerges rom the in raorbital oramen or
notch and provides sensory innervation to the ipsilateral
lower eyelid, nasal sidewall and ala, upper lip, and medial
cheek. T e in raorbital notch is approximately 0.7 to 1.0
cm below the in raorbital rim and just medial to the mid-
pupillary line (Fig. 4-4).54 T e nerve can be blocked either
percutaneously or intraorally, the latter providing less pain
and discom ort. T e percutaneous approach is achieved by
palpating the in raorbital rim, then slowly advancing the
needle ~1 cm below that point, and injecting 1 to 2 mL
o anesthetic. With the intraoral approach, the needle is
S
advanced through the gingival buccal sulcus at the apex o
c
t
the canine ossa or about 1 cm, at which point 1 to 2 mL o
i
o
n
anesthetic is injected just over the periosteum (Fig. 4-5).54
1
o urther decrease the pain and discom ort o the intra-
oral approach, a topical mucosal anesthetic can be applied
:
:
prior to injection.
S
u
r
g
Ma n d IBu l a r (V3) n er Ve Br a n c Hes
i
c
l
P
r
One o the branches o the mandibular (V3) nerve is the
i
n
c
mental nerve, which provides sensory innervation to
i
p
Infra orbita l the ipsilateral chin and lower lip, including the adjacent
l
s
ne rve mucosa and gingiva. T e mental nerve emerges rom the
Me nta l ne rve mental oramen, which is located midway along the height
o the mandibular bone, approximately 2.5 cm lateral to
Figure 4-4 Loc tion o supr or it l, in r or it l, nd midline and just medial to the midpupillary line (Fig. 4-4).
m nt l or min , s w ll s distri ution o trig min l With age, the mandible atrophies at the alveolar ridge and
n rv locks. A. Supr or it l nd supr trochl r n rv because o this, in older patients the oramen lies closer to
lock. B. In r or it l n rv lock. C. M nt l n rv lock. the upper margin o the mandible.54 Similar to the in ra-
orbital nerve, the mental nerve can be blocked either per-
Another branch o V1 is the anterior ethmoidal nerve, cutaneously or intraorally. T e percutaneous approach
which gives rise to the external nasal nerve. T e external can be achieved by advancing the needle at the location o
nasal nerve emerges rom in between the lower border o the mental oramen and injecting 1 to 2 mL o anesthetic.
the nasal bone and the upper lateral nasal cartilage, and T e intraoral approach can be achieved by advancing the
provides sensory innervation to the ipsilateral nasal dor- needle into the in erior labial sulcus between the lower
sum, nasal tip, and columella. By palpating the junction rst and second premolars and injecting 1 to 2 mL o anes-
between the mobile lateral cartilage and the rm nasal thetic just over the periosteum (Fig. 4-5). As previously
bones, and injecting 1 mL o anesthesia, the external nasal described, the intraoral approach is less pain ul, especially
nerve can be e ectively anesthetized.54 when coupled with topical mucosal anesthetics.

A B

42 Figure 4-5 Intr or l n rv lock t chniqu or th (A) in r or it l nd (B) m nt l n rv s.

 Dors a l digita l
ne rve
Dors a l digita l
a rte ry
1
Gre a te r
a uricula r
ne rve

Erb’s point
Pa lma r digita l Pa lma r digita l
Tra nsve rs e A ne rve a rte ry
ce rvica l
Exte rna l
ne rve
jugula r ve in
Pa ire d dors a l digita l
ne rve s a nd a rte ry

C
h
Clavicle

p
t
r
S te rnocle idoma s toid Tra pe zius

4
Figure 4-6 er 's point nd th post rior tri ngl o th

:
:
n ck.

a
n
s
t
h
Another branch o V3 is the auriculotemporal nerve,

s
which provides sensory innervation to the ipsilateral ante-

i
rior auricle, lateral temple, and temporal scalp. T is nerve Pa ire d pa lma r digita l

n
runs deep and posterior to the temporomandibular joint B

d
ne rve s a nd a rte ry

a
( MJ) be ore emerging super cially to travel with the Figure 4-7 A. In th digit, th dors l nd p lm r rt ri s

n
super cial temporal artery. T e auriculotemporal nerve nd n rv s run tog th r. B. Dors l ppro ch or digit l

l
g
can, there ore, be blocked by palpating the MJ with the n rv lock.

s
i
jaw open and injecting 2 to 3 mL o anesthetic superior to
this joint at the zygomatic arch.54
d Ig It a l Bl o c k s
g r ea t er a u r Ic u l a r a n d
Digital nerve blocks can be used to provide anesthesia or
t r a n s Ver s e c er VIc a l n er Ves procedures involving the phalanges and nails. Each digit
receives sensory innervation rom our nerves, two dorsal
T e greater auricular and transverse cervical nerves are
and two ventral, which lie on the lateral aspects o the digit
branches o the cervical plexus and emerge at Erb’s point
(Fig. 4-7). In order to provide anesthesia to the entire digit,
(Fig. 4-6), which is located in the posterior triangle o
anesthetic is placed around these our nerves at the base
the neck, near the midpoint o the posterior border o
o the digit. ypically, 1% to 2% lidocaine without epineph-
the sternocleidomastoid muscle. T e greater auricular
rine is used, out o concern that epinephrine may increase
nerve innervates the ipsilateral angle o the jaw to the
the risk o vascular compromise to the digit. T is potential
submandibular area and the posterior auricle, while the
phenomenon, however, has been re uted in several stud-
transverse cervical nerve provides sensory innervation to
ies.57,58 In order to achieve adequate vasoconstriction and
the ipsilateral in erior central border o the mandible and
minimize the risk o bleeding, proper use o a tourniquet
the anterior neck.56 o help accentuate the landmarks o
can be employed.53,59
the posterior triangle (comprised o the clavicle in eriorly,
T e most widely used approach or digital blocks is the
sternocleidomastoid muscle anteriorly, and trapezius
dorsal approach, which is less pain ul, whereby the needle
posteriorly) and identi y Erb’s point, the patient’s head
is initially advanced rom the dorsal side o the digit and
can be turned 45 degrees against resistance. Injection o
subsequently to the palmar/plantar side o the digit (Fig.
2 to 3 mL o anesthetic into Erb’s point will block both
4-7). Using this approach, the needle is placed into the web
nerves.54
space at the dorsolateral side o the digit and advanced
slowly while injecting approximately 1 mL o anesthesia.
n er Ve Bl o c k s o n t He T e needle is then partially withdrawn, redirected to the
ventrolateral side o the digit, and slowly advanced while
eXt r eMIt Ies injecting an additional 1 mL o anesthesia. T e procedure
is then repeated on the opposite side.59
Ner ve blocks are particularly use ul or surgical pro- While an extremely rare potential complication, care-
cedures involving the hands, eet, and digits. A thor- ul consideration must be taken to avoid digital ischemia.
ough understanding o the anatomic locations o the Several actors may contribute to digital ischemia, includ-
sensor y ner ves o the extremities will help with such ing the use o epinephrine, excessive pressure rom tour-
procedures. niquets, or excessive time under tourniquet application, 43
1 circum erential ring blocks, and postoperative burns to
anesthetized ngers.59 As mentioned previously, use o
T e ulnar nerve provides sensory innervation to the
palmar and dorsal sides o the last one and one-hal digits
epinephrine should be avoided, especially in patients with (Fig. 4-8). T is nerve runs deep to the f exor carpi ulna-
a history o peripheral vascular disease, vasospastic dis- ris tendon and its insertion into the pisi orm bone.57 T e
ease, connective tissue disease, or severe hypertension, or f exor carpi ulnaris tendon can be accentuated by f exing
in those with a recent history o trauma to or in ection o the wrist in a slightly ulnar direction. An ulnar block can
the digit.58 ourniquet use should be limited to 15 minutes be per ormed by injecting 3 to 5 mL o anesthetic just lat-
or less. Finally, the maximum recommended volume o eral (radial) to f exor carpi ulnaris tendon on the proximal
anesthesia or digital blocks should be 8 mL per digit, out crease o the wrist.57 In addition, one can also use the ulnar
o concern or potential vascular compromise.7 pulse as a landmark and inject just medial to the ulnar
artery. A third technique or per orming an ulnar block
involves placement o the injections at the elbow, where
Ha n d n er Ve Bl o c k s the ulnar artery travels between the olecranon process and
epicondyle o the humerus.57
Hand (wrist) blocks can be used to provide anesthesia T e radial nerve provide sensory innervation to two-
S
to select regions o the hand, especially or procedures thirds o the dorsal hand extending rom the wrist to the
c
t
on the palm where multiple anesthetic injections may be
i
proximal interphalangeal joint o digits two to our and
o
n
required, and which can be quite pain ul, particularly since the dorsal side o the rst digit. T is nerve runs on the
1
topical anesthestics are relatively ine ective on thick gla- lateral border o the radius dorsal to the radial styloid pro-
brous skin. Sensory innervation to the palm is mediated
:
:
cess and deep to the f exor carpi radialis tendon. A radial
mainly through the median and ulnar nerves, as well as a nerve block can be per ormed by injecting 4 to 5 mL o
S
u
super cial branch o the radial nerve. A thorough under- anesthetic in the area lateral to the radial artery and deep
r
g
standing o the anatomic location o these nerves and
i
to the f exor carpi radialis.57
c
their respective sensory regions will help with appropriate
l
P
placement o nerve blocks o the hand. Potential compli-
r
i
n
cations associated with improper technique include intra- f o o t n er Ve Bl o c k s
c
i
p
neural and intra-arterial injections o anesthesia.
l
T e median nerve provides sensory innervation to the
s
Sensory innervation to the oot is provided through ve
rst three and one-hal o palmar digits, the correspond- nerves: the posterior tibial, the super cial peroneal, the
ing two-thirds o the palmar sur ace, and a portion o the deep peroneal, the sural, and the saphenous nerves (Fig.
dorsal hand extending rom the proximal interphalan- 4-9). A thorough understanding o the anatomic location o
geal joint to the tip o the ngernail on the second, third, these nerves and their respective sensory regions will help
and medial hal o the ourth digit (Fig. 4-8). T e median with appropriate placement o nerve blocks or the oot.
nerve is located in the midline o the volar side o the T e posterior tibial nerve innervates the plantar sur ace
wrist between the palmaris longus tendon and the f exor o the oot, except or the medial sur ace, which is inner-
carpi radialis tendon.57 By having the patient appose the vated by the saphenous nerve, the lateral sur ace, which is
thumb and th digits, the palmaris longus tendon can be innervated by the sural nerve, and a small region between
accentuated (Fig. 4-8). T e needle can be inserted at the the rst and second toe, which is innervated by the deep
proximal wrist crease, and advanced medial (ulnar) to the peroneal nerve. On the dorsum o the oot, the super cial
palmaris longus tendon and under the f exor retinaculum, peroneal nerve innervates the middle dorsum, while the
where 3 to 5 mL o anesthetic can be injected to provide sural nerve and the saphenous nerves innervate the lateral
anesthesia to most o the radial side o the palm.57 and medial sides, respectively; the deep peroneal nerve
innervates a small area between the rst and second toes
S e ns o ry Inne rvatio n o f the Hand (Fig. 4-9). Nerve blocks or the oot are primarily per ormed
around the ankle. Prior to starting any nerve blocks, the
areas around the ankle should be thoroughly prepped with
antiseptic solution to minimize the risk o in ection.
Ra dia l ne rve T e posterior tibial nerve can be blocked at the medial
ankle. Here, the nerve runs posterior to the posterior tibial
Ulna r ne rve
artery en route toward the plantar sur ace o the oot. With
the patient in a supine position and the oot externally
rotated, one can palpate the posterior tibial artery, then
advance the needle posterior to the artery at the upper hal
o the medial malleolus and anterior to the calcaneal ten-
don, and inject 3 to 4 mL o anesthetic.55
T e sural nerve travels on the lateral side o the ankle
Me dia n ne rve more super cially than the posterior tibial artery, pass-
ing between the Achilles tendon and the lateral malleolus
on its way toward the lateral border o the oot. With the
patient in a prone position, the needle is advanced at the
posterior distal tip o the lateral malleolus between the
Figure 4-8 S nsory inn rv tion o th dors l nd p lm r Achilles tendon and lateral malleolus, and 3 to 4 mL o
44 h nd nd digits y th m di n, r di l, nd uln r n rv s. anesthetic is injected.55,60
 S e ns o ry Inne rvatio n o f the Fo o t
1
De e p pe rone a l
Sa phe nous ne rve
ne rve
S upe rficia l
S upe rficia l pe rone a l ne rve
pe rone a l
ne rve

S ura l
ne rve

C
h
p
Pos te rior

t
tibia l ne rve

r
4
S upe rficia l

:
pe rone a l

:
ne rve S a phe nous

a
n
ne rve

s
t
h
s
S ura l ne rve

i
n
d
a
n
l
g
s
i
De e p pe rone a l
ne rve
Figure 4-9 S nsory inn rv tion o th dors l nd pl nt r oot nd digits y th post rior ti i l,
s ph nous, d p p ron l, sup rf ci l p ron l, nd sur l n rv s.

T e saphenous nerve travels along the medial sur ace o anesthetized adequately with local in ltration, deep pero-
the cal and passes subcutaneously anterior to the medial neal nerve blocks are rarely per ormed. Nonetheless, in
malleolus and medial to the saphenous vein on the way order to properly per orm a deep peroneal nerve block, a
toward the medial sur ace o the oot. A saphenous nerve needle can be advanced immediately lateral to the exten-
block can be per ormed advancing the needle anterior to sor hallucis longus tendon but medial to the dorsalis pedis
the medial malleolus and medial to the saphenous vein artery, and 3 to 5 mL o anesthetic can then be injected.55
and injecting 3 to 4 mL o anesthetic into the subcutane-
ous tissue.55
T e common peroneal nerve gives rise to both the a d Ver s e r ea c t Io n s
super cial and deep peroneal nerves. T e super cial pero-
neal nerve runs deep along the anterolateral border o the Although generally sa e to administer, local anesthetics can
cal to the ankle, where it pierces the deep ascia to become cause regional and systemic adverse reactions. Regional,
super cial, and subsequently splits into the medial dorsal or local, reactions are those that occur around the site o
and the intermediate dorsal cutaneous nerves, which give application or injection. Systemic reactions include aller-
rise to the dorsal digital nerves. o per orm a super cial gic reactions and toxicities, as well as rare conditions,
peroneal nerve block, a line is drawn rom the distal ante- such as methemoglobinemia, which may occur in certain
rior aspect o the lateral malleolus to the anterior border predisposed individuals. In the ollowing sections, we will
o the medial malleolus. T e needle is then advanced into discuss these potential adverse reactions, including their
the subcutaneous tissue midway between the anterior tib- assessment and management.
ial sur ace and the lateral malleolus, in a traverse ashion,
and 3 to 6 mL o anesthetic is injected toward the medial
malleolus.55 l o c a l a d Ver s e r ea c t Io n s
T e deep peroneal nerve lies lateral to the extensor
hallucis longus tendon and the dorsalis pedis artery. T is Local adverse reactions occur at the site o injection
nerve innervates only a small portion o the oot, the or topical application. ypically, with topical anesthet-
rst web space. As such, given that this small area can be ics, these reactions include erythema, edema, tingling or 45
1 stinging, and color changes such as blanching, petechiae,
purpura, and/or temporary hyperpigmentation. Local side
Epinephrine should be used with caution in patients
taking beta-blockers and tricyclic antidepressants. In
e ects are sel -limiting and resolution is seen a ter with- these clinical scenarios, the use o epinephrine can result
drawal o the anesthetic. opical corticosteroids may has- in unopposed alpha-adrenergic activity, which may cause
ten recovery. a signi cant rise in blood pressure and heart rate, and can
With in ltration, causes o local reactions include lead to cardiac arrhythmias.15 Furthermore, absolute con-
improper injection technique or the addition o epineph- traindications to epinephrine include uncontrolled hyper-
rine. With the ormer, nerve injury may result rom direct thyroidism, severe hypertension, and pheochromocytoma.
nerve transection, pressure-induced ischemia, and/or vas-
cular compromise secondary to destruction or damage to
local vasculature.61 ypically, the hallmark o intraneural a l l er g Ic r ea c t Io n s
injection and impending nerve damage is acute pain and
paresthesias, which should signal that immediate retrac- Systemic adverse events may be subdivided into toxic
tion o the needle rom the site o injection must occur. reactions as well as ype I and ype 4 hypersensitivity
Epinephrine is added to anesthetics to provide vaso- reactions. ype 1 IgE-mediated reactions are immedi-
S
constriction, thereby increasing the local concentration ate with the rare potential or atal anaphylactic events.
c
t
Signs and symptoms are listed in able 4-11. Allergic
i
and duration o the anesthetic, while reducing potential
o
n
systemic toxicity. T e addition o epinephrine to local reactions occur more requently with ester-derived anes-
1
anesthetics, however, has been implicated in tissue necro- thetics as compared to amide-derived anesthetics. Esters
are metabolized to PABA, a common allergen, which can
:
:
sis, particularly with in ltration into the digits.53 T is
theoretical risk is even higher or patients with a history cross-react with paraphenylenediamine hair dyes, sul o-
S
u
o hypertension, peripheral vascular disease, or vasospas- nylureas, and thiazides.64 No cross-reactivity occurs with
r
g
amide anesthetics. Rare cases o amide-induced allergic
i
tic disease. As such, it is o ten recommended that local
c
reactions are likely due to the methylparaben preserva-
l
in ltration o epinephrine into the digits, such as during
P
tive chemically related to PABA used in the preparation
r
digital blocks, should be avoided. T at being said, digi-
i
n
o injectable anesthetics.63,64 Antihistamines and corti-
c
tal ischemia can also occur ollowing injection o exces-
i
p
sive volumes o anesthesia, even without the addition o costeroids can be used to treat mild allergic reactions. In
l
the unlikely event o an anaphylactic reaction, treatment
s
epinephrine. reatment options or epinephrine-induced
digital vasospasm and ischemia include vasodilators, such with 0.3 to 0.5 mg epinephrine subcutaneously, basic li e
as phentolamine and nitroglycerin.58,62 Phentolamine is support, and transport to an acute care acility should be
an alpha-adrenergic blocker that produces vasodilation, promptly initiated.
while nitroglycerin induces vasodilation through pro- o date, there are no speci c recommendations or
duction o nitric oxide. Local injection o phentolamine testing o potential allergic reactions to anesthetics. T e
(0.5 mg/mL) and topical application o nitroglycerin have possibility o a reaction to preservatives should always be
been used to reverse epinephrine-induced digital vasospasm. considered.64 I a patient has a positive history o allergic
reaction to PABA or methylparabens, preservative- ree
anesthetic may be used. I the history is unclear, intrader-
s ys t eMIc a d Ver s e r ea c t Io n s mal skin testing with a small aliquot o preservative- ree
lidocaine or patch testing may be a rational approach.65
rue systemic adverse reactions to local anesthesia are Alternatively, in patients with suspected allergy to anes-
rare.63 When they do occur, these reactions may be sub- thetics, other agents may be employed or local anesthesia.
divided into toxic reactions or hypersensitivities. Such Examples include diphenhydramine 1% and benzyl alco-
adverse reactions must be di erentiated rom psychogenic hol 0.9%, as well as intradermal tramadol and metoclo-
attacks and epinephrine reactions. T e latter typically pres- pramide.17,66,67 Studies with diphenhydramine, however,
ent as vasovagal episodes, o ten in response to procedural have shown that it has a smaller duration o action than
anxiety elt by the patient, including ear o needles and/or lidocaine, can be potentially more sedating, and even elic-
ear o pain. T e resulting increased parasympathetic tone its more pain.66 In one patient, skin necrosis was reported
mani ests as lightheadedness, diaphoresis, nausea, bra- with diphenhydramine.67 Studies with intradermal trama-
dycardia, hypotension, presyncope, and/or syncope.6 T e dol have demonstrated e ective anesthesia in comparison
most important step in treating such reactions is to rec- to prilocaine, but also a higher incidence o injection-site
ognize their psychogenic nature and to di erentiate these reactions.68,69 T ere ore, given that alternatives to local
symptoms rom those due to toxicity and/or hypersensitiv- anesthetics are o ten subobtimal, we recommend consul-
ity. Subsequently, to alleviate psychogenic symptoms, the tation or allergy testing to rule out a true allergy to local
patient can be reassured, placed in a calm environment, and anesthetics and to identi y sa e anesthetic options.
brought into the rendelenburg position. Some patients
are more sensitive to epinephrine, and may appreciate
f ushing, palpitations, and anxiety, even with small doses s ys t eMIc t o XIc It y
o local anesthesia. T e adrenergic e ects o epinephrine
may be mistaken or an allergic reaction, especially since Systemic toxicity may a ect the CNS and cardiovascular
they share many similar symptoms, including tachycardia. systems. T is occurs when blood levels o anesthetic rise
Measurement o blood pressure may be help ul in this situ- above a certain threshold, which can occur rom adminis-
ation, as blood pressure tends to drop during anaphylaxis, tering excessive amounts, inadvertent intravascular injec-
46 but will be elevated during epinephrine reactions. tion, rapid absorption, or abnormal drug metabolism.63
Rapid absorption is seen with application o topical anes-
thesia to the mucous membranes. Abnormal drug metab- Ta bLe 4-13
1
olism is seen in patients with a history o liver disease, li i t xi i
renal disease, pseudocholinesterase de ciency, and sec-
ondary to interaction with other medications.27,70 Among s m li i
anesthetics, lidocaine toxicity is the most likely severe l v si s mp m
adverse event the clinician may encounter. Lidocaine is an
1st St g : 1–6 µg/mL T lk tiv , git t d, ppr h nsiv ,
amide anesthetic rapidly metabolized by the hepatic P450
lighth d d, drowsy, disori nt d,
system (CYP1A2 and CYP3A4) into two major metabo- tinnitus, circumor l num n ss,
lites, monoethylglycinexylidide (MEGX) and glycinexyli- m t llic t st
dide (GX). GX is pharmacologically similar to MEGX but
less potent. Lidocaine is plasma protein bound and has a 2nd St g : 6–12 µg/mL N us , vomiting, muscl
twitching, tr mors, lurr d vision,
hal -li e o 1.5 to 2 hours.71 Liver disease raises the level
s izur s (g n r liz d tonic/clonic)
o lidocaine whereas renal disease raises the level o its
metabolites. Certain medications which inhibit the cyto- 3rd St g : >12 µg/mL C rdi c nd r spir tory

C
h
chrome P450 system, can subsequently theoretically alter d pr ssion, dysrhythmi s, c rdi c

p
the levels o lidocaine ( able 4-12). With topical anesthe- rr st

t
r
sia, location o application may play an important role.

4
Due to the absence o the stratum corneum on mucosal

:
sur aces, blood levels o topically applied lidocaine are

:
without direct supervision. wo cases involved applica-
increased because o enhanced penetration. In act, serum tion o compounded anesthetics to the bilateral legs, rom

a
n
lidocaine levels a ter application to mucosal sur aces have the groin to ankles under occlusion or longer than 60

s
been demonstrated to approach those associated with

t
minutes.34 Another case involved application to the entire

h
parenteral administration.71,72 T e maximum doses o top- back, which generally represents 18% o the total body

s
i
ical lidocaine should not, there ore, exceed the maximum sur ace area.73 All persons applied the anesthetic them-
doses associated with intravenous lidocaine injection.

n
selves prior to arriving at the treatment centers. No direct

d
Lidocaine has a narrow therapeutic window where the physician supervision, prescription, or clear directions

a
n
therapeutic dose approaches the toxic dose. Signs and regarding application were provided.

l
symptoms may be subtle at rst, but may progress rap-

g
Anesthetic potency directly correlates to the degree o
idly toward cardiovascular and respiratory depression i

s
systemic toxicity. More potent anesthetics, such as bupi-

i
le t unrecognized ( able 4-13).27 In act, there have been vacaine and etidocaine, appear to be more cardiotoxic
a ew reported cases o topical anesthetic-induced atality than other anesthetics.27 In act, given that bupivacaine
as a result o negligent prescribing, instruction, oversight, enters the sodium channel rapidly but leaves slowly, it has
and monitoring. T e victims were all in their early twen- a greater potential to induce a serious re-entrant arrhyth-
ties receiving topical anesthetics or laser treatment. Areas mia that may be re ractory to de brillation. In pregnancy,
o gross negligence included application to excessive sur- the potential cardiac toxicity o bupivacaine is even more
ace areas under occlusion or extended periods o time severe, likely due to increased progesterone levels as well
as impeded venous return.6
T e most important step in the management o anes-
Ta bLe 4-12 thetic toxicity is early recognition. Initial management
includes stopping the delivery o the anesthetic and main-
c h m P450 I hibi
taining ventilation and oxygenation. Hypoxia and acidosis
a miod ron M thylpr dnisolon can decrease the seizure threshold and enhance the car-
diotoxicity o local anesthetics.27 Seizures can be treated
a zol s ( ucon , itr con , M tronid zol and potentially prevented with diazepam, thiopental
k tocon )
sodium, and propo ol.27 Hypotension is initially treated
b nzodi z pin s Nic rdipin with administration o intravenous f uids, and i marked,
Cr m z pin Ni dipin may require vasopressors.27 Bradycardia and decreased
myocardial activity may require inotropic agents, such
Cim tidin P ntoxi yllin as epinephrine or ephedrine.27 Bretylium is used to treat
Cl rithromycin Propo ol recalcitrant dysrhythmias. Amrinone, a phosphodiester-
ase inhibitor that increases cAMP in the myocardium and
Chlor mph nicol Propr nolol
enhances contractility, can be used when conventional
Cyclosporin Quinidin inotropes are ine ective. A detailed algorithm or treat-
D n zol SSRIs ment o anesthetic-induced cardiovascular toxicity and
seizures has been recently published.27
D x m th son T tr cyclin
Dilti z m T r n din
Me t HeMo g l o BIn eMIa
erythromycin Thyroxin
Isoni zid V lproic cid Methemoglobin is the oxidized orm o hemoglobin. In
this orm, iron exists in its erric 3+ state and is unable to
M th don V r p mil
adequately carry oxygen. Normal physiological conditions 47
1 Ta bLe 4-14
(which allows or more rapid f uid suction) and the nee-
dle is subsequently switched to a smaller 30 gauge nee-
M h m bi mi dle. Local in ltration is delivered using 30 gauge, 0.5 or
1 inch needles. Needles with a larger bore diameter are
M h m bi not commonly used due to increased pain and discom ort.
c i % si s mp m Conversely, the 32 gauge needle is too small and f exible,
limiting the ease o injection. T e operative site should be
0–3 Norm l l v ls
outlined with appropriate markings, given that in ltration
3–15 Skin discolor tion (p l , lu , o the skin may distort lesional and anatomic borders. In
gr y) patients on blood thinners and/or with a history o excess
15–20 Cy nosis bleeding, lidocaine with epinephrine may be used and
allowed to sit or 7 to 15 minutes a ter in ltration, to allow
25–50 Lighth d dn ss, h d ch ,
or adequate vasoconstriction. Finally, on in ected areas, a
con usion, w kn ss, dyspn ,
greater volume o anesthesia may be required, given that
p lpit tions, ch st p in
local anesthetics are less e ective in acidic environments.
S
50–70 a lt r d m nt l st tus, d l rium, For surgical procedures that require multiple injections
c
t
i
d th o anesthesia, it is help ul to advance the needle into pre-
o
n
viously anesthetized sites to help minimize pain and dis-
1
com ort. T is is particularly use ul when per orming ring
:
:
permit the constant reduction o iron back to the errous blocks. Ring blocks are practical or cyst excisions and/
2+ state by NADH methemoglobin reductase, allowing or incision and drainage o abscesses. T ey are also e ec-
S
u
tive or procedures involving the scalp, pinna o the ear,
r
low levels o methemoglobin to be maintained. However,
g
i
when this natural process is interrupted, methemoglo- and nose. For procedures involving large sur ace areas o
c
l
bin levels may rise and oxygen delivery to tissue alls. the ace, especially the nose and lips, as well as the scalp,
P
r
Progressively worsening signs and symptoms ensue with hands, eet, and digits, nerve blocks are particularly use ul.
i
n
c
greater methemoglobin concentrations ( able 4-14). A clear prerequisite is the availability o regional nerves
i
p
to be blocked. T e bene ts o nerve blocks include the
l
Prilocaine and benzocaine are two topical anesthetics
s
which have been shown to precipitate methemoglobin- decreased amount o anesthetic needed, ewer injection
emia.74 Rare cases have also been reported with the topi- sites, and reduced tissue distortion. Disadvantages include
cal use o EMLA, due to the presence o prilocaine in the the lag time to complete anesthesia o distal structures, as
preparation.27 T e onset o symptoms may be delayed well as the lack o hemostasis that would otherwise occur
or a ew hours as the metabolites o the above anesthet- with local in ltration. Nerve blocks are particularly use-
ics, rather than the anesthetics themselves, lead to the ul or surgical excisions on the acral sur aces, digits, and
adverse reactions. the ace, ablative laser resur acing o the ace, botulinum
Certain patient populations are at higher risk o devel- toxin injections to the palms and soles, hair transplanta-
oping methemoglobinemia. Among them are individuals tion, medium and deep chemical peels o the ace, and or
with G6PD de ciency, methemoglobin reductase de - some practitioners, perioral ller injections.54,75
ciency, and those simultaneously taking methemoglo- In large areas where nerve blocks are not possible (i.e.,
binemia precipitating drugs such as sul onamides and trunk and limbs), tumescent anesthesia can be employed
antimalarials.74 In ants and children are in a high-risk to deliver large volumes o dilute anesthetic. With this
group because doses are o ten greater per kilogram o technique, higher maximum doses o lidocaine are deliv-
body weight, hemoglobin F is more susceptible to oxida- ered without toxicity. While this technique is most popu-
tion, and newborns have low levels o reductive enzymes. lar or tumescent liposuction, its utility has also expanded
Diagnosis is best achieved through arterial blood gas and to other procedures including laser resur acing, ace/neck
serum methemoglobin levels. Pulse oximetry generally is li ting, ambulatory phlebectomy, and so t-tissue recon-
unreliable. Management includes removal o the o end- struction.76– 78 T e concentration o lidocaine and epi-
ing agent, supplemental oxygen, and observation in mild nephrine can be varied based on anatomic location. For
cases when levels are below 30%. Intravenous methylene example, brous areas including the back, upper abdo-
blue 1 to 2 mg/kg is indicated in more severe cases. Ascor- men, and breasts tend to require a higher concentration
bic acid 300 to 1000 mg/d IV over 3 to 4 doses is reserved o lidocaine (1000 to 1250 mg/dL), whereas less brous
or patients with G6PD de ciency in whom methylene areas, such as the hips and thighs, require a lower concen-
blue is contraindicated.74 tration o lidocaine (500 to 700 mg/dL).
opical anesthesia is particularly e ective or surgical
and cosmetic procedures. While more e ective on mucosal
Pr a c t Ic a l a PPl Ic a t Io n s sur aces and areas with a thinner stratum corneum, topical
preparations such as EMLA and topical lidocaine, includ-
T e majority o cutaneous surgical procedures are per- ing compounded ormulations, allow or e ective anesthe-
ormed using 1% lidocaine with or without epinephrine sia or super cial surgical procedures, laser procedures,
or anesthesia. For more involved procedures, longer-act- ller injections, and chemical peels. opical anesthesia is
ing anesthetics, such as bupivacaine, may be added and/ particularly help ul in per orming cutaneous procedures
or mixed to maximize the duration o anesthesia while in children, including treatment o warts and molluscum,
minimizing risks. Commonly, local anesthetic is initially as well decreasing the pain associated with intralesional
48 drawn rom the bottle using a large 16 or 18 gauge needle injections, including in ltration o local anesthetic.
 T e techniques described above can be combined and
used in cutaneous surgical procedures to achieve optimal
18. Moore DC, Bridenbaugh LD, T ompson GE, Bal our RI,
Horton WG. Factors determining dosages o amide-type
1
local anesthetic drugs. Anesthesiology. 1977;47:263– 268.
anesthesia without the need or general anesthesia. In
19. Howe NR, Williams JM. Pain o injection and duration o an-
certain patients, low-dose benzodiazepines, such as diaz- esthesia or intradermal in ltration o lidocaine, bupivacaine,
epam (2 to 5 mg) and lorazepam (1 to 2 mg), may be used and etidocaine. J Dermatol Surg Oncol. 1994;20:459– 464.
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experience or the patient. Finally, in some circumstances, ates pain on skin in ltration with lidocaine, with or without
epinephrine. Anesth Analg. 1987;66:572– 574.
local anesthesia may not su ce, and options may include
21. Stewart JH, Chinn SE, Cole GW, Klein JA. Neutralized lido-
conscious sedation and/or general anesthesia. In general, caine with epinephrine or local anesthesia– II. J Dermatol
each patient must be assessed on a case-by-case basis. Surg Oncol. 1990;16:842– 845.
22. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with
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1989;15:1081– 1083.
CONCLUSION 23. Lewis-Smith PA. Adjunctive use o hyaluronidase in local an-
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C
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h
adjunct to surgical procedures. J Dermatol Surg Oncol.
A detailed and comprehensive understanding o the indica-

p
1994;20:842– 844.

t
tions and contraindications o local anesthetics, their phar- 25. Adriani J, Dalili H. Penetration o local anesthetics through

r
macologic properties, potential adverse e ects, and proper

4
epithelial barriers. Anesth Analg. 1971;50:834– 841.
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:
:
and com ort. T e use o topical application, local in ltra- J Am Acad Dermatol. 2000;43:286– 298.
27. Naguib M, Magboul MM, Samarkandi AH, Attia M. Adverse

a
tion, eld blocks, nerve blocks, tumescent techniques,

n
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s
t
anesthesia without the risks o general anesthesia. As the

h
28. Chen BK, Eichen eld LF. Pediatric anesthesia in dermatologic
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novel agents and delivery systems will likely ollow, provid- 2001;27:1010– 1018.
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n
ing the practitioner with an arsenal o tools with which to

d
a ter topical application o EMLA cream on a toddler with
adequately and e ciently deliver local anesthesia.

a
molluscum contagiosum. Pediatr Emerg Care. 2000;16:

n
252– 254.

l
g
30. Friedman PM, Fogelman JP, Nouri K, Levine VJ, Ashino R.
r ef er en c es

s
Comparative study o the e cacy o our topical anesthetics.

i
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51. Lillis PJ. Liposuction surgery under local anesthesia: limited 70. Klein JA, Kassarjdian N. Lidocaine toxicity with tumescent
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S
u
and techniques. Dent Clin North Am. 2002;46:719– 732, ix. caine applied to the ace on the serum levels o lidocaine
r
g
53. Denkler K. A comprehensive review o epinephrine in the n- and its metabolite, monoethylglycinexylidide. Aesthet Surg J.
i
c
ger: to do or not to do. Pla st Reconstr Surg. 2001;108:114– 124. 2010;30:853– 858.
l
P
54. Eaton JS, Grekin RC. Regional anesthesia o the ace. Derma- 72. Oni G, Brown S, Kenkel J. Comparison o ve commonly-
r
i
tol Surg. 2001;27:1006– 1009. available, lidocaine-containing topical anesthetics and
n
c
55. Cohen SJ, Roenigk RK. Nerve blocks or cutaneous surgery their e ect on serum levels o lidocaine and its metabolite
i
p
on the oot. J Dermatol Surg Oncol. 1991;17:527– 534. monoethylglycinexylidide (MEGX). Aesthet Surg J. 2012;32:
l
56. Randle HW, Salassa JR, Roenigk RK. Know your anatomy. 495– 503.
s
Local anesthesia or cutaneous lesions o the head and neck– 73. Berkman S, MacGregor J, Alster . Adverse e ects o topical
practical applications o peripheral nerve blocks. J Dermatol anesthetics or dermatologic procedures. Expert Opin Drug
Surg Oncol. 1992;18:231– 235. Saf. 2012;11:415– 423.
57. Earle AS, Blanchard JM. Regional anesthesia in the upper ex- 74. Coleman MD, Coleman NA. Drug-induced methaemoglobi-
tremity. Clin Pla st Surg. 1985;12:97– 114. naemia. reatment issues. Drug Saf. 1996;14:394–405.
58. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epi- 75. de Almeida AR, Kadunc BV, de Oliveira EM. Improving botu-
nephrine in digital blocks: myth or truth? Pla st Reconstr Surg. linum toxin therapy or palmar hyperhidrosis: wrist block and
2001;107:393– 397. technical considerations. Dermatol Surg. 2001;27:34– 36.
59. O’Donnell J, Wilson K, Leonard PA. An avoidable complica- 76. Keel D, Goldman MP. umescent anesthesia in ambula-
tion o digital nerve block. Emerg Med J. 2001;18:316. tory phlebectomy: addition o epinephrine. Dermatol Surg.
60. Sarra an SK, Ibrahim IN, Breihan JH. Ankle- oot periph- 1999;25:371– 372.
eral nerve block or mid and ore oot surgery. Foot Ankle. 77. Hanke CW. T e tumescent acial block: tumescent local anes-
1983;4:86– 90. thesia and nerve block anesthesia or ull- ace laser resur ac-
61. Ben-David B. Complications o peripheral blockade. Anesthe- ing. Dermatol Surg. 2001;27:1003– 1005.
siol Clin North America . 2002;20:695– 707. 78. Coleman WP III, Klein JA. Use o the tumescent technique
62. Heard CM, LaJohn S, Fletcher JE. An accidental ringblock o or scalp surgery, dermabrasion, and so t tissue reconstruc-
the great toe? Paediatr Anaesth. 2001;11:123. tion. J Dermatol Surg Oncol. 1992;18:130– 135.

50
 Ch a p t e r

5 Aseptic Technique
Ji H n y & J rry D. Br w r

In t r o d u c t Io n A super cial SSI is de ned as an in ection con ned to

the epidermis, dermis, or subcutaneous tissues occurring
within 30 days o the surgical procedure in the presence
Surgical site in ections (SSI) represent a leading cause o
o at least one other sign o in ection: purulent drainage
morbidity ollowing inpatient surgical procedures, and
rom the incision site, aseptic isolation o microbes, the
constitute up to one-third o all nosocomial in ections.1,2
diagnosis o a SSI made by an attending physician, or other
Fortunately, there is a much lower risk o in ection ol-
signs o in ection such as erythema, edema, tenderness, or
lowing dermatologic procedures than there is with more
warmth at the incision site ( able 5-1) (Fig. 5-1).16,17
invasive surgical procedures. Dermatologists per orm
In addition, certain actors endogenous to the patient
over 3.9 million procedures each year and are estimated
can increase the risk o in ection. Advanced age, obe-
to have an in ection rate o only 3.5%.3– 9 Although the risk
sity, immunosuppression, diabetes mellitus, malignancy,
o in ection is low, SSI can lead to increased morbidity,
chronic obstructive pulmonary disease (COPD), in ec-
expense, and distress or the patient during the postopera-
tious diseases, malnutrition, chronic alcohol or tobacco
tive period.10
use, or a bleeding diathesis all lead to a greater risk o
Historically, surgical procedures were associated with
postoperative in ection.3,15,17 Although these chronic con-
high rates o in ection and sepsis, as well as patient mor-
ditions can be well managed, it can be di cult to ully
tality. It was not until 1865 that Joseph Lister signi cantly
eliminate these risk actors prior to cutaneous procedures.
improved patient outcomes a ter his experimentation
Knowledge o these conditions be orehand, along with a
with various antiseptic techniques.11 Lister required the
thorough preoperative evaluation, can allow the physician
patient’s wounds to be cleansed with carbolic acid prior to
to take additional precautions be ore the procedure, such
surgery.11 He also required the surgical sta to scrub their
as placing the patient on an appropriate antibiotic.
hands with the acid prior to procedures and to soak instru-
Factors that are considered exogenous to the patient
ments and towels in carbolic acid be ore using them in
also contribute to the development o in ection. Exog-
surgery.11,12 As a result, surgeries that had once been asso-
enous actors are largely modi able and correlate with
ciated with a 50% mortality rate due to in ection showed
the quantity o microbes trans erred to the patient dur-
vast improvements in patient survival.11,12 In the years that
ing the procedure rom patient care personnel, surgical
ollowed, other scientists and researchers continued to
equipment, and the surrounding environment.17,18 T e
improve upon Lister’s techniques, which ultimately led to
risks associated with exogenous actors can be minimized
the strict standards o antisepsis in place today.
by proper antiseptic preparation o the surgical sta
T is chapter discusses the current recommendations
and proper sterilization o the surgical instruments. T e
or sterile technique with speci c application to derma-
length o the surgical procedure also positively correlates
tologic procedures. It is important to recognize that the
with the development o SSI. For every hour o surgery
bacterial load on the patient’s skin strongly correlates
per ormed, the risk o in ection is doubled.19
with the risk o SSI; there ore, proper preoperative pre-
cautions and aseptic technique are imperative to decrease
the patient’s bacterial load and the subsequent risk o
in ection.13– 15 T is chapter will also provide in ormation Ta Bl e 5-1
regarding the antiseptic agents available today, proper cd c d i ii SSI
preoperative preparation o the patient and surgical sta ,
and proper outpatient sterilization and storage o surgical cd c d f i i S p f i S i Si
instruments. I i
Th d v opm nt o n in ction within 30 d o th surgic
d e In It Io n o Su r g Ic a l proc dur th t is con n d to th skin nd subcut n ous
SIt e In ec t Io n tissu s, p us on ddition sign or symptom:
1. Puru nt dr in g rom th incision sit
T e Centers or Disease Control (CDC) have ormally 2. Iso tion o org nisms rom th incision sit
de ned what constitutes an SSI to help ensure prompt 3. a t st on o th o owing: p in or t nd rn ss, oc iz d
recognition by healthcare pro essionals. As dermatologic sw ing, r dn ss, or h t
procedures are mostly con ned to the super cial tis- 4. Di gnosis o SSI by th surg on or tt nding
physici n 15–18
sues, the de nition o a super cial SSI is provided here.
1 Sk In r eSId en t a n d
t r a n SIen t l o r a
One o the skin’s major unctions is to provide a protective
barrier against the external environment and its microor-
ganisms. It is estimated that over 1014 bacteria colonize
the human body, inhabiting speci c anatomic locations
which depend upon the pH, temperature, oxygen, water,
and nutrient availability or the bacteria.24 Most microbial
f ora are considered commensal organisms that reside in
the super cial layers o the skin and hair ollicles, and can
be urther categorized into resident or transient f ora.24,25
Resident f ora is comprised o multiple, stable micro-
organisms that live and multiply on the skin.26 It is largely
S
c
composed o gram-positive bacteria such as Staphylococcus
t
i
o
epidermidis, which comprises up to 90% o the population
n
o aerobic bacteria.24 T e number o people colonized
1
with Staphylococcus aureus is increasing, with an esti-
:
:
mated colonization rate o 30% to 50%.27 As a result, the
S
number o people colonized with community-acquired
u
r
strains o MRSA has also increased.17,27 It is important
g
i
c
to recognize that S. aureus remains the most common
pathogen isolated rom SSI ( ollowed by S. epidermidis,
P
r
Enterococcus, and Escherichia coli) with as ew as 3 × 1014
i
n
c
staphylococci required or pus ormation.17,28 Because S.
i
p
aureus is the most common pathogen isolated rom SSI,
s
Figure 5-1 a n x mp o surgic sit in ction. it is important to place the patient on an antibiotic that
has excellent coverage or S. aureus i a wound becomes
in ected postoperatively.
ransient f ora consists o the microbes temporarily
In order to estimate the patient’s risk o SSI postop- trans erred to the skin rom direct contact with a per-
eratively, a set o guidelines categorizing wounds into son, object, or the surrounding environment. Gram-neg-
our di erent classes were created (see able 5-2). Most ative bacteria and Streptococcus species are considered
dermatologic procedures are per ormed on clean, class I to be transient because they cannot survive on the skin
wounds, with a less than 5% risk o postoperative in ec- or a long time.24,29 Patients who have been hospitalized
tion. As the wounds themselves are not in ected, it is o ten recently or who have diabetes mellitus are also more likely
the microbial f ora o the surrounding skin that poses the to be transiently colonized with gram-negative bacte-
greatest risk o in ection.20,21 ria.20,30 Since transient f ora causes the majority o SSI, it is,

Ta Bl e 5-2
W c ssi i i es i I i r is

c ss t yp d s ip i ex p s I i r is
C ss I C n Noncont min t d wounds cr t d Most d rm to ogic <5%20,22
using st ri t chniqu 17,20,22,23 proc dur s
C ss II C n Cont min t d Wounds th t r oc t d in Proc dur s oc t d 10%20,22
cont min t d r s such s th or on th or or
mucos , r spir tory tr ct, xi , nd g nit i mucos
p rin um; or in which minor br ks in
st ri t chniqu occurr d during th
proc dur 17,20,22,23
C ss III Cont min t d Wounds th t r cont min t d Proc dur s on 20%–30%20,22
s cond ry to tr um or r cut y in m d tissu
in m d; or in which m jor br ks in
st ri t chniqu occurr d during th
proc dur 17,20,22,23
C ss IV In ct d Wounds th t r gross y puru nt or In ct d cysts or 30%–40%20,22
n crotic17,20,22,23 bsc ss s
52
 Ta Bl e 5-3
1
mi bi S i
Gram-Positive Bacteria
24,25,29,31
S. epidermidis Compris s up to 90% o th robic skin or
S. aureus estim t d to co oniz 30%–50% o h thy p op 17,29 Most common y co oniz s th int rtriginous
r s, n r s, p rin um, xi , nd to w bs27,29,31 Th r t o MRSa a co oniz tion is incr sing with
rising proportion o community cquir d str ins32
Micrococci l ss common th n st phy ococci29,31 Th r r t st 8 dif r nt sp ci s o Micrococcus th t r
pr s nt on th skin with Micrococcus luteus b ing th most common 24,29
P. acnes Most common y co oniz s r s rich in s b c ous g nds nd r ch s its p k round pub rty24,29,31
Streptococcus Alpha h mo ytic Streptococcus most common y co oniz s th oroph rynx24,25,29

C
Beta h mo ytic Streptococcus do s not common y co oniz th skin du to th high ipid cont nt o

h
th skin, which inhibits growth o th sp ci s24,29

p
t
Gram-Negative Bacteria

r
5
Acinetobacter, E. coli, Do not common y compris th r sid nt microbi or nd r mor ik y to b ound tr nsi nt y

:
Proteus, Klebsiella, on th skin. Most common y ound in r s o high moistur , such s th xi , to w b sp c s, nd

:
Enterobacter, P. aeruginosa int rtriginous r s.24,25,29,31 P ti nts th t h v und rgon ong t rm hospit iz tion, hospit work rs,

a
nd p ti nts with di b t s m itus r t n incr s d risk or gr m n g tiv co oniz tion.29,33

s
p
Acinetobacter is stim t d to co oniz up to 25% o p op .25,29,31 Pseudomonas r qu nt y co oniz s

t
i
th xt rn r34

c
T
Fungi

c
h
n
Pityrosporum R quir s ipids or growth nd most common y co oniz s r s rich in s b c ous g nds25,31

i
q
u
Candida albicans C n b ound on th mucous m mbr n s25,29,31 Mor common in immunosuppr ss d nd di b tic
p ti nts29,31
a
M thici in r sist nt Staphylococcus aureus.

there ore, important to reduce the number o microorgan-

isms that are temporarily trans erred to the patient’s skin Pr eo Per a t Iv e Ba t h In g
by using antiseptic preparations and proper sterile tech-
nique ( able 5-3).15 Currently, there are no recommendations regarding
Patients undergoing more extensive dermatologic pro- bathing prior to dermatologic procedures; however, pre-
cedures are at an increased risk o in ection and should operative bathing may be bene cial or patients undergo-
be placed on a prophylactic antibiotic be ore the proce- ing extensive procedures who are more likely to be at an
dure. T is helps to decrease the overall bacterial load on increased risk o in ection. It is thought that bathing the
the patient’s skin at the time o surgery.15,35 More in or- day be ore surgery with an antiseptic or bar soap helps
mation regarding the types o patients who could bene t to decrease the overall bacterial load. A 2012 Cochrane
rom prophylactic antibiotics will be ound in the chapter review ound that patients who washed themselves using
entitled, Antibiotic Prophyla xis. 4% chlorhexidine gluconate or regular bar soap prior to
surgical operations had lower rates o in ection than those
who did not bathe preoperatively.30 More research with
Pr ePa r a t Io n o t h e Pa t Ien t speci c application to dermatologic procedures needs to
be conducted however, so that more ormal recommenda-
Preoperative preparation is an essential element in preven- tions can be made.
tion o SSI. T e amount o preparation required depends
on the invasiveness o the procedure. Ideally, a thorough
preoperative evaluation should be conducted or derma- h a Ir r emo va l
tologic procedures that are scheduled in advance; speci c
in ectious precautions, such as prophylactic antibiotics Procedures located in hair bearing areas may require
or preoperative bathing, can then be recommended or hair removal prior to surgery. Excess hair can inter ere
patients at an increased risk o in ection.20 Depending on with suturing o the incision site, application o adhesive
the extent o the procedure, the patient’s street clothes dressings, and the visibility o the operative eld.36,37 Hair
may need to be removed and replaced with a reshly has been speculated to increase the rate o SSI, although
laundered hospital gown. Other precautions, such as hair a 2011 Cochrane review ailed to nd evidence to sup-
removal and antiseptic skin preparation, can be addressed port this claim.38 Clipping the hair is pre erable to shaving
on the day o the procedure. because shaving traumatizes the skin, leading to enhanced 53
1 bacterial proli eration and an increased risk o in ec-
tion.3,19,21,26,38 Clipping the hair is quick, atraumatic, and
remain active or the entire procedure.40 wo o the most
commonly used antiseptics are chlorhexidine gluconate
leaves the hair about 1 mm in length.38 Depilatory creams and povidone– iodine. Although larger studies have ailed
can also be used or hair removal in areas that are di cult to show a signi cant di erence between the two agents,
to clip or shave, but must be applied the day be ore surgery smaller studies have shown chlorhexidine gluconate to
to be e ective, and are thought to carry the same risk o be superior.41 Chlorhexidine may be even more e ective
in ection as shaving.31,38 when combined with isopropyl alcohol. In 2010, a study
conducted by Darouiche et al.42 ound 2% chlorhexidine
gluconate in combination with isopropyl alcohol (70%) to
a n t ISePt Ic Sk In Pr ePa r a t Io n be more e ective than povidone–iodine (10%) in prevent-
ing SSI ollowing clean-contaminated surgical procedures.
Reducing the bacterial load on the skin prior to derma-
tologic procedures can signi cantly decrease the patient’s
risk or developing a SSI. Use o e ective antiseptic agents a n t ISePt Ic S
as well as irrigation o the area with normal saline can
S
help to diminish some o the bacterial load.25,39 Numer- Chlorhexidine is one o the most e ective and popular anti-
c
t
ous antiseptic agents are available or dermatologic pro- septic agents used today. Its activity is concentration depen-
i
o
n
cedures ( able 5-4). T e optimal antiseptic agent would dent.44 At higher concentrations, it is bactericidal with a
1
remove most o the resident and transient f ora quickly and quick onset o action and a broad spectrum o antimicrobial
:
:
S
u
r
g
Ta Bl e 5-4
i
c
a is p i a s
P
r
i
n
a is p i o s r si a i i bi
c
i
p
a m is a i iy a i iy a i iy c s
s
Ch orh xidin Bigu nid R pid Y s (up to Gr m positiv s C n b mor xp nsiv
(Ch or pr p) th t binds to ons t o 48 h)27,46 Gr m n g tiv s th n oth r products44 Is not
(Hibic ns) th str tum ctivity.21,45 Fungi in ctiv t d by b ood or oth r
corn um o Do not n d Virus s45,47 prot in rich subst nc s45 M ny
th skin.43 to w it unti pr p r tions cont in isopropy
B ct ricid dry44 coho , which c n incr s th
t high mm bi ity o th product 48
conc ntr tions44 Shou d not b us d n r th
y s or rs b c us o th risk
o ototoxicity nd irrit tion to
th corn nd conjunctiv o
26,44,49–54
th y
Iodophors Bound to R quir s 3–5 l itt r sidu Gr m positiv s In ctiv t d by b ood nd oth r
(B t din ) w t r so ub min to dry ctivity.43,55 Gr m n g tiv s prot in rich subst nc s.30,55
(Povidon –iodin ) c rri rs such to r ch u Povidon Fungi Do s not f ctiv y ki
s povidon ; ctivity21,55,56 pro ongs th Virus s27,55 spor s.27,55 Iodin c n b
iodin is b ct ricid irrit ting nd d to t mpor ry
b ct ricid 55 ctivity o st ining o th skin 55 C n r r y
iodin 44 d to syst mic toxicity i rg
mounts r pp i d on th
mucos sur c s, sp ci y in
in nts21,26,44,50
a coho D n tur s Quick st No r sidu Gr m positiv s C nb mm b wh n
(Isopropy coho ) b ct ri c ons t o ctivity onc Gr m n g tiv s xpos d to h t 48 l itt ctivity
(ethy coho ) w prot ins.47,57 ction v por t d 55,58 Fungi g inst spor producing
a ctivity is o th l ss vir b ct ri 59 C nnot r mov
conc ntr tion ntis ptics cov r g 57,58 org nic m t ri or sur c dirt
d p nd nt 47 rom th skin 60
Ph no ic B ct riost tic; S ow ons t Y s (Up to 6 h)58 Gr m positiv s H x ch oroph n is bsorb d
compounds Forms m o ction 58,59 l ss gr m n g tiv rom th skin nd t high
(H x ch oroph n ) ov r th skin 59,61 cov r g ( sp ci y conc ntr tions which c n
(Tric os n) P. aeruginosa) b toxic, p rticu r y in
(Ch oroxy no ) l ss ung n on t s58,62 H x ch oroph n
cov r g c n b com cont min t d by
l ss vir gr m n g tiv b ct ri 61,62; not
cov r g 58,59,61 common y us d tod y63
54
 Be ore application o any antiseptic, it is important to
remove any dirt or organic material rom the skin with
1
soap and water.17 T e antiseptic should be applied to the
area in concentric circles, beginning rom the operative
site with extension outward to the surrounding skin.17
Applying the antiseptic to the surrounding skin is impor-
tant both to decrease the bacterial load and to prevent
the surrounding bacteria rom migrating to the incision
site.4 T is action will also decrease the likelihood o surgi-
cal instrument contamination i the instrument comes in
contact with the surrounding skin during the procedure.4
In addition, the concentric motion used when applying the
antiseptic creates riction on the sur ace o the skin, allow-
ing or deeper penetration.64 Antiseptic agents are avail-
Figure 5-2 Povidon –iodin ntis ptic pp ic tion. able in disposable, one-time-use packages or in multi-use

C
h
bottles. Disposable, one-time-use packages are e ective,

p
user riendly, and have a lower risk o bacterial contamina-

t
activity.47 In addition, it binds to the stratum corneum o the

r
tion than multi-use bottles.66

5
skin, which prolongs the duration o activity.3,64 Chlorhexi- Another technique currently being implemented by
dine does not become inactivated when it is wiped away

:
general surgeons to decrease the risk o in ection is the

:
rom the skin or when it comes into contact with bodily application o a cyanoacrylate microbial sealant to the

a
s
f uids.3 It should not be used near the eyes or the inner skin be ore clean surgical operations.67 T e sealant can

p
ear because the detergent can be irritating to these struc- be applied with a sterile applicator a ter antiseptically

t
i
c
tures.26,49– 52 Rarely, serious complications such as dea ness prepping the skin. Use o a sealant may be bene cial or

T
and blindness have occurred.4,49–51,53,65 extensive dermatologic procedures as an additional way

c
h
Historically, iodine has been used as an antiseptic agent to prevent normal f ora rom migrating into the operative

n
i
q
since the early 1900s. Iodine bound to water-soluble iodo- area; however, studies have ailed to nd any signi cant

u
phors, such as povidone, is currently used, because its di erences on the incidence o SSI a ter preparation o the
direct application is too irritating to the skin.55 Moreover, skin with a cyanoacrylate sealant.67
the iodophor prolongs the duration o iodine’s antiseptic
activity on the skin.55,59 Iodine is bactericidal with a broad
antimicrobial range, but requires several minutes to dry Pr eo Per a t Iv e ma r k In g Pen S
to reach ull activity.41,56 Other disadvantages o iodine
are that it can stain the skin temporarily, and that it can Skin lesions are commonly outlined with a marking pen
also be inactivated by bodily f uids, including blood.3,4,64 prior to dermatologic procedures both to veri y the loca-
In addition, the product loses its antimicrobial activity tion and to accurately identi y the borders o the lesion.68
when it is wiped rom the skin.1 Iodine containing prod- Nonetheless, preoperative marking pens have been
ucts should not be used in patients who have an iodine or associated with bacterial cross-contamination between
shell sh allergy (Fig. 5-2).4 patients.69,70 Old or dried out marking pens (greater
Alcohol is a commonly used antiseptic or minor der- than 3 months) have been ound to harbor bacteria and
matologic procedures. It is the most rapidly acting o should not be used on patients.69,71 Instead, an ethanol-
the antiseptic agents, but has no residual activity once it based ink permanent marking pen or a gentian violet
evaporates rom the skin.4,17,55,58 Alcohol has broad anti- marking pen should be used.71 T ere should also be a
microbial activity but does not e ectively kill spores.17,59 2 to 10 minute inter val between uses to prevent cross-
Isopropyl alcohol is generally recommended over ethyl contamination.69,70,72,73 T e ethanol-based ink in perma-
alcohol because it causes less skin irritation and has nent marking pens is bactericidal and can decrease the
greater antimicrobial activity.26,55,58 In general, alcohols risk o in ection.69,72,73 Gentian violet marking pens have
have been ound to be more e ective when used in con- broad antimicrobial coverage as well but do not e ec-
junction with other antiseptic agents such as chlorhexi- tively kill Mycoba cterium species.71 As a result, bottled
dine.26,42 It is important to keep in mind that alcohol can solutions o gentian violet need to undergo periodic
become f ammable in the presence o heat, such as with autoclaving, because they are prone to contamination
electrocoagulation.48 with Mycoba cterium chelona e.74 Furthermore, the use o
Phenol-derivatives such as hexachlorophene are slow- disposable marking pens is encouraged in patients who
acting bacteriostatic agents that have excellent gram-positive are immunosuppressed or who have known colonization
coverage but lack adequate gram-negative coverage, espe- with a multidrug resistant organism.68– 70
cially against Pseudomona s aeruginosa.59 Hexachloro-
phene has a very slow onset o action, requiring multiple
days o application in order to be as e ective as the other d r a PIn g
antiseptic agents, but has a longer duration o activity (up
to 6 hours).58 It has been ound to be toxic when applied to Sterile drapes are placed around the incision site prior to
large body sur ace areas and bottles o hexachlorophene dermatologic procedures to prevent the surrounding bac-
are also prone to bacterial contamination.61,62 As a result, teria on the skin rom entering the incision site as well as
this agent is not commonly used today.59 rom coming into contact with the instruments and gloves 55
1 o the surgical sta . Un ortunately, studies have ailed to
nd a reduction in the rate o in ection with the use o
and water to remove the organic contents prior to using
the alcohol-based handrub. T e use o alcohol-based hand
plastic adhesive drapes during surgical procedures, and antiseptics is increasing because they are user riendly,
have actually ound patients to be at a slightly increased have a quick onset o action, and are as e ective as aque-
risk o in ection with their use.2 T is is thought to be due ous scrubbing agents.59,78,79 T ey have also been shown to
to increased moisture being trapped beneath the drapes, be e ective against multidrug resistant organisms, such as
creating an environment that enhances bacterial proli era- MRSA and vancomycin resistant Enterococcus (VRE), but
tion.75 As a result, the drapes should be chemically pre- it is important to keep in mind that they lack su cient
treated to be moisture resistant. T e drapes can be cloth, activity against Clostridium dif cile.80 An additional ben-
plastic, or paper and can be prepackaged within dispos- e t o alcohol-based handrubs is that they are less likely to
able surgical kits. Cloth drapes are not commonly used in cause irritant contact dermatitis or drying o the skin in
the outpatient setting, but they should be composed o at comparison to washing with soap and water.78
least a 270 thread count pima cotton to provide a more Aqueous antiseptic scrubs are water-based solutions
e ective moisture barrier.26,76 Most o the drapes used or containing chlorhexidine gluconate or povidone– iodine
dermatologic procedures are disposable paper drapes. which require the hands and arms to be wet prior to
S
T ese drapes should be laminated prior to surgery to scrubbing with a sponge or brush.59 Chlorhexidine based
c
t
i
provide an adequate moisture barrier.76 In addition, some aqueous scrubs are slightly more e ective than povidone–
o
n
plastic drapes come with an adhesive on the margins o iodine based aqueous scrubs in decreasing the number o
1
the drape, to better hold the drape in place.26 colony orming units on the skin.59
:
:
Alcohol-based handrubs that contain chlorhexidine
gluconate or povidone– iodine are extremely e ective
S
Pr ePa r a t Io n o t h e Su r g eo n
u
because the added ingredients prolong the duration o
r
g
i
antiseptic activity o the alcohol in addition to broadening
c
Preparation o the sta is one o the most important ways the antimicrobial coverage.59 A 2008 study requiring der-
P
r
to prevent SSI. It has been postulated that the highest matologic surgical sta to use an alcohol-based, chlorhex-
i
n
c
rate o bacterial trans er occurs due to physical contact idine gluconate handrub ound a signi cant decrease in
i
p
with the surgical sta during the procedure.13 In order to the number o postoperative SSI.5,6
s
diminish the quantity o bacteria trans erred rom the sta In addition to hand antisepsis, there has been a recent
to the patient, it is important to decrease the bacterial load debate over the potential consequences o the presence
o the sta with preoperative hand washing and proper o nger nail polish and jewelry during preoperative anti-
sterile attire. Recent studies have ound that by incorpo- septic preparation. It has been proposed that nger rings
rating speci c in ection-control practices in dermato- decrease the e ectiveness o antiseptic handrubs by acting
logic surgery, such as wearing surgical caps with the hair as a reservoir or bacteria, although there has been insu -
tied back in a ponytail or bun, jewelry restrictions (only cient evidence to support this statement.78,81 T ere is also
a smooth wedding band allowed), use o chlorhexidine– the concern that rings can tear surgical gloves more read-
alcohol handrub preoperatively, and sterile gloves, the ily, thereby increasing the risk o skin exposure during the
rate o SSI can be decreased rom 2.5% to 0.9%.5 Although procedure.59,81 It is also thought that nail polish might har-
these practices may be e ective in in ection prevention, bor excess bacteria and increase the risk o SSI, but there is
they may not be cost e ective. Another study with similar insu cient evidence to support this claim.81 On the other
in ection rates minimized costs by only using sterile gloves hand, arti cial nails have been ound to harbor bacteria
and cloth drapes or more extensive, reconstructive proce- and ungi, increasing the patient’s exposure to microor-
dures and nonsterile gloves or the rest.77 ganisms during the procedure.17 As a result, arti cial nails
are generally not recommended during extensive surgical
procedures.
Wa Sh In g h a n d S
During dermatologic procedures, gloves o the surgical
St er Il e a t t Ir e
sta can become per orated or torn, thereby exposing the
T e surgical attire worn or dermatologic procedures var-
underlying skin; it is, there ore, important to thoroughly
ies with each institution, although it o ten corresponds
rid the skin o potential pathogens prior to procedures.
to the invasiveness o the procedure. A recent survey o
Washing hands with soap and water removes most o the
dermatologic surgeons ound that they are more likely
transient f ora o the skin, but ails to inhibit the growth
to wear additional surgical garments such as surgical
o the resident f ora. On the other hand, antiseptic hand
caps and masks or more invasive procedures like abla-
preparations remove all o the transient f ora in addition
tive resur acing, liposuction, blepharoplasties, and Mohs
to inhibiting the growth o the resident f ora.78
micrographic surgery, in comparison to minor procedures
T ere are three types o antiseptic hand preparations
such as shave or punch biopsies.82
available: alcohol-based handrubs, aqueous hand scrubs,
and alcohol-based handrubs containing active ingredients
such as chlorhexidine gluconate or povidone– iodine.59 g l o v eS
Alcohol-based hand antiseptics can contain ethanol, iso-
propanol, or n-propanol and require rubbing o the hands Wearing gloves during surgical procedures not only pro-
until the solution has ully evaporated.59 I the hands are vides protection or the patient against potential pathogens,
56 visibly soiled, they should be thoroughly washed with soap but also protects the surgical sta rom being exposed to
bodily f uids. Since the beginning o their use in the early
1900s, sterile gloves have largely reduced the number o
1
SSI.83 T ey have been the standard o care during invasive
surgical procedures or many years, although recent stud-
ies with speci c application to dermatologic procedures
have ound nonsterile gloves to be equally e ective in the
prevention o SSI.84,85 T ere have been similar ndings
in studies conducted by specialists in other elds.86 It is
important to keep in mind that the results o these studies
did not pertain to longer, more invasive dermatologic pro-
cedures such as reconstruction a ter Mohs surgery. Wear-
ing an additional set o gloves, which is known as double
gloving, does not reduce the rate o SSI;87 however, double
gloving does decrease the risk o glove per oration.87

C
h
ma SkS

p
t
r
5
Surgical ace masks were originally designed to decrease
the expulsion o microorganisms rom the mouth and

:
:
nasopharynx o the surgical sta during surgery to reduce

a
the rate o in ections.88 Un ortunately, studies have ailed to

s
nd evidence to support a reduction in the rate o in ec-

p
t
i
tions with their use.88 T is may be a consequence o the

c
T
mask being worn inappropriately, such as being tied too

c
h
loosely around the back o the neck. T is allows bacte-

n
i
ria rom the mouth and nasopharynx to f ow out rom

q
u
the sides o the mask.88,89 More importantly, it is hypoth-
esized that the bacteria shed rom the skin o surgical sta Figure 5-3 Prot ctiv c m sk.
during the procedure has an even greater impact on the
rate o in ection than the bacteria shed rom the respira-
tory tract.88– 90 T e risk o in ection is increased with each in ection prevention by protecting the patient rom being
person that enters the operating room,89 which is why exposed to bacteria shed rom their skin.89 Surgical scrubs
protective clothing may be more bene cial or in ection are recommended or dermatologic surgeries. T ey should
prevention than ace masks. be reshly laundered, as scrubs worn or longer periods o
Masks carry the additional bene t o providing pro- time tend to harbor more bacteria.93 I the scrubs are visibly
tection or the surgical sta rom the patient’s bodily f u- soiled with blood or other f uids, OSHA regulations require
ids during the procedure.91 Some o the disposable ace the scrubs to be exchanged or a reshly laundered pair.17
masks have a protective shield that protects the eyes rom Sterile surgical gowns can be worn over scrubs to pre-
splashes during the procedure. T e Occupational Sa ety vent the bacteria on the skin and clothing o the surgi-
and Health Administration (OSHA) regulations require cal sta rom directly contacting the patient and rom
all surgical sta to wear protective eyewear in addition becoming airborne.32 Most surgical gowns worn today are
to ace masks during all procedures at heightened risk or composed o nonwoven materials and are disposable, one-
exposure to bodily f uids (Fig. 5-3).17 time-use gowns.32 Reusable gowns are associated with a
greater risk o in ection;94 however, more research needs
to be conducted regarding the rates o in ection with sterile
h a Ir c o v er S versus nonsterile surgical gowns in outpatient dermato-
logic surgery.
Hair covers are an essential part o the surgeon’s attire or
inpatient surgical procedures, although there is no evi-
dence to support a reduction in the risk o SSI with their St er Il Iz a t Io n a n d Pa c k a g In g
use.89 Hair has been ound to harbor Staphylococcus and
Streptococcus species, and i shed while in contact with
o In St r u men t S
the patient’s incision site, could potentially increase the
patient’s risk o in ection;92 thus, hair coverings may be As most dermatologic procedures are per ormed in an
bene cial in dermatologic procedures as they should be outpatient setting, there is great variability as to how sur-
help ul in preventing bacteria on the scalp and hair rom gical instruments are managed. Some o ces may utilize
being shed during the procedure. disposable surgical instruments or dermatologic pro-
cedures, whereas other o ces may employ their own
method o instrument sterilization. Dermatologic o ces
Sc r u BS a n d g o Wn S see a high volume o patients daily and need to have a large
amount o supplies available; there ore, the ideal method o
As previously mentioned, protective clothing worn by sterilization would be quick, e ective, and able to sterilize
the surgical sta may be the most bene cial method o large amounts o materials at one time. 57
1 Ta Bl e 5-5
S ii i m s S i I s s

S ii i m d s ip i c s
St m utoc v Produc s 100% humidity t t mp r tur V ry f ctiv . C n b us d or g ss b k rs, c oth
o 121°C; ef ctiv y st ri iz s instrum nts nd p p r tow s, g uz , nd p stic d vic s.97 Must
within 15 min t st b , high pr ssur o 2 h v contro , such s bio ogic indic tor, in p c
tmosph r s96; Must ow 5–10 min or th to monitor f ctiv n ss.17,96 Th high st m c n
instrum nts to dry76 du sh rp dg s o instrum nts76
Dry h t High r t mp r tur s r us d or ong r V ry f ctiv or h t r sist nt m t ri s, th t is,
p riod o tim du to ck o moistur 76 instrum nts nd g ssw r , but c oth, p p r, nd
p stic c nnot b st ri iz d with this m thod.82
Cost f ctiv nd do s not du instrum nts99
S
Co d st ri iz tion Du to incomp t st ri iz tion, it is consid r d Not common y us d in pr ctic du to incomp t
c
t
disin ct nt m thod; g ut r d hyd is th st ri iz tion; not f ctiv g inst b ct ri spor s or
i
o
n
most common y us d g nt but t k s 10 h to virus p rtic s.82,97 In ctiv t d by org nic m t ri s;
1
t k f ct nd must b buf r d to pH o Buf r d so utions on y st up to 4 wk76
8.5 to b com sporicid 76
:
:
Ch mic v V rsion o th st m utoc v ; a ch mic l ow r moistur d cr s s th risk or instrum nt
S
u
so ution k ps th humidity to ss th n 15%76 du ing; l ss tim r quir d or drying 76
r
g
i
c
G s st ri iz tion ethy n oxid st ri iz s th instrum nt ov r ef ctiv or instrum nts th t r h t nd
m ny hours t ow t mp r tur 96 moistur s nsitiv .96 ethy n oxid is toxic nd
P
r
c rcinog n.97 a r must b iso t d rom th
i
n
c
g n r work r . Not common y us d 76
i
p
Source: D t rom S bb n Je. Surv y o st ri t chniqu us d by d rm to ogic surg ons. J Am Acad Dermatol. 1988;18:1107–1113.
s
Be ore instruments can be disin ected or sterilized,
organic debris such as blood, dirt, or bodily f uids must
Su r g Ic a l In St r u men t
be removed.95,96 T is can be accomplished by cleaning Pa c k a g In g a n d St o r a g e
the instruments with water and a detergent manually
or by a mechanical unit such as an ultrasonic cleaner, Instruments can be packaged with cloth or paper, or
washer– disin ector, or a washer– sterilizer.96 T e advan- placed in a plastic sel -seal sterilization pack (Fig. 5-4).76
tages o an ultrasonic cleaner over manual cleaning are For sel -seal sterilization packs, one side o the package
that the instruments are cleaned aster (within 5 minutes) is transparent and the other side is paper, which can be
and that the sta are not at risk or injury rom handling sealed with a special autoclave tape or heat sealer.76 Instru-
the sharp instruments.76 Instruments should be cleaned ments should be autoclaved in the open position (e.g.,
immediately ollowing surgery to prevent drying o the hemostats) so that all areas o the instrument are steril-
organic material on the sur ace o the instrument.76 All ized. Additionally, rubber or gauze can be placed over the
instruments should be thoroughly inspected a ter clean- sharp edges o the instruments to prevent dulling.76 On
ing and, i their hinges need lubrication, instrument milk
should be applied.76 Oils should not be used or lubrica-
tion because they cause the instruments to become sti
a ter autoclaving.76
Sterilization destroys all microbes and spores and can
be accomplished by various methods ( able 5-5). Most
o ces that sterilize surgical instruments use steam auto-
claving as their pre erred technique.97 Steam autoclaving
is generally very quick and e ective. In a survey conducted
among 614 dermatologic surgeons, 67% reported using
steam autoclaving as their desired method o instrument
sterilization.82 On the other hand, more and more o ces
are using disposable one-time-use surgical kits. T e dis-
posable instruments can be slightly more expensive, but
are user riendly and reliable. I the surgical equipment
or packaging appears discolored or damp, there is a risk
o bacterial contamination and the package should be Figure 5-4 Surgic instrum nt tr y s tup with st ri
replaced with another sterile surgical kit.98 dr p .
58
the other hand, instruments can be placed openly in the
autoclave and then stored in a disin ectant holding solu-
1
tion upon removal, such as glutaraldehyde or peracetic
acid. It is important to keep in mind that disin ectants do
not adequately kill spores, which increases the risk o bac-
terial contamination and shortens the shel li e.76,96 As a
result, this technique is not commonly used.
T e time allotted or storage depends on the mate-
rial in which the instruments are packed and the mois-
ture content o the storage environment. T e sterilized
instruments should be stored in a closed cabinet with
adequate bug and dust control; the date and time o
sterilization should be externally visible on each indi-
vidual pack.100 T ere should also be an external indi-
cator, indicating that the instrument pack has been Figure 5-5 S s st ri iz tion p cks or surgic instru

C
h
adequately sterilized.76 T e more impermeable the pack- m nts.

p
aging is to moisture, the longer the instruments can be

t
r
sa ely stored. T is is why instruments that are placed

5
in sealed packages have a longer shel li e.100 T e sel - Po St o Per a t Iv e Wo u n d

:
seal sterilization packs can be stored or up to 1 year.76
d r eSSIn g S

:
Instruments wrapped in two layers o 140 thread-count

a
s
muslin can be stored or approximately 7 weeks, but the

p
storage time can be increased up to 9 months when the A ter the procedure, white petrolatum can be applied to

t
i
the wound be ore the sterile dressing is placed. T ere is

c
packs are sealed in a polyethylene bag.100 Instruments

T
wrapped in a single layer o crepe paper can be sa ely no signi cant di erence in the rate o in ection with the

c
h
stored or approximately 8 weeks.100 Multi-use surgical application o white petrolatum in comparison to topi-

n
i
cal antibiotic ointments.102,103 White petrolatum may also

q
instruments that require packaging in between uses are

u
more likely to become contaminated. It is important to be bene cial over topical antimicrobial agents because
thoroughly inspect the package be ore use, because a antimicrobials are more likely to cause an allergic con-
puncture as small as 1.1 mm has been shown to cause tact dermatitis.104 A sterile postoperative wound dressing
bacterial contamination o the instruments.101 should remain in place or at least 24 to 48 hours.17 I a
wound is le t to heal by secondary intention, it should be
packed with sterile gauze and then covered with a sterile
Pr ePa r a t Io n o dressing.17 It is important to ollow up with the patient to
ensure that their wound is healing appropriately and to
t h e Su r g Ic a l Su It e have them return to the o ce as soon as possible i they
exhibit any signs o in ection.
T e ideal surgical suite would have a ventilation system
in place that maintains a positive pressure in the room,
preventing less clean air rom f owing in the direction o c o n c l u SIo n
cleaner air.17 Some hospital operating rooms use laminar
airf ow systems that pass through a high-e ciency par- In summary, the risk o SSI ollowing dermatologic pro-
ticulate air (HEPA) lter.17 In addition, OSHA requires cedures is quite low. Speci c actors place certain patients
all equipment and environmental sur aces contami- at greater risk o in ection over others, but it is the overall
nated with blood or other bodily f uids to be disin ected bacterial load o the patient that has the greatest impact
in between procedures and at the end o each day with on the rate o SSI. T is can be minimized with adequate
an Environmental Protection Agency (EPA) approved antiseptic preparation o the patient and surgical sta
disin ectant.17 and proper sterilization o the surgical equipment. I the
It is also important to prepare the surgical suite prior patient begin to experience signs and symptoms sugges-
to dermatologic procedures. Primarily, this includes set- tive o in ection during the postoperative period, he or she
ting up a table or mayo stand with a sterile drape and then should return to the o ce or urther evaluation and man-
placing the sterile surgical instruments over the drape agement to avoid more serious sequelae.
(Fig. 5-5). Anticipating which instruments may be needed
prior to the operation may also be help ul in maintain-
ing sterile technique during the procedure. Particularly i r e er en c eS
the patient is suspected to have a bleeding diathesis, it is
important to set up the electrocautery equipment be ore- 1. ow gh S, Cheadle WG, Lowry SF, Malangoni MA, Wilson
hand. T is includes application o a disposable, sterile tip SE. Signi cant reduction in incidence o wound contami-
and a sterile sleeve or surgical glove around the handle nation by skin f ora through use o microbial sealant. Arch
Surg. 2008;143:885– 891; discussion 91.
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sterile technique while grasping the equipment during ing surgery or preventing surgical site in ection. Cochrane
the procedure.26 Databa se Syst Rev. 2007;(4):CD006353.

59
1 3. Hurst EA, Grekin RC, Yu SS, Neuhaus IM. In ectious com-
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25. Gould D. Skin f ora: implications or nursing. Nurs Stand.
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ney ME. Prospective evaluation o dermatologic surgery tory cream or preoperative skin preparation. A prospec-
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u
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cochlear ototoxicity o topical antiseptics assessed by evoked an aqueous alcoholic solution vs traditional surgical hand-

C
potentials. Laryngoscope. 2000;110:1522– 1527. scrubbing and 30-day surgical site in ection rates: a random-

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55. Durani P, Leaper D. Povidone-iodine: use in hand disin ec- ized equivalence study. JAMA. 2002;288:722– 727.

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tion, skin preparation and antiseptic irrigation. Int Wound J. 80. Gordin FM, Schultz ME, Huber RA, Gill JA. Reduction in

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2008;5:376– 387. nosocomial transmission o drug-resistant bacteria a ter

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5
56. Lenhardt HF, Lachapelle NC. Povidone-Iodine as a topical introduction o an alcohol-based handrub. In ect Control
antiseptic. Va Med Mon (1918). 1961;88:454– 457. Hosp Epidemiol. 2005;26:650– 653.

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57. Webster J, Bell-Syer SE, Foxlee R. Skin preparation with 81. Arrowsmith VA, aylor R. Removal o nail polish and nger
alcohol versus alcohol ollowed by any antiseptic or pre- rings to prevent surgical in ection. Cochrane Databa se Syst

a
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venting bacteraemia or contamination o blood or trans u- Rev. 2012;5:CD003325.

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sion. Cochrane Databa se Syst Rev. 2009;(3):CD007948. 82. Sebben JE. Survey o sterile technique used by dermatologic

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58. Chlorhexidine and other antiseptics. Med Lett Drugs T er. surgeons. J Am Acad Dermatol. 1988;18:1107– 1113.

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1976;18:85–86. 83. Ritter MA, French ML, Eitzen H. Evaluation o microbial

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59. anner J, Swarbrook S, Stuart J. Surgical hand antisepsis to contamination o surgical gloves during actual use. Clin

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reduce surgical site in ection. Cochrane Databa se Syst Rev. Orthop Relat Res. 1976;(117):303– 306.

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2008;(1):CD004288. 84. Xia Y, Cho S, Greenway H , Zelac DE, Kelley B. In ection

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60. Hobson DW, Woller W, Anderson L, Guthery E. Develop- rates o wound repairs during Mohs micrographic surgery
ment and evaluation o a new alcohol-based surgical hand using sterile versus nonsterile gloves: a prospective random-
scrub ormulation with persistent antimicrobial characteris- ized pilot study. Dermatol Surg. 2011;37:651– 656.
tics and brushless application. Am J In ect Control. 1998; 26: 85. Rhinehart MB, Murphy MM, Farley MF, Albertini JG. Sterile
507– 512. versus nonsterile gloves during Mohs micrographic surgery:
61. Crowder VH, Welsh JS, Bornside GH, Cohn I Jr. Bacterio- in ection rate is not a ected. Dermatol Surg. 2006;32:170–
logical comparison o hexachlorophene and polyvinylpyr- 176.
rolidone-iodine surgical scrub soaps. Am Surg. 1967; 33: 86. Chiu WK, Cheung LK, Chan HC, Chow LK. A comparison
906– 911. o post-operative complications ollowing wisdom tooth
62. Kimbrough RD. Review o the toxicity o hexachlorophene, surgery per ormed with sterile or clean gloves. Int J Oral
including its neurotoxicity. J Clin Pharmacol. 1973;13:439–444. Ma xillo ac Surg. 2006;35:174– 179.
63. Ehrenkranz NJ. Bland soap handwash or hand antisepsis? 87. anner J, Parkinson H. Double gloving to reduce surgi-
T e pressing need or clarity. In ect Control Hosp Epidemiol. cal cross-in ection. Cochrane Databa se Syst Rev. 2006; (3):
1992;13:299– 301. CD003087.
64. anner J. Methods o skin antisepsis or preventing SSIs. 88. Lipp A, Edwards P. Disposable surgical ace masks or pre-
Nurs imes. 2012;108:20, 22. venting surgical wound in ection in clean surgery. Cochrane
65. Morgan JP, Haug RH, Kosman JW. Antimicrobial skin prep- Databa se Syst Rev. 2002;(1):CD002929.
arations or the maxillo acial region. J Oral Ma xillo ac Surg. 89. Ritter MA, Eitzen HE, Hart JB, French ML. T e surgeon’s
1996;54:89–94. garb. Clin Orthop Relat Res. 1980;(153):204– 209.
66. Woodhead K, aylor EW, Bannister G, Chesworth , Ho - 90. Ritter MA, Eitzen H, French ML, Hart JB. T e operating
man P, Humphreys H. Behaviours and rituals in the oper- room environment as a ected by people and the surgical
ating theatre. A report rom the Hospital In ection Society ace mask. Clin Orthop Relat Res. 1975;(111):147– 150.
Working Party on In ection Control in Operating T eatres. 91. Weber A, Willeke K, Marchioni R, et al. Aerosol penetration
J Hosp In ect. 2002;51:241– 255. and leakage characteristics o masks used in the health care
67. Lipp A, Phillips C, Harris P, Dowie I. Cyanoacrylate micro- industry. Am J In ect Control. 1993;21:167– 173.
bial sealants or skin preparation prior to surgery. Cochrane 92. Dineen P, Drusin L. Epidemics o postoperative wound
Databa se Syst Rev. 2010;(10):CD008062. in ections associated with hair carriers. Lancet. 1973;2:
68. Cronen G, Ringus V, Sigle G, Ryu J. Sterility o surgical site 1157– 1159.
marking. J Bone Joint Surg Am. 2005;87:2193– 2195. 93. Krueger CA, Murray CK, Mende K, Guymon CH, Gerlinger
69. adiparthi S, Shokrollahi K, Juma A, Croall J. Using marker L. T e bacterial contamination o surgical scrubs. Am J
pens on patients: a potential source o cross in ection with Orthop (Belle Mead NJ). 2012;41:E69–E73.
MRSA. Ann R Coll Surg Engl. 2007;89:661– 664. 94. Moylan JA, Kennedy BV. T e importance o gown and drape
70. Ballal MS, Shah N, Ballal M, O’Donoghue M, Pegg DJ. T e barriers in the prevention o wound in ection. Surg Gynecol
risk o cross-in ection when marking surgical patients prior Obstet. 1980;151:465– 470.
to surgery - review o two types o marking pens. Ann R Coll 95. Harrison SK, Evans WJ, LeBlanc DA, Bush LW. Cleaning
Surg Engl. 2007;89:226– 228. and decontaminating medical instruments. J Healthc Mater
71. Russell PG, McKinnell H. Cross in ection risk in surgical Manage. 1990;8:36– 42.
marking pens. J Pla st Reconstr Aesthet Surg. 2007;60:572–573. 96. Goss LK. Staying up to date on disin ection and steril-
72. Cao LY, aylor JS, Vidimos A. Patient sa ety in dermatology: ization techniques: brush up on AORN’s recommenda-
a review o the literature. Dermatol Online J. 2010;16:3. tions or perioperative practice. Pla st Surg Nurs. 2012;32:
73. T omas RJ, Goodbourne C, Goldie B. T e transmission o 112– 116.
MRSA via orthopaedic marking pens– act or ction. Ann R 97. Geisse JK. T e dermatologic surgical suite. Semin Dermatol.
Coll Surg Engl. 2004;86:51– 52. 1994;13:2– 9. 61
1 98. Dancer SJ, Stewart M, Coulombe C, Gregori A, Virdi M.
Surgical site in ections linked to contaminated surgical
102. Smack DP, Harrington AC, Dunn C, et al. In ection and
allergy incidence in ambulatory surgery patients using white
instruments. J Hosp In ect. 2012;81:231– 238. petrolatum vs bacitracin ointment. A randomized con-
99. Pollack SV. Rapid instrument sterilization. J Dermatol Surg trolled trial. JAMA. 1996;276:972– 977.
Oncol. 1990;16:438– 439. 103. Dixon AJ, Dixon MP, Dixon JB. Randomized clinical trial o
100. Mallison GF, Standard PG. Sa e storage times or sterile the e ect o applying ointment to surgical wounds be ore
packs. Hospitals. 1974;48:77– 78, 80. occlusive dressing. Br J Surg. 2006;93:937– 943.
101. Waked WR, Simpson AK, Miller CP, Magit DP, Grauer JN. 104. Sheth VM, Weitzul S. Postoperative topical antimicrobial
Sterilization wrap inspections do not adequately evaluate use. Dermatitis. 2008;19:181– 189.
instrument sterility. Clin Orthop Relat Res. 2007;462:207–211.
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62
 Ch a p t e r Digital Imaging in

6 Dermatologic Surgery
Andr a M. Hui, N i Brody, & Dani M. Si g

In t r o d u c t Io n or at de nitive endpoints. In addition, in a process termed

image registration, multiple images o the same subject
area are aligned and overlaid in a manner that allows one
Dermatology has always been a visual eld, dependent
to compare changes over a period o time using both visual
on visible changes on the skin or correct diagnosis and
and computational methods4 in a manner ar simpler than
monitoring o therapy. Be ore the invention o photogra-
could be accomplished with lm. Photography provides a
phy, dermatological disease was painstakingly catalogued
uniquely visual medical record that cannot be obtained by
with drawings, paintings, and moulages. Photography,
descriptive documentation alone.
especially digital photography, has trans ormed the way
T ere have also been advances in computerized assess-
dermatology is practiced by capturing a patient’s derma-
ment o pigmented lesions and early identi cation o mel-
tological complaint as it is presented and integrating these
anoma. By per orming analysis on large numbers o digital
images into patient care.
photographs o melanoma, so tware systems are able to
As ar back as the 1860s, silvered copper plate daguerre-
“learn” the visual characteristics o both malignant and
otypes and early photographs were ound in specialized
nonmalignant lesions. A ter doing so, these systems can
dermatological publications such as Alexander John Bal-
then rapidly and consistently identi y melanomas, even
manno Squire’s Atlas o the Diseases o the Skin.1 It was
when the lesion is atypical, thereby potentially avoiding
there ore natural or dermatology to continually adopt
unnecessary biopsies.
new technologies and techniques in photography and
printing as they became available. T is allowed or derma-
tology to ourish as a specialty in which a patient’s disease d Ig It a l Ph o t o g r a Ph y
process could be visually documented in detail along with
its histology. T e development o the 35 mm Kodachrome Fu n d a men t a l s
(Eastman Kodak Company, Rochester, NY) became the
gold standard o clinical dermatologic photography.2 Conceptually, a digital camera is similar to a lm camera.
However, lm photography was limiting due to its cost Light rom the scene to be photographed enters the cam-
and processing time. Despite these limitations, it endured era, passes through a lens and potentially some mirrors,
or over a century. and is eventually “captured.” T e undamental di erence
Digital photography is a relatively recent advance in is that instead o lm, the light lands on a charge-coupled
the capture and storage o visual in ormation. As digital device (CCD). It is this device that converts the light into
photographic technology has advanced and increased in digital in ormation that is interpreted by the camera to
accessibility and cost-e ectiveness, dermatologists have produce a digital image. T e CCD trans orms the light
been at the ore ront o its utilization in patient care. Digi- into voltage, which then becomes converted into binary
tal photography has quickly become the standard method data that is stored on the camera’s memory card. T e CCD
or photographic documentation or both clinical applica- is o critical importance in a digital camera because the
tions and publication purposes.3 In addition to replacing CCD’s “resolution,” or the density o the digital pixels in
lm photography in dermatological study and practice, the CCD, greatly a ects the quality o the image.3 Digital
digital photography also o ers many advantages. Some photography has now achieved such high resolution that
o these are straight orward, such as a switch rom a lm it rivals the quality o lm photography with the added
medium with a limited existence under routine storage to advantages o ease o use and ef ciency.
a reproducible, immortal digital medium. For example, Digital photograph resolution requires enough pixels
the archival and quick retrieval o digital images is made to create an image in which the individual pixels produce
signi cantly simpler and more cost-e ective than retrieval the desired details on viewing. As a baseline comparison,
o lm images as they can be stored and searched on a a typical 35 mm Kodachrome 25 slide (in which the pho-
computer. Beyond these types o advantages, however, are tosensitive elements o the 24 × 36 mm image are silver
entirely new options that are made possible by digital pho- grains as compared with pixels) has about the equivalent
tography. resolution o a 20 megapixel (MP) image.5 CCD resolu-
With many dermatologic diseases, it is important to tion varies greatly by camera make and model. Studies
know whether a particular lesion is new or recurrent. o have shown that a minimum resolution o 768 × 512 is
accomplish this goal, multiple photographs can be com- suf cient or in-of ce dermatological use.6 With this
pared over time by documenting the patient’s initial pre- minimum resolution in mind, a trade-o must be made
sentation and then obtaining serial photographs over time between higher-resolution images (which because o their
1 higher pixel density, require more computer memory to
store) and lower-resolution images (which require less TABl e 6-1
computer memory). A CCD with a resolution comparable di i c o i r
to that o lm would require 33.6 MB o storage be ore
General Information and Reviews
compression. From a practical perspective, any image o
greater than a single MP will suf ce or clinical use. http://www.dpr vi w.com/
http://www.digita cam rar vi w.com/
s el ec t In g a c a mer a http://r vi ws.cn t.com/digita cam ras/
http://www.pcmag.com/r vi ws/digita cam ras
Like lm cameras, digital cameras come in both “single
lens re ex” (SLR) and point-and-shoot (PAS) varieties. http://www.st v s digicams.com
SLR cameras are generally more exible, o ten o ering Manufacturer Websites
an external ash and interchangeable lenses. T e result o
Canon http://www.usa.canon.com/cusa/consum r/
this exibility is generally higher image quality, but SLR
S
products/cam ras
cameras are consequently bulkier and costlier than PAS
c
t
cameras. Fuji m http://www. uji m.com/products/digita _
i
o
n
PAS digital cameras are an excellent choice or inex- cam ras/
1
perienced photographers because they are easy to use. Hass b ad http://www.hass b adusa.com/
:
T ese cameras are less expensive because they utilize a
:
Kodak http://stor .kodak.com/cam ras
xed lens and built-in ash, and are subsequently much
S
u
smaller and lighter in weight than SLR cameras. Photog- l ica http://us. ica cam ra.com
r
g
raphers will o ten set PAS cameras on “automatic,” which
i
c
Nikon http://www.nikonusa.com
a
allows the camera to make all the choices regarding expo-
P
sure, white balance, color balance, ocus, and ash. As O ympus http://www.o ympusam rica.com/cpg_
r
i
n
s ction/ind x.asp
the name implies, “pointing and shooting” is exactly how
c
i
p
these types o digital cameras may be used, and end results Panasonic http://shop.panasonic.com/shop/cam ras
s
are o ten quite acceptable and use ul in a clinical setting. and camcord rs
One should be aware that automatic mode does not always P ntax http://www.p ntaximaging.com/
provide optimal results because variables such as ambient
lighting or patient position may a ect image consistency Ricoh http://www.ricoh.com/r_dc/
especially when serial photographs are desired. For the Sony http://www.sony.com/cam ras
vast majority o of ce photography, the latest generation
o PAS cameras is an excellent choice.
SLR cameras have interchangeable lenses and ashes.
T e lenses may be ocused manually to allow or precise
capture o the object. T e photographer may control s el ec t In g h a r d w a r e
all aspects o image capture, including exposure, white
and color balance, and ash synchronization. T e SLR c o mPu t er
camera body tends to be much larger than a PAS body,
which allows or a bigger CCD and thus higher resolution Although pro essional digital artists and others in simi-
images, sometimes as high as that o lm photography. An lar pro essions require very power ul computers or their
SLR system is the best choice to obtain publication-quality day-to-day work, the requirements o a dermatological
photographs. However, due to the cumulative cost o the practice looking to store and annotate digital imagery are
SLR body, lens, ash, and other accessories, the SLR sys- not as stringent.
tem may be an order o magnitude more costly than a PAS T e rst choice to be made is the plat orm. As o
camera. 2012, the two most popular plat orms are Microso t
One should select a digital camera system based on Windows and Apple OS X.8 In previous years, the ability
clinical requirements and cost. For example, i one plans o these plat orms to share data was somewhat limited,
to take photographs solely or clinical use, a PAS may be so the best choice was usually whichever plat orm was
more than suf cient. I the clinician plans on publishing already in use in a practice/ organization. T is is less o
photographs or cost is not a large actor, an SLR system a concern with more recent systems and there ore the
may be more appropriate. Also, i image quality and con- choice is primarily based upon personal pre erence,
sistency is paramount, an SLR system is the best choice as unless local in ormation technology (I ) policies dictate
it allows the photographer to precisely control all aspects other wise.
o image capture. For aesthetic procedures, high-quality A ter a plat orm is chosen, the decision between a desktop
cameras and sel -contained systems such as the VISIA and a laptop can be made. I portability is not required, the
Complexion Analysis or OMNIA Imaging systems7 allow best decision is likely a desktop machine, which or a given
precise, reproducible capture rom the same perspective, price always provides more processing power/storage when
which can be a highly desirable eature in the current contrasted with an equivalently priced laptop. In either
medicolegal climate. case, the next important attribute is the amount o hard
T ere are many excellent online resources that one may uti- drive space. T e larger the drive, the more images can be
64 lize to learn and compare digital camera systems ( able 6-1). stored.
 TABl e 6-2
1
d s d vi
ext rna hard Th s ar hard driv s (o t n o th sam kind ound in aptops) that ar p ac d into xt rna nc osur s and
driv conn ct d to a comput r via a t mporary conn ction (such as a USB). Whi conn ct d, th hard driv can b
acc ss d simi ar y to an int rna hard driv but th conn ction is o t n substantia y s ow r than conn ctions us d
int rna y by th comput r. B caus th s ar actua hard driv s, th ir siz s ar o t n arg , with 2 t rabyt s b ing
common as o 2012. Gradua y th s driv s with moving parts ar b ing supp ant d by so id stat driv s (SSD),
which ar r adi y avai ab in siz s up to 960 gigabyt s.
USB stick, or Th s ar sma “sticks” that p ug into a comput r’s USB port. Th y ar typica y ch ap r, and th r or s ow r and
“thumb driv ” sma r, than most hard driv s. Typica USB stick siz s ar in th hundr ds o m gabyt s to th 128 gigabyt rang .
Compact f ash Th s ar storag cards that ar o t n us d as th primary storag m chanism or digita cam ras, and typica y
or SD cards hav siz s ranging rom m gabyt s to 128 gigabyt s.

C
N twork This typ o storag r rs to th acc ssing o storag on anoth r comput r syst m ov r a n twork. This sort o

h
storag s tup might b mad avai ab by an IT d partm nt or third party storag so ution. N twork storag d vic s and

a
p
syst ms o t n hav arg capaciti s but ar g n ra y s ow r to acc ss than oca storag . This may b id a or

t
r
d rmato ogy practic s, which uti iz s ria photography and tota body photography.

6
C oud storag “C oud” storag r rs to th acc ssing storag syst ms ov r th int rn t in th “c oud.”This is simi ar to n twork

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:
storag in conc pt, but b caus int rn t conn ctions ar o t n s ow r than oca n twork conn ctions, this typ o

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storag can b signi cant y s ow r than oca storag . How v r, th r may b ga imp ications to storing pati nt

i
g
data on a c oud, such as acc ss audit ogs, that cannot b provid d by most c oud storag provid rs.

i
t
a
I
m
a
g
d at a st o r a g e o compression: lossy and lossless. Lossless compression

i
n
g
is compression that is reversible: one can always obtain

i
n
While the local computer’s hard drive is usually the pri- the original data rom the compressed data. A common

D
mary storage mechanism, there are many other types o le ormat or lossless compression is agged Image File

r
m
storage. A ew types are listed in able 6-2. Format ( IFF). Images may be edited and resaved with-

a
out losing image quality.9 T e quality o IFF images is

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o
independent o camera manu acturer and is ideal or

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g
s t o r a g e r eq u Ir emen t s record-keeping and sharing as its interpretation is uni-

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versal. RAW le ormat is the “raw” uncompressed data

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r
When choosing how to store data, it is important to know that comes directly rom the camera’s sensor. Each camera

g
how extensive that data will be. In the context o digital manu acturer has its own version o the RAW ormat.10

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y
photography, the two main actors are the number o As would be expected, lossless ormats result in very large
photos to be stored and the resolution o each photo. T e le sizes. Lossy compression is compression that actually
higher the resolution, the more storage is required per “loses” in ormation, and the original in ormation cannot
photo. Multiplying by the number o images to be stored
gives a rough estimate o the required amount o storage.
able 6-3 lists some common image storage requirements,
with some other storage sizes or context. TABl e 6-4
In able 6-4, “compression” re ers to the removal o m fdi i m ppi i mms a
super uous in ormation to reduce the storage require-
Pr op rativ Out in o xcis d tissu and margins
ments or a particular set o data. T ere are two types imag on y is mark d on th pr op rativ imag
on y. Subs qu nt stag s ar mark d on
additiona copi s o th sam imag .
TABl e 6-3 Pr stag imag An imag is obtain d prior to ach stag .
s r i f di i P p Out in o xcis d tissu and margins
ar mark d. For ach subs qu nt stag ,
s e th d ct o th prior stag is accurat y
d pict d.
1 m gapix photo, uncompr ss d 2–5 MB
Intraop rativ During ach stag , th xcision margins
5 m gapix photo, uncompr ss d 5–15 MB imag ar mark d on th pati nt. A t r xamining
th tissu histo ogica y, th positiv
1 m gapix photo, compr ss d 0.5–1 MB
margins ar mark d. Th map th n
5 m gapix photo, compr ss d 2–8 MB accurat y d picts th p ann d d ct.
1 DVD ROM (sing ay r) 4.7 GB Postop rativ An imag o th d ct is obtain d a t r
imag th tissu is xcis d. Margins ar th n
1 B u ray disc (sing ay r) 25 GB
mark d.
Human DNA ~800 MB a
Data rom l in t a .20 65
1 be retrieved or rebuilt rom the compressed in ormation.
In digital photography and imagery, lossy compression is
so tware such as Can eld’s Mirror Suite can allow the prac-
titioner to quickly select “be ore” and “a ter” photos and
used to remove visual in ormation that does not greatly position them side-by-side. T is is especially use ul in the
a ect the appearance o the image. A popular le or- of ce setting to review results with the patient during an
mat utilizing lossy compression is the JPEG image. Lossy appointment. T e Mirror system may be customized with
image le size is signi cantly smaller when compared with diagnosis and procedure libraries so that practitioners can
lossless compression images. easily search and organize their images.15 Several electronic
medical record systems designed speci cally or dermatol-
ogy such as Nex ech Dermatology So tware16 or Moderniz-
d Ig It a l Ima g In g a n d ing Medicine17 o er easy integration o digital photographs
into the patient’s chart, streamlining diagnosis, planning,
c o mmu n Ic a t Io n s In med Ic In e and results. For cloud-based sharing o clinical images,
point-o -care HIPAA-compliant systems such as ClickMe-
It is vital to maintain secure, Health Insurance Portability dix work well. For sharing o nonidenti able clinical images,
online services such as Picasa, Flickr, or Photobucket are
S
and Accountability Act (HIPAA) compliant image stor-
easy and o ten ree to use.
c
age and transmission. Although there are speci c rules
t
i
High-end packages such as Adobe Photoshop are valu-
o
and regulations regarding the protection o private health
n
in ormation, there are no standards or de-identi ying able or manipulating images, although open source so t-
1
clinical data such as digital images in dermatology.11 On ware such as GIMP o ers many o the same eatures. From
:
:
the ore ront is Digital Imaging and Communications in an ethical perspective, image manipulation may be a use-
ul way to show a patient possible outcomes, but it should
S
Medicine (DICOM), the international standard or medi-
u
not be used to create images that do not re ect reality.
r
cal images and related in ormation, which de nes the nec-
g
i
c
essary ormat and quality o medical images or clinical
a
use.12 DICOM was rst developed in the 1980s or use in
P
Ph o t o g r a Ph Ic t ec h n Iq u es
r
i
dose planning in radiation therapy and its standards were
n
c
developed by the American College o Radiology and the
i
p
Excellent clinical photography depends on the consistency
National Electrical Manu acturers Association. In 1993,
o the images captured. In a series o images concerning a
s
the rst standard was published. DICOM quickly became
particular patient or procedure result, all images should
implemented in almost every radiological device, allowing
accurately represent the di erences at each time point
or a completely digital work ow to replace lm.12
without variables introduced by the photography itsel .
Recently, DICOM released Supplement 142, which pro-
A basic understanding o photographic principles such
vided guidelines on de-identi cation.11,13 Although digital
as ocus, exposure, lighting, and raming is necessary to
dermatologic imaging was not speci cally mentioned,
achieve a high level o image consistency.
“the removal or distortion o the actual pixel data where
there is possibility o visually identi ying the individual in
the images” is pertinent to our eld and may be accom-
plished by using a black bar over eatures such as the eyes
Pa t Ien t Po s It Io n In g
or identi ying tattoos.
It is highly likely that DICOM may also be the uture T e clinical presentation o the patient or lesion should
or digital imaging sharing in dermatology as well. More be as clear as possible. In all photographs, it is ideal to
in ormation can be ound at http://dicom.nema.org/. utilize a solid-color neutral background. Neutral grey,
which re ects 90% o visible light, is soothing to the eye
and makes a good wall color, although lighter skin is best
Ima g In g s o Ft w a r e captured on dark backgrounds while darker skin is best
captured on light backgrounds. T e photographic rame
Many digital cameras come with basic photography so t- should be ree o distractions such as clothing, jewelry,
ware which allows the user to adjust variables such as con- makeup, and excess hair. Brightly colored clothing or sur-
trast and brightness, and make changes such as removing roundings may render a color cast upon the subject, and
red eye. Some so tware programs also aid in sorting and items or urniture in ront o the light source may result
archiving. However, dermatologic photography and medi- in unwanted shadows. For body photography, clothing
cal records require a more ef cient work ow which allows should ideally be removed or at least covered with a drape;
the clinician to take a photograph and rapidly integrate the clothing should never be visible in the photograph. Dis-
image into the medical record. Most importantly, the so t- posable gowns may be provided to the patient when taking
ware must be compliant with the HIPAA. hal -body photography.
Some basic eatures o photography so tware include pan For acial photography, the patient should present with
and zoom controls, side-by-side comparison, measurement a clean ace ree o any makeup or excess oil. T e sheen
and annotation, and linking to consent orms. Some so t- rom makeup containing minerals or rom natural oils
ware also includes “live image overlay,” which is a method may inter ere with the image especially i a ash is uti-
o superimposing the live preview rom the camera with lized. I a patient cleans his or her ace prior to being pho-
prior digital photographs o the patient or lesion in ques- tographed, a ew minutes (or more or cosmetic images,
tion.14 T is is particularly help ul in acquiring serial pho- since the acial state o hydration is critical) should elapse
tographs used to compare changing or new lesions such to allow any transient erythema to dissipate. Men should
66 as in total body photography ( BP). HIPAA-compliant trim, or ideally shave, their acial hair. Excess hair should
be secured behind the ace with a headband or ponytail
holder. T e patient should keep a relaxed, neutral expres-
type o lighting may be obtained by utilizing an external
ash mount system, twin-light mounted system, or several
1
sion in all photographs unless the photograph is meant to external ashes in a studio setting. Ring ashes are use ul
demonstrate a pathological (i.e., Bell’s palsy) or therapeutic or images o the anogenital area or oropharynx, as they
(i.e., botulinum toxin injection outcome) process. provide even lighting, although a loss o depth perception
For surgical photography, the area o interest should be is the price o even illumination. T ese lighting systems
care ully “ ramed” with drapes. T e eld should be ree o may be metered (con gured) to achieve excellent three-
as much excess uid as possible to allow or clear visual- dimensional, evenly lit subjects. PAS systems that “wash
ization o the area. Again, all distractors such as hair and out” or overexpose on close imaging may be “ xed” by
shadows should be eliminated. covering the ash with a di user made o white tissue or
a piece o soda bottle roughened with sandpaper. T e ash
cover itsel can be treated in a similar manner. All o these
c o mPo s It Io n approaches reduce battery li e as the ash may re at a
higher output setting; the latter may also a ect resale value.
Consistent scene composition helps to ensure that the

C
h
quality o photographic results and serial photography are

a
c a mer a s et t In g s

p
also consistent. Clinicians may utilize just a ew standard

t
distances in order to achieve this consistency; or exam-

r
6
ple, a hal -body shot ollowed by a body area shot (such ex Po s u r e
as the upper arm) ollowed by a close-up o the lesion in

:
:
question. Ideally, each distance should have similar ram- In an ideal world, small apertures ( /22 or /32) combined

D
ing, lighting, and camera settings. Using a camera’s zoom

i
g
with lighting that emulates the color temperature o day-

i
t
unction (as made popular by PAS cameras) is suboptimal

a
light (5500 K) can allow both excellent depth o eld and
because zooming does not achieve consistent magni ca-

I
minimal blurring. o attain ideal sharpness and illumina-

m
tion; in addition, digital zoom lenses cause loss o image

a
tion o the subject, the aperture o the lens (the diameter

g
quality due to interpolation o data as the magni cation

i
n
o the opening) should be set as wide open as possible.

g
increases. o achieve consistent image results, it is best T e larger the aperture, the aster the shutter speed will

i
n
to move the camera itsel than to use the zoom unction, be, which allows or the sharpest photos by minimizing

D
especially in serial photography. Standard anatomic posi- potential blurring rom subject movement. In addition, the

r
m
tioning is a requirement or BP. Face-on shots o the head larger the aperture, the thinner the depth o eld (the range

a
and neck with the nasal tip at the level o the earlobe allow

t
o distance that is acceptably sharp). A thin depth o eld

o
consistency when creating a series. Side views o the ace

o
can be utilized to ocus speci cally on one lesion or even

g
taken at a 90 degree angle allow or urther consistency.

i
one aspect o the lesion. T e camera can be set to “Aperture

c
S
Oblique shots may be taken where necessary to highlight Priority” to allow or the best control o depth o eld and

u
r
a particular nding.

g
image sharpness. In contrast, one can set the camera to a
T e patient can also be moved into predetermined

r
small aperture such as /22 to allow a larger range o dis-

y
positions. It may be help ul to put a mark on the oor tance to be in ocus. Flash (discussed later) may be used to
(e.g., with tape) to guide patients into standard positions. ensure maximal sharpness and illumination o the subject.
Any external lighting should also be in its usual position
to provide the most uni orm illumination o the patient.
Close-up photos o an individual lesion or eruption may Fo c u s
be taken with an indexed measurement scale, which is
o ten attached to the bottom o the camera. T e ruler at Manual lens ocus is best or accomplishing exact ocus
the end o the scale is pressed gently against the lesion and upon the lesion or area o attention. For the purposes o
appears in the photograph. T is accessory also provides dermatologic imaging, a portrait lens with ocal length
a consistent distance rom which the photograph may be o 60 to 100 mm ocal length equivalent is an excellent
taken and stabilizes the camera against shaking. Printed choice. Most 60 mm lenses, or example, allow or close
sticker rulers such as those produced by Delasco are use ul ocus at a usual distance o 8 inches or excellent close-
both to identi y patients and to provide a size re erence. up photography, although a 90 to 100 mm lens is ideal or
T e sticker should be placed below the lesion and should recording aesthetic procedures where oreshortening is
be visible within the rame o the photograph to provide a undesirable.
measuring scale. Many o today’s SLR and PAS systems have auto o-
cus systems using low power re ected in rared light that
achieve superb ocus with less e ort. In both systems, the
l Ig h t In g ocused area appears as a “box” within the view nder or
camera display, which illuminates and then adjusts the
It is important that lighting remain consistent when tak- lens ocus when the shutter button is depressed hal way
ing serial photographs. Di erences in lighting may inaccu- down. One should be sure that the area o interest is com-
rately represent changes in the skin at each time point. A pletely in ocus be ore taking the photo. Equally important
camera’s built-in ash is not ideal or dermatologic photog- to proper ocusing is holding the camera steady by bracing
raphy. Its head-on illumination tends to atten contours. it with two hands. T e elbows should be held against the
Oblique lighting is superior in that it can reveal textures body. I a view nder is used, the camera should be braced
and shapes with much more three-dimensionality. T is against the ace while looking through the view nder. 67
1 A method or manually ocusing a xed- ocal length
lens such as 60 mm is called “body ocusing.”14 T e ocus
between the time o the biopsy and the surgery date,
resulting in a well-healed, o ten indiscernible scar. Sur-
ring can be set to desired distance index points, which geries are sometimes cancelled due to inability to nd the
are ound on the top o the lens. T e ocus ring is usu- site, and patients are sometimes sent back to their re er-
ally marked with distances such as 1 oot, 5 eet, in nity, ring physicians to veri y the site. In addition, biopsy sites
and may be changed by rotating the ring. T e photogra- may be very dif cult to nd on immunocompromised or
pher sets a desired index point and then looks through severely sun-damaged patients, who may have many skin
the view nder, moving back and orth until the subject cancers in one area as well as a history o multiple prior
is ocused in the view nder, and then the photograph is procedures.
taken. T is simple method allows or highly reproducible Dermatology is unique in that biopsy site descriptions
photographs in a clinical setting. include much more than laterality. Although some may
consider terms such as “medial,” “temporal,” or “mandibular”
help ul, multiple procedures may at times have been per-
w h It e Ba l a n c e ormed in those areas or within the same cosmetic units.
Errors still occur. riangulation o biopsy sites rom two
S
Adjustment o white balance permits accurate render- points such as an anatomical landmark and a di erent
c
t
ing o color depth by ensuring that neutral colors such
i
lesion may be help ul, but triangulation is time-consuming,
o
n
as white and grey are accurately represented in the same sometimes inaccurate (e.g., i a triangulation point such
1
light. Generally, the auto white balance unction in either as a seborrheic keratosis changes in appearance), and
SLR or PAS systems is excellent in today’s cameras. One
:
:
open to interpretation especially i a triangulation point
may also select a preset white balance to adjust or certain is a cosmetic unit such as “temple.” Additionally, measure-
S
u
lighting conditions, such as Daylight, Flash, Fluorescent, ments may change a ter a biopsy site heals and the tissue
r
g
Cloudy, or ungsten. o assure maximal control o white
i
contracts.
c
a
balance, one may use a grey card or manually adjust the Photography, with consistent camera angles and ocal
P
white balance within the camera, and then save the preset
r
distances, allows or the most accurate demarcation and
i
n
or use in the same lighting conditions.
c
documentation o the biopsy site, when used to supple-
i
p
ment the in ormation documented in the physical exami-
s
r es o l u t Io n nation, such as size and location. In a 2009 study by
McGinness et al., 271 Mohs surgical sites were identi ed
Image resolution is the amount o detail which a camera on the day o the surgery by patient, physician, or both,
can capture, measured as pixels. T e more pixels an image and then identi ed using a preoperative biopsy-site pho-
has, the more detail may be depicted in the nal image. tograph. T e patient incorrectly identi ed 16.6% o sur-
Image resolution setting may be ound on a camera as gical sites, surgeons 5.9%, and both patient and surgeon
“image quality” or “image size.” For dermatologic photo- 4.4%. When preoperative biopsy-site photographs were
graphs, we recommend setting the camera to as high qual- utilized, photography reduced the site identi cation error
ity a resolution as possible. One must keep in mind that the rate in the sampled Mohs surgical operations to zero.19
higher quality the image, the larger the le size will be; this
must be taken into consideration or image storage pur-
poses.6 One MP is adequate or the vast majority o images. BIo Ps y s It e Ph o t o g r a Ph y
For images above 5 MP only discerning imagers will see
di erences. In order or biopsy-site photographs to be use ul, they
must be accurate. T e lesion should be identi ed on the
patient with a surgical marker prior to taking the photo-
u s es o F d Ig It a l Ph o t o g r a Ph y graph. T e composition should include use ul anatomic
In d er ma t o l o g Ic s u r g er y landmarks such as the lips, eyes, or nose. Ideally, two pho-
tographs should be obtained: a photograph taken rom
a distance to identi y nearby anatomy, and a close-up or
Although dermatologists are less requently the targets
macro photograph to identi y the biopsy site in detail and
o malpractice litigation than practitioners o other elds,
possibly some nearby landmarks. I there are many poten-
cosmetic and surgical procedures do present legal risks.
tial biopsy and/or surgical sites which are visible within
With respect to Mohs surgeons, a leading cause o mal-
one image, markings may be made electronically with a
practice suits has been operating on the wrong site.18
tablet or mouse at later appointments. When per ormed
Digital photography allows or dermatologic surgeons to
properly, biopsy-site photography leaves little to no ambi-
achieve precise veri cation o biopsy sites, anatomical
guity. Proper imaging using a consistent array o views o
landmarks, and Mohs mapping, thus protecting them-
anatomical sites ensures the accuracy o images.
selves against errors and providing a superior level o care
and sa ety.
Prior to per orming a surgery, dermatologic surgeons mo h s mIc r o g r a Ph Ic
depend upon multiple sources to correctly identi y sur-
gical sites. T ese sources o ten include patients and their s u r g er y ma PPIn g
amily, physician re erral letters, written descriptions
and diagrams on medical records, gauze dermabrasion, Mohs micrographic surgery (MMS) is a technique that
68 and biopsy-site scars. Weeks and even months may pass examines 100% o the margins o excised tissue histologically
in order to remove skin cancers completely. MMS has
been extensively utilized and studied or the treatment o
digital photographs taken at di erent time points may be
aligned by a technique termed image registration.4 T is
1
nonmelanoma skin cancers (NMSC), particularly in areas relies on optimal standardization o patient positioning,
where tissue conservation is vital, such as the ace. Accu- lighting, and conditions to ensure that the only variable
rate mapping o excised tissue in its correct anatomical within the photograph is the patient’s skin. ransparency
position on the patient is a undamental aspect o MMS. image overlay so tware is available, which allows the phy-
ypically a hand-drawn map is utilized to diagram excised sician to correctly position the patient prior to taking the
specimens and margins relative to anatomical landmarks, photographs. Subtle clinical changes may then be eas-
o ten with preprinted templates or speci c anatomic ily detected by comparing changes over time using both
sites. However, hand-drawn gures are limited by inaccu- visual and computational methods.
racies or inconsistencies and nonstandardized templates. BP is also help ul in preventing excess prophylac-
Errors in margin status may then occur. Instant lm has tic excisions in patients with a history o dysplastic nevi
been utilized or margin mapping but is limited by small and/or melanoma. In these patients, multiple unneces-
print size (no larger than 3 × 4 inches), lm that is one- sary excisions can result in an increase in dis gurement,
time-use only (thus increasing cost), and a glossy lm sur- morbidity, and expense. In a study by Cohen et al.,24 1630

C
h
ace, which makes writing dif cult. pigmented lesions were prophylactically excised rom

a
p
Digital photography has recently allowed or ast, 78 patients with stage I or II melanoma; only 12 unsus-

t
r
accurate mapping in MMS. T is method quickly pro- pected melanomas were ound, and thus 136 lesions were

6
duces high-quality images precisely by depicting the removed or each melanoma ound. T e li etime rate at

:
actual de ect in relation to its anatomic location or MMS which an individual mole rom a 20 year-old trans orms

:
mapping. Images may be obtained preoperatively, intra- into a melanoma by the age o 80 years is estimated to be

D
i
operatively, and postoperatively ( able 6-4). While the 0.03% in men and 0.009% in women.25 Even i all dysplastic

g
i
t
specimens are being prepared, the images may be quickly nevi were surgically excised in a patient, new nevi would

a
I
downloaded to the computer. MMS map markings may be continue to occur de novo. BP allows or precise, close

m
a
made on printed images or on the computer using a tablet monitoring o all existing nevi and aids in detection o

g
i
or digital imaging so tware. Histologic ndings are pre- new lesions, thus potentially saving patients rom unnec-

n
g
cisely correlated with margins and location on the patient. essary excisions o pre-existing, stable nevi. Consumer

i
n
Maps can then be printed out or saved to the patient’s applications or whole body photography exist, such as

D
electronic medical record. T is will likely be the way that UMSkinCheck, that are excellent when used as part o a

r
m
the procedure will be done in the uture everywhere, but well-thought-out surveillance protocol.

a
t
or now paper is still the standard o care.

o
o
g
o t h er d Ig It a l Ima g In g

i
c
S
t o t a l Bo d y Ph o t o g r a Ph y

u
mo d a l It Ies Fo r u s e In

r
g
d er ma t o l o g Ic s u r g er y

r
y
T e early detection o malignant melanoma is vital, as
earlier diagnosis and treatment is associated with better
prognosis. T e 5 year survival a ter treatment o mela- In VIVo c o n Fo c a l mIc r o s c o Py
noma less than 1 mm thick (stage IA) is 95%, compared
with a survival rate o less than 45% or melanomas more In vivo con ocal microscopy allows or digital noninvasive
than 4 mm thick.21 Routine ull-body skin checks can help high-resolution high-contrast optical imaging in real time.
detect early melanomas but are limited by lack o precise It has been utilized to examine NMSC, melanomas, and
documentation and the naked eye. other skin conditions.26– 28 Con ocal microscopy utilizes
Patients with a history o melanoma, multiple dys- near-in rared laser and water immersion objective lenses to
plastic nevi or a strong amily history o melanoma may examine thin sections o human skin in vivo.29 Skin is then
be ollowed closely with BP, also known as whole body examined by horizontal “en ace” sections o skin instead
integumentary photography. BP has shown to aid in the o the vertical sections ound in routine histology. Section
detection o early melanomas by detecting slight changes thickness is between 3 and 5 µm thick, thus providing a
in existing lesions and recognizing clinically subtle early very high resolution. Skin may be examined to the level o
malignant melanoma.22 BP establishes a baseline rom the papillary and upper reticular dermis. Compared with
which to compare uture changes in lesions and on the routine histology, the skin is imaged in its native state with-
body as a whole. Photographs o multiple anatomical out the need or biopsy, xing, sectioning, and staining. All
areas are obtained, usually according to a template o images obtained with an in vivo con ocal microscopy sys-
standardized positions.23 Speci c moles may be ollowed tem may be saved and reviewed at a later date.
with serial dermatoscopic photography, which may also Con ocal microscopy is probably best known or its use
be added to the medical record. BP may be per ormed in identi cation o basal cell carcinoma. Excellent corre-
in a clinic, ideally with photography studio set-up and lations between con ocal microscopy and standard his-
template so tware. Several manu acturers also o er BP tological examination have aided with in vivo diagnosis
systems, or patients may go to designated BP centers and o basal cell carcinoma.28 Although several more studies
bring the photographs back to their dermatologist. need to be per ormed to determine sensitivity and speci-
Comparison o serial photographs is an important step city, the use o in vivo con ocal microscopy may at some
in detecting subtle changes on the patient’s skin. Multiple point eliminate the need or biopsy altogether. 69
1 o Pt Ic a l c o h er en c e t o mo g r a Ph y
permanent way to document a patient’s baseline and then
monitor progress and outcomes, and also plays an impor-
tant role in improving surgical accuracy. Photographs can
Optical coherence tomography (OC ) is another digital, be easily integrated into the medical record or accurate
noninvasive, cross-sectional imaging modality or skin, patient assessment. Digital imaging can also be utilized to
conducted in vivo and in real time. OC is similar to detect cancerous lesions, which may otherwise be missed
ultrasound imaging but utilizes in rared light to measure by the trained eye. With the basic principles discussed in
echo delays and intensity o back re ection. It provides this chapter, any dermatologic surgeon can consistently
two-dimensional vertical images with a depth o up to produce high quality digital photographs, which will help
1.5 mm, which allows or examination o the epidermis him or her achieve the highest level o care.
and upper dermis, as well as some appendages. Lateral
resolution is quite high at 10 to 15 µm.30 Many dermato-
logic conditions, both benign and malignant, have been
characterized by OC and correlated with histopathol- gl o ssa r y
ogy.31 Because OC is noninvasive and reproducible, it
S
may be use ul in monitoring and evaluating the e ects o Aperture: the diameter o the lens opening that determines
c
t
treatments or in ammatory skin conditions over time. In
i
the amount o light to which the camera sensor may be
o
n
addition it may be use ul or diagnosing skin cancers and exposed.34
1
may help to avoid biopsies. OC appears to allow or very CCD: a device that converts the light into digital in orma-
sensitive and speci c identi cation o basal cell carcinoma
:
tion that is interpreted by the camera to produce a digital
:
and work is ongoing to con rm this early data. image.
S
u
Depth o eld: distance between the closest and arthest
r
g
in- ocus area o a photograph. Inversely proportional to
i
mel a FIn d
c
a
the aperture.
P
Resolution: the amount o detail a camera can capture, mea-
r
i
MelaFind is an FDA-approved digital, noninvasive, ully
n
sured as pixels.
c
i
automatic, computerized diagnostic system or aiding
p
Shutter speed: length o time that the aperture o the lens is
detection o early melanoma and to identi y pigmented open, exposing the camera sensor to light. For example, a
s
lesions that should be considered or biopsy to rule out shutter speed o 1/250 will expose the sensor or 1/250th
melanoma. MelaFind utilizes visible and in rared light o a second.
to illuminate the skin dermatoscopically with 10 narrow White balance: adjustment that permits accurate rendition
spectral bands emitted rom a hand piece. T e depth o color depth such that neutral colors such as white and
o analysis extends to 2.5 mm beneath the skin sur ace. grey are accurately represented in the same light.
Each band is captured by a camera within the hand piece
and transmitted to the attached computer or automatic
processing and analysis. T e resulting images are high r eFer en c es
resolution at 1280 × 1000 pixels and may be saved in the
patient’s medical record. T e entire process o image cap- 1. Squire AJB. Atla s of the Disea ses of the Skin. London:
J Churchill; 1878.
turing takes a ew seconds. T e multispectral images are 2. Siegel DM. Resolution in digital imaging: enough already?
analyzed using preset algorithms, which then provides an Semin Cutan Med Surg. 2002;21(3):209– 215.
objective assessment in under 1 minute.32 3. Ratner D, T omas CO, Bickers D. T e uses o digital photog-
In a multicenter prospective trial by Monheit et al., raphy in dermatology. J Am Acad Dermatol. 1999;41(5):749–
MelaFind achieved a sensitivity o 98.4% or thin melano- 756. doi:10.1016/s0190-9622(99)70012-5.
4. Joshua E L. Image registration o sequential transparent photo-
mas (125 o 127 melanomas) with a biopsy ratio o 10.8:1, graphs to localize and detect new versus recurrent tumors in
compared with the average biopsy sensitivity o 78% in dermatologic and Mohs micrographic surgery. Am Acad Derma-
a dermatologist reader study. When borderline lesions tol. 2011;64(4):786.e1–786.e2. doi:10.1016/j.jaad. 2010.08.035.
were included (high-grade dysplastic nevi, atypical mela- 5. Lang ord M. Ba sic Photography. 7th ed. Burlington, MA:
nocytic proli erations, or hyperplasias), the sensitivity o Ox ord: Focal Press; 2000.
6. Bittor A, Fartasch M, Schuler G, Diepgen L. Resolution
MelaFind was 98.3%, with a biopsy ratio o 7.6:1. Its speci- requirements or digital images in dermatology. J Am Acad
city was 9.5%, signi cantly higher than that o investiga- Dermatol. 1997;37(2 Pt 1):195– 198.
tors (3.7%).33 Dermatologists must be aware that due to 7. http://www.can eldsci.com/imaging_systems/ acial_systems/
low speci city, a higher number o biopsies may be recom- VISIA_Complexion_Analysis.html. Accessed July 28, 2014.
mended by the MelaFind system or many benign lesions. 8. http:/ / stats.wikimedia.org/ archive/ squid_reports/ 2012-09/
SquidReportOperatingSystems. Accessed July 28, 2014.
T us, only lesions that are clinically suspicious or mela- 9. http:/ / partners.adobe.com/ public/ developer/ en/ ti / IFF6.
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c o n c l u s Io n 11. Freymann JB, Kirby JS, Perry JH, Clunie DA, Ja e CC.
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the patient. Surgical and therapeutic outcomes are assessed 12. http://medical.nema.org/. Accessed July 28, 2014.
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14. Witmer WK, Lebovitz PJ. Clinical photography in the derma-
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doi:10.1016/j.sder.2012.06.004. a population-based estimate. Arch Dermatol. 2003;139(3):
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so tware/Mirror_so tware/Mirror_PhotoFile.html. Accessed 26. Gonzalez S, Gonzalez E, White WM, Rajadhyaksha M,
July 28, 2014. Anderson RR. Allergic contact dermatitis: correlation o in
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17. http://www.modmed.com/dermatology/integrate-seamlessly/. matol. 1999;40(5 Pt 1):708– 713.
Accessed July 28, 2014. 27. Langley RG, Rajadhyaksha M, Dwyer PJ, Sober AJ, Flotte J,
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Incidence o and risk actors or medical malpractice lawsuits and malignant melanocytic skin lesions in vivo. J Am Acad
among Mohs surgeons. Dermatol Surg. 2006;32(1):79– 83. Dermatol. 2001;45(3):365– 376.
19. McGinness JL, Goldstein G. T e value o preoperative 28. Gonzalez S, annous Z. Real-time, in vivo con ocal re ec-
biopsy-site photography or identi ying cutaneous lesions. tance microscopy o basal cell carcinoma. J Am Acad Derma-
Dermatol Surg. 2010;36(2):194– 197. doi:10.1111/j.1524-4725. tol. 2002;47(6):869–874.
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whole body cutaneous photography. J Am Acad Dermatol. 33. Monheit G, Cognetta AB, Ferris L, et al. T e per ormance o

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laxis o malignant melanoma. Ann Surg. 1991;213(4):308–314.

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71
 Ch a p t e r The Surgical Suite: Equipment

7 and Accreditation
Riley McLean & Mary E. Maloney

T e surgical suite sets the tone o the o ce or the patient “grand athering.” Reputable contractors should have cop-
and staf and helps create the rst impression o any prac- ies o the regulations and will be a valuable asset in the
tice. T e suite is more than the our walls and also includes process o build-out or renovation o pre-existing space.
the important surgical equipment (Fig. 7-1, able 7-1). o
create a positive atmosphere or patient care, it is crucial to
consider all aspects o surgical suite design and unction. Su r g ic a l Su it e
T is chapter will review both practical tips or the design
o the surgical space as well as the recommended standards T e room needs to be large enough to allow adequate
o major accrediting organizations. In the ideal world, the movement around the surgical table. Accreditation stan-
surgeon would design their space rom the ground up. T is dards require at least 3 t around each side o the table and
is usually not possible however, and retro tting existing 150 sq t o open oor space at a minimum. Counter space,
space is the norm. Some aspects o design are expensive, an electrosurgical unit, a surgical tray, one or two chairs or
whereas others may be impossible given the structural consultation, a rolling stool, and possibly a computer station
components o an existing building. T e result is almost will all require a oor space ootprint. T e layout will take
always a compromise. T is chapter covers what would ide- into account the shape o the room, the amount o equip-
ally be included in a dermatologic suite, with the caveat ment that can be wall mounted and the amount o oor
that most surgeons will likely not be ortunate enough to equipment. Other equipment such as lasers or light banks
be able to include everything. Furthermore, since products or PD may be stored in the surgical suites or may be rolled
change rapidly both as a result o technological advances in or use at the appropriate time. It is important to know
and because companies come, go and merge, it would be what unctionality is needed or each room so as to plan the
inappropriate to endorse any particular product or brand. space accordingly. I you are going to keep lasers in each
T e recommendations here will ocus on eatures o equip- room, be sure to add that square ootage to the oor plan.
ment rather than speci c models. Ventilation is crucial and the building must have a ven-
Regulations concerning many o ce eatures will be tilation system. Surgical suites cannot have open windows.
mandated by state departments o health rather than Although windows are important or natural light and aes-
national organizations or accreditation bodies. A review thetics, they are not considered to be ventilation sources.
o such state regulations is beyond the scope o any text. I at all possible, individual thermostatic control o each
Be advised that you should obtain your state regulations room should be provided. T e laboratory must be kept
early in any renovation project. Renovation may lead cool to assist in maintaining cryostat temperatures. How-
to the requirement to comply with new regulations, ever, a cool temperature will be uncom ortable or many
rom which older space may have been exempted due to patients when they are immobile and in a gown, neces-
sitating a higher room temperature.
Walls and oors must be both washable and durable.
A durable neutral paint is best or walls. Because equip-
ment requently mars the walls, choosing a standard color
will allow or retouching paint to keep the room looking
resh. Flooring is an important choice, with several ac-
tors to consider. T e rst is the slippery nature o ooring
materials. Ceramic may be much more slippery when wet,
and because many spills occur, the oor o surgical space
is requently wet. A second consideration is leg atigue.
Hard sur aces are much more di cult to stand on or
long periods o time. T ere are several ooring sur aces
available that have greater give or are “so ter” and reduce
atigue. Carpet was at one time popular, but is harder to
keep clean, and cannot be recommended.
Halls should be wide enough or a stretcher to turn and
Figure 7-1 Storage and work space. Note that the counter doors wide enough to allow stretcher access. In hospitals
is clear o storage items, upper cabinets have locks, and and hospital clinics, regulations (either Joint Commission
there are 18 in between the cabinet and the ceiling with on Accreditation o Health Care Organizations (JCAHCO)
nothing stored in this space. and/or state agencies) will mandate these standards,
TAbLE 7-1
1
Su gi l Suit Sp ifi tions nd equipm nt P m t s

B si ex min tion r oom Po du r oom c l ss a Op ting F ility

Corridors Pu lic hallways must e at least 5 t wide without o struction rom equipment, vending machines, or drinking
ountains.
Doorways I wheelchairs or stretchers will e regularly used, doorways should e at least 3 t 8 in wide. I not, doorways must
e at least 2 t 10 in wide.
Minimum size 80 sq t o clear oor area. There must e at least 120 sq t o clear oor 150 sq t o clear oor space with
o room 28 in o clear space at the oot, head, and sides area with a minimum minimum dimension o 12 t.
o examination ta le. dimension o 10 t. 3 t There must e 3.5 t o clear space
o clear space should e at at the head, oot, and sides o
the oot, head, and sides examination ta le.

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o examination ta le.

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Ceiling height Minimum height o 7 t 10 in. Rooms with ceiling mounted equipment and lighting should e high enough to

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accommodate equipment.

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Ceiling Smooth, nona sorptive, and a le to withstand Smooth, nona sorptive, Monolithic, scru a le. No

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material scru ing and chemical cleaning. and a le to withstand cracks. Penetrations in the ceiling

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scru ing and chemical or pipes, lighting, and other

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cleaning. necessities should e gasketed.

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Wall nishes Washa le, water resistant, a le to withstand Washa le, water resistant, Monolithic, scru a le, and

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chemical cleaning and scru ing. a le to withstand chemical tightly sealed.

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cleaning and scru ing.

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Flooring Slip resistant, low glare material. Carpet is Slip resistant, low glare Scru a le, monolithic, smooth.

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choices permissi le i tightly glued down. Floors should material. Carpet is Slip resistant and easy to move

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e easy to maintain, clean, and am ulate on permissi le i tightly glued wheeled equipment on.

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down. Floors should e

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easy to maintain, clean,

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and am ulate on

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bathrooms Handicapped accessi le with gra ars. Doors to restrooms should open outward to ensure access in a medical

a
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emergency. For patient hand washing stations, sinks should e hands ree. I a sensor activated sink is used, a

d
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ackup power source is required. For sinks using single levers, lade handles should e at least 4 in in length.

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Nursing Nursing station with work counter, Nursing station with work Nursing station with work

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stations communication system, charting space, and counter, communication counter, communication system,

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room or supplies. system, charting space, charting space, and room or

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and room or supplies. supplies. I postoperative recovery

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does not occur in the operating
room, the recovery space should
e visi le rom the nursing station.
Hand washing Hand sanitizer as well as hand washing stations Scru acilities must e hands ree
should e availa le in num ers great enough and operated y knee, oot, or
to satis y the acility’s In ection Control Risk sensor control. Sensor controlled
Assessment requirements. sinks must have power supply
Sinks must e 144 in 2 in area at a minimum, ackup. The scru acility may e
well tted with sealed asins, and the distance located outside o the operating
rom the point o aucet discharge to the suite and can service two adjacent
ottom o the sink must e at least 10 in. Splash rooms. The design o the surgical
should e minimized y of setting the sink drain sinks should minimize splash
rom elow the sink waterspout. Nothing can e and regulate water pressure and
stored elow the sink space. temperature. Proper antiseptic
scru washes should e provided.
Sinks in examination rooms should e hands
ree. I sinks are sensor operated, they must
have an alternate energy source in the event o
a power outage. Nonautomatic sinks must have
single levers or wrist lades at least 6 in in length.
Each sink should e accompanied y a liquid or
oam soap as well as a hands ree drying device
such as an automatic hand dryer or paper towel
dispenser.
(continued ) 73
1 TAbLE 7-1 (Continued )
Su Su Sp f o s equ pm P m s

B s ex m o r oom Po u r oom c ss a Op F y
Sterilization The acility must have a system or equipment sterilization and designated space or handling and storage o
acilities oth clean and dirty supplies. Carts or other vehicles used or transport o supplies must e cleaned and sanitized
regularly. A soiled holding area or of site sterilization or a soiled work room or onsite sterilization should e
separated rom the storage space or sterile equipment. I sterilization is completed onsite, an adequate work
sur ace, sink, and the required sterilizers and washing equipment should e provided as well as a separate clean
room or assem ly and terminal sterilization o equipment. biohazard waste services and receptacles should e
readily accessi le in areas where soiled equipment is held or processed. The design o the storage space should
demonstrate consideration or ventilation, humidity, and temperature control.
Medical A crash cart should e availa le or surgical acilities. Its storage space should include a port or charging and there
S
emergencies should e an alternative source o power.
e
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t
Drug Medication distri ution stations should e locked and in the event that controlled su stances are availa le on site,
i
o
n
distri ution the re rigerator that they are stored in should e dou le locked. The drug distri ution station should also have a
1
work counter and sink availa le.
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Patient sa ety Patients’privacy should e maintained throughout their visit. Examination rooms should have closa le doors,
and security recovery areas should have curtain enclosures, and hallways leading to patient care rooms should have restricted
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access.
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Patient medical records o all media types should e maintained in a secure space as determined y acility layout
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and unction. The records should e restricted through remote location or limited staf access and all ef orts should
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e made to ensure that they are not lost or damaged.
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whereas private o ces may only be regulated by the state. Locks must be kept on any cabinets in which medica-
Exit signs and emergency lighting are sa ety eatures that tions or sharps are stored. T ese can be a keyed lock or a
will be dictated by the type o practice and/or state policy. key pad combination lock. T e latter rees staf rom need-
ing a key.

St Or a g e
Ha n d c l ea n Sin g
Deciding on the unction o each room and storing enough
supplies within the space will acilitate e cient procedure Sin k
ow. Keeping su cient supplies o commonly used mate-
rials within procedure rooms will keep staf in the room Hand cleansing is the cornerstone o in ection control
instead o running or supplies elsewhere in the o ce. Keep- and should include a surgical scrub at the beginning o
ing inventory low while maintaining adequately stocked each surgical session. As accreditation requirements
rooms can be a delicate balance to achieve. include a sink in each room with a minimum clearance
T ere are many storage limit regulations that the sur- rom spout to sink basin o 10 in, designing a deep sink
geon should be aware o when designing a surgical suite. to minimize “splash” adds little expense. T ese can be t-
For example, the JCAHO requires 18 in o empty space ted with oot pedals which limit bacterial re-exposure, in
between the ceiling and the highest storage unit. In clinical contrast to hand aucets. I applying or JCAHO accredi-
spaces, nothing can be stored underneath the sink, even i tation, the use o oot, knee, or sensor controlled sinks is
a cabinet is present. o ensure that staf does not unwit- a necessity.
tingly violate this regulation, a solid ront can be installed, Another alternative is designed scrub sinks which come
rather than a door which should not be used. as multiple or single stations. T ese are much larger and
Choosing the type o cabinets is a decision or the sur- deeper than standard sinks, but also have a larger oot-
geon to make. Cabinets come in all styles, materials (such print, which can take up valuable space.
as wood or laminate) and prices. Some physicians like glass
doors on some or all o the cabinets, which allows or easy
location o materials, and which can be use ul to determine Ha n d Sa n it iz er
when rooms require restocking. However, with glass door
cabinets, any “mess” can easily be seen by patients and their Foam hand sanitizer dispensers should be both outside
amilies, necessitating organization. and inside the room, allowing all health care personnel to
Similarly, counters are available in many styles, colors, apply oam both when entering and leaving the room. It is
and nishes. T e sur ace should be nonporous and easily best to have a standard location or mounting these units
cleanable. Countertops adjacent to hand washing stations so that each room provides the same time e cient motion
should be made o porcelain, stainless steel, a solid sur ace or hand cleansing. Accreditation standards require the
material, or laminate with an impervious seal to ensure use o hand sanitizers in addition to sinks but do not
74 adherence to JCAHO regulations (Fig. 7-2).1 address the location o the units.1
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Figure 7-2 A. Sink with oot pedals to activate water. B. Large, traditional scrub sinks.

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Wa St e to be used in any receptacles used or disposal o blood

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saturated gauze or tissue.

a
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Each room must also have a sharps container. T ere are

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T ere should be a covered trash receptacle in every room,1,2

A
several options or maintaining these, the most common

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as well as one rolling trash receptacle, usually known as a

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one being to have a contract with a pickup and disposal

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kick bucket. T e kick bucket should be emptied between

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company. T e size o the bin and the time interval o col-

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patients so that there is no bloody or soiled gauze remain-

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lection can be set to match the volume o sharps waste

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ing in the room at the start o the next case (Fig. 7-3). In

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produced in the o ce. In smaller communities, there may

n
addition, the rolling kick bucket can easily be moved to
be an option to receive and return bins through a package
a position that optimizes use and prevents bloody waste
delivery service.
rom soiling the oor. Best practice would dictate that the
covered trash receptacle should be operated by a oot li t
top, but this is not mandated by any regulations at this Wa l l -MOu n t ed it eMS
time. Red liner bags, indicating contaminated waste, need
Wall mounting reduces clutter on counters, leaves more
open oor space, and minimizes trailing cords. Items
that may be wall mounted include otoscopes, ophthal-
moscopes, hy recators, blood pressure cuf s, oxygen,
suction, racks or orms and anything else that has wall
mount capability. Any items requiring wall mounting
should be appropriately sized. Electrical cords pose a
hazard or patients and staf alike and may lead to alls i
not hard wired or i they do not have a dedicated outlet
(Fig. 7-4).

eq u iPMen t
Suction and oxygen are not required by JCAHO in proce-
dural rooms i sedation is not being used, although they
may be help ul i the building has already been con gured
Figure 7-3 “Kick bucket” waste receptacle is on wheels. to provide one or both o them. Centrally sourced oxygen 75
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Figure 7-5 Rolling soiled linen bin. This can be stored
Figure 7-4 This is a wall computer mount with keyboard inside or outside o the room.
and monitor at eye level and the hard drive wall mounted
above.

is particularly use ul or the patient requiring constant

supplementary oxygen or who has a vasovagal episode. I
unavailable rom a central source, bottled oxygen kept in a
central, easily accessible location will usually be acceptable
in these situations.
T e need or suction in the surgical suite is both provider
and case dependent. Some surgeons like to use suction
during their procedures, whereas others do not. Suction
can be very help ul when used in surgery on rapidly bleed-
ing wounds, but is not essential. I wall suction is avail-
able, this alleviates the need to have an additional piece
o rolling equipment, lessening the potential or clutter in
the o ce. Excellent rolling suction units are also available.
Although not required, having a phone extension in
each room can be use ul, especially i interpreter ser-
vices are provided or patients via the telephone. Having
a phone in the room can also be use ul or any calls that
need to be made while the patient is still in the o ce, such
as visiting nurse ollow-up, transportation, or even 911
calls (Figs. 7-5 and 7-6).

Su PPl ieS
It is important to evaluate each item needed in the exami-
nation room, to nd the least intrusive storage area, and
to investigate options or wall rather than counter stor-
age. Additional items that may be wall mounted include Figure 7-6 Rolling blood pressure cuf . Can be rolled out
76 computers, chart racks, magazine racks, examination and o the room to preserve oor space.
 Su r g ic a l t a Bl eS
1
Surgical tables or chairs are key equipment and care should
be taken in selecting them. Patients need to rest com ort-
ably; tables or chairs must be wide enough to t ull- gured
individuals and have enough padding to be com ortable
or longer procedures. T ey must allow the surgeon easy
access to the surgical site. In dermatologic surgery this
means being con gured to allow the head and neck to be
easily reached. ables and chairs should be tested to ensure
that they can be elevated high enough or a tall surgeon to
work com ortably and that they can descend low enough
or a short surgeon to work com ortably, or to allow any
Figure 7-7 Wall mounting o all possible equipment pre- surgeon to sit while working. Not all tables are able to do

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this. Using “step ups” or stools is reasonable, but should be

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serves oor space. This shows mounted examination gloves,

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needed only i two people o unequal heights are working

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hand cleanser, orms and consents, and sharps disposal.

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together, and should not be thought o as an alternative to

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a table that cannot go high enough or low enough to be
surgical gloves, hand cleanser dispensers, and even suture unctional in the operating room.

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storage units. T ere are countless wall storage devices that In addition to having a su cient range o height, tables

T
can be purchased rom o ce supply houses and medical must also have mechanical head-up, tilt, and oot-up options.

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suppliers (Fig. 7-7). T ese eatures allow endless positioning possibilities or both

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Figure 7-8 A–D. Examination table demonstrating multiple positions. D shows the important Trendelenburg position. 77
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Figure 7-9 Rolling padded arm table. This can be stored
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in other locations and brought in the room only when
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needed.
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patient and surgeon com ort. Although some tables come
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with a xed oot position, surgery should not be per-
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ormed in a setting in which the rendelenburg position
(tilt down) cannot be achieved. ables come with oot
pedals, hand controls, and the ability to preprogram cer- Figure 7-11 Surgeon’s stool.
tain positions. Preprogramming the rendelenburg posi-
tion may be very use ul in an emergency. Because patients Some additional supplies may be necessary to provide
come in all shapes and sizes, a preprogrammed “ avorite” easy access to the surgical site. An attachable arm rest or a
position is only a starting point to get the patient and sur- ree standing arm table should be available to allow correct
geon com ortable. Having pillows available to pad or prop positioning o the upper extremity during surgery. For surgi-
up older or disabled individuals may make a substantial cal sites on the posterior head, neck, or back, some surgeons
dif erence in achieving patient com ort. have a ace pillow, or “donut” pillow to allow the patient to
lie in a ace down position with some com ort. Others sim-
ply position the patient so that the site is as accessible as
possible or the surgery to be per ormed (Figs. 7-8 to 7-10).
Rolling stools allow the physician to sit while operating,
which some practitioners nd use ul and others strongly
dislike. T e use o stools does allow surgeons o unequal
heights to work at approximately the same level in relative
com ort. Keep in mind, however, that stools do take up a
great deal o oor space (Figs. 7-11 and 7-12).

Figure 7-10 Attachable arm board. Note that it is much

narrower than the arm table in Figure 7-9 but requires no
78 oor space. Figure 7-12 “Step ups” come in various heights.
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Figure 7-13 A, B. Mayo stand.

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Instrument stands are needed to position the instruments

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in an accessible place and must be mobile as surgical posi-

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tioning may change. When selecting a stand, it is impor-

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tant to consider that some models with our wheels may

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be too mobile while others with two wheels are not quite
as easy to move but are more stable when in position. T e
stand should be sturdy, as the lighter weight stands tend
not to hold up to heavy use (Fig. 7-13).

l ig Ht S
Surgical lights are one o the most important items in
the operating suite. Adequate bright light is crucial, as
is the ability to ocus on deep, open wounds. Although
there are many relatively inexpensive single or double
light units that do not use re ective technology, these
units tend to be underpowered and their arms tend to
“dri t” without regular maintenance and repair. Larger,
re ective lights with more robust articulating arms of er
greater range in positioning and better “holding” o the
light source, but come with a larger price tag. T ese
larger lights also need greater ceiling height to accom-
modate the articulating arms. Ceiling heights should be
built to accommodate the larger lights, even i smaller
lights are installed initially with the plan to upgrade at
a later date, as re tting can be expensive or impossible
(Figs. 7-14 and 7-15). Figure 7-14 Re ective OR light with articulating arms. 79
1 and osters the ability to deliver a higher quality o care.
T ere are also nancial incentives or having an accred-
ited acility. Not only is this marketable as a sign o quality
o care, but in some cases insurance companies will pay a
acility ee i the organization is certi ed by a nationally
recognized organization.3*
T e JCAHO is most commonly known or its role in
accrediting hospital acilities but it has developed stan-
dards or outpatient acilities as well. T e outpatient
guidelines established by the Facility Guidelines Institute,
which are used as a standard by the Joint Commission, are
an excellent re erence point or preparing your acility or
a JCAHO survey.
T e requirements or outpatient care acilities include
architectural, material, and layout considerations. As “an
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outpatient acility that has within it physician o ce(s) and
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space(s) or the per ormance o invasive procedures,” a
o
Figure 7-15 Light with three-light con guration. This
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tends to be hotter, with less robust articulating arms. dermatologic surgical suite would need to meet the stan-
1
dards o an o ce-based surgical acility. While the oper-
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ating suite is the subject o this chapter, some additional
details about basic examination rooms and o ce layout
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eMer g en c y eq u iPMen t
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are included or your consideration, as the surgical suite
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seldom exists independent o an o ce practice. In addi-
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T ere are no regulatory requirements about the types o tion to basic examination rooms, which are sel -explana-
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emergency equipment that need to be available in the sur- tory, JCAHO has requirements or both procedure rooms
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gical suite. T ere should be both an emergency plan and and operating rooms. Under the American College o
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Surgeons Surgical Facility Classes, dermatologic surgical
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su cient equipment to support a patient until emergency
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s
support arrives. suites quali y or Class A operating acility status based on
All staf should have basic li e support training, and a their use or minor surgeries prepared under topical and
log should be kept to be certain that all certi cates are local anesthesia.
current. Surgeons and mid-level providers should con- T e process o accreditation begins with the selection
sider advanced cardiac li e support training. An o ce plan o the accrediting agency, o which there are three well-
should be developed so that each staf member has a role known national groups—the JCAHO, the Accreditation
in the event o an emergency, such as calling 911, bringing Association or Ambulatory Health Care (AAAHC), and
oxygen and placing it on the patient, bringing any other the American Association or Accreditation o Ambula-
equipment, or starting CPR. tory Surgical Facilities (AAAASF). Accreditation or der-
T e minimal level o emergency equipment includes matologic surgical acilities is most commonly obtained
oxygen, nasal cannulas or oxygen administration, an auto- through JCAHO or the AAAHC. Some o their standards
mated external de brillator (AED), blood pressure cuf s, are presented in the charts below ( able 7-2). Should the
and a back board to allow CPR. I a surgeon or staf is qual- surgeon choose to have their surgical suite accredited, the
i ed, a ull crash cart with medications, cardiac monitor, handbooks or accreditation will be valuable during prep-
oxygen saturation monitor, de brillator, and intubation aration or the site survey.
equipment can be maintained. T is cart requires regular he process o accreditation is both rigorous and
maintenance to keep equipment unctional, including in ormative and the choice o organization should be
battery checks and replacing expired medications. T is based on what works best or each individual o ice.
cart review should be documented in a log and the log W hile the AAAHC requires that many procedures and
reviewed regularly or quality assurance. protocols be provided in written ormat, this process
Monitoring equipment includes cardiac and oxygen enables the practitioner to tailor the way to handle
saturation monitoring devices. T ese may be important issues to it his or her practice.2 On the other hand,
or some procedures. Each o ce should evaluate the pro- the JCAHO regulations ensure that the layout and low
cedures per ormed to ascertain the equipment necessary. o the o ice meets standards that should lead to bet-
ter patient care and quality improvement. Finally, this
decision may be made or the surgeon. For example,
a c c r ed it a t iOn Pr Oc eSS the surgeon who is a part o a large health care orga-
nization that has pursued accreditation through one o
Although not currently required o dermatologic surgi- these organizations may be expected to ollow suit. We,
cal acilities, accreditation by one o the major health care however, strongly recommend considering both sets o
accreditation groups serves several purposes. First, the standards while designing your o ice. he combination
process o applying or accreditation serves as a re ec- o well-thought-out space and sa ety considerations
tive experience, through which the organization can iden- coupled with introspective protocol design should
ti y weaknesses and seek to improve them. Secondly, the increase patient sa ety, satis action, and in turn make
process can improve the medical team’s morale and pride, the surgeon’s job more enjoyable.
80
 TAbLE 7-2
1
St d ds f om th Joi t c ommissio o a dit tio of H lth c O g iz tio s (Jc a HO), th
a dit tio a sso i tio fo a mbul to y H lth c (a a a Hc ) d th a m i a sso i tio fo
a dit tio of a mbul to y Su gi l F iliti s (a a a a SF)
Standard 1: Rights o A practice must treat patients with dignity and respect through its communication with patients and
patients with other providers, its proper use o patients’medical records, and whether the organization realistically
presents the tasks it is capa le o to the pu lic.
Standard 2: There should e a selected governing ody within the organization that determines the policies and
Governance procedures that are required or appropriate unctioning o the organization. This governing ody must
initiate plans or nancial health, risk management, quality improvement e orts, and proper credentialing
o employees.
Standard 3: The administration o the organization seeks to en orce the policies and procedures esta lished y the
Administration governing ody, to maintain nances, to hire and manage employees, and to ensure patient and provider

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sa ety through in ection and injury control plans.

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Standard 4: Quality o Quality o care is assessed ased on use o evidence ased medicine, judicious testing and re errals to

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care provided specialists, good communication with patients and other providers, and whether the organization has an

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7
internal, ongoing assessment o their quality o care.

:
Standard 5: Quality Providers and administrators should participate in an ongoing quality per ormance assessment using peer

:
management and review, sel re ection, and external per ormance measures as arometers. Quality improvement projects

T
h
improvement should document oth the issue at hand and the per ormance goal.

e
S
Standard 6: Clinical All aspects o patient care including of ce encounters, la results, telephone encounters, and in ormation

u
r
g
records and health rom outside providers should e documented in a uni orm way in a medical records system that is secure

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c
in ormation and con dential. In addition to inspecting individual patient charts, the AAAHC surveyor will also assess

a
l
the policy or access, use, storage, discard, and release o medical records.

S
u
i
t
Standard 7: In ection The organization should promote patient and employee sa ety through en orced protocols on in ection

e
:
prevention and control prevention, disaster preparedness, and medical error reporting.

E
q
and sa ety

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Standard 8: Facilities The acilities and layout used y the organization are appropriate or the tasks at hand and meet all state

m
e
and environment and local codes. Cleanliness, good lighting, and reduction o patient hazards (i.e., use o slip resistant

n
t
oors, employee awareness o disaster preparedness plans, adequate medical emergency training and

a
n
equipment) will e assessed at the onsite visit.

d
A
The time to achieve accreditation will vary depending on the accrediting ody. JCAHO accreditation will e issued when it inspects an institu

c
c
tion, on its regular schedule. AAAHC requires an application with a ee. The organization sends the manual or compliance, and when ready, the

r
e
applicant will ask or a site inspection. Preparation usually takes months. Inspection and certi cation y state oards depends directly on the

d
i
t
state and always adds time to the process o uilding or renovation. The process, no matter which agency is involved, is slow and requires plan

a
t
ning, work, and attention to detail.

i
o
n
r eFer en c eS 2. Accreditation Association or Ambulatory Health Care.
Accreditation Handbook 2011 For Ambulatory Health Care.
Skokie, IL: Accreditation Association or Ambulatory Health
1. T e Facility Guidelines Institute. Guidelines for Design and Care Inc; 2011.
Construction of Health Care Facilities. Chicago, IL: American 3. Sterling JB, Hanke CW. Of ce accreditation in dermatology.
Society or Healthcare Engineering o the American Hospital Semin Cutan Med Surg. 2005;24(3):128– 132.
Association; 2010.

81
 Ch a p t e r

8 Surgical Instruments
Zena Pinnella, Kerri Robbins, & Aaron K. Joseph

In t r o d u c t Io n prior to Mohs micrographic surgery. T ey are available

in disposable or nondisposable orms, or as a single-use
curette blade that may be used on a scalpel handle. Ideally,
Dermatologic surgery encompasses a wide range o proce-
a curette will remove more riable tumor-in ltrated tissue
dures necessitating an even larger variety o surgical tools.
while leaving behind normal skin. Curette heads are either
Use o the best instruments and proper maintenance o
round or oval and vary in size rom 1 to 9 mm (Fig. 8-1). A
all surgical supplies can help the surgeon achieve optimal
surgeon can normally purchase approximately 50 dispos-
results while capitalizing on their investment. Consistently
able curettes or the price o a single nondisposable curette.
organized surgical trays help minimize the risk o acciden-
T e disposable curettes have lightweight plastic handles,
tal injuries and maximize e ciency in the procedure room.
whereas the reusable curettes are made o stainless steel.
A reusable curette may seem more cost-e cient, but it is
In St r u men t S important to remember that these instruments need to
be sharpened periodically to prevent dulling o the sharp
Instruments used or dermatologic surgery are typically scraping edge. A dull curette may result in unnecessary
small, easy to maneuver, and allow or delicate handling o damage to tissue.1
tissues. T e most commonly used tools include curettes,
scalpels, scissors, skin hooks, hemostats, needle holders,
and orceps. All these tools are available in a variety o Sc a l pel Ha n d l eS
qualities and costs, and it is in the surgeon’s best interest
to select the most economical tools that will aid in deliver- Scalpel handles may be at or round, thin or thick, textured
ing the desired results. In general, higher quality instru- or smooth. T e most commonly used handles in dermato-
ments are more durable, easier to use, and longer lasting, logic surgery include the Bard– Parker #3 and Beaver han-
and are usually covered by a warranty that ranges rom dles. T e Bard– Parker #3 handle may be at or round and
1 to 5 years. Modern instruments are most commonly is available with an etched ruler. T is inexpensive scalpel
made rom surgical stainless steel with carbon alloy, chro- holds a variety o scalpel blades, including the most pop-
mium, nickel, and tungsten carbide. ularly used #10, #11, and #15 blades. T e smaller, mini-
Beaver handle is available in a hexagonal or round shape
(Fig. 8-2). T is handle is used or more delicate work
c u r e t t eS around the eye or ear. It is not as versatile as the Bard–
Parker #3 handle because it must be used with certain
Curettes are used or tumor removal, to better de ne blades, such as the #64 and #67 Beaver blades, Beaver
tumor margins prior to excision, and or tumor debulking mini-blade, and the 60 degree lamellar blade. T ese blades

Figure 8-1 Curettes in three di erent sizes with round Figure 8-2 Scalpel handles: round handle; Beaver; Bard–
and square handles. Parker, at (le t to right).
 1

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Figure 8-4 Dermablade.

t
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8
precision, is the disposable razor blade. However, these

:
:
blades must be separated and sterilized by o ce staf and
can pose a sharps hazard. T e unsa e use o any sharp sur-

S
u
ace is strongly discouraged by the Occupational Sa ety

r
g
i
and Health Administration (OSHA).4 A similar, more con-

c
a
l
venient (but more expensive) alternative is the prepack-

I
n
aged Dermablade (Fig. 8-4), which also of ers a plastic

s
t
r
holder that helps to reduce the risk o accidental injury.

u
m
e
n
Figure 8-3 Scalpel blades: 15, 15c, 10, 11, 64 Beaver (top

t
Sc ISSo r S

s
to bottom).
A wide variety o surgical scissors is available to suit the
are tted into a collet, which tightens around the blade dermatologic surgeon’s needs. Scissors are available in both
when the scalpel handle is turned. T e Siegel scalpel is right-handed and le t-handed versions and may be short or
avored by some surgeons when per orming Mohs micro- long with either sharp or blunt-tips. Long-handled scissors
graphic surgery. Its round, knurled handle allows or easy are reserved or cases in which the surgeon per orms exten-
positioning when excising circular or ovoid specimens.2 sive undermining or needs to work in deep tissue planes.
Short-handled scissors are used or ner procedures on the
Sc a l pel Bl a d eS head and neck. Scissors with blunt-tips are ideal or under-
mining tissue, whereas sharp-tipped scissors are used
T e most popular blade used in excisional surgery is the or sharp dissection. Scissor blades vary rom straight to
#15 blade, which has a sharp convex belly. T e #15c blade curved and serrated to smooth (Fig. 8-5). Straight blades
is a smaller variant o the traditional #15 blade, which are used or trimming skin and cutting sutures, whereas
allows or better control when working in small con ned curved blades are typically used or blunt dissection. Ser-
areas. T e #10 blade is a larger, wider, and more convex rated blades are particularly use ul or immobilizing skin
version o the #15 blade. It is used or excisions o thick with little subcutaneous tissue when cutting. Stainless steel
skin such as on the back. T e #11 blade is tapered to a scissors are the most popular and least expensive. T ey
sharp point and is thus used or incision and drainage, may also have tungsten carbide inserts that strengthen
removal o milia, and precise cutting o aps. T e #67 Bea- the blade but increase the cost. It is important to use these
ver blade is small with a convex belly and sharp tip. Similar instruments properly to avoid misalignment and prevent
to the #15c blade, the #67 blade is best or delicate work in dulling o the tips.
small areas. T e #64 Beaver blade has a rounded tip, which T e Gradle scissor is small, curved, and tapered to a
allows or easier maneuvering in arched structures such as ne point, which allows or precise cutting during skin
the pinna (Fig. 8-3). Scalpel blades are available in stainless tag removal and delicate dissection in certain areas, such
steel or carbon steel. Carbon steel is sharper; however, it as on the ace. Similar to the Gradle scissor, the Westcott
is also more expensive and dulls more quickly than stain- and Castroviejo scissors have a very ne, sharp tip that is
less steel blades.1 Blades may also be coated with e on to use ul or handling delicate periorbital tissue (Fig. 8-6).
decrease drag through tissue.3 Unlike the Gradle scissor, these scissors are spring-loaded.
T e iris scissor has a short handle, sharp tip, and extremely
sharp cutting edges, making it ideal or dissecting and cut-
BIo pSy Bl a d eS ting through tissue on the ace and neck. T e blade may
be either curved or straight. T is scissor is available with
T e #15 scalpel blade may also be used to per orm shave smooth blades, or one smooth paired with one serrated
biopsies. An economical alternative, which allows greater blade. T e long-handled Metzenbaum scissor may have 83
1
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1
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g
i
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p
l
e
s
Figure 8-5 Large scissors: curved short-handled scissors, Figure 8-6 Small scissors: Castroviejo, Iris, Gradle (top to
Metzenbaum, Mayo (top to bottom). bottom).

a curved or straight blade with a sharp or blunt-tip. It is Sk In Ho o k S

available in several sizes and is thus widely used or sharp
or blunt dissection in areas that require a reach. T e Mayo T e dermatologic surgeon may use skin hooks to
scissors’ handle and blade are roughly equal in length; manipulate tissue with minimal trauma. Skin hooks are
this instrument is used or blunt dissection. T e S-curved available in single- or multiple-pronged models. T e
LaGrange scissor is long-handled and used or undermin- single-pronged and double-pronged hooks are used to
ing dome-shaped lesions, removing punch biopsy speci- elevate aps, undermine very delicate skin, and stabilize
mens, and harvesting hair transplant donor gra ts. Most
o these tissue scissors are available in the supercut variety,
meaning that one o the blades has a ne serrated edge and
that the other is sharp.
In addition to tissue scissors, dermatologic surgeons
also require suture-removal scissors. While the ne, sharp
Gradle, Westcott, and Iris scissors should never be used
to cut sutures, other tissue scissors like the Mayo may be
used or this purpose, although it is important to note that
tissue scissors will dull much more rapidly when also used
to cut suture. T e Northbent or O’Brien scissors are spe-
cially designed scissors or suture removal. T e Northbent
scissor has a curved lower blade with a hook that easily
catches the suture loop (Fig. 8-7). T e O’Brien scissor has
a short-angled blade that cuts suture at its tip, preventing
unwanted nicks in the skin.
Finally, the dermatologic surgeon should be amiliar
with bandage-cutting scissors. T e widely used Lister Figure 8-7 Suture removal and cutting: orceps, hooked
scissors have large, blunt-tips with gently curved blades suture removal, operative suture-cutting scissors (le t to
84 making them ideal or cutting dressings. right).
 1

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a
Figure 8-8 Single-pronged skin hooks: curved and shep- Figure 8-10 Hemostats: large straight, delicate straight,

p
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e
herd’s curved (top to bottom). delicate curved (le t to right).

r
8
:
:
tissue during dissection and prior to suturing (Fig. 8-8). n eed l e Ho l d er S

S
T e double-pronged hooks of er greater stability and thus

u
r
g
lead to decreased risk o injury to the surgeon (Fig. 8-9). T e

i
A wide variety o needle holders, available in right-handed

c
multiple-pronged hooks are used or handling larger aps.

a
l
or le t-handed versions, are available to the dermatologic

I
Skin hooks may also be used to maintain tension on the

n
surgeon. o avoid damaging the instrument and associ-

s
wound when placing buried or running sutures. Skin hooks

t
r
ated needle, the surgeon generally pairs small needle hold-

u
vary in their degree o sharpness, curvature, and length.

m
ers with small needles and large needle holders with large

e
n
needles. T is is also important to prevent the needle rom

t
s
Hemo St a t S slipping out o the needle holder’s grasp. T e jaws o nee-
dle holders may be either smooth or serrated.
Hemostats are used to clamp bleeding vessels prior to T e Baumgartner and Mayo– Hegar needle holders are
ligation or electrocoagulation. Hemostats are available strong with serrated jaws and are used or skin surgery on
in a variety o types depending on the surgeon’s pre er- the back. T e Crile–Wood needle holder is long with a
ence and need. T ese include regular and delicate, as well gently tapered, blunt-tip designed to hold larger needles
as curved and straight versions (Fig. 8-10). T e authors (4-0 and larger), and is primarily used or skin surgery
eel that the delicate versions tend to be more e cient at on the trunk, extremities, and scalp. Needle holders used
grasping smaller vessels. T e Jacobson hemostat is ideal or more delicate procedures should be small and have
or dermatologic surgery because it can easily grasp small smooth jaws to prevent damage to the ner needles and
vessels with its ne tip. T e Halsted Mosquito hemostat suture (Fig. 8-11). T e Neuro-smooth needle holder has
is also popular in cutaneous surgery. Hemostats should a narrower tip, which is more appropriate or ne suture
not be used as needle holders. T ey do not grip the needle material (5-0 and smaller). T e Webster and Halsey nee-
ef ectively and in turn, the hard sur ace o the needle will dle holders have narrow, smooth or nely serrated jaws
damage the clamping sur ace o the hemostat. that are ideal or the ne suture work that is per ormed in

Figure 8-9 Double-pronged skin hooks: multiple sizes Figure 8-11 Needle holders: small le t-handed, small
(close up). right-handed, large right-handed (top to bottom). 85
1 cutaneous acial surgery. T e Castroviejo needle holder
has a detachable spring handle and sel -locking device
and is designed or very delicate work in the periorbital
region.
Needle holders must be durable and withstand distor-
tion rom constant metal-to-metal contact. High-end
needle holders, which can be identi ed by gold handles,
have alloy inserts o tungsten carbide on the jaw sur aces
to provide additional protection. However, these inserts
may wear away with time, making it even more important
to use the appropriately sized needle or the instrument
being used.

Fo r c epS
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e
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In dermatologic surgery, orceps should be lightweight and Figure 8-13 Delicate orceps: Bishop–Harmon, ophthal-
i
o
n
easy to manage to allow or precise manipulation o tissue mic, small toothed (top to bottom).
1
and suture needles. T e tips may be smooth, toothed, or
serrated. Smooth orceps in ict minimal damage to tissue,
:
:
tipped Bishop– Harmon orceps are popular (Fig. 8-13).
but tissue is more prone to slip rom its grasp. Although T ey have three holes on each side o the handle, which
S
u
serrated tips allow or rm grasp o tissue, they can cause make them even more lightweight, and they are available
r
g
crush injury to delicate areas, resulting in suboptimal
i
with or without teeth. Jewelers’ orceps are small with
c
a
wound healing. oothed orceps reduce crush injury and
l
a ne, sharp tip, which is use ul or suture removal and
P
still allow or rm grasp o tissue. T e tips o orceps vary
r
grasping small vessels.
i
n
rom delicate (<0.6 mm), to regular (1– 1.5 mm), to heavy
c
i
p
(>1.6 mm).
l
mISc el l a n eo u S In St r u men t S
e
Many dermatologic surgeons pre er the larger Adson
s
orceps or grasping the thick tissue o the proximal
extremities and trunk. Adson orceps have wide handles Additional instruments used in dermatologic surgery
or easy grasping and their tapered tips are available in include eye shields, chalazion clamps, Allis clamps, towel
both serrated and toothed models. T e Adson orceps clamps, periosteal elevators, bone chisels, nail splitters, and
without teeth, also called plat orm Adsons, may be used nail elevators. Eye shields protect the eye during certain
to grasp surgical needles or sa e trans er to the needle procedures that are in close proximity to the globe, such
holder during suturing. T e Brown– Adson orceps are as laser, cautery, or eyelid surgery. T ese are available in
similar to the Adson orceps except that they have eight metal or plastic varieties, but caution must be taken when
or nine teeth on each side o the orceps jaw, which allows using plastic eye shields as CO 2 or erbium lasers can burn
or enhanced tissue grasping, but produces a greater risk through the plastic. In general, plastic shields should be
o crush injury (Fig. 8-12). Grae e orceps have wide jaws used or radio requency treatments and metal eye shields
with a row o six or eight teeth and are use ul or grasping or laser resur acing.5 Eye shields come with either a small
cartilage. handle attached or a small suction cup or easy removal.
For more delicate work on areas with thinner skin (such Chalazion clamps are used to isolate eyelid, lip (mucosal),
as the eyelids, hands, and glans penis) the smaller, ne- and cheek tumors. One end o the clamp has a attened solid

A B

Figure 8-12 A. Forceps: Adson without teeth, Brown–Adson, Adson with teeth (top to bottom). B. Close up: Adson
86 without teeth, with teeth, Brown–Adson (le t to right).
 surgical tray and stand. T e Mayo surgical stand comes
in two-wheeled and our-wheeled versions; both can be
1
adjusted to the surgeon’s pre erred height. Surgical instru-
ments should be placed on top o the removable surgical
tray in a manner that reduces needlestick injuries. T e
instruments should not overlap, and gauze should not
cover any sharp instruments.
Every excision tray should contain a marking system
(commonly a marking pen or liquid gentian violet with a
toothpick or wooden cotton-tipped applicator), ruler, or-
ceps, scissors, scalpel handle, and a curette i needed or
tumor debulking. Once the tray is opened, sterile gauze,
scalpel blades, cotton-tipped applicators, and el a pads to
transport surgical specimens to the laboratory should be
added i desired. I a repair tray is needed, it should contain

C
h
a needle holder, suture-cutting and undermining scissors,

a
Figure 8-14 Ocular instruments: chalazion clamp, metal

p
skin hooks, and a cup with sterile saline to store any skin

t
e
eye shield and suction cup, eyelid retractor (top to bottom).

r
gra ts. Once the repair tray is opened, scalpel blades, ster-

8
ile gauze, cotton-tipped applicators, and suture materials
plate available in several shapes, and the other end is open

:
should be added.

:
(Fig. 8-14). T is design allows the clamps to hold delicate tis-

S
sue without causing damage. Allis clamps have sharp teeth

u
r
g
that are used to grasp tissue. As their sharp teeth can damage In St r u men t ma In t en a n c e

i
c
tissue, Allis clamps are mostly used to grasp stif , brous tis-

a
l
I
sue or tissue that is to be removed. T ey are available in a vari-

n
Proper sterilization and handling o surgical instruments

s
ety o sizes, the smallest with 4 × 5 teeth and the largest with 9

t
are necessary to optimize the per ormance and durabil-

r
u
× 10 teeth. owel clamps have curved ends that lock in place

m
ity o the tools. Soon a ter use, surgical tools should be

e
to anchor surgical towels and drapes within the sterile eld. submerged in a solution o warm water and instrument

n
t
Periosteal elevators are used to li t periosteum rom

s
detergent. Any remaining residue may be gently removed
bone and to li t ull-thickness skin aps. Periosteal eleva- with a plastic brush or ultrasonic cleaner.6 A terwards,
tors generally combine two dif erent ends: a large, at the instruments should be rinsed with water and then
blade or retraction and a smaller, curved tip or re ection completely dried be ore sterilization to avoid rusting or
and retraction o tissue. T ey are commonly used with staining with water spots.7 Be ore sterilization, the sharp
bone chisels to obtain samples o bone or periosteum that instruments should be inspected or nicks, and tissue-
need evaluation or tumor invasion. For nail surgery, nail grasping tools should have aligned tips. Periodic instru-
splitters have sharp tapered tips used to cut the nail plate. ment sharpening and restoration are needed to optimize
Nail elevators separate the nail rom the so t tissue below the ability and extend the li e o surgical tools.
without damaging the nail bed. T ere are several methods o sterilization commonly
utilized. Steam sterilization with an autoclave is the
t He Su r g Ic a l t r a y easiest and most commonly used method in the o ce
setting. T is autoclave uses high pressure (2 atm pres-
A properly organized surgical tray is imperative or maxi- sure) and high temperature (121°C) or 20 to 30 minutes
mizing the e ciency and sa ety o a given procedure to sterilize instruments. T is method o sterilization is
(Fig. 8-15). A sterile drape should cover the stainless steel nontoxic to the patient and staf and allows prepackaging
o instrument trays, which is time-e cient. However, the
disadvantage to this method is that the humidity rom
distilled water may dull sharp instruments. T e chemical
autoclave uses a mixture o alcohol and ormaldehyde,
which decreases the humidity and causes less dulling o
sharp instruments than the steam autoclave. Another
method o sterilization uses dry heat to kill microorgan-
isms. Although this method is cheap and does not dull
sharp instruments, the tools cannot be placed in paper
or plastic packages. As this presents a problem or pre-
paring and storing instruments or later use, this method
is usually reserved or sterilizing a particular instrument
or immediate use. Gas sterilization, which has excel-
lent microbicidal activity, is mostly used in hospitals as
it is expensive, time-consuming, and uses toxic ethylene
oxide gas. Cold sterilization is inexpensive, but it is not
recommended as a sole method o sterilization as it is
Figure 8-15 Surgical excision and repair tray: space is le t unreliable in clearing bacterial spores and the hepatitis
between instruments or easy identif cation and sa ety. B virus. 87
1 In j u r y pr ev en t Io n
scalpel, a scalpel blade remover should always be used.
T ere are various blade removal devices, including single
blade removers and reusable blade removers that deposit
Every surgeon, scrub nurse, and resident should take reed blades into an attached puncture proo container
the necessary precautions to avoid in icting injury upon (Fig. 8-16). Needle holders should never be used to remove
themselves or others around them. Surgical personnel risk a blade as this is an unsa e practice and will also damage
percutaneous injury and subsequent in ection with blood- the needle holder. Ideally, surgical personnel should have a
borne pathogens. Conversely, percutaneous injury to the “sa e zone” or instrument passing, such as a tray, to avoid
surgeon may place the patient at risk o disease trans er. hand-to-hand passing o sharp instruments.
T e major pathogens o concern are HIV, hepatitis B virus,
and hepatitis C virus.
T e rst precaution that the surgeon and assistant
should take is wearing properly tted gloves. Loose gloves c o n c l u SIo n
may catch on sharp instruments as well as obscure the view
o the surgical eld.8 Secondly, the surgical tray should be
T e dermatologic surgeon must have knowledge o the
S
neatly and properly set up with all instruments clearly
e
best surgical instruments and appropriate wound closure
c
t
visible and pointing away rom the surgeon’s hand. Dur-
i
o
materials to ef ectively deliver the most precise outcome.
n
ing the procedure, the surgeon should work away rom
It is important to properly handle and sterilize surgical
1
their hand or the assistant’s hand. Only one hand should
tools to increase their longevity and maximize their utility.
be present in a surgical eld when a sharp instrument is
:
:
Appropriate scheduling and surgical tray organization will
present and the instrument should not be moving. When
S
greatly enhance the speed, sa ety, and ow in the surgical
u
stabilizing or manipulating tissue, the surgeon or assis-
r
suite.
g
tant should use an instrument instead o their hands to
i
c
a
avoid unnecessary exposure in the surgical eld.9 It is also
l
P
important to use scalpel handles or needle holders when r eFer en c eS
r
i
n
handling scalpel blades or needles, respectively. Needles
c
i
p
should not be recapped. When removing a blade rom the 1. Neuberg M. Instrumentation in dermatologic surgery. Semin
l
e
s
Dermatol. 1994;13(1):10– 19.
2. Peterson SR, Goldberg LH. T e rounded Siegel scalpel han-
dle: a better instrument or curved incisions. J Drugs Derma-
tol. 2003;2(6):617– 618.
3. Weber LA. T e surgical tray. Dermatol Clin. 1998;16(1):17– 24.
4. Occupational Sa ety and Health Administration. Protecting
Yourself When Handling Contaminated Sharps. Washington,
DC; 2011. http://www.osha.gov/OshDoc/data_Bloodborne-
Facts/bb act02.pd . Accessed August 21, 2012.
5. Ries WR, Clymer MA, Reinisch L. Laser sa ety eatures o eye
shields. La ser Surg Med. 1996;18(3):309– 315.
6. Geisse JK. T e dermatologic surgical suite. Semin Dermatol.
1994;13(1):2– 9.
7. Sebben JE. Sterilization and care o surgical instruments and
supplies. J Am Acad Dermatol. 1984;11(3):381– 392.
8. rizna Z, Wagner RF. Preventing sel -in icted injuries to the der-
matologic surgeon. J Am Acad Dermatol. 2001;44(3):520–522.
9. Nori S, Greene MA, Schrager HM, Falanga V. In ectious oc-
cupational exposures in dermatology– A review o risks and
prevention measures. I. For all dermatologists. J Am Acad
Figure 8-16 Blade removal instruments. Dermatol. 2005;53(6):1010– 1019.

88
 Ch a p t e r Preoperative and

9 Postoperative Antibiotics
Micha M. Wo z & Christoph r J. Arp y

In t r o d u c t Io n simple removal o the sutures will alleviate the patient’s

symptoms and promote healing. Clinical signs which help
to di erentiate between these possibilities include mini-
A discussion o antibiotic use in procedural dermatology
mal warmth, tenderness, and induration, absence o ever,
should begin with the principles o when not to use anti-
and inability to express purulent material or wounds
biotic agents, as the majority o cutaneous procedures do
reacting to suture as opposed to in ection (Fig. 9-2). Clini-
not require their use. T e dermatologic surgeon, like any
cal experience with the normal healing process is particu-
medical practitioner, should be guided by the undamental
larly important during postoperative days 3 to 10 when
rule primum non nocere— rst do no harm. Medications,
low-grade cellulitis may be more di cult to distinguish
including topical antibiotics, have side e ects. T ey also
rom a suture reaction. Sutures have varying tissue reac-
have costs, both to the patient and to health care systems,
tivity, and amiliarity with suture properties is important
whether direct nancial ones or indirect ones, such as rom
when assessing postsurgical wounds. Speci c procedures,
the emergence o multidrug-resistant microorganisms.
such as skin gra ts and larger f aps, have higher associated
Evidence-based medicine teaches us that the use o rou-
in ection risks and so may avor the use o prophylactic
tine antimicrobial prophylaxis, which was once common
antibiotics.7 Prophylaxis has been traditionally assumed
practice in dermatologic surgery, is no longer indicated.
necessary or certain patient populations, such as those
T is principle applies both to topical and systemic anti-
at risk or endocarditis or prosthetic joint in ection. How-
biotic agents. T e incidence o wound in ection in cuta-
ever, even in these instances, evidence-based medicine
neous surgery is very low. Rates o surgical site in ection
teaches us that the uni orm use o antibiotics is more likely
in clean wounds typically range between 1% and 3%.1– 4 In
to do harm than good.
Mohs surgery, rates all below 3% ( able 9-1).
T e risk o iatrogenic bacteremia ollowing dermato-
logic surgery on clean skin has been ound to be smaller Impo r t a n c e o f Su r g Ic a l
than the risk o random bacteremia in healthy individuals
leading a normal li estyle.4 For example, the risk o bacte- pr epa r a t Io n
remia ollowing teeth brushing has been estimated to be
between 20% and 40%, compared to <2% or surgery on Avoidance o unnecessary antimicrobials requires a thor-
clean, nonmucous membrane skin.6 ough preoperative evaluation, including clinical assessment
Certain anatomic sites, such as the lips, ears, and groin, o skin condition, a detailed medical history, in ormation
are susceptible to a higher risk o bacteremia.7 Similarly, on current medications and over-the-counter supplements,
any breach in mucous membranes leads to higher risk o drug allergies, previous surgeries, the presence o oreign
surgical site in ection.8 T us, procedures on certain ana-
tomic sites may warrant prophylactic antibiotic coverage
(Fig. 9-1). Postoperatively, all wound in ections require
antibiotic treatment, and those that are rankly purulent
or f uctuant require drainage and occasionally packing as
well. T is assumes, however, that one can distinguish nat-
ural wound healing rom wound in ections. For example,
nonpurulent erythema may be the result o irritation rom
sutures rather than bacterial colonization. In such cases,

TAbl e 9-1
c i I i I i i
5
d i p s

c i i r s
Figure 9-1 Fu thickn ss mucosa d ct a t r w dg
excisions 1.9%–2.3%
xcision or squamous c carcinoma. Th anatomic sit
Mohs surg ry 0.7%–2.3% and typ o proc dur n c ssitat prophy actic anti iotic
th rapy with a road sp ctrum anti iotic giv n th pr s
CO2 r sur acing 1.1%–7.6%
nc o mouth ora.
1 TAbl e 9-2
10
W c ssi i i

l i
c s S gi
c ssif i i i gs c pi i s
I: C an Noninf am d skin; Non ; st ri
no contamination t chniqu
II: C an Ora or r spiratory Minor r aks in
Contaminat d mucosa, axi ary or st ri t chniqu
p rin a skin
III: Contaminat d Inf am d skin; trauma Major r aks in
induc d wounds st ri t chniqu
S
c
IV: In ct d N crotic tissu ; Visi
t
i
o
pr s nc o or ign contamination
n
mat ria
1
:
Source: Adapt d with p rmission rom Maragh Sl , Ot y CC, Ro nigk
:
RK t a . Anti iotic prophy axis in d rmato ogic surg ry: updat d
S
guid in s. Dermatol Surg. 2005;31(1):84.
u
r
g
i
c
a
overt in ection in such cases is important to ensure that
P
r
patients do not sel -medicate inappropriately or seek care
i
n
c
outside the dermatologic surgical setting because o a lack
i
p
o education about the healing process. Proper wound
s
dressings and adequate postoperative care are important
Figure 9-2 l t ch k primary r pair sit 6 w ks a t r
surg ry. Sutur granu omas (arrows) ar asi y con us d tools in the e ort to reduce postprocedural complications.
with at postop rativ in ction. Th pati nt has minima
t nd rn ss, no drainag , and no oth r c inica signs o ov rt
in ction.
c l a SSI Ic a t Io n o Wo u n d S
Wounds in dermatologic surgery, most o which are clean,
objects, such as pacemakers, de brillators or prosthetics, can be classi ed according to surgical technique, anatomic
a history o wound in ections or postsurgical endocarditis, site, and preoperative condition o the wound ( able 9-2).
and valvular heart disease or congenital mal ormations. T is classi cation is based on the CDC guidelines or pre-
Prior to excisional or Mohs surgery, the surgeon should vention o surgical wound in ections and has been ound
also be aware o anatomic variations, tumor biology, prop- to be a strong predictor o subsequent in ection.4
erties o the various local anesthetic agents, instrumenta- All other things being equal, class I wounds do not require
tion and suturing techniques. Local anesthetics requently antibacterial prophylaxis. For class II wounds, antibacterial
used in dermatologic surgery, such as lidocaine and bupi- prophylaxis is indicated only or immunocompromised
vacaine, have been ound to have bacteriostatic and ungi- patients, such as transplant recipients or those receiving
static properties.9 Avoidance o unnecessary antimicrobials chemotherapy.10 T is traditionally has not included HIV-
also presupposes meticulous attention to aseptic technique in ected patients unless the surgery involves the perineum.11
and hemostasis. Dermatologic surgery is generally consid- Regardless o wound classi cation, immunocompromised
ered to be clean rather than sterile. T is, however, does not patients, including HIV-in ected patients, require close
exonerate the surgeon or the surgical team but rather man- ollow-up, because altered unction o the immune sys-
dates heightened vigilance. Improper surgical technique, tem can lead to delayed or atypical presentations o wound
such as leaving large dermal and subcutaneous de ects in ections. Cultures should be obtained at the rst sign o
while approximating only the epidermal edges, can predis- in ection. Appropriate, broad-spectrum antimicrobial cov-
pose to f uid collection and in ection. Similarly, improper erage should be instituted and later tailored according to
instrument handling can convert a clean surgical eld to the culture results. Class III and IV wounds always require
a contaminated one. Subepidermal blood accumulation antibiotic coverage, which is aimed not only at reducing the
or hematoma ormation can serve as a nidus or in ec- risk o postsurgical complications but also at treating the
tion, highlighting the importance o meticulous hemosta- active in ection.
sis without excessive electrocoagulation, which can leave
devitalized tissue. Although second intention healing can
be use ul under certain circumstances, closing a wound by a n a t o mIc c o n SId er a t Io n S
rst intention promotes hemostasis, reduces dead space,
and decreases the risk o in ection. Furthermore, while In a large prospective study, several anatomic sites were
wounds that require granulation seldom become in ected ound to have signi cantly higher rates o postoperative
90 in normal hosts, the distinction between colonization and in ections.1 T ese sites included all procedures below
 TAbl e 9-3
o skin f aps on the nose, the in ection rate rose to 3.1%.
Here, too, suboptimal circulation at the surgical site likely
1
a mi Si s dp du s I s d contributed to the increased risk o in ection, as well as
7
r isk I i
prolonged surgical times and tissue manipulation close to
the nostrils. By extension, additional anatomic locations
Si s dp du s I s d r isk
and procedures may be considered or preoperative anti-
I i
biotic prophylaxis on a case-by-case basis. For example,
Anatomic ocation l ow r g; groin surgery on distal extremities, particularly on those with poor
l ips or ars (w dg xcision) vascular supply, may warrant preoperative prophylaxis.
Anatomic sites with signi cant hair growth also war-
Typ o proc dur F aps ( sp cia y nos )
rant special consideration. A Cochrane Review on pre-
Skin gra ts
operative hair removal ound that clipping or depilatory
creams are associated with a reduced, statistically sig-
ni cant, incidence o postoperative wound in ections as
the knee, wedge excisions o the lip or ear, and lesions in compared to shaving.13 Rates o in ection with shaving

C
the groin ( able 9-3). In addition, skin gra ts on any site

h
were statistically equivalent to the rates o in ection with-

a
and skin f aps on the nose have been associated with a

p
out hair removal, which may be explained by the act that

t
higher than average risk o in ection. Suboptimal circula-

r
small oci o microtrauma can allow bacteria access to

9
tion to these sites may contribute to their increased risk the skin surrounding the surgical wound. T e Cochrane
o postoperative in ection. Increased density o sebaceous

:
Review included many nondermatologic surgeries. How-

:
glands, increased humidity at mucosal or intertriginous ever, one may sa ely conclude that hair clipping should

P
sur aces and increased wound tension may also avor bac-

r
be the pre erred method o hair removal in dermatologic

o
terial colonization and subsequent in ection. Accordingly, procedures, i not to decrease the risk o in ection, then at

p
antibiotic prophylaxis has been suggested or procedures least to allow better visualization o the surgical eld.

r
a
involving certain anatomic sites or speci c procedures, as

t
i
v
summarized in able 9-3, and as illustrated in Figure 9-3.
pa t Ien t f a c t o r S

a
A prospective study o Mohs surgery revealed that

n
d
62.5% o post-Mohs wound in ections occurred on the

P
o
nose, although the overall in ection rate on the nose was Numerous patient and environmental actors contribute

s
t
still only 0.5%.12 On the other hand, with the inclusion

o
to the risk o developing postoperative wound in ections.

p
T e condition o the skin surrounding the surgical site is

r
a
a crucial actor. Absent other indications, procedures on

t
i
v
noninf amed, nonin ected, surgically scrubbed skin do

A
not require prophylactic antibiotics.14– 16 However, anti-

n
t
biotics are necessary, both therapeutically and to prevent

i
i
o
urther spread o in ection, on overtly in ected skin. It is

t
i
best to delay elective procedures on overtly in ected skin,

c
s
although avoidance may not be possible in the setting
o aggressive cancers, riable tumors, or some high-risk
hosts. Although the standard or cutaneous procedures
is not to use antibiotic prophylaxis, patient comorbidities
may mandate antibiotic use. For example, diabetes mel-
litus and chronic renal insu ciency are known to impair
host immunological de enses. Well-controlled diabetes
does not warrant antimicrobial prophylaxis, but poor
glucose control is an independent risk actor or in ection
and should be considered in the individual patient assess-
ment.17 Nicotine has also traditionally been thought o as
an independent risk actor or the development o wound
in ections, particularly a ter major visceral surgery.18
However, an observational study limited to dermatologic
surgical procedures disputes the presence o an increased
risk o in ection in smokers.19 In any event, the micro-
angiopathy associated with diabetes and smoking does
increase the risk o necrosis, which is o particular impor-
tance in reconstructive surgery. Smokers may, there ore,
be advised to stop smoking, at least perioperatively. I
they are unable to cease, a reduction is help ul in the
Figure 9-3 Int rpo ation f ap and burow’s gra t or a arg weeks prior to and a ter surgery. Similar to diabetes, mal-
Mohs d ct invo ving th nasa sid wa and a a. Th com nutrition and obesity are independent risk actors or the
p xity o th r pair, anatomic sit and duration o th pro development o postoperative wound in ections.18,20,21
c dur warrant strong consid ration or prophy actic ora T ese patient-dependent actors illustrate the importance
anti iotics. o a thorough preoperative evaluation ( able 9-4 a and b). 91
1 TAbl e 9-4 TAbl e 9-5
r isk f si d m S gi Si c i c i i 23
s wi h ig s r isk
10
I i s a s o m

p i r isk c mm d is s c ii s w i a ibi i p y xis

f s a ss i i s is r mm
Nutritiona Ma nutrition, o sity Past m dica history Pr vious inf ctious
ndocarditis; transp ant
Immun d f cts Inh rit d immun disord rs;
r cipi nts with va vu opathy
h mato ogica ma ignanci s; HIV/
AIDS; chronic r na or iv r dis as ; Structura h art d f cts Prosth tic va v or prosth tic
dia t s m itus; advancing mat ria us d in cardiac r pair
ag , corticost roid or oth r
Cong nita h art d f cts Unr pair d cyanotic h art
immunosuppr ssant m dications
(CHD) dis as ( .g., shunts); r pair d
S
(inc uding transp ant pati nts);
CHD during 6 months aft r
c
concurr nt inf ction
t
proc dur
i
o
n
Wound sit Inf ct d or co oniz d
1
Oth r exc ssiv a coho or to acco us
:
R c nt hospita ization
:
T e absence o hemodynamically signi cant f ow abnor-
S
S g yr r isk f s malities generally leads to a lower-risk classi cation. Com-
u
r
pared to guidelines published prior to 2007, the current
g
i
c
Tota op rativ tim AHA recommendations include signi cantly ewer patients
a
in the high-risk category. However, in other countries,
P
Improp r or nonst ri t chniqu
r
i
such as the United Kingdom, expert panels have advised
n
c
F aps or skin grafts against any prophylaxis or in ectious endocarditis.26 From
i
p
Hair shaving a socioeconomic perspective, this may appear reasonable,
s
partly because prophylaxis is not 100% e ective and partly
because the number o treated cases needed to prevent a
single case o in ectious endocarditis is very large.5
Selection o an appropriate antibiotic is o para-
mount importance in preventing in ectious endocarditis.
In f ec t Io u S en d o c a r d It IS a n d Approximately one-third o in ectious endocarditis cases
are caused by pathogens not appropriately covered by
n o n va l v u l a r c a r d Io va Sc u l a r
the administered prophylaxis.27 For keratinized skin, the
d ev Ic e-r el a t ed In f ec t Io n S predominant organisms are streptococci and staphylo-
cocci, speci cally Staphylococcus aureus and β-hemolytic
According to the American Heart Association (AHA), streptococci, but multiple other pathogens have been
high-risk cardiac conditions generally warrant antibi- reported. Assessing individual patient risk actors is there-
otic prophylaxis.22,23 T e AHA provides guidelines which ore important in selection o the appropriate agent.28,29
detail those conditions which should be classi ed as high For example, or procedures on oral mucosal sur aces, the
risk. However, the undamental principles o dermato- antimicrobial agent must cover Streptococcus viridans.
logic surgery and wound classi cation remain the same.
Surgical sites exhibiting actively in ected skin require
both therapeutic and prophylactic antibiotics. Similarly, pr o St h e t Ic j o In t In f ec t Io n S
high-risk surgical sites and procedures breaching mucous
membranes require antibiotic prophylaxis regardless o Skin in ections are a common source o late-onset arti -
the patient’s cardiac status. It is also important to note cial joint in ection.30– 32 Patients with a history o recent
that the majority o in ectious endocarditis cases are not joint replacement are also at higher risk or arti cial joint
attributable to invasive procedures.24,25 Moreover, approx- in ection.33 T us, prevention o surgical site in ection is
imately hal o the reported cases o in ectious endocar- particularly important in patients with prosthetic joints.
ditis occurred in individuals without a detectable cardiac As in endocarditis, arti cial joint in ection secondary to
abnormality. dermatologic procedures is thought to occur by hematog-
In ectious endocarditis and nonvalvular cardiovascular enous seeding. However, because o the low incidence o
device-related in ections are typically the result o bacte- bacteremia on nonin ected, nonmucosal sites a ter derma-
remia. T e AHA categorizes risk actors or endocarditis tologic surgery, antibiotic prophylaxis to prevent arti cial
into high, moderate, and negligible categories.23 Gener- joint in ection is not necessary except in high-risk patients.
ally, high-risk indications include the presence o pros- High-risk patients include those with a history o previ-
thetic heart valves or substantial cardiac valvular and f ow ous prosthetic joint in ection, patients undergoing a total
dys unction. Other high-risk indications include a history joint replacement within the previous 2 years and patients
o endocarditis and congenital heart disease ( able 9-5). with certain comorbidities, including insulin-dependent
ransplant patients require antibiotic prophylaxis i they (type I) diabetes, malignancy, immunosuppression, HIV,
92 have a history o valvulopathy. malnourishment, and hemophilia ( able 9-6).
 TAbl e 9-6
Mohs procedures and the varying lengths o such proce-
dures, individual assessment o risk actors and case-by-
1
p i s hi r isk d i j i I i s7 case analysis are o particular importance.
Procedural dermatology includes not only traditional sur-
c ii s w i a i i i p y xis gical techniques but also numerous nonsurgical procedures.
is r Generally, routine small-sample biopsies, such as punch and
shave procedures not involving mucous membranes, typi-
Joint sp cif c Prosth tic joint r p ac m nt during 2 y ars
a t r th proc dur ; cally do not require antibiotic prophylaxis.24 Similarly, non-
invasive procedures, such as nonablative laser techniques
Pr vious prosth tic joint in ction;
and percutaneous intravascular procedures, generally do
In ammatory arthropathi s ( .g., rh umatoid not require prophylaxis. On the other hand, any procedure
arthritis) that causes more widespread destruction o the epidermis
Past m dica Immunosuppr ssion; insu in d p nd nt and dermis can lead to bacterial invasion and, there ore,
history dia t s; HIV/AIDS; ma ignancy; requires consideration o antimicrobial prophylaxis. T is
ma nourishm nt; h mophi ia includes laser resur acing and other cosmetic procedures.38

C
h
a
p
t
po St o per a t Iv e In d Ic a t Io n S

r
Concerning procedures on the oral mucosa, both the

9
American Dental Association (ADA) and the American

:
Regardless o the procedure per ormed, the anatomic site

:
Academy o Orthopedic Surgeons (AAOS) provide guid-
or the patient’s risk actors, postoperative complications

P
ance.34 T e ADA– AAOS guidelines recommend antibiotic

r
prophylaxis or all procedures in which mucosal bleeding may require the use o antibiotics. However, the thresh-

o
old or antimicrobial use may be lower or certain patient

p
is anticipated. T is can be thought o as equivalent to
populations, such as the immunocompromised, and or

r
a
procedures likely to breach mucous membranes and is

t
certain anatomic sites and procedures, such as skin gra ts

i
v
there ore in keeping with the principles o dermatologic
and f aps, or which the risk o necrosis is higher. Although

a
surgery which have already been discussed.

n
the diagnosis o a postoperative wound in ection may be

d
straight orward, it is also subject to considerable inter- and

P
o
c o n SId er a t Io n o f intraobserver variability, which suggests that experience

s
t
o
and a amiliarity with normal variations can be help ul.

p
pr o c ed u r a l t ec h n Iq u e T e 1992 CDC de nitions o nosocomial in ections give

r
a
some guidance39:

t
i
v
More complex surgical techniques carry higher rates o

A
postoperative wound in ection than simple excisions.1,35,36 1. Purulent discharge rom the incisional wound

n
t
As gra ts and f aps are associated with signi cantly higher 2. Organism isolated on culture o aseptically obtained

i
i
o
than average in ection rates, simple reconstruction should f uid or tissue

t
i
be per ormed whenever possible. Hemorrhagic compli- 3. One or more o the ollowing: pain, tenderness, local

c
s
cations are an independent risk actor or development swelling, redness, heat
o postoperative wound in ection, which emphasizes the 4. T e surgeon deliberately reopens the wound (unless
importance o excellent hemostatic control.3,35 Similarly, culture o the incision is negative)
excessive wound tension can lead to tissue necrosis and 5. T e treating physician diagnoses a nosocomial in ection
create a nidus or in ection. Excessive tissue injury, such as
that due to crush injury rom tissue orceps, may inf uence Diagnosis o a nosocomial in ection is made when at
postoperative complication rates. Generally, the larger the least one o the above actors is present and the in ection
surgical de ect, the greater the risk o postoperative com- occurs within 30 days o surgery. Diagnosing an overt
plications. T ere ore, procedures should be per ormed surgical site in ection warrants aggressive and tailored
with a view to minimizing tissue injury and avoiding high- therapy to prevent bacteremia and urther complications.
tension closures. An adequate blood supply to the surgical Obtaining cultures and sensitivities is crucial in directing
site is also essential or wound healing. therapy and minimizing complications.
Mohs micrographic surgery incorporates traditional
and innovative surgical techniques but di ers rom most
standard dermatologic procedures in that wounds are le t pa t h o g en S
open while surgical specimens are examined histopatho-
logically. Patients are typically bandaged and then leave Knowledge o anatomy and microbiology is necessary to
the operating room to await the results o their micro- select the antibiotic agent with the spectrum o coverage
scopic analysis. Sterility is there ore reduced and wound most suitable or the speci c situation and procedure.
exposure time is generally thought to be a risk actor or Most surgical site in ections are caused by resident f ora.40
in ection. According to some authors, the in ection rate T is highlights the importance o adequate antiseptic
doubles with each hour o surgery.37 Nevertheless, stud- preparation o the surgical site. For example, chlorhexi-
ies examining the risk o surgical site in ection involving dine has been ound to signi cantly reduce coagulase-
Mohs surgery consistently reveal that the overall in ection negative staphylococci at the end o surgery.41 T e choice
rate remains very low.12 T us, antibiotic prophylaxis is not o antiseptic depends on the anatomic site, type o proce-
generally indicated. However, due to the heterogeneity o dure and resident microf ora. Blood can neutralize certain 93
1 antiseptics, and the duration o action di ers markedly
between the available agents.
o adverse e ects, expense and the emergence o multidrug-
resistant microorganisms. Local knowledge o antimicro-
Endogenous cutaneous f ora include S. aureus, coagu- bial susceptibilities in communities and institutions is also
lase-negative staphylococci, Streptococcus pyogenes, entero- important, particularly or MRSA in ections. For purposes
cocci, and Escherichia coli.28 Nonbacterial organisms, such as o daily practice, three considerations determine the choice
Candida, can also cause in ection and postoperative compli- o prophylactic antibiotics: rst, the status o the wound and
cations.29 S. viridans and peptostreptococci are the primary the condition o the surgical site; second, the anatomic site;
pathogens arising rom mucosal sur aces.10 However, the third, whether the patient’s comorbidities warrant antimi-
single most important organism responsible or surgical site crobial prophylaxis. T e choice o therapeutic antibiotics
in ection is S. aureus, which colonizes both mucosa and adja- in postsurgical wound in ections should be guided similarly
cent sur aces, including the nasal mucosa and perineum, and but, in addition, cultures and sensitivities should be obtained.
is ound in particularly high concentrations in diseased skin. At minimum, this typically requires a wound swab. In some
An epidemiological concern arises rom the increasing inci- circumstances, a tissue culture may be required.
dence o methicillin-resistant S. aureus (MRSA), both com-
munity-acquired (CA-MRSA) and health care-associated
S
(HC-MRSA).42 HC-MRSA may be community-onset and r o u t e o f a d mIn ISt r a t Io n
c
t
i
includes invasive and noninvasive MRSA diagnosed within
o
n
12 months ollowing a surgical procedure, hospitalization, Antibiotics can be administered topically or systemically.
1
dialysis, or residence in a long-term care acility. Invasive Use o perioperative topical antibiotics has been standard
:
practice or many dermatologists in the past.48 However,
:
HC-MRSA can cause sepsis and in ect cerebrospinal f uid,
pleural f uid, pericardial f uid, bone, and viscera. It carries a topical antibiotics are not indicated a ter clean dermato-
S
u
20% mortality rate.7 Risk actors or invasive HC-MRSA also logic procedures.49 Randomized studies have shown that
r
g
i
include age greater than 65 years, A rican American heri- the application o white petrolatum leads to statistically
c
a
tage and male gender. Because o the central role o S. aureus equivalent rates o in ection compared to application o
P
r
in surgical site in ection, as well as the di culties involved topical antibiotics, such as bacitracin.50– 52 T e argument
i
n
c
in treating MRSA, screening and preoperative decontami- against use o topical antibiotics in standard dermatologic
i
p
nation protocols or MRSA colonization have been sug- procedures is underscored by the risk o contact dermati-
s
gested.43,44 However, the utility o such protocols depends on tis and anaphylaxis.53– 58 In addition, white petrolatum is
the local prevalence o MRSA, surgical technique, and pro- typically much less expensive or the dermatologist and
cedural acilities.45 T us, awareness, risk actor evaluation, the patient. opical antibiotics may play a role in manage-
and case-by-case analysis remain critical. ment o class III or IV wounds, whether preoperatively or
Individual patient groups are at increased risk o contaminated sites or postoperatively to prevent surgical
in ection due not only to altered immunity but also to site in ections. However, overtly in ected wounds that
increased microbial colonization and altered composition are manipulated through surgical procedures should be
o resident and transient microf ora. For example, colo- treated aggressively with systemic antimicrobials.
nization with disease-causing strains o S. aureus is more opical antimicrobial e ects can also be achieved by
prevalent in individuals with atopic dermatitis and may special wound dressings. Silver sul adiazine has been a
be an important aggravating actor or dermatitis.46 Simi- mainstay or burn patients, as it has activity against gram-
larly, diabetic patients are more prone to staphylococcal positive and gram-negative bacteria as well as yeast.59,60
and candidal skin in ections as a result o altered immu- A prospective, randomized controlled study o routine
nity and deranged homeostasis. Generally, patients with in rainguinal revascularization incisions ound that silver
innate or acquired immunode ciencies warrant special dressings reduced the risk o postsurgical complications
consideration, as do patients at increased risk o severe compared to conventional dressings.61 Although there is
complications rom surgical site in ections. Although some evidence or the use o silver dressings in acute and
the mechanism o seeding is similar, the microorganisms chronic wounds, the data are not conclusive.62 Silver dress-
responsible or in ectious endocarditis and prosthetic joint ings also carry the risks o argyria, contact dermatitis, ana-
in ection are di erent. T e majority o in ectious endo- phylaxis, and bone marrow toxicity, although this risk is
carditis is caused by low-virulence streptococci, while probably lower than previously thought.63 Honey-impreg-
arti cial joint in ections are typically caused by S. aureus nated dressings are another potential tool or the topical
and S. epidermidis.47 Patient comorbidities, immune sta- prevention and treatment o wound in ections. Honey has
tus, and associated susceptibility to speci c pathogens are been ound to be e ective against MRSA, although one
there ore critical in preoperative evaluation and selection study ailed to show a positive e ect on chronic venous
o antimicrobial agents with adequate coverage. ulcers.64– 66 More studies are needed to investigate its use
as a prophylactic agent.
T e AHA and ADA– AAOS guidelines recommend
c h o Ic e o f a n t IbIo t Ic S systemic antimicrobials as prophylactic agents to prevent
in ectious endocarditis and prosthetic joint in ection.
Clinical context is usually the determining actor in the Analogously, systemic rather than topical agents should be
choice o prophylactic and therapeutic antibiotics. T e ana- used to prevent other postoperative complications arising
tomic site, condition o the skin, patient comorbidities and rom surgical site in ection. Systemic agents protect the
history o in ection, and the type o procedure and local bloodstream and prevent the dissemination o pathogens.
epidemiological data all need to be evaluated. Other con- Selection o an agent depends on patient-speci c actors
94 siderations include the patient’s history o allergies, the risk as well as the agent’s spectrum o activity ( able 9-7).
 TAbl e 9-7
c Sys i a i i i s us i d i S y67

a i i yS S a i i i a sa i s c ye mi is s

Staphylococcus Staphylococcus Streptococcus Streptococcus Escherichia coli Pseudomonas

aureus (mSSa ) aureus (mr Sa ) pyogenes viridans ( -eSbl ) p s i s i s
P nici in >80% r sistanc Poor Good Good Poor Good Poor
Amoxici in >80% r sistanc Poor Good Good Mod rat Mod rat Poor
Dic oxaci in >80% r sistanc Poor Good Mod rat Poor Poor Poor
erythromycin Mod rat Mod rat Mod rat Mod rat Poor Mod rat Poor
Azithromycin Mod rat Mod rat Mod rat Mod rat Poor Mod rat Poor
Doxycyc in Mod rat Mod rat Mod rat Mod rat Mod rat Mod rat Poor
Minocyc in Mod rat Mod rat Mod rat Mod rat Inad quat data Mod rat Poor
C pha xin Good Poor Mod rat Mod rat Mod rat Good Poor
C azo in
Cipro oxacin Poor to Mod rat Poor to Mod rat Poor to Mod rat Inad quat data Good No data Good
l vo oxacin Mod rat Mod rat Mod rat Good Good Mod rat Good

sci t oi i t nA vi t ar p o ts oP d n a vi t ar p o rP :: 9 r t p a hC

1
9
5
1 t ImIn g o f a d mIn ISt r a t Io n
Antibiotics can be administered pre-, intra-, and postop-
eratively. Because most severe complications o surgical
site in ections, including in ectious endocarditis and pros-
thetic joint in ections, are caused by bacteremia, antibiot-
ics should generally be delivered systemically. Ideally, the
antibiotic should be in the bloodstream when the opera-
tion begins to prevent systemic bacterial dissemination
and to ensure that the antibiotic is present in the wound
coagulum at the time o surgery.68,69 T us, prophylactic
antibiotics should be administered preoperatively within
a time rame that ensures their presence in the blood-
stream at the time o incision and repair. T e AHA rec-
S
ommends 30 to 60 minutes preoperative dosing, whereas
c
t
the ADA– AAOS recommends 60 minutes preoperative
i
o
n
dosing. Intraoperative administration o topical antibiot-
1
ics is probably not bene cial or standard dermatologic
procedures2,14,70 but may be indicated or procedures with
:
:
delayed closures, particularly Mohs surgery.71,72 Analo-
S
u
gously, the need or a repeat dose o intra- or postop-
r
g
erative systemic antibiotics administered or prophylaxis
i
c
a
depends on the length o the procedure, the preoperative
P
indication, and the hal -li e o the antimicrobial agent.
r
i
n
c
i
p
a n a t o mIc SIt e
s
Figure 9-4 Right ow r xtr mity wound 10 days a t r
Generally, antibiotics given to prevent in ections rom xcision o a squamous c carcinoma in a 76 y ar o d
cutaneous procedures need to target staphylococci and woman with g d ma and atrophic skin. Not th c ntra
streptococci. Procedures per ormed on intertriginous, partia d hisc nc and asymm tric adjac nt ryth ma
du to c u itis. Cu tur s r v a d a po ymicro ia in c
moist or macerated areas also need to target gram-neg-
tion with staphy ococci, Proteus, and Morganella sp ci s.
ative organisms. However, staphylococci remain the most
common cause o surgical site in ections even in such
areas. Streptococcal and coli orm bacteria need to be con-
sidered in the perioral area, ear, perineum, and below the macrolide antibiotics, such as erythromycin and azithro-
waist in diabetic patients. Systemic agents commonly used mycin.7 Some f uoroquinolones, such as ciprof oxa-
or prophylaxis on nonmucosal sur aces include cepha- cin, have better activity against pseudomonal species
lexin and dicloxacillin.37 Both agents are active against and, may, thus, be indicated or procedures on the ear.
gram-positive organisms and also cover common gram- For openly in ected wounds or postsurgical in ections,
negative pathogens.73 T ese agents can also be used as therapy should always be tailored to the cultures and
more prolonged therapy or overt in ection. o target S. sensitivities (Fig. 9-4). Dosage varies according to the
viridans and peptostreptococci on oral mucosal sur aces, individual antibiotic and the patient’s comorbidities and
the AHA guidelines recommend the use o amoxicillin.23 allergies. Standardized guidelines tailored to speci c
For perineal skin, a penicillinase-resistant agent, such anatomic sites exist but actual antibiotic use depends
as amoxicillin-clavulanate, should be used. Alternatives on patient characteristics and local epidemiological data
or penicillin-allergic patients include clindamycin and ( able 9-8).

TAbl e 9-8
S s r i s a i i i us i c ci i S i s7

u t k u t k po
l i 1s l i o a s p i i a y po m i i s p i i a y
l ips or ars (w dg C pha xin; dic oxaci in C indamycin; azithromycin C azo in; c triaxon C indamycin
xcision)
Gra ts, nos aps C pha xin; dic oxaci in C indamycin; azithromycin C azo in; c triaxon C indamycin
Groin and ow r g C pha xin; TMP SMX; TMP SMX; vo oxacin C indamycin; C indamycin; g ntamycin
vo oxacin g ntamycin
96 TMP SMX; trim thoprim su am thoxazo , dou str ngth.
o t h er c o n SId er a t Io n S 4. Rosengren H, Dixon A. Antibacterial prophylaxis in derma-
tologic surgery: an evidence-based review. Am J Clin Derm.
1
2010;11(1):35– 44.
Surgical site in ections generally originate at the time o 5. Shurman DL, Benedetto AV. Antimicrobials in dermatologic
the procedure, but typically become clinically evident surgery: acts and controversies. Clin Dermatol. 2010;28(5):
505– 510.
only several days later. T is is one reason why antibiotic 6. Pallasch J, Slots J. Antibiotic prophylaxis and the medically
prophylaxis, i indicated, should be administered such compromised patient. Periodontol 2000. 1996;10:107– 138.
that the antibiotic is present at the surgical site and in the 7. Wright I, Baddour LM, Berbari EF, Roenigk RK, Phillips PK,
bloodstream at the time o the rst incision. Suture reac- Jacobs MA. Antibiotic prophylaxis in dermatologic surgery:
tions and contact dermatitis rom topical antibiotics or advisory statement 2008. J Am Acad Dermatol. 2008;59(3):
464– 473.
wound dressings can mimic in ection. Experience should 8. Wood LD, Warner NM, Billingsley EM. In ectious complica-
guide the clinician in making an assessment. However, i tions o dermatologic procedures. Dermatol T er. 2011;24(6):
there is any concern or in ection, wound cultures should 558– 570.
be sent. While awaiting the culture results, the risks and 9. Kretschmer L, Zimmermann O, Stein A, Sebastian G; Com-
bene ts o initiating antibiotic therapy can be weighed mission or Quality Assurance o the German Dermatol-

C
ogy Society and the Pro essional Association o Surgical and
according to the individual presentation and the patient’s

h
Oncological Dermatology. [Perioperative antibiotic therapy

a
comorbidities and risk actors.

p
in dermatology. Guidelines o the Commission or Quality

t
In addition to bacteria, ungi, and viruses may prove to Assurance o the German Dermatology Society and the Pro es-

r
9
be complicating actors in dermatologic procedures and sional Association o Surgical and Oncological Dermatology].
wound healing. Patients with a known history o her- Hautarzt. 2001;52(7):609– 614.

:
:
10. Maragh SL, Otley CC, Roenigk RK, Phillips PK; Division o
pes simplex or zoster may require antiviral prophylaxis. Dermatologic Surgery, Mayo Clinic, Rochester, MN. Antibi-

P
Patients undergoing resur acing procedures are at par-

r
otic prophylaxis in dermatologic surgery: updated guidelines.

o
ticularly high risk o viral reactivation. T us, some authors Dermatol Surg. 2005;31(1):83– 91.

p
advocate standard antiviral prophylaxis or certain cos- 11. Nichols RL. Surgical antibiotic prophylaxis. Med Clin North

r
a
metic or ablative laser procedures.38,74 Similarly, patients Am. 1995;79(3):509– 522.

t
i
12. Maragh SL, Brown MD. Prospective evaluation o surgical

v
with a history o mucocutaneous candidiasis undergoing site in ection rate among patients with Mohs micrographic

a
procedures on mucosal or intertriginous sur aces may

n
surgery without the use o prophylactic antibiotics. J Am

d
require addition o an anti ungal agent, either topically Acad Dermatol. 2008;59(2):275– 278.

P
o
or systemically. More studies, including randomized 13. anner J, Woodings D, Moncaster K. Preoperative hair

s
removal to reduce surgical site in ection. Cochrane Databa se

t
controlled trials, are needed to investigate the utility and

o
Syst Rev. 2006;19(3):CD004122.

p
e cacy o antiviral and anti ungal prophylaxis in derma- 14. Bencini PL, Galimberti M, Signorini M, Crosti C. Antibiotic

r
a
tologic procedures. prophylaxis o wound in ections in skin surgery. Arch Derma-

t
i
v
tol. 1991;127(9):1357– 1360.
15. Haas AF, Grekin RC. Antibiotic prophylaxis in dermatologic

A
n
c o n c l u SIo n surgery. J Am Acad Dermatol. 1995;32(2 Pt 1):155– 176.

t
i
16. Rabb DC, Lesher JL Jr. Antibiotic prophylaxis in cutaneous

i
o
surgery. Dermatol Surg. 1995;21(6):550– 554.

t
i
Adhering to the generally accepted standard o care in 17. Dixon AJ, Dixon MP, Dixon JB. Prospective study o skin sur-

c
s
dermatologic procedures includes knowing and applying gery in patients with and without known diabetes. Dermatol
Surg. 2009;35(7):1035– 1040.
the principles o when to use and not use antibiotic agents. 18. Olsen MA, Lock-Buckley P, Hopkins D, Polish LB, Sundt
T is, in turn, involves amiliarity with the in ection risks M, Fraser VJ. T e risk actors or deep and super cial chest
associated with speci c procedures and anatomic sites, surgical-site in ections a ter coronary artery bypass gra t
classi cation o wounds, individual patient risk actors, surgery are di erent. J T orac Cardiova sc Surg. 2002;124(1):
proper surgical preparation, likely pathogens, and proper 136– 145.
19. Dixon AJ, Dixon MP, Dixon JB, Del Mar CB. Prospective
selection o antimicrobial agents. Proper procedural care study o skin surgery in smokers vs. nonsmokers. Br J Derma-
does not start with the procedure itsel but rather with a tol. 2009;160(2):365– 367.
systematic preoperative patient evaluation and does not 20. Bumpous JM, Johnson J . T e in ected wound and its
end with the last suture or wound dressing, but rather management. Otolaryngol Clin North Am. 1995;28(5):
with a thorough postprocedural ollow-up. T us, assess- 987– 1001.
21. Malone DL, Genuit , racy JK, Gannon C, Napolitano LM.
ing the pre- and postoperative needs or antibiotics is an Surgical site in ections: reanalysis o risk actors. J Surg Res. 2002;
integral part o patient care. 103(1):89– 95.
22. Baddour LM, Bettmann MA, Bolger AF, et al. Nonvalvular
cardiovascular device-related in ections. Circulation. 2003;
108(16):2015– 2031.
r ef er en c eS 23. Wilson W, aubert KA, Gewitz M, et al. Prevention o
in ective endocarditis: guidelines rom the American Heart
1. Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospective Association: a guideline rom the American Heart Associa-
study o wound in ections in dermatologic surgery in the ab- tion Rheumatic Fever, Endocarditis, and Kawasaki Disease
sence o prophylactic antibiotics. Dermatol Surg. 2006;32(6): Committee, Council on Cardiovascular Disease in the Young,
819–826. and the Council on Clinical Cardiology, Council on Cardio-
2. Futoryan , Grande D. Postoperative wound in ection rates in vascular Surgery and Anesthesia, and the Quality o Care and
dermatologic surgery. Dermatol Surg. 1995;21(6):509– 514. Outcomes Research Interdisciplinary Working Group. Circu-
3. Rogues AM, Lasheras A, Amici JM, Guillot P, Beylot C, a- lation. 2007;116(15):1736– 1754.
ïeb A. In ection control practices and in ectious complica- 24. Dajani AS, aubert KA, Wilson W, et al. Prevention o bacte-
tions in dermatological surgery. J Hosp Infect. 2007;65(3): rial endocarditis. Recommendations by the American Heart
258– 263. Association. JAMA. 1997;277(22):1794– 1801. 97
1 25. Durack D . Prevention o in ective endocarditis. N Engl J
Med. 1995;332(1):38– 44.
determination o S. aureus isolated in adolescent and adult
patients with atopic dermatitis. J Derma tol. 2009;36(2):
26. Richey R, Wray D, Stokes , Guideline Development Group. 75– 81.
Prophylaxis against in ective endocarditis: summary o NICE 47. McGowan DA. Dentistry and endocarditis. Br Dent J. 1990;
guidance. BMJ. 2008;336(7647):770– 771. 169(3– 4):69.
27. Durack D , Kaplan EL, Bisno AL. Apparent ailures o 48. Lapolla WJ, Levender MM, Davis SA, Yentzer BA, Willi ord
endocarditis prophylaxis. Analysis o 52 cases submitted to a PM, Feldman SR. opical antibiotic trends rom 1993 to 2007:
national registry. JAMA. 1983;250(17):2318– 2322. use o topical antibiotics or non-evidence-based indications.
28. National Nosocomial In ections Surveillance (NNIS) report, Dermatol Surg. 2011;37(10):1427– 1433.
data summary rom October 1986– April 1997, issued May 49. Levender MM, Davis SA, Kwatra SG, Willi ord PM, Feld-
1997. A report rom the NNIS System. Am J Infect Control. man SR. Use o topical antibiotics as prophylaxis in clean
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29. National Nosocomial In ections Surveillance (NNIS) 445– 451.
System Report, data summary rom January 1992 to June 50. Campbell RM, Perlis CS, Fisher E, Gloster HM Jr. Gentami-
2002, issued August 2002. Am J Infect Control. 2002;30(8): cin ointment versus petrolatum or management o auricular
458– 475. wounds. Dermatol Surg. 2005;31(6):664– 669.
30. Ainscow DA, Denham RA. T e risk o haematogenous in ec- 51. Dixon AJ, Dixon MP, Dixon JB. Randomized clinical trial
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tion in total joint replacements. J Bone Joint Surg Br. 1984; o the e ect o applying ointment to surgical wounds be ore
66(4):580– 582. occlusive dressing. Br J Surg. 2006;93(8):937–943.
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31. Berbari EF, Hanssen AD, Du y MC, et al. Risk actors or 52. Smack DP, Harrington AC, Dunn C, Howard RS, Szkutnik
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prosthetic joint in ection: case-control study. Clin Infect Dis. AJ, Krivda SJ. In ection and allergy incidence in ambulatory
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1998;27(5):1247– 1254. surgery patients using white petrolatum vs bacitracin oint-
32. Maderazo EG, Judson S, Pasternak H. Late in ections o total ment. A randomized controlled trial. JAMA. 1996;276(12):
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joint prostheses. A review and recommendations or preven- 972– 977.
tion. Clin Orthop Relat Res. 1988;(229):131– 142. 53. Dyck ED, Vadas P. Anaphylaxis to topical bacitracin. Allergy.
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33. Advisory statement. Antibiotic prophylaxis or dental pa- 1997;52(8):870– 871.
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tients with total joint replacements. American Dental Asso- 54. Eedy DJ, McMillan JC, Bingham EA. Anaphylactic reactions
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ciation; American Academy o Orthopaedic Surgeons. J Am to topical antibiotic combinations. Postgrad Med J. 1990;
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Dent Assoc. 1997;128(7):1004– 1008. 66(780):858– 859.
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34. American Dental Association; American Academy o Ortho- 55. Gette M , Marks JG Jr, Maloney ME. Frequency o postop-
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pedic Surgeons. Antibiotic prophylaxis or dental patients erative allergic contact dermatitis to topical antibiotics. Arch
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with total joint replacements. J Am Dent Assoc. 2003; 134(7): Dermatol. 1992;128(3):365– 367.
895–899. 56. Knowles SR, Shear NH. Anaphylaxis rom bacitracin and
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35. Amici JM, Rogues AM, Lasheras A, et al. A prospective study polymyxin B (Polysporin) ointment. Int J Dermatol. 1995;
o the incidence o complications associated with dermato- 34(8):572– 573.
logical surgery. Br J Dermatol. 2005;153(5):967– 971. 57. Marks JG, Belsito DV, DeLeo VA, et al. North American Con-
36. Sylaidis P, Wood S, Murray DS. Postoperative in ection tact Dermatitis Group patch test results or the detection o
ollowing clean acial surgery. Ann Pla st Surg. 1997;39(4): delayed-type hypersensitivity to topical allergens. J Am Acad
342– 346. Dermatol. 1998;38(6 Pt 1):911– 918.
37. Nestor MS. Perioperative use o antibiotics: preventing and 58. Zappi EG, Brancaccio RR. Allergic contact dermatitis rom
treating perioperative in ections. J Drugs Dermatol. 2005;4(6 mupirocin ointment. J Am Acad Dermatol. 1997;36(2 Pt 1):
suppl):S34–S36. 266.
38. Nestor MS. Prophylaxis or and treatment o uncomplicated 59. Ho mann S. Silver sul adiazine: an antibacterial agent or
skin and skin structure in ections in laser and cosmetic sur- topical use in burns. A review o the literature. Scand J Pla st
gery. J Drugs Dermatol. 2005;4(6 suppl):S20–S25. Reconstr Surg. 1984;18(1):119– 126.
39. Horan C, Gaynes RP, Martone WJ, Jarvis WR, Emori G. 60. Pruitt BA Jr, McManus A , Kim SH, Goodwin CW. Burn
CDC de nitions o nosocomial surgical site in ections, wound in ections: current status. World J Surg. 1998;22 (2):
1992: a modi cation o CDC de nitions o surgical wound 135– 145.
in ections. Infect Control Hosp Epidemiol. 1992;13(10): 61. Childress BB, Berceli SA, Nelson PR, Lee WA, Ozaki CK.
606– 608. Impact o an absorbent silver-eluting dressing system on
40. Hirschmann JV. Antimicrobial prophylaxis in dermatology. lower extremity revascularization wound complications. Ann
Semin Cutan Med Surg. 2000;19(1):2–9. Va sc Surg. 2007;21(5):598– 602.
41. Veiga DF, Damasceno CA, Veiga-Filho J, et al. Povidone io- 62. Collier M. Silver dressings: more evidence is needed to sup-
dine versus chlorhexidine in skin antisepsis be ore elective port their widespread clinical use. J Wound Care. 2009;18(2):
plastic surgery procedures: a randomized controlled trial. 77– 78.
Pla st Reconstr Surg. 2008;122(5):170e–171e. 63. Messingham MJ, Arpey CJ. Update on the use o antibiot-
42. Awad SS, Elhabash SI, Lee L, Farrow B, Berger DH. In- ics in cutaneous surgery. Dermatol Surg. 2005;31(8 Pt 2):
creasing incidence o methicillin-resistant Staphylococcus 1068– 1078.
aureus skin and so t-tissue in ections: reconsideration o 64. Blaser G, Santos K, Bode U, Vetter H, Simon A. E ect o
empiric antimicrobial therapy. Am J Surg. 2007;194(5):606– medical honey on wounds colonised or in ected with MRSA.
610. J Wound Care. 2007;16(8):325– 328.
43. Cordova KB, Grenier N, Chang KH, Du resne R Jr. Preopera- 65. Jull A, Walker N, Parag V, Molan P, Rodgers A. Honey as Ad-
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Dermatol Surg. 2010;36(10):1537– 1540. ulcers. Br J Surg. 2008;95(2):175– 182.
44. van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupiro- 66. Visavadia BG, Honeysett J, Dan ord M. Manuka honey dress-
cin ointment or preventing Staphylococcus aureus in ec- ing: an e ective treatment or chronic wound in ections. Br J
tions in nasal carriers. Cochrane Databa se Syst Rev. 2008; Oral Ma xillofac Surg. 2008;46(8):696–697.
(4):CD006216. 67. Wilson JW, Estes LL. Mayo Clinic Antimicrobial T erapy
45. Dzubow L. Apples, oranges, and methicillin-resistant Staphy- Quick Guide. New York, NY: Mayo Clinic Scienti c Press/
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46. Kim DW, Park JY, Park KD, et al. Are there predominant 68. Burke JP. Maximizing appropriate antibiotic prophylaxis or
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69. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL,
Burke JP. T e timing o prophylactic administration o antibi-
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cin or intraincisional antibiotic prophylaxis in dermatologic
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otics and the risk o surgical-wound in ection. N Engl J Med. surgery. Arch Dermatol. 2002;138(9):1145– 1148.
1992;326(5):281– 286. 73. Gilbert DN, Moellering RC, Sande MA. T e Sanford Guide to
70. Cruse PJ, Foord R. A ve-year prospective study o 23,649 Antimicrobial T erapy. Hyde Park, V : Antimicrobial T erapy,
surgical wounds. Arch Surg. 1973;107(2):206– 210. Inc; 2003.
71. Griego RD, Zitelli JA. Intra-incisional prophylactic antibiot- 74. Beeson WH, Rachel JD. Valacyclovir prophylaxis or herpes
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 Ch a p t e r

10 Wound Healing
Kath r n A. N lan, L a Braun, & R b rt S. K rsn r

In t r o d u c t Io n cause o the wound, chronic wounds are generally associ-

ated with physiological impairments that slow or prevent
healing, such as advanced age or underlying disorders.
A classic de nition o wound healing is that it is a dynamic
process, involving multiple types o cells, cytokines, and
chemical mediators that work together in a complex Wo u n d d ept h
interaction. Although knowledge o wound healing is
important in all medical elds, it is particularly signi -
T e depth o a wound has a signi cant impact on how
cant to dermatologists as they create and care or more
wounds heal, the healing process and its clinical manage-
wounds than all other specialties.1 T e basic science o
ment. For example, i the injury is limited to the epider-
wound healing can be divided into ve phases: hemosta-
mis, the epidermis can relatively easily regenerate itsel ,
sis, in ammation, proli eration, tissue remodeling, and
without scarring. T is, similar to limited injury in the
nally resolution (Fig. 10-1).2 However, these phases do
liver, is one o the ew instances in which regeneration,
not always occur sequentially but are rather highly inte-
as opposed to repair, occurs a ter injury. However, with
grated and o ten overlap. We will describe these phases o
deeper wounds, involving part or all o the dermis and
wound healing and also discuss several important actors
deeper layers, regeneration does not occur, but rather a
that impair wound healing.
repair process is initiated that usually results in scarring.
Interestingly, regeneration can sometimes occur in spe-
Wo u n d Mec h a n Is Ms ci c situations even when the dermis is involved. One
example o this is in early ( rst two trimesters) etal skin
wounds. Although not entirely understood, this is likely
a c u t e a n d c h r o n Ic Wo u n d s due to a reduced in ammatory response and the presence
o higher concentrations o glycosaminoglycans and type
Wounds can be classi ed as either acute or chronic on the III collagen and decreased levels o trans orming growth
basis o the length o the time it takes to complete epithe- actor b1 ( GF-b1), seen in etal dermis. Overall, these
lialization, one o the elements o the proli erative phase actors are likely important in mediating regeneration
o the healing process. Although the exact time distinction rather than repair.3
used in classi cation can be arbitrary and may be a ected Wound classi cation is based on the depth o involve-
by a number o actors such as the shape, location, and ment. Super cial wounds involve only the epidermis and

He mos ta s is Infla mma tion

Ve s s e l Va s cula r Prolife ra tion

cons triction pe rme a bility

P la te le t Ma s t ce ll Angioge ne s is Re mode ling

a ctiva tion de gra nula tion
Re -e pithe lia liza tion
Coa gula tion Comple me nt
ca s ca de sys te m Gra nula tion Wound
a ctiva tion tis s ue contra ction
Fibrin clot Re s olution

Injury Day 1 Day 3 We e ks Months

Figure 10-1 Phas s w un h al ng. Up n njur , th n t al h m stat c r sp ns nv lv s plat l ts as th pr mar
r sp n rs. Th s s ll w b n ammat n wh ch ncr as s vascular p rm ab l t , all w ng acc ss r n utr ph l an
macr phag rv act rs. Pr l rat n n th l al c lls an k rat n c t s pr m t s r p th l al at n. Ult
mat l pr gr ss n t r m l ng an r s lut n th w un ccurs.
 1
Epide rmis
Eros ion

S upe rficia l pa rtia l thickne s s

De rmis

De e p pa rtia l thickne s s

C
h
a
Fa t

p
t
r
Full thickne s s

1
0
:
Mus cle

:
W
u
n
Figure 10-2 Cl n cal class f cat n w un pth. Sup rf c al an nt rm at part al
th ckn ss w un s nv lv p rm s an upp r rm s wh l p an ull th ckn ss

H
w un s nv lv p r rmal la rs. Part al th ckn ss w un s w ll l av r mnants

a
l
rmal app n ag s wh l ull th ckn ss w un s w ll n t. (R rawn w th p rm ss n r m

n
g
S wa MG, L nar L, Pa tt JR, Cr ss KM, G m M, F sh JS. Class f cat n burn njur s
us ng n ar n rar sp ctr sc p . J Biomed Opt. 2006;11(5):054002–054002–6.)

upper dermis. I only the epidermis is lost, this is termed approximating the edges. In contrast, secondary inten-
an erosion. T e term partial-thickness wound re ers to tion healing occurs when an acute wound is le t to heal
tissue destruction that extends into but not completely on its own. A third type o wound healing, tertiary inten-
through the dermis. T is is in contrast to ull-thickness tion, is sometimes described. T is re ers either to delayed
wounds, which extend through the dermis to involve the primary closure o a wound that is purposely le t open and
subcutaneous tissue (Fig. 10-2). or when a primarily closed wound dehisces and is le t to
T ese classi cations are important in that partial thick- heal on its own. An example o healing by tertiary inten-
ness and ull-thickness wounds epithelialize by di erent tion would be a patient who returns 3 to 4 days a ter an ini-
mechanisms. As the deep dermis is not a ected in partial- tial wound occurs, at which time debridement and wound
thickness wounds, the adnexal structures that are pres- cleansing are per ormed. T is can be use ul in the man-
ent in the dermis are preserved. T ese structures act as agement o certain contaminated crush wounds or mam-
a reservoir o keratinocytes and help repopulate the epi- malian bites (Fig. 10-3).
thelial cells o the epidermis. Keratinocytes rom these
structures and rom the edge o the wound migrate across
the sur ace o the wound to orm the new epidermis. In
ph a s es o f Wo u n d h ea l In g
contrast, when the deep dermis is a ected in ull-thick-
ness wounds, the adnexal structures are destroyed, and h eMo s t a s Is
keratinocytes epithelialize the wound only rom its edges.
Moreover, the adnexal structures do not regenerate and Immediately a ter the skin is injured, small vessels con-
are replaced with scar tissue. Full-thickness wounds o ten strict in the wound area, which causes the injured small
heal by contraction, while there is minimal contraction vessels to be compressed. T is adhesiveness within the
in partial-thickness wounds. Contraction involves move- endothelial lining leads to vessel occlusion, a process
ment o pre-existing tissue centripetally and the wound which aids in hemostasis. Platelets are activated at the
area is decreased. T is may result in cosmetically dis gur- site o blood vessel injury by thrombin, as well as exposed
ing contractures.1 extracellular matrix, and aggregate in the severed ves-
sels. Platelets help initiate the clotting cascade and release
many mediators rom their granules including adenosine
t ypes o f h ea l In g diphosphate (ADP), thromboxane A2, serotonin, bro-
nectin, von Willebrand actor, and brinogen.1 Fibrinogen
Wounds heal by one o three general mechanisms. T e is subsequently converted by thrombin to brin which is
most common mechanisms are healing by primary inten- deposited in the platelet plug and orms the core o the
tion and secondary intention healing. Primary inten- brin clot. T is matrix stabilizes the wound and acts as a
tion healing re ers to the surgical closure o a wound by provisional sca old or wound healing. 101
1 Platelets are not only essential to hemostasis, but
they also contribute to re-epithelialization, broplasia,
and angiogenesis. Platelets promote tissue regeneration
through the release o growth actors like GF-α, GF-
β, and PDGF that are part o the wound repair process.1
T ese actors help promote cell migration, proli eration,
and ormation o granulation tissue.
A ter the initial hemostatic response mediated by plate-
lets, coagulation occurs through the intrinsic and extrinsic
A pathways. When tissue is injured, it releases tissue actor,
which activates the extrinsic coagulation pathway. Acti-
vated endothelial cells and monocytes also express tissue
actor and participate in coagulation. Platelet aggregation
triggers Hageman actor XII to initiate the intrinsic coagu-
lation cascade, which nally results in the trans ormation
S
o prothrombin into thrombin. T is then converts brino-
c
t
gen into insoluble brin.
n
1
In f l a MMa t Io n
:
:
B
S
Med iATo RS o F ACUTe iNFLAMMATio N.
u
r
g
T ere are several key mediators o acute inf ammation
c
a
( able 10-1). Arachidonic acid (AA) metabolites are re-
l
P
leased rom the phospholipid cell membrane by phos-
r
n
pholipase A2 and then acted upon by cyclooxygenase or
c
p
5-lipoxygenase. Cyclooxygenase then produces prosta-
l
glandins like PGI2, PGD2, and PGE2, which mediate vaso-
s
dilation and increased vascular permeability. PGE2 is also
an important mediator o pain and ever. 5-lipoxygenase
C produces leukotrienes including L B4, which attracts and
activates neutrophils, and L C4, L D4, and L E4 (also
Figure 10-3 Cl n cal class f cat n pr mary, s c n ary, known as the slow reacting substances o anaphylaxis),
an t rt ary w un h al ng. A. Pr mary nt nt n h al ng
which in turn mediate increased vascular permeability
nv lv s surg cal cl sur an app s t n w un g s.
and vasoconstriction.
B. S c n ary nt nt n h al ng all ws w un b t f ll
w th granulat n t ssu . C. T rt ary nt nt n s lay In addition, mast cells have an important role in inf am-
pr mary cl sur a w un . R pr uc w th p rm ss n mation. T ese cells are widely distributed throughout
r m T mby BK. Fundamental Nursing Skills and Concepts, connective tissue and can be activated by tissue trauma
9th . Ph la lph a: L pp nc tt W ll ams &W lk ns;2009. (as well as other mechanisms like the cross-linking o IgE
in allergic reactions). Mast cells release pre ormed hista-
mine granules, which mediate an immediate inf amma-
tory response that causes vasodilation o arterioles and
increases vascular permeability. T ey are also involved in

TABLe 10-1
I mm ry M rk rs I v v d i W u d h i g

c ss
M di rs ei s ids M s c s c mp m n u r p is M r p g s
exampl s Pr staglan ns PGe 2, H stam n C1, C3a, C3b, C5a TNF α, iL 1, iL 4, F br n ct n FGF,
PGd 2, LTe 2 iL 8 Pd GF, VeGF
L uk tr n s LTC4, LTd 4,
LTe 4
Funct ns Pr staglan ns, ncr as Vas lat n, Phag cyt s s, lys s, Phag cyt s s, Phag cyt s s,
vascular p rm ab l ty; ncr as an agglut nat n x at v burst f br blast r cru tm nt,
l uk tr n s, vascular m cr rgan sms ang g n c
vas c nstr ct n, p rm ab l ty
ncr as vascular
p rm ab l ty, n utr ph l
r cru tm nt
102
maintenance o the in ammatory response through the
production o AA components like leukotrienes. oll-
NeUTRo PHiL ARRiVAL ANd FUNCTio N.
1
Neutrophils are the rst white blood cells to arrive at the
like receptors ( LRs) are another important mediator site o injury. T eir arrival and unction can be divided
o acute in ammation, especially in in ection. LRs are into seven steps. First, in a step termed margination, vaso-
present on cells o the innate immune system, including dilation slows the blood ow in postcapillary venules and
macrophages and dendritic cells. LRs are activated by neutrophils marginate rom the center o the ow to the
pathogen-associated molecular patterns (PAMPs) that periphery. Within 1 hour o the onset o in ammation, the
are commonly shared by microbes. For example, CD14 is endothelial margin o the venules is covered with neutro-
a LR on macrophages that recognizes lipopolysaccha- phils. Next, rolling o neutrophils occurs. T is involves the
ride (a PAMP) on the outer membrane o gram-negative upregulation o selectins on endothelial cells. Speci cally,
bacteria. T e activation o LRs results in the upregula- P-selectin is released rom Weibel– Palade bodies, which is
tion o NF-ĸB, a nuclear transcription actor that activates mediated by histamine, while E-selectin is induced by tu-
immune response genes leading to production o multiple mor necrosis actor ( NF) and IL-1. Selectins then bind
immune mediators. LRs are also present on cells involved to sialyl-Lewis X on leukocytes and promote the rolling
in adaptive immunity, such as lymphocytes, and there ore

C
o leukocytes along the vessel wall. Next, cellular adhe-

h
play an important role in mediating chronic in ammation.

a
sion molecules (ICAM and VCAM) are upregulated on

p
T e complement system is an essential group o media-

t
the endothelium by NF and IL-1. Also, integrins are up-

r
tors in the acute in ammatory response. Complement regulated on leukocytes by C5a and L B4. T is interaction

1
0
describes a system o 11 proin ammatory serum proteins between the adhesion molecules and integrins results in
that circulate as inactive precursors. T ey are activated by the adhesion o leukocytes to the vessel wall. O note, an

:
:
three separate pathways: the classical pathway in which C1 autosomal recessive de ect o integrins results in leukocyte

W
binds IgG or IgM that is bound to antigen, the alternative adhesion de ciency, which is characterized by recurrent

u
pathway where microbial products directly activate comple- bacterial in ections that lack pus ormation due to im-

n
ment, and the mannose-binding lectin (MBL) pathway in paired adhesion o neutrophils. A ter adhesion, leukocytes

H
which MBL binds to mannose on microorganisms to acti- transmigrate across the endothelium o postcapillary ve-

a
vate complement. All o these pathways result in a cascade nules and move toward chemical attractants like the bacte-

l
n
o sequential reactions, which produce multiple end prod-

g
rial products IL-8, C5a, and L B4. A ter this chemotaxis,
ucts (C3a, C5a, C3b, etc.) that help destroy and prevent phagocytosis occurs. T is involves the consumption o
damage by the invading organism or toxin. In regard to pathogens or necrotic tissue and is enhanced by opsonins
wound healing, some o these end products, such as C3b, such as IgG and C3b. Pseudopods extend rom leukocytes
activate phagocytosis, and C5 to C9 (membrane attack com- to orm phagosomes, which are internalized and merge
plex), enhance lysis and agglutination o invading organisms. with lysosomes orming phagolysosomes. An example o a
Other products like C3a and C5a (also known as anaphyla- de ect in phagolysosome ormation and protein traf cking
toxins) activate mast cells and basophils to release histamine. is Chediak–Higashi syndrome. T is syndrome is charac-
Hageman actor or actor XII is a vital mediator o acute terized by an increased risk o pyogenic in ections, neutro-
in ammation. It is an inactive proin ammatory protein penia, ailed bacteriolysis, and albinism because the de ect
produced in the liver and then activated upon exposure to in protein traf cking prevents melanin rom being passed
subendothelial or tissue collagen. Hageman actor in turn to other cells. A ter necrotic tissue and pathogens have
helps activate the coagulation and brinolytic systems, been consumed by phagocytosis, they are destroyed by an
complement, and the kinin system. Kinin cleaves high– O 2-dependent mechanism. O 2 is converted to O 2 radicals
molecular-weight kininogen to bradykinin, which medi- by NADPH oxidase, which is then converted to H 2O 2 by
ates vasodilation and increased vascular permeability as superoxide dismutase. Finally H 2O 2 is converted by myelo-
well as pain. peroxidase to HOCl, which generates the oxidative burst in
phagolysosomes that destroys phagocytosed material. Sev-
CARd iNAL SiGNS o F iNFLAMMATio N. T ere eral diseases result rom de ects in these steps. First, a de-
are ve cardinal signs that characterize acute in amma- ect in NADPH oxidase results in chronic granulomatous
tion: rubor, calor, tumor, dolor, and loss o unction. Al- disease, which leads to recurrent in ections with catalase-
though some o these signs may also be present in chronic positive organisms like Staphylococcus aureus and Pseudo-
in ammation, they are o ten absent. Rubor re ers to the mona s cepacia. A de ciency o myeloperoxidase results in
redness seen in acute in ammation and is o ten associated de ective conversion o H 2O 2 to HOCl and puts patients
with calor or warmth. T ese signs are due to vasodilation with this de ciency at a higher risk or Candida in ections.
resulting in increased blood ow. T e key mediators o this Finally, neutrophils undergo apoptosis and disappear with-
process are prostaglandins, histamine, and bradykinin, in 24 hours a ter resolution o the in ammatory stimulus.
which induce relaxation o arteriolar smooth muscle. T e
third cardinal sign, tumor, re ers to the swelling seen in
in ammation when uid rom postcapillary venules leaks MACRo PHAGeS. In wounds, macrophages pre-
into the interstitial space. Histamine causes endothelial cell dominate a ter neutrophils and peak 2 to 3 days a ter
contraction and tissue damage resulting in endothelial cell in ammation begins. Macrophages are o ten considered
disruption and leakage. Dolor or pain is another cardinal the most important regulatory cells in the in ammatory
sign o in ammation and is due to bradykinin and PGE2 reaction during wound healing. Macrophages are derived
sensitization o sensory nerve endings. T e nal cardinal rom monocytes in blood and arrive to the wound site by a
sign is unctio laesa or “loss o unction” o the in amed mechanism similar to that described or neutrophils: mar-
area, which is a consequence o the other cardinal signs. gination, rolling, adhesion, and transmigration. Monocytes 103
1 are recruited to the wound site by chemoattractants such
as monocyte chemoattractant protein-1 (MCP-1)4 and
lium exposure, and Crohn’s disease. In contrast, caseating
granulomas exhibit central necrosis and are characteristic
macrophage in ammatory protein-1 (MIP-1).5 Extracellu- o tuberculosis and ungal in ections. T ere are three im-
lar matrix degradation products such as bronectin rag- portant steps in granuloma ormation. First, macrophages
ments, collagen ragments, and thrombin are also speci c process and present antigen via MHC class II to CD4+
chemoattractants or monocytes.6 Similar to neutrophils, helper cells. Next, this interaction leads macrophages to
they utilize phagocytosis, but macrophages destroy phago- secrete IL-12, which induces CD4+ helper cells to di -
cytosed material using enzymes in an O 2-independent erentiate into the H1 subtype. Finally, H1 cells secrete
process. A ter phagocytosis, macrophages digest and kill IFN-γ, which converts macrophages to epithelioid histio-
pathogenic organisms, destroy any remaining neutrophils, cytes and giant cells.
and scavenge tissue debris. T ese important processes As in ammation begins to resolve, in ammatory ac-
help induce angiogenesis and the ormation o granula- tors are broken down and ewer are secreted. T e presence
tion tissue essential to the structural stabilization o the o macrophages has been shown to delay wound contrac-
wound. Macrophages also release chemotactic actors tion and there ore macrophages may need to leave the
such as bronectin, which attract broblasts to the wound wound site be ore later stages o healing occur.9
S
site. T ese chemotactic actors also help to localize in am-
c
t
mation and improve adhesion o broblasts to brin in
n
the transition between the in ammatory and proli erative pr o l If er a t Iv e ph a s e
1
phases o wound repair. Macrophages increase collagen
:
Approximately 2 to 3 days a ter the initial wound was made,
:
deposition because their presence directly correlates with
the deposition o collagen in the wound.7 When macro- broblasts start to enter the wound site, thereby initiating
S
u
phages are absent, signi cantly ewer broblasts migrate to the proli erative phase o healing, even i the in ammatory
r
g
the wound site, and those that do are immature. Moreover, phase has not yet ended. T e proli erative phase is gen-
c
a
erally characterized by granulation tissue ormation and
l
the angiogenic capacity o macrophages has been demon-
P
r
strated by inducing neovascularization in the cornea using epithelial migration over the provisional matrix within the
n
wound, or re-epithelialization (Fig. 10-4).
c
macrophage-derived growth actor in a rat model. New
p
blood vessel growth seems to ollow a gradient o angio-
l
ANGio GeNeSiS. Angiogenesis or neovascularization
s
genic actor produced by hypoxic macrophages, because
macrophages do not produce this angiogenic actor when is an essential step in wound healing as it allows oxygen
either ully oxygenated or anoxic. Macrophages also are and nutrients to reach broblasts and epithelial cells. It is,
an important source in the production o growth actors, there ore, required or other stages o wound healing, such
and synthesize and secrete broblast growth actor (FGF), epidermal and broblast migration, to occur. T e ruby red
PDGF, vascular endothelial growth actor (VEGF), GF-a, color o healing tissue signi es the occurrence o angio-
and GF-b.8 T ese cytokines have an important role in cell genesis and the presence o capillaries. Macrophages and
migration and proli eration as well as matrix production. other cells release cytokines that stimulate angiogenesis
Overall, macrophages play an important role in the transi- during wound healing. Other actors that stimulate angio-
tion rom in ammation to repair. genesis include low oxygen tension, lactic acid, and bio-
genic amines.10
CHRo NiC iNFLAMMATio N. Generally the acute Normally, the dermal vasculature remains inactive, but
in ammatory response lasts approximately 2 weeks. How- in response to injury, endothelial cells begin the process
ever, as discussed previously, in ammation that persists o angiogenesis. T ey activate other endothelial cells,
or a long period o time (months or years) is called chron- undergo cell proli eration, orm a tubule structure, sprout
ic in ammation. T e presence o necrotic tissue, oreign into the wound clot, reconstruct and stabilize the basement
material that cannot be phagocytosed and pathogens are membrane, and nally remodel the tissue. Endothelial cells
all associated with chronic in ammation. Granulocytes located at the tips o capillaries migrate to the wound and
leave the wound site through lysis and migration a ter the extend cytoplasmic pseudopodia. Migration into the peri-
acute in ammatory phase; however, should they or other vascular space also occurs and collagenase is secreted.11 As
in ammatory cells persist, chronic in ammation ensues proli eration o endothelial cells has been hypothesized to
and is characterized by mononuclear cells, speci cally be the result o cell migration, it is believed that heparin,
lymphocytes, macrophages, and monocytes. In particular, bronectin, and other actors that stimulate migration also
macrophages that have phagocytosed oreign material lead to endothelial proli eration.
remain at the wound site i they are unable to solubilize
the ingested material. T ese macrophages then attract - Re-ePiTHeLiALiz ATio N. Re-epithelialization is the
broblasts, which produce increased quantities o collagen process through which the epidermis is restored a ter an
and can slowly induce ormation o a granuloma. Granu- injury to the skin. Re-epithelialization generally re ers to
lomatous in ammation is characterized by the presence o basal cell proli eration and epithelial migration occurring
epithelioid histiocytes (macrophages with abundant pink in the brin bridgework inside a clot.12 In a clean surgical
cytoplasm) that usually surround giant cells, and a rim wound epithelial cells generally migrate downward deep in
o lymphocytes. Granulomas are generally divided into the dermis.13 Generally, re-epithelialization is comprised o
two subtypes: caseating and noncaseating. Noncaseating several processes including the migration o epidermal ke-
granulomas lack central necrosis. Common etiologies in ratinocytes rom wound edges, the proli eration o kerati-
the ormation o this type o granuloma include reactions nocytes, di erentiation o the epithelium into strati ed epi-
104 to oreign material, sarcoidosis, catscratch disease, beryl- dermis, restoration o an intact basement membrane zone,
 1
Wound ma cropha ge s
re le a s e a ngioge nic
a nd che mota ctic
cytokine s

TGF-be ta VEGF

Endothe lia l ce lls

C
Fibrobla s ts migra te

h
unde rgo

a
to wound prolife ra tion

p
t
r
1
0
Angioge ne s is

:
:
W
Colla ge n

u
KGF-ß Myofibrobla s ts

n
de pos ition

H
a
l
n
g
Wound
Ke ra tinocyte contra ction
prolife ra tion

Re -e pithe lia liza tion

Figure 10-4 Pr l rat v phas n w un h al ng.

and the repopulation o specialized cells that direct sensory the wound. When this migration stops, the keratinocytes
unction (Merkel cells), pigmentation (melanocytes), and reattach to the underlying substratum, reconstitute the
immune unctions (Langerhans cells).1 basement membrane, and then recommence terminal di -
Keratinocyte migration occurs early on in wound re- erentiation to produce a strati ed epidermis.1
epithelialization, and epidermal keratinocytes initially T e next important step in the re-establishment o skin
respond to injury by migrating rom the ree edges o the integrity is the ormation o an intact basement membrane
wound within 24 hours. At approximately 12 hours postin- zone. T e basement membrane zone orms an adhesion
jury, the epidermal cells become elongated and attened, structure and its upper portion allows attachment o basal
lose their cell– cell and cell– matrix attachments, develop keratinocytes through the ormation o a hemidesmosome-
pseudopod-like projections named lamellipodia, retract anchoring lament complex. T e lower part o the zone
their intracellular tono laments, and orm actin laments helps to stabilize the attachment o the underling dermis
at the edge o the cell cytoplasm.1 through anchoring brils.1 T e basement membrane zone
Although the mechanisms o re-epithelialization are returns to normal only 7 to 9 days a ter the re ormation o
still not completely understood, the “leap rog” theory is the epidermis.1
one o the most accepted models. T is theory describes
the migration o epidermal cells two or three cell lengths FiBRo PLASiA. T is stage consists o the proli eration
rom their initial position and the sliding or rolling o o broblasts, the accumulation o ground substance and
these cells over epidermal cells already in the wound.1 T e collagen production. Fibroblasts are derived rom mesen-
migrating cells then become xed, and other epidermal chymal cells and are present at the site o the wound in
cells migrate over these cells. As the epidermal layer pro- the rst 24 hours, although they are most prevalent by the
gressively advances, the epithelial de ect closes (Fig. 10-5).1 10th day.14
Re-epithelialization also involves increased proli era- Fibroblasts attach to the brin matrix o the clot at
tion o the keratinocytes located behind the migrating the wound site and produce mucopolysaccharides and
cells, in order to have an adequate supply o cells to cover glycoproteins, which comprise the ground substance. 105
1 Ke ra tinocyte s dis ta l to wound e dge le a pfrog
ove r a dja ce nt ce lls to migra te into wound be d.

S tra tum corne um

S tra tum gra nulos um

S tra tum s pinos um

S tra tum ba s a le
S
c
t
n
1
Ke ra tinocyte s from s tra tum
:
ba s a le move into wound be d.
:
S
Figure 10-5 L ap r g th ry r p th l al zat n. Th s th ry pr sum s that tw t
u
r
thr c ll lay rs k rat n cyt s r m th w un g ar n uc t v an all
g
nt th b tt m th w un b . Th y ar th n anch r t th bas m nt m m
c
a
bran by a h m sm s m anch r ng lam nt c mpl x. (R rawn w th p rm ss n
l
P
r
r m Bryant RA. Acute and Chronic Wounds: Nursing Management, 2n . St L u s,
n
Mo : M sby; 2000. C pyr ght els v r.).
c
p
l
s
Fibroblasts also produce contractile cells called myo bro- tein chains. wo o the polypeptide chains are identical
blasts. T ese cells are present by the th day a ter injury alpha-1 proteins and the other is an alpha-2 protein. T e
and are involved in pulling the edges o the wound together. tropocollagen molecules are initially united by hydrogen
Fibroblasts are also critical to wound healing due to bonding but then covalent cross-links are ormed, creat-
their role in synthesizing collagen. Collagen bers make ing collagenous brils. T e tensile strength o collagen is
up approximately 80% o dry weight o the dermis and pro- thought to be due to these intermolecular cross-links.1 It
vide strength, structure, and stif ness to dermal tissue.15 has been shown that the tensile strength o the wound is
Generally, type I collagen accounts or approximately 80% directly proportional to the amount o collagen present.17
o collagen ound in the dermis o adults, whereas type At 6 weeks a ter the initial injury, approximately 80% o the
III collagen constitutes 10% o collagen. However, during original strength o the tissue has been regained. However,
early wound healing, type III collagen is the predominant the morphology and diameter o the collagen brils do not
collagen synthesized. regain their appearance in normal skin until 180 days a ter
By the second day a ter injury, collagen production the initial injury.18
begins. Collagen is rst secreted in a orm that is not strong
and is analogous to an amorphous gel. Maximum produc-
tion o collagen does not begin until the th day and then IMpa Ir ed Wo u n d h ea l In g
continues or a minimum o 6 weeks.16 Fibroblasts also
produce glycosaminoglycans, which together with colla- a n d r Is k f a c t o r s
gen are the major components o the extracellular matrix.
Various actors can lead to impaired wound healing. In
MATURATio N. T e nal phase o wound healing, general these actors can be divided into local actors that
maturation, includes collagen cross-linking, collagen re- directly in uence the wound itsel and systemic actors
modeling, wound contraction, and repigmentation. ro- that in uence the overall health o the person and there-
pocollagen comprises a triple helix ormed by three pro- ore af ect their ability to heal ( able 10-2).19

TABLe 10-2
l sy mi f a i W h i
l Hyp x a in ct n Trauma e ma isch m a F r gn B y

sy mi d ab t s Ag ng V n us Sm k ng Hyp pr t n m a immun suppr s n M cat ns ( . .,

insuf c ncy St r s, NSAid s)

106
 l o c a l f a c t o r s t h a t IMpa Ir
T is shi t in the balance o proteases can lead to the rapid
degradation o the growth actors that appear in chronic
1
Wo u n d h ea l In g wounds.21 Also, bacteria in in ected wounds orm bio lms
or aggregated bacteria embedded in a sel -secreted extra-
o xyGeN. Oxygen is an essential component or wound cellular polysaccharide matrix21 and are particularly resis-
healing due to its central role in energy production as tant to antibiotic treatment.
well as its unction in the superoxide production that kills Common bacteria in wounds are S. aureus, Pseudomo-
pathogens. It is vital in preventing wounds rom in ection, na s aeruginosa, and β-hemolytic streptococci. Bio lms
increasing keratinocyte di erentiation, inducing angio- containing P. aeruginosa are particularly prevalent among
genesis, migration and re-epithelialization, promoting chronic ulcers and the protective microenvironment
wound contraction, and enhancing collagen synthesis and ound in bio lms shields these bacteria rom phagocyto-
broblast proli eration.20 sis. It has been postulated that this may be an important
In the early wound, the microenvironment is o ten mechanism in the resistance o chronic wounds to antibi-
hypoxic due to high oxygen consumption by metabolically otic treatment.
active cells and vascular disruption. Also, some systemic

C
h
conditions like diabetes can impair vascular ow, which

a
s ys t eMIc f a c t o r s t h a t IMpa Ir

p
exacerbates the hypoxia in the wound site and inter eres

t
with wound healing. Chronic wounds have been ound to Wo u n d h ea l In g

r
1
be signi cantly more hypoxic than control tissue. Stud-

0
ies have shown that the tissue oxygen concentration in d iABeTeS MeLLiTUS. Diabetes mellitus is a major

:
:
chronic wounds when measured transcutaneously is problem worldwide with an estimated 346 million people

W
between 5 and 20 mm Hg, whereas control tissues have su ering rom this disease as o 2012.22 Although diabetes
oxygen concentrations o 30 to 50 mm Hg.12 a ects many organ systems, its detrimental e ects in

u
n
Although chronic hypoxia delays wound healing, tem- wound healing can create some o its most devastating se-

H
porary hypoxia a ter injury can actually stimulate repair.13 quelae. T is population is also particularly susceptible to

a
As discussed previously, temporary hypoxia in acute the development o chronic nonhealing diabetic oot ul-

l
n
wounds can induce growth actor and cytokine produc- cers due to sensory neuropathy, which makes the patient

g
tion in macrophages, broblasts, and other cells.13 T ese less aware o when injury occurs. T ese oot ulcers occur
cytokines include GF-β, PDGF, VEGF, endothelin-1, and in 15% o all people with diabetes19 and are associated with
NF-α. signi cant morbidity, preceding 84% o diabetes-related
In normal wound healing, reactive oxygen species like lower-leg amputations.23
H 2O 2 and superoxide can act as cellular messengers and Several complex mechanisms underlie the pathophysi-
stimulate essential wound healing processes such as angio- ology o diabetic oot ulcers and other chronic wounds in
genesis, cell motility, and the action o cytokines. Overall, diabetics. Diabetic oot ulcers are always associated with
proper oxygen levels play a vital role in promoting and sus- hypoxia, which as discussed previously, is detrimental to
taining healthy wound healing. When oxygenation o the wound healing. Diabetes is o ten associated with severe
wound is reduced, healing is compromised and chronic peripheral artery disease with atherosclerosis a ecting
wounds can result. A therapeutic option that addresses the more distal arteries like the popliteal and tibial arteries.
problem o tissue hypoxia is hyperbaric oxygen therapy.13 T is peripheral artery disease in combination with dia-
Although the availability o this treatment is limited, it can betic neuropathy predisposes to higher rates o nonheal-
improve healing in hypoxic wounds.19 ing ulcers and limb loss in diabetic patients.24 Moreover,
via a separate mechanism, the ormation o advanced
iNFeCTio N. T e disruption o the skin barrier through glycation end products or AGEs that are associated with
injury allows pathogens access to underlying tissues. hyperglycemia in diabetes are associated with impaired
Wounds can be classi ed by increasing levels o in ection: wound healing in diabetic mice.25 Finally, diabetic wounds
contamination, colonization, and local in ection, to inva- are associated with various elements o immune compro-
sive in ection.19 Wound contamination is de ned as non- mise like de ects in leukocyte chemotaxis, phagocytosis,
replicating organisms present at the wound site, whereas and bactericidal capacity, de ective -cell immunity and
colonization re ers to replicating organisms on the wound dys unctions o broblasts and epidermal cells. T is dys-
in the absence o tissue damage. Local in ection, also regulation is responsible or impaired bacterial clearance in
known as critical colonization, re ers to microorganism individuals with diabetes as well as delayed and impaired
replication in the wound and the beginning o a local tis- wound repair.26,27
sue response. Invasive or spreading in ection re ers to the
presence o replicating organisms within a wound and AGiNG. Advanced age is another systemic actor that
subsequent host injury.21 has a detrimental e ect on wound healing. With advanced
When pathogens remain in the wound site, in amma- age, the supply o cutaneous nerves and blood vessels de-
tion becomes prolonged. Bacteria and endotoxins prolong creases. Also, there is a general thinning o tissue in both
the elevation o proin ammatory cytokines like IL-1 and the dermis and basement membrane. Finally, there is a
NF-α, which extends the in ammatory phase.19 T is leads loss o collagen as well as decreased ability to produce
to an increased level o matrix metalloproteases, proteases more collagen. Overall, these physiologic changes associ-
which can degrade the extracellular matrix. Conversely, ated with aging result in slower and impaired wound heal-
there is a decreased level o natural protease inhibitors.19 ing in elderly individuals.28,29
107
1 VeNo US iNSUFFiCieNCy. Chronic venous insu - numbers o broblasts, delayed epithelialization, reduced
wound contraction,49– 51 and impaired angiogenesis.52
ciency plays a major role in impaired wound healing, and
venous leg ulcers account or 40% o wounds on the lower Systemic glucocorticoids, also commonly used in the
extremities.23 T e pathogenesis o venous insuf ciency treatment o in ammatory conditions, are widely known
involves incompetent venous valves, venous obstruction, to inhibit wound repair through their suppressive e ects
and inadequate muscle pump unction. Some risk actors on cellular wound responses, including collagen synthesis
or the development o chronic venous disease include a and broblast proli eration.19 Steroids also cause wounds
amily history o venous disease, advanced age, prolonged to heal with reduced wound contraction and incomplete
standing, obesity, smoking, sedentary li estyle, and high granulation tissue.47 In addition to these e ects on repair,
estrogen states.30– 39 T ese changes lead to congestion and systemic corticosteroids also predispose to wound in ec-
pooling o blood in super cial veins causing venous hy- tion, which as discussed previously, is detrimental to the
pertension. I sustained, this venous hypertension is as- healing process.19
sociated with venous hypertensive microangiopathy. Also, Interestingly, topical steroids actually seem to be
these changes result in a pericapillary brin cu . T e com- bene cial to wound healing. Low-dose topical cortico-
steroids have been shown to suppress hypergranulation,
S
bination o high venous pressure and abnormal capillaries
reduce exudate, and accelerate wound healing.19 How-
c
results in vessels that are abnormally permeable and leads
t
to the accumulation o water, large proteins, and red blood ever, caution should be used with these agents as there
n
cells in the interstitial space.40,41 T ese macromolecules is potentially an increased risk o in ection with long-
1
are thought to trap matrix material and growth actors, term use.53
:
:
making them unavailable or tissue repair. Moreover, the
S
ormation o the perivascular brin cu decreases delivery
c o n c l u s Io n
u
r
o oxygen and nutrients. T is contributes to skin hypoxia
g
c
and cell death causing venous ulcers.42
a
l
Wound healing is critical to understanding dermatology
P
r
and optimizing results o dermatologic surgery. In addi-
SMo KiNG.
n
Smoking is associated with impaired
c
tion to understanding the normal repair process, appre-
p
wound healing and adverse outcomes ollowing surgery.
ciating the di erences between acute and chronic wounds
l
Mechanisms or this impairment include vasoconstriction
s
and having insight into actors that hasten and delay heal-
which induces ischemia in the wound area, impaired bac-
ing are o great importance. Opportunities to enhance
teriocidal mechanisms, altered collagen metabolism, and
clinical outcomes exist through improved healing.
a reduced in ammatory healing response.43
A review o our randomized trials evaluating the
e ect o preoperative smoking cessation on postoperative r ef er en c es
wound healing ound that smoking cessation signi cantly
reduced the incidence o surgical site in ection (odds ratio 1. Li J, Chen J, Kirsner R. Pathophysiology o acute wound heal-
0.40, 95% CI 0.20– 0.83).44 Other studies have shown that ing. Clin Dermatol. 2007;25:9– 18.
2. Gosain A, DiPietro LA. Aging and wound healing. World J
active smoking is associated with postoperative complica-
Surg. 2004;28:321– 326.
tions and particularly increases the risk o such complica- 3. Scheid A, Wenger RH, Scha er L, et al. Physiologically low
tion in people with other risk actors or impaired healing, oxygen concentrations in etal skin regulate hypoxia-inducible
such as diabetes.45 actor 1 and trans orming growth actor-beta3. FASEB Jl.
2002;16:411– 413.
4. Kunkel SL, Standi ord , Kasahara K, Strieter RM. Stimulus
Med iCATio NS. Several major categories o medica- speci c induction o monocyte chemotactic protein-1 (MCP-
tion have signi cant adverse e ects on wound healing. T e 1) gene expression. Adv Exp Med Biol. 1991;305:65– 71.
three major classes o drugs we will discuss are chemother- 5. Sherry B, ekamp-Olson P, Gallegos C, et al. Resolution o
apeutics, nonsteroidal anti-in ammatory drugs (NSAIDs) the two components o macrophage in ammatory protein
1, and cloning and characterization o one o those compo-
and glucocorticoids. nents, macrophage in ammatory protein 1 beta. J Exp Med.
Most chemotherapeutic drugs inhibit rapid cell divi- 1988;168:2251– 2259.
sion, angiogenesis, and cellular metabolism, all critical 6. Postlethwaite AE, Kang AH. Collagen-and collagen peptide-
elements o wound healing. Many o these medications induced chemotaxis o human blood monocytes. J Exp Med.
inhibit DNA, RNA, and protein synthesis and there ore 1976;143:1299– 1307.
7. Lewis JS, Lee JA, Underwood JC, Harris AL, Lewis CE. Mac-
cause decreased broplasia and neovascularization o rophage responses to hypoxia: relevance to disease mecha-
wounds.46,47 Also, some chemotherapeutic agents' detri- nisms. J Leukoc Biol. 1999;66:889– 900.
mental e ects on wound healing may be due to their e ect 8. Falanga V. Growth actors and wound healing. J Dermatol
on VEGF, an important actor in angiogenesis in the early Surg Oncol. 1993;19:711– 714.
stages o wound healing.48 9. Newton PM, Watson JA, Wolowacz RG, Wood EJ. Mac-
rophages restrain contraction o an in vitro wound healing
NSAIDs, like ibupro en, are widely used in the treatment model. Inf ammation. 2004;28:207– 214.
o pain and in ammation. Although there is little data to 10. Remensnyder JP, Majno G. Oxygen gradients in healing
support the idea that short-term usage o NSAIDs inter- wounds. Am J Pathol. 1968;52:301–323.
eres with wound healing, some studies have shown that 11. Sethi KK, Yannas IV, Mudera V, Eastwood M, McFarland C,
long-term usage o NSAIDs can negatively impact wound Brown RA. Evidence or sequential utilization o bronectin,
vitronectin, and collagen during broblast-mediated collagen
healing. Systemic use o ibupro en has been shown to have contraction. Wound Repair Regen. 2002;10:397– 408.
an antiproli erative e ect on wound healing in animal mod- 12. andara AA, Mustoe A. Oxygen in wound healing– more
108 els, and results in weakened breaking strength, decreased than a nutrient. World J Surg. 2004;28:294– 300.
13. Rodriguez PG, Felix FN, Woodley D , Shim EK. T e role o
oxygen in wound healing: a review o the literature. Dermatol
34. Fowkes FG, Lee AJ, Evans CJ, Allan PL, Bradbury AW, Ruck-
ley CV. Li estyle risk actors or lower limb venous re ux in
1
Surg. 2008;34:1159– 1169. the general population: Edinburgh Vein Study. Int J Epide-
14. Doillon CJ, Dunn MG, Bender E, Silver FH. Collagen ber miol. 2001;30:846– 852.
ormation in repair tissue: development o strength and 35. Sadick NS. Predisposing actors o varicose and telangiectatic
toughness. Coll Relat Res. 1985;5:481– 492. leg veins. J Dermatol Surg Oncol. 1992;18:883– 886.
15. Booth BA, Polak KL, Uitto J. Collagen biosynthesis by human 36. Iannuzzi A, Panico S, Ciardullo AV, et al. Varicose veins o the
skin broblasts. I. Optimization o the culture conditions or lower limbs and venous capacitance in postmenopausal wom-
synthesis o type I and type III procollagens. Biochim Biophys en: relationship with obesity. J Va sc Surg. 2002;36:965– 968.
Acta. 1980;607:145– 160. 37. Evans CJ, Fowkes FG, Hajivassiliou CA, Harper DR, Ruck-
16. Howes EL, Harvey SC. T e strength o the healing wound in ley CV. Epidemiology o varicose veins. A review. Int Angiol.
relation to the holding strength o the catgut suture. N Engl J 1994;13:263– 270.
Med. 1929;200:1285– 1291. 38. Browse NL. T e etiology o venous ulceration. World J Surg.
17. Dodson MK, Magann EF, Meeks GR. A randomized com- 1986;10:938– 943.
parison o secondary closure and secondary intention in 39. Browse NL, Burnand KG. T e cause o venous ulceration.
patients with super cial wound dehiscence. Obstet Gynecol. Lancet. 1982;2:243– 245.
1992;80:321– 324. 40. Franzeck UK, Haselbach P, Speiser D, Bollinger A. Micro-

C
18. Walters MD, Dombroski RA, Davidson SA, Mandel PC, angiopathy o cutaneous blood and lymphatic capillaries in

h
Gibbs RS. Reclosure o disrupted abdominal incisions. Obstet chronic venous insuf ciency (CVI). Yale J Biol Med. 1993;66:

a
p
Gynecol. 1990;76:597– 602. 37– 46.

t
19. Guo S, Dipietro LA. Factors a ecting wound healing. J Dent 41. Leach RD, Browse NL. E ect o venous hypertension on ca-

r
1
Res. 2010;89:219– 229. nine hind limb lymph. Br J Surg. 1985;72:275– 278.

0
20. Bishop A. Role o oxygen in wound healing. J Wound Care. 42. Falanga V, Eaglstein WH. T e “trap” hypothesis o venous ul-
2008;17:399– 402. ceration. Lancet. 1993;341:1006– 1008.

:
:
21. Edwards R, Harding KG. Bacteria and wound healing. Curr 43. uran A, Mascha EJ, Roberman D, et al. Smoking and periop-

W
Opin In ect Dis. 2004;17:91– 96. erative outcomes. Anesthesiology. 2011;114:837– 846.
22. Ginter E, Simko V. ype 2 diabetes mellitus, pandemic in 21st 44. Sorensen L . Wound healing and in ection in surgery. T e

u
n
century. Adv Exp Med Biol. 2012;771:42– 50. clinical impact o smoking and smoking cessation: a system-
23. Brem H, omic-Canic M. Cellular and molecular basis o atic review and meta-analysis. Arch Surg. 2012;147:373– 383.

H
wound healing in diabetes. J Clin Invest. 2007;117:1219– 1222. 45. Wukich DK, McMillen RL, Lowery NJ, Frykberg RG. Surgi-

a
24. Santilli JD, Santilli SM. Chronic critical limb ischemia: di- cal site in ections a ter oot and ankle surgery: a comparison

l
n
agnosis, treatment and prognosis. Am Fam Physician. o patients with and without diabetes. Diabetes Care. 2011;

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1999;59:1899– 1908. 34:2211– 2213.
25. Huijberts MS, Schaper NC, Schalkwijk CG. Advanced glyca- 46. Waldron DR, Zimmerman-Pope N. Super cial skin wounds.
tion end products and diabetic oot disease. Diabetes Metab In: Slatter D, ed. Textbook o Small Animal Surgery. Philadel-
Res Rev. 2008;24(suppl 1):S19–S24. phia, PA: Saunders; 2002:259–274.
26. Loots MA, Lamme EN, Zeegelaar J, Mekkes JR, Bos JD, Mid- 47. Franz MG, Steed DL, Robson MC. Optimizing healing o the
delkoop E. Di erences in cellular in ltrate and extracellular acute wound by minimizing complications. Curr Probl Surg.
matrix o chronic diabetic and venous ulcers versus acute 2007;44:691– 763.
wounds. J Invest Dermatol. 1998;111:850– 857. 48. Erinjeri JP, Fong AJ, Kemeny NE, Brown K , Getrajdman GI,
27. Gary Sibbald R, Woo KY. T e biology o chronic oot ulcers in Solomon SB. iming o administration o bevacizumab chemo-
persons with diabetes. Diabetes Metab Res Rev. 2008;24:25–30. therapy a ects wound healing a ter chest wall port placement.
28. Mendelsohn FA, Divino CM, Reis ED, Kerstein MD. Cancer. 2011;117:1296– 1301.
Wound care a ter radiation therapy. Adv Skin Wound Care. 49. Dong YL, Fleming RY, Yan Z, Herndon DN, Waymack JP.
2002;15:216– 224. E ect o ibupro en on the in ammatory response to surgical
29. Bowering CK. Diabetic oot ulcers. Pathophysiology, assess- wounds. J Trauma. 1993;35:340– 343.
ment, and therapy. Can Fam Physician. 2001;47:1007– 1016. 50. Dvivedi S, iwari SM, Sharma A. E ect o ibupro en and di-
30. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. T e clo enac sodium on experimental would healing. Indian J Exp
epidemiology o varicose veins: the Framingham Study. Am J Biol. 1997;35:1243– 1245.
Prev Med. 1988;4:96– 101. 51. Krischak GD, Augat P, Claes L, Kinzl L, Beck A. T e e ects
31. Callam MJ. Epidemiology o varicose veins. Br J Surg. 1994;81: o non-steroidal anti-in ammatory drug application on inci-
167– 173. sional wound healing in rats. J Wound Care. 2007;16:76– 78.
32. Chiesa R, Marone EM, Limoni C, Volonte M, Petrini O. 52. Jones MK, Wang H, Peskar BM, et al. Inhibition o angiogen-
Chronic venous disorders: correlation between visible signs, esis by nonsteroidal anti-in ammatory drugs: insight into
symptoms, and presence o unctional disease. J Va sc Surg. mechanisms and implications or cancer growth and ulcer
2007;46:322– 330. healing. Nat Med. 1999;5:1418– 1423.
33. Scott E, LaMorte WW, Gorin DR, Menzoian JO. Risk ac- 53. Ho man D, Moore K, Cooper R, Eagle M, Cooper S. Use o top-
tors or chronic venous insuf ciency: a dual case-control ical corticosteroids on chronic leg ulcers. J Wound Care. 2007;
study. J Va sc Surg. 1995;22:622– 628. 16:227– 230.

109
 Ch a p t e r

11 Dressings and Postoperative Care

Dani A. Davis

Th e pu r po s e o f w o u n D c a r e wounds, or exogenous, which may be in ectious, surgical,

or traumatic wounds. T ere is also a surgical classi cation
o wounds. Class I are clean wounds or a clean surgical
Mother Nature has been able to repair damaged integu-
site sparsely colonized with bacteria; Class II are clean-
ments or at least hal a billion years. Scars and scabs are
contaminated wounds or a clean surgical site heavily colo-
evident in the ossil record since the beginning o terres-
nized with bacteria, such as the groin. Class III wounds
trial li e.1 So why has there been an explosion o interest in
are contaminated, either due to unclean technique or
wound care since the last World War? Quite simply, because
colonization with bacteria be ore surgery, such as rom
o aster and better healing. Smugly one-upping Mother
trauma. Class IV wounds are in ected. As the class number
Nature, modern dressings are an entire paradigm shi t rom
increases, complications increase and outcomes worsen.
the standard approach taken since time immemorial.
Wounds may also be classi ed into our stages o heal-
As there are hundreds o dressings, bandages, and
ing: hemostatic, inf ammatory, proli erative, and remodel-
wound-care products available, the purpose o this chap-
ing.5 Although healing is a continuum, each one o these
ter is not to catalog the daily changing varieties, but rather
stages is a macroscopic benchmark indicating a change
to provide a compendium o wound-care classes in order
in the wound microenvironment.6 Hemostasis begins
to understand their advantages and disadvantages.2 T ese
immediately a ter wounding and is usually measured in
products include specialty items marketed or leg ulcers,
minutes. T e inf ammatory stage also begins immediately
decubitus ulcers, burns, and stoma care, which may have
as neutrophils are recruited to digest the wound margins.
crossover potential or postsurgical skin care, especially
T is stage lasts less than a week, at which point the proli -
or granulating surgical de ects.3
erative phase is recognized. As the neutrophils diminish,
In the United States particularly, nomenclature may be
macrophages enter the wound and master dermal cells
con using. A dressing is generally something placed directly
begin the process o rebuilding the skin rom the dermis
on a wound, whereas a bandage supports that dressing,
up. Rebuilding human skin during this proli erative phase
while being external to it and the wound. T e purpose o all
takes months and is considered to last rom the rst week
wound coverings, including scabs or crusts, is to provide a
to the third month. Finally, as proli eration subsides, the
barrier between the internal and external world. Presuming
wound contracts and remodels into a mature structure
that there is no in ection, many consider the most important
with vasculature that will permanently sustain it. Most
unction o this barrier to be wound hydration or at least anti-
wound healing is complete by 6 months, but nal matura-
dehydration. However, an ideal covering will also protect
tion can take up to a year.
and support the wound, provide hemostasis and analgesia,
absorb exudate, debride slough, regrow what is missing, will
be easily applied and removed, and be inexpensive.4 Exudate Dr es s in g s
absorption is a close second in importance to wound hydra-
tion. Dressings absorb exudate by capillarity, which is de ned T ere are more than a hand ul o dressing classi cations
as the sum o the hydrophilic sur ace orces that cause liquid ( able 11-1). None are all-inclusive; there is always some
to move along the sur ace o a solid, like watercolor paint composite bandage that does not neatly t the scheme.
between the hairs o a paintbrush. Wound debridement is
also important. T ere are our types o debridement: auto-
lytic, mechanical, chemical, and surgical. T e latter two are
exogenous and, although part o wound care, are generally TAbl e 11-1
not a part o wound dressings. Autolytic debridement occurs s m t cl yD
naturally when a dressing hydrates a wound, and it is yet
Primary v rsus s condary
another reason why moist healing is so important. Wounds
are mechanically debrided when dry adherent dressings are Adh siv v rsus nonadh siv
removed, taking bits o crust with them. Occ usiv v rsus nonocc usiv
Traditiona v rsus mod rn
c h a r a c Ter iz a Tio n o f w o u n Ds Natura v rsus synth tic
Non io ogic v rsus io ogic v rsus iosynth tic
Wounds may be described as acute or chronic, ull thick-
Gas or iquid p rm a v rsus imp rm a
ness or partial thickness, endogenous, such as vascular
T ey are not exclusive either, and it is o ten help ul to use
several commonly used classi cations together. Any mod-
HyDr OCOl l OiD. Hydrocolloid dressings are unique
1
in several ways.10 Composed o gelatin or cellulose, they
ern bandage will be sel -cra ted or pre abricated in layers.7 are typically composite dressings, the primary purpose o
From internal to external, the six typical parts include the which is hydration. For this reason, they are good or auto-
wound base, and the hydrating, absorbing, wound adher- lytic debridement, but they are only moderately absorp-
ing, contouring, and border adhering layers. tive. Although chemically similar to the collagen dressings
below, the collagen that eventually becomes gelatin comes
GAu z e. T e word “gauze” probably derives rom a place rom multiple organ systems and multiple species (bovine
name in the Middle East, and this type o dressing has and porcine), and is hydrolyzed into an amino acid gel.
been used or millennia. Gauze can be used as a primary Hydrocolloids are one o the ew dressing materials that
or secondary dressing, can hydrate or desiccate, be cot- are both gas and liquid impermeable. Persistent occlusion
ton or synthetic, or can be used as a bandage. However, with a hydrocolloid dressing can limit oxygenation and
because o tradition and its low cost, by ar the most com- impede healing. An added adhesive makes hydrocolloid
mon gauze is spun cotton thread woven into cloth. dressings adherent to the wound and its border, but as exu-

C
Nearly all modern cotton is grown rom a single spe- date is absorbed the adhesive will release rom the wound.

h
a
cies o long staple “King cotton” that, unless treated, has Frequent dressing removal can deepithelialize the wound

p
t
only modest absorption o 10% o its weight. Cotton wool, periphery. Like most occlusive, adhesive dressings, hydro-
colloid dressings are o ten promoted as a bacterial barrier.

1
or linters, is the unspun, absorptive, curly ber that sur-

1
rounds the cotton seed and was developed as a dressing by
HyDr OGel s .

:
the pioneers o aseptic surgery. By dry weight the cotton Hydrogels are even better autolytic

:
boll is 90% cellulose, an insoluble, brous plant polymer o dressings than hydrocolloids. Hydrogel dressings are

D
repeating D-sucrose units. T e 0.5% dry-weight waxes that produced as nonadhesive, water or glycerin gel sheets or
coat the bers substantially diminish capillarity. Waxes gel-impregnated gauze sheets. T ey are gas permeable,

n
and o -white coloring are typically removed by bleach and liquid impermeable, and somewhat absorptive.11 Speci c

g
heat, independent o the sterilization process. Because cot- to this large product line, hydrogels are purported to have

a
n
ton is a biologic material, it is biodegradable and cotton analgesic or soothing properties. Glycerin attracts water

d
P
dressings must be requently changed. Unless it is coated, hygroscopically rather than through capillarity. Capillarity

o
cotton is adherent and will mechanically debride the absorption does not alter the absorbing solid molecules,

t
o
wound when removed. Cotton is gas and liquid permeable. but glycerin expands into a lubricating gel when hydrated

p
Polyester and polyamide gauzes have the same advan- by wound exudate.

a
t
tages over cotton gauze as synthetic clothing. T ese syn-

v
thetic gauzes are more durable, produce less lint, and are FOAm. Foam dressings are like mattresses, composed o

C
a
not biodegradable, but are typically less absorptive than exible and rm, but low-density, polyurethane, a synthet-
medical grade cotton. ic isocyanate that combines the best properties o plastic
Impregnated gauze has two components: gauze and and rubber.12 T ese products are highly varied and absor-
its coating. T e coating makes it nonadherent and limits bent open-cell sheets. Like hydrogels, they are gas per-
mechanical debridement, but capillarity su ers. Impreg- meable and liquid impermeable, but they are also hugely
nated gauze remains both gas and liquid permeable, and is absorbent and thermally insulating. Many oam products
typically made o cotton muslin, polyester, or acetate. T e have an adhesive that can strip the surrounding epithe-
wide variety o coatings include saline, Ringer’s solution, lium. T e uid-logged dressing can exacerbate maceration
petrolatum or proprietary ointments, bismuth tribromo- o the skin surrounding the wound. Because they can be
phenate, iodine, silver, zinc oxide, erric oxide, oat glucan, used as compression bandages, they have the ideal quali-
and scarlet red (o-tolylzo-o-tolyazo-beta-napthol) ( able ties or postliposuction care.
11-2). Polyesterized gauze is a cotton- or rayon-based
composite dressing that is commonly used to con orm a
cra ted, layered bandage or a well-debrided wound that
s Ol iD Fil ms . Polyurethane can be manu actured in a
highly varied spectrum rom low to high density depend-
makes little exudate.
ing on which isocyanate and hydroxyl groups are polym-
erized. High-density polyurethane can be rigid, as in ur-
Al GiNATes . Alginates are manu actured rom braid- niture varnish, or exible, as in plastic kitchen wrap, but
ed or matted brown seaweed polysaccharide salts. T ese as a class polyurethanes tend to be clear, thin, and tena-
lightweight products can absorb 20 times their dry cious. Polyurethane lm dressings are sel -adhesive, gas
weight o exudate to orm a wound-shaped gel.8 In its permeable, and liquid impermeable like their low-density
unaltered orm, sodium alginate is widely used in culi- oam counterparts, but they are speci cally nonabsorbent
nary arts as a taste- ree thickener. However, it is the cal- because they are bubble- ree.13 For this reason their use
cium salt o alginate that is used or wound dressings, and is limited to nonexudative wounds, although some uid
neither its taste nor its smell are pleasant. Alginates have can be drained by puncturing the dressing material. T e
an inherent musty odor that turns rapidly noxious with translucence o high-density polyurethane lms allows
bacterial overgrowth. T eseare gas and liquid perme- the wound to be visualized through a thin, exible, dura-
able and can acilitate autolytic debridement, but are so ble dressing, which may last or more than a week. Films
absorptive that they can overdr y a nonexudative wound.9 can be the most dif cult dressings to remove because
Most alginate products require a secondary dressing or their thinness makes them challenging to grasp and their
bandage. impermeability makes adhesive removers less e ective. 111
1 TAbl e 11-2
w ound Dr ssings
produ t c om on nts exam l s Manufa tur rs
i p gnat d ga Wat
sa n
P t o at
Pa a n J on t s th & N ph w
b th t o oph nat X oo K nda H a th
s ca t d s ca t d m dap x
Oat g can bCG at x Am s c nt c td.
r ng ’ o t on T nd W t m d n ind t
iod n inad n sy tag n x
s v Act coat s th & N ph w
s
z nc ox d / c ox d
c
Po y t d ga Po y t / a c co po t T a K nda H a th
t
o
A g nat b a d d o att d own aw d po y accha d Ca aG nat , Ca as o Ca ngton l a
n
1
Ca oF x, Ka to tat ConvaT c
C a o K nda H a th
:
:
max o m d n ind t
s
m g o mö ynck H a th
Ag s t s th & N ph w
g
T gag n 3m
c
a
Hya o c ac d Hya on c ac d Hya o Convat c
P
r g n ca HA mPm m d ca
n
c
Hyd oco o d Occ v od at y a o pt v d ng ad Hyd oco b t k
p
o g at n o c o P aco D x
Co p Co op a t Co
Co d , D oDer m, ConvaT c
s gnaf x
ut c K nda H a th
ex d m d n ind t
r p ca s th & N ph w
Hyd og Wat o g yc ng h t ax ng o t Ca aD , Ca as a t, Ca ngton l a
h a ng Ca as o , Ca asyn
V g on Cr ba d inc
Aq a t D x
Aq af o, C a , C ag K nda H a th
D aG m d n ind t
Hyp g , No g mö ynck H a th
F xG s th & N ph w
Foa H gh y a o nt op n c h t F x an b t k
Ca as a t Foa Ca ngton l a
l yo oa ConvaT c
C a oa , Hyd a o , K nda H a th
Opt oa m d n ind t
m p x, m t af x mö ynck H a th
A vyn s th & N ph w
r ton 3m
Co ag n (a o A o nt, n o p ot n that p o ot Co ag n m d , Co ag n b oCo m d ca T ch
o og c d ng ) co ag n o gan at on s k nT p
F aco P eth con
Co po t Co p x, t ay d a w th an adh nt band A d John on & John on
od Va o K nda H a th
s t ata o m d n ind t
Ad mö ynck H a th
r p mPm m d ca
Wo nd a contact Po ya d n t that p ot ct wo nd a m pt mö ynck H a th
Con o ant, P o o s th & N ph w
N T ac Wn d l a
T gapo 3m
F T an c nt, adh nt po y than an C a t Con d
b oc v John on & John on
b t , Po y k n K nda H a th
112 m , m po mö ynck H a th
Ops t , u n F x s th & N ph w
T gad 3m
l iq u iD Fil ms . Like solid polyurethane lms, liquid
Bio l o g ic Dr es s in g s /s k in
1
lms are gas permeable, but liquid impermeable. T ey are
applied with an alcohol vehicle that evaporates leaving s u Bs TiTu Tes
the lm adherent as a residue. T e lm is most commonly
composed o acrylate, a vinyl polymer common to instant Wound dressings are designed to acilitate healing. Bio-
glues, but also can be made o nitrocellulose lacquer.14 T e logic dressings acilitate healing, but can also acilitate
lacquer grade is less ammable than classic guncotton wound closure by incorporating some orm o skin rom
nitrocellulose. the dressing into the wound ( able 11-3).19 When intended
as simply a covering, biologic dressings are used as brie y
as other dressings, usually or a matter o days be ore being
COl l AGeN. Familiar as a cosmeceutical, bovine type I changed. As a skin substitute, however, the components o
collagen also has a place in wound healing regimens. T is a biologic dressing may remain in place or as long as a year
insoluble protein is surprisingly absorbent and provides or may be permanent.20 For convenience, biologic dress-
moist healing and autolytic debridement once saturated. ings are usually grouped by the type o skin layers they
It is manu actured in many orms that ll and con orm to cover or replace, including epidermis, dermis, or both.

C
the wound bed, but requires an additional dressing to hold

h
T e tissue source is also considered, whether xenogeneic,

a
it in place. When exogenous collagen is placed in a wound,

p
allogeneic, autogenic, or synthetic. T e speci c composi-

t
it stimulates host collagenesis and collagen organization.15 tion o each layer is then described. Finally, consideration

1
As with injectable collagen and biologic dressings, bovine

1
is given to how the tissues are handled, and whether they
collagen allergy is possible, but in this instance is eas- are cultured or simply processed by cleaning, ltering, or

:
:
ily treated by removing the temporary dressing rom the radiating. Many o the products contain bovine or porcine
wound bed.

D
xenogeneic components that exclude their use in sensitive
patients.
HyAl u r ONiC ACiD. Hyaluronic acid (HA) is the

n
g
most common glycosaminoglycan in the human body. ePiDer mAl . T ere are three types o epidermal bio-

a
However, the average human body may have only 15g HA

n
logic dressings. In less than a month Epicel (Genzyme

d
total, much o which is continuously regenerated. Humans

P
issue Repair Corporation) can co-culture nearly 2 m 2 o

o
have three hyaluronidases that daily degrade roughly a mixed murine xenogeneic and autogenic epidermal cell

t
o
third o that 15 g.16 More than just dermal slime, HA orga- sheets rom two 6 cm excision donor sites.21 Vancomycin,

p
nizes cutaneous hydration and cellular traf c via its pri- amikacin, or murine protein sensitivity exclude its use. It

a
mary receptor, CD44. Dermal HA acts a promoter o early

t
is generally used or extensive burns when ew autogenic

v
in ammation, acilitates in ammatory cell migration into donor sites are available, and is considered an expensive

C
granulation tissue, and, as a major component o the basal

a
skin substitute. Laserskin (Fidia Advanced Biopolymers),
keratinocyte extracellular matrix, acilitates reepithelial- also known as Vivoderm (ER Squibb and Sons), seeds
ization.17 HA dressings can be thought o as the animal 10 day old cultured autogenic epidermal cells on laser-
equivalent o alginate dressings as the two polysaccharides per orated HA sheets or immediate engra tment. It is
are similar; both are absorbent, biodegradable, gas and generally used or lower-leg ulcers.22 Suprathel (Institute
liquid permeable products that orm a wound-shaped gel o extile and Process Engineering; Burn Department o
when hydrated. Marienhospital) is a synthetic epidermal equivalent com-
prised o lactide, methylcarbonate, and caprolactone.23
WOu ND bAs e. Wound base dressings are synthet- It is a thin elastic mesh, best considered as a permanent
ic, made rom per orated polyamide, and protect the hydrating dressing and best used or its analgesic proper-
base while trans erring wound exudate to secondary ties which are superior to those o hydrogels.
dressings.
Der mAl . T ere are as many allogeneic dermal skin
COmPOs iTe. Composite dressings are not a dress- substitutes as all other biologic dressings combined. T ere
ing type, but are rather several types or layers o dressing are also two xenogeneic products. Oasis (Healthpoint)
materials pre abricated into a single product. Like the is an acellular porcine xenogra t that retains its collagen
motherboard in your computer, a bundled unit may be sca olding, extracellular matrix proteins, and growth ac-
less expensive than purchasing each component sepa- tors.24 It is marketed or lower-extremity ulcerations and
rately, but the convenience is not itsel inexpensive and is widely used as a dermal replacement. Permacol ( issue
there is no choice among the individual components. Science Laboratories) is processed rom porcine skin simi-
T e most common composite dressing is the omnipres- lar to Alloderm®(Li ecell) and has similar indications.25
ent adhesive strip, created by Band-Aid®.Although moist Alloderm®is an acellular cadaveric dermal replacement
healing was not championed by science until the 1960s, widely used as a tissue ller under aps and gra ted burns.26
the Band-Aid®strip was invented in 1921, machine made Gra tJacket (Wright Medical echnologies), Neo orm
by 1924, sold in sterilized orm by 1938, and converted (Mentor Corporation), and DermaMatrix (Synthes) are
to plastic and vinyl bandages in the 1950s.18 At their best similar allogeneic cadaveric dermal replacements that are
composite dressings and bandages can encourage widely rendered acellular by varying proprietary techniques. T ree
available autolytic debridement. However, wound-edge additional allogeneic dermal substitutes do not remove
maceration and adhesive contact dermatitis are not broblasts be ore implantation. It is unclear how long the
uncommon. broblasts remain viable in the host, but their presence has 113
1 TAbl e 11-3
B olo De

Type n me c ompo t o s ou e M u tu e
ep d a ep c ep d a h t A to G nz T r pa Co p,
Ca dg , mA
la kn ep d on HA h t Cx a to F d a Advanc d b opo , A ano
T , ita
s p ath Th n a tc h s n in t t t of T xt and P oc
eng n ng, D nk ndo f, G an
D a Oa Ac a d a x nog aft X no/p H a thpo nt, Fo t Wo th, TX
P aco Ac a d a x nog aft X no/p T sc nc l a o ato , Andov , mA
A od ® Ac a d a a og aft Ao l f c , b anch g, NJ
s
G aftJack t W ght m d ca T chno og , inc.,
c
A ngton, TN
t
o
N ofo m nto Co po at on, s anta ba a a, CA
n
D amat x s nth , inc., W t Ch t , PA
1
iCX sKN C a d a a og aft Ao int c t x, l td., manch t , u K
:
D ag aft C a d a and nth t c Cx a o Advanc d b oH a ng, inc., l a Jo a, CA
:
a og aft
s
T an C t C a d a x no and X no/p Advanc d b oH a ng, inc., l a Jo a, CA
g
a og aft on n on at x Cx a o
c
a
Co po t b o an Po c n d on n on at x X no/p u Dl l a o ato , inc., r ockfo d, il
P
w th con h t s n
n
c
int g a bov n d w th t po a X no/ int g a
p
a t c cov ng s n l f s c nc Co p, P a n o o, NJ
A to
Ap g af bov n and a og n c d X no/ O ganog n , inc, Canton, mA
w th a og n c p d Cx a o
OC Po c n and a og n c d X no/p O t c int nat ona , inc., N w yo k, Ny
w th a og n c p d Cx a o
A tog aft Cs s Cx a to un v t of C nc nnat , C nc nnat , OH
FTs G A to
s Ts G A to
ep d A to
X nog aft Po c n X no/p b nnan m d ca , st. Pa , mN
A o, a og n c; A to, a tog aft; , ov n ; Css , c t d kn t t t ; Cx, c t d; p, po c n ; n, nth t c; x no, x nog n c.

been con rmed at least 6 months a ter trans er. ICX-skin dermis autogra ted with split-thickness skin.31 Apligra
(Intercytex) includes an allogenic collagen layer that retains (Organogenesis) composite skin substitute uses bovine
its broblasts.27 Dermagra t (Advanced Healing) seeds xenogeneic collagen and allogeneic neonatal broblasts
neonatal broblasts onto a polyglactin scaf old.28 ranscyte as a dermal replacement and covers them with a corni-
(Advanced Healing) manu actures a composite xeno- and ed epidermis o allogeneic epidermal keratinocytes.32 It
allogeneic dermal replacement in which a nylon mesh sca - is most requently used or chronic lower-extremity ulcer-
old is rst covered with porcine collagen and later seeded ations. OrCel (Ortec International) is a similar bilami-
with neonatal broblasts.29 nar product, in which neonatal broblasts and keratino-
cytes are cultured on opposite sides o a porcine collagen
COmPOs iTe. Composite biologic dressings are highly sponge. Although not as widely used as the well-known
complex products that replace both the dermis and epi- Apligra , OrCel has gained a treatment niche or skin dis-
dermis. Biobrane (UDL Laboratories) is similar to rans- eases such as epidermolysis bullosa.33
cyte, in which porcine broblasts are seeded on bilaminar
polyamide mesh. T e mesh is then covered with a thin
silicone sheet, which temporarily simulates the epidermis s k in g r a f Ts
until marginal reepithelialization incrementally sheds it.30
Integra (Integra Li e Sciences Corp) utilizes bovine col- Until recently, humans have historically gra ted skin,
lagen and glycosaminoglycan as a dermal analogue and whether autologous or otherwise, with poor success.
silastic covering as a temporary epidermal analogue. T e Xenogeneic gra ts are immunologically rejected and
xenogeneic matrix becomes remodeled and a vascularized unction only as temporary dressings. Pig-skin xeno-
autogenic dermis is ormed within 1 to 2 months, at which gra ts are still available in North America; rog skin had
114 time the silastic covering may be removed and the neo- a small regional market in the past. Popularized use o
small human allogra ts in the 1860s led to the published
success o autogra ts by the end o the nineteenth cen-
biOl OGiC s eAl ANTs . T rombin, brin, and plate-
1
let solutions can be potent hemostatic sealants although
tury.34,35 T e end o the twentieth century saw the devel- they are not dressings.40 Fibrin gauze is also available
opment o cultured bilayers o autogeneic keratinocytes and will be discussed with the dressings later. Bovine,
and broblasts at the University o Cincinnati, paving the human, and recombinant thrombin is available. Because o
way or volume skin replacement rom a small donor site known or potential problems including immunologic host
( able 11-3). response and venous thrombosis, use has trended toward
recombinant thrombin. T rombin is dispensed as a pow-
der in a vial and is reconstituted with a ew milliliters o
h eMo s Ta Tic Dr es s in g s
sterile diluent which can then be directly dripped onto the
wound with a syringe or used with an absorbent neutral pH
Hemostasis is the rst phase in wound healing. Hemostatic
gelatin sponge. A normal clotting cascade is required or
agents have multiplied in recent years and may share eatures
success. T ere are more numerous options or brin seal-
with the dressings discussed previously. However, their pri-
ants, which have been available in Europe or 40 years and
mary purpose is to provide hemostasis in an acute wound.

C
in the United States or 20 years. All o the our brin seal-

h
a
ants presently on the US market involve a double plunger
s TyPTiCs. Chemical

p
hemostats are topical astringents

t
syringe that mixes thrombin and brinogen rom various
that denature proteins, plugging the ori ces o the tran-
sources. isseel (Baxter), Evicel (Ethicon), and Crosseal

1
sected postcapillary venules and staunching bleeding rom

1
(Ethicon) should be reserved or venous oozing whereas
nicks. Common examples are silver nitrate, aluminum sul-
Floseal (Baxter) may be superior or arteriolar bleeding

:
:
ate, aluminum chloride, and erric sul ate. Silver nitrate and
because o its particular tamponade e ect. T ere is one
aluminum sul ate (alum) are used as solids. T ey are mildly

D
platelet glue available in the United States. Application
hemostatic, antiseptic topicals commonly used both in medi-
o platelet gel is even more complicated than most brin
cal practice and as domestic styptic pencils. Somewhat more

n
glues, requiring the patient’s centri uged blood to provide

g
e ective than the solid styptics, aluminum chloride and erric
hal o the product. T e platelets are thought to provide a

a
sul ate are liquid suspensions applied with a cotton-tip swab.

n
superior clot and increased growth actors during repair.

d
Erroneously called erric subsul ate, erric sul ate, or Monsel’s

P
solution, may leave an iron tattoo, due to errugination.36,37

o
s yNTHeTiC s eAl ANTs . T ree nonbiologic glues are

t
o
available.41 Cyanoacrylate should not be used directly on

p
PHys iCAl HemOs TATs . wo physical hemostatic
vessels because o embolization risk, but is appropriate or

a
agents are available. Bone wax is a paraf n/beeswax mix-

t
postcapillary venule bleeding at wound edges. Polyethylene

v
ture that physically occludes small vessels in bone; its per-
sistence in a healing wound may promote in ection and glycols (PEG) comprise a amily o large polymer molecules

C
a
granulation tissue. Its use has diminished in avor o alkyl- which are widely used in every aspect o the medical, phar-
ene oxide, a carbon and oxygen, hydrophilic, and water macologic, and ood industries. T ey work rapidly, are con-
soluble polymer that does not have the disadvantages o venient to use, and serve as moderate hemostatic agents,
paraf n although it has similar texture and workability.38 but since PEG swells to many times its size over several
days, it should not be used where vascular compression is
biODeGr ADAbl e HemOs TATiC AGeNTs . a concern. Like biologic glues, PEG sealant is dripped onto
As in chronic wound dressings, cellulose, gelatin and col- wounds rom a dual plunger syringe. Glutaraldehyde is a
lagen can provide hemostasis to acute wounds and they simple symmetric carbon and oxygen compound most re-
are biodegradable. As in chronic wound dressings, cellu- quently used as a cytotoxic agent. When covalently bound
lose, gelatin and collagen can provide hemostasis to acute to albumin, it provides a sca old or clots to orm, but its
wounds and they are biodegradable.39 Oxidized cellulose cytotoxicity un ortunately persists and the adjacent cells
has been used as a hemostatic agent since World War II. are killed. For this reason, glutaraldehyde cross-linked
In its modern orm, it looks and can be handled like cotton albumin is best reserved or adult cardiac surgery.
dressing, does not adhere to instruments, and may com-
pletely degrade in situ within months. Oxidation lowers HemOs TATiC Dr es s iNGs . Fibrin, chitin, and
the pH o the product and initiates clot ormation, but zeolite have been added to gauze bandages, which, in con-
limits its use with other hemostatic agents. Gelatin used junction with compression, can stop catastrophic bleed-
as an absorbable hemostatic agent is whipped into a oam, ing. Fibrin is available as a glue or as a dressing in which
baked, and then processed as a lm, sponge, or powder. lyophilized brinogen and thrombin coat cotton gauze.
Gelatin swells more than other biodegradable agents, pro- T is coating increases shel li e and eliminates premixing,
viding a physical matrix or clot ormation, and can also be but the product can be prohibitively expensive and the
sutured into place. Since it is neutral in pH, it can be used gauze is brittle. At the present time its use should probably
with other neutral hemostatic agents. Bovine collagen I is be restricted to the battle eld, or which purpose the Red
taken rom cowhide and processed into either a powder Cross initially created it. Chitin (acetyl glucosamine) is a
or compressed cotton-like sheets. Collagen initiates clot- long chain polymer derived rom glucose, making it struc-
ting by platelet activation. Patients, there ore, need to have turally similar to cellulose. It is ound in arthropod exoskel-
normal platelet unction or collagen bandages to provide etons, where it unctions like the keratin protein ound in
hemostasis. In general, absorptive dressings can also mammals and birds. Exoskeletons o shrimp and crab can
staunch minor venous or capillary bleeding. In act, many be deacetylated to yield chitosan (glucosamine), a superior
alginates were originally marketed or this indication. hemostatic agent. Chitosan achieves hemostasis by adher- 115
1 TAbl e 11-4
h mo t tic a t

Typ s ub t c n m M uf ctu
s typt c s v n t at Va ou
A u nu u at
A u nu ch o d
F c u at
Phy ca h o tat Pa a n/ wax bon wax eth con
A ky n ox d Ot n C d
b od g ada h o tat C uo s u g c , s u g oa eth con
G at n G oa , G f Pf
Co ag n Av t n Davo
s
H tat int g a
c
t
in tat eth con
o
n
b o og c g u Th o ngu Th o n Jmi mona ch
1
ev th o eth con
:
:
r coth o z y og n t c
F ngu T ,Fo a baxt
s
ev c , C o a eth con
g
P at tgu V tag O thov ta
c
a
synth t c a ant Cyanoac y at D a ond eth con
P
PeG Co a baxt
n
c
G uta a d hyd b og u C yo
p
H o tat c d ng F n DFs D A can r d C o
Ch t n r DH ma n Po y
Ch to an H Con H Con m d ca
z o t q u kC ot z m d ca

DFs D, D y F n s a ant D ng ; PeG, Po y thy n g yco ; r DH, r ap d D p oy nt H o tat.

ing to the wound and mechanically occluding blood ves- primary dressing to the wound. However, in classical
sels.42 Zeolite is a regularly microporous aluminosilicate terms a bandage is external to an underlying dressing and
mineral commercially used as an adsorbent and molecu- secures the dressing in place ( able 11-5). Most bandages
lar sieve.43 As a powder, it is use ul only or low-pressure are wraps and tapes.
wound packing. When enclosed in cotton mesh, it is more
success ul in staunching arterial bleeding. Blood and zeo- TAPe. ape is a common way to externally f x a dressing
lite yield a pro oundly exothermic reaction that can cause and provide a compact, durable bandage. Most tapes have
burns. For this reason, newer zeolite dressings are partially one-sided, pre-applied adhesive that was historically latex-
prehydrated, lessening heat production to not much more based and is now mostly acrylate-based. A large number
than body temperature ( able 11-4). o tapes are available allowing the clinician to choose the
appropriate level o adhesion, strength, translucence, and
permeability ( able 11-6). Hair, oil, dirt, blood, and other
Ba n Da g es moisture can impede the per ormance o tape. Addition-
al skin adhesives may improve the per ormance o both
T ere is no specif c eature that distinguishes a bandage dressings and bandages, but they are most commonly
rom a dressing. Dressings may be layered or have adhe- used with tape.
sive, and secondary dressings may be used to secure the
s KiN ADHes iVe. Skin adhesives can help skin stick to
tape, other skin, or medicated dressing materials. Synthet-
TAbl e 11-5 ic acrylates in various orms are used or most dressings
r ol of B d and bandages with pre abricated adhesives and are used to
attach skin to skin, thereby f lling the role o sutures. Hor-
K p th d ng c an
ticultural adhesives are volatile liquids that, when applied
Ho d a wound d ng n p ac
and dried, can augment tape’s adherence to skin.
r t ct ov nt o th wound dg
Many common liquid adhesives are derived rom plant
i p ov th p ph a wound nv on nt
sources with geographic niches. Mastic, gum Arabic, and
r duc w ng and h o hag
benzoin tincture are some examples.44 Mastic is a pine-
P ov d uppo t o an nju d
scented resin o a Pistachia tree grown on the Greek island
P ov d pa n
116 o Chios; and gum Arabic is a resin rom an Acacia tree
 TAbl e 11-6
application. T ere is a wide body o dissenting literature
regarding traditional suturing versus CA glue as a suture-
1
c ommon Typ s o Tap replacing wound closure. T e popular consensus seems to
be that octyl-CA is aster, suturing is stronger, and that
Typ f atur s exampl Mr the expense and cosmesis o the two can be equivalent
depending on individual usage, the product applicator,
Pap l ght adh v , m c opo 3m
p a ty st t p 3m
and the amount o product applied.49

Pa t c T an c nt, t nd b nd 3m ADHes iVe r emOVer . Plant resins and cyanoacry-

towa d occ v T an po 3m late can both be slowly removed with most oils, such as
C oth k Wov n; d a , Hypa x s &N mineral oil or petrolatum. Proprietary removers generally
o da , ha va a m d po 3m contain hydrocarbons, including heavy naphtha, which is
t tch a ong oth ax D apo 3m a roughly 10 carbon, petroleum-based alkane, and mineral
(wa p and woo ) spirits, which are not petroleum-based and have a longer
carbon backbone. T ese solvents are recognized by their

C
ea tc e a t c ty e a top a t bAG

h
viscosity, smell, and orange color. Acetone, in the orm o

a
p
s con l ght adh v , K nd oa 3m nail polish remover, is widely used to remove adhesives

t
t an c nt
rom skin, but its medical use is discouraged because o

1
1
Foa Th a and phy ca m c o oa 3m its toxicity.
f

:
:
Ca t ng s t ong, p o o nd s cotchca t 3m Wr AP. Gauze wraps have been in existence since pre-

D
o d ng historic times. As mentioned previously, they are a widely
available product or inexpensively securing a bandage
m , an act ; 3m, 3m, m nn apo , mN; s &N, s th & N ph w, to a dressing. T ey of er minimal support and compres-

n
g
l ondon, u K; bAG, b do AG, Ha g, G any. sion and can mechanically debride exposed wounds; they

a
can also be absorbent, whether moistened or medicated.

n
d
Unna boot is an eponymous medicated wrap created by

P
o
that grows in the Sahel, a strip o land that extends through Paul Unna. It is a zinc and erric oxide-impregnated gauze

t
the Sahara rom the Atlantic Ocean to the Red Sea. Com- wrap largely used or lower-extremity ulcerations. ube

o
p
pound tincture o benzoin is a vanilla-scented resin rom bandages, generically known as stockinette, may be gauze,

a
a Styra x tree that grows in T ailand and Indonesia. T ere net, mesh, polyester, or cotton. Stockinettes apply moder-

t
v
is no chemical benzoin in tincture o benzoin, which is ate continuous pressure across the length o the bandage

C
though to be an adulteration o the personal name Benja- and are meant or durable, lightweight dressing immobi-

a
min. Mastisol (Ferndale Laboratories Inc.) contains both lization. Sel -adhering bandages are crinkled, stretchable
Pistachia and Styra x resins.45 wraps that sel -cohere. Some tape may be required or a
Nitric acid and wood pulp yield nitrocellulose/pyroxy- completely coherent bandage, but the tape secures the
lin, that, when dissolved in ether, makes collodion, a word dressing to itsel so that no adhesive touches the skin. As
that means glutinous in Greek. Nitrocellulose and ether an aside, tape should always be used to secure wraps since
are both combustible, but collodion is not combustible pins can destroy wrap, dressings, and bandages, and punc-
when dried on skin.46 Rather, it is exible and sticky, a ture skin. Proper wrapping tension is required with all
good adhesive or bandages, and now only occasionally bandages, but sel -cohering bandages will not accommo-
used in liquid dressings. date urther stretch i applied too tightly. One advantage o
Most tapes, adhesive dressings, and transdermal patches sel -coherent bandages is the ability to easily reuse or repo-
adhere to skin with the synthetic vinyl resins methacry- sition them once they have been placed. Elastic bandages
late and epoxy diacrylate.47 Like lidocaine, cyanoacrylate are generally divided into short-stretch and long-stretch
adhesive (CA) was discovered during World War II, but categories. T e classic long-stretch elastic bandage is the
was not marketed until the postwar boom. T ere are sev- ACE (3M), an acronym or all-cotton elastic. ACE wraps
eral CA adhesives available that vary by the length o their have reached their centennial; they can stretch many times
carbon backbone. ypical supermarket-brand glues are their length, but tend to bunch with time. Short-stretch
methyl- or ethyl-cyanoacrylate, and are used to seal hand or lymphedema wraps are pre erred or edematous or
dermatitis ssures and to provide a protective membrane dependent wounds as they provide greater and more even
or super cial wounds in athletes and string musicians. compression. Compression hose may also be used to x
T ese glues are brittle and last or 1 to 2 days. Butyl-cya- a dressing in place. Compression will be discussed later.
noacrylate has been used as a surgical skin adhesive in
Europe and as a veterinary adhesive in the United States bOl s Ter . A surgical bolster is a bandage that supports a
since the 1970s. However, it was not until 1998 that octyl- gra t a ter its placement on its new vascular bed. Although
cyanoacrylate was approved or human use in the United some authors have admonished against their use, bol-
States.48 Butyl-CA may be stronger, but octyl-CA is more sters are still more o ten used than not. T e noun bolster
exible. Cyanoacrylate unctions by polymerizing in the means pillow and the verb means to support. T e classic
presence o hydroxyl molecules ound in water. Blood gra t bolster is some orm o impregnated gauze uf tied
rapidly sets CA, but otherwise its set time is on the order in place with nonabsorbable sutures radiating rom the
o minutes. Cotton bandages adhere immediately to CA wound edge. Published bolster and bolster-equivalents
and the two should not be used together during medical have also been cra ted o aquaplast, polyurethane sponge, 117
1 cotton wadding, cyanoacrylate glue, mepitel, allevyn, jelo-
net, and vacuum dressings.50
recalcitrant edema rom distal to proximal with sequential
pressure waves. T ey are used primarily or chronic lymph-
edema o the extremity. Compression garments are a thera-
bANDAGiNG TeCHNiq u es . An entire sub- peutic necessity a ter liposuction and specialized product
culture, closely associated with the military, developed lines have developed around their use.
around bandage application. T e Esmarch triangular (cra-
vat) bandage amously has 32 di erent applications, some
o which have been adopted by the Boy Scouts o America To pic a l en z yMes
or their uni orm and rst aid practices. Roller bandages
are variants o tube bandages and are used to immobilize T ree topical enzymes are available to debride necrotic
extremities. ailed and tube bandages have traditional wounds. T e collagenase Santyl (Smith & Nephew) is
applications or common injuries. As a rule, bandages an ointment that can remove thick, collagenous, dermal
should be wrapped rom distal to proximal with gradually debris without harming the remaining ragile granulation
diminishing tension. tissue.55 It is most requently used or burns. Papain, known
s
ourniquets developed rom gauze bandages, when a as papaya proteinase I, is a cysteine proteinase derived
c
strip o cloth was turned until it restricted catastrophic rom the South American papaya. Accuzyme (Healthpoint)
t
o
blood ow. Although less requently used today and seem- and Pana l (Healthpoint) contain papain and its activator
n
urea to enzymatically debride necrotic wounds without
1
ing to have no cutaneous application, medical variants o
tourniquets can be use ul in restricting procedural bleed- damaging viable tissue. In November 2008, the FDA rec-
:
:
ing o the distal extremity. emporary sequential tourni- ommended their discontinuation, citing unregulated use
s
quets are used or intravenous regional anesthesia (IVRA), which had resulted in blindness and tachycardia. However,
a Web search per ormed in July 2012 returned over 400
g
also known as the Bier block. IVRA provides an anesthe-
c
tized, exsanguinated limb or brie procedures such as cumulative hits, with many seemingly active sales sites, sug-
a
gesting that the product is still readily available and its side
P
botulinum toxin injection or hyperhidrosis, nail surgery,
e ects should, there ore, be more widely publicized. Finally,
n
and micrographic surgery.51
c
trypsin in a castor oil vehicle is made by several companies.
p
rypsin is a vertebrate serine protease that digests proteins
COmPr es s iON. Compression is a key eature by cleaving lysine or arginine.56
o bandages in general, but several special situations
require compression bandages. Negative-pressure wound
therapy (NPW ), or vacuum assisted wound closure, g r o w Th f a c To r s
utilizes a nonadherent oam base covered by an occlu-
sive lm dressing to orm a seal. A single drainage tube Healthy, healing wounds produce an exudate that stimu-
is connected to a vacuum that evacuates both liquid lates the surrounding cell lines to proli erate. Chronic
in the orm o wound exudate and gas. Used mostly or wound exudate inhibits growth.57 T ere are a surprising
chronic wounds on the lower extremity, NWP may number o identi able actors in exudate.58 T e actors
also be used as a bolster substitute to quickly secure a that are thought to be most important are listed in able
large gra t in place. T e negative pressure is continuous, 11-7. In general these actors encourage angiogenesis
but suction may be applied either continuously or inter- and di erentiation o cellular lines such as broblasts,
mittently.52 keratinocytes, and lymphocytes.59 Advances in molecu-
Compression improves healing o lower-extremity lar biology have not only allowed the identities o those
wounds and can relieve vascular discom ort.53 T ere are growth actors to be determined, but have also allowed
three types o compression garments or the lower leg, a their production. Application o growth actors both
pneumatic compression garment, sequential compression individually and together has been shown to improve
stockings, and anti-embolism stockings. Over-the-counter healing.
compression hose are generally known as anti-embolism Although each actor has been investigated in turn, only
stockings and provide less than 20 mm Hg compression three products are currently marketed or human admin-
which is unlikely to exacerbate undiagnosed vascular dis- istration.60 First, platelet derived growth actor (PDGF)
ease. Four classes o prescription hose are available in has three isomers. T e BB subunit, becaplermin, has been
roughly 10 mm Hg increments or gradually worsening developed and marketed as Regranex (Healthpoint) since
venous disease. Pressure is not equally exerted along the 2002. Its use has been restricted to chronic lower-extrem-
stocking. It is greatest at the ankle and diminishes toward ity wounds and it works best to promote angiogenesis on a
the knee, which is why these hose are o ten called sequen- clean vascularized base. In patients with previous known
tial or gradient compression stockings. It is imperative that malignancy, death rom metastasis is ve times greater
compression does not impair arterial ow. Distal pulses i more than two tubes (>30 g) are used, prompting the
should be evaluated and the ankle brachial index (ABI) FDA to issue a black box warning in June 2009. Platelet
should be determined. T e ABI is calculated rom the blood rich plasma is a technique that produces a ve times con-
pressure (leg divided by arm) with a Doppler ow detector centrated platelet product or direct autodeposition on a
and sphygmomanometer at the pressure when the pulse debrided chronic wound. It is thought that the alpha gran-
resumes a ter occlusion. An ABI o 1.0 is normal, and less ules in the platelets provide concentrated PDGF as well
than 0.8 is indicative o arterial disease, a contraindica- as other growth actors.61 Finally, epidermal growth actor
tion to lower-extremity compression.54 Pneumatic com- (EGF) may improve chronic leg wound repair.62,63 EGF is
118 pression units are complex, restrictive garments that milk also used in anti-aging cosmetics.
 t a bl e 11-7
1
g hF K a ff c H

g hF
F m p b a o K p m F
ep d m
eGF P end h c M d ng g n ,
F m nch m / p d m m g n
t GF α K n c K n c
P
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FGF M c ph g end h c M nch m m g n
F F

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KGF F ep h ep d m m g n

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p
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GCs F end h c WbC a ng g n ,h m p c

1
M c ph g m g n

1
il 6 t mph c b l mph c

:
M c ph g P n mm ,h m p c

:
m g n

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in u n k
iGF F end h c ep h mg n, m nch m

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g
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in uk n 8

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il 8 end h c WbC in mm ch m x
ep h c

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v
PDGF end h c F M nch m , h m p c

C
F WbC mg n
VeGF K n c end h c a ng g n
M c ph g
t n m ng
t GF β F end h c inh p n m c
K n c F p ;p m n n m nch m
l mph c K n c gu ; ng g n
M c ph g M c ph g
P

eGF, FGF, iGF, KGF, PDGF, t GF, VeGF, p d m , f , n u n k ,k n c ,p d v d, n m ng, v cu nd h g wh

c p c v ; il , in uk n; GCs F, g nu c c n mu ng c .

Hyper ba r ic o x yg en t Her a py cycles lasting 60 to 90 minutes. In the United States, the

expense can vary widely, but hospital-based sessions cost
Hyperbaric oxygen therapy (HBOT) provides an oxygen $1000 to $2000. More than 50 sessions are typically pre-
pressure greater than that o atmospheric pressure and scribed.64 When approved by Medicare, collections maxi-
also provides an increased respiratory oxygen concentra- mized at $50,000 are allowed. Proponents o HBOT or
tion, which may be help ul in treating a variety o disor- lower-leg ulcerations, specif cally diabetic oot and leg
ders. Average sea level atmospheric pressure is roughly 1 ulcerations, state that its use is statistically associated with
bar (14.5 psi) and decreases with elevation. Pro essional ewer patient procedures, ewer amputations, and greater
medical HBOT chambers can be pressurized to 6 bar, wound healing.65
but utilization requires proximity to a regional medical
center. Prescription home medical or portable units can po s t pr o c ed u r a l w o u n d c a r e
be pressurized to 0.5 bar above local atmospheric pres-
sure which may not be great enough or many indications. His t o r y. By the mid-nineteenth century, scientif c
Oxygen concentration is generally increased to as much bias was f rmly settled on escherization, the athers o
as 100% with an oxygen helmet or mask with intermittent antisepsis believing that less purulence in an undressed
air breaks during which 21% oxygen (air) is breathed. Pro- wound meant ewer in ections. A ter World War II, lesser-
essional treatment sessions, called dives, are pressurized known studies reported that occlusion improved healing 119
1 t a bl e 11-8
75
t opic l a n i ep ic

s pec r m u e di v n ge
l q d
i p p / h c h b d s p p D g, mm
P vd G+ s p p ef c c m v d w h g, d,
Ch h x d b d s p p; P c c x c ( h gh c c )
m v d
ac c c d b d C x c ( h gh c c )
Hd g p xd M m P p c ;e v c c d
ch m c d d m
s d m h p ch b d s ph c cc d c z w h D g
s
C m d m
c
b c c C c g
n m c G+ s ph c cc c ,c c g
M p c b d s ph c cc d c z
1
d
:
:
s d z b d P p i h p h z
n z b d i h p h z
s
b z p xd b d M v hc 10% c c g
g
c
G+/−, G m p v , g v ; [h ], h gh c c .
P
c
p
in human burn scars and vascular stasis ulcerations.66– 69 some sort, secondary intent, which is granulation, gra t-
T is culminated in the now- amous George Winter study ing, or a combination o these techniques.
showing that controlled porcine skin wounds healed bet- Primarily approximated wounds will epithelialize in
ter and aster with a hydrating dressing.70 wo years later, about a week depending on site, blood supply, and other
dermatologists repeated this study in humans and the era actors, at which point the super cial sutures will have
o moist healing was born.71 Moist healing increases eschar accomplished their goal. T e purpose o postoperative
autolysis, increases local growth actors, and reduces bar- approximated-wound care is to (1) remove crust and (2)
riers to epidermal migration while creating a voltage gra- prevent its re ormation. For crust removal, clinicians tend
dient that improves epidermal migration. to express personal pre erences or water, soap and water,
saline, dilute peroxide, 3% peroxide, bleach wash, or ben-
Wo u n D in FeCt io n . Anti-in ectives may be used zoyl peroxide washes. Most clinicians recommend 3%
as prophylaxis or treatment, may be used be ore, dur- peroxide as it is inexpensive, cleans thoroughly, has some
ing, or a ter the procedure, and may be orally ingested or antibacterial cytotoxic e ect, and has an e ervescence
topically applied. Oral antibiotics are covered elsewhere. that grati es caregivers and patients. However, other cli-
opical antiseptics are typically liquids or ointments nicians err on the side o prudence or the same cytotoxic
( able 11-8). For mechanical reasons, ointment use is reasons and recommend only soap and shower water. As
limited to postprocedure care. Most liquids are used or with chronic wounds, lubrication is the most critical step,
site preparation, but they may also be used or postproce- which is easily accomplished with topical petrolatum.
dure care, like hydrogen peroxide. Isopropyl alcohol and Dressing occlusion is generally unnecessary i lubrication
chlorhexidine are common and e ective liquids or site is generous, but a simple composite bandage may prevent
preparation. T e f ammability o alcohol may limit its use accidental removal o petrolatum, especially during sleep
or some procedures. Bleach baths and nasal mupirocin and under clothing.
can be help ul to preoperatively limit staphylococcal colo- One o the unintended successes o Mohs micrographic
nization. Because o their limited bacterial spectrum and surgery is a detailed knowledge o normal wound granu-
widespread resistance, there is no compelling evidence lation.3 Retrospective analysis o decades o granulated
that antibiotic ointments are superior to vehicle or rou- wounds resulted in a re ned understanding o the timing,
tine wound care.72,73 Both bacitracin (2003) and neomy- results, and complications o second intent healing. Any o
cin (2010) have been nominated in the past as the contact the chronic wound-care products can certainly be used or
allergen o the year.74 granulating wounds. Alginates, collagens, and oams are
use ul or exudative wounds; hydrocolloids and hydrogels
Pr o t o t yPiCa l Ca r e Fo r a Po s t s u r Gi- are use ul or hydrating wounds. However, the techniques
Ca l Cu t a n eo u s Wo u n D. Most o the products used or approximated wounds are o ten equally e ective.
listed in this chapter are intended or chronic wounds. T e Occlusion with a composite dressing may lessen caregiver
very existence o a chronic wound implies that something duties, with its convenience justi ying its expense.
is awry. However, surgical wounds are acute and most heal T e use o bandages, dressings, and wound care is a
without expensive or complicated care. Surgical wounds creative art aided by an ever-expanding armamentarium
120 heal by either primary intent, that is, by approximation o o products. Working knowledge o both time-tested
standards as well as the burgeoning advances is essential
or any health pro essional caring or cutaneous wounds.
24. Hodde JP, Ernst DM, Hiles MC. An investigation o the long-
term bioactivity o endogenous growth actor in OASIS
1
Wound Matrix. J Wound Care. 2005;14:23– 25.
T e attentive clinician should be able to discern what is
25. Harper C. Permacol: clinical experience with a new biomate-
good or untoward in any class o wound and cra t both a rial. Hosp Med. 2001;62:90– 95.
bandage and a wound-care regimen to speed healing. 26. Wainwright DJ. Use o an acellular allogra t dermal matrix
(Alloderm) in the management o ull-thickness burns. Burns.
1995;21:243– 248.
r ef er en c es 27. Boyd M, Flasza M, Johnson PA, Roberts JS, Kemp P. Integra-
tion and persistence o an investigational human living skin
1. Davis P, Kenrick P. Fossil Plants. Washington, DC: Smithson- equivalent (ICX-SKN) in human surgical wounds. Regen Med.
ian Books, 2004. 2007;2:369– 376.
2. Hess C , ed. Clinical Guide: Wound Care. 5th ed. Spring- 28. Omar AA, Mavor AI, Jones AM, Homer-Vanniasinkam S.
house, PA: Lippincott Williams & Wilkins; 2004. reatment o venous leg ulcers with Dermagra t. Eur J Va sc
3. Falanga V, Zitelli JA, Eaglstein WH. Wound healing. J Am Endova sc Surg. 2004;27:666– 672.
Acad Dermatol. 1988;19(3):559– 563. 29. Lukish JR, Eichelberger MR, Newman KD, et al. T e use o a
4. Fonder MA, Lazarus GS, Cowan DA, Aronson-Cook B, Kohli bioactive skin substitute decreases length o stay or pediatric

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AR, Mamelak AJ. reating the chronic wound: a practical burn patients. J Pediatr Surg. 2001;36:1118– 1121.

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30. McHugh P, Robson MC, Heggers JP, Phillips LG, Smith DJ

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approach to the care o nonhealing wounds and wound care

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5. Stadelmann WK, Digenis AG, obin GR. Physiology and and ull-thickness thermal injury. Surgery. 1986;100:661–664.

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healing dynamics o chronic cutaneous wounds. Am J Surg. 31. Groos N, Guillot M, Zilliox R, Braye FM. Use o an arti cial

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1998;176(2A Suppl):26S– 38S. dermis (Integra) or the reconstruction o extensive burn
scars in children. About 22 gra ts. Eur J Pediatr Surg. 2005;15:

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6. Midwood KS, Williams LV, Schwarzbauer JE. issue repair

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and the dynamics o the extracellular matrix. Int J Biochem 187– 192.

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Cell Biol. 2004;36(6):1031– 1037. 32. rent JF, Kirsner RS. issue engineered skin: apligra , a
7. Jones V, Grey JE, Harding KG. ABC o wound healing: wound bi-layered living skin equivalent. Int J Clin Pract. 1998;52:
dressings. BMJ. 2006;332:777– 780. 408– 413.

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8. Remminghorst U, Rehm BHA. Microbial production o algi- 33. Hasegawa , Suga Y, Mizoguchi M, et al. Clinical trial o allo-

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nate: biosynthesis and applications. In: Rehm BHA, ed. Mi- geneic cultured dermal substitute or the treatment o intrac-

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table skin ulcers in 3 patients with recessive dystrophic epi-

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crobial Production of Biopolymers and Polymer Precursors:

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Applications and Perspectives. Nor olk, VA: Caister Academ- dermolysis bullosa. J Am Acad Dermatol. 2004;50:803– 804.

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34. Hauben DJ, Baruchin A, Mahler A. On the history o the ree

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ic Press; 2009.
skin gra t. Ann Pla st Surg. 1982;9(3):242– 245.

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35. Smahel J. T e healing o skin gra ts. Clin Pla st Surg. 1977;

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native. J Dermatol Surg Oncol. 1992;18(11):992– 995.
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36. Goldberg HC. Monsel’s solution. J Am Acad Dermatol. 1981;

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o acute wounds: a review o the literature. Int Wound J.

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2008;5(5):602– 613. 5:613.
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11. Dumville JC, O’Meara S, Deshpande S, Speak K. Hydrogel

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dressings or healing diabetic oot ulcers. Cochrane Databa se and ef cacy. Arch Dermatol. 1964;90:226– 228.
Syst Rev. 2011(9):CD009101. 38. Wang MY, Armstrong JK, Fisher C. A new, pluronic-based,
12. Fletcher J. Understanding wound dressings: oam dressings. bone hemostatic agent that does not impair osteogenesis.
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13. Lionelli G ., Lawrence W . Wound dressings. Surg Clin N 39. Schonauer C, essitore E, Barbagallo G, Albanese V, Moraci
Am. 2003;83(3):617– 638. A. T e use o local agents: bone wax, gelatin, collagen, oxi-
14. Robins P, Goldberg L, Moy R, et al. T e e ectiveness o liq- dized cellulose. Eur Spine J. 2004;13(Suppl 1):S89–S96.
uid bandage as an adhesive and antimicrobial agent. J Drugs 40. Palm MD, Altman JS. opical hemostatic agents: a review.
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15. akeda U, Izawa M, Koeda , Shibata U. Laboratory studies o 41. Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Sha-
collagen wound dressing (CAS). Part I. Experimental use on piro ML, Lawson JH. A comprehensive review o topical he-
skin excisions and burns. J Dermatol. 1983;10(5):475– 486. mostatic agents: ef cacy and recommendations or use. Ann
16. Stern R. Hyaluronan catabolism: a new metabolic pathway. Surg. 2010;251(2):217– 228.
Eur J Cell Biol. 2004;83(7): 317– 325. 42. Bhuvanesh G, Abha A, Shalini S, Mohammad SA. Prepara-
17. Matou-Nasri S, Ga ney J, Kumar S, Slevin M. Oligosaccha- tion o chitosan– polyethylene glycol coated cotton mem-
rides o hyaluronan induce angiogenesis through distinct branes or wound dressings: preparation and characteriza-
CD44 and RHAMM-mediated signalling pathways involving tion. Polymers Advan echnol. 2008;20:58– 65.
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122
 Sect ion
S i l S ills
2
ch a pt er

12 Biopsy Techniques
Anthony M. Rossi, Erica H. Lee, & Kishwer S. Nehal

In t r o d u c t Io n single lesion, biopsy site selection is straight orward. I

the disease process is more di use, as in exanthems, then
proper site selection is important. T ere are anatomical
A skin biopsy is de ned as sampling o the integumentary
locations that are more amenable to healing and less prone
system or histologic evaluation and is a power ul diagnos-
to scar development. In addition, there are areas that may
tic tool or the dermatologist. Although a biopsy may seem
be prone to a higher background o histological change,
straight orward, its utility is enhanced when the clinician
which could then obscure key histologic ndings. Gener-
understands its applications and limitations. As with all
ally, it is best to avoid per orming biopsies below the knee
diagnostic tools, the pretest probability that a patient will
i possible because o the increased risk o in ection and
have a speci c disease takes into account the prevalence o
delayed wound healing. Sites overlying joints also have a
the disease and the clinical ndings. A histological diagno-
poorer healing outcome and potential or worsened scar-
sis should then be clinically correlated with the physician’s
ring. T e back o ten heals with stretched scars and is a
di erential diagnosis. A skin biopsy is considered the gold
site in which wound care can be logistically di cult to
standard or the diagnosis o skin lesions and requires that
per orm.2 I possible, biopsy o the central ace should be
the clinician be amiliar with certain key concepts.
avoided or cosmetic reasons.
O equal importance is selection o the lesion to be
u SeS a n d In d Ic a t Io n S biopsied. Morphological appearance and the clinician’s
suspicion o the pathology will guide the choice o where
T e skin biopsy has several indications1: the biopsy should be per ormed. For a biopsy o a possible
cancer, it is best to sample the entire growth. I this is not
Establishing or excluding a cutaneous diagnosis easible, then the thickest portion o the tumor should
Monitoring the evolution o a disease or treatment e ects be biopsied to best assess the depth o the neoplasm. For
Determining the extent o a skin tumor inf ammatory disorders, the most recent lesion will gen-
issue sampling or culture (bacterial, ungal, or viral organisms) erally be most diagnostic. T is is especially true when a
issue or genetic or gene rearrangement evaluations ( -cell
diagnosis o vasculitis is suspected. o improve diagnostic
lymphomas)
accuracy, it is important to avoid any necrotic, excoriated,
Cosmetic removal o tissue
or secondarily in ected lesions. For primary vesicles or
A ter the decision to per orm a biopsy has been made, bullae, the edge o the lesion and perilesional skin should
prior to obtaining consent, the type o biopsy and site selec- be biopsied ( or direct immunof uorescence (DIF) biopsy
tion with relevant photography should be per ormed. In site selection, see section on ISSUE PROCESSING). In
addition, relevant medical history, anesthesia selection, and primary ulcers or necrotic lesions, the edge o the lesion
consideration o antibiotic prophylaxis should be reviewed. and adjacent normal skin should be sampled, as many
ulcer edges may show pseudoepitheliomatous or second-
ary changes. In annular patches or plaques, the edge will
SIt e a n d LeSIo n SeLec t Io n usually demonstrate more “active” disease as compared to
the center ( able 12-1).
T e selection o a representative lesion takes into account T e suspected level o pathology will also guide biopsy
the best site or diagnosis and cosmesis. When there is a selection, since certain dermatologic disorders a ect the
2 TAbLE 12-1
It is currently not recommended to stop anticoagula-
tion, including aspirin or war arin,3 or a routine skin
L si t p dc sp di g bi ps biopsy. T e risks and consequences o a thrombotic event
secondary to changes in anticoagulation outweigh the
r mm d d t p d risk o cutaneous bleeding complications.4 Multiple stud-
L si t p Si f bi ps ies have analyzed the outcomes o patients undergoing
skin surgery while on anticoagulant medications. Alca-
Suspected malignant Excisional iopsy or sampling o
neoplasm thickest portion o tumor lay reported that no signi cant bleeding events occurred
in 16 patients undergoing cutaneous skin surgery while
In ammatory disorders Most recent lesion on war arin therapy compared to 77 control patients.5
Primary vesicle or ulla Edge o lesion plus perilesional Cook-Norris et al.6 conducted a retrospective review o
skin patients undergoing cutaneous surgery and showed that
clopidogrel-containing anticoagulation was 28 times more
Ulcer Edge o ulcer plus perilesional skin
likely than no anticoagulation and six times more likely
Annular patches/plaques Advancing edge than aspirin monotherapy to result in severe complica-
S
e
tions a ter Mohs surgical procedures (p < 0.001 and p =
c
Suspected panniculitis Incisional iopsy or dou le punch
t
i
0.022, respectively). In a meta-analysis, Lewis et al. con-
o
technique
n
cluded that while low, the risk o bleeding among antico-
2
agulated patients may be greater than that o patients not
:
:
taking anticoagulants. Among patients taking aspirin or
deeper layers o the dermis (i.e., morphea), subcutane- war arin, 1.3% and 5.7%, respectively, experienced a severe
S
u
ous at (i.e., panniculitis), or ascia (i.e., eosinophilic as- postoperative complication. Patients taking war arin had
r
g
ciitis). I a super cial biopsy is per ormed in these cases,
i
an approximately seven times greater incidence o mod-
c
a
the histological diagnosis may be missed completely. A
l
erate-to-severe complications compared to controls (OR,
S
k
super cial biopsy o a neoplasm can also at times yield 6.69; 95% CI, 3.03–14.7, p < 0.001), while patients taking
i
l
l
inconclusive results, leading to a need or rebiopsy.
s
aspirin or NSAIDs were more than twice as likely to have
a moderate-to-severe complication compared to controls
Pr eo Per a t Iv e eva Lu a t Io n (OR, 2.0; 95% CI, 0.97– 4.13, p = 0.06).7 Although these
studies examined skin surgeries, these same principles
Although a skin biopsy is a low-risk procedure, it is still apply to biopsies as well, since even a routine biopsy can
important to review the patient’s medical history. A stan- lead to signi cant bleeding in anticoagulated patients.
dardized checklist is recommended be ore proceeding. T e use o herbal supplements or homeopathic medi-
Reviewing the medical history will alert the physician to cations such as garlic supplements may also increase
any underlying conditions that may lead to poor or delayed the risk o bleeding. Strict attention should be given to
wound healing or impaired hemostasis ( able 12-2). proper hemostasis and postoperative wound care in the
anticoagulated patient.

TAbLE 12-2
a n t IbIo t Ic Pr o Ph yLa x IS
P i ps c klis T e risk o in ection a ter a skin biopsy is low. Wright
Medications Anticoagulants: war arin; et al.8 analyzed data rom our dif erent studies and esti-
clopidogrel; da igatran; mated the risk o bacteremia rom dermatologic proce-
dipyridamole; aspirin; nonsteroidal dures at 1.9%. T ere are speci c circumstances, however,
anti in ammatories (NSAIDs); in which antibiotic prophylaxis is recommended or skin
Homeopathic medications surgery. It is, there ore, important to be amiliar with the
Allergies Lidocaine, epinephrine, acitracin, current guidelines or antibiotic prophylaxis or bacte-
latex, adhesive rial endocarditis and hematologic joint in ection (see
chapter 9).9 T ere are also certain clinical scenarios that
Medical history Dia etes; hepatitis; leeding
may increase the risk o in ection, requiring appropriate
diathesis; pregnancy; to acco
preprocedure precautions to be taken. For patients with
use; lymph node dissection; acial
herpes; keloid/hypertrophic scar total joint replacements who are in the immediate postop-
erative period, we recommend consulting with the patient’s
Orthopedic history Joint replacement orthopedic surgeon. When biopsies must be per ormed in
Cardiac history Endocarditis; pacemaker/ areas o previous lymph node dissection or lymphedema,
def rillator; congenital heart precautions against in ection should be taken. For neutro-
de ect; artif cial heart valves/stent; penic patients, sterile technique is recommended. It is at
hypertension/heart disease the discretion o the clinician to decide whether antibiotic
Immunosuppression Solid organ transplantation; prophylaxis should be given ( able 12-3).
immunosuppressive medication; Dixon et al. evaluated 5091 lesions that were surgi-
HIV/AIDS; chemotherapy cally removed without pre- or postprocedure antibiotics.
T e overall rate o surgical site in ections was low, but in
Other relevant history Radiation, neutropenia, other
124 certain situations the rate was greater than 5%, including
 TAbLE 12-3
additional management, such as excision or Mohs micro-
graphic surgery, is indicated at a later time. McGinness
2
c li i l f sf v i us a i i i et al. conducted a study o 271 surgical sites and asked
P p l xis patients undergoing Mohs surgery to indenti y their
Wound location Increased risk o in ection when lesion site without preoperative photography. In this
wounds are located in particular study, the patient incorrectly identi ed 45 o 271 surgical
anatomic sites such as the lip, the sites (16.6%), and the physician incorrectly identi ed 16 o
ear, the perineum, the inguinal area, 271 surgical sites (5.9%). However, all surgical sites were
and elow the knee 10 correctly identi ed when preoperative biopsy-site photog-
Type o procedure biopsy invading mucosa raphy was used.12 Images should be taken to capture the
biopsy site and a topographical landmark to aid in uture
Skin condition Clean versus contaminated wounds identi cation. Patient images are part o the medical record
Patient varia les Lymph node dissection; and there ore subject to Health Insurance Portability and
immunosuppressed patients Accountability Act (HIPAA) compliance (see chapter 6).
due to HIV/AIDS, malignancy,

C
h
chemotherapy, uncontrolled

a
p
dia etes
bIo PSy St ePS

t
e
r
1
2
For all biopsies, a standardized site preparation protocol
procedures per ormed in the groin, skin gra ts, wedge

:
is essential both or ef ciency and patient sa ety. T e Joint

:
excisions o the lip or ear, and procedures below the knee.10 Commission on Accreditation o Healthcare Organization

b
When the biopsy site is prepped with an antimicrobial

i
o
(JCAHO) recommends a sequential order o steps. T ese

p
topical preparation it is considered to be a “clean” proce-

s
include: marking the site with a surgical pen, a “time out”

y
dure, but this is not the case i the area is already in ected

T
or patient and site identi cation, cleansing the biopsy site

e
or contaminated, or i there is mucosal involvement. For

c
with a topical antimicrobial, draping the site i necessary,

h
most biopsies, there is no need or pre- or post-antibiotic

n
and nally anesthetizing the area.

i
q
prophylaxis, although prophylaxis may be considered or

u
e
procedures below the knee, wedge biopsies o the lip and

s
ear, and lesions in the groin, as well as in patients with a n t ImIc r o bIa L Pr ePa r a t Io n
uncontrolled diabetes, alcoholism, malnutrition, and
immunosuppression. T e use o topical antimicrobial cleansing agents prior
to a skin biopsy is an important step in the prevention o
surgical site in ections. Ideally, the antiseptic should be
In f o r med c o n Sen t quick acting, provide a sustained duration o action, have
a broad antimicrobial spectrum, and be nonallergenic.
Prior to the biopsy a comprehensive discussion o the T e most common antimicrobial agents used or biopsies
technique, rationale, risks, bene ts, possible outcomes, include 70% alcohol, povidone-iodine, and chlorhexidine
and alternatives between the clinician and patient should gluconate ( able 12-5).13– 16
be per ormed (see chapter 3) ( able 12-4).11Patients are Darouchie et al. compared the rate o surgical site in ec-
encouraged to ask questions and restate in ormation in tions using povidone-iodine versus a chlorhexidine-alco-
their own words be ore proceeding. hol preoperative skin scrub during clean-contaminated
surgeries. T e chlorhexidine-alcohol group had a lower
overall rate o surgical site in ection, super cial incisional
Ph o t o g r a Ph y in ection and deep incisional in ections. T ere were no
signi cant di erences in adverse events.17
High-resolution standardized digital images are encour-
aged to document lesion morphology and location. A digi-
tal image will also aid in identi cation o the biopsy site i a n eSt h eSIa
T e majority o cutaneous biopsies require the use o local
TAbLE 12-4 injectable anesthetics, though topical anesthesia may be
I c s c p s Ski bi ps used in select circumstances (see chapter 4). T e main-
stay o anesthesia or skin biopsies is injectable 1% or 2%
Rationale/ enef ts Reason or iopsy lidocaine (Pregnancy Category B), with or without epi-
Technique Type o iopsy, methods o nephrine (1:100,000 to 1:200,000). Lidocaine is an amide
anesthesia, hemostasis, suturing and anesthetic and metabolized by the hepatic microsomal
wound dressing enzymes. T ere ore, caution should be taken in patients
with severe liver dys unction. T e use o epinephrine pro-
Alternatives O servation
motes vasoconstriction, which takes approximately 15
Risks Include any potential complications minutes to occur. Counteracting the vasodilatory e ects
( leeding, in ection, scar, num ness, o the anesthetic, epinephrine aids in hemostasis, and
pain); inconclusive diagnosis; risk o prolongs the anesthetic e ect by slowing its clearance. A
no iopsy/delay in diagnosis
concentration o 1:10,00,000 is the lowest that can achieve 125
2 TAbLE 12-5
t pi l a n i i r bi l Pr p r i ns14–16

g r up Sp ru o ns Sus in d a ivi y c n s
Alcohol 60%–95% Gram +/−; Fastest None No spores; amma le
Mycobacterium
Tuberculosis; ungi;
enveloped viruses
Povidone iodine Gram +/− Fast None Sensitivity
Iodophor ( etadine) Gram +/− Moderate Up to 1 h; intermediate Ef ective dry; skin a sorption;
to minimal i wiped rom Potential systemic toxicity with
the skin neonates or large sur ace area
S
Hexachlorophene (pHisoHex) Gram + Slow Yes Teratogen; neurotoxic
e
c
t
Chlorhexidine (hi iclens) Gram +/−; Fast Yes; Additive ef ect with Eye irritation; ototoxic
i
o
n
M.Tuberculosis; ungi; repeated use
2
enveloped viruses
:
:
benzalkonium Gram +/− Slow None Nonirritating
S
u
r
g
i
c
a
e ective vasoconstriction. Epinephrine is a beta and alpha T e use o smaller needles (30 gauge)
l
S
agonist and its use is contraindicated in patients with Quick needle insertion with slow injection
k
i
Bu ering the anesthetic to a physiologic pH with sodium
l
hyperthyroidism and pheochromocytoma. It should be
l
s
used with caution in patients taking beta-blockers, mono- bicarbonate
amine oxidase inhibitors, tricyclic antidepressants, and Warming the anesthetic
phenothiazines, as these patients may be more sensitive T e depth o injection is guided by the type o skin
to its e ects. Caution should also be exercised when using biopsy. Injection into the subcutis is less pain ul than a der-
epinephrine in patients with severe hypertension, cardio- mal injection but requires 5 to 10 minutes or the anesthetic
vascular disease, or narrow angle glaucoma.18 e ects to reach the skin sur ace. Injection in the super -
T e use o epinephrine in anesthesia o the digits or cial dermis to create a “wheal” is more pain ul but provides
closed spaces (ears, penis) has been controversial or ear immediate anesthesia. T is wheal e ect also creates an
o necrosis secondary to vasoconstriction. However, mul- elevated rm plat orm, which acilitates shave biopsies.
tiple studies have re uted this concern and show epineph-
rine to be sa e.19 In the ew cases o digital necrosis, vessel
compression due to the tamponade e ect o excessive h emo St a SIS
anesthetic volume was cited as the cause. Epinephrine is
however, contraindicated or digital anesthesia in patients T e degree o bleeding is related to the type o biopsy and
with severe peripheral vascular disease. Side e ects asso- the anticoagulation status o the patient. T e most com-
ciated with epinephrine include palpitations, tachycardia, mon types o hemostatic agents include: chemical agents,
elevated blood pressure, and headache, which tend to be electrosurgery, and suturing. Prolonged compression can
sel -limited and more common when injection occurs in also acilitate hemostasis. Certain hemostatic agents are
highly vascular areas such as the ace and scalp. better suited or speci c biopsy techniques and will be dis-
Common adverse e ects o local anesthesia include cussed later.
vasovagal reactions (hypotension, bradycardia, diapho- For super cial biopsies such as shaves, snips, or
resis, syncope) and can be mitigated by reassuring the curettes, a chemical hemostatic agent, or styptic, should
patient, placing them in supine or rendelenburg position, suf ce. wenty percent aluminum chloride hexahydrate
and using techniques to minimize pain. rue allergic reac- in an alcohol base and erric subsul ate are commonly
tions to local anesthetics ( ype I, IgE-mediated) are rare used agents. Although erric subsul ate is a more e ective
and represent less than 1% o adverse reactions to local hemostatic agent, aluminum chloride is usually pre erred
anesthesia. I a patient has a true allergy to both amide as the ormer can pigment dermal tissue causing tattooing.
and ester anesthetics, other choices or local anesthesia Both are applied using a cotton tipped applicator and pres-
include injections o normal saline with benzyl alcohol sure to the wound bed or approximately 1 to 2 minutes.21
preservative or 1% diphenhydramine with or without epi- I a styptic does not suf ce or a greater amount o
nephrine.20 hemostasis is needed, electrosurgery may be used. (see
Measures taken to minimize the pain associated with chapter 14). Heat or electricity is delivered to the bleed-
local injections include: ing point via a metal tip (monopolar or bipolar electrode)
Use o topical anesthesia (important in children) connected to an electrosurgical source. I the patient has
Verbal distraction an implantable cardioverter de brillator, pacemaker, or
Mechanical distraction such as pinching the site, or applica- both, the electric current may inter ere with normal unc-
126 tion o cold/ice or a vibratory stimulus tioning o these devices. In patients with an implantable
cardioverter de brillator, bipolar electrosurgery or heat
electrocautery should be used.22 For patients with pace-
2
makers, electrosurgery may be used i the power output o
the device is kept to a minimum and short pulses o less
than 5 seconds are utilized. In patients with either device,
thermocautery, also called heat cautery, is sa e.23

bIo PSy t ec h n Iq u eS
T ere are six main biopsy techniques: snip, curette, shave,
punch, incisional, and excisional biopsy. As with any sur-
gical procedure universal precautions should be ollowed.
For most biopsies, clean surgical technique is appropriate
but or incisional and excisional biopsies, sterile technique Figure 12-2 Curette (lesion is scraped using the sharp

C
h
is recommended. T e set-up or the biopsy tray should be side o the curette).

a
p
standardized so the clinician is amiliar with all materials.

t
e
r
1
2
Sn IP bIo PSy spoon type and the sharper ring curette. T e surround-
ing skin is held taut with the nondominant hand while

:
:
Snip or scissor biopsies are ideal or pedunculated lesions, the dominant hand, in a smooth movement, removes the

b
lesion. Curettes should not be used on lax skin as they

i
o
which can be pulled away rom the base and severed.

p
o ten cause tearing (Fig. 12-2). I the lesion is not com-

s
Either iris or gradle scissors are o ten used. Local anes-

y
pletely removed with the rst pass the process is repeated.

T
thesia or this type o biopsy includes ormation o a wheal

e
Hemostasis can be obtained via pressure, chemical hemo-

c
or bleb. It is important that the lesion be pulled but not

h
stasis, or electrosurgery. Healing occurs by secondary

n
overly extended with the orceps as this can result in a

i
q
intention. T e scar may be hypopigmented, especially in

u
wider or deeper de ect. Pressure hemostasis is o ten suit-

e
patients with darker skin types, which should be discussed

s
able or these super cial biopsies although or larger or
more vascular lesions chemical hemostasis or electrosur- be ore the biopsy.
gery can be utilized. Healing occurs by secondary inten-
tion (Fig. 12-1). Sh a v e bIo PSy

c u r e t t e bIo PSy T e shave biopsy is a commonly per ormed procedure.

Shave biopsies can be used to diagnose a variety o skin
disorders, including neoplasms and inf ammatory enti-
Curette biopsies are intended or super cial epidermal
ties. Intradermal anesthesia with wheal ormation serves
lesions in which a plane o dissection exists between the
to elevate the lesion while ensuring adequate anesthesia o
neoplasm and the underlying dermis. Examples o lesions
the peripheral borders. While holding the lesion taut with
suitable or a curette biopsy include seborrheic keratoses
the nondominant hand, orceps, or a skin hook, the der-
and molluscum contagiosum. Although some use curette
matologist can utilize a 10 or 15 scalpel blade or a f exible
biopsies or certain malignant neoplasms such as basal cell
concave razor blade (i.e., Dermablade®) in a parallel sawing
carcinomas, the destructive orce o the curette may shear
motion (Fig. 12-3a,b). Hemostasis may be achieved with
the tissue, making it more di cult to interpret histologi-
pressure, chemical hemostasis, or electrosurgery (Fig.
cally. T ere are two main types o curettes: the Volkmann
12-3c). Healing occurs by secondary intention. It is worth
noting that as the depth o shave increases the risk o sub-
sequent scarring increases.
T ere is a learning curve associated with per ormance
o shave biopsies as the depth is guided by the operator’s
angulation o the blade. When greater blade angulation is
utilized, the term “deep shave” or “shave excision” is used;
this type o biopsy has also been re erred to as a “saucer-
ization biopsy” when it samples the epidermis along with
a portion o the dermis, the whole dermis, or subcutane-
ous at. Regardless o the shave biopsy technique used, the
goal is to obtain a single, un ragmented, saucer-shaped
biopsy specimen with consistent depth.
A saucerization biopsy is particularly use ul in diagnos-
ing lentigo maligna (malignant melanoma in situ) o the
ace. Lentigo maligna lesions can be quite large and a com-
plete excisional biopsy may not be easible. It is important,
Figure 12-1 Snip iopsy (lesion is held with orceps; however, to obtain a su ciently large and representative
gradle scissor is poised at ase to snip). sample, as benign oci may be present within a larger 127
2

B
S
e
c
A
t
i
o
n
2
:
:
S
u
r
g
i
c
a
l
S
k
i
l
l
s
Figure 12-3 Shave iopsy – A. injection o anesthesia;
C B. shave removal o lesion with Derma lade; C. aluminum
chloride hemostasis.

malignant lesion, leading to sampling error and a delay in diagnosis in 79 o 84 specimens.26 Local anesthesia o the
the diagnosis o malignancy.24 When biopsying suspected epidermis, deep dermis, and subcutaneous at is needed or
mycosis ungoides (cutaneous -cell lymphoma), an entity a punch biopsy. I sutures will be used to close the de ect,
that can be subtle histologically, a broad shave biopsy may it is important to anesthetize the surrounding area as well.
be superior to a smaller biopsy. Shave biopsies can also T e skin should be held taut and perpendicular to the
be used or small dysplastic nevi because they allow the relaxed skin tension lines o the area being sampled. T e
pathologist to visualize the epidermis at the shoulders o punch instrument is pushed vertically into the skin and
the lesions.25 A super cial shave biopsy may not provide rotated in one direction (twisting back and orth may lead
adequate depth to distinguish an invasive squamous cell to epidermal shearing). It is apparent that the subcutaneous
carcinoma rom a keratoacanthoma type squamous cell tissue is reached when there is a loss o dermal resistance
carcinoma, and it is important to obtain a su ciently deep (this can be obscured in brosing conditions). T e biopsy
and wide sample when biopsying these types o lesions. specimen is held gently by orceps to minimize crush arti-
act, and detached rom the base with iris scissors (Fig.
12-4a,b). Since the skin is held at right angles to the relaxed
Pu n c h bIo PSy skin tension lines, the circular de ect created is trans ormed
into an oval shape when the skin is released. T is allows a
T e punch biopsy is an excellent tool or sampling derma- linear closure with minimal dog-ear ormation to be per-
tologic processes occurring in the dermis and subcutane- ormed, which is important or optimal cosmesis. Simple
ous at, including inf ammatory dermatoses, neoplasms, interrupted sutures with slight eversion o the skin edges
and panniculitides. T e punch instrument is a circular, hol- can achieve hemostasis and a satis actory linear scar. On the
low, metal cylinder with a cutting edge that is connected ace, using a 5-0 or 6-0 suture can avoid noticeable suture
to a plastic handle. T e specimen size is determined by marks. When larger punch diameters are used, an absorb-
the diameter o the cylinder (range is rom 2 to 8 mm). A able dermal interrupted suture may also be utilized. In areas
sample larger than 2 mm in diameter is generally recom- that are not amenable to sutures, a hemostatic sponge, such
mended. However, in a study o 84 cases o 2 mm punch as Gel oam®, can provide hemostasis when applied to the
biopsies compared to their corresponding excisional speci- biopsy site and then “sealed” with a compression bandage.
128 mens, the dermatopathologist was able to make a correct T is material can be le t in place to degrade on its own.
 these cases, an aggressive subtype was not apparent in the
original biopsy.28
2
In c ISIo n a L bIo PSy
When the lesion in question is large or the pathology is
suspected to be within the deeper dermis or subcutis, an
incisional or wedge biopsy may also be utilized. T e biopsy
specimen may be composed exclusively o lesional tissue
or may contain normal bordering skin. T e skin sample is
usually as wide and as deep as needed to obtain su cient
tissue. A 15 blade is routinely used and a perpendicular
A super cial incision is made on both sides o the area to be
biopsied. T e blade is incised deeply and angled toward

C
h
the central axis until it reaches the appropriate depth. T e

a
p
biopsy tissue should be obtained in one piece to ensure

t
e
precise orientation when processing. Forceps and scissors

r
1
are used to grasp the specimen and detach it. Hemostasis

2
can be obtained with electrosurgery. Deep dermal absorb-

:
:
able sutures and super cial nonabsorbable epidermal

b
sutures may be used to reapproximate the skin edges.

i
o
p
s
y
T
exc ISIo n a L bIo PSy

e
c
h
n
i
An excisional biopsy is an elliptical excision down to

q
u
subcutaneous at used to histologically evaluate a cuta-

e
s
neous lesion in its entirety. T is technique is important
B when biopsying suspected malignant neoplasms, notably
malignant melanoma, in which histopathologic analysis
Figure 12-4 Punch iopsy – A. arrel rotating into skin; o the entire lesion is crucial or diagnosis and staging.
B. specimen li ted with orceps and snipped with gradle It is important to consider the cosmesis o the resulting
scissors.
wound as well. Orienting the tissue along naturally occur-
ring relaxed skin tension lines is recommended. Utilizing a
For thicker anatomic areas or lesions in the subcutane- 15 blade in a perpendicular orientation, an elliptical shape
ous at, the “double punch” technique helps ensure ade- is incised to the subcutaneous at or suspected lesion
quate sampling o the dermal or subcutaneous tissue. In depth. A disc excision can also be per ormed instead. An
this technique, a larger punch instrument is used, ollowed advantage o a disc excision is that it allows the clinician
by a smaller diameter punch into the de ect to sample the to per orm the excisional biopsy rst, and then to deter-
deeper tissue. T is is use ul when biopsying a suspected mine the axis o closure once the tissue has been removed.
panniculitis. Punch instruments can also be used to score With proper undermining, the de ect will naturally align
around a cutaneous lesion or to incise the skin super - in the direction o least tension, or along relaxed skin ten-
cially in areas o thin epidermis. sion lines. T e central portion o the wound is closed with
For large or broad suspected malignant neoplasms a subcutaneous and epidermal sutures a ter which removal
punch biopsy may not accurately de ne the ull extent o o redundant dog-ears can be per ormed (Fig. 12-5a–c). o
the lesion. Russell et al. compared shave biopsies to punch maintain proper orientation o the specimen, a marking
biopsies or the diagnosis o basal cell carcinoma. T e diag- suture can be placed to correlate the histologic margin with
nostic accuracy rates were similar; 80.7% or punch biop- the clinical orientation. When the clinical margin does not
sies (n = 57) and 75.9% or shave biopsies (n = 29). T ere provide su cient histological clearance, the biopsy edges
was no statistically signi cant tendency to overdiagnose will be involved with tumor and an additional excisional
or underdiagnose any particular tumor subtype based on procedure will be indicated.
the type o biopsy procedure used.27 Haws et al. reviewed Since the degree o atypia or depth o invasion is
232 biopsy specimens and their corresponding wide exci- o ten not uni orm in malignant lesions, excisional biop-
sions to determine the correlation between basal cell car- sies decrease the risk o sampling error. Egnatios et al.29
cinoma subtypes in these specimens. Eighty-eight percent reviewed 609 melanoma biopsy specimens, o which 51%
(205/232) were shave biopsies and 12% (27/232) were were shaves, 19% punches, and 30% excisions. Residual
punch biopsies; the total specimen accuracy rate was 82%. melanoma was seen in 240 patients (39%) a ter de nitive
Mixed histological subtypes were present in 54% o cases, wide local excision; 60% o these had undergone a shave
and hal contained an aggressive subtype (in ltrative, mor- biopsy. en percent (59 patients) had a tumor ( )-category
phea orm, or micronodular). T ere was an 18% (42/232) upgrade a ter wide local excision; 64% o this group was
discordance rate between the biopsy specimen subtypes sampled by a shave biopsy. Seven percent o patients with
when the growth patterns were mixed. In 40% (17/42) o a -category upgrade had negative margins initially. A 129
2

A
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2
:
:
S
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g
i
c
a
l
S
k
i
l
l
s
Figure 12-5 Excisional iopsy; A. incision over elliptical
C
surgical markings; B. excised tissue; C. f nal sutured line.

positive biopsy margin and greater tumor thickness were T ere is concern that a wide excisional biopsy or a
determined to be predictors o -category upgrade. wide local excision or treatment o melanoma may pre-
Johnson et al. studied the impact o incisional biopsy on clude the use o a subsequent sentinel lymph node biopsy
melanoma microstaging. O 1783 patients who underwent by disrupting lymphatic drainage. O 1395 patients who
an incisional biopsy, 250 (14%) presented with a residual had lymphatic mapping/sentinel lymph node biopsies
lesion; the mean Breslow’s depth in this group was 0.66 mm or malignant melanoma, Gannon et al.32 identi ed 104
compared to a mean Breslow’s depth o 1.07 mm (p = 0.001) patients who had wide local excision be ore sentinel node
a ter complete excision. Upstaging, which was associated biopsy and compared them to patients who had had con-
with a poorer prognosis because o a signi cant change in comitant procedures. In 97/104 (93%), the surgical de ects
Breslow’s depth or the presence o ulceration a ter comple- were closed primarily or with a skin gra t, while seven
tion excision, occurred in 53 o 250 patients (21%).30 A shave patients (7%) had rotation f aps. Median ollow-up was 51
biopsy signi cantly increased the odds o upstaging a ter months. In the previously excised group, 19 patients (18%)
excision o the residual lesion compared to the use o a punch had a positive sentinel lymph node biopsy and our o these
biopsy. Shave biopsies increased the odds o upstaging by 2.3 (21%) had recurrences (three distant ailures and one local
compared with punch biopsies (OR = 2.3; 1.03–5.20). and distant ailure). T ere were no lymph node recurrences
Similarly, in 2010, Ng et al. compared partial and exci- in a mapped or unmapped basin in the 104 patients with a
sional biopsy techniques or accuracy o histopathological negative or positive sentinel node. T e authors concluded
diagnosis and microstaging o cutaneous melanoma rom that sentinel lymph nodes can be success ully identi ed
1995 to 2006.31 T ey reported increased odds o histopath- and accurately ref ect the regional lymph node drainage
ologic misdiagnosis associated with using a punch biopsy status in melanoma patients who have already had wide
(OR, 16.6; 95% CI, 10– 27) (p < 0.001), or shave biopsy local excisions. However, the e ectiveness o sentinel
(OR, 2.6; 95% CI, 1.2– 5.7) (p = 0.02), compared to an exci- node mapping and sampling in patients who have under-
sional biopsy. Speci c subgroups were associated with an gone extensive reconstruction o the primary excision
increased likelihood o misdiagnosis, including acral len- site remains to be de ned. Leong et al. reported similarly
tiginous melanoma (OR, 5.1; 95% CI, 2– 13) (p < 0.001), that sentinel lymph node biopsies could be success ully
desmoplastic melanoma (OR, 3.8; 95% CI, 1.1– 13.0) per ormed a ter wide excision or truncal and extrem-
(p = 0.03), and nevoid melanoma (OR, 28.4; 95% CI, ity melanomas with no di erence in relapse- ree survival
7– 115) (p < 0.001). T e rates o microstaging inaccuracy (p = 0.209) or overall survival (p = 0.692). T ey reported
by punch biopsy (34%) and shave biopsy (19%) were com- a single alse-negative result, which occurred in a patient
130 parable to other reported rates o 16% to 43%. whose truncal excision was closed with a rotation f ap.33
 T e need to assess the depth o a suspected malignancy
applies to cutaneous squamous cell carcinoma as well. In
Sc a LP
2
2010 the American Joint Committee on Cancer published
revised staging guidelines or cutaneous squamous cell Scalp biopsies may be per ormed or analysis o ollicu-
carcinoma. Based on evidence-based data, new high-risk lar disorders. T e ideal biopsy should go to the depth o
eatures included: greater than 2 mm tumor thickness, the subcutis to ensure that the entire ollicle is sampled.
Clark level greater than IV, perineural invasion, anatomic O ten punch biopsies are the technique o choice. I the
site, and degree o histological di erentiation. When biop- punch diameter is large enough the biopsy can be bisected,
sying a suspected cutaneous squamous cell carcinoma, allowing the pathologist to cut one-hal o it in transverse
the physician should choose the technique that will allow sections. It has been reported that noncicatricial alopecias
the best measurement o tumor depth as this will have may be better appreciated on transverse sections while
implications or tumor staging. scarring alopecias may be better diagnosed on longitudi-
nal sections.35 T e plane o the biopsy should be parallel
to the growing hair sha ts to avoid ollicle transection and
SPec Ia L SIt eS resultant alopecia.

C
Since the scalp has a rich vascular supply, taking time

h
a
h ea d /n ec k or the vasoconstrictive e ect o epinephrine in the local

p
t
e
anesthetic to occur is recommended. A cross-over stitch,

r
1
It is important to exercise caution when per orming or cutaneous gure o eight stitch, may produce the

2
biopsies in certain anatomical areas o the head and desired hemostasis. It may be help ul to place the sutures

:
be ore per orming the biopsy36 so that the suture can be

:
neck. T e super cial temporal branch o the acial nerve
tied as soon as the tissue is removed. Using rapidly dissolv-

b
lies just below the thin dermis and subcutaneous at in

i
o
the so-called “danger area.” T is location lies midway ing sutures will circumvent the need or suture removal in

p
s
between the lateral eyebrow and anterior temporal hair- an area obscured by hair growth. Gel oam is a quick and

y
T
e ective hemostatic agent that can be easily placed into

e
line (the area ormed by drawing a line rom the tragus to

c
the punch biopsy wound as an alternative to sutures.

h
the lateral eyebrow and a line rom the tragus to highest

n
i
orehead rhytid). T e spinal accessory nerve also courses

q
u
super cially in the posterior triangle at Erb’s point, where Pa LmS/So LeS

e
s
the posterior edge o the sternocleidomastoid muscle
meets a perpendicular line drawn midway rom a line When per orming biopsies on the palms, soles, digits, or
connecting the angle o the jaw and the mastoid process. toes it has been shown that local anesthesia with epineph-
Anatomical variations exist, so caution is advised in these rine is sa e to use.37 However, an excessive volume o liq-
areas.34 T e third acial danger zone is in the location uid can cause tamponade o the vessels in a closed space
o the marginal mandibular ner ve that courses super- such as the digit or toe. Addition o epinephrine actually
cially as it exits the parotid gland at the angle o the allows or lower anesthetic volumes to be used.38 Cor-
mandible. As it crosses that angle, the ner ve is only cov- rect injection technique, such as aspirating to avoid ves-
ered by skin, subcutaneous at, and super cial muscular sel penetration, and proper selection o patients (absence
aponeurosis (SMAS). Most individuals have a marginal o thrombotic or vasospastic conditions or uncontrolled
mandibular ner ve that remains at or above the level o hypertension) helps to minimize possible complications.
the mandible, although in about 20% o people this nerve
can descend 1 to 2 cm into the neck below the angle o
the mandible. g en It a L SkIn
T e rich vasculature o the upper and lower lip is an
important consideration or biopsies in this location. T e Genital skin, like lip mucosa, has the tendency to heal well
superior and in erior labial arteries are branches o the a ter cutaneous biopsy i proper technique is used. T e
acial artery, which arises rom the external carotid artery. texture o the genital skin may make it di cult to obtain
T e labial arteries are ound deep to the lip mucosa but clean cuts with a scalpel, so using non-toothed orceps and
can course more super cially in older patients. T e lip gradle scissors may be used instead. When per orming a
has a bidirectional blood source due to anastomoses and punch biopsy, it is important not to advance the punch too
bleeding must be anticipated. A chalazion clamp may help deeply as it may penetrate underlying structures. Using
to control bleeding while also stabilizing the tissue. T is the punch instrument to score the site to a super cial
added tension can acilitate easier sampling. Another way depth either on the glans penis, penile sha t, or vulva, and
to avoid traumatizing the biopsy sample is to use gradle then using gradle scissors to snip the scored biopsy speci-
scissors to sample the intended site. Sometimes a “bleb” o men will help to obtain the tissue more readily.
anesthesia may elevate the plane o the lesion acilitating
easier procurement. Silk may be used as the suture mate-
rial due to its so t nature and ease o handling. T e mucosa Wo u n d d r eSSIn g S
o the lip heals well as long as the vermillion border has
not been violated. Involvement o the vermillion border Postbiopsy wound care is essential or proper healing and
may create a more visible scar. prevention o in ection. For clean biopsy wounds, petrola-
When per orming biopsies o the ear, it is important to tum is recommended over a topical antibiotic or wound
prevent the exposure o cartilage to minimize the risk o care. T ere are many types o dressings that can be placed,
in ection or chondritis. including pressure dressings or added hemostasis, or 131
2 di erent colloid dressings or exudative wounds. For a
comprehensive review, see chapter 11.
occur in areas such as the back even when the de ect is
closed primarily, due to the orce o muscle movement.
Suture marks can also be unsightly; use o rapidly dis-
solving sutures or the timely removal o nondissolvable
t ISSu e Pr o c eSSIn g sutures can lessen this risk. Persistent numbness or pain
may also rarely complicate the postbiopsy course.
T e skin biopsy is generally processed in standard 10%
ormalin or para n embedding and stained with an array
o histological stains, including antibodies or immuno- c o n c Lu SIo n
histochemistry. For DIF, it is important to check with the
histopathology lab or their pre erence o media. Many T e skin biopsy is an essential diagnostic tool or the
labs pre er transport media such as Michel’s medium or practicing dermatologist and dermatologic surgeon.
normal saline. For DIF evaluation, selection o the lesion Appropriate site and lesion selection, choosing the best
to be biopsied is o great importance. For presumed dis- biopsy method, and using proper surgical technique will
coid lupus, porphyria, or drug-induced pseudoporphyria,
S
all enhance the diagnostic yield with a minimum o com-
e
the sample is taken rom exposed lesional skin, whereas
c
plications. Preoperative evaluation and in ormed consent
t
i
or systemic lupus erythematous a biopsy rom exposed
o
should be obtained and the use o standardized digital
n
normal skin is more appropriate. For cutaneous vasculitis, photography is recommended or comprehensive docu-
2
such as Henoch Schönlein purpura, lesional skin o less mentation. Patient expectations should be addressed to
:
:
than 24 hours’ duration is optimal. For suspected pemphi- avoid any misconceptions about the procedure. While
gus or pemphigoid skin lesions the sample is taken rom
S
skin biopsies are generally low risk, universal precautions
u
the edge o an intact bulla along with perilesional skin; or
r
should always be ollowed and each patient should be
g
i
oral mucosal lesions a perilesional biopsy should be taken.
c
assessed to minimize the risks due to anesthesia, in ection,
a
l
In dermatitis herpeti ormis, the optimal DIF sample or poor wound healing.
S
k
would be clinically normal perilesional skin.39 With advances in cutaneous imaging such as dermos-
i
l
l
s
Other diagnostic techniques that may be per ormed on copy and con ocal microscopy, visualization o lesional
processed tissue include polymerase chain reaction (PCR) architecture and cellular atypia may decrease the need or
based analysis o -cell receptor gene rearrangement to cutaneous biopsies. However, the skin biopsy will likely
assess clonality in cutaneous lymphomas. Cultures may remain the best diagnostic tool or cutaneous lesions or
also be per ormed on fresh un xed tissue or the detection many years to come.
o various in ectious organisms, such as bacterium, ungi,
mycobacterium, and protozoa.
a c k n o WLed g men t
c o mPLIc a t Io n S
We would like to thank Indira Singh or her help with the
Although complications o a biopsy can include in ection, gures and illustrations.
bleeding, and scar, the small sample o tissue taken less-
ens the degree to which these occur. Hemorrhage rom
r ef er en c eS
the biopsy site, while uncommon, usually occurs within 24
hours, and the patient should be educated regarding how 1. Dengel L, urza K, Noland MM, Patterson JW, Slinglu CL
to apply pressure to the area. Jr. Skin mapping with punch biopsies or de ning margins
T e in ection rate seen a ter cutaneous biopsies is ortu- in melanoma: when you don’t know how ar to go. Ann Surg
nately very low. Biopsies below the knee, areas a ected by Oncol. 2008;15:3028– 3035.
2. ziotzios C, Pro yris C, Sterling J. Cutaneous scarring: patho-
lymphedema, intertriginous areas or skin olds, and areas
physiology, molecular mechanisms, and scar reduction thera-
involving cartilage are more likely to develop in ection. peutics Part II. Strategies to reduce scar ormation a ter der-
Despite the low risk o in ection, many patients still use matologic procedures. J Am Acad Dermatol. 2012;66:13– 24.
antibiotic creams or ointments, which can lead to irritant 3. Stables G, Lawrence CM. Management o patients taking
or allergic contact dermatitis and delayed wound healing. anticoagulant, aspirin, non-steroidal anti-inf ammatory and
other anti-platelet drugs undergoing dermatological surgery.
Smack et al.40 compared the application o topical bacitra-
Clin Exp Dermatol. 2002;27:432– 435.
cin to petrolatum a ter various dermatologic procedures 4. Callahan S, Goldsberry A, Kim G, Yoo S. T e management
and ound no statistically signi cant di erence in the rate o antithrombotic medication in skin surgery. Dermatol Surg.
o surgical site in ections. T e in ections that did occur in 2012;38:1417– 1426.
the bacitracin cohort were caused by gram-negative bacilli, 5. Alcalay J. Cutaneous surgery in patients receiving war arin
therapy. Dermatol Surg. 2001;27:756– 758.
which were likely a result o the selective removal o gram-
6. Cook-Norris RH, Michaels JD, Weaver AL, et al. Complica-
positive skin f ora. T e bacitracin group also had a higher tions o cutaneous surgery in patients taking clopidogrel-
incidence o allergic contact dermatitis. Since petrolatum containing anticoagulation. J Am Acad Dermatol. 2011;65:
has been shown to be bene cial in speeding reepithelial- 584– 591.
ization and promoting the growth o natural skin f ora, it 7. Lewis KG, Du resne RG Jr. A meta-analysis o complications
attributed to anticoagulation among patients ollowing cuta-
may be used or wound care ollowing routine biopsies.
neous surgery. Dermatol Surg. 2008;34:160– 164.
Scars, whether depressed, hypertrophic, or keloidal, are 8. Wright I, Baddour LM, Berbari EF, et al. Antibiotic prophy-
potential complications o a biopsy and the patient should laxis in dermatologic surgery: advisory statement 2008. J Am
132 understand these risks. Atrophic or spreading scars can Acad Dermatol. 2008;59:464– 473.
 9. National Institute or Health and Clinical Excellence. Pro-
phylaxis against in ective endocarditis: antimicrobial pro-
26. odd P, Garioch JJ, Humphreys S, Seywright M, T omson J,
du Vivier AW. Evaluation o the 2-mm punch biopsy in der-
2
phylaxis against in ective endocarditis in adults and children matological diagnosis. Clin Exp Dermatol. 1996;21:11– 13.
undergoing interventional procedures. London;2008. http:// 27. Russell EB, Carrington PR, Smoller BR. Basal cell carcino-
www.nice.org.uk/ nicemedia/ pd / CG64NICEguidance.pd . ma: a comparison o shave biopsy versus punch biopsy tech-
Accessed September 23, 2013. niques in subtype diagnosis. J Am Acad Dermatol. 1999;41:
10. Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospective study 69– 71.
o wound in ections in dermatologic surgery in the absence o 28. Haws AL, Rojano R, ahan SR, Phung L. Accuracy o biopsy
prophylactic antibiotics. Dermatol Surg. 2006;32:819–826. sampling or subtyping basal cell carcinoma. J Am Acad Der-
11. Perlis CS, Campbell RM, Perlis RH, Malik M, Du resne RG Jr. matol. 2012;66:106– 111.
Incidence o and risk actors or medical malpractice lawsuits 29. Egnatios GL, Dueck AC, Macdonald JB, et al. T e impact o
among Mohs surgeons. Dermatol Surg. 2006;32:79– 83. biopsy technique on upstaging, residual disease, and outcome
12. McGinness JL, Goldstein G. T e value o preoperative biopsy- in cutaneous melanoma. Am J Surg. 2011;202:771– 777.
site photography or identi ying cutaneous lesions. Dermatol 30. Karimipour DJ, Schwartz JL, Wang S, et al. Microstaging
Surg. 2010;36:194– 197. accuracy a ter subtotal incisional biopsy o cutaneous mela-
13. Veiga DF, Damasceno CA, Veiga-Filho J, et al. Povidone io- noma. J Am Acad Dermatol. 2005;52:798–802.
dine versus chlorhexidine in skin antisepsis be ore elective 31. Ng JC, Swain S, Dowling JP, Wol e R, Simpson P, Kelly JW. T e

C
plastic surgery procedures: a randomized controlled trial. impact o partial biopsy on histopathologic diagnosis o cuta-

h
Pla st Reconstr Surg. 2008;122:170e– 171e. neous melanoma: experience o an Australian tertiary re erral

a
p
14. ucker KJ, Larson JL, Idris A, Curtis AB. Advanced cardiac service. Arch Dermatol. 2010;146:234– 239.

t
e
li e support: update on recent guidelines and a look at the u- 32. Gannon CJ, Rousseau DL Jr, Ross MI, et al. Accuracy o lym-

r
1
ture. Clin Cardiol. 1995;18:497– 504. phatic mapping and sentinel lymph node biopsy a ter previ-

2
15. Darmstadt GL, Hossain MM, Choi Y, et al. Sa ety and e ect ous wide local excision in patients with primary melanoma.
o chlorhexidine skin cleansing on skin f ora o neonates in Cancer. 2006;107:2647– 2652.

:
:
Bangladesh. Pediatr Infect Dis J. 2007;26:492–495. 33. Leong WL, Ghazarian DM, McCready DR. Previous wide lo-

b
16. Bibbo C, Patel DV, Gehrmann RM, Lin SS. Chlorhexidine pro- cal excision o primary melanoma is not a contraindication

i
o
vides superior skin decontamination in oot and ankle surgery: or sentinel lymph node biopsy o the trunk and extremity. J

p
s
a prospective randomized study. Clin Orthop Relat Res. 2005; Surg Oncol. 2003;82:143– 146.

y
438:204– 208. 34. Symes A, Ellis H. Variations in the sur ace anatomy o the

T
e
17. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine- spinal accessory nerve in the posterior triangle. Surg Radiol

c
h
Alcohol versus povidone-iodine or surgical-site antisepsis. N Anat. 2005;27:404– 408.

n
i
Engl J Med. 2010;362:18– 26. 35. Ozcan D, Ozen O, Seckin D. Vertical vs. transverse sections

q
u
18. Dzubow LM. T e interaction between propranolol and epi- o scalp biopsy specimens: a pilot study on the comparison o

e
s
nephrine as observed in patients undergoing Mohs’ surgery. J the diagnostic value o two techniques in alopecia. Clin Exp
Am Acad Dermatol. 1986;15:71–75. Dermatol. 2011;36:855– 863.
19. Wilhelmi BJ, Blackwell SJ, Miller J, Mancoll JS, Phillips LG. 36. McKerrow KJ, Grande DJ. Figure eight closure. J Am Acad
Epinephrine in digital blocks: revisited. Ann Pla st Surg. Dermatol. 1991;24:146– 148.
1998;41:410– 414. 37. Firoz B, Davis N, Goldberg LH. Local anesthesia using bu -
20. Eggleston S , Lush LW. Understanding allergic reactions to ered 0.5% lidocaine with 1:200000 epinephrine or tumors o
local anesthetics. Ann Pharmacother. 1996;30:851– 857. the digits treated with Mohs micrographic surgery. J Am Acad
21. Palm MD, Altman JS. opical hemostatic agents: a review. Dermatol. 2009;61:639– 643.
Dermatol Surg. 2008;34:431– 435. 38. Krunic AL, Wang LC, Soltani K, Weitzul S, aylor RS. Digi-
22. Voutsalath MA, Bichakjian CK, Pelosi F, Blum D, Johnson tal anesthesia with epinephrine: an old myth revisited. J Am
M, Farrehi PM. Electrosurgery and implantable electronic Acad Dermatol. 2004;51:755– 759.
devices: review and implication or o ce-based procedures. 39. Minz RW, Chhabra S, Singh S, Radotra BD, Kumar B. Di-
Dermatol Surg. 2011;37:889– 899. rect immunof uorescence o skin biopsy: perspective o an
23. Senthuran S, o WD, Vuylsteke A, Solesbury PM, Menon immunopathologist. Indian J Dermatol Venereol Leprol.
DK. Implanted cardiac pacemakers and de brillators in an- 2010;76:150– 157.
aesthetic practice. Br J Anaesth. 2002;88:627–631. 40. Smack DP, Harrington AC, Dunn C, et al. In ection and al-
24. Stevens G, Cocherell CJ. Avoiding sampling error in the biop- lergy incidence in ambulatory surgery patients using white
sy o pigmented lesions. Arch Dermatol. 1996;132:1380– 1382. petrolatum vs bacitracin ointment. A randomized controlled
25. Abbasi NR, Shaw HM, Rigel DS, et al. Early diagnosis o trial. JAMA. 1996;276:972– 977.
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2004;292:2771– 2776.

133
 Ch a p t e r

13 Hemostasis
Wil r d A. Lum ang, M ghan Schar , &Th mas Stask

In t r o d u c t Io n aggregate at the site o injury, they induce actors that ur-

ther potentiate vasoconstriction. T romboxane A2, made
rom arachidonic acid on platelet membranes; endothelin,
Management o bleeding is undamentally important in
released rom the injured endothelium; and serotonin,
any surgical procedure. Historically, surgeons applied
released rom activated platelets, are all power ul vasocon-
boiling oil solution and soothing balms to detoxi y and
strictors. Bradykinin and brinopeptides, both involved in
cauterize wounds. It was in the sixteenth century that the
the coagulation scheme, are also capable o contracting
French surgeon, Ambroise Paré, revolutionized the prac-
vascular smooth muscle.2
tice o surgery by introducing the use o vascular ligatures
to control bleeding in amputations, sucking chest wounds
and chronic ulcers.1 T e elds o medicine and surgery Pl a t el e t Pl u g f o r ma t Io n
have undergone signi cant trans ormation since then.
Dermatologic surgeons have become more cognizant o T ere are three steps necessary or e ective platelet plug
hemostasis because they now per orm invasive o ce- ormation – platelet adhesion, granule release, and platelet
based procedures, o ten on patients with complicated aggregation. Injury to the intima o a vessel wall exposes
medical histories. Adequate control o bleeding during collagen brils in the subendothelium, leading to plate-
these procedures is vital to achieving optimal outcomes. let adherence. T is process requires von Willebrand ac-
T e overall sa ety o dermatologic surgery is well estab- tor (vWF), a subendothelial protein that cements platelet
lished, but complications do arise and are o ten attribut- adhesion by binding to glycoprotein receptors on the plate-
able to bleeding. let membrane.3
T is chapter will review the principles o hemostasis as Platelet adhesion is ollowed by activation, whereby
they relate to cutaneous surgery. Normal hemostasis, as the release o storage granules is initiated. T e granules
well as disorders, medications, and supplements that a ect contain important signaling actors, including adenosine
hemostasis will be discussed. Various surgical approaches diphosphate (ADP), calcium, serotonin, thromboxane
and relevant hemostatic agents used to control bleeding A2, and α-granule proteins. T ese mediate the recruit-
during procedures will be presented. ment o circulating platelets to the site o injury caus-
ing platelet aggregation, with ADP playing a critical role.
ADP causes con ormational changes in glycoprotein IIb/
BIo l o g y o f n o r ma l IIIa to allow or binding o brinogen, a key component
Hemo s t a s Is in the ormation o the brin clot. Platelets adhere to one
another via the glycoprotein IIb/ IIIa receptor- brinogen
Understanding the principles behind hemostasis can complex.3
lead to better utilization o the various tools available As a result o platelet adhesion and aggregation, phos-
to achieve hemostasis during dermatologic surgery. It is pholipase C and A2 are activated, producing arachidonic
also important to understand the mechanisms behind acid. Cyclooxygenase trans orms arachidonic acid to pros-
the medications that alter coagulation. T e hemostatic taglandin, which is converted to thromboxane A2. T rom-
process can be divided into our physiologic events that boxane A2 is a potent vasoconstrictor and rein orces
are intimately linked and occur in conjunction with each platelet aggregation by stimulating platelet activation and
other – vasoconstriction, platelet plug ormation, brin degranulation.3
clot ormation, and brinolysis. A schematic o normal T e result o the release reaction is compaction o
hemostasis is shown on Figure 13-1, and is discussed in platelets into a plug. Concurrently, alterations occur in the
detail below. phospholipids o the platelet membrane allowing calcium
and clotting actors to bind to the platelet sur ace, which
is important in the ormation o active complexes o the
Va s o c o n s t r Ic t Io n coagulation pathways.2

Damage to blood vessels during surgery precipitates the

process o hemostasis. Vascular constriction is the initial f IBr In c l o t f o r ma t Io n
response to this injury and is dependent on local con-
traction o smooth muscle. T is process is closely linked Although platelet plug ormation occurs within seconds o
to platelet plug ormation. When platelets adhere and injury, the brin clot orms over several minutes, ollowing
 2
Ve s s e l injury

1 Va s ocons triction

P la te le t a ctiva tion Coa gula tion ca s ca de

S ube ndothe lia l colla ge n

Intrins ic Extrins ic
pa thway pa thway
VWF

C
h
a
P la te le t a dhe s ion Clotting fa ctors Tis s ue fa ctor

p
VIII, IX, XI, XII fa ctor VII

t
e
r
1
3
Common
P la te le t gra nule re le a s e pa thway

:
:
Glycoprote in ADP, s e rotonin, Prothrombin

H
e
IIb/Illa Ca 2 +, fibrinoge n

m
Fa ctor X, VII

o
s
t
P la te le t a ggre ga tion

a
Thrombin

s
i
s
P la te le t plug Fibrinoge n Fibrin
2
forma tion

Fibrin clot
3
polyme riza tion

4 Fibrinolys is

Figure 13-1 Schematic of the four interrelated physiologic processes of hemostasis. vWF, von
Willebrand factor; ADP, adenosine diphosphate; Ca 2+, calcium)

a series o steps through what is known as the coagulation f brinogen to f brin, which then polymerizes to orm the
cascade. T e f nal product is a stabilized hemostatic plug. f brin clot.3,4
Fibrin clot ormation involves two exquisitely regulated
pathways. T e intrinsic pathway begins with actor XII,
and through a series o enzymatic reactions, leads to acti-
vation o actors XI, IX, and VIII.3 T e intrinsic pathway Fibr in o l ys is
components are intrinsic to the circulating plasma and do
not require a sur ace to initiate the process. T e extrin- In addition to the clot ormation that must occur to pre-
sic pathway, however, can only be initiated upon expo- vent bleeding at the time o vascular injury, two related
sure o tissue actor on the injured vessel wall, and begins processes exist to prevent clot propagation beyond the site
when tissue actor activates actor VII in the presence o o injury. First, there is eedback inhibition on the coagu-
calcium. Ultimately, the two converge to a common lation cascade, which deactivates the enzyme complexes
pathway with activation o actor X, which converts pro- leading to thrombin ormation. Second, mechanisms o
thrombin to thrombin. Although thrombin has several f brinolysis allow or f brin clot breakdown and subse-
unctions, its most important role is in trans orming quent repair o the injured vessel.2 135
2 During wound healing, the brin clot is lysed to restore
blood f ow. T e main enzyme in this process is plasmin,
o vascular injury. here are, however, disorders o
hemostasis that can complicate surgical procedures.
which degrades the brin mesh. Plasmin is converted rom hese disorders may be inherited or acquired. Integral
plasminogen by several activators, including tissue plas- to dermatologic surger y should be proper screening
minogen activator and urokinase plasminogen activator. o patients or these disorders. A preoperative histor y
Other mechanisms ensure that brinolysis occurs at a should be taken, including medical conditions, medi-
controlled rate and pre erentially at the site o clot orma- cations, allergies, and amily histor y. Although it may
tion. For example, tissue plasminogen activator is more not be necessar y to ask about speci ic disorders, sim-
e cient when bound to brin, so that plasmin is ormed ple historical questions can provide hints to underlying
selectively on the clot. T ere are also plasmin inhibitors, bleeding disorders. For example, a histor y o nosebleeds
such as α2-antiplasmin, which ensure that clot lysis does or excessive bleeding with tooth loss should be elicited
not occur too quickly.2 in children. In women, menorrhagia is o ten a clue to
an underlying condition. A amily histor y o excessive
bleeding with procedures may indicate the presence
d Is o r d er s o c o a g u l a t Io n o an inherited coagulation disorder. As with all dis-
S
orders o coagulation, consultation and management
c
t
i
Several physiologic antithrombotic mechanisms exist with a hematologist is highly recommended. able 13-1
o
n
to prevent clotting under normal circumstances. hey lists some o the more common disorders that a ect
2
preser ve blood luidity and localize clotting to sites hemostasis.
:
:
S
u
r
g
i
c
TAbLe 13-1
a
l
S
3,5,6
I h i a q i di a i H i
k
i
l
l
s
c ii u yi d f i y m
Inherited
von Will rand dis as Typ 1 D smopr ssin (DDAVP) pr op rativ ly
vWF and Factor VIII l v ls low Conc ntrat d vWF and Factor VIII in usion
Most common and mild st
Typ 2
vWF l v ls normal, ut dys unctional
Four su typ s: 2A, 2b, 2M, 2N
Typ 3
vWF a s nt
Factor VIII l v ls low
Plat l t disord rs Dys unctional Gp I /IX r c ptor Consultation with h matologist r comm nd d
b rnard—Souli r Plat l t adh sion d ct
Glanzmann throm asth nia Dys unctional Gp II /IIIa r c ptor
Plat l t aggr gation d ct
H mophilia A Factor VIII d f ci ncy Factor VIII r plac m nt +/− DDAVP
X link d r c ssiv 50 U/kg initially, th n 25 U/kg q12h
H mophilia b (Christmas Factor IX d f ci ncy Factor IX r plac m nt
dis as ) X link d r c ssiv
H mophilia C (Ros nthal Factor XI d f ci ncy Daily r sh roz n plasma in usions
syndrom ) Autosomal r c ssiv , Ashk nazi J ws
Acquired
Ur mia Impair d plat l t unction
Spl nom galy Plat l t s qu stration
bon marrow ailur Low plat l t production Plat l t in usion
Autoimmun throm ocytop nia Idiopathic, drug induc d or s condary to Glucocorticoids, c ssation o drug
viral in ction; autoanti odi s orm d against
plat l ts
Liv r ailur A normal synth sis o vitamin K d p nd nt
clotting actors
Factors II, VII, IX, and X

136 vWF, von Will rand Factor; Gp, glycoprot in.

 In Her It ed d Is o r d er s
likrein can result in prolonged P , but patients have nor-
mal hemostasis and do not require plasma replacement or
2
o f Hemo s t a s Is surgery. Activation o the extrinsic pathway via tissue actor
VIIa complex is su cient or hemostasis in these patients.3
PLATeLeT DISo RDeRS. Approximately 1% o the
population is a ected with von Willebrand disease, mak-
ing it the most common congenital bleeding disorder. a c q u Ir ed d Is o r d er s
However, only 10% o patients experience signi cant bleed- o f Hemo s t a s Is
ing.5 As discussed above, vWF plays a key role in platelet
aggregation. Patients with von Willebrand disease can CHRo NIC DISeASeS. Disorders o hemostasis can
either have low, dys unctional, or absent vWF. Most com- be acquired due to chronic disease or use o medica-
monly, patients have low levels and mild disease. Surgical tions a ecting critical steps in the hemostatic pathways.
prophylaxis with desmopressin or 1-desamino-8-arginine Patients with uremia and paraproteinemias may have
vasopressin (DDAVP) causes release o endothelial stores excessive bleeding due to dys unctional platelets. Patients
o vWF and is e ective in 80% o patients. wenty percent with bone marrow ailure due to malignancies can have

C
h
o patients with severe disease require selective actor VIII low platelet levels. T ere are autoimmune conditions that

a
p
replacement, which contains high levels o vWF. reatment can cause thrombocytopenia, which are easily treated

t
is recommended or 3 to 5 days a ter minor surgery, and or with glucocorticoids or cessation o the o ending agents.

r
1
up to 10 days ollowing major surgery.5 Patients with liver disease rom alcoholic or nonalcoholic

3
Other rare inherited disorders o platelet unction exist, related causes can have coagulopathies due to abnormali-

:
:
including de ciencies in platelet receptors and abnormali- ties in vitamin K-dependent clotting actors ( able 13-1).

H
ties associated with platelet granules. Bernard–Soulier syn-
MeDICATIo NS.

m
drome is the absence or dys unction o the glycoprotein Ib/ Most acquired coagulation de -
IX receptor. Glanzmann thrombasthenia is the absence or ciencies are secondary or related to medications. O ten

s
t
a
dys unction o the Gp IIb/IIIa receptor. T ese two inher- patients are on medications that may a ect hemostasis. A

s
i
s
ited disorders cause severe platelet dys unction resulting ull list o medications including supplements and herbal
in abnormal plug ormation, and therapy is always needed products is important to obtain. Understanding the mech-
prior to surgery.6 anism o action o these medications is important to prop-
erly address potential hemostasis issues prior to surgery.
Co AGULATIo N CASCADe DISo RDeRS. Medications can be subdivided into platelet inhibitors or
Disorders o the coagulation cascade pathways can be coagulation actor inhibitors. able 13-2 lists these medi-
inherited or acquired. Most o the inherited disorders o cations.
coagulation involve a single component o the coagulation Platelet inhibitors a ect hemostasis by inhibiting enzymes
cascade, the most common being actor VIII de ciency or or receptors that are critical in platelet activation, adhesion,
hemophilia A. T is is an X-linked recessive disorder a ect- aggregation, and ultimately plug ormation. T ese agents are
ing one in 10,000 males. Levels o actor VIII below 5% are used in treating coronary artery disease, peripheral vascular
usually seen in patients with symptomatic disease; however, disease, or strokes. Some patients use these medications as
patients can present with milder disease with levels up to a means o preventing such conditions rom occurring. T e
25%. Severe disease is seen with levels below 1%, which most common drug used is aspirin, an irreversible cyclooxy-
o ten causes bleeding even without discernible trauma. genase inhibitor o ten taken in combination with other
Patients with hemophilia A will characteristically bleed into antiplatelet agents. T ienopyridines are a class o drugs that
so t tissues, muscles, and weight-bearing joints. Postsurgi- reversibly inhibits ADP-receptor binding to decrease platelet
cal bleeding is o ten delayed, occurring hours to days later; aggregation. Clopidogrel (Plavix) is widely used and recog-
large hematomas may orm.3 reatment with plasma prod- nized. Prasugrel (E ent) is a newer drug that is more potent
ucts enriched with actor VIII prior to surgery is key. T e than clopidogrel.7 Dipyridamole (Persantine) actually has no
use o desmopressin (DDAVP) will also transiently increase clinical e ects on hemostasis even though it has anti-platelet
the level o actor VIII by two- to three old.5 activity. However, when mixed with aspirin (Aggrenox), it
Hemophilia B (Christmas disease) is an X-linked reces- can impair hemostasis. T is drug is used ollowing mechani-
sive disorder caused by de ciency o actor IX. It occurs cal heart valve placement and in stroke patients.
in 1 in 100,000 males. Clinically hemophilia B is indis- Prior to 1993, guidelines or dermatologic surgery were
tinguishable rom hemophilia A. Factor IX replacement to stop antiplatelet agents up to 7 to 10 days prior to sur-
therapy is the treatment.5 Factor XI de ciency (Rosenthal gery.8 In recent years, the paradigm has shi ted to support
Syndrome) is inherited in an autosomal recessive ashion continuing medically necessary aspirin. Although the use
and is most commonly seen in Ashkenazi Jews. In contrast o these antiplatelet agents can elevate the risk o bleed-
to actors VIII and IX, levels o actor XI do not correlate ing,8– 12 temporary cessation can result in li e-threatening
well with propensity or bleeding. Perioperative treatment complications. Reports o thrombotic complications such
with daily in usions o resh- rozen plasma is needed.3 as strokes, transient ischemic attacks, myocardial in arc-
De ciencies o actors V, VII, X, and II (prothrombin) are tions, and pulmonary emboli have been widely publi-
exceedingly rare autosomal recessive conditions. T erapy cized.10,13,14 As a result, it is now recommended to continue
with resh- rozen plasma is indicated or surgical procedures, medically necessary aspirin in patients undergoing cuta-
although concentrated prothrombin may also be utilized.3 neous surgery. I aspirin is used primarily or prophylaxis
Inherited de ciencies o the intrinsic pathway involving or pain management, discontinuation 7 to 10 days prior to
actor XII, high– molecular-weight kininogen, and prekal- surgery is recommended. 137
2 TAbLe 13-2
medi tions th t a ffe t He ost sis7–17

medi tion me h nis of a tion co ents

Oral Platelet inhibitors
Aspirin Irr v rsi l inhi iti n Co X 1 and Co X 2 e cts last r li plat l t
D cr as d thr m xan A2 pr ducti n
D cr as d plat l t aggr gati n and
d granulati n
N nst r idal anti in ammat ry drugs R v rsi l inhi iti n Co X 1 and/ r Co X 2 Disc ntinu 2–3 d pri r t surg ry
Thi n pyridin s R v rsi l inhi iti n ADP r c pt r inding Prasugr l m r p t nt than cl pid gr l
Ticl pidin (Ticlid) D cr as d plat l t aggr gati n and
S
Cl pid gr l (Plavix) activati n
c
t
Prasugr l (ef nt)
i
o
n
Dipyridam l (P rsantin ) Ph sph di st ras inhi it r, incr as s cAMP V ry littl ct n h m stasis, unl ss
2
Dipyridam l + Aspirin (Aggr n x) and l cks ADP inding mix d with aspirin
:
D cr as d plat l t aggr gati n
:
Vas dilati n
S
u
r
Parenteral Platelet inhibitors
g
i
c
a
Glyc pr t in II /IIIa inhi it rs Inhi it inding t glyc pr t in II /IIIa Us d in c njuncti n with aspirin and
l
S
A cixima (R Pr ) D cr as d plat l t aggr gati n h parin; us d during acut c r nary
k
i
l
epti atid (Int grilin) syndr m s
l
s
Tir an (Aggrastat)
Oral Coagulation Factor Inhibitors
War arin Inhi its vitamin K p xid r ductas M nit r d with INR
D cr as d uncti n Fact rs II, VII, IX,
and X
Da igatran (Pradaxa) Dir ctly inhi its thr m in N m nit ring r quir d
D cr as d rin rmati n
Rivar xa an (Xar lt ) Fact r Xa inhi it r N m nit ring r quir d
Parenteral Coagulation Factor Inhibitors
H parin, Acc l rat s antithr m in activity, inhi its H parin m nit r d with PTT
L w–m l cular w ight H parin Fact r Xa Administ r d su cutan usly r
(L v n x) intrav n usly
F ndaparinux (Arixtra) Fact r Xa inhi it rs Administ r d su cutan usly, n
m nit ring r quir d

Trad nam s drugs ar in par nth sis.

Glycoprotein IIb/IIIa inhibitors are a newer class o o the risk o death, recurrent myocardial in arction, and
antiplatelet agents and include abciximab (ReoPro), epti - stroke in patients with recent myocardial in arctions. As
batide (Integrilin), and tiro ban (Aggrastat). T ese medi- with antiplatelet agents, there are studies showing ele-
cations are given intravenously and are used in the setting vated risk o bleeding in patients taking war arin.9 T e
o acute coronary syndromes. T ey are, there ore, more previous recommendation was to stop war arin 3 days
commonly encountered in the inpatient setting. prior to surgical procedures. However, given the recorded
Medications can also af ect hemostasis by inhibiting complications o thromboembolic events in patients who
coagulation actors. T e most widely known and used discontinue this medication, it is no longer advisable to
drug in this category is war arin, which inhibits vitamin discontinue it, provided it is within therapeutic range.13,16
K-dependent clotting actors.15 War arin activity is highly INR should be checked within 24 hours be ore surgery to
variable depending on dietary vitamin K intake, liver unc- ensure that levels are not supratherapeutic, in which case
tion, coexisting medical conditions, concurrent medica- the surgery should be delayed until appropriate levels are
tions, and variations in cytochrome activity. T e goal INR reached.
usually ranges rom 2 to 3, unless the indication is or a T ere are newer anticoagulants that dermatologic sur-
mechanical heart valve (2.5– 3.5). Indications or the use geons will likely encounter in their practice. Dabigatran
o war arin include prophylaxis and treatment o venous (Pradaxa) is an oral medication that directly binds to
thrombosis, thrombosis prophylaxis in patients with atrial thrombin, and is indicated or thromboembolic prophylaxis
138 brillation and mechanical heart valves, and reduction in patients with atrial brillation.17 Factor Xa inhibitors are
another new group o antihemostatic drugs. Rivaroxaban
(Xarelto) alls in this category and is taken orally or the
is interesting to note that a signi icant number o surgi-
cal patients use supplements; 22% take herbs and 51%
2
prevention o deep vein thrombosis and thromboembolic use vitamin supplements.18 More and more patients
complications o atrial f brillation. As with the thienopyri- turn to supplements as an alternative to conventional
dines, there is no means o monitoring the level o antico- pharmaceuticals. Because these products are thought
agulation on these newer drugs.17 T eir ability to increase to be naturally occurring, they are perceived to be
bleeding risks during cutaneous surgery as compared to sa e. Many supplements can have an e ect on coagu-
older drugs has yet to be established. lation, and are there ore important to physicians who
per orm surger y. When obtaining a list o medications
rom patients, dermatologic surgeons should also ask
Her Ba l , d Ie t a r y, a n d or over-the-counter drugs and supplements so that
Ho meo Pa t HIc s u PPl emen t s patients can be assessed and counseled regarding their
risk or bleeding.
Supplements come in a variety o orms, including T ere are various proposed mechanisms by which sup-
herbs, botanicals, minerals, vitamins, and hormones. It plements can impair hemostatic unction ( able 13-3).

C
h
a
p
t
TAbLe 13-3

r
1
3
18–22
H b ,di H p hi s pp h a ff H i

:
:
Supplements with Antipla telet Ca pa bility Proposed Couma rin-conta ining Supplements (Continued) Proposed

H
Mechanism Mechanism

m
Arnica Montana A, b R d cl v r (Tri olium pratense)

s
t
bladd rwrack (Fucus vesiculosus) F Sw t cl v r (Melilotus of cinalis, Melilotus alba)

a
s
i
s
Chin s agrim ny (Agrimonia pilosa) A Sw tw druf (Galium odoratum)
Dansh n A, C Supplements with Unknown Antipla telet/
Anticoa gula tion Mecha nisms
D ng quai (Angelica sinensis) C Anis (Pimpinella anisum) Unkn wn/
unc rtain
ev ning primr s (Oenathera biennis) b bil rry (Vaccinium)
Fish il b br m lain
Garlic A, b, C, F Cat’s claw (Uncaria tomentosa)
Ging r b D vil’s claw (Harpagophytum procumbens)
Gingk D Cay nn ruit (Capsicum rutescens)
Gins ng b, C, D C l ry (Apium graveolens)
Gluc samin b Chin s p ny (Paeoniae rubra)
Grap s d xtract A, C, F Ch ndr itin
Gr n t a (Camellia sinensis) b C l us (Solenostemon)
Guarana (Paullinia cupana) b F v r w (Tanacetum parthenium)
H rs ch stnut s d (Aesculus hippocastanum) C Fritillaria cirrhosa
H rs radish (Armoracia rusticana) b, C Geum japonicum
H rs tail rush (Equisetum) C, e Guggul (Commiphora wightii)
Lic ric D Lonicera japonica
o ni n (Allium cepa) b o il wint rgr n (m thyl salicylat )
P ncitrin (Poncirus tri oliate) b, e Papain (Carica papaya)
Scutellaria baicalensis C R d chili p pp r (Capsaicin)
Turm ric r t (Cucuma longa/aromatica) A R ishi ruit (Ganoderma lucidum)
Couma rin-conta ining Supplements St. J hn’s w rt (Hypericum per oratum)
Al al a (Medicago sativa) Similar t Saw palm tt (Serenoa repens)
war arin
F nugr k (Trigonella oenum-graecum) Whit will w (Salix alba)
A, Inhi its c llag n induc d plat l t aggr gati n; b, Inhi its thr m xan rmati n; C, Inhi its ad n sin diph sphat ; D, Inhi its plat l t
activating act r; e, Inhi its thr m in; F, inhi its rin rmati n. 139
2 Some can a ect platelet unction via inhibition o plate-
let aggregation, acting as inhibitors o various actors
o Per a t IVe ma n a g emen t
that promote platelet aggregation, while others contain o f Hemo s t a s Is
coumarin or coumarin-like ingredients that behave like
war arin. Pr eo Per a t IVe Pr ePa r a t Io n
Ginkgo (Ginkgo biloba) is a popular supplement used
to enhance memory and treat peripheral vascular dis- A certain amount o bleeding is expected during cutane-
ease, erectile dys unction, macular degeneration, tinnitus, ous surgery, although bleeding can become overwhelming
and vertigo. It inhibits platelet-activating actor, which is when it occurs in multiple areas o the surgical eld. T ere
an important mediator o platelet aggregation.19 Garlic are basic preparations prior to surgery that can make intra-
(Allium sativum) has been shown to inhibit ADP-induced operative bleeding more manageable. As cutaneous surgery
platelet aggregation and degranulation. T ere have been patients are awake and only undergo local anesthesia, noth-
reports o spontaneous postoperative bleeding in patients ing could be more aggravating or anxiety-provoking than an
taking garlic, but most problems are encountered in ill-prepared physician who is about to per orm surgery in a
patients taking higher-than-recommended dosages or in
S
disorganized procedure suite. T e room should be prop-
patients also taking antiplatelet agents.20
c
erly prepared or surgery, with all surgical instruments in
t
i
Ginseng (Pana x ginseng) is thought to be the most place and the appropriate electrosurgical tool ready. T ere
n
popular supplement worldwide. It is used to improve
2
should be enough supplies on the surgical tray, including
physical, mental, and sexual per ormance, as well as to gauze or cotton-tip applicators or blotting. Some surgical
:
:
treat and prevent cancers and improve immunity. T e o ces also utilize suction to manage bleeding. Suturing
active components o ginseng are steroidal compounds
S
materials should be easily accessible. Assistants should be
u
called ginsenosides, which inhibit cyclooxygenase and
r
g
properly trained, especially in simple maneuvers such as
i
thromboxane A2 synthase in vitro.19 However, the clini-
c
direct pressure application on the bleeding site until more
a
l
cal evidence or increased bleeding with ginseng is
S
permanent measures are in place. T ere should be ample
k
limited to a ew case reports.20 T e second best-selling
i
lighting, and the patient should be properly positioned. It
l
l
s
herbal supplement in the United States is St. John’s wort. should be common practice that patients are in a reclining
Its antidepressant e ects are attributed to hypericum position, with gauze at the most dependent portion o the
which inhibits serotonin reuptake and downregulates surgical eld to avoid pooling o the blood. Knowledge o
serotonin receptors. Although St. John’s wort will inter- anatomy, speci cally the vasculature o the surgical site, is
ere with metabolism o war arin, it does not directly vital in preparing or expected bleeding.
a ect coagulation.19 Dermatologists have a variety o tools to control
T ere have been several studies on the hemostatic excessive bleeding during surgery – rom the most basic
e ects o sh oil. T e omega-3 atty acids in sh oil are method o direct pressure to hemostatic agents that initi-
responsible or its antiplatelet activity. However, study ate the coagulation scheme.
results have been mixed, with some studies showing mod-
erately increased bleeding times and reduced in vitro plate-
let aggregation, while others show no e ect on hemostatic Va s o c o n s t r Ic t Io n
parameters. When combined with antiplatelet agents such
as aspirin, a ew studies have shown increased bleeding Epinephrine is added to anesthetics or vasoconstric-
times.20 Vitamin E also has antiplatelet activity, but this tion to localize the anesthetic e ects o the medication
appears to be dose dependent. Studies have shown that and provide hemostasis. Epinephrine can be diluted to
low doses o vitamin E (lower than 400 IU/d) do not a ect 1:100,000 or 1:300,000 and added to the anesthetic prior
platelet activity. However, when taken at doses higher than to injection. Although the onset o action o anesthetics is
400 IU/d (up to 1200 IU/d), inhibition o arachidonic acid very ast, epinephrine has a slower onset o action, and at
metabolism resulting in reduced platelet unction has been least 15 minutes should be allowed or ull vasoconstric-
reported.20 tive e ect. T ere has been controversy over using epi-
It is di cult to draw solid conclusions about the e ect nephrine in digital blocks, but recent literature suggests
o supplements on hemostasis, or to determine how clini- that in patients with no prior history o peripheral vascu-
cally signi cant these e ects are. Well-controlled clinical lar disease, uncontrolled hypertension, diabetes mellitus,
trials are lacking, and most o the literature consists o case or vasospastic or thrombotic disease, small volumes o
reports and anecdotal evidence o an increased propen- dilute epinephrine (1:200,000) are sa e to use or digital
sity or bleeding while taking certain herbal medications. anesthesia.23 Epinephrine, mixed at 1:1,000,000 dilution,
For now, one o the best and sa est methods o preparing can provide dramatic hemostasis during liposuction in the
patients or surgery is to adequately screen them or sup- orm o tumescent anesthesia.24
plements and homeopathic remedies. Dermatologic sur-
geons should amiliarize themselves with the list o ered in
able 13-3. It is not necessary to discontinue supplements c o mPr es s Io n a n d
or less invasive dermatologic procedures, such as biopsies s u t u r In g t ec Hn Iq u es
or excisions. However, cessation o these products prior to
more invasive procedures (liposuction) may be bene cial T e oldest mechanical method o halting bleeding is the
as discontinuation o supplements will cause little to no application o pressure. Mechanical pressure takes many
harm. Agents with antiplatelet activity should be stopped orms in dermatologic surgery. Direct digital pressure or
140 7 to 10 days prior to surgery. clamping o pro usely bleeding vessels with a hemostat
 2

A B

C
h
a
Figure 13-2 Handl st l surgical instrum nt us d t achi v rapid h m stasis. A. bl ding surgical sit in antic agu-

p
t
lat d pati nt. B. bl ding c ntr ll d with circum r ntial c mpr ssi n w und using h m stat handl .

r
1
3
:
:
achieves temporary hemostasis until a more de nitive action in ltrating tumors on the lip, temple, and preauricular

H
can be per ormed. Depending on the anatomic site, certain cheek. A gure-o -eight stitch or a square stitch can be

m
instruments can also be help ul. T e chalazion clamp, used used around bleeding vessels that may be di cult to visu-
or mucosal sur aces such as the lip, provides stabilization alize. For slow oozing at the wound edge, a singular or run-

s
t
a
as well as hemostasis while per orming a procedure. At the ning horizontal mattress suture will provide compression

s
i
s
nasal ala, compression rom the inside o the nasal vestibule and assist with hemostasis. Another use ul technique is
using cotton-tipped applicators helps to tamponade vessels the purse string suture, which can be placed in a trans-
as well as retract and immobilize the ree edge o the ala. cutaneous or subcuticular ashion (Fig. 13-4). ension is
T e looped handles o steel surgical instruments can pro- applied by pulling at the ends o the suture, thus applying
vide compression during procedures, as shown in Figure circum erential pressure by constricting the center o the
13-2. T ese can be particularly use ul on convex areas such wound. T is can be particularly help ul or large de ects o
as the orehead or the scalp. Handles o steel instruments the scalp le t to heal by second intention. Another help ul
can be used to compress open wounds circum erentially suturing technique or the highly vascularized skin o the
so that the surgical eld can be kept dry or cautery. T is scalp is the running-locked suture, which permits rapid
technique can be particularly use ul in controlling bleeding closure o wounds and control o bleeding (Fig. 13-5).
while biopsies on the scalp are per ormed and in providing Although bolsters are commonly used to secure skin
rapid compression o arterial bleeds. gra ts, they can be particularly use ul in providing com-
ourniquets are another mechanical means o achiev- pression and achieving hemostasis, especially in areas that
ing hemostasis. In cutaneous surgery, tourniquets are are very di cult to bandage. ie-over bolsters are use ul
more commonly used on digits, especially during nail sur- when placed over open wounds that are allowed to heal
gery (Fig. 13-3). Properly used, tourniquets provide com- by secondary intention, especially in patients with coagu-
pression o digital arteries and better visualization o the lopathies (Fig. 13-6). Bolsters can be le t in place or 1 week
surgical eld. T ere are various methods to place a digital postoperatively without the need or dressing changes.
tourniquet. A quarter-inch Penrose drain can be wrapped
around the base o the proximal phalanx and clamped and
drawn taut with a hemostat, or the tip o a surgical glove el ec t r o s u r g er y
can be snipped and rolled proximally, exsanguinating the
digit. Pneumatic tourniquets and Marmed digital tourni- Electrosurgery is one o the most common hemostatic tech-
quets also exist or this purpose.25 Although the exact rela- niques used in dermatology. During electrosurgery, an elec-
tionship between tourniquet pressures and neurovascular tric current is applied to tissues. T e tissue does not conduct
injury is not clearly de ned, the application o digital tour- the current e ciently, and this resistance to f ow results in
niquets should be limited to no more than 15 minutes to conversion o the electric energy to heat energy which coag-
minimize the possibility o neurovascular damage.26 ulates proteins and damages tissue. T e our main modalities
Suture ligation and various suturing techniques are o electrosurgery are electrodesiccation, electro ulguration,
excellent tools to control bleeding. T ere are situations electrocoagulation, and electrosection. Both electrodesicca-
when pressure and electrosurgery may be inadequate, tion and electro ulguration use monoterminal and are su -
especially when vessels greater than 2 mm in diameter cient in thrombosing small super cial vessels.
are involved. I arteries are visualized and need to be sac- Electrocoagulation and electrosection use biterminal
ri ced during surgery, ligation o the vessels in advance devices and cause deeper ablation. Because electrocoag-
will prevent excessive bleeding. Vessels should be clamped ulation provides deeper penetration o current, it is the
with ne-tipped hemostats and absorbable sutures (such best modality to use or hemostasis. T e bipolar electrode
as polyglactin 910) should be used in ligating them. T is allows the current to pass directly between two tips o the
technique is especially use ul during extirpation o deeply electrode orceps. It creates less surrounding tissue damage 141
2

A B
S
c
t
i
n
2
:
:
S
u
r
g
i
c
a
l
S
k
i
l
l
s
Figure 13-3 T urniqu t us d during nail surg r rh -
m stasis. A. Pati nt d ns a larg r gl v and th gl v tip
v r th af ct d ng r is cut. B. C mpr ssi n vascula-
C tur is achi v d as th gl v is r ll d pr ximall . C. N t
th l dl ss ld during th pr c dur .

while achieving hemostatic e ects to those o the unipolar the patient, it is the sa est modality to use in patients with
electrode. implantable electronic devices, but electrocoagulation
Electrocautery does not trans er current to the tissues, with the bipolar electrode is also sa e.
but converts electric energy to thermal energy within the It is important to maintain a dry surgical eld, as electric
device, which is then passed to tissues. T is technique current does not e ectively pass through blood. It is also
only works to control minimal bleeding and is best when important to minimize the amount o excess charred tissue,
used in a dry eld. Because current is not trans erred to as it may lead to inf ammation and poor wound healing.27

A B

Figure 13-4 Plac m nt purs string sutur h lps r duc th risk l ding. P l pr p l n sutur can plac d
142 A. su cuticularl with an scap l p, r B. transcutan usl .
 CAUSTIC AGeNTS. Caustic agents are some o the
2
most commonly used products in dermatology, especially
or minor procedures. T e common mechanism o action
in this group is tissue necrosis, causing protein precipita-
tion that promotes tissue coagulation and thrombus or-
mation. T ese styptic agents are inexpensive and easy to
handle. T ey are rubbed onto the wound using gauze or
cotton-tipped applicators. One particular disadvantage is
the risk o pigmentary alteration at the site o application.
Ferric subsul ate (Monsel’s solution) and silver nitrate can
cause tattooing o the skin by leaving dermal deposits o
iron and silver, respectively. Aluminum chloride solution
(Drysol), commonly used ollowing super cial biopsies,
is less likely to leave pigment particles. Excessive applica-

C
tion o caustic agents should be avoided as they can cause

h
a
localized inf ammatory reactions and impede wound heal-

p
ing.28,29 An added bene t o these agents is their antimicro-

t
Figure 13-5 A running-l ck d sutur n th scalp all ws

r
r rapid cl sur and c ntr l l ding. bial properties.29,30

1
3
One new caustic agent that has been recently approved
by the government and has been extensively used in the

:
:
t o PIc a l Hemo s t a t Ic a g en t s battle eld is mineral zeolite (QuikClot). T is agent is

H
derived rom lava rock and is made up o silicon, alu-

m
opical hemostatic agents play an important role in both minum, sodium, and magnesium. It causes an exothermic

s
common and complex dermatologic procedures. T ese reaction at the site o application by rapidly absorbing

t
a
s
agents can be classi ed based on their mechanism o action water, leaving behind a concentrated quantity o platelets

i
s
and include physical or mechanical, caustic, biologic, and and clotting actors that leads to rapid clotting. Older or-
physiologic agents. Some agents induce protein coagulation mulations have caused severe thermal burns, but the new
and precipitation that results in occlusion o small cutaneous ormulation can only reach a maximum wound tempera-
vessels, whereas others take advantage o the later stages o ture o 105°F.31
the coagulation cascade. Hemostatic ability, tissue reactivity, Zinc chloride paste, a product o important historical
biodegradability, ease o sterilization, and cost are important value in the eld o Mohs micrographic surgery, is still
considerations when choosing a topical hemostatic agent.28 available as a hemostatic agent (Z squares).32 Like other
able 13-4 reviews topical hemostatic agents that are caustic agents, it is applied directly to the bleeding site,
readily available. Some are used in dermatology on a day- but can cause signi cant discom ort. Because o their
to-day basis, whereas others have very limited use. antitumor properties, zinc paste compounds are touted as
homeopathic agents or curing skin cancer.33

A B

Figure 13-6 A. An p n w und l t t h al s c ndar int nti n in c nchal wl a pati nt with

c agul path . B. A ti - v r lst r with silk sutur s s rv s as a c mpr ssiv dr ssing t h lp c ntr l
l ding. 143
2 TAbLe 13-4
t opi l He os i a gen s26–41

He os i a gen f or ul ions me h nis o a ion co en

Caustic agents
Zinc chl rid Past Pr t in c agulati n l ading t Us limit d y pain
Gauz (Z squar s) thr m us rmati n
F rric su sul at (M ns l’s 20% S luti n Pr t in c agulati n du t l w pH Ir n particl s can tatt tissu s
s luti n) and xidati n y su sul at gr up
Silv r nitrat Sticks, 10% s luti n Fr silv r i ns caus pr t in Pr cipitat d pr t ins l av thin
c agulati n schar, small risk tatt
Aluminum chl rid 20%–70% s luti n Hydr lyz d t HCl, causing pr t in
S
c agulati n and vas c nstricti n
c
t
i
o
Min ral Z lit P wd r A s r s wat r m l cul s and Minimal risk th rmal injury
n
(QuikCl t) caus s x th rmic r acti n;
2
c nc ntrat s plat l ts and cl tting
:
:
act rs r rapid c agulati n
S
Biologic physical agents
u
r
g
G latin (G l am, G lf lm, F am, p wd r, f lm, A s r s wat r, cr at s structural May s ak d in rric su sul at
i
c
a
Surgi am) sp ng m shw rk r plat l t aggr gati n r thr m in
l
S
k
o xidiz d c llul s M sh, gauz , sp ng s, Pr vid s a structural m shw rk r Antimicr ial pr p rti s
i
l
l
s
(Surgic l, o xyc l) and f rillar tu ts plat l t aggr gati n
P ly N ac tyl gluc samin Film P sitiv charg attracts n gativ ly exp nsiv ; littl us in
(H mC n, Chit S al, charg d rythr cyt s d rmat l gy
Syv kPatch, Cl Sur P.A.D.)
Micr f rillar c llag n P wd r, am, f lm Pr vid s matrix r plat l t
(Avit n , H listat, Instat) adh r nc and activati n
Pr QR p wd r P wd r F rms artif cial sca with o v r th c unt r
(bi li ) hydr philic p lym rs and
p tassium salts
Physiologic hemostatic agents
epin phrin S luti n Vas c nstrict r C mm nly administ r d with
an sth tic
C cain S luti n, p wd r, g l Vas c nstrict r
Thr m in (Thr m in JMI, S luti n, p wd r C nv rts f rin g n t f rin, b vin and human d riv d; may
Fl S al, evithr m) activat s plat l ts and th r caus diss minat d intravascular
cl tting act rs c agul pathy
Fi rin s alants (Tiss l, Inj cta l dual Thr m in and f rin g n mix d at
Cr ss al, evic l) syring , spray applicati n sit r sulting in f rin
rmati n
Plat l t g ls (SmartPR P) G l C nc ntrat d plat l ts and gr wth b vin , r can individually
act rs augm nt c agulati n pr par d r m pati nt’s plat l ts
Mechanical
b n wax Wax Tamp nad s l ding n xp s d Tissu r acti ns; inhi iti n
(o st n ) n st g n sis; limit d us in
d rmat l gy
Cyan crylat s Liquid glu S l p lym rizing causing adh si n b st us d in p diatric pati nts
(D rma nd, band Aid Liquid tissu and physical arri r t and sup rf cial w unds; s m
bandag , Tissu Glu) l ding anti act rial pr p rti s

Trad nam s ag nts ar in par nth sis.

144
bIo Lo GIC PHySICAL AGeNTS. Biologic physical pain, myocardial in arction, syncope, stroke, seizures, and
death. It is available in 4% and 10% solutions, as well as in a
2
hemostatic agents mimic physiologic mediators o plate-
let aggregation. T ey vary in origin (plant, algae, bovine, mixture o 0.5% tetracaine, 1:2,000 epinephrine, and 11.8%
human), but they work similarly by providing a matrix to cocaine gel ( AC). T is product is o minimal use in der-
which platelets adhere and promote thrombus organiza- matology. It is utilized in otolaryngology and ophthalmol-
tion. T ese products can be le t intact on the wound, since ogy when per orming procedures on mucosal sur aces.38
they would be absorbed or metabolized completely within T rombin-derivative products (T rombostat, T rom-
a ew weeks, but they carry the risk o in ection.28 T ey are bin-JMI, FloSeal) direct the conversion o brinogen to
relatively inexpensive, readily available, pliable, and easy brin. T ey take advantage o natural physiologic pro-
to handle. cesses, thereby avoiding oreign body or inf ammatory
Gelatin (Gel oam) is a hygroscopic substance, absorb- reactions. opical thrombin may be applied to the wound
ing many times its weight in water or liquid. It creates a bed as a solution via a saturated gauze or spray, or as a pow-
moist environment to promote clotting and granulation der applied directly to the wound bed. Newer ormulations
tissue ormation. It works best or di use small-vessel ooz- require mixture at the bedside and skill on the part o the
applicator. Care must be taken to avoid introducing throm-

C
ing and can be combined with topical agents such as er-

h
ric subsul ate or thrombin to increase e cacy.34 Cellulose bin into larger caliber vessels, as systemic exposure may

a
p
lead to disseminated intravascular coagulation or death.32

t
(Oxycel, Surgicel) is an oxidized plant product ormulated

r
as a mesh, gauze, sponges, or brillar tu ts. T e material Bovine-derived thrombin should not be used in patients

1
3
is placed in the wound bed with rm pressure until the allergic to bovine products. T e high cost o thrombin-
bleeding stops. It can be le t in place and allowed to absorb derived products may be prohibitive or routine use, but

:
:
over a ew weeks,34 with low rates o in ection due to anti- they can be use ul in patients with platelet dys unction.28

H
bacterial properties o the cellulose.28 T e use o cellulose Fibrin sealants ( isseel, Crosseal) are prepared rom

m
creates a low-pH environment and thus it inactivates other cryoprecipitates (homologous or synthetic) and have the
advantage o not promoting inf ammation or tissue necro-

s
biologically active topical agents such as thrombin.34

t
a
sis. Like some o the newer ormulations o thrombin

s
A complex polysaccharide produced by ermenting

i
s
microalgal cultures called poly-N-acetyl glucosamine products, they require skill during application and are very
(HemCon, SyvekPatch, Clo-Sur PAD, ChitoSeal) is avail- expensive. T e sealant is administered using a dual syringe
able or small wounds and is more o ten used in trauma, compartment system. In one compartment are brino-
maxillo acial, and neurosurgery because o its ability to stop gen, actor XIII, bronectin, and brinolysis inhibitors.
signi cant arterial bleeding. T is agent is positively charged T e second compartment contains thrombin and calcium
and attracts the negatively charged erythrocytes to create a chloride.39 Proper mixing o the two sets o components is
clot, and may induce vasospasm to enhance hemostasis.31 important to achieve maximum e ect. Onset o action is
Micro brillar collagen (Avitene, Instat, Helistat, Heli- usually within 30 seconds, and the clot is reabsorbed over
tene, Collastat, Collatene) is composed o re ned bovine 5 to 10 days. Applications in dermatologic surgery include
collagen brils that provide a matrix or platelet adhesion, improving gra t survival, particularly in di cult locations
which results in initiation o the coagulation cascade.35 with high shearing orces and its use in patients with coagu-
T is product is marketed as sheets, sponges, or powder lopathies such as hemophilia and von Willebrand disease.28
and is applied to the wound bed with dry instruments and Platelet gels (Vitagel) have been used as hemostatic
rm pressure. Despite its bovine origin, it has low immu- agents ollowing cosmetic procedures such as liposuction
nogenicity.32 A physical hemostatic agent that is available and laser resur acing.40,41 T ey are made o a concentrated
over-the-counter is Pro QR Powder (Bioli e), which con- bovine collagen-platelet combination, which speeds the
tains hydrophilic polymers and potassium salts that cre- conversion o brinogen to brin when applied to bleeding
ates an arti cial crust when applied to a bleeding wound.28 sites. T ey are superior to brin glues in that they improve
overall clot strength and acilitate tissue regeneration.40
PHySIo Lo GIC AGeNTS. Physiologic agents can
be subdivided into two subgroups – those causing vaso- MeCHANICAL AGeNTS. Bone wax is used to tam-
constriction (epinephrine, cocaine) and those containing ponade bleeding over exposed bone, and acts as a physical
clotting products (thrombin, brin sealant, platelet gel). barrier to bleeding. It is composed o beeswax and iso-
Epinephrine, as discussed earlier, is commonly adminis- propyl palmitate and may contain almond oils or salicyclic
tered with injectable anesthetics. It can be topically applied acid.42 Although it is relatively inexpensive, the use o bone
on the wound bed with gauze or dispersed with a hypo- wax may lead to an increased risk o in ection, oreign
dermic needle. Concentrations ranging rom 1:1,000 to body granulomatous reactions, and inhibition o new tis-
1:1,000,000 are typically used.36 Rare tachyarrhythmias sue growth. A synthetic, water-soluble alternative to bone
have been reported to cause atality,37 but this is usually a wax, Ostene, does not impede osteogenesis or increase
result o systemic administration. risk or in ection.43
Cocaine is a potent vasoconstrictor that has been Cyanoacrylates (Dermabond, Band-Aid Liquid Band-
used or medicinal purposes since 1884. It has a mode o age) are glue polymers that create tissue adhesion, caus-
action similar to that o epinephrine, activating adrener- ing a physical or mechanical means o stopping bleeding.
gic receptors on blood vessels. Adverse reactions, such as T ey are typically used in the emergency setting to treat
tachycardia and hypertension, exist at even low dosages. super cial wounds in the pediatric population or patients
More serious reactions include cardiac arrhythmias, chest with cognitive de cits.28

145
2 Po s t o Per a t IVe ma n a g emen t r ef er en c es
Bleeding complications are inevitable, even in cutane- 1. Drucker CB. Ambroise Pare and the birth o the gentle art o
ous surgery. Management o bleeding does not end at surgery. Yale J Biol Med. 2008;81:199– 202.
2. Gonzalez EA, Jastrow KM, Holcomb JB, et al. Hemostasis,
the completion o the procedure. Equally critical is the surgical bleeding, and trans usion. In: Brunicardi FC, Anders-
postoperative period, especially during the rst 48 hours en DK, Billiar R, et al. eds. Schwartz’s Principles of Surgery.
when bleeding is likely to occur. Dermatologic surgeons 9th ed. New York, NY: McGraw-Hill; 2010.
should be particularly aware o the varied presentations 3. Konkle B. Bleeding and thrombosis. In: Longo DL, Fauci AS,
o bleeding complications (arterial bleeding, hematoma Kasper DL, et al. eds. Harrison’s Principles of Internal Medi-
cine. 18th ed. New York, NY: McGraw-Hill, 2012.
ormation) and their potential sequelae (f ap ailure, tissue 4. Kumar A, Kar S, Fay WP. T rombosis, physical activity, and
necrosis, dehiscence, in ection). acute coronary syndromes. J Appl Physiol. 2011;111:599– 605.
Immediately a ter surgery, the patient should have an 5. Peterson SR, Joseph AK. Inherited bleeding disorders in der-
appropriate pressure dressing placed. Various orms o matologic surgery. Dermatol Surg. 2001;27:885,
pressure dressings can be used. Folded absorbent gauze 6. Seligsohn U. reatment o inherited platelet disorders. Hae-
S
mophilia . 2012;18:161– 165.
over a nonadherent dressing can be rein orced with 7. Lazar LD, Linco AM. Prasugrel or acute coronary syn-
c
t
adhesive tape. Dental rolls are particularly use ul as a
i
dromes: aster, more potent, but higher bleeding risk. Cleve
n
pressure dressing over small surgical sites. Close atten- Clin J Med. 2009;76:707– 714.
2
tion should be paid when dressing a site in which com- 8. Goldsmith SM, Leshin B, Owen J. Management o patients
plex reconstruction ollowing tumor extirpation has been taking anticoagulants and platelet inhibitors prior to derma-
:
:
tologic surgery. J Dermatol Surg Oncol. 1993;19:578– 581.
per ormed. A bulkier dressing should be placed to pro- 9. Lewis KG, Du resne RG Jr. A meta-analysis o complications
S
u
vide compression and immobilization and avoid shearing attributed to anticoagulation among patients ollowing cuta-
r
g
orces over the site. A bolster dressing may be sutured in neous surgery. Dermatol Surg. 2008;34:160– 164.
i
c
a
place over gra t sites to increase take and provide com- 10. Cook-Norris RH, Michaels JD, Weaver AL, et al. Complica-
l
S
pression. tions o cutaneous surgery in patients taking clopidogrel-con-
k
taining anticoagulation. J Am Acad Dermatol. 2011;65:584–
i
l
Patients should receive speci c written instructions, not
l
s
591.
only regarding postoperative wound care, but also review- 11. Holmes DR Jr, Kereiakes DJ, Kleiman NS, Moliterno DJ, Patti
ing the signs and symptoms o bleeding complications. G, Grines CL. Combining antiplatelet and anticoagulant ther-
T ey should be instructed in the use o direct pressure over apies. J Am Coll Cardiol. 2009;54:95– 109.
bleeding or oozing sites and be provided a contact number 12. Bunick CG, Aasi SZ. Hemorrhagic complications in dermato-
logic surgery. Dermatol T er. 2011;24:537– 550.
to receive urther guidance i needed. When true emer- 13. Kovich O, Otley CC. T rombotic complications related to
gencies do occur, the physician should be easily accessible discontinuation o war arin and aspirin therapy periopera-
to address the complication. Persistent bleeding despite tively or cutaneous operation. J Am Acad Dermatol. 2003;48:
prolonged direct pressure should be investigated. T e sur- 233– 237.
gical site may need to be reopened and explored so that 14. Alam M, Goldberg LH. Serious adverse vascular events as-
sociated with perioperative interruption o antiplatelet and
bleeding vessels can be cauterized or ligated. In patients anticoagulant therapy. Dermatol Surg. 2002;28:992– 998.
with altered coagulation, appropriate topical hemostatic 15. Stewart LC, Langtry JA. Clopidogrel: mechanisms o action
agents may need to be used. In the event o a hematoma, and review o the evidence relating to use during skin surgery
evacuation may be necessary to address the source and procedures. Clin Exp Dermatol. 2010;35:341– 345.
prevent necrosis or in ection. It is o critical importance 16. Schanbacher CF, Bennett RG. Postoperative stroke a ter stop-
ping war arin or cutaneous surgery. Dermatol Surg. 2000;
that an expanding hematoma near the eye or on the neck 26:785– 789.
be addressed to prevent catastrophic damage to the eye or 17. Davis EM, Packard KA, Knezevich J , Campbell JA. New and
compression o the airway. Anticoagulated patients and emerging anticoagulant therapy or atrial brillation and acute
those undergoing extensive procedures, such as extensive coronary syndrome. Pharmacotherapy. 2011;31:975– 1016.
reconstruction ollowing skin cancer surgery and cervico- 18. sen LC, Segal S, Pothier M, Bader AM. Alternative medi-
cine use in presurgical patients. Anesthesiology. 2000;93:148–
acial liposuction, are at a much higher risk o developing 151.
bleeding complications. 19. Beckert BW, Concannon MJ, Henry SL, Smith DS, Puckett
CL. T e e ect o herbal medicines on platelet unction: an in
vivo experiment and review o the literature. Pla st Reconstr
Surg. 2007;120:2044– 2050.
c o n c l u s Io n 20. Stanger MJ, T ompson LA, Young AJ, Lieberman HR. An-
ticoagulant activity o select dietary supplements. Nutr Rev.
2012;70:107– 117.
Success ul hemostasis in dermatologic surgery is not 21. Dinehart SM, Henry L. Dietary supplements: altered coagula-
limited to knowing the various techniques o controlling tion and e ects on bruising. Dermatol Surg. 2005;31:819–826.
bleeding during the intraoperative period. Patients must 22. Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks o
be properly assessed or risks o bleeding and have under- herbal, homeopathic, and dietary supplements: a hidden night-
lying conditions addressed prior to surgery. Patients must mare or plastic surgeons? Aesthet Surg J. 2012;32:332–346.
23. Krunic AL, Wang LC, Soltani K, Weitzul S, aylor RS. Digi-
be closely ollowed and instructed regarding the proper tal anesthesia with epinephrine: an old myth revisited. J Am
care o the operative site during the postoperative period. Acad Dermatol. 2004;51:755– 759.
Multiple hemostatic agents are now available, and more 24. Klein JA. umescent technique or local anesthesia improves
are being developed as our knowledge and understanding sa ety in large-volume liposuction. Pla st Reconstr Surg. 1993;92:
o the physiologic basis o hemostasis continue to evolve. 1085– 1098.
25. Harrington AC, Cheyney JM, Kinsley-Scott , Willard RJ. A
T ese agents, however, should not serve as substitutes or
146 meticulous surgical technique.
novel digital tourniquet using a sterile glove and hemostat.
Dermatol Surg. 2004;30:1065– 1067.
26. Rich P. Nail biopsy: indications and methods. Dermatol Surg.
2001;27:229– 234.
36. Glasson DW. opical adrenaline as a hemostatic agent. Pla st
Reconstr Surg. 1984;74:451– 452.
2
27. Hainer BL. Fundamentals o electrosurgery. J Am Board Fam 37. Vaughan RW. Ventricular arrhythmias a ter topical vasocon-
Pract. 1991;4:419– 426. strictors. Anesth Analg. 1973;52:161– 165.
28. Palm MD, Altman JS. opical hemostatic agents: a review. 38. Long H, Greller H, Mercurio-Zappala M, Nelson LS, Ho -
Dermatol Surg. 2008;34:431– 445. man RS. Medicinal use o cocaine: a shi ting paradigm over
29. Olmstead PM, Lund HZ, Leonard DD. Monsel’s solution: a 25 years. Laryngoscope. 2004;114:1625– 1629.
histologic nuisance. J Am Acad Dermatol. 1980;3:492– 498. 39. Martinowitz U, Schulman S. Fibrin sealant in surgery o patients
30. Spacciapoli P, Buxton D, Rothstein D, Friden P. Antimicrobial with a hemorrhagic diathesis. T romb Haemosta sis. 1995;
activity o silver nitrate against periodontal pathogens. J Peri- 74:486– 492.
odontal Res. 2001;36:108– 113. 40. Bhanot S, Alex JC. Current applications o platelet gels in
31. Alam HB, Burris D, DaCorta JA, Rhee P. Hemorrhage con- acial plastic surgery. Facial Pla st Surg. 2002;18:27– 33.
trol in the battle eld: role o new hemostatic agents. Mil Med. 41. Farrior E, Ladner K. Platelet gels and hemostasis in acial
2005;170:63– 69. plastic surgery. Facial Pla st Surg. 2011;27:308– 314.
32. Larson PO. opical hemostatic agents or dermatologic sur- 42. Howard C, Kelley RR. T e e ect o bone wax on the healing
gery. J Dermatol Surg Oncol. 1988;14:623– 632. o experimental rat tibial lesions. Clin Orthop Relat Res. 1969;
33. Brown CW Jr, Goldstein GD, Birkby CS. Auto-Mohs.com. 63:226– 232.

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Dermatol Surg. 2001;27:975– 978. 43. Vestergaard RF, Jensen H, Vind-Kezunovic S, Jakobsen ,

h
34. Sileshi B, Achneck HE, Lawson JH. Management o surgical Søballe K, Hasenkam JM. Bone healing a ter median sternot-

a
p
hemostasis: topical agents. Va scular. 2008;16:S22–S28. omy: a comparison o two hemostatic devices. J Cardiothorac

t
35. Alexander JM, Rabinowitz JL. Micro brillar collagen (Avi- Surg. 2010;5:117.

r
1
tene) as a hemostatic agent in experimental oral wounds.

3
J Oral Surg. 1978;36:202– 205.

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:
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147
 Ch a p t e r

14 Electrosurgery
J M ti &Tim thy S. W

in t r o d u c t io n Bovie, “an eccentric inventor with a doctorate in plant

physiology,” developed the rst electrosurgical device that
o ered both cutting and coagulation.2 Cushing, a neuro-
Electrosurgery re ers to the use o high- requency alternat-
surgeon at Peter Bent Brigham Hospital in Boston, became
ing current (AC) to ulgurate, coagulate, desiccate or cut
interested in this device and started using electrosurgery
living tissue. In true electrosurgery, an electrical current is
in his surgical cases in 1926. When these devices were rst
used to generate heat within the tissue itsel . Electrosur-
used in the operating room, Bovie controlled the output
gery is used widely in the eld o dermatology to provide
o the electrosurgical device. T roughout the years, Bovie
hemostasis in surgical procedures and is a undamental
and Cushing made many modi cations to the original
component o electrodesiccation and curettage. Further-
electrosurgical units (ESUs), adding monopolar and bipo-
more, it is also commonly used to destroy small benign
lar electrodes with blended wave orms. Because o their
super cial lesions such as angio bromas, brous papules,
in uence, electrosurgical devices are still o ten colloqui-
acrochordons, seborrheic keratoses, verrucae, pyogenic
ally called “Bovies.”5
granulomas, and molluscum contagiosum.1 Electrosurgi-
In 1937, the low-powered hy recator was developed
cal devices were developed in the early twentieth century,
by the Birtcher Corporation. It was named as a portman-
and remain widely used today.
teau o “high requency eradicator,” and became the rst
In contrast, electrocautery ( rom Greek kauterion,
nonground return electrosurgical device. Many outpa-
branding iron), is not a true orm o electrosurgery because
tient of ces today use a nonground return electrosurgical
no electrical current enters the patient.2,3 In electrocautery,
device similar to the original hy recator.7
electrical current is used to heat a conductor, which then
directly heats the tissue.
El Ec t r ic it y Ba c kg r o u n d
His t o r y A comprehensive review o the physics o electricity is
beyond the scope o this discussion, although an under-
T e orerunners o electrosurgery were developed in the late standing o basic electrical principles is use ul. Both elec-
nineteenth century. T e Oudin coil was developed in 1899 trocautery and electrosurgery use the ow o electrons to
as a trans ormer designed to produce high voltage arcs and per orm work. T e ow o electrons is termed current (I)
discharges that could cause super cial tissue damage or and is de ned as the number o electrons that move through
destruction. In 1891, Jacques Arsène d’Arsonval, a French a conductive medium over time. A common analogy used
physician, noted that currents with requencies higher than to illustrate current is to imagine a pump pushing water
10 kHz passed through human tissue without neuromus- through a pipe: Just as water molecules ow through the
cular stimulation or tetany.4 In 1900, a Parisian physician, pipe, electrons ow through a conductive medium. In this
Joseph Rivière, described treating an ulcer on a patient’s analogy, current describes the number o water molecules
hand using high- requency sparks.2 Walter de Keating-Hart that pass through the pipe over time. Current is measured
and Pozzi used sparks rom an Oudin coil on the skin in in amperes (amps); one amp is equivalent to 6.24 × 1018
1907, and introduced the term fulguration to describe the electrons passing through an electrical circuit every second.
super cial carbonization that resulted.5 Fulguration derives Resistance, measured in ohms, is impedance to the ow
rom the Latin word, fulgur, which means lightning. o electrons. In the analogy above, the diameter o the pipe
T e term electrocoagulation (derived rom Latin coagu- is analogous to the resistance (R) o an electrical circuit.
lare, to curdle) was rst used by Doyen in 1909 to describe Voltage is the electrical potential energy between two
coagulation o tissue rom direct contact with an elec- points and is measured in volts (joules per coulomb); it can
trode.6 Doyen added an indi erent electrode to the circuit be conceptualized as the electromotive orce that drives
to allow electricity to ow back into the electrosurgical the current through the medium. A water pump provides
device. T e indi erent electrode prevented shocks by pro- a pressure di erence in a pipe circuit and causes water to
viding a path or the return o the current and enhanced its ow; voltage is analogous to the di erence in water pres-
penetration into tissues.5 Soon a ter, the term electrodesic- sure. Current, voltage, and resistance are related by the
cation entered the lexicon to describe the slow dehydra- ormula, voltage (V) = current (I) × resistance (R).
tion o tissues using an electrical current. A di erence in potential energy can be used to do work.
T e largest advancements in the eld were made by Just as owing water can drive a turbine, an electric current
William Bovie, Ph.D. and Harvey Cushing, M.D. In 1920, can be used to convert potential energy into kinetic energy,
 or desiccate. Radio requency electricity can heat tissue
through two mechanisms: ohmic heating or dielectric
2
i
heating. In ohmic heating, heat is generated by resistance
+ to the ow o electrons. As electrons collide with atoms
V in the tissue, they release kinetic energy, producing heat
R
at the site o application. Living tissue conducts electric-
- ity poorly, and ohmic heating is the mechanism utilized
in electrosurgery.8 In dielectric heating, atoms align them-
selves in an electromagnetic eld. As the electromagnetic
eld oscillates at a high requency, the molecules rotate to
Figure 14-1 a te ti Ci c it. align with it, thereby colliding with other molecules and
distributing energy in the orm o heat. Dielectric heating
occurs at requencies above 500 MHz and is the mecha-
light, or heat. Power describes the rate at which an electri- nism by which microwave ovens operate.
cal charge is trans erred or used and is measured in watts

C
h
(joules per second). Power also describes the rate at which
El Ec t r o s u r g ic a l d Ev ic Es

p
work is per ormed. Power, current, and voltage are related

t
e
by the ormula, power (P) = current (I) × voltage (V).

1
For current to ow, there must be potential di erence Although a variety o electrosurgical devices are avail-

4
between the primary electrode and the method o ground- able on the market today, most consist o three or our

:
:
ing or dispersion. In a Direct Current (DC) circuit, elec- main components: a trans ormer to increase the current’s
trons ow in one direction only, whereas in an AC circuit,

E
voltage; an oscillating circuit; an electrode to trans er the

e
electrons ow rst in one direction and then in the other current to the patient; and in some devices, an electrode

c
t
direction (Fig. 14-1). When depicted graphically against return.10

s
time, DC voltage has constant polarity and is seen as a hori- In most ESUs, current rom a standard household outlet
zontal line. AC voltage is seen as a sine wave that alternates rst passes through a trans ormer that increases its volt-

e
between positive and negative around 0 (Fig. 14-2). T e re- age. T e current then passes through an oscillating circuit

y
quency at which the current changes polarity is described that increases its requency. T e oscillating circuit may be
in hertz (Hz), or cycles per second. In the United States, composed o a spark gap, thermionic vacuum tube, or solid
household wall outlets typically supply 110 to 120 V AC at state transistor, though modern ESUs almost exclusively
50 to 60 Hz. AC is used to supply electrical power through- use transistors. Once the current’s voltage and requency
out the United States because high voltages can be trans- are increased, it is delivered to the treatment electrode and
mitted across great distances with minimal loss in energy. to the patient’s tissue. T e active electrode delivers the cur-
T e requency o electrical output also a ects the tis- rent to the patient; current returns to the ESU through the
sue response. For example, electrical current at 50 to 60 passive, indi erent, or dispersive electrode. Alternately, in
Hz provokes muscle contraction and tetany by causing low-powered electrosurgical devices such as the hy reca-
depolarization o the neuromuscular junction. However, tor, the patient’s capacitance acts as a sink or the current
requencies above 100,000 Hz do not cause muscle con- and no return electrode is needed.
traction or tetany. Electrosurgical instruments used today Once the electrical current enters the tissue, Ohmic
emit current rom 100,000 to 4,000,000 Hz (0.1– 4 MHz); heating produces heat. Below 45°C, no permanent damage
a range that alls into the radio requency range.8,9 T us to cells occurs. From 45°C to 60°C, proteins x, solidi y and
electrosurgery is sometimes re erred to as radio requency become opaque, similar to cooked egg whites. T is pro-
electrosurgery. cess is termed coagulation.11 As temperature increases to
100°C, aqueous contents evaporate and the tissues “dry,” a
process termed desiccation. Above 100°C, the tissues begin
El Ec t r o s u r g Er y to char and are reduced to carbon, a process aptly called
carbonization.
MEc Ha n is M o f HEa t in g T e e ect o an electrosurgical current on tissue is
dependent on many actors including: the degree o heat-
In electrosurgery, radio requency current enters the ing (as described previously); the wave orm and mode; the
patient and generates heat that is used to cut, coagulate, type o electrode (monopolar versus bipolar); the current
density; the power setting; the shape o the electrode tip;
the type o tissue; the time in contact with tissue; and the
surgeon’s technique.

Wa vE o r M a n d Mo d E – “Cu T, Co a g u -
l a TE, a n d Bl En d ”. All ESUs emit a sinusoidal wave-
orm o AC. T ese sine waves can be continuous or inter-
rupted, which a ects the tissue response. A continuous sinu-
soidal wave orm heats the tissue rapidly, causing vaporiza-
tion o water within cells and tissue cutting (Fig. 14-3). T e
Dire ct curre nt Alte rna ting curre nt tissue heats rapidly and relatively little heat is dispersed into
Figure 14-2 d i ect a te ti c e t. the surrounding tissue.12 T us, cutting current vaporizes 149
2 Low
volta ge
High
volta ge
1

0.5

1 2 3 4 5

CUT BLEND 1 COAG

100% 50% on 6% on –0.5
S
e
50% off 94% off
c
t
i
Figure 14-3 C tti , b e e , c ti w e ms. A
a p e y c tti w e m is i te pte si e w e.
2
The t e is e ti e y w, b t c e t is hi h bec se Wave
:
it is c ti s y. a b e e c e th sp essi e
:
ps i e ect ic c e t s th t the ps betwee the Wave le ngth
S
c e t w e e.a c ti w e m is
i te pte w e m with eq e t ps i which
i
c
c e t is bei e i e e , e i t hi he t e.
S
k
i
I
s
tissue without causing surrounding coagulation (Fig. 14-4).
In the cutting wave orm, the voltage is relatively low, but the
average current is high. Wave le ngth
In contrast, coagulation is achieved by slower tissue
heating. In the coagulation setting, proteins are xed, and
Dis ta nce
tissue gradually dehydrates (Fig. 14-4). o achieve slower B
heating in the coagulation setting, the output wave orm
Figure 14-5 A. d mpe si e w e. The mp it e the
is either interrupted or damped, allowing heat to dissi- si e w e ec e ses e time e t esist ce i the
pate during the interruptions in current ow. As an anal- system. B. a typic si e w e with the w e e th sh w
ogy, imagine placing a pan over a ame and removing it: the x xis mp it e sh w the y xis.
the pan heats only while over the ame, so the net e ect
is slower heating o the pan’s contents. In coagulation
amplitude decreases over time due to resistance within the
modes, the unit is switched o or short periods o time,
circuit (Fig. 14-5).13
interrupting the output o continuous sine waves (Fig.
“Blended” modes are used to obtain both cutting and
14-3). T is on/o cycle is termed the duty cycle. Alter-
coagulation. In “blended” modes, the unit is switched o
natively, the current can be damped with a diminution o
or short periods o time, interrupting the output o con-
voltage over time. A damped wave occurs when the wave’s
tinuous sine waves (Fig. 14-3). A blended mode is achieved
by altering the duty cycle o the ESU output. ESUs achieve
di erent amounts o cutting and coagulation by altering
the duty cycle.6 Di erent “blends” utilize preset duty cycles
Pure cut Ble nd Coa g
to provide varying combinations o cutting and coagula-
tion. T ese blends are determined by ESU manu acturers.

c u r r En t d En s it y
Current density signi cantly modulates the e ect o an
electrosurgical current on tissue. Current density can be
controlled by changing the total current produced or by
changing the sur ace area o the electrode in contact with
the tissue. I the current is held steady, changing the sur-
ace area o the electrode in contact with the tissue will
Low The rma l s pre a d /cha rring High change the rapidity with which the tissue heats and dehy-
drates (Fig. 14-6). Smaller electrodes heat or dehydrate
Low Volta ge High tissue much more quickly due to a higher current density,
Figure 14-4 Tiss e e ects i e epe i e ect and thus are better or cutting. In contrast, larger elec-
150 s ic it setti . trodes are more appropriate or coagulation.
 Curre nt conce ntra tion a nd he a t
Incre a s e s
2
Low curre nt
High curre nt
conce ntra tion Ele ctrode
conce ntra tion
(de ns ity) s ize
(de ns ity)

Powe r s e tting re quire me nt

Incre a s e s Bipola r Monopola r
Figure 14-6 C e t e sity epe s e ect e size Figure 14-7 Bip m p e ect es (the i ec
p we . C e t e sity c be c t e by ch ti c e t is epicte with ws).

C
i the s ce e the e ect e i c t ct with the

h
tiss e. l e e ect es p ce w c e t e sity and current returns to the ESU through the return elec-

p
t
he t tiss e m e s w y. Sm e ect es c ce t te the

e
trode (Fig. 14-8). Monopolar electrosurgery can deliver
c e t, pi y he ti the tiss e.

1
di erent modes o energy that result in the clinical e ects

4
o cutting, desiccating, or coagulating tissues. T e mono-

:
:
Current density is greatest at the active electrode and polar electrode can either directly contact tissue or can be
used in close proximity to urther modulate the current’s

E
dissipates as it moves rom the treatment area. Monopo-

e
clinical e ect.

c
lar, biterminal ESUs utilize return electrodes with a large

t
sur ace area to lower current density as the current exits T e hy recator is a specialized low power orm o

s
the patient and decrease the risk o a burn or shock. I the monopolar electrosurgery. As noted previously, in this
return electrode is poorly applied and only a small portion instrument, the body’s capacitance unctions as a ground

e
or electrons and current ows without the use o a

y
o the return electrode is in contact with the patient, current
concentrates at the place o exit and can burn the patient. return electrode. Because there is no return electrode i
the patient is in contact with a grounding electrode, cur-
rent will exit through the skin at the site o contact with
Mo n o po l a r v Er s u s Bipo l a r grounding electrode. T e high current density at the exit
point can lead to a burn or shock. Hy recators are best
T ere are two types o electrodes used in electrosurgery: used on conscious patients who will be able to indicate i
monopolar and bipolar (Fig. 14-7). In most monopolar they are inadvertently touching an object that can act as a
applications, the surgeon manipulates the active electrode grounding electrode.

Active ca ble
Ele ctros urgica l
unit
Active
e le ctrode

Re turn
e le ctrode

Re turn ca ble

Figure 14-8 M p e ect s ic it. The c e t t e s m the e ect s i

c it t the cti e e ect e, th h the p tie t ispe ses th h the et
e ect e. 151
2 Re us a ble e le ctrode s

713B

714

727
Ele ctros urgica l
unit
705A

716
S
Figure 14-9 Bip e ect s ic it. The c e t 7-221-S
e
c
t es m the e ect s ic it t e p e the
t
i
e ect e, th h the tiss e, th h the the p e
the e ect e. 7-221-A
2
:
:
138004
In bipolar electrosurgery, the surgeon manipulates both
S
the active and passive electrode in the orm o electri- 1380018
cally isolated orceps (Fig. 14-9). Current ows down the
i
c
active electrode into the patient and returns via the pas-
7-222-A
S
sive electrode. Electricity only enters the tissue that is held
k
i
between the electrodes. Bipolar electrosurgery is a low-
s
7-222-L
power application, and is less likely to cause signi cant
surrounding tissue damage. However, the ull spectrum o
electrosurgical outcomes such as cutting or ne desicca- 138019
tion is not possible using bipolar electrosurgery. Figure 14-10 The e is wi e i ti i e ect e tip size
c ti .
Mo n o t Er Min a l v Er s u s Bit Er Min a l
Monoterminal electrosurgery re ers to an electrosurgi- or wire loop is e ective at cutting tissues. A needle elec-
cal unit that has an active electrode without a return or trode can also be used or cutting, but is more commonly
dispersive electrode. In contrast, biterminal units have used or ne desiccation or destruction o small cutaneous
an active electrode and a return electrode. Monopolar lesions. A ball electrode is o ten used in laparoscopic sur-
units (one active electrode) can either be monoterminal gery or blunt dissection, although the large sur ace area
or biterminal. Monopolar biterminal units consist o an could be used success ully to provide hemostasis. Forceps
active electrode and a distant return electrode. In contrast that clasp tissue are o ten used or hemostasis, cauterizing
to monopolar units, bipolar units are always biterminal. the vessel being grasped. A variety o other electrode tips
Bipolar units utilize an active and return electrode in an have been developed or di erent indications in dermatol-
electrically isolated pair o orceps. ogy, obstetrics and gynecology, and surgery.
Surgical technique also determines outcomes. Depend-
ing on how the active electrode is used and how ar rom
o t HEr f a c t o r s a f f Ec t in g the tissue it is applied (i.e., desiccation vs. ulguration), cut-
c l in ic a l o u t c o ME ting, coagulation, or desiccation can all occur with the same
power and mode settings. issue type a ects outcomes as
In addition to wave orm and power settings, other actors well. For the dermatologist, this is perhaps less important,
a ect the nal clinical outcome. T ese include the shape but it should be noted that dermis, adipose tissue, muscle,
o the electrode, the surgeon’s technique and the type and ascia vary in their response to electrical current.
o tissue.
T e current density can be controlled by changing the
sur ace area o the electrode in contact with the tissue or t Er Min o l o g y o f El Ec t r o s u r g Er y
by changing the total current used. At a constant power
setting, a smaller electrode delivers current through a Several terms have been developed to describe di erent
smaller sur ace area, increasing current density and heat- types o electrosurgery. T e di erences between these
ing tissue more quickly than a larger electrode, and thus is orms o electrosurgery are primarily o historical impor-
better or cutting. In contrast, larger electrodes heat more tance, although electro ulguration is o ten di erentiated
slowly and are more appropriate or coagulation or desic- rom cutting, electrodesiccation, and electrocoagulation
cation. T ere are signi cant variations in electrosurgical because the electrode tip is above the surgical eld rather
electrodes to re ect the di erent uses (Fig. 14-10), and than in contact with the tissue. Furthermore, electrocau-
152 some are designed or very speci c applications. A blade tery is not a true orm o electrosurgery.
 2 mm in diameter.14 T e surgical eld must be dry or the
current will simply disperse without a ecting the under-
2
lying tissue. Electro ulguration is used clinically or light
Cutting = va poriza tion hemostasis o a surgical site. It can also be used to treat
super cial tumors o the epidermis, such as seborrheic
keratoses, verruca plana, epidermal nevi, actinic keratoses,
acrochordons, or angiomas.

A
El Ec t r o d Es ic c a t io n
In 1914, William Clark described dehydration o tissue
without carbonization by using very ne sparks generated
rom an Oudin coil. Clark used the term desiccation ( rom
Fulgura tion Latin desiccare, to dry out) to describe this action.15 In con-

C
h
trast to electro ulguration, during electrodesiccation, the

p
electrode is placed in contact with the tissue (Fig. 14-11).

t
e
Classically, monoterminal units are used to achieve elec-

1
4
trodesiccation. With the correct combination o power
B
setting and electrode tip, the tissue heats more slowly and

:
:
gradually dehydrates. Like electro ulguration, electrodes-

E
iccation is best used to treat super cial epidermal tumors.

e
c
I per ormed correctly, electrodesiccation should result in

t
De s s ica tion = coa gula tion little scarring because treatment is directed primarily at

s
the epidermis. Lesions that can be treated well with elec-
trodesiccation include telangiectasias, seborrheic kerato-

e
y
ses, verruca plana, angiomas, and colloid milia.
C
Figure 14-11 A. Tiss e c tti si e ect s e y. El Ec t r o c o a g u l a t io n
r pi he ti tiss e t hi h tempe t es e s t
p iz ti the p cti ste m, e i t tiss e Electrocoagulation is the process by which proteins in the
c tti the th c ti . C tti c eithe be
tissue are denatured. Electrocoagulation and electrodes-
cc mp ishe by si hi h, c st t c e t si
we c e t s f cie t y pe i s time. B. E ec iccation occur by a similar process, though electrodes-
t ti . ti esc ibes the est cti iccation occurs through slow tissue dehydration, while
s t tiss e by e ect ic sp k th t j mps the p m electrocoagulation occurs through protein denaturation.
e ect e t the tiss e with t the e ect e t chi Classically, electrocoagulation is per ormed with a bitermi-
the tiss e. Hi h t e sp ks es t i pi tempe t e nal unit. As a result, the current can penetrate more deeply
ch es i the tiss e, e i t s pe ci c ti into the dermis. T ere ore, electrocoagulation is use ul or
c b iz ti . C. E ect esicc ti e ect c treating dermal tumors or adnexal neoplasms. It is also
ti . The e ect e is p ce i c t ct with the tiss e, very e ective at providing hemostasis in the surgical eld.
wi the c e t t i se e i y th h the tiss e. Both electrodesiccation and electrocoagulation can be
I e ect esicc ti , the tiss e he ts s w y used with curettage to treat super cial cutaneous neo-
y ehy tes. E ect c ti i c t st t the pi plasms such as basal cell or squamous cell carcinomas. In
ch es i tempe t e c se by e ect c ti .
this technique, the tumor is rst treated with electroco-
agulation or electrodesiccation. T e electrode is moved
slowly across the tumor until the tissue is charred. Follow-
ing the rst pass o electrodesiccation, a curette is used to
El Ec t r o f u l g u r a t io n remove the charred tissue and tumor. In order to ensure
that the borders o the tumor are adequately treated, the
Fulguration describes the destruction o so t tissue by an curette should be applied in all directions (north– south,
electric spark that jumps rom an electrode to the tissue east– west, clockwise, and counterclockwise) around the
without the electrode touching the tissue (Fig. 14-11). surgical site. umors are typically so ter than the underly-
When held close to the tissue, the current sparks in a ing normal dermis and separate easily when treated with a
cone-shaped distribution to the tissue. Electro ulguration curette. When this technique is used to treat keratinocyte
utilizes a low-amperage current with high voltage. o per- derived skin cancers, two more passes o electrodesicca-
orm electro ulguration, the current must be o suf ciently tion and curettage should be applied to ensure adequate
high voltage to spark across the gap between the electrode removal. Note that this technique is not appropriate or
and the tissue. High-voltage sparks result in rapid temper- aggressive growth patterns, such as morphea orm, in l-
ature changes in the tissue, leading to super cial coagula- trative, or micronodular basal cell carcinomas, or or
tion and carbonization. T e carbonization o ten protects aggressive or deep squamous cell carcinomas. Electro-
the underlying tissue rom urther damage. Electro ulgura- desiccation and curettage works in part because o the
tion can be used to control bleeding in small vessels up to di erence in texture between tumor and normal dermis. 153
2 In lesions that are in ltrative, the borders o the tumor
cannot be appreciated and there is a risk o undertreating
bone. It should also not be placed over a prosthetic device,
which can also lead to a shock. Hair inhibits contact
the neoplasm. between the pad and the skin and it is recommended that
all hair be shaved at the site o return electrode placement.
It is essential to take a ew precautions to prevent
El Ec t r o s Ec t io n res and burns in the surgical unit.18 Oxygen or other
ammable gases should be turned o prior to surgery.
A cutting current uses an undamped current to quickly Alcohol-based preparing solutions, i allowed to pool on
heat and vaporize tissue in the treatment area. An ESU’s the patient’s skin or wick into the patient’s hair or linens,
cutting setting generates high temperatures at the elec- can ignite during electrosurgery. T ere ore, the cleanser
trode quickly, allowing or easy cutting through tissue used to prepare the skin should not be ammable or
while preventing signi cant surrounding damage. Due to should be allowed to dry thoroughly prior to draping.
the local e ect o the electrode, a purely cutting current Extreme care and caution should be used when per orm-
will not provide much hemostasis. However, a blended ing electrosurgery around the eye. Sparks rom the elec-
current can both cut and provide hemostasis. Hemostasis trode can easily cause damage to the cornea or globe.
S
is the main bene t o using electrosection with a blended
e
Electrosurgical procedures also result in a plume o
c
t
current rather than scalpel excision. Electrosection can be
i
smoke created when cells are heated to the point o boil-
used to cut the skin, provide undermining, remove acro- ing, leading to dispersal o cellular contents as ne par-
2
chordons, intradermal nevi, or other papillomatous or ticles. Surgical smoke is composed o 95% water and 5%
exophytic skin lesions. Dermatologic surgeons have also
:
:
particulate matter, including blood and tissue particles,
used electrosection to debulk large tumors or lesions such chemicals, viruses, and bacteria.19 raditional surgical
S
as rhinophyma or acne keloidalis nuchae. masks capture particles greater than 5 µm in diameter, but
i
will not lter particles o smaller size. Un ortunately, most
c
El Ec t r o c a u t Er y ESUs create particles o roughly 0.07 µm, which deposit in
S
k
the alveoli once inhaled.20 T ese substances can produce
i
s
For centuries, metal objects have been heated by re and upper respiratory irritation, and have in vitro mutagenic
applied to tissue to cauterize and provide hemostasis. potential.21 In addition, the surgical plume can contain
oday, electricity is used to heat a metal lament that is phenols, nitriles, hydrocarbons, ormaldehyde, hydrogen
placed in direct contact with tissue, resulting in cautery cyanide, and a variety o trace toxic gases.22,23 Although
and hemostasis.16 Resistance is placed in the path o the there has been no documented transmission o in ectious
electron ow, resulting in heat ormation in a wire la- disease through surgical smoke, the potential or gener-
ment. T is principle is also used to heat the wire lament ating in ectious viral ragments, particularly ollowing
o a kitchen toaster, electrical stove element, and conven- treatment o verrucae, may exist.24– 27 An e ective smoke
tional light bulbs. evacuation or ventilation system should be considered to
In electrocautery, electrical current does not enter the prevent the inhalation o noxious smoke and vapors pro-
patient, and thus it is sa e to use in patients with pacemak- duced during electrosurgical operations.28 Consideration
ers and implantable cardioverter-de brillators (ICDs). should also be given to wearing high ltration masks dur-
However, electrocautery can cause damage to adjacent tis- ing electrosurgical procedures.29
sues because substantial heat is o ten required to obtain
hemostasis. Electrocautery devices can use either DC or El Ec t r o s u r g Er y a n d
AC and are currently sold as disposable battery powered
units (DC) or permanent units that utilize AC supplied by iMpl a n t a Bl E d Ev ic Es
wall outlets. Because no current enters the patient, elec-
trocautery is not a true orm o electrosurgery. When treating patients with implantable cardioverter-
de brillators or pacemakers (cardiovascular implantable
electrical devices, or CIEDs), it is important to exercise
s a f Et y care. Electrosurgical devices can inter ere with CIEDs in
several ways. Skipped beats, inhibition, reprogramming
Several sa ety concerns are associated with the use o elec- o a pacemaker, ring o an ICD, asystole, bradycardia,
trosurgical devices: shock, burns, inhalation o the surgi- triggering unneeded tachyarrhythmia therapy and battery
cal smoke plume, and speci c risks o using electrosurgery depletion have all been reported as possible complica-
around the eye. T e risk o electric shock can be minimized tions, though the rates are quite low (0.8 cases/100 years
by ensuring that the patient is not in contact with an alter- o surgical practice).30,31
nate ground. It is essential to avoid this both in “grounded” Monopolar electrosurgery is the most common source
devices with a dispersive electrode and with “ungrounded” o electrical inter erence with cardiac devices in the oper-
devices such as a hy recator. Care must also be taken to ating room. In order to prevent adverse events, caution
prevent close contact to other nonelectrically active wires should be used in this setting. A position paper by the
to prevent electrical trans er to another circuit.17 Heart Rhythm Society/American Society o Anesthe-
o prevent electrosurgical burns, it is important to siologists recommended that a patient’s cardiovascular
properly place the return or dispersive electrode. T e device specialist be consulted by the procedural team
dispersive electrode should be placed overlying muscle, prior to surgery. Factors that a ect the treatment plan
which is much more conductive than adipose tissue or include the type o device, type o surgery, and whether
154
the patient is pacemaker dependent.32 Because o the
complexity o the devices available on the market, there is r Ef Er En c Es
2
no longer one standard recommendation or per orming
1. Elliott JA. Electrosurgery: its use in dermatology, with a
electrosurgery in patients with cardiovascular devices. In review o its development and technologic aspects. Arch
order to minimize complications, particularly given the Dermatol. 1966;94:340– 350.
variety o modern CIED, many centers per orm electro- 2. Frew JW. Per orming surgery with a single electron: electro-
surgery in coordination with a pacemaker team in order surgery and quantum mechanics. ANZ J Surg. 2009;79:680–
682.
to minimize complications.33,34 In addition, the Heart
3. Blankenship ML. Physical modalities. Electrosurgery, electro-
Rhythm Society/American Society o Anesthesiologists cautery, and electrolysis. Int J Dermatol. 1979;18:443– 452.
recommends that all pacemakers, ICDs and cardiac resyn- 4. D’Arsonval A. Action physiologque des currants alternati s.
chronization devices be interrogated within 1 month ol- CR Soc Biol (Paris). 1891;43:283.
lowing an electrosurgical procedure using a monopolar 5. Pollack SV, Carruthers A, Gerkin RC. T e history o electro-
surgery. Dermatol Surg. 2000;26:904– 908.
device.32 I electrosurgery must be per ormed, techniques
6. Massarweh NN, Cosgri N, Slakey DP. Electrosurgery: his-
that can be used to limit complications include the use tory, principles, and current and uture uses. J Am Coll Surg.
o bipolar orceps, low power, short bursts o power (less

C
2006;202:520– 530.

h
than 5 seconds), and avoiding the area around the ICD 7. Sebben JE. T e status o electrosurgery in dermatologic prac-

p
or pacemaker.35 Bipolar orceps are generally sa er to use tice. J Am Acad Dermatol. 1988;19:542– 549.

t
e
8. Zinder DJ. Common myths about electrosurgery. Otolaryngol
in patients with a CIED because the electrical current

1
Head Neck Surg. 2000;123:450– 455.

4
only passes through the tissue between the orceps, thus 9. Friedman J. T e technical aspects o electrosurgery. Oral Surg
minimizing the chance that the current will inter ere with Oral Med Oral Pathol. 1973;36:177– 187.

:
:
the cardiovascular device. Low power and short bursts 10. Pollack SV, Grekin RC. Electrosurgery and electroepilation.

E
help minimize the amount o current that the patient is In: Roenigk RK, Roenigk HH, eds. Roenigk & Roenigk’s Der-

e
matologic Surgery: Principles and Practice. New York, NY:

c
exposed to, thus potentially decreasing the risk to the car-

t
Marcel Dekker; 1996: 220– 221.
diovascular device. 11. Eggleston JL, Von Maltzahn WW. Electrosurgical devices. In:

s
I the patient’s cardiovascular device specialist can- Bronzino JD, ed. T e Biomedical Engineering Handbook. 2nd
not be reached prior to surgery, it should be noted that ed. Boca Raton, FL: CRC Press LLC; 2000.

e
12. Wright VC. Contemporary electrosurgery: physics or physi-

y
electrocautery can be sa ely used in these patients in all
cians. J Fam Pract. 1994;39(2):119– 122.
locations. Electrocautery uses heat rather than an electri-
13. Sebben JE. Electrosurgery: high- requency modalities. J Der-
cal current to provide hemostasis, so it will not inter ere matol Surg Oncol. 1988;14:367– 371.
with the CIED. Although electrocautery results in more 14. Brill AI. Electrosurgery: principles and practice to reduce
tissue burning than electrosurgery, it does not require risk and maximize ef cacy. Obstet Gynecol Clin North Am.
intraoperative monitoring and is sa e to use in unstable 2011;38:687– 702.
15. Clark WL. T e desiccation treatment o congenital and
patients.
new growths o the skin and mucous membranes. JAMA.
Similar precautions are taken with patients with cochlear 1914;LXIII:925– 929.
implants. Cochlear implants are electrical devices that are 16. Gandsas A, Adrales GL. Energy sources. In: alamini MA, ed.
surgically implanted under the periosteum o the cranium Advanced T erapy in Minimally Inva sive Surgery. Hamilton,
and electrically stimulate the auditory nerve. Cochlear ON: BC Decker; 2006; 3.
17. Robinson N, Barnes KS, Govekar HR, Stiegmann GV, Dunn
implants can be damaged by an electrical current in the
CL, McGreevy F . Antenna coupling – a novel mechanism o
vicinity o the device, and use o electrosurgical devices radio requency electrosurgery complication: practical impli-
around the cochlear implant may compel surgical replace- cations. Ann Surg. 2012;256:213–218.
ment o the implant. T e British Cochlear Implant Group 18. Spruce L, Braswell ML. Implementing AORN recommended
sa ety guidelines dictate that monopolar electrosurgery practices or electrosurgery. AORN J. 1995;95:373– 384.
19. Gonzalez-Bayon L, Gonzalez-Moreno S, Ortega-Perez G.
should not be used on the head and neck, and bipolar elec-
Sa ety considerations or operating room personnel during
trosurgery should not be used within 2 cm o the implant.36 hyperthermic intraoperative intraperitoneal chemotherapy
Monopolar electrosurgery can be sa ely per ormed below per usion. Eur J Surg Oncol. 2006;32:619– 624.
the neck in patients with implants.37 Electrocautery can be 20. Ulmer BC. T e hazards o surgical smoke. AORN J. 2008;
sa ely per ormed in the head and neck region o patients 87:721– 738.
21. Barrett WL, Garber SM. Surgical smoke: a review o the lit-
with cochlear implants.
erature. Surg Endosc. 2003;17:979– 987.
22. Gatti JE, Bryant CJ, Noone RB, Murphy JC. T e mutagenicity
o electrocautery smoke. Plast Reconstr Surg. 1992;89:781–784.
c o n c l u s io n 23. Moot AR, Ledingham KM, Wilson PF, et al. Composition o
volatile organic compounds in diathermy plume as detected
Over the past 100 years or so, electrosurgery has become a by selected ion ow tube mass spectrometry. ANZ J Surg.
2007;77:20– 23.
undamental tool in the dermatologists’ armamentarium. 24. Baggish MS, Poiesz BJ, Joret D, Williamson P, Re al A. Pres-
Electrosurgical tools have evolved, becoming sa er and ence o human immunode ciency DNA in laser smoke.
more ef cient with technological advances. Furthermore, La sers Surg Med. 1991;11:197– 203.
dermatologists have expanded the uses o electrosurgery 25. Garden JM, O’Banion MK, Bakus AD, Olson C. Viral disease
beyond hemostasis and cutting to include the treatment transmitted by laser-generated plume (aerosol). Arch Derma-
tol. 2002;138:1303– 1307.
o benign and malignant neoplasms, super cial and deep 26. Gloster HM Jr, Roenigk RK. Risk o acquiring human papil-
ablations, and cosmetic purposes. Due to the wide range lomavirus rom the plume produced by the carbon dioxide
o uses or electrosurgery, it will likely continue to play an laser in the treatment o warts. J Am Acad Dermatol. 1995;32:
important role in clinical care. 436– 441.
155
2 27. Garden JM, O’Banion MK, Sheinitz LS, Pinski KS, Bakus AD,
Reichmann ME. Papillomavirus in the vapor o carbon diox-
the American Society o Anesthesiologists (ASA), and in
collaboration with the American Heart Association (AHA),
ide laser treated verrucae. JAMA. 1988;259:1199– 1202. and the Society o T oracic Surgeons (S S). Heart Rhythm.
28. Bigony L. Risks associated with exposure to surgical smoke 2011;8:1114– 1154.
plume: a review o the literature. AORN J. 2007;86(6):1013– 33. Misiri J, Kusumoto F, Goldschlager N. Electromagnetic inter-
1024. erence and implanted cardiac devices: the medical environ-
29. Lewin JM, Brauer JA, Ostad A. Surgical smoke and the der- ment (part II). Clin Cardiol. 2012;35:321– 328.
matologist. J Am Acad Dermatol. 2011;65:636– 641. 34. Stone ME, Salter B, Fischer A. Perioperative management
30. El-Gamal HM, Du resne RG, Saddler K. Electrosurgery, o patients with cardiac implantable electronic devices. Br J
pacemakers and ICDs: a survey o precautions and compli- Anaesth. 2011;107:i16– i26.
cations experienced by cutaneous surgeons. Dermatol Surg. 35. Healey JS, Merchant R, Simpson C, et al. Canadian Cardio-
2001;27:385. vascular Society/Canadian Anesthesiologists’ Society/Cana-
31. Matzke J, Christenson LJ, Christenson SD, Atanashova N, dian Heart Rhythm Society joint position statement on the
Otley C. Pacemakers and implanatable cardiac de ribilla- perioperative management o patients with implanted pace-
tors in dermatologic surgery. Dermatol Surg. 2006;32:1155– makers, de brillators, and neurostimulating devices. Can J
1162. Cardiol. 28(2):141– 151.
32. Crossley GH, Poole JE, Rozner MA, et al. T e Heart Rhythm 36. Frampton SJ, Ismail-Koch H, Mitchell E. How sa e is dia-
S
Society (HRS)/American Society o Anesthesiologists (ASA) thermy in patients with cochlear implants. Ann R Coll Surg
e
Expert Consensus Statement on the perioperative manage- Engl. 2012;94:585– 587.
c
t
i
ment o patients with implantable de brillators, pacemak- 37. Poetker DM, Runge-Samuelson CL, Firszt JC, Wackym PA.
ers and arrhythmia monitors: acilities and patient manage- Electrosurgery a ter cochlear implantation: eighth nerve elec-
2
ment this document was developed as a joint project with trophysiology. Laryngoscope. 2004;114:2252– 2254.
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156
 Ch a p t e r

15 Cryosurgery
J m s M. Sp nc r & Summ r D. Moon

In t r o d u c t Io n Ba s Ic Pr In c IPl es
Cryosurgery is among the most power ul and e cient Cryosurgery is unique because it provides a sa e, e ective,
tools used in dermatology. T is minimally invasive and and economically easible method o treating a variety o
cost-e ective procedure is valuable or the treatment o dermatological conditions. T e subzero temperatures which
many benign, premalignant and certain super cial malig- it achieves cause cellular damage and death through heat
nant lesions, and is an alternative or patients who are bed- extraction. T e cellular damage itsel occurs through direct
ridden, have blood-borne illnesses, or simply do not wish injury, vascular stasis, apoptosis, and immunologic e ects.
to undergo a surgical excision. As with any procedure, Freezing temperatures cause direct injury by creat-
the risks and bene ts must be properly explained. Cryo- ing an osmotic gradient. Crystallization outside the cells
surgery has truly stood the test o time and with proper causes water to rush outward, which leads to internal
training may be used to treat a wide variety o cutaneous dehydration, organelle damage, cell membrane and cyto-
lesions with ease. skeleton changes which compromise the integrity o the
cell. Additional reezing creates internal crystallization,
which causes cell lysis. During the thawing process the
HIs t o r y osmotic gradient reverses as ice crystals reorganize within
the cell; this leads to urther destruction as water moves
Cryosurgery is one o the oldest and most versatile proce- back into the cells, causing urther swelling and cell lysis.
dures in dermatology. T e medical use o cold dates back T e initial e ect o cryosurgery on blood vessels is vaso-
over 4,000 years, when ancient Egyptians used it as a local constriction, which leads to cellular hypoxia and blood
anesthetic to minimize the pain o trauma and decrease stasis. As the tissue thaws, a compensatory vasodilatation
in ammation. Baron Dominique Larrey, the military sur- occurs, which brings in ree radicals, causing peroxidation
geon o Napoleon’s army, used ice and snow to pretreat o membrane lipids.
injured limbs be ore amputation. In 1851, James Arnott Apoptotic cells are thought to contribute to cell death
o London pioneered a local analgesic using ice and saline and are ound at the periphery o the central necrotic
or palliative treatment o cancerous tumors in terminally area.8,9 Apoptosis increases progressively 2 to 8 hours a ter
ill patients. As the rst to achieve temperatures around the initial reezing.9,10
−24°C, Arnott is o ten described as the ather o “mod- Cryosurgery’s ability to generate long-term memory
ern” cryosurgery.1 In 1899, Campbell White, a New York cells is attributed to a cytokine and delayed -cell response
dermatologist, became the rst to success ully treat warts, induced by cryoablation.11 T e rst reports o the immu-
nevi, keratoses, and skin cancers with a cotton-tipped nologic e ect o cryosurgery showed a reduction o meta-
applicator dipped into lique ed air. In 1907, another der- static disease a ter cryoablation o the primary tumor.12,13
matologist, H. H. Whitehouse, engineered the rst spray Murine models demonstrate inhibition o secondary and
device delivering cryogen.2 Soon therea ter, W. A. Pusey metastatic tumor growth through cryoablation o tumor
promoted carbon dioxide to treat acne and nevi.3,4 Liq- tissue.14 Further analysis has revealed that cryosurgery
uid nitrogen (LN) replaced carbon dioxide as the primary may enhance the uptake o tumor antigens by dendritic
cryogen in 1948. During this time, LN was applied to cells, resulting in induction o tumor-speci c CD8+ cells
lesions using a cotton-wool swab. In the mid-1960s with responsible or in vivo regression o both treated and dis-
the help o Whitehouse’s ideas, Setrag Zacarian and Doug- tant tumors.15
las orre made cryogen delivery more e cient. Zacarian Necrosis occurs at the center o the treatment area
designed the method o indirectly administrating LN by where temperatures reach −40° to −50°C. T e rate o reez-
cooling copper cylinders while orre developed a reli- ing determines the nal temperatures achieved by the
able LN spraying system.5 Around the same time, Irving target tissue. T e recommended temperature and rate at
S. Cooper, a neurosurgeon, ound a way to bring LN to a which reezing temperatures are achieved di er or benign
controlled temperature o −195°C, which is the tempera- and malignant lesions. A moderate-to-rapid reeze speed
ture we use in dermatology today. In 1968, Michael Bryne with a goal o −20° to −25°C is recommended or benign
developed the rst commercially available handheld cryo- lesions. A rapid reeze, with a goal o −50°C or lower, is
surgical device.6,7 required to treat malignant lesions.
2 Flash reezing with LN kills the cell whereas slow thaw-
ing prolongs the time at which the tissue remains at subzero
temperatures, which increases intracellular ice ormation.
A single reeze– thaw cycle may be su cient or benign
lesions; repeated cycles are usually needed or malignant
lesions. Using multiple reeze– thaw cycles on premalig-
nant or malignant lesions allows the cryogen to penetrate
more deeply and leads to greater cellular destruction.
T e space between the lesion and the cryogen deter-
mines the nal temperature o the target tissue. Air and
keratin are poor thermal conductors, and it may there ore
be help ul to debulk lesions with excess keratin prior to
treatment. A plastic cone shield or an otoscope nasal spec-
ulum may be used between the cryogen tip and the tissue
to localize therapy and prevent overspraying.
S
When treating benign lesions in sensitive locations, one
c
t
Figure 15-2 Dif r nt typ s o pro s.
i
may consider using a cotton-tipped applicator dipped in
o
n
LN instead o using an open spray. T is technique is usu-
2
ally less pain ul and more easily tolerated. A small amount pling devices can be added to monitor the temperatures
:
:
o LN is poured into a cup or stainless steel bowl to reduce achieved by the tissue, through needles placed beneath the
the risk o contamination, which may occur i the applica-
S
lesion. T ermocouples are not used requently by derma-
u
tor is reintroduced into the container ollowing treatment
r
tologists but may be help ul or the novice.
g
i
o warts or other in ectious lesions.
c
l
S
k
t ec Hn Iq u es
i
eq u IPmen t
l
l
s
Cryosurgery requires a cryogen and a delivery unit. In der- T ere are ve main methods used or the delivery o cryo-
matology, the ideal cryogen is LN, most commonly deliv- gen in dermatology: open spray, cone de ned spray, cham-
ered in a handheld spray unit (Fig. 15-1). T ese units are ber, probe, and intralesional.
equipped with interchangeable apertures and probe tips ■ Open spray is the most versatile way to reeze lesions
o various sizes (Fig. 15-2). Spray tips are available start- and is the pre erred method o most dermatologists.
ing rom 1 to 2 mm in size. Cones are available to prevent Open spray delivers LN through an attachment at the
overspray and to localize tissue destruction. LN is widely spray unit’s open end. Attachment tips come in a variety
accepted as the ideal cryogen because o its ease o trans- o diameters: A (largest), B, C, D, or E (smallest). T e
port, sa ety, low cost, ease o storage, and low tempera- larger the diameter, the more cryogen delivered per unit
tures.16 Storage tanks or LN are available in capacities o time. Freeze time is relative to the speed o the cryo-
5, 10, 25, 30, 35, and 50 L (Fig. 15-3). gen as it is released rom the gun. Larger tips (A) are
Cotton-tipped applicators or a metal probe dipped in reserved or larger malignancies. T e most commonly
LN are acceptable treatment options or benign lesions but used tips are B and C. T e E tips come with a back vent
do not achieve the temperatures necessary to treat prema- that allows or a more precise and streamlined spray,
lignant or malignant lesions. Cotton-tipped applicators making its use ideal or small, circumscribed, or delicate
work well or patients who have lesions in sensitive areas lesions. T e open-spray technique is ideal or irregular
or or those who cannot tolerate the reezing temperatures lesions. I the system clogs while spraying, this is a sign
achieved by the spraying or probe techniques. T ermocou- that the LN is not clean and should be replaced.

158 Figure 15-1 H ndh ld liquid nitrog n spr y units. Figure 15-3 Liquid nitrog n stor g cont in r.
■ Cone de ned spray uses the same methods as the open
spray but adds a cone between the lesion and the unit.
■

■
Do not treat a lesion that is bleeding.
Malignant cells are more resistant to reezing than
2
Using this technique concentrates the spray or greater normal cells.
accuracy and penetration. It is essential to apply pres- ■ Cartilage and bone are very resistant to reezing.
sure to the cone in order to eliminate lateral leakage. ■ Melanocytes, basal cells, and keratinocytes are very
Cones come in various sizes and materials, and should sensitive to reezing.
be washed in between patients to prevent contamina- ■ Connective tissue, broblasts, and viruses are less
tion and the spread o in ection. sensitive to reezing.
■ Chambers should be reserved or thick malignancies ■ Healing time increases away rom the ace.
because o the technique’s rapid delivery o LN. T e ■ Cryosurgery on the lower extremities may take months
chamber technique uses metal cylinders with a rubber to heal.
base on one side, which is applied rmly to the target
tissue. T e opposite end allows a large amount o LN Pa t Ien t s el ec t Io n a n d
to ow into the chamber at a constant rate. Chambers Pr eo Per a t Iv e Pr ePa r a t Io n
are available in various sizes. For malignant lesions,

C
h
it is important to select a chamber size that ts the T e indications or cryosurgery are extensive but the

p
lesion and includes the proper margins or the lesion.

t
decision to treat depends on a number o actors. Patient

r
■ Probe techniques are reserved or contact cryosurgery. expectations, skin type, and overall health are important

1
5
A probe is used to deliver LN rom the unit via a conduit aspects to consider. Cryosurgery itsel is usually well tol-
line, which maintains a closed system. Ideally, the probe erated, but erythema, swelling, pain, and blistering com-

:
:
should t the shape o the lesion. It is better to use a monly ollow treatment. Depending on the location and

C
smaller rather than a larger probe that does not t prop-

r
depth o the reezing, symptoms may take up to 6 weeks

y
erly; using a smaller probe avoids reezing healthy tissue.

o
or complete resolution. Patients with Fitzpatrick skin

s
u
■ T e intralesional technique should be reserved or types III–VI are particularly prone to hypopigmentation.

r
g
deep-seated tumors. It consists o inserting one to sev- All patients should be warned o the possibility o hypo-

r
eral sterile open, closed, or double cannula probes into

y
or hyperpigmentation ollowing treatment. Although most
one side o the tumor and running the probe intersti- patients heal with minimal complications, cryosurgery
tially along the largest axis o the lesion at its deepest should be avoided in patients with severe arteriosclerosis o
point until it appears on the sur ace at the other side.16 the lower extremities. reating leg lesions in patients with
LN is then sprayed into the cannula. Ice orms within this condition may lead to prolonged healing times as well
the core o the lesion with minimal sur ace destruction as the possibility o additional complications.
in comparison to the other techniques. T e portability o cryosurgery makes it particularly use-
ul or patients in nursing homes and or those who have
A more recent technique utilizes an in rared sen- di culty leaving home. Additional patient populations
sor attachment placed at the probe tip to measure tem- who may bene t rom cryosurgery include high-risk sur-
peratures attained on the skin sur ace be ore and during gical candidates, patients with poor wound healing, and
cryosurgery.17 T is device uses a three-color– coded light those with allergies to local anesthesia. Cryosurgery has the
system to indicate the temperature at the skin’s sur ace. It bene t o being blood ree, there ore making it an excel-
also includes an integrated tracker, which displays the total lent option or managing dermatologic mani estations in
reeze time as well as the time at which the desired temper- patients with blood-borne diseases such as HIV or Hepa-
ature is reached. T e duration o most treatments ranges titis B and C.
rom 5 to 10 seconds. A recent paper on the treatment o
actinic keratoses (AKs) with the integrated in rared sensor
achieved a 100% response rate when controlling the tem-
perature to −5°C.17
c l In Ic a l a PPl Ic a t Io n s
When per orming cryosurgery, it is essential to keep the
ollowing concepts in mind: v Ir a l v er r u c a e
■ T e optimal reeze– thaw sequence consists o a ast reating warts with cryosurgery can be a challenge and may
reeze and slow thaw. require multiple attempts ( able 15-1). Some patients pre er
■ One reeze– thaw cycle is usually su cient or benign the use o a cotton-tipped applicator, whereas others pre er
lesions. the LN spray. Paring down lesions or pretreating warts with
■ Premalignant or malignant lesions typically require two a keratolytic agent may result in higher cure rates.
reeze– thaw cycles.
■ Complete thawing is required when per orming
multiple cycles. a c r o c Ho r d o n s (s k In t a g s )
■ Proper contact with the lesion is essential.
■ Air, keratin, and cotton are poor thermal conductors. reating skin tags with LN requires a cup and orceps. T e
■ o direct treatment, use o a cone or nasal speculum LN is poured into a cup and the orceps is allowed to soak
may be considered. in the LN or about 20 seconds. When the orceps are cov-
■ T e diameter o the lesion treated is essentially equal to ered by rost, the stalk o the tag is grasped or approxi-
the depth. mately 10 seconds (Fig. 15-4). ags can also be removed
It is better to undertreat than to overtreat benign lesions. by scissors or electrosurgery.
■
159
2 Ta bLe 15-1 g r a n u l o ma a n n u l a r e
d i ft i i s t B i
m i l i wi h l i i ni Cryosurgery can be used in the treatment o granuloma
annulare. A prospective trial in Germany ound that one
B i l i :F w r d i reeze– thaw cycle with LN or nitrous oxide using a closed
>100°c / i probe technique or 10 to 60 seconds produced excellent
results. Resolution o the lesions occurred in 25 o the 31
V rruc vulg ris 10 patients (80.6%); only one relapse occurred during 2 years
a crochordon 10 o ollow-up.18
Molluscum cont giosum 10–20
Gr nulom nnul r 10–60 Pr u r Ig o n o d u l a r Is
Prurigo nodul ris 15–30
Cryosurgery is one o the treatments o choice or prurigo
S
Cut n ous l rv migr ns 5–7 nodularis. T e open-spray technique is commonly used
c
or 15 to 30 seconds depending on the thickness o the
t
S orrh ic k r tosis 5–15
i
o
lesion. T e use o cold tends to relieve symptoms by break-
n
Sol r l ntigo 3–7
2
ing the itch– scratch cycle.
a cn 5–7
:
:
Hyp rtrophic sc rs/k loids 30 c u t a n eo u s l a r va mIg r a n s
S
u
r
H m ngiom s 10–20
g
i
Resistant cases o cutaneous larva migrans may respond
c
Pyog nic gr nulom s 20–30
l
to the open-spray technique o cryogen applied at both
S
k
V scul r m l orm tions 30 ends o the trail. Freezing should be carried out or 5 to
i
l
l
s
7 seconds.16
Premalignant and malignant lesion: Flow Rate >100°C/min
a ctinic k r tosis 5–30
s eBo r r HeIc k er a t o s es
L ntigo m lign 2 × 30
b s l nd squ mous c ll c rcinom 2 × 30 Cryosurgery is among the astest and most e cient way to
K posi’s s rcom 2 × 30 treat seborrheic keratoses (SKs). It is essential that treat-
ment be per ormed only when the diagnosis is certain since
reezing a pigmented melanocytic lesion could potentially
mo l l u s c u m c o n t a g Io s u m harm the patient. Most lesions are treated with the open-
spray technique and commonly require only one treat-
Molluscum contagiosum can be treated with either open ment. SKs should be rozen or 5 to 15 seconds and should
or closed techniques. T e lesion should be centered include a 1 to 2 mm rim around the lesion (Fig. 15-5).
about 2 mm below the open-spray nozzle and the reeze
allowed to spread just outside the margin o the lesion. For s o l a r l en t Ig In es
the probe technique, a ne-point probe the same size or
slightly smaller than the lesion should be used. Melanocytes are particularly susceptible to cold, mak-
ing cryosurgery an excellent choice or treatment o solar

Figure 15-5 Tr tm nt o s orrh ic k r tosis with h nd

160 Figure 15-4 Tr tm nt o crochordon with orc ps. h ld liquid nitrog n spr y unit.
lentigines and ephelides. It is a good idea to con rm the diag-
nosis by dermoscopy prior to treatment. When in doubt, it
2
is always sa er to biopsy the lesion. Once the diagnosis is
con rmed, an open-spray technique directed perpendicu-
lar to the lesion or 3 to 7 seconds is usually su cient or
treatment, being certain to reeze the entire lesion.

acne
Cryosurgery can be particularly use ul during pregnancy
or as an alternative treatment or patients who do not wish
to use systemic or topical treatments or pustules and/or
cysts. Cold initially has an in ammatory e ect and within
24 to 48 hours the pustules and cysts tend to resolve more

C
quickly than without any treatment.16 An open-spray tech-

h
nique is used, reezing the entire lesion or 5 to 7 seconds.

p
t
Patients should be educated regarding the possibility o

r
1
drainage a ter the procedure and should be instructed to

5
apply topical antibiotics or vaseline ollowing treatment.

:
:
Spraying should never be per ormed on incised or drain-
ing lesions due to the risk o local crepitation or insuf a-

C
r
y
tion o nitrogen within the wound.

o
s
Figure 15-6 Tr tm nt o ctinic k r tosis on th t mpo

u
r
r l r gion with h ndh ld liquid nitrog n spr y unit.

g
HyPer t r o PHIc s c a r s a n d k el o Id s

r
y
Cryosurgery alone or in combination with the use o their overall appearance and makes it easier to hide them
intralesional corticosteroids may treat some patients with with makeup. Venous lakes can be treated with previously
hypertrophic scars or keloids success ully. However, there rozen probes applied with pressure or 4 to 5 seconds.21
is always a risk or additional scarring. An open spray or Large nodular lesions should be grasped with the probes
cotton-tipped applicator dipped in nitrogen is used, and until they are rozen down to their base.
the cryogen is applied to each lesion or about 30 seconds.19
I the lesion is large, preprocedure debulking may be con- a c t In Ic k er a t o s es
sidered. Multiple treatments may be necessary or thick or
recurring lesions. reatments should be spaced 1 month Cryosurgery is among the most common treatments or
apart to allow or adequate healing be ore evaluating the AKs. reatment times vary rom 5 to 30 seconds depend-
patient’s response to the procedure. ing on the amount o excess keratin on top o the lesion.
T ick lesions may be debulked or pretreated with emol-
Hema n g Io ma s lients. T e open-spray technique is used, allowing or a
1 to 2 mm margin o reeze surrounding the lesion (Figs.
Controversy exists regarding whether hemangiomas should 15-6 and 15-7). reating AKs with cryosurgery is believed
be treated or le t alone to resolve spontaneously. Ideally, to be highly e ective, but its actual e ectiveness has been
a capillary hemangioma should be treated as soon as it poorly documented. In 1982, Lubritz reported a single
appears; the decision to treat is, there ore, made immedi-
ately a ter diagnosis.20 Super cial hemangiomas are treated
directly using a tted probe placed over the lesion. A single
application o LN or about 10 to 20 seconds is usually su -
cient, treating until the cryogen reaches 1 to 2 mm outside
the lesion’s border.

Pyo g en Ic g r a n u l o ma s
Pyogenic granulomas can be treated using either the
probe or the open spray technique. Freezing temperatures
should reach the base o the tumor or optimal treatment.

va s c u l a r ma l Fo r ma t Io n s
When lasers ail in the treatment o vascular mal orma-
tions, cryosurgery can be a use ul alternative. T e ability to Figure 15-7 Tr tm nt o ctinic k r tosis on th h lix o
reduce the thickness o certain capillary lesions improves th r with h ndh ld liquid nitrog n spr y unit. 161
2 retrospective review o his personal experience treat-
ing 70 patients with 1018 AKs with cryosurgery. Patients
T e reezing circle should be allowed to advance 1 to 2
mm outside the vascular lesion.
were ollowed or 1 to 8.5 years a ter treatment. A 98%
cure rate was reported.22 A more recent prospective study
o 89 patients with 421 AKs treated with cryosurgery at Po s t o Per a t Iv e c a r e a n d
various reeze times reported only a 67.2% response rate.23 ex Pec t ed s Id e eFFec t s
In patients with multiple AKs, one can consider pretreat-
ment with topical eld therapy such as 5% uorouracil or Cryosurgery is a ast, simple, and e cient tool, but there is
imiquimod or 2 to 4 weeks, which should lead to ewer always a risk o side e ects and potential or a long recov-
lesions, a need or less reezing, and better cold penetra- ery process. It is important to discuss the risks and to sup-
tion i cryotherapy is subsequently required. ply patients with a list o written instructions regarding
postoperative care, anticipated healing time, expected
symptoms, and possible complications.
l en t Ig o ma l Ig n a Patients should be instructed to wash the wound with
soap and water once or twice daily, and to dress it i the
S
Melanocytes are sensitive to cold, and cryosurgery may area is draining or has a bullous reaction. T ey can be
c
t
i
there ore be considered as a treatment option or selected instructed to apply topical antibiotic ointment or vaseline
o
n
patients with lentigo maligna (LM) who cannot toler- daily to avoid secondary in ection. Healing time depends
2
ate surgery. An aggressive double reeze– thaw cycle with on the number o reeze– thaw cycles, the temperature
:
1 cm margins is advised.16 Recurrence rates vary rom 0% achieved, and the location and depth o the lesion. It is
:
to 40% with patient ollow-up ranging rom 7 months to important to keep in mind that the deeper the reeze and
S
u
4 years.24– 29 Biopsies are absolutely necessary ollowing the poorer the circulation at the site, the longer the recov-
r
g
i
treatment, however, to con rm the absence o invasive ery process.
c
malignancy. Cryosurgical treatment o LM has been asso- Erythema, edema, and itching and burning are expected
l
S
k
ciated with the development o amelanotic lentigo maligna almost immediately ollowing treatment. Applying a topi-
i
l
l
melanoma (ALMM).30 Because repigmentation can occur, cal moisturizer ollowing cryosurgery may ease pruritus.
s
close posttreatment ollow-up is required. Pain can occur and sometimes requires topical or oral
analgesics. Vesicle or bulla ormation may occur 1 to
5 days a ter treatment; these usually contain clear uid.
Ba s a l c el l c a r c In o ma a n d Occasionally the bulla may be hemorrhagic or exudative.
s q u a mo u s c el l c a r c In o ma Postoperative erythema and discom ort can last or sev-
eral weeks. As melanocytes are extremely sensitive to cold,
Cryosurgery is a simple and e ective treatment or selected hypo- and hyperpigmentation are always risks, which may
nonmelanoma skin cancers. Well-de ned and super cial lead to a suboptimal cosmetic result. Each patient should
basal cell carcinoma (BCC) or squamous cell carcinomas be educated regarding these risks and bene ts be ore
(SCC) less than 2 cm in diameter are ideal candidates or treatment is per ormed.
this type o treatment. reatment with open spray should
consist o a double reeze– thaw cycle per ormed or 30 to
60 seconds depending on the thickness o the lesion. One c o mPl Ic a t Io n s
may consider debulking thick lesions or using electroco-
agulation and curettage be ore cryosurgery. A meta-anal- Proper training in cryosurgery decreases the risk or com-
ysis evaluating 50 patients with primary BCC ollowed or plications but does not eliminate it. Bleeding is possible
5 years a ter LN treatment reported recurrence rates rang- with deep reezing and may require electrocoagulation or,
ing rom 0% to 20.4%.31 Results rom a combination treat- more rarely, suturing o a vessel. Lesions may become sec-
ment o curettage and cryosurgery in a 2011 prospective ondarily in ected i they are not properly cleaned. Patients
trial o 69 patients with 100 non acial tumors less than may complain o a headache ollowing cryosurgery to
or equal to 2 cm in diameter who were ollowed or 1 to the ace or scalp. Nitrogen gas insuf ation is rare but can
5 years a ter treatment resulted in a 99% recurrence- ree occur i open-spray technique ollows a biopsy o a lesion.
end point.32 umors included in this trial consisting o Syncope may occur in patients who are nervous or hyper-
super cial BCC, super cial nodular BCC with papillary sensitive to cold. Hypopigmentation and hyperpigmen-
dermal invasion, SCC in situ, and SCC with papillary der- tation can also occur. Pigment changes may blend over
mal invasion. Cryosurgery in these instances should not time or may be a permanent complication. Hypertrophic
replace surgical removal as the treatment o choice, but scarring, alopecia and paresthesias are rare but have been
can be an alternative option or poor surgical candidates or reported as complications ollowing cryosurgery.
patients who do not wish to undergo an invasive procedure.

r ec en t a d va n c emen t s
k a Po s I’s s a r c o ma
Cryopeeling is a newer modality currently being evaluated
Cryosurgery using an open spray or probe technique is as another tool or dermatologists to use as eld therapy.
an option or patients with Kaposi’s sarcoma. A double Cryopeeling uses cryosurgery in a di use manner on sun-
reeze– thaw cycle or open spray and a single application damaged skin to promote skin rejuvenation and decrease
162 when using a probe usually provides adequate treatment. the likelihood o AKs or skin cancers developing in the
 uture. A study by Chiarello, ollowing 373 patients with
34,604 AKs over 6.5 years concluded that the incidence o
5. orre D. Cradle o cryosurgery. NY State J Med. 1967;67:465–
467.
2
6. Rubinsky B. Cryosurgery. Ann Rev Biomed Eng. 2000;2:157–
SCC was greatly reduced with cryopeeling. Conservative
187.
estimates rom the literature predict that 34 SCCs should 7. Ku ik EG, Gage AA, Lubritz RR, Graham GF. Millenium
have appeared yearly in these 373 patients i these areas paper: history o dermatologic cryosurgery. Dermatol Surg.
were le t untreated. T e incidence o SCC over the entire 2000;26:715– 722.
6.5 year study was 33, with no metastases. Not all 373 8. Hollister WR, Mathew AJ, Baust JG, et al. E ects o reezing
on cell viability and mechanisms o cell death in human pros-
patients were ollowed or 6.5 years.33 More studies will
tate cancer cell line. Mol Urol. 1998;2:13– 18.
there ore be required to evaluate the long-term success o 9. Gage AA, Baust JM, Baust JG. Experimental cryosurgery
cryopeeling. investigation in vivo. Cryobiology. 2009;50:229– 243.
10. Forest V, Peoc’h M, Campos L, Guyotat D, Vergnon JM.
E ects o cryotherapy or chemotherapy on apoptosis in non-
Pa l l Ia t Iv e t r ea t men t small-cell lung cancer xenogra ted into SCID mice. Cryobiol-
ogy. 2005;50:29– 37.
11. Adams S, O’Neil DW, Bhardwaj N. Recent advances in den-
Palliative treatment with cryosurgery is an excellent

C
dritic cell biology. J Clin Immunol. 2005;25(3):177– 188.
option or patients with large or dis guring lesions who

h
12. Gage AA. Cryosurgery or oral and pharyngeal carcinoma.

p
are unable or unwilling to undergo recommended treat- Am J Surg. 1969;118:669– 672.

t
ment. Cryosurgery can reduce bleeding, local in ection, 13. Soanes WA, Ablin RJ, Gonder MJ. Remission o metastatic

r
1
and pain, thereby allowing the patient to have a better lesions ollowing cryosurgery in prostatic cancer: immuno-

5
logic considerations. J Urol. 1970;104:154– 159.
quality o li e. T e open spray and chamber techniques
14. Joosten JJ, Muijen GN, Wobbes , Ruers J. In vivo destruc-

:
:
are commonly used. Attempting to shave or debulk large tion o tumor tissue by cryoablation can induce inhibition o
lesions prior to treatment is not advised because most

C
secondary tumor growth: an experimental study. Cryobiology.

r
y
have an enormous network o neovascularization. Large 2001;42(1):49– 58.

o
15. Udagawa M, Kudo-Saito C, Hasegawa G, et al. Enhancement

s
tumors can be treated with ractional or segmental cryo-

u
o Immunologic umor regression by intratumor administra-

r
surgery. Fractional cryosurgery34 consists o reducing the

g
tion o dentric cells in combination with cryoablative tumor
extent o the area treated by beginning treatment in the

r
y
pretreatment and bacillus calmette-guerin cell wall skeleton
center, allowing the area to heal, and then working rom stimulation. Clin Cancer Res. 2006;12:7465– 7475.
the inside out. Segmental cryosurgery divides lesions into 16. Pasquali P, Sebastian GJ, Zouboulis CC, et al. Cryosur-
quadrants, treats one area at a time, and allows or healing gery. Surgery of the Skin: Procedural Dermatology. 2nd ed.
Edinburgh London, New York: Mosby Elsevier;2010:153– 166.
between treatments.16 Both treatments are equally e ec-
17. Goldberg LH, Kaplan B, Vergilis-Kalner I, Landau J. Liquid
tive; personal com ort and experience will be the guides nitrogen: temperature control in the treatment o actinic ker-
or treatment. atosis. Dermatol Surg. 2010;36:1956– 1961.
18. Blume-Peytavi U, Zouboulis CC, Jacobi H, Scholz A, Bisson
S, Or anos CE. Success ul outcome o cryosurgery in pa-
c o n c l u s Io n tients with granuloma annulare. Br J Dermatol. 1994;130(4):
494– 497.
19. Zouboulis CC, Zouridaki E, Rosenberger A, Dalkowski A.
Cryosurgery is a rst-line option or treating many benign Current developments and uses o cryosurgery in the treat-
and premalignant lesions. Because o its versatility and ment o keloids and hypertrophic scars. Wound Repair Regen.
2002;10:98– 102.
low cost, it has become one o the most requently used
20. Castro-Ron G, Pasquali P. Management o hemangiomas.
techniques in dermatology. T e treatment parameters and Special Symposium. Pediatr Dermatol. 1997;14:70–71.
healing times vary depending on the lesion, while compli- 21. Suhonen R, Ku ik EG. Venous lakes treated by liquid nitro-
cations and side e ects are usually minimal and well toler- gen cryosurgery. Br J Dermatol. 1997;137:1018–1019.
ated. O ering cryosurgery as a palliative treatment option 22. Lubritz RR, Smolewski SA. Cryosurgery cure rate o actinic
keratoses. J Am Acad Dermatol. 1982;7:631– 632.
or patients who do not wish to undergo surgical excision
23. T ai KE, Fergin P, Freeman M, et al. A prospective study o
may increase their quality o li e. Using cryosurgery as an the use o cryosurgery or the treatment o actinic keratoses.
adjunct to surgical or topical treatments or premalignant Int J Dermatol. 2004;43:687– 692.
or malignant lesions should in theory decrease the likeli- 24. Ku ik EG, Gage AA. Cryosurgery or lentigo maligna. J Am
hood o recurrences although to date there has been no Acad Dermatol. 1994;31:75– 78.
25. Dawber RP, Wilkinson JD. Melanotic reckle o Hutchinson:
research to prove its e ectiveness. With proper training, all
treatment o macular and nodular phases with cryotherapy.
dermatologists should be able to use cryosurgery with ease Br J Dermatol. 1979;101:47– 49.
as a treatment option or many common cutaneous lesions. 26. Zacarin SA. Cryosurgical treatment o lentigo maligna. Arch
Dermatol. 1982;118:89– 92.
27. Bohler-Sommereggar K, Schuller-Petrovic S, Neumann R,
r eFer en c es Müller E. Cryosurgery o lentigo maligna. Pla st Reconstr Surg.
1992;90:436– 440; discussion 441– 444.
1. Arnott J. On the Treatment of Cancers by Regulated Applica- 28. Bohler-Sommereggar K, Schuller-Petrovic S, Knobler R, Neu-
tion of an Anaesthetic Temperature. Edinburg, UK: Churchill mann PR. Reactive lentiginous hyperpigmentation a ter cryo-
Livingstone; 1955. surgery or lentigo maligna. J Am Acad Dermatol. 1992;27:
2. Whitehouse HH. Liquid air in dermatology; its indications 523– 526.
and limitations. JAMA. 1907;49:371– 377. 29. Collins P, Rogers S, Goggin M, Manning W. Cryotherapy or
3. White AC. Liquid air in medicine and surgery. Med Rec. lentigo maligna. Clin Exp Dermatol. 1991;16:433– 435.
1899;56:109– 112. 30. McKenna DB, Cooper EJ, Kavanagh GM, Davie RM, McLaren
4. Pusey WA. T e use o carbon dioxide snow in the treatment KM, idman MJ. Amelanotic malignant melanoma ollowing
o nevi and other lesions o the skin. JAMA. 1907;49:1354– cryosurgery or atypical lentigo maligna. Clin Exp Dermatol.
1356. 2000;25(8):600– 604. 163
2 31. T iessen MR, Neumann MH, Schouten LJ. A systemic review
o treatment modalities or primary basal cell carcinomas.
33. Chiarello SE. Cryopeeling (Extensive Cryosurgery) or treat-
ment o actinic keratoses: an update and comparison. Derma-
Arch Dermatol. 1999;135:1177– 1183. tol Surg. 2000;26:728– 732.
32. Peikert JM. Prospective trial o curettage and cryosurgery 34. Goncalves JC. Fractional cryosurgery. A new technique or
in the management o non- acial, super cial, and minimally basal cell carcinomas o the eyelids and periorbital area. Der-
invasive basal and squamous cell carcinoma. Int J Dermatol. matol Surg. 1997;23:475– 481.
2011;50:1135– 1138.
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164
 Ch a p t e r Suture Closure Materials

16
and Techniques
Ia A. Mah r, Jam s D. R ss , Th zar Shi ,
Mar ar t Ma , & J r m B rd a

In t r o d u c t Io n t Is s u e r ea c t Iv It y

Suturing is one o the oundational skills o dermatologic Although all sutures will initiate some degree o host
surgery.1 Dermatologic surgeons must amiliarize them- response, the magnitude o this response can vary widely.
selves with both the physical properties o suture mate- In general, there are several guidelines which can be reli-
rial, as well as the available suturing techniques in order to ably ollowed. First, larger sutures will cause a larger host
ensure the best results or their patients. response, urther supporting the general recommendation
o using the smallest suture that is reasonable or a given
de ect. Second, multi lament sutures will elicit a larger
inf ammatory host response than mono lament due to
their larger relative sur ace area. T ird, natural materials
Ba s Ic s u t u r e Pr o Per t Ies such as silk will cause a larger response than their synthetic
a n d t er mIn o l o g y cousins. Finally, absorbable sutures tend to cause a larger
response than nonabsorbable sutures.
Be ore he or she can select the proper suture material or
a given closure, the dermatologic surgeon must under- d Ia me t er a n d u s P s Iz e
stand the properties that di erentiate the various suture
materials, and the terminology used to describe these T e size o suture is reported by the United States Phar-
properties. macopeia (USP) as the diameter o a given suture material
necessary to obtain a certain tensile strength. T is diameter
is then reported as a number o zeroes, with ewer zeroes
c o n Ig u r a t Io n a n d c o a t In g representing larger diameter. For example, 3-0 Prolene
(Ethicon Inc., Somerville, NJ) has a larger diameter than
Con guration re ers to whether a suture material has a 6-0 Prolene. However, given the act that not all materi-
single strand (mono lament), or multiple braided strands als have the same inherent strength, it ollows that not all
(multi lament).2 Mono lament sutures generally exhibit sutures with the same USP size have the same diameter. 4-0
less resistance when being pulled through tissue and have Ethilon (Ethicon), with its relatively high tensile strength,
a lower risk o in ection.3 However, they exhibit greater is signi cantly ner than 4-0 silk, which is an inherently
memory – the suture’s tendency to retain its packaged weaker material. A ter choice o suture material, it is gen-
shape – and are consequently more di cult to handle erally advocated to select the smallest diameter possible to
than their multi lament counterparts. achieve the necessary tensile strength.
Multi lament sutures, on the other hand, are more pli-
able and handle more easily. T e braided nature o multi- t en s Il e s t r en g t h
lament sutures creates natural crevices or bacteria, and
higher rates o surgical site in ection have been demon- T e tensile strength o suture material can be character-
strated relative to mono lament sutures.4,5 ized in two ways – absolute and e ective. Absolute ten-
Braided sutures have more sur ace area than their sile strength, which is reported in pounds, is the weight
mono lament counterparts. T is increase in sur ace an untied piece o suture can withstand without breakage.
area increases resistance to being pulled through tissue E ective tensile strength, on the other hand, is the weight
and allows inf ammatory cells better access to the suture that suture can withstand a ter it has been tied. For a given
material. T us, multi lament sutures tend to be more suture, e ective tensile strength is approximately one-
reactive and are absorbed more quickly. In an attempt third o the absolute tensile strength. In general, synthetic
to negate the in ection risk associated with multi lament suture materials have a higher tensile strength than their
sutures, antibacterial coatings have been added to multi- natural counterparts.
lament sutures. Although triclosan-coated polyglactin
910 (Vicryl PLUS, Ethicon Inc., Summers, NJ) has been
shown to decrease postoperative pain in the pediatric a Bs o r Pt Io n
surgery population,6 no consistent decrease in wound
in ection rates relative to uncoated suture has been dem- Absorption is the result o enzymes and other biologic sub-
onstrated.7– 9 stances causing a loss o integrity o suture material through
2 a variety o mechanisms. Although sutures are classically
de ned as “absorbable” versus “non-absorbable,” it is impor-
t h e n eed l e
tant to note that capacity or absorption is not synony-
mous with tensile strength. For example, some absorbable T e needle is an important part o the suture apparatus.
sutures, like poliglecaprone 25 (Monocryl: Ethicon), have a Many di erent needle morphologies exist, but ew are
very high initial tensile strength, but are absorbed very rap- regularly used in cutaneous surgery. T e most commonly
idly. Synthetic polymeric sutures, such as polyglactin 910, used needle is curved, 3/8 o a circle, with a triangular
are absorbed by hydrolysis, causing less tissue reactivity shape. T ese needles come in two orms: reverse cutting
than natural protein based sutures, such as gut, which are and conventional cutting. Reverse cutting needles, which
absorbed by proteolysis. are more commonly used, have the sharp edge on the out-
side o the needle, which is usually away rom the wound
edge. For this reason, they are less likely to tear through
tissue toward the sur ace or wound edge during closure.
co e Ic Ien t o r Ic t Io n Conventional cutting needles, with the sharp edge on the
inside o the curve, are both weaker and more prone to
T e coe cient o riction is a measure o how easily
S
tissue tearing. Needles come in a number o sizes, and the
suture passes through tissue. Materials with a low coe -
t
nomenclature used to describe them varies greatly based
i
cient o riction, such as polypropylene, pass through
on manu acturer. apered needles are cylindrical with a
tissue with ease, but generally have poor knot security.
2
sharp point. T ey exhibit greater resistance to movement
Mono lament materials will o ten have lower coe -
through tissue and dull more quickly than cutting variants
:
:
cients o riction than multi lament sutures. A low
making them less suitable or cutaneous surgery.
S
coe cient o riction is especially desirable in the case
Needle size should be selected based on the thickness
r
o subcuticular sutures that are intended or removal,
o the skin being sutured. T icker skinned areas avor the
i
as decreased resistance will minimize damage to tissue
a
use o larger needle sizes whereas smaller needles should
during removal. Due to improved knot security, sutures
S
be used in thinner skinned areas.
with a higher coe cient o riction are pre erred in high-
i
s
tension wounds.
Wo u n d c l o s u r e ma t er Ia l s
el a s t Ic It y v er s u s Pl a s t Ic It y Suture materials have long been classi ed as either absorb-
able or nonabsorbable. T is section will review both com-
Elasticity re ers to the ability o a suture material to return mon and historically signi cant types o material in each
to its original shape and length a ter stretching. T is is category.
an important characteristic to consider when per orming
surgery in areas prone to edema, such as the eyebrows.
Plasticity, on the other hand, is the tendency o suture
t h e a Bs o r Ba Bl e s u t u r es
material to maintain its new con guration a ter stretching.
Absorbable materials are commonly used or placement o
Very plastic sutures may be loosened a ter the resolution
dermal sutures. In this role, they provide tensile strength
o postoperative edema, and this can contribute to poor
or the wound early in the wound healing period. T e
wound-edge approximation.
suture is broken down by enzymatic degradation and/or
hydrolysis, and no removal is required. At one time, surgi-
cal gut represented the most commonly used absorbable
memo r y suture. oday, however, several newer alternatives exist
that are more desirable or a number o reasons. able 16-1
T e memory o suture is the tendency to retain its original summarizes the properties o the absorbable sutures.
shape despite manipulation. Sutures with high memory,
such as nylon, are o ten used or super cial wound clo- Su Rg Ic Al g u T. All types o surgical gut are
sure given their ability to maintain approximation despite mono lament sutures composed primarily o collagen
edema and intermittent physical stress. T ese materials are, prepared rom either cow or sheep intestine. oday, it
however, more di cult to handle and have less knot secu- comes in three distinct types: plain, chromic, and ast-
rity than others. absorbing. Plain surgical gut, as the name implies, con-
sists o untreated gut bers. It has a holding time o ap-
proximately 7 days, and is absorbed within 10 to 14 days.
Kn o t s ec u r It y Although it was once among the most popular sutures,
its tissue reactivity and relatively poor tensile strength
Knot security is de ned as the orce necessary to cause a limit its utility in modern surgery. Chromic gut, which
knot to slip or untie. T is value is directly proportional to has been tanned with chromate salts to increase longev-
the coe cient o riction o the suture material. Silk, with ity, has a holding time o 14 days, and it is usually ab-
its high coe cient o riction, has excellent knot security. sorbed in 3 weeks.10 Fast-absorbing gut is plain gut that
Conversely, a suture with low coe cient o riction like has been heated or more rapid absorption. With ab-
polypropylene has poor knot security, and a higher num- sorption occurring in 5 to 7 days, it is use ul as a sur ace
ber o throws is o ten utilized by the surgeon using these suture when postoperative removal would be di cult or
166 types o suture. any reason.
 TABl e 16-1
2
P p i ab b b s

I ii r i ti
e K ti t i t i c p
m i c f i h i s i r i i s s ab p i
P ai s r i a t M am t Fair P r Hi h l w 0% b 7–10 d 70 d
c hr mi t M am t Fair P r M d rat l w 0% b 90 d
21–28 d
Fast abs rbi M am t Fair P r Hi h l w 0% b 7 d 20–40 d
s r i a t
P i a id M ti am t g d g d l w M d rat 35% at 21 d 60–90 d

c
(D ®)

h
a
p
P a ti M ti am t g d g d l w Hi h 75% at 14 d, 60–70 d

t
910 (Vi r ®, 25% at 28 d

r
1
P s rb®)

6
P a ti 910 M ti am t g d g d l w Hi h 50% at 5 d, 40 d

:
:
(Vi r Rapid ®) 0% b 14 d

S
P i apr M am t g d g d Vr w V r hi h 60% at 7 d, 90–120 d

t
25 (M r ®) 30% at 14 d

r
c
g m r 631 M am t g d P r Vr w Hi h 50% at 21 d 90–110 d
(Bi s ®)

s
r
P di a M am t P r P r Vr w Hi h 60% at 14 d, 180–240 d

M
(PDS II®) 40% at 28 d a

a
t
P trim th M am t Fair g d l w V r hi h 60% at 28 d, 60–180 d

r
i
a
arb at 30% at 42 d

s
(Ma ®)

a
d
a
F r s t r siz s 4 0 a d sma r.

T
h
i
q
Po l yg l yc o l Ic Ac ID. Polyglycolic acid (Dexon: pain in pediatric patients but have not consistently shown

s
USSDG, Norwalk, C ) is a synthetic, multi lament suture any decrease in in ections with triclosan coated sutures.
that was rst released in 1970. It is coated with Poloxamer Vicryl Rapide (Ethicon) is a gamma-irradiated orm o
188, a lubricant that decreases the coe cient o riction polyglactin 910 that loses its tensile strength within 14 days,
and increases ease o handling. Dexon retains 89% o its much aster than polyglactin 910. As such, it can be used as
tensile strength at day 7, 63% at day 14, and 17% at day a super cial suture that does not need uture removal. A
21.4 With the advent o newer products such as polyglactin small study o acial wounds ound it to be equivalent to
910, polyglycolic acid has seen its use decline, and it is no polypropylene.11
longer widely available.
Po l Ig l ec APRo n e 25. Poliglecaprone 25 (Monocryl:
Po l yg l Ac TIn 910, AkA Po l yg l Ac TIc Ethicon) is a synthetic mono lament with the highest ini-
Ac ID. Polyglactin 910 (Vicryl: Ethicon; Polysorb: USS- tial tensile strength o all the materials in this section. T at
DG) is a multi lament, synthetic suture released soon a - tensile strength, however, rapidly degrades. T is prop-
ter polyglycolic acid. As a multi lament suture, with high erty makes poliglecaprone most suitable or acial wounds
knot security, it is use ul or the closure o high-tension where rapid absorption is desirable and high sustained ten-
wounds where knot slippage could cause loosening o the sions are not an issue. Poliglecaprone maintains 60% o this
dermal sutures. It is less inf ammatory than surgical gut, strength at day 7, 30% at day 14, and is absorbed within 3 to
and retains tensile strength longer than polyglycolic acid. 4 weeks.12 In a head to head study, it was shown to be less
It was ound to have 65% o its original strength at 14 days, reactive than Vicryl Rapide when used or dermal sutures.13
and 40% at 3 weeks. It is then completely dissolved by 60 A small study showed no di erence between super cial clo-
to 90 days via hydrolysis, which partially explains its lower sures with poliglecaprone 25 and polypropylene,14 which
immunogenicity. raises the possibility o cost-e ective use o a single suture
Vicryl is available in both dyed and undyed orms. T e or both deep and sur ace closure.
dyed orm is rarely used in cutaneous surgery due to risk o
visible sutures within the healing wound. Vicryl Plus (Ethi- g l yc o MeR 631. Glycomer 631 (Biosyn: USSDG) is a
con) is a product that is coated with triclosan, a topical anti- mono lament, synthetic suture that is similar to poligle-
biotic. Studies have demonstrated decreased postoperative caprone 25, but it dissolves more slowly. It retains 49% 167
2 o its original tensile strength at 3 weeks, and it is com-
pletely absorbed in 3 to 6 months.15 It also has a lower coe - TABl e 16-3
cient o riction than poliglecaprone 25, which leads to s p i i s c i b a i l i
easier handling but poorer knot security.15
ti r
Po l yDIo xAn o n e. Polydioxanone (PDSII: Ethicon) l i g ( )
is a synthetic mono lament suture renowned or prolonged
Fa 60 5–7
tensile strength. It retains 74% o its original strength at
2 weeks, 50% at 4 weeks, and 25% at 6 weeks. It is absorbed n a dS ap 5 0, 6 0 7–10
at a slow rate over 6 months. It is most use ul in high-tension e tr miti s 4 0, 5 0 10–14
areas, where long-term support or the wound is required.
Tr 4 0, 5 0 10–14
Use on thinner-skinned areas can cause long-standing
lumps and spitting sutures due to the prolonged absorption
time. Although the sti ness o polydioxanone makes it rela-
tively di cult to handle, it has low tissue reactivity and it can s u r g Ic a l s Il K
S
be sa ely used in areas o high tension.
t
i
Surgical silk is a braided, natural substance that is coated
Po l yTRIMeTHyl en e c ARBo n ATe. Polytri-
2
with wax or silicone to decrease coe cient o riction. It is
methylene carbonate (Maxon: USSDG) is another syn- dyed black or better visualization. Surgical silk truly excels
:
:
thetic mono lament suture that is composed o a copo- in the areas o so tness, ease o handling, and knot stability.
lymer o glycolide and trimethylene carbonate. Compared
S
However, as a natural product, it is highly reactive in tissue.
with PDS, it has an increased ease o handling. T e tensile
r
It is this tendency to elicit reactions that limits its use ul-
i
strength o polytrimethylene carbonate is measurable or ness in cutaneous surgery. Silk is use ul or closing biopsy
a
42 to 92 days.10
S
sites in sensitive areas such as the mouth or genitals.
i
ABSo RBABl e STAPl eS. Insorb (Incisive Surgery,
s
Plymouth, MN) is a synthetic absorbable suture made o n yl o n
a polylactic and polyglycolic acid copolymer. It maintains
40% o its initial tensile strength at 2 weeks, and has a tis- Nylon, in all o its orms, represents the most commonly
sue hal -li e o 10 weeks. Although animal studies have been used suture in dermatologic surgery. It is a synthetic
promising, no human studies have shown superiority in product, chemically inert, and it is available as both a
terms o cosmetic results or in ection. A study in post-tissue mono lament (Ethilon: Ethicon; Monoso : USSDG; Der-
expander breast reduction showed no di erence in scar malon: USSDG) and braided (Nurolon: Ethicon; Surgilon:
characteristics and a nding o “increased cost e cacy.”16 USSDG) suture. T e braided orms, which are coated
However, this calculation was based on $1500 per hour with silicone, are easier to handle and have better knot
operating room time, and is unlikely to be applicable to security, but are more expensive and have higher tissue
outpatient procedures. reactivity.

t h e n o n a Bs o r Ba Bl e s u t u r es Po l yPr o Pyl en e
able 16-2 summarizes the properties o the nonabsorb- Polypropylene (Prolene: Ethicon; Surgipro: USSDG) is a
able sutures. able 16-3 summarizes the common time to synthetic mono lament that is primarily known or its
removal in various areas. very low coe cient o riction. As such, it is the suture

TABl e 16-2
P p i n b b b s

e K ti t i
m i c f i h i s i r i i s
Si M ti am t e t e t Hi h l w
n (D rma ®, ethi ®, M s ®) M am t Fair Fair l w Hi h
n (n r ®, S r i ®) M ti am t g d g d l w Hi h
P pr p (Pr ®, S r ipr ®) M am t P r P r l w M d rat
P st r (Da r ®, M rsi ®) M ti am t g d g d M d rat Hi h
P st r, at d (ethib d®) M ti am t g d Fair M d rat Hi h
P b t st r (n va ®) M am t Fair Fair l w Hi h
168
o choice or running subcuticular sutures, and can be
removed a ter wound healing with minimal tissue dis-
one to dry. When compared with sutures, it was shown to
be aster and equally e cacious or the closure o lacera-
2
ruption or destruction. In addition, polypropylene’s high tions, with no di erence in cosmetic outcome.18
plasticity makes it use ul in areas that may experience
severe swelling postoperatively. Drawbacks o polypro-
pylene include high memory, which makes handling and n -Bu t yl -2-c ya n o a c r yl a t e
knot tying more di cult, and costly.
N-butyl-2-cyanoacrylate (Indermil: Covidien; PeriAcryl:
Glu-Stitch) is another long chain cyanoacrylate that is
Po l yes t er approved or use in the United States. When compared
with traditional suture, it was shown to equally e ec-
Polyester sutures (Dacron: USSDG; Ethibond: Ethicon; tive or securing ull-thickness skin gra ts on the ace.19
Mersilene: Ethicon) are braided, multi lament syn- Although this adhesive is 3 to 4 times weaker than Derma-
thetic products with good handling and very high tensile bond based on bonding strength, a head-to-head study
strength. In act, o all suture materials, polyester is second showed no di erence between the two when used on acial

c
only to surgical steel in terms o strength.17 It is available lacerations in pediatric patients.20 When selecting tissue

h
a
plain, or coated with polybutylate. Although the coated

p
adhesives, the decision comes down to cost, availability,

t
orms have lower coe cient o riction and hence glide and physician pre erence.

r
1
more easily through tissue, they are also more prone to

6
breakage.
a d h es Iv e s t r IPs

:
:
S
Po l yBu t es t er Steri-strips (Steristrips: 3 M) are thin adhesive strips that

t
can be used, in certain situations, or the closure o small,

r
Polybutester (Nova l: USSDG) is a synthetic, thermoplas- super cial de ects. o use, they are placed on the skin, per-

c
tic polymer o glycol and polybutylene terephthalates. It was pendicular to the direction o the wound, to bring the edges

s
designed to be stronger, less sti , and to have a lower coe - together and generate a small amount o tension. Steri-

r
cient o riction than nylon or polypropylene. It is charac- strips have been shown to be an equivalent replacement

M
terized by good handling, high elasticity, and very low tissue or epidermal sutures during the repair o cheek de ects

a
t
reactivity. a ter excision o malignancy.21 Although Steri-strips are

r
i
a
occasionally used in addition to continuous subcutaneous

s
sutures, a large review suggests this gives no bene t.22

a
s u r g Ic a l s t a Pl es

d
T
Staples have long been used or wound closure by surgeons
Wo u n d c l o s u r e t ec h n Iq u es

h
in a number o surgical specialties. T ey are composed o

i
q
stainless steel and o er the ollowing bene ts: extremely
high tensile strength, ease and speed o placement, and d eeP s u t u r es

s
low tissue reactivity. When compared with sutures, steel
staples have a lower incidence o in ection when closing Deep, subcuticular, or buried sutures are a key element
contaminated wounds.1 Staples are commonly used or in optimizing cosmetic results. T e deep suture provides
wounds on the scalp, and they are easily removed with a tensile strength to the wound, closes dead space, and
hemostat or specialized extractor. aids in everting the wound edges. Eversion o the wound
edges prevents ormation o a depressed scar as the
wound undergoes 3-dimensional contraction during scar
t Is s u e a d h es Iv es maturation.23

issue adhesives o er the chance to close surgical wounds

without puncture sites, track marks, or need or postoper- s ImPl e Bu r Ied In t er r u Pt ed s u t u r e
ative removal o sutures. T ey can be applied quickly and
easily to nearly any area o the body. T ey are most o ten T e classic buried interrupted suture is an inverted sim-
used in small wound under minimal tension. oday, there ple interrupted stitch entirely contained within the der-
are two commonly used tissue adhesives in cutaneous mis and with the knot buried. Although suture marks are
surgery: 2-octylcyanoacrylate (Dermabond: Ethicon) and absent, it produces minimal eversion, increasing the risk
n-butyl-2-cyanoacrylate (Indermil: USSDG; Glu-Stitch: o a depressed scar (Fig. 16-1).24
Glu-Stitch Inc., Delta, BC, Canada).
Bu r Ied v er t Ic a l ma t t r es s s u t u r e
2-o c t yl c ya n o a c r yl a t e
In contrast to the circular shape o the buried interrupted
2-octylcyanoacrylate (Dermabond: Ethicon) is a long chain suture, the lateral aspects o the buried vertical mattress
cyanoacrylate that has been on the market in the United suture traverse the dermis at a higher point than the medial
States since 1998. It is applied to the skin immediately sur- aspects o the stitch, providing wound edge eversion and
rounding, but not within, the surgical wound. T ree layers acilitating the creation o a ne imperceptible scar.25 Mul-
are generally used, with time in between or the previous tiple groups have demonstrated good aesthetic results with 169
2
S
t
i
S imple burie d inte rrupte d s uture
2
Figure 16-1 A simp b ri d i t rr pt d s t r . Burie d ve rtica l ma ttre s s s uture
:
:
S
r
i
the use o buried vertical mattress sutures in the absence
a
o epidermal sutures.21,26
S
In order to create the everting, “heart-shaped” pro le
i
s
o the buried vertical mattress the ollowing steps should
be taken; the needle enters the underside o the dermis in
a vertical direction until upward pressure on the skin sur-
ace can be perceived. At this point orceps or a skin hook
are used to turn the skin edge outward as the needle is
advanced through the tissue until it exits into the wound
bed at a descending angle. T e needle then enters the
opposite wound edge at a level equal to that o its exit and
at an ascending angle. T e needle is pushed out away rom
the wound edge and allowed to turn on its axis until it exits
the dermal undersur ace (Fig. 16-2).
It may be di cult to generate the heart-shaped pro le o
the buried vertical mattress in thin-skinned areas or when
exposure is limited due to closely spaced dermal sutures. T e
percutaneous buried vertical mattress suture may be use-
ul in such cases. By exiting and reentering the skin sur ace
through the same puncture sites on either side o the wound Butte rfly va ria nt
edge, the suture material is buried within the dermis while a Figure 16-2 A b ri d v rti a mattr ss (t p), a d th b t
vertical mattress con guration is created (Fig. 16-3). When t r varia t th b ri d v rti a mattr ss (b tt m).
utilizing this technique it is advisable to use a low-reactivity
absorbable suture such as polydioxanone or polyglecaprone
to minimize the risk o transepidermal elimination. Bu r Ied Pu l l ey s t It c h va r Ia n t s
T e pulley stitch utilizes mechanical advantage to close
Bu r Ied h o r Iz o n t a l ma t t r es s wounds under greater tension than could be closed with
sut ur e other suture variants. Buried pulley stitch variants, executed
with an absorbable suture, allow the tension-bearing suture
T e ully buried horizontal mattress suture consists o two to be le t in vivo, thus providing added tensile strength to
horizontally oriented hal loops that approach, but do not the wound, while eliminating the risk o suture marks asso-
pierce, the skin sur ace as they travel parallel to the wound ciated with super cial tension bearing sutures.28,29
edge (Fig. 16-4).27 T e horizontal mattress provides added T e subcutaneous inverted cross mattress stitch (SICM)
wound-edge eversion to the a orementioned advantages is executed by throwing a vertical mattress suture. How-
o traditional buried interrupted sutures. Super cial knot ever, instead o tying that suture o , a second continu-
placement and a decreased ability to close dead space are ous vertical mattress pass is per ormed 3 to 4 mm rom
weaknesses. T is technique is most use ul when deep the rst. T e ree ends o the suture are then tied to each
sutures and eversion are required in narrow or tight other (Fig. 16-5).29 In addition to being use ul or closing
spaces where it is o ten di cult to execute a buried verti- wounds under high tension, the SICM is use ul as the ini-
170 cal mattress suture. tial tension-bearing suture in thin-skinned areas such as
 Pe rcuta ne ous burie d ve rtica l ma ttre s s s uture Burie d horizonta l ma ttre s s s uture
from a bove
2

c
h
a
p
t
r
1
6
:
:
S
t
r
c
s
r
B

M
a
t
r
i
a
s
a
d
T
h
Figure 16-4 A dia ram th b ri d h riz ta mattr ss

i
s t r as vi w d r m ab v .

q
s
tension.30,31 Absorbable and nonabsorbable suture mate-
rial can be used. I absorbable material is used, the suture
is placed by rst securing a buried dermal knot at one end
C o the wound be ore passing the needle through the apex o
the wound.30 I nonabsorbable material is selected, the tail
Figure 16-3 Th p r ta s v rti a mattr ss. A. Th o the suture is securely taped to the skin, or tied o with
d is i s rt d th d p s r a th d rmis a d a sliding knot. T e needle is then advanced by taking hori-
is p sh d t th pid rma s r a . B. Th d is r i
zontal bites at the dermal– epidermal junction on alternate
s rt d thr h th sam p t r h a d ta s a s p r
ia bit r ssi th w d d b r iti th s i sides, with some overlap (Fig. 16-6). Once the end o the
s ra th pp sit sid th w d. Th d is wound is reached, the suture is tied and buried i absorb-
th r i s rt d i t th sam p t r sit a d p sh d able, or tied and secured to the skin i nonabsorbable. T e
thr h th thi ss th d rmis. C. Th a s t r main disadvantages o the traditional subcuticular clo-
rati . B t ri a d iti thr h th sam sure are its time-consuming and technically challenging
p t r sit s th s t r b ri s its i t th d rmis. nature, decreased ability to evert wound edges, and the
risk o transepidermal elimination o sutures when using
an absorbable material.
atrophic, actinically damaged orearm skin. By distribut- Everting variants o the subcuticular closure have been
ing the tension across the two adjacent throws the risk o reported to overcome the limited eversion provided with
the suture tearing through thin tissue is reduced. typical subcuticular techniques.32 T e running percuta-
neous vertical mattress suture technique uses the “in and
out” technique o the interrupted percutaneous vertical
r u n n In g s u Bc u t Ic u l a r s u t u r e mattress to produce eversion while burying the suture
material in the dermis. T e technique begins with a bur-
Subcuticular closure is used in areas where track marks ied vertical mattress. T e non-needle end o the suture is
would be unacceptable and in anatomic areas with high cut and a series o alternating deep passes paralleling the 171
2 S ICM Running s ubcuticula r s uture

A B
4

3
S
t
i
A
2
2 Running pe rcuta ne ous ma ttre s s s uture
:
:
S
X
r
1 5
i
a
S
i
1 De e p to s upe rficia l on s ide A X X
s
2 S upe rficia l to de e p on s ide B

3 Adva nce 5 mm down wound a nd de e p to s upe rficia l on A X X

4 S upe rficia l to de e p on B

5 Tie ne e dle e nd to s upe rficia l e nd

X X
Figure 16-5 A dia ram th s b ta s i v rt d
mattr ss s t r . St p b st p i str ti s ar i strat d
th dia ram.

X = Puncture s ite
wound edge and super cial dermal passes crossing the = De e p pa s s
wound edge perpendicularly continue along the length o = S upe rficia l pa s s
B
the wound. When the end o the wound is reached, the last
deep loop o suture is le t long and tied o to the needle
end o the suture. Figure 16-6 A. Th t pi a r i s b ti ar s r .
B. Th r i p r ta s mattr ss s t r .

s u Per Ic Ia l s u t u r es
bites or areas such as the thin periorbital skin. T e simple
In t er r u Pt ed s u t u r es interrupted can be used to correct uneven wound edges
by taking a more super cial bite on the higher side and a
SIMPl e In TeRRu PTeD Su Tu Re. T e simple deeper bite on the lower side.
interrupted stitch is the most basic suture technique in Advantages include technical simplicity, knot security,
cutaneous repair (Fig. 16-7). It is per ormed by insert- enhanced eversion o the wound, and precise epidermal
ing the suture needle at an angle greater than 90 degrees approximation. T e main disadvantage is the development
approximately 5 mm rom the wound edge, rotating the o track marks i sutures remain in place or an extended
wrist so that the needle takes a pear-shaped path as it tra- period o time.
verses perpendicular to the long axis o the wound and
emerges rom the opposite side. T e epidermis is approxi-
mated and a surgeon’s knot is tied. T e wider base o the h o r Iz o n t a l ma t t r es s s u t u r es
suture pass recruits tissue toward the center o the wound,
orcing the super cial tissues upward and naturally evert- T e horizontal mattress suture is per ormed by beginning as
ing the wound edges as the suture is tightened. T e depth i placing a simple stitch. Instead o securing the interrupted
and breadth o the stitch should directly correlate with the stitch, the needle is advanced orward approximately 5 mm
172 thickness o the skin being sutured – or example, smaller down the length o the wound and a simple backstitch is
 S imple inte rrupte d s uture The “figure of 8” s uture
2

S uture is pa s s e d a round
tra ns e cte d ve s s e l in two “s a me

c
dire ction” pa s s e s cre a ting a n “x”

h
a
or “8” s ha pe d configura tion

p
t
Figure 16-9 Th s t r is pass d ar d a tra s t d

r
1
b d v ss with tw , sam dir ti pass s. This i ds

6
a “ ” r “8” shap d rati wh th s t r is ti d.

:
A

:
S
Corre cting “s te p off” with the s imple inte rrupte d s uture placed in the reverse direction. T e suture is then tied with a

t
surgeon’s knot (Fig. 16-8). T is technique decreases tension

r
c
on, and everts, the wound edges, and it aids in hemostasis
by closing dead space. However, i tied too tightly, horizon-

s
tal mattress sutures may compromise the blood supply rom

r
the super cial dermal plexus resulting in epidermal necro-

M
a
sis. In addition, they may be di cult to remove, are more

t
technically challenging and take more time to per orm. For

r
i
a
these reasons, the horizontal mattress stitch is o ten used

s
a
in conjunction with other interrupted and running sutures.

d
T e hal buried horizontal mattress, or tip stitch, is a

T
variant o the horizontal mattress that is use ul or secur-

h
B ing triangulated wound edges. By making a horizontal

i
q
Figure 16-7 A. Simp i t rr pt d s t r . B. I strati pass through the dermis o the triangulated f ap tip, the tip
st p f rr ti t h iq with th simp i t r stitch minimizes the risk o vascular strangulation.

s
r pt d s t r . A sma r, m r s p r ia bit is ta
th hi h sid .
Ig u r e o “8” s u t u r e
Horizonta l ma ttre s s s uture T e gure o “8” suture is used primarily as a hemostatic
suture. wo parallel passes are per ormed on either side o
a bleeding vessel without reversing the direction o the nee-
dle (Fig. 16-9). T is suture may be per ormed with absorb-
able suture i it is placed in subcutaneous tissue, or with
X nonabsorbable suture i it is placed on the skin sur ace.
X

v er t Ic a l ma t t r es s s u t u r e
X X T e ar- ar-near-near vertical mattress suture is per ormed
by beginning with a wider and deeper simple interrupted
stitch. Instead o tying the stitch, the needle is reversed
and a second, more super cial interrupted backstitch is
placed medial and super cial to the rst, then secured
(Fig. 16-10). T e vertical mattress stitch is used to enhance
wound-edge eversion at locations such as the helical rim,
X = Puncture s ite where a depressed scar would distort the natural contour
= S uture on s kin s urfa ce o a ree margin. As a mattress suture, it closes dead space,
= S uture ma te ria l be low s kin s urfa ce thereby decreasing tension and providing hemostasis.
Care should be taken to avoid excessive tightening o the
knot, which can strangulate the wound edges and cause
Figure 16-8 Th h riz ta mattr ss s t r . necrosis. Like the horizontal mattress suture, the vertical 173
2 Ve rtica l ma ttre s s s uture the wound (Fig. 16-10). T e last loop is not tightened but
le t long and tied to the ree end. Maintaining the unda-
5 mentals o the simple interrupted suture, such as punctur-
ing the skin at an angle o 90 degrees or greater and taking
pear-shaped bites, helps produce maximal eversion. An
additional strategy to maximize eversion while minimiz-
ing tissue handling that can cause vascular strangulation
is to apply slight upward pressure on the needle once it
1 4 3 2 punctures the skin sur ace on the rst wound edge. A or-
A B ceps or skin hook is then used to apply inward pressure on
the opposite wound edge as the needle is pushed through.
T e combination o upward pressure on the needle with
counter-pressure helps “bunch” deep tissue onto the nee-
dle producing an everting bite.
T is stitch may be locked to provide additional hemo-
S
stasis by passing the needle back under the loop o suture
t
i
spanning the wound a ter completion o the stitch and prior
to pulling the suture through and taking the next bite.34 As
2
with any hemostatic stitch, tissue strangulation may occur
:
:
i excessive tension in applied. T e main advantages o
the simple running are even distribution o tension, ease
S
1 La rge bite on s ide A o placement, ability to correct uneven wound edges, and
r
i
2 La rge bite on s ide B increased speed o wound closure. Disadvantages include
a
decreased knot security and risk o epidermal necrosis i
S
3 Reve rs e ne e dle dire ction a nd ta ke s ma ll bite on s ide B tied too tightly. In addition, the entire length o the repair is
i
s
4 Ta ke s ma ll bite on s ide A at risk or dehiscence should one o the knots ail.

5 Tie
r u n n In g ma t t r es s s u t u r es
Figure 16-10 A dia ram th v rti a mattr ss s t r .
Running mattress sutures may be used to accentuate
wound-edge eversion.32,35– 37 All running mattress sutures
mattress is technically challenging, takes additional time
begin with the same knot as a simple running suture. T e
to per orm, and is commonly used in combination with
horizontal mattress variant then uses bites in alternating
other methods o closure.
directions with each pass advanced approximately 5 mm
down the wound edge (Fig. 16-11). T e running hori-
Pu l l ey s t It c h zontal mattress produced superior results to simple run-
ning suture in one small study (Fig. 16-12).36 T e vertical
T e pulley stitch can be viewed as a variant o the vertical
mattress. T e pulley stitch is use ul or relieving tension on
tight wounds and may be used as a temporary suture to aid
closure, or le t in place. Like any super cial tension-bearing
suture, the risk o suture marks are increased i this suture
is le t in vivo. Unlike the vertical mattress where the needle
direction is reversed and the knot tied entirely on one side
o the wound, in the pulley suture both passes are made in
a single direction and the knot is tied across the wound.
Variants o this suture exist, but all involve multiple
passes through the tissue be ore tying. T ese multiple
passes allow or the creation o mechanical advantage as
well as resistance to suture loosening be ore tying is com-
pleted.33 Pulley sutures are use ul or aiding closure in
high-tension areas such as the scalp or lower extremities.

r u n n In g s u Per Ic Ia l s u t u r es
s ImPl e r u n n In g s u t u r e
T e simple running stitch is begun as i placing a tradi-
tional simple interrupted suture at one apex o the wound. Running s uture. La s t loop is le ft long
a nd tie d to the fre e ne e dle e nd
T e non-needle suture tail is cut and simple stitches are
174 placed in approximately 5 mm apart along the length o Figure 16-11 Th simp r i s t r .
 Horizonta l running ma ttre s s s uture been reported to maximize eversion while maintaining
ease o suture removal.35
2
X X
c o n c l u s Io n
X X Suturing is one o the oundational skills o dermatologic
surgery. A ull understanding o suturing techniques and
X X materials allows surgeons to optimize results or their
patients.
X X
r e er en c es
X X
1. Hochberg J, Meyer K, Marion M. Suture choice and other

c
methods o skin closure. Surg Clin North Am. 2009;89:627–

h
X X

a
641.

p
2. Bennett RG. Selection o wound closure materials. J Am Acad

t
r
Dermatol. 1988;18:619– 637.

1
3. Gabrielli F, Potenza C, Puddu P, Sera F, Masini C, Abeni D. Su-

6
ture materials and other actors associated with tissue reac-

:
X = Puncture s ite tivity, in ection, and wound dehiscence among plastic surgery

:
= S urfa ce s uture outpatients. Pla st Reconstr Surg. 2001;107:38– 45.

S
= De e p s uture 4. ajirian A, Goldberg D. A review o sutures and other skin

t
closure materials. J Cosmet La ser T er. 2010;12:296– 302.

r
5. Bloom B, Goldberg D. Suture material in cosmetic cutaneous

c
surgery. J Cosmet La ser T er. 2007;9:41– 45.
Figure 16-12 Th r i h riz ta mattr ss s t r . 6. Ford H, Jones P, Gaines B, Reblock K, Simpkins D. Intra-

s
operative handling and wound healing: controlled clinical

r
trial comparing coated VICRYL plus antibacterial suture

M
(coated polyglactin 910 suture with triclosan) with coated

a
mattress variant combines deep bites which cross the

t
VICRYL suture (coated polyglactin 910 suture). Surg In ect.
wound bed diagonally with super cial bites that cross the

r
2005;6:313– 321.

i
a
wound edge in the super cial plane (Fig. 16-13). As run- 7. Seim B, ønnessen , Woldbaek P. riclosan-coated sutures

s
a
ning mattress sutures are o ten di cult to remove, modi- do not reduce leg wound in ections a ter coronary artery
bypass gra ting. Interac Cardiova sc T orac Surg. 2012;15:

d
cations with alternating simple and mattressed bites have

T
411– 415.
8. Chang W, Srinivasa S, Morton R, Hill A. riclosan-impreg-

h
nated sutures to decrease surgical site in ections: systematic

i
q
Running ve rtica l ma ttre s s s uture review and meta-analysis o randomized trials. Ann Surg.
2012;255:854– 859.

s
9. Chen SY, Chen M, Dai N , Fu JP, Chang SC, Deng SC.
Do antibacterial-coated sutures reduce wound in ection
in head and neck cancer reconstruction? Eur J Surg Oncol.
x x 2011;37:300– 304.
x 10. Sanz LE, Patterson JA, Kamath R, Willett G, Ahmed SW, But-
x x x x ter eld AB. Comparison o Maxon suture with Vicryl, chro-
mic catgut, and PDS sutures in ascial closure in rats. Obstet
Gynecol. 1988;71:418–422.
11. Parell GJ, Becker G. Comparison o absorbable with nonab-
sorbable sutures in closure o acial skin wounds. Arch Facial
x x x x Pla st Surg. 2003;5:488–490.
12. Bezwada RS, Jamiolkowski DD, Lee IY, et al. Monocryl suture,
a new ultra-pliable absorbable mono lament suture. Bioma-
terials. 1995;16:1141– 1148.
13. Niessen FB, Spauwen PH, Kon M. T e role o suture material
x x x x in hypertrophic scar ormation: Monocryl vs. Vicryl-rapide.
Ann Pla st Surg. 1997;39:254– 260.
14. Rosenzweig L, Abdelmalek M, Ho J, Hruza G. Equal cosmetic
outcomes with 5-0 poliglecaprone-25 versus 6-0 polypropylene
or super cial closures. Dermatol Surg. 2010;36:1126–1129.
15. Molea G, Schonauer F, Bi ulco G, D’Angelo D. Comparative
study on biocompatibility and absorption times o three absorb-
able mono lament suture materials (Polydioxanone, Poligle-
caprone 25, Glycomer 631). Br J Plast Surg. 2000;53:137–141.
16. Cross K, eo E, Wong S, et al. T e absorbable dermal staple
X = Puncture s ite device: a aster, more cost-e ective method or incisional clo-
= S upe rficia l s uture sure. Pla st Reconstr Surg. 2009;124:156– 162.
17. Edlich R, Drake D, Rodeheaver G, et al. Syneture stainless S EEL
= De e p s uture suture. A collective review o its per ormance in surgical wound
closure. J Long erm Ef Med Implants. 2006;16:101–110.
18. Sniezek PJ, Walling HW, DeBloom JR, 3rd, et al. A randomized
Figure 16-13 Th r i v rti a mattr ss s t r . controlled trial o high-viscosity 2-octyl cyanoacrylate tissue 175
2 adhesive versus sutures in repairing acial wounds ollowing
Mohs micrographic surgery. Dermatol Surg. 2007;33:966– 971.
28. Giandoni MB, Grabski WJ. Surgical pearl: the dermal buried
pulley suture. J Am Acad Dermatol. 1994;30:1012– 1013.
19. Craven NM, el er NR. An open study o tissue adhesive in ull- 29. Yag Howard C. Novel surgical approach to subcutaneous clo-
thickness skin gra ting. J Am Acad Dermatol. 1999;40:607–611. sure: the subcutaneous inverted cross mattress stitch (SICM
20. Bernard L, Doyle J, Friedlander SF, Eichen eld LF, Gibbs NF, Stitch). Dermatol Surg. 2011;37:1503– 1505.
Cunningham BB. A prospective comparison o octyl cyanoac- 30. Genders R, Hamminga E, Kukutsch N. Securing the subcu-
rylate tissue adhesive (dermabond) and suture or the closure ticular running suture. Dermatol Surg. 2012;38:1722– 1724.
o excisional wounds in children and adolescents. Arch Der- 31. Alam M, Posten W, Martini M, Wrone D, Rademaker A.
matol. 2001;137:1177– 1180. Aesthetic and unctional e cacy o subcuticular running
21. Plotner A, Mailler Savage E, Adams B, Gloster H. Layered epidermal closures o the trunk and extremity: a rater-blind-
closure versus buried sutures and adhesive strips or cheek ed randomized control trial. Arch Dermatol. 2006;142:1272–
de ect repair a ter cutaneous malignancy excision. J Am Acad 1278.
Dermatol. 2011;64:1115– 1118. 32. Maher I, Bingham J, Mellette R. A running modi cation o
22. Kolt JD. Use o adhesive surgical tape with the absorbable the percutaneous buried vertical mattress. Dermatol Surg.
continuous subcuticular closure. Anz J Surg. 2003;73(8): 2012;38:1560– 1562.
626– 629. 33. Snow SN, Dortzbach R, Moyer D. Managing common sutur-
23. Dresner H, Hilger P. Comparison o incision closures with ing problems. J Dermatol Surg Oncol. 1991;17:502– 508.
S
subcuticular and percutaneous staples. Arch Facial Pla st 34. Kouba D, Miller S. “Running pleated” suture technique oppos-
Surg. 2009;11:320– 326. es wound edges o unequal lengths. Dermatol Surg. 2006;32:
t
i
24. Fiennes AG. Interrupted subcuticular polyglactin sutures or 411– 414.
abdominal wounds. Ann R Coll Surg Engl. 1985;67:121– 121. 35. Krunic A, Weitzul S, aylor RS. Running combined simple
2
25. Zitelli JA, Moy RL. Buried vertical mattress suture. J Derma- and vertical mattress suture: a rapid skin-everting stitch. Der-
tol Surg Oncol. 1989;15:17– 19. matol Surg. 2005;31:1325– 1329.
:
:
26. Singer A, Gulla J, Hein M, Marchini S, Chale S, Arora B. Single- 36. Moody B, McCarthy J, Linder J, Hruza G. Enhanced cosmetic
layer versus double-layer closure o acial lacerations: a random- outcome with running horizontal mattress sutures. Dermatol
S
ized controlled trial. Plast Reconstr Surg. 2005;116:363–368. Surg. 2005;31:1313– 1316.
r
27. Alam M, Goldberg L. Utility o ully buried horizontal mat- 37. Zuber . T e mattress sutures: vertical, horizontal, and cor-
i
a
tress sutures. J Am Acad Dermatol. 2004;50:73– 76. ner stitch. Am Fam Physician. 2002;66:2231– 2236.
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176
 Ch a p t e r The Elliptical Excision

17 and its Variations

Joseph F. Sobanko & Ch istophe J. Mi e

In t r o d u c t Io n depth, and location o the procedure. Discom ort is most

severe in the rst 24 to 48 hours a ter surgery, swelling
usually subsides by 1 week, and bruising usually subsides
T e elliptical excision is the workhorse procedure to
a ter 1 to 2 weeks.
remove cutaneous lesions. Although the term “elliptical”
Patients should have realistic expectations about the
requently describes the design o excisions in the der-
appearance o the scar. Erythema limited to the suture
matologic and plastic surgery literature, it inaccurately
line o ten persists or 1 to 2 weeks, and eversion o the
describes the surgical design in practice. As opposed to an
scar edges can take approximately 3 to 4 months to at-
ellipse, which has a curved shape along its entire bound-
ten. Changes in sensation, such as numbness, tingling,
ary, a usi orm excision has two sides that taper to a sharp
and eeting sharp pains are common or up to several
point at each end. Recognizing that most surgeons employ
months postoperatively.2 Patients should understand that
a “ usi orm” design, this chapter will use the terms “ellipti-
the appearance and sensation o the scar evolve consider-
cal” and “ usi orm” excisions interchangeably. T is chap-
ably over the rst 3 to 6 months postoperatively. Finally, as
ter will ocus on the design and execution o the elliptical
wrong-site surgery is the most common reason or mal-
excision and its variations. Each o the ve individual steps
practice claims against dermatologic surgeons,3 in ormed
required to success ully complete a surgical excision will
consent must include con rmation o the site o the exci-
be discussed in detail. T e skills necessary to design and
sion with the patient.
execute an elliptical excision provide the oundation to
progress to more technically advanced surgical proce-
dures, such as cutaneous aps. In t r a o Per a t Iv e eva l u a t Io n
a n d ex ec u t Io n
Pr eo Per a t Iv e eva l u a t Io n
a n d In f o r med c o n s en t eva l u a t Io n o f t h e l es Io n
T e surgeon and his or her sta should per orm a thor- Be ore anesthetizing the area, the surgeon must rst care-
ough preoperative evaluation to ensure the patient’s sa ety ully examine the lesion to be excised as well as the sur-
and to optimize outcomes o any cutaneous surgical pro- rounding skin. Proper lighting is essential as the surgeon
cedure. Especially important items that could alter the stretches the skin and palpates the lesion to detect subtle
surgeon’s practice or a ect outcomes include the patient’s changes between normal and pathologic skin. Accurate
history o transmissible disease, whether the patient takes demarcation o the clinical margins o the lesion deter-
oral anticoagulants, the presence o implantable electrical mines the accuracy o the surgical margins o the excision.
devices, and concerns regarding antibiotic prophylaxis.1 Underestimation o the clinical size o the lesion increases
T e reader is re erred to other chapters in this book or the risk or incomplete excision and positive pathologic
comprehensive coverage o these topics. margins. Overestimation o the clinical size o the lesion
A ter a thorough preoperative evaluation, the surgeon will result in an unnecessarily large excision that could
must obtain in ormed consent. A care ul in ormed con- compromise cosmetic or unctional outcomes. T rough
sent sets realistic expectations or the patient and reduces visual inspection and palpation, the surgeon estimates the
the risk o litigation rom consequences that the patient anatomic depth o invasion o the lesion and uses a surgi-
had not expected. T e main risks associated with an cal marking pen to delineate its peripheral margins. T e
elliptical excision include scarring, bleeding, in ection, surgeon should also meticulously inspect the surrounding
and incomplete resection o the lesion. Cosmetic dis g- skin and outline any suspicious lesions that may collide
urement and compromised unction o critical anatomic with the surgical margins or design o the excision.
structures should occur rarely with a care ully designed A ter determining the clinical margins o the lesion,
and executed elliptical excision. As the risks associated the surgeon must determine the surgical margin, which
with an elliptical excision are relatively low, in ormed con- includes a rim o normal tissue around the periphery and
sent requently ocuses on ensuring that the patient has deep aspects o the lesion. T e size o the surgical mar-
realistic expectations or the postoperative appearance gins will vary, depending on the clinical and/or pathologic
and recovery. Expected immediate postoperative sequelae diagnosis o the lesion as well as the intent o the excision.
a ter the excision include mild discom ort, swelling, and Narrow surgical margins are more common when the
bruising, which vary in severity according to the size, lesion is benign or when the primary intent o the excision
2 is to obtain tissue or pathologic diagnosis. Wider surgical
margins are more common when the lesion is malignant
or when the primary intent o the excision is de nitive
removal. T e surgical margins may require adjustment i
there are suspicious lesions adjacent to the primary lesion.
Sound knowledge o anatomy is essential to be able to
per orm surgical excisions sa ely and ef ciently. T e sur-
geon should anticipate encountering any vital underlying
anatomic structures, such as motor nerves or large cali-
ber vessels. Preoperative marking o the expected path o
these underlying structures on the skin sur ace optimizes
intraoperative sa ety. Once the surgical site is adequately
marked, the surgeon should again con rm with the patient
that the site is correct and explain the size o the clinical
and surgical margins.
S
e
c
t
i
o
s t a n d a r d el l IPt Ic a l
n
2
exc Is Io n d es Ig n
:
:
S
T e design o the elliptical excision is the rst step in
g
optimizing the aesthetic surgical result. Optimal design
i
c
a
respects ree margins, maintains the normal contour o
S
the skin, places the scar within cosmetic subunit junction
k
i
lines, and orients incisions parallel to relaxed skin tension
s
lines.

Pr es er v In g f r ee ma r g In s :
o r Ien t In g t h e l o n g a x Is o f
t h e el l IPs e Per Pen d Ic u l a r Figure 17-1 An e iptica excision that demonst ates
t o f r ee ma r g In s imp ope o ientation and has es ted in a change in a
position o the ee ma gin.
o preserve the position o ree margins, such as the eye-
lid, distal nose, lips, and helical rim, the surgeon should that is three times greater than its short axis will create
orient the usi orm excision with its long axis perpendicu- apical angles o 30 degrees.5 However, excisional geome-
lar to the ree margin. T is orientation will place the ten- try and mathematical calculations show that a design with
sion vectors o the elliptical excision parallel to the ree circular arcs and a 3:1 length to width ratio actually creates
margin, thereby avoiding distortion. T e tension vectors apical angles closer to 70 degrees.6 In practice, a usi orm
run perpendicular to the long axis o the usi orm exci- design with 70 degree angles will result in signi cant ten-
sion, are greatest at the central, widest portion o the usi- sion o the wound edges and create redundant, upwardly
orm design, and diminish toward each o the apices o the protruding tissue at the apices o the excision.7 Redundant
wound. Closing the wound requires recruitment o tissue tissue cones, sometimes re erred to as “dog-ears,” standing
rom each side. I the usi orm excision is designed paral- cones, or Burow’s triangles, can compromise even the best
lel to the ree margin, then the tension vectors will pull executed closure by leaving an unaesthetic contour at the
the margin either up or down (Fig. 17-1). Near the lower ends o a ne-line scar.
eyelid, or example, a usi orm excision oriented parallel to T e length to width ratio and angles at the apices o the
the lid margin risks ectropion. By contrast, orienting the usi orm excision are the key design elements that in u-
excision perpendicular to the eyelid margin preserves the ence contour. T e most common source o contour irregu-
position o the ree margin. larity a ter a usi orm excision is a standing cone, or tissue
protrusion, that results rom an insuf cient length:width
ratio (i.e., the usi orm design is too short) and excessively
Pr es er v In g c o n t o u r : d es Ig n In g obtuse angles at the apices o usi orm design. Fine line
t h e el l IPs e w It h a s u f f Ic Ien t contour o cutaneous surgical excisions can be maintained
l en g t h :w Id t h r a t Io by lengthening the ellipse design, which subsequently
creates a longer scar. In order or the arci orm-designed
Standard design o an elliptical excision has two sym- ellipse to generate a ne line contour with apical angles
metric arcs that mirror one another along a long axis and o 30 degrees, a length to width ratio closer to 7:1 may be
intersect to orm an apex at each end.4 T e goal o this arci- necessary.6 A scar length that is seven times greater than
orm design is to create a ne, straight-line scar and avoid the width o the excision is impractical however, given that
redundant tissue cone ormation a ter excision and sutur- many patients are concerned with their appearance and
178 ing. Common dogma states that an ellipse with a long axis desire the shortest, least noticeable scar.
 S ta ndard a rciform e llips e Arciform e llips e de s ign Rhombus e llips e de s ign
2
with 3:1 le ngth:width ra tio with 30° a ngle s re duce s s ca r le ngth a nd
re duce s like lihood of
Ha s a pica l a ngle s >>30° Ha s a le ngth:width ra tio re dunda nt cone s
a nd incre a s e s ris k of clos e r to 7:1
re dunda nt cone s

Clos e r 30° 30°

to 70°

3:1

C
h
3:5 - 5:1

a
p
t
e
1
7
7:1

:
:
Figure 17-2 The homb s design o the e ipse mo e easi y c eates sho te apica

T
ang es and ed ces the sca ength in addition to the ike ihood o ed ndant cones.

h
e
E
i
p
t
i
c
A simple design variation to the traditional curved sur ace area o the two sides is equivalent to a traditionally

a
E
lines o the elliptical excision can reduce redundant cones designed ellipse but the larger o the two triangles is placed

x
c
while simultaneously minimizing the scar length. Rather on the more tightly adherent skin and the looser skin has a

i
s
i
smaller triangle o skin excised.4 T e end result remains a

o
than creating curved arcs around the lesion to be excised,

n
straight-line tissue incisions that are angled in the shape o a ne linear scar.

a
n
rhombus can be made, allowing or 30 degree apical angles

d
i
and generating a much shorter length to width ratio o 3 to

t
c a mo u f l a g In g s c a r s by

s
V
3.5:1.6 Straight lines taper to the apices more rapidly than

a
curved lines, decrease the angle at the apices, and minimize o r Ien t In g t h e el l IPs e a l o n g

i
a
c o s me t Ic s u bu n It j u n c t Io n l In es

t
the risk o standing cones, as shown in Figure 17-2.

i
o
n
issue distensibility plays a practical role in usi orm exci-

s
sion design. T e elasticity o skin within a given anatomic Linear scars that con orm to cosmetic subunit junction
location can impact the likelihood o redundant cone or- lines help to camou age scars. Orientation o the ellipse
mation. For example, the bound-down skin o the pretibial along cosmetic subunit junction lines is especially advan-
lower extremity or nasal tip requently displays raised tis- tageous on the ace, where shadows in concavities and
sue cones i 30 degree apical angles are selected. T e cir- re ections at convexities demarcate areas on the ace.
cum erential contractile orces rom the surrounding skin Common examples on the ace include the shadow at the
also make these areas challenging to bring together even i concave melolabial old, which divides the cheek rom the
a rhombus-shaped length to width ratio o 3 to 3.5:1 is cho- lip, and the convex ridge where the orehead transitions
sen. By elongating the rhombus-shaped design with a length to the temple (Fig. 17-3). Orienting the elliptical excision
to width ratio o approximately 4:1 or 5:1 and creating api- within these cosmetic subunit junction lines makes the
cal angles closer to 15 to 20 degrees, the wound may be scar less noticeable, as the viewer expects to see a shadow
closed under minimal tension and with a lower risk o con- or re ection in these areas.
tour de ormity.8 Conversely, anatomic locations with elastic
skin such as the dorsal hand or scrotum can be aesthetically r ed u c In g t en s Io n a n d
repaired with a design that is less than 3:1 and with angles
slightly greater than 30 degrees. Small residual tissue pro- c a mo u f l a g In g s c a r s by
trusions in these locations o ten spontaneously regress. o r Ien t In g t h e el l IPs e Pa r a l l el
Most elliptical excisions are designed to have equivalent t o r el a x ed s kIn t en s Io n l In es
areas o skin to be removed on each side o the skin lesion,
but this presumes that the laxity o skin is equivalent on both Sutured wounds that heal under minimal tension o ten
sides o the de ect. T is may not be the case in anatomic create the least conspicuous scar lines. Minimization o
areas where the skin transitions between thick and thin skin scar tension may be acilitated by orienting the long axis
or rom tightly adherent to loosely bound skin. Anatomic o the ellipse parallel to the direction o a relaxed skin ten-
examples o these transitions in skin quality include the sion line. On the ace, these lines o tension are partly the
temple and naso acial sulcus. When encountering a de ect result o muscular orces under the skin being transmitted
to be excised in such a location, it may be advantageous to through ascial attachments. T e curvilinear acial relaxed
design an ellipse with triangles o unequal areas – the overall skin tension lines are perpendicular in orientation to the 179
2 T e scar should never be oriented along relaxed skin ten-
sion lines at the expense o the position o a ree margin.
For example, a horizontal ellipse that con orms to the
relaxed skin tension lines on the orehead but elevates the
position o the brow is undesirable. It is better to preserve
the position o the brow and orient the scar perpendicular
to the relaxed skin tension lines.
On the trunk and extremities, the lines o tension are
less apparent, since contraction o the underlying muscles
does not accentuate the lines o tension. Pinching the skin
to determine where the urrows and ridges are ormed
can be especially help ul to determine lines o tension
on the trunk and extremities.9 As a rule, the lines o ten-
sion should be determined with the patient in a neutral
position, which requires that the patient be upright with
S
e
the arms by his or her side and palms o the hands gently
c
t
i
acing orward. Changes in patient position can mask the
o
n
true lines o tension. A classic example in which position
2
in uences surgical design is seen in the alignment o the
:
:
relaxed skin tension lines on the back. I the patient lies
supine with his/her arms under his/her chin, the lines o
S
tension on his/her back will appear to run perpendicular
g
i
to the vertebral column. When he/she sits upright in the
c
a
neutral position, it is obvious that the lines o tension run
S
k
at an in erolateral tangent rom the vertebral column. On
i
s
the back, one can accentuate the lines o tension by hav-
ing the patient sit at attention while bringing the scapulae
together (Figs. 17-5 and 17-6).

Figure 17-3 E iptica epai a ong a cosmetic j nction

ine a ows o camo aging o sca s. va r Ia t Io n s o f t h e el l IPs e
direction o contraction rom the underlying muscles and T ere are instances in which designing a usi orm exci-
can be accentuated by having the patient per orm dynamic sion that creates a straight-line scar is not ideal. Special
movements with their mouth, eyes, and orehead. A classic consideration must be given to the shape o the usi orm
example on the ace is to orient the long axis o the ellipse design when the lesion to be excised is overlying a con-
parallel to the crow’s eet in the lateral canthus (Fig. 17-4). vex sur ace, is contained within a nonlinear relaxed skin

A B C

Figure 17-4 E iptica epai within e axed skin tension ines a ows o camo aging o sca s, A. Mohs de ect, B. immedi-
180 ate postope ative appea ance, C. 6 weeks postope ative y.
 2

C
h
a
Figure 17-5 C vi inea e axed skin tension ines on the Figure 17-6 Accent ation o ines o tension on back by

p
t
e
to so change with movement. b inging scap ae togethe .

1
7
tension line, or is approaching an important anatomic struc- when the olds become accentuated while the patient

:
:
ture. In these scenarios, alteration o the shape or length o smiles. o create a scar with a curvilinear shape that

T
the ellipse o ten results in enhanced cosmesis. Please see mimics the relaxed skin tension lines on the cheek, one

h
e
Figure 17-7 or a review o these design variations. can consider a design modi cation called the crescentic

E
ellipse. Whereas the standard usi orm design has sides o

i
p
t
equal length that join to orm a linear scar, the crescen-

i
c
c r es c en t

a
tic design employs two lines o di erent length to create a

E
curvilinear, arci orm scar. On the cheek, the lateral or pos-

x
c
Certain anatomic locations display relaxed skin tension terior limb o the crescentic design has a longer, arci orm

i
s
i
o
lines that are curvilinear rather than simply straight lines. design that alls within the curvilinear relaxed skin ten-

n
T is is most evident on the skin o the cheek, particularly sion lines, and the medial or anterior limb has a shorter,

a
n
d
i
t
s
Va ria tions of e llips e

V
a
i
a
t
i
o
n
s
Burow’s
Cre s ce nt S -pla s ty M-pla s ty a dva nce me nt

De s ign: S tra ight, La zy S Bifurca tion of fus iform Fus iform de s ign with
reve rs e de s ign dis pla ce d tria ngle

Indica tions : Us e ful in a na tomic Convex s urfa ce, S horte ns s ca r Zigza g s ha pe a llows
a re a s with curve d (e.g. pre ma xilla ry che e k, le ngth a nd is us e ful for ca moufla ging
re la xe d s kin te ns ion extre mitie s ) whe n a pproa ching of s ca rs
line s (e.g. che e k) fre e ma rgins s uch
a s the eye lid

Wa rning: Une qua l le ngth of S uture bite s s hould be Us e of 'tip s titch' a llows Orie nta tion mus t e ns ure
2 s ide s re quire s horizonta l be twe e n for prope r contour but tha t te ns ion ve ctors do
a tte ntion to de ta il s ide s. Dia gona l bite s ris ks is che mia if pla ce d not pull on a dja ce nt fre e
whe n s uturing. be twe e n s ide s will to clos e to dis ta l e nd ma rgins
Minimize re dunda nt cre a te a n uninte ntiona lly of s kin
cone s by s uturing long, s tra ight-line s ca r.
with the rule of ha lve s.

Figure 17-7 Design va iations o the e ipse that a ow o enhanced cosmesis in ce tain sit ations. 181
2 straight line that runs parallel to the relaxed skin tension
lines. Because these two lines are o unequal length, the
with 30 degree apical angles that are hal the length o a
typical triangle and whose adjoining limbs meet at the
resultant scar becomes curved a ter the two sides are midpoint o the edge o the de ect. T e appearance o
sutured together. As the di erence in length between the these neighboring triangles mimics the letter “M.” T is
two limbs increases, the nal curvature o the sutured scar variation o the ellipse shortens the scar line by converting
increases. However, an increased discrepancy in length it rom a straight line to a V-shape at the end. T e length o
between the limbs will create a standing cone on the lon- the M-plasty and redundant cone can be shortened urther
ger, curved limb, which can be minimized by distributing by simply repeating the division o the “M” with multiple
the excess length by suturing with the rule o halves or by smaller triangles. T is “nested” M-plasty allows or less
excising a Burow’s triangle (see section on standing cone excision o normal tissue and is use ul or excisions on at
de ormities). and concave skin sur aces.14 Some consider the M-plasty
a modi ed V-Y-plasty and design the shoulders o the
s -Pl a s t y adjacent triangles more widely in order to avoid tissue
protrusions.15 Regardless o the conceptualization o this
usi orm variation, a hal -buried horizontal mattress (e.g.,
S
All scars contract up to 30% over time.10 Although this
e
“tip stitch”) allows the sutured end to sit at and avoid
c
contraction may not diminish the cosmetic nature o a
t
i
puckering. T e M-plasty is a help ul modi cation to the
o
scar on a planar sur ace, linear scars on convex and con-
n
usi orm closure and best used on the ace when approach-
2
cave sur aces have the potential to become depressed or
ing vital structures such as the eyelid and lower lip or when
elevated, respectively. Scar inversion on convex sur aces
:
:
a de ect has one end that is wider than the other.
may be avoided by lengthening the excision so that the
S
total scar length becomes greater than the linear distance
g
between the two ends.11,12 Practically, this is executed by s er Ia l el l IPt Ic a l exc Is Io n s
i
c
altering the straight usi orm design into a “lazy-S” shape.
a
S
As the scar contracts, the “lazy-S” shape usually straight- Complete excision o a lesion is sometimes not possible
k
i
ens, but the extra length gained rom the modi ed design or practical because the tension on the closure would be
s
reduces the risk o scar inversion. Convex sur aces where too great to accomplish in a single stage. Congenital nevi,
this particular elliptical design variation is ideal include or example, are sometimes large enough that complete
the premaxillary cheek, chin, and the dorsal orearms and removal o the growth would result in dys unction or dis-
hands. I a de ect on the preseptal lower eyelid or in raor- gurement o the anatomic site. For instances in which
bital cheek has its long axis in a horizontal direction (i.e., it is impractical to excise a lesion in toto, the surgeon
parallel to the to the lid margin), the “lazy-S” design helps may take advantage o the skin’s inherent tissue creep
to redirect tension vectors to preserve the position o the by excising the lesion via serial procedures. T is method
ree margin o the lower eyelid. By drawing superior and o excision allows or a lesion to be removed in stages –
in erior standing cones perpendicular to the eyelid margin the number o stages being proportional to the size o
at each end o the de ect, the surgeon will create a lazy- the lesion relative to the speci c anatomic location. T is
S shape that allows closure with tension vectors that are modality o ten signi cantly reduces the nal length o
horizontal, or parallel to the lid margin. the scar. o start, rather than initially designing an ellipse
T e surgeon must pay particular attention to the order that is at least three times greater than the width o the
and placement o sutures when repairing an S-plasty lesion, an ellipse with apical angles o less than 30 degrees
design. Once the specimen is excised in the shape o an and measuring the length o the lesion is excised and
“S,” novice surgeons are prone to convert the S-shape repaired. A ter 8 to 12 weeks o healing, so the tension on
back into an ellipse by taking diagonal bites between sides the skin decreases, the scar and a similar strip o lesion
rather than horizontal bites between sides. T is results in are removed again with a similar design. T is process is
an unintentionally straight-line scar that is longer than the repeated until no urther pathology remains on the skin
initially designed curvilinear scar. Beginner surgeons also (Fig. 17-8). T e ultimate result is a shorter, more aestheti-
have a tendency to “chase” redundant tissue cones with cally elegant scar.
their scalpel, creating an unnecessarily long scar. Both o
these undesirable outcomes can be avoided with precise
placement o the rst buried suture. When aligned prop- bu r o w ’s a d va n c emen t f l a P:
erly, this initial suture will create crescent-shaped de ects
a va r Ia t Io n o n t h e el l IPs e
on either side o the suture, with each crescent inverted
in orientation relative to one another T erea ter, care ully
T e Burow’s wedge closure is o ten considered a cutaneous
placed buried sutures will convert the remaining areas
advancement ap but can also be simply conceptualized
into the desired S-shape.
as an extension o the usi orm excision.16 T is particular
elliptical variation displaces one-hal o the linear scar into
m-Pl a s t y a more desirable location simply by modi ying the typical
usi orm design. Rather than to have two adjoining trian-
T e total length o an elliptical excision can be shortened gles meet in the center to orm an ellipse, this design shi ts
when the scar approaches vital adjacent structures with one o the two triangles laterally. T is tangential move-
the use o an M-plasty (Fig. 17-7).13 One or both ends o a ment that displaces the scar produces a zigzag shape but
usi orm design are converted rom a single triangle with the overall outline camou ages well when used properly in
182 an apical angle o 30 degrees to two adjacent triangles opportune locations such as the lips and eyebrow.17
 2

C
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7
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a
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x
c
i
s
i
o
n
a
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d
i
t
s
V
Figure 17-8 An examp e o se ia e iptica excisions that a ows o emova o a esion with ed ced sca ength. An 8

a
i
week inte va occ ed between excisions.

a
t
i
o
n
s
a n es t h es Ia attention away rom the site o injection and keep the nee-
dle and the syringe away rom patient’s view. Holding the
A ter designing the ellipse on the skin, the patient is ready skin taut or pinching the skin helps to distract rom the
or local anesthesia. Local anesthesia can distort the clini- slight pain with brisk insertion o a 30 gauge needle into
cal margins o a lesion and alter tension on the skin, so it the subcutaneous layer. Slow delivery o anesthesia into
is pre erable to complete the surgical design prior to anes- the subcutaneous layer allows in ltration under minimal
thesia. Most elliptical excisions can be per ormed sa ely resistance. Although initial injection into the super cial
under local anesthesia in an of ce-based, outpatient set- dermis may provide quicker anesthesia, patients usu-
ting. Local anesthesia o ten obscures the clinical margins ally experience pain because the dense dermis resists the
o cutaneous lesions and should not be injected until the injection more than the looser at. For larger procedures
clinical and surgical margins have been care ully marked. requiring excision into the subcutaneous at, patients may
One percent o lidocaine with 1:100,000 epinephrine is eel ewer needle sticks by rst in ltrating the super cial
typically used or local anesthesia because o its avor- subcutaneous at under minimal resistance, then inject-
able sa ety and pharmacodynamic pro le. For excisions ing the dermis. Freshly mixed lidocaine has a higher
covering large sur ace areas, similar pain control with an pH (pH ~6.5) than premixed lidocaine, which improves
even lower risk o lidocaine toxicity may obtained by using patient com ort upon injection. Bu ering the anesthetic
decreased concentrations o lidocaine, such as 0.5% lido- with 1:10 ratio o 8.4% sodium bicarbonate to lidocaine
caine with 1:200,000 epinephrine, which is also commer- raises the product pH and ultimately decreases pain with
cially available.18 in ltration.19 T e onset o lidocaine action upon injec-
Injecting local anesthesia is the rst invasive step o tion is almost immediate, and the duration o action is 1
the procedure. Care ul technique helps to minimize pain, to 2 hours. However, it is prudent to wait a ew minutes
decrease patient anxiety, and establish rapport. Anxious a ter local in ltration has been per ormed to optimize the
patients may be placed at ease by reassuring them that the ull vasoconstrictive e ects o the epinephrine.20 Clini-
procedure will not begin until complete local anesthesia cally, vasoconstriction is evident when a ring o pallor is
has been obtained. T e health pro essional injecting the observed around the surgical area in ltrated with lido-
anesthesia should make all e orts to divert the patient’s caine mixed with epinephrine. 183
2 Pr eo Per a t Iv e a n t Is ePs Is surgeon is ready to begin the procedure. Precise surgical
technique is necessary to ensure a ne, linear scar. Execu-
tion o the elliptical excision involves ve successive steps:
A ter marking the clinical and surgical margins and ensur-
incision, excision, undermining, hemosta sis, and suturing.
ing complete anesthesia, the surgical site and the sur-
Meticulous execution o each step maximizes the unc-
rounding skin are scrubbed widely with an antiseptic, and
tional and aesthetic outcomes and results in reproduc-
sterile drapes are placed to protect the scrubbed eld rom
ibly excellent scars. Errors in early steps will make precise
contamination. T e reader is re erred to additional chap-
execution o subsequent steps more dif cult. T e remain-
ters on antisepsis or complete coverage o this topic. Ster-
der o this chapter details the necessary steps to properly
ile technique not only minimizes the risk or in ection, but
per orm each o these ve tasks so that successive portions
it also in uences the execution o the procedure. Bulky
may be executed with ease.
drapes that decrease the size o the surgical eld or shi t
while working impair operative ef ciency and increase the
risk o contaminating the eld. In c Is Io n
S
e
T e goal o the initial incision is to release the skin to the
eq u IPmen t n eed ed
c
t
i
desired anatomic depth and to create smooth and perpen-
o
f o r Pr o c ed u r e
n
dicular wound edges without a tissue bevel. Be ore initiat-
2
ing the procedure, the surgeon should have a clear plan
:
or the anatomic depth o the incision ( able 17-2). T e
:
A care ully prepared surgical tray includes all the instru-
desired anatomic depth will vary based on the location and
S
ments and supplies necessary to complete the elliptical
u
intention o the procedure. In most cases, the depth o the
r
excision without interruption. T e reader is re erred to the
g
incision will correspond to the intended anatomic plane
i
c
chapter on surgical instrumentation or a comprehensive
a
discussion. T is section will brie y mention some general or the subsequent steps o excision and undermining.
S
k
principles. Management o the surgical tray a ects both T e incision should create wound edges that are sharply
i
perpendicular to the skin sur ace, because any bevel o
s
sa ety and operative ef ciency. A cluttered surgical tray
increases the risk or exposure to sharp instruments and the dermis or at will impede the direct apposition o
makes it harder to locate the desired instruments. T e the epidermal edges during suturing. Sound technique
scalpel blade and scissors should be as sharp as possible. is necessary to prevent a beveled skin edge. T e scalpel
Dull instruments orce the surgeon to use excessive pres- handle tends to all toward the surgeon’s dominant hand,
sure and increase procedure time. o avoid tissue trauma, similar to the eraser end o a pencil, thereby positioning
the surgeon should use a orceps with teeth (e.g., Adson the blade in an undesirable beveled position. T e surgeon
orceps). T e teeth o the orceps allow manipulation o the must compensate or this natural tendency by taking care
tissue without trauma. Please see able 17-1 or a list o the to hold the scalpel perpendicularly to the skin sur ace
instruments and materials essential to per orm an excision. throughout the entire pass o the incision.
Cleanly incised wound edges acilitate precise apposi-
tion o the epidermis and dermis during suturing. A sharp
t ec h n Iq u e scalpel should incise the skin smoothly with minimal
downward pressure. I the surgeon orces the scalpel with
Sound surgical design is the rst step in achieving an downward pressure in an attempt to reach the desired
excellent surgical outcome. A ter anesthetizing, cleaning depth in one pass, or i the scalpel edge is dull, the scalpel
and draping the eld, and organizing the surgical tray, the may succumb to chatter, resulting in jagged wound edges.
o avoid chatter, especially in thick or brotic skin, more
than one pass o the scalpel may be necessary to reach the
desired depth. Stabilizing the skin with the nondominant
TAbl E 17-1 hand or the hands o a surgical assistant places tension on
I m i l s gi l ex i i the skin sur ace and acilitates entry into the correct surgi-
cal plane. In addition, particularly in loose skin with thin
Sca pe and sca pe ade dermis, creating taut skin with manual pressure assists
Forceps – Adson type with teeth in preventing “chatter” o the blade, which creates jagged
cuts. As noted earlier, designing the usi orm excision as a
Need e driver
rhombus rather than a true ellipse also assists in creating
Scissors – Iris and Metzen aum smooth, nonjagged strokes since a straight line is easier to
Skin hook – sing e or dou e prong incise than a curved line.
One important, yet requently overlooked portion o
Suture materia incising the skin is the continuation o the incision up
Sharps receptac e to and including the apical angles at the proper depth.
Similar to the tendency or the blade to all ipsilaterally,
E ectrosurgica instrument
there is a tendency to incise the outer, lateral parts o the
Gauze ellipse correctly but create a shallower, angled incision
Cotton tipped app icators toward the apices. T is error ails to ully release the der-
mis, resulting in an uneven removal o the specimen and
Specimen container
184 beveled edges at the apices that can prevent proper tissue
 TAbl E 17-2
2
Id s rgi P f re i i g d u d rmi i g

l ti Pr f rr d a t mi P c mm t /c riti s tr t r t c id r
Trunk and Junction o su cutaneous at and ascia. In On the trunk, proxima extremities and neck, aim or the junction
extremities arger individua s, it may e di cu t to go a etween the tight y organized, compact, co umnar ce s adherent
the way down to “deep” ascia. to the underside o the dermis and the under ying, ooser, arger
at ce s that invest the ascia.
Hands and eet Junction o su cutaneous at and dorsa Take care to preserve the vesse s which ie in the amina direct y
superf cia ascia eneath the dorsa superf cia ascia.
l atera ace Junction o the su cutaneous at and SMAS The motor nerves rom the acia nerve a ways ie deep to the
most superf cia ayer o SMASa . Excision at the junction o the
su cutaneous at and SMAS wi protect the motor nerves.

C
h
Centra 1/3 o a. Sma excisions: junction o su cutaneous because the ranches o the acia nerve have ar orized, excision

a
p
ace and sca p at and SMAS deep the SMAS is ess ike y to cause motor def cits (e.g., excision

t
e
r
. l arge excisions: deep to the musc es o o mid ine and paramedian ronta is does not eave motor def cit

1
7
acia expression or SMAS on the orehead).

:
:
a
In areas where the musc es o acia expression are ayered, e.g., ip depressors and e evators, the motor nerves innervate the deepest musc es

T
rom their superf cia sur ace.

h
e
E
i
p
t
i
c
apposition when suturing. In addition, there is a tendency tension allows the surgeon to trim ush with the dermis

a
E
to take numerous passes with the scalpel toward the api- and create a sharply perpendicular wound edge along the

x
c
ces to release the tissue in this location. Single, smooth ull thickness o the skin ap. In many cases, trimming the

i
s
i
o
incisions are pre erred at each apical angle so as to avoid lagging at is best accomplished a ter undermining.

n
jagged marks on the sur ace.

a
n
T e scalpel blade chosen or the procedure is dictated

d
exc Is Io n

i
by the anatomic location. Excisional sites with thin to

t
s
V
moderately thick dermis, such as the cheeks, orehead,

a
T e excision has two purposes, either to ensure complete

r
nose, lips, and distal extremities, are best incised with

i
a
removal o a lesion or to restore contour by removing the

t
a #15 scalpel blade. Incision o skin with thick dermis,

i
o
standing cone or excess tissue during the reconstruction

n
namely the trunk and proximal extremities, is best per-

s
ormed with the larger #10 blade. Finally, in thin skin with (this latter purpose is addressed at the end o this chap-
high aesthetic importance such as the eyelid, a beaver ter). Based on the clinical examination and pathology o
blade or #15c blade allows or smooth, sharp incisions the preoperative biopsy, the surgeon must determine the
with minimal tissue drag. With sound technique, the sur- anatomic depth o the excision. T e depth o excision
geon will accomplish a uni orm release to the desired ana- should maximize the likelihood o complete removal with
tomic depth along the entire incision line and create clean minimal collateral damage to important anatomic struc-
wound edges without a bevel. tures. Deeply in ltrating tumors may require excision at
It should be noted that the epidermis and dermis have a depth that causes predictable morbidity. For example, a
greater sur ace tension compared to the at. A ter incising
through the dermis, the epidermis and dermis immedi-
ately retract away rom the incision, and the subcutaneous
at tends to lag toward the center o the wound. T e lag-
ging subcutaneous at can impede apposition o the der-
mis during suturing. Most surgeons have seen at lobules
extruding through the wound a ter placement o a deep
suture (Fig. 17-9). T e lagging at also tends to obscure
visualization o the reticular dermis, which is the primary
target o buried dermal sutures. rimming the lagging at
ush with the dermis optimizes precise approximation
o the dermis and allows clear visibility o the reticular
dermis during placement o the buried dermal sutures.
T e surgeon can stabilize the lagging at with the orceps
and trim with the scissors. Excessive traction on the lag-
ging at should be avoided, because it requently causes
a reverse bevel (i.e., a bevel away rom the wound edge),
which makes it more dif cult to place the deep sutures Figure 17-9 An untrimmed at eve impedes proper
without a prominent dimple. Stabilizing the at without wound edge apposition when suturing. 185
2 tumor that invades the deep at on the temple may require
excision through the super cial musculoaponeurotic sys-
tem (SMAS) and may sacri ce the temporal branch o the
acial nerve. By contrast, the surgeon can almost always
dictate the anatomic plane when excising standing cones
or excess tissue during the reconstruction.
T e goal o the excision is to remove the skin in a uni-
orm anatomic plane with minimal morbidity to the
underlying structures. Ideally, the preceding incision has
released the skin to the desired anatomic depth, and the
excision continues a clean li t o tissue in the same surgi-
cal plane. In areas with thick subcutaneous at, a dispar-
ity between the depths o the incision and excision may
create unnecessary challenges during the closure. For
example, i the incision extends to the ascia, but the tis-
S
e
sue is excised at the level o the super cial subcutaneous
c
t
Figure 17-10 Examination o an excisiona specimen
i
at, then the island o subcutaneous at at the base o the
o
demonst ates neven emova which can t ans ate into
n
wound can impede advancement o the wound edges dur-
2
dif c ty eapp oximating the wo nd and/o an inc eased
ing the closure and complicate hemostasis by obscuring ike ihood o ed ndant tiss e cones.
:
:
blood vessels.
On the scalp, central ace and temples, hands and eet,
S
and male genitalia, the subcutaneous at is either thin knowledge o the surgical planes. Compared to the scalpel,
g
i
or indistinct (e.g., on the mid chin, the mentalis inserts
c
scissors provide more tactile eedback, which helps the
a
directly into the dermis and there is not a distinct layer surgeon eel the release o tissue and maintain a uni orm
S
k
o at), so the surgeon encounters the underlying muscle
i
anatomic plane. T e scissors should split the anatomic
s
or ascial layer immediately a ter release o the dermis. plane with ease, especially in healthy skin without brosis
On the cheeks, neck, trunk, proximal extremities, and rom a previous scar. Undue resistance during the exci-
emale genitalia, there is requently a thicker layer o sion should prompt the surgeon to reevaluate the accuracy
subcutaneous at. In these locations, a layer o colum- o the anatomic plane. In contrast to scissors, the blind
nar, compact, and tightly organized at cells adheres to sharp edge o the scalpel blade more easily breaches tis-
the underside o the dermis. A surgical plane separates sue planes. Especially in areas with thick subcutaneous
these tightly organized columnar cells rom a deeper at, such as the abdomen or proximal thigh, there is a ten-
layer o larger, more loosely organized at that invests dency or the scalpel to cut progressively deeper during
the ascia. Vigorous scrubbing with gauze can o ten the excision and or the underside o the specimen to have
dislodge these deeper, loosely organized, larger at cells scalloped edges (Fig. 17-10). T e surgeon should aim or a
rom the ascia. During the incision, the scalpel will nd clean separation o anatomic planes and an excision speci-
a releasing point at the junction o these two layers o men with a uni orm thickness, which re ects the accuracy
at. Using the scissors to eel the release, the surgeon can o the plane o excision.
e ortlessly excise the specimen at the junction o these
two at layers.
Assuming deeper excision is not necessary or onco- u n d er mIn In g
logic reasons, the optimal planes or excision var y by
location. In general, excising at the junctions o tissue Undermining acilitates advancement o skin edges by
planes improves operative e iciency by minimizing releasing either the skin edges or ap rom underlying
bleeding and by allowing e ortless dissection. On the adhesions. Undermining can also acilitate eversion o the
trunk and extremities, the surgeon will usually excise wound edges during suturing. T e surgeon must make
tissue in the plane where the subcutaneous at meets the two key decisions when undermining: (1) the ideal ana-
deep muscular ascia. In order to preser ve the underly- tomic plane or undermining; and (2) the extent o under-
ing branches o the acial ner ve on the lateral ace and mining (i.e., how widely to undermine). In most cases, the
neck, the surgeon excises at the junction o the subcu- anatomic plane or undermining coincides with the depth
taneous at and ascia o the SMAS. On the scalp, where o the incision and the plane o the excision.
there is no risk or motor de icits, and on the central I the surgeon is working in an ef cient surgical plane,
ace, where there is minimal risk or motor de icits rom undermining should occur with ease. Undue resistance
working in a deep surgical plane, the anatomic plane while undermining usually signi es an inef cient ana-
o excision may var y, depending on the extent o the tomic plane (e.g., most commonly splitting the subcuta-
procedure. On the midline orehead, or example, the neous at or attempting to split the dermis, rather than
surgeon may choose to stay above the rontalis muscle working at the junction o the at and ascia). T e ideal
or a small excision but may excise deep to the rontalis surgical plane varies based on the location (see able
to remove bulk and acilitate tissue advancement or a 17-2 speci ying ideal anatomic planes or excision and
large excision. undermining). In some instances, undermining at a more
T e surgeon can use either the scissors or the scalpel or super cial anatomic depth than the excision can mini-
the excision. Scissors have some advantages over the scal- mize morbidity. For example, i excision o the SMAS
186 pel, especially when the surgeon does not have intimate is necessary or clearance o a tumor on the temple, the
surgeon may decrease morbidity to the underlying tempo-
ral branches o the acial nerve by undermining the edges h emo s t a s Is
2
o the reconstruction super cial to the SMAS.
It should be noted that skin undermined too super - When the prior steps o incision, excision, and under-
cially (e.g., immediately subdermal) may not have ade- mining are per ormed correctly, the amount o bleeding
quate per usion.21,22 o optimize blood supply the skin is present within the surgical wound should be minimal.
typically undermined so that a layer o tight columnar cells However, meticulous hemostasis must still be obtained
rom the subcutaneous at remain adherent to the under- prior to proceeding with suturing. Although rarely li e-
lying dermis. For example, on the central ace (e.g., nose, threatening, postoperative hematomas rom cutaneous
lips, and central orehead) and scalp, undermining deep surgical excisions can signi cantly compromise the aes-
to the muscles o acial expression or galea, respectively, thetic outcome and are o ten avoidable. A detailed discus-
is desirable in most cases. By contrast, on the lateral ace, sion regarding the numerous electrosurgical modalities
temple, and posterior triangle o the neck, undermining by which bleeding vessels are treated is beyond the scope
super cial to the SMAS and investing ascia o the neck, o this chapter, and readers are re erred to other relevant
respectively, preserves unction o the underlying motor chapters in this book or a more detailed discussion on

C
electrosurgery. A ew guiding principles may help the sur-

h
nerves.

a
p
T e lateral extent o undermining varies according to geon while attempting to stop intraoperative bleeding.

t
e
the procedure. Wide undermining may be necessary when First, a thorough preoperative assessment o bleeding

1
risk can help to avoid uncontrolled perioperative bleeding.

7
operating in areas where the dermis is rmly adherent to
the ascia and muscles below, such as on the lip or chin. For Precise cauterization o vessels ensures optimum hemo-

:
:
most primary closures, wide undermining rarely increases stasis and minimizes collateral tissue damage. T is can be
acilitated by indirect electrosurgery whereby the surgeon

T
mobility o the skin edges. Usually, minimal undermining

h
e
(0.5– 1.0 cm) suf ces. In some instances, especially deep gently picks up the bleeding area with orceps or a deli-

E
wounds and sites with thin overlying dermis such as the cate hemostat and an assistant touches the orceps handle

i
p
with the electrosurgical device. T e orceps or hemostat

t
dorsal hands, no undermining may be necessary. Fascial

i
c
releases the tissue once the area has been suf ciently

a
plication sutures can advance tissue, decrease undermin-
desiccated.

E
ing requirements, and minimize the sur ace tension that

x
c
is transmitted to sutures.23 o help decide whether under- For sites that have brisk amounts o bleeding, the sur-

i
s
i
geon should rmly compress the area with gauze pads in

o
mining is necessary, the surgeon can take a skin hook to

n
place the leading edge o skin in an everted position. I the nondominant hand ollowed by a slow, rolling release

a
n
underlying adhesions x the skin in an inverted position, o the tissue to visualize and grab the bleeding site with

d
the orceps or hemostat. Because gravity will cause blood

i
t
undermining will help.

s
to move downward, hemostasis is more ef cient when the

V
Undermining too widely can also threaten the skin’s

a
blood supply.22 In general, the surgeon should aim to surgeon begins this task at the superior pole o the wound.

i
a
T is will prevent pooled blood rom obscuring the surgi-

t
undermine just enough to move the skin so that the edges

i
o
cal site and allows the surgeon to nd the vessels more

n
approximate without tension. Frequent assessment o skin

s
mobility while undermining helps to avoid unnecessarily easily.
wide undermining. Sharp undermining with scissors is Once the base o the wound has de nitive hemostasis,
much more ef cient than blunt undermining. With thor- the surgeon must ensure that the undermined wound
ough knowledge o anatomy, the surgeon can undermine edges have suf ciently stopped bleeding. T e most ef -
sharply and with con dence. Compared to the scalpel, cient means o evaluating the undermined areas is to have
scissors allow sharp undermining with better tactile eed- an assistant “walk the edges” with skin hooks whereby
back. T e scissors precisely release the skin at the desired the tissue is li ted, everted, and shown to the surgeon.
surgical plane. A ter the initial releasing cut, the surgeon Any culprit vessels may be stopped to ensure there will
can ef ciently undermine the remaining skin by sliding be no bleeding during and a ter suturing. Electrosurgery
one blade o the scissors in the newly released space and should then be applied directly with the device tip to any
use the second blade to complete the cut. Using this slide remaining bleeding areas that are too small or the indi-
and divide technique o undermining,24 the surgeon does rect method with orceps. Hemostasis may be considered
not have to rediscover the pre erred undermining plane complete when the surgeon can visualize the de ect with-
with each new cut. out any blood pooling at the base or edges o the wound.
Countertraction with skin hooks greatly acilitates
undermining. Compared to orceps, skin hooks allow s u t u r In g
orce ul countertraction o the skin without epidermal
trauma. T e skin hook should be placed rmly at the A layered wound closure allows or optimal cosmesis and
desired depth o undermining (usually under the dermis) the number o suture layers selected to repair a wound is
and immediately over the point o undermining. I the dependent upon the depth and location o the wound. For
skin hook is placed too super cially, or example, in the ull-thickness de ects, a minimum o two layers allows or
mid dermis, the instrument tends to slip rom the skin. I precise approximation o the dermal and epidermal edges,
the skin hook is placed remotely rom the point o under- while reducing the tension on the sur ace o the incision
mining with the scissors, the orces o countertraction via wound eversion. In this scenario, deep sutures are
diminish and undermining is more dif cult. T ere ore, placed to close the dermis in a buried vertical mattress
as the scissors progress to a new spot, the retracting skin ashion ollowed by cuticular sutures that reapproximate
hook should ollow. the epidermis. For deeper and larger wounds, a deep layer 187
2 o sutures to approximate the subcutaneous tissue may be
placed prior to the buried vertical mattress sutures. T is
o begin, the needle is passed starting rom the under-
mined plane, aiming or the desired location o the peak
deepest layer o sutures eliminates dead space and relieves o the heart-shaped loop. T e distance o the peak o the
additional tension on the incision line, thus reducing heart-shaped loop rom the incised wound edge varies
the likelihood o uture scar inversion. Fascial plication depending on the thickness o the dermis. In general,
sutures also per orm a similar unction or deep excisional thicker dermis requires a greater distance o the peak o
wounds such as on the back or cheek.23 the heart-shaped loop rom the incised wound edge. Once
the tip o the needle reaches the mid dermis or papillary
dermis, the needle is rotated toward the incised wound
d er ma l s u t u r es edge. As the needle is rotated toward the center o the
wound, the wound edge must be retracted aggressively
Deep sutures eliminate dead space, approximate the der- in an everted position. T is aggressive retraction ensures
mis and epidermis, and provide strength to the wound that the tip o the needle will reach the incised wound edge
as the scar matures. Judicious selection o the suture and at a greater depth, usually in the reticular dermis. When
needle, a thought ul plan or suture sequence, and posi- the peaks lie closer to the underside o the epidermis than
S
e
tioning relative to the wound are the rst steps or e ec- the valley o the heart-shaped loop, the epidermis and
c
t
i
tive execution o the buried vertical mattress suture, the super cial dermis o the incised wound edge naturally
o
n
workhorse deep suture technique or cutaneous recon- snap back toward the center o the wound. T e surgeon
2
struction.25 T e anatomic layers requiring suturing will observes this natural “snap” upon release o the retracting
:
:
vary by site, depth, and complexity o the wound, and a orceps or skin hook a ter completing the suture bite. T e
comprehensive discussion o these various wounds lies “snap” o the epidermis and super cial dermis toward the
S
beyond this scope o this chapter. center o the wound is a quality control checkpoint. I the
g
i
T e buried vertical mattress suture creates the same “snap” does not occur, then there is a high likelihood o a
c
a
heart-shaped loop as a cutaneous vertical mattress suture gap between the wound edges.
S
k
(Fig. 17-11),26 except that the knot lies at the bottom o T e needle is then passed in the opposite side o the
i
s
the loop and there is no risk or suture marks on the epi- wound in a path that creates a mirror image o the rst
dermis. T is course o the needle acilitates wound ever- side. T e needle enters the wound in the deep reticular
sion and counteracts the contractile orces to prevent an dermis and must aim to create a peak o the heart-shaped
inverted or depressed scar. In cross section, the buried loop in the more super cial dermis. Retracting the skin
vertical mattress suture has a heart-shaped loop with two edge in an everted position with the skin hook or orceps
peaks at the level o the mid dermis or deep papillary der- naturally acilitates the proper suture path. In practice, the
mis and a valley at the depth o the deep reticular dermis. start o the second throw requires extension o the wrist
As the di erence in depth between the peaks and valley and will eel like the tip o the needle is aiming upward.
o the suture path increases, the degree o eversion will Once the tip o the needle reaches the peak, the needle is
increase. rotated toward the base o the wound and exits at the level
o the undermined plane.
T e thickness o the dermis determines the path o
the buried vertical mattress suture. In areas with thicker
dermis (e.g., the back or proximal extremities), the path
o the suture must have a greater di erence in height
between the peaks and valley o the buried vertical mat-
tress suture. o achieve this greater di erence, the sur-
geon must take a wider bite (i.e., urther rom the wound
edge) with the skin edge retracted aggressively in an
everted position. In practice, a wide bite with the skin
edge retracted aggressively eels like the suture needle is
passing parallel to the underside o the epidermis or as
A
long as possible. In areas with thinner dermis (e.g., eye-
lid and dorsal hand and orearm), the ideal di erence in
height between the peaks and valley o the buried vertical
mattress sutures is smaller. o achieve this minimal di -
erence, the surgeon must take a narrow bite (i.e., closer
to the wound edge) with the skin edge retracted in a less
aggressive vertical position. In practice, a narrow bite
with a gently retracted everted edge eels like the suture
needle is passing parallel to the vertical ace o the incised
skin edge. Another way to describe the di erence in the
suture path or thick versus thin dermis is to conceptu-
alize the distance o the peaks o the heart-shaped loop
B
rom the incised wound edge. In thick dermis, the peaks
Figure 17-11 A. Sho t, b oad hea t-shaped oop o o the heart-shaped loop will lie urther rom the incised
thick de mis. B. Ta na ow hea t-shaped oop o thick wound edge and the path o the suture creates a broad-
188 de mis based, heart-shaped loop. In thin dermis, the peaks o the
heart-shaped loop lie closer to the incised wound edge
and the path o the suture creates a narrow, tall, heart-
running continuous, vertical mattress, and horizontal
mattress.28 Anatomic sites bearing more postoperative
2
shaped loop (Fig. 17-11). tension, such as the chest and back, may be best repaired
o achieve per ect apposition o the wound edges, the with an absorbable or nonabsorbable running subcuticu-
path o the buried vertical mattress suture on one side lar suture. T e nonabsorbable suture can be removed at
should be a mirror image o the suture path on the other 1 week. Because scars are inherently weaker than nor-
side. When the paths o the buried vertical mattress suture mal tissue, particularly early in the postoperative period,
on each side are not mirror images, the wound edges will placing an absorbable running subcuticular suture at a
not appose each other precisely. As a rule, the side with tension-bearing site may reduce the likelihood o the scar
the bite o suture more super cial relative to the epidermis widening or spreading.
will have a wound edge that is depressed relative to the T e type and caliber o the suture, the size o the needle,
other side (see section on troubleshooting). and the timing o suture removal also in uence execution
T e suture is now ready to be tied with the knot bur- o the top sutures. T e surgeon must be aware that smaller
ied at the depth o the undermined plane. An e ective caliber sutures have a lower risk o leaving track marks
instrument tie is necessary to prevent an “air knot” and compared to thicker caliber sutures when percutaneous

C
h
to ensure that the suture snugly approximates the wound cuticular sutures are per ormed. E ective placement o

a
p
edges. T e surgeon may consider a “V-area” that is the buried vertical mattress sutures nearly eliminates tension

t
e
empty airspace between the running end (e.g., suture on the wound edges and allows the surgeon to use lower

1
7
point) and ree end o the suture (i.e., “tail”). T e needle caliber sutures. In addition, smaller suture needles (e.g.,
driver does all o the work in this “V,” allowing or ef - P-3) should be used to suture delicate wound edges. Larger

:
:
cient and e ective knot-tying. T e knot may be tied by needles increase the likelihood o tearing delicate wound

T
wrapping the running end o the suture around the needle edges. Finally, percutaneous epidermal sutures should

h
e
one time. T e needle holder then grasps the ree end o be removed as early as possible to avoid track marks. In

E
the suture and pulls it in the same direction o the pre- wounds with e ective placement o deep sutures, the top

i
p
t
vious wrapping motion and cinches the knot rmly, not sutures do not bear tension and can be removed within 5

i
c
a
orce ully, down.27 T is knot is repeated again in the same to 7 days in most cases, especially on the head and neck.

E
direction, while uture throws are alternated in direction. Leaving the sutures or a longer time o ers little advan-

x
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I the surgeon wishes to secure the knot, which is help- tage, as the deep sutures bear the tension that keeps the

i
s
i
o
ul or wounds under some tension, the ree end o the wound rom dehiscing.

n
suture may be pulled up while the working end is relaxed Once the surgeon has chosen the suture materials, an

a
n
a ter the second at throw. Alternatively, a surgeon’s knot important decision that must be made is selecting the re-

d
i
t
secures the suture by per orming a double wrap on the quency o the top sutures and the distance o the suture

s
V
rst throw o the instrument tie.27 bites rom the wound edge. In general, skin with a thinner

a
T e deep sutures should support the dermis along dermis requires a higher requency o sutures (i.e., sutures

i
a
t
the entire wound and still allow easy manipulation o placed closer together) and suture bites that are closer to

i
o
n
the epidermal edges. o ensure an adequate number o the wound edge. T e top sutures help to accentuate the

s
deep sutures, the surgeon can apply the “pull test.” T e eversion, de ned as upward sloping skin edges that meet
pull test consists o applying lateral pressure to tr y to per ectly at the peak without any plateau or inversion. I
spread the wound edges rom each other. Additional the bite o the suture is too ar rom the wound edge, it can
deep sutures may be prudent in any gap produced by the create an eversion– inversion phenomenon.
pull test. o assess proper depth o the deep suture, the T e top sutures should be thrown with minimal tension.
surgeon can use the skin hook or orceps to retract the Excessive tension increases the risk or wound necrosis
epidermis and super cial dermis. Resistance signi es and suture marks. As a quality control measure to assess
that the suture was placed too super cially, usually as a the tension on the sutures, the surgeon should be able to
result o using a circular, rather than heart-shaped, path slide one arm o the orceps under the suture loop without
o the suture. dif culty. I the top sutures are thrown with tension, a gap
will orm at the points o entry and exit. T e process o
Cu TICu l Ar Su Tu r ES. Even with care ul tech- reepithelialization begins immediately to close this gap, so
nique when per orming the deep sutures, the wound edg- track marks are sure to occur, even i the top sutures are
es requently bene t rom an additional layer o super cial removed be ore 1 week.
sutures or precise approximation o the epidermal edges. T e rst step in placing accurate top sutures is to rec-
I the deep sutures have been placed e ectively, the epi- ognize which side o the wound is riding higher than the
dermis and dermis should not have a gap between them other. T e high side either obscures visibility o the lower
and the top sutures should not need to bear tension. How- wound edge by sliding over it like a shingle on a roo or it
ever, minor height discrepancies a ter placement o the bleeds because its super cial dermis is exposed. T e high
deep sutures are common. T e primary purpose o the top side o the wound is usually slightly more delicate and can
sutures is to correct these height discrepancies. be more challenging to manipulate. It is o ten more ef -
T e anatomic location o the surgical excision o ten dic- cient to correct height discrepancies o the wound edge by
tates the manner in which “top” sutures are placed. en- biting the high side rst. T e general guideline to correct
sion- ree sites such as the head and neck lend themselves height discrepancies with top sutures is: “Bite high on the
to percutaneous epidermal sutures with nonabsorbable high side, and bite low on the low side.” In other words, the
or ast-absorbing sutures. T e types o knots selected or needle should approach the high side with a shallow bite
this layer o sutures vary and include simple interrupted, in the super cial dermis (i.e., close to parallel to the plane 189
2 o the epidermis) that is relatively close to the wound edge.
A ter showing the tip o the needle between the wound c o r r ec t In g r ed u n d a n t
edges, the surgeon has control o this side o the wound. t Is s u e c o n es
T e surgeon must then depress the wound edge until it
matches the height o the opposite side. T e needle is then Despite proper excision design and technical execution,
passed with a deeper and wider bite that precisely matches the surgeon must be prepared to address redundant tis-
the wound edges. sue cones that orm at the edges o wound repair. Redun-
dant tissue cones can spontaneously regress over time and
the likelihood o contour improvement is proportional to
r ed u n d a n t t Is s u e c o n es the actual height o the cone as well as the length o time
since surgery.30 Although it is certainly possible to allow
Redundant tissue cones are commonly encountered at redundancies to “settle out,” the contour de ormation o
the end o a repair and can compromise the cosmetic the surgical site o ten detracts rom the aesthetic result. In
outcome by creating abnormal contour at one or both order to please the patient with the immediate postopera-
ends o an elliptical excision. As wound edges are sutured tive result, these redundancies are usually best removed at
S
e
the time o surgical excision.
c
together, skin becomes displaced along the central axis.
t
i
Surgical removal o standing tissue cones can be per-
o
T is displaced skin produces raised edges that orm at
n
the distal portions o the closure due to excess tissue ormed in numerous ways (Fig. 17-12). T e manner in
2
compression.29 Many names have been given to these which a cone is excised is in uenced by the surgical
:
site, the adjacent relaxed skin tension lines, and the
:
cones: dog-ears, Burow’s cones, and triangles. T e der-
location o adjacent rhytides. I a relaxed skin tension
S
matologic surgeon must be mind ul o how these cones
orm and o how to address them in order to obtain opti- line is continuous and parallel with the sutured wound
g
i
then straight elliptical excision around the tissue can be
c
mum cosmesis.
a
per ormed. In this scenario, arched incisions are made
S
k
immediately around the redundancy and are extended
i
a v o Id In g r ed u n d a n t as ar distal as the conical protrusion reaches. Another
s
method o creating a straight-line removal is to li t up
t Is s u e c o n es the redundant cone with orceps or a hook and incise
the cone directly down the center to the distal end o
T ree main actors a ect redundant tissue cone ormation.
the raised area. Once incised, each triangle o skin can
First, the apical angles directly in uence the likelihood o
be draped over the new de ect and trimmed so that a new
protruding tissue cones. Conceptually, i the closure o a
elliptical de ect can be sutured into a straight line. Attempts
usi orm excision is thought o as a parallel advancement
to remove less skin than extends to the distal raised area
o two edges then the apical angles experience rotational
will result in a persistent contour de ormity. Novice sur-
orces. As this apical angle increases, particularly beyond
geons requently will take less skin than is required to
30 degrees, so too does the potential or creation o raised
remove a redundant cone which results in “chasing” the
excess skin.7,29 Second, as the length o a usi orm closure
contour de ormity over a number o excisions, decreasing
is reduced, the likelihood o redundant cones becomes
the likelihood o an elegant, aesthetic result.
higher, because there is less tissue to counteract the com-
T ere are instances in which redundant cones are
pression o the sutured edges. Finally, when the opposing
removed in a curved or perpendicular ashion in order
wound edges are o di erent lengths, redundant cones are
to better camou age the scar within the relaxed skin ten-
more likely to orm i not addressed properly.
sion lines or adjacent rhytides (Fig. 17-12). T is technique
Redundant tissue cones can be avoided by many o the
is similar to the incisions necessary to surgically excise a
designs and surgical techniques noted previously in this
redundant cone to create a straight-line scar. T e distin-
chapter and include:
guishing eature, however, is that the rst incision with
1. Creation o apical angles o 30 degrees or less with a the scalpel occurs speci cally in the direction where the
rhombus-shaped usi orm excision new scar line is desired. Once this ull-thickness inci-
2. Ensuring that the sides o each ellipse are equal sion is made through the skin to the appropriate depth,
when operating on a planar sur ace the remaining ap o skin is draped over the wound and
3. Converting the rhombus into an S-shape design on trimmed and a new, angled de ect may be sutured.
convex sur aces Once the surgeon becomes com ortable with excision
4. Continuing smooth, nonbeveled incisions all the way o redundant cones, this technique may allow minimiza-
to each apex so that excess dermal or subcutaneous tion o scars and conservation o tissue by excising lesions
tissue does not obstruct wound closure as a circle rather than with a usi orm ellipse design. T e
5. Properly undermining around the entire wound, disadvantages o the usi orm excision design include
particularly beyond the apices.7 poor compensation or the variability in regional tissue
6. I a redundant cone is anticipated because o sides laxity that exist along redundant cone de ormity sites in
o unequal length, then the wound edges may be addition to the potential to remove excessive amounts
sutured together in a manner that progressively o healthy tissue due to a predetermined design.31 In
divides the wound into “halves” in order to equalize act, on nonwrinkled skin, optimal scar orientation can
the length discrepancy. T is technique can be be challenging and it may be common to nd that a cre-
enhanced even urther by taking horizontal mattress ated ellipse gapes wider and in a di erent direction than
190 bites o the longer wound edge. initially anticipated by the surgeon.32 Circular excisions
 S tra ight e lliptica l excis ion tion and enhanced cosmesis. T e excision may be divided
into ve individual steps – incision, excision, hemosta-
2
sis, undermining, and suturing. Pro ciency in the skills
to per orm these steps will allow the surgeon to begin
to obtain reproducibly excellent results and progress to
more technically advanced surgical procedures, such as
cutaneous aps.

r ef er en c es
1. Otley CC. Perioperative evaluation and management in der-
matologic surgery. J Am Acad Dermatol. 2006;54(1):119– 127.
A 2. Macrae WA. Chronic pain a ter surgery. Br J Anaesth. 2001;87
(1):88– 98.

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Hockey s tick 3. Perlis CS, Campbell RM, Perlis RH, Malik M, Du resne RG Jr.

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a
Incidence o and risk actors or medical malpractice lawsuits

p
among Mohs surgeons. Dermatol Surg. 2006;32(1):79– 83.

t
e
4. Goldberg LH, Alam M. Elliptical excisions: variations and the

1
eccentric parallelogram. Arch Dermatol. 2004;140(2):176–180.

7
5. Dunlavey E, Leshin B. T e simple excision. Dermatol Clin.

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1998; 16(1):49– 64.

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6. Moody BR, McCarthy JE, Sengelmann RD. T e apical angle:

T
a mathematical analysis o the ellipse. Dermatol Surg. 2001;

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e
27(1):61– 63.

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7. Weisberg NK, Nehal KS, Zide BM. Dog-ears: a review. Der-

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p
matol Surg. 2000;26(4):363– 370.

t
i
8. Cook J, Zitelli JA. Primary closure or midline de ects o the

c
a
nose: a simple approach or reconstruction. J Am Acad Der-

E
matol. 2000;43(3):508– 510.

x
c
B 9. Borges AF. Relaxed skin tension lines (RS L) versus other

i
s
i
skin lines. Pla st Reconstr Surg. 1984;73(1):144– 150.

o
M-pla s ty

n
10. Robinson J, Hanke CW, Siegal DM, Fratila A. Surgery of the

a
Skin: Procedural Dermatology. Philadelphia, PA: Elsevier;

n
d
2010:239– 250.

i
t
11. Zitelli JA. IPS or a better ellipse. J Am Acad Dermatol. 1990;

s
V
22(1):101– 103.

a
12. Mizunuma M, Yanai A, sutsumi S, et al. Can dog-ear orma-

i
a
tion be decreased when an S-shaped skin resection is used in-

t
i
o
stead o a spindle skin resection? A three-dimensional analy-

n
s
sis o skin surgery techniques using the nite element method.
Pla st Reconstr Surg. 2000;106(4):845– 848; discussion 9– 51.
13. Salasche SJ, Roberts LC. Dog-ear correction by M-plasty.
J Dermatol Surg Oncol. 1984;10(6):478– 482.
14. Krishnan RS, Donnelly HB. T e nested M-plasty or scar
length shortening. Dermatol Surg. 2008;34(9):1236– 1238.
15. Wisco OJ, Wentzell JM. When an M is a V: vector analysis
C calls or redesign o the M-plasty. Dermatol Surg. 2009;35
(8):1271– 1276.
Figure 17-12 The va ying methods o emoving e- 16. Gormley DE. A brie analysis o the Burow’s wedge/triangle
d ndant tiss e cones. An e iptica excision o the cone principle. J Dermatol Surg Oncol. 1985;11(2):121– 123.
c eates a contin o s inea sca (A), whi e the hockey-stick 17. Oberemok S, Eliezri Y, Desciak E. Burow’s wedge ap revisited.
(B), and M-p asty techniq es, c ve o sho ten the sca , Dermato Surg. 2005;31(2):210– 216; discussion 6.
18. Morganroth PA, Gel and JM, Jambusaria A, Margolis DJ,
espective y. Note that in a 3 examp es, the sca pe b ade
Miller CJ. A randomized, double-blind comparison o the to-
incises om the dista skin p cke ing to the base o the tal dose o 1.0% lidocaine with 1:100,000 epinephrine versus
tiss e cone, which ens es that the ed ndant skin is y 0.5% lidocaine with 1:200,000 epinephrine required or e ec-
emoved and p ope sca conto is achieved. tive local anesthesia during Mohs micrographic surgery or
skin cancers. J Am Acad Dermatol. 2009;60(3):444–452.
19. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with
epinephrine or local anesthesia. J Dermatol Surg Oncol.
o lesions with subsequent removal o redundant tissue 1989;15(10):1081– 1083.
cones into desired areas can reduce scar size, decrease 20. Sobanko JF, LJ, Swanson NA, Lee KK. Biopsy techniques. In:
Rigel DS, Robinson JK, Ross MI, et al., eds. Cancer of the Skin.
operative time, and allows or potentially better oriented 2nd ed. Philadelphia, PA: Saunders; 2011:434– 443.
wounds.33– 35 21. Pearl RM, Johnson D. T e vascular supply to the skin: an
anatomical and physiological reappraisal– Part I. Ann Pla st
Surg. 1983;11(2):99– 105.
c o n c l u s Io n 22. Pearl RM, Johnson D. T e vascular supply to the skin: an ana-
tomical and physiological reappraisal– Part II. Ann Pla s Surg.
1983;11(3):196– 205.
Proper design and execution o the elliptical excision 23. Kantor J. T e ascial plication suture: an adjunct to layered
and its variations allows or improved patient satis ac- wound closure. Arch Dermatol. 2009;145(12):1454– 1456. 191
2 24. Boyer JD, Zitelli JA, Brodland DG. Undermining in cutaneous
surgery. Dermatol Surg. 2001;27(1):75– 78.
31. Lee S, Murakami CS, Suryadevara AC. issue conservation
using circular de ect with dog-ear de ormities excision tech-
25. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol nique. Laryngoscope. 2011;121(11):2299– 2304.
Surg Oncol. 1989;15(1):17– 19. 32. Hudson-Peacock MJ, Matthews JN, Lawrence CM. Relation
26. Davis JS. T e on-end or vertical mattress suture. Ann Surg. between size o skin excision, wound, and specimen. J Am
1933;98(5):941–951. Acad Dermatol. 1995;32(6):1010– 1005.
27. Nevarre DR. Increasing ef ciency in the operative eld: knot 33. Ek L, Hogstedt B, Herrstrom P. Scar area and cosmetic out-
tying, instrument ties, and locking the suture. Ann Pla st Surg. come a ter circular and elliptical excision o small skin lesions.
1998;40(3):313–315. J Cutan Med Surg. 2004;8(1):11– 15.
28. Kudur MH, Pai SB, Sripathi H, Prabhu S. Sutures and suturing 34. Seo SH, Son SW, Kim IH. Round excisions lead to shorter
techniques in skin closure. Indian J Dermatol Venereol Leprol. scars and better scar positioning than traditional elliptical
2009;75(4):425–434. excisions. Dermatology. 2008;217(3):276– 280.
29. Dzubow LM. T e dynamics o dog-ear ormation and correction. 35. Hudson-Peacock MJ, Lawrence CM. Comparison o wound
J Dermatol Surg Oncol. 1985;11(7):722– 728. closure by means o dog ear repair and elliptical excision.
30. Lee KS, Kim NG, Jang PY, et al. Statistical analysis o surgical J Am Acad Dermatol. 1995;32(4):627– 630.
dog-ear regression. Dermatol Surg. 2008;34(8):1070– 1076.
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192
 Ch a p t e r

18 Random Pattern Flaps

M rg r t M nn, J r my Bord u , & Rob rt S ng m nn

In t r o d u c t Io n skin tension lines, and boundaries between cosmetic

units should be maintained. Generous undermining is
o ten needed or proper mobilization, but care must
Random pattern aps are an indispensable reconstruction
be taken to per orm it in the proper plane ( able 18-2)
option or closure o wounds which may not be suitable
and in such a way as to minimize unnecessar y vascular
or healing by second intention or repair with a linear clo-
trauma. Movement o the lap should create minimal
sure. De ects too large to close in a side-to-side ashion
tension and virtually imperceptible distortion o sur-
may be ideally suited or such aps, which are recruited
rounding structures.
rom adjacent tissue reservoirs and use tissue with a simi-
At the same time, or optimal design and survival o
lar skin match. When second intention healing or linear
a random pattern ap, one must balance its blood sup-
closure may result in distortion o ree margins, well-
ply with the limitations o the donor tissue. Random
designed random pattern aps can be help ul in redirect-
pattern aps can carr y a signi cant risk or ischemia
ing and redistributing tension vectors and allow incision
i excessive tissue manipulation occurs or i the ap is
lines to be hidden along cosmetic boundaries and relaxed
improperly designed. T us, care ul design and surgical
skin tension lines.
technique are essential to optimize ap survival. radi-
Random pattern aps are so named because their blood
tional dogma dictates that a ap should have a length
supply is not based on a single vessel, but on the “random”
to width ratio no more than 4:1. Although the surviv-
albeit copious subdermal plexus. Advancement, rotation,
ing ap length is partially dependent upon the width o
and transposition aps are all types o random pattern
its base, it is now well understood that ap ischemia is
aps, each named based on the type o movement the
in uenced to a greater extent by per usion pressure and
ap undergoes ( able 18-1). Advancement aps slide in a
the tension across the wound. Ischemia occurs when the
straight line rom the donor site to the recipient site. Rota-
per usion pressure drops below the critical closing pres-
tion aps rotate in an arc about a pivot point. ransposi-
sures o the arterioles in the subdermal plexus, which
tion aps move rom the donor site to the de ect over a
can occur due to signi cant edema or venous conges-
peninsula o uninvolved intervening skin.
tion in the ap. Patient risk actors such as smoking
and diabetes can also result in vasoconstriction. Excess
Gen er a l c o n c ept s tension at the ap tip or edges can constrict small arte-
rioles, leading to the possibility o ischemia. Widening
the ap recruits additional subdermal arterioles or
Prior to any reconstruction, the surgeon must ensure
increased collateral circulation but does not necessarily
that complete tumor clearance has been obtained. he
change its per usion pressure. However, when properly
goal o a well-designed repair is to optimize unctional
designed, widening a ap can displace the de ect over a
and aesthetic outcomes. During lap design, one must
larger area, which in turn, distributes the tension over a
identi y a donor site or tissue reser voir – ideally with
larger sur ace.
a color, texture, and thickness similar to that o the
Minimizing tension across a ap is critical or its sur-
de ect. Incision lines should be drawn along relaxed
vival as well as a success ul aesthetic and unctional out-
come. Poorly designed aps can create undue secondary
movement resulting in distortion o anatomic landmarks
and ree margins. T e primary movement o a ap is its
Ta Bl e 18-1 intended movement into the de ect itsel . Secondary
c ifi i fs gi F movement is the movement o the adjacent skin in the
Mov m nt typ a dv nc m nt opposite direction. One must anticipate the true extent o
Rot tion the primary and secondary movement when designing a
Tr nsposition ap. When a ap is rotated or transposed into place, piv-
Int rpo tion otal restraint may limit its movement and reach or may
create tension at its tip, which can lead to ischemia or
V scu r supp y R ndom
a rt ri /a i ree-margin distortion. T us, one must plan in advance
Muscu ocut n ous by oversizing the ap to compensate or pivotal restraint.
With proper oresight and understanding o ap dynam-
Con gur tion Rhombic ics, one can maximize the likelihood o a success ul out-
Bi ob d
come o any random pattern ap.
2 Ta Bl e 18-2
p fu i i gb l i

l i u i i gp I s
Sc p Subg e t nsiv v scu tur
For h d Subg or subcut n ous t bov Supr orbit nd supr troch r n rv
ront is sci
T mp /Zygom tic rch Sup r ci subcut n ous t T mpor br nch o th ci n rv
M ndib Sup r ci subcut n ous t M rgin m ndibu r br nch o th ci n rv
e r a bov p richondrium
l ip a bov orbicu ris oris l bi rt ry
S
Nos a bov p richondrium/p riost um
c
t
i
o
R st o c Sup r ci subcut n ous t, bov th P rotid duct, br nch s o th ci n rv
n
p rotid duct
2
T rmin h ir b ring r Subcut n ous p n H ir p pi /bu bs
:
:
l t r n c Sup r ci subcut n ous t Spin cc ssory n rv
S
u
r
Trun /e tr miti s a bov muscu r sci
g
i
c
H nds nd t Subd rm
S
i
s
o the ap. As a result, i the tension vector or a side-to-
Gen er a l c o n c ept s side closure is improperly designed or distorts ree mar-
gins, the undesirable tension vector may not change.
a. Create incisions along relaxed skin tension lines and ypically, the length to width ratio o an advancement ap
maintain boundaries between cosmetic units. should be no more than 3:1 on the ace and 2:1 on the trunk
b. Identi y donor sites with potential reservoirs o tissue. and extremity or there will be a risk o distal ischemia, which
c. Avoid distortion o anatomic landmarks and ree will vary depending upon the per usion pressure o the ap
margins. and the tension under which the wound is closed. A ap
d. Maintain shape and symmetry. with a 4:1 ratio closed with little tension and a good per u-
e. Repair de ect with skin o similar characteristics. sion pressure will survive, while a ap with 1.5:1 ratio under
. Balance blood supply and tissue restraint by signi cant tension will be at signi cant risk o necrosis.
i. understanding the e ects o per usion pressure
and tension on ap ischemia.
ii. distributing ap tension in the desired direction, c l a s s Ic a d va n c emen t Fl a ps
over an area larger than that o the de ect. (u n Il a t er a l a n d BIl a t er a l )
iii. optimizing primary movement and minimizing
secondary movement. Advancement aps can be designed with their redundant
iv. anticipating ap shortening caused by pivotal cones displaced either unilaterally (U-plasty) or bilaterally
restraint. (H-plasty) i tissue reservoirs are available and movement
rom both sides o the de ect is required (Fig. 18-1). T e
H-plasty is most o ten used or eyebrow de ects, where
a d va n c emen t Fl a ps scars can be hidden along the upper and lower aspects o
the brow (Fig. 18-2). Similarly, one can design an advance-
Conceptually, an advancement ap can be thought o as a ment ap such that only a single cone is displaced uni-
variation o the linear closure, in which one or both o the laterally (Burow’s advancement) or bilaterally (A to or
redundant cones are displaced laterally. T e ap slides uni- O to ) (Figs. 18-3 and 18-4). Classic advancement aps
directionally in a straight line rom the donor to the recipient are requently a desirable reconstructive option because
site. T e major advantage o an advancement ap compared their incision lines can be well hidden along a ree margin
to a linear closure is its ability to displace tissue redundancies or cosmetic boundaries such as the eyebrow, hairline, and
(dog-ears) away rom ree margins to a more aesthetically suit- vermilion borders o the lips.
able location. T e advancing limb o the ap can be hidden in
creases, along the hairline or between cosmetic units. Closure
o the displaced dog-ears advances the ap toward the de ect o t o l a n d c r es c en t Ic
and distributes wound tension away rom the wound. mo d IFIc a t Io n s
T e main drawback o these aps is that their tension
vector is unchanged rom that o a direct side-to-side Variations on the classic advancement ap include
194 repair – both are oriented parallel to the primary motion O-to-L repair, or Burow’s advancement ap, in which
 2

A A

C
h
p
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r
1
8
:
:
R
n
d
A A

o
m
P
t
t
r
n
F
p
s
Figure 18-1 Uni t r U p sty nd bi t r H p sty dv nc m nt p. R dund nt con s r disp c d t r y.

A B

C D

Figure 18-2 a bi t r dv nc m nt p or or h d d ct sup rior to th y bro . A. Post Mohs surg ry d ct

ith d sign or bi t r dv nc m nt p H p sty . Th dv ncing imbs o th p r hidd n ong th n tur hori
zont or h d rhytid nd th upp r sp ct o th bro . B. Fin ound c osur . Not in this mp , r dund nt tissu
is v n d out during c osur by pp ying th “ru o h v s,” voiding th n d or st nding con s. C. a t sutur r mov
1 . D. a t o o up in 3 months. 195
2

A A A A

B B
B B
S
c
t
i
o
n
2
:
:
S
u
A A
r
g
A A
i
c
B B C C
B B C C
S
i
s
Figure 18-3 On sid d dv nc m nt p. A. Buro ’s dv nc m nt. B. a to T F p.

A B

C D

Figure 18-4 a Buro ’s dv nc m nt p on th upp r ip. A. Post Mohs surg ry d ct. B. D sign or
on sid d Buro ’s dv nc m nt p. Incision in s r hidd n ong th v rtic ip in nd v rmi ion
196 bord r. C. Fin ound c osur . D. Sutur r mov t 1 .
 2

x>y
y

C
h
p
t
r
y

1
A A x=y

8
A A

:
:
x

R
n
d
o
Figure 18-5 Modi d cr sc ntic dv nc m nt p. Th curvi in r d sign incr s s th f ctiv ngth o th short r

m
horizont imb to m tch th oth r sid .

P
t
t
r
n
F
the redundant tissue is not excised as a “dog-ear” but is lines. T e classic crescentic ap is the perialar crescentic
evened out during closure by extending the length o the advancement ap, in which the lateral cheek is advanced

p
s
ap and applying the “rule o halves.” Similarly, the cres- into the de ect with removal o a crescent shape along the
centic modi cation lengthens the advancing limb o the ala and nasolabial old. One disadvantage o this ap is
de ect, making a standing cone unnecessary and avoid- that it can obliterate the apical or hairless triangle i the
ing the need or unsightly incisions that violate adjacent crescent is incised/resected along the alar crease and onto
cosmetic boundaries or lines (Fig. 18-5).1 T e crescentic the nasal sill (Fig. 18-7).
modi cation is particularly use ul or upper lip, nasal
sidewall, and orehead de ects (Fig. 18-6). exeCUTION OF THe CReSCeNTIC MODIFI-
Ca TION (Fig. 18-8)
per Ia l a r c r es c en t Ic 1. Design a classic O-to- or A-to- advancement ap.
a d va n c emen t Fl a p 2. Lengthen the advancing limb in a curvilinear
ashion, e ectively creating equal lengths along both
T is variation o the basic advancement ap is use ul along sides o the wound. T e angle o the curvilinear
curvilinear cosmetic units because o its curved incision incision should be less than 30 degrees to avoid

A B

Figure 18-6 a to T c osur ith cr sc ntic modi c tion. A. Post Mohs surg ry d ct. Not th curvi in
r d sign n g t s th n d to r mov st nding con s. B. Fin ound c osur . 197
2
S
c
t
i
o
n
2
:
:
S
u
r
g
i
c
S
i
s
Figure 18-7 Cr sc ntic dv nc m nt p. Th p ri r d sign hid s th incision ong th r cr s nd n s si .

A B C

D E F

Figure 18-8 Cr sc ntic dv nc m nt p on th upp r ip. A. C ssic y d sign d dv nc m nt p ou d vio t th

cosm tic bound ri s o th nos . B. Cr sc ntic modi c tion ith incisions ong th n s si nd r cr s . C. a t rn tiv
d sign ith r mov o in rior con through th mucos ip. D. Fin ound c osur . E. Sutur r mov 1 . F. Fo o up
3 months. Not th hidd n incision in ong th r cr s , v rtic ip in , nd v rmi ion bord r. On dis dv nt g
o this dv nc m nt p d sign is th pot nti or u n ss ong th mucos ip. This is du to tissu r dund ncy ong
th mucos h n th p is dv nc d in th horizont is. This usu y improv s ith tim but th r dund ncy c n b
r mov d ith sm iptic cision th t c n b hidd n in th mucos ip. To void ip u n ss, r th r th n disp cing th
in rior con horizont y ong th v rmi ion bord r, on cou d t rn tiv y t nd th r dund nt con o tissu through
th uninvo v d v rmi ion bord r to th mucos ip. Ho v r, m ticu ous c r must b t n to r ign th v rmi ion bord r.
In this p ti nt, th u n ss improv d signi c nt y ith tim nd sh d c in d ny r visions. Sh so d v op d sm sutur
198 gr nu om t th squ r d of portion o th p th t r so v d ith r mov o th sutur nd intr sion n og.
 any elevation o adjacent tissue or the necessity o exeCUTION OF THe Hel ICa l a DVa NCe-
2
removing an additional dog-ear due to secondary MeNT Fl a P (w ITH POSTa URICUl a R SkIN
movement. INTa CT, Fig. 18-9)
1. Extend the helical de ect to the helical sulcus. Square
Hel Ic a l a d va n c emen t Fl a p o the margins o the wound to allow or optimal
reapproximation o the helical rim and to prevent
T e helical advancement ap is particularly use ul or notching.
repairing helical de ects involving the skin and cartilage o 2. Incise through anterior helical skin and, i necessary,
the mid-to-superior helix, and not occupying more than through cartilage in eriorly along the helical sulcus
30% o the helical circum erence. T e robust vascular rom the de ect to the lobule. Undermine along
supply to the posterior helix allows or long incisions to the postauricular sulcus to maintain the broad
be made along the helical sulcus and, i necessary, through postauricular vascular pedicle.
cartilage, leaving the postauricular helical skin intact with a. I the de ect is along the mid- or in erior portion
minimal risk o ap necrosis.2 Burow’s triangles can be o the helical rim, an incision can be made

C
h
excised rom the lobule and less requently the scapha to through and through the skin to create a thin

p
acilitate movement. A large postauricular standing cone helical pedicle.

t
is also excised. Compared to wedge repairs, the helical 3. o prevent helical rim notching, the epidermis along

r
1
advancement ap preserves the natural contour o the ear the helical rim should be hypereverted with vertical

8
and minimizes the reduction in its size. A less requently mattress sutures.

:
used technique involves making a ull-thickness incision 4. Redundant lobule skin

:
along the anterior and posterior aspects o the helical sul- a. Can be removed as a Burow’s triangle at the

R
cus. Although simpler to per orm, this design has a more lobule

n
d
precarious blood supply because o the narrow pedicle o b. Modi ication: A Z-plasty incision can be

o
m
the ap. In either design, to prevent a reduction in the made at the lobule to remove the redundancy

P
size o the lobule, rather than removing the Burow’s tri- without a reduction in the size o the lobule

t
t
angle, a Z-plasty modi cation can be used.3 (Fig. 18-10).

r
n
F
p
s
A B C

D E F G

Figure 18-9 H ic dv nc m nt p. A. Post Mohs d ct. B. D sign o th h ic dv nc m nt p ith incision m d

ong th h ic su cus through th d rmis nd c rti g , pr s rving th post rior cut n ous p dic b s . a Buro ’s
tri ng is cis d t th obu to ci it t mov m nt. a rg post uricu r st nding con is cis d. C, D. Fin ound
c osur . Not th incision in hid s ong th h ic su cus. V rtic m ttr ss sutur s r us d to c os th pid rmis
ong th h ic rim to pr v nt notching s rro . E, F. Sutur r mov t 10 d ys. G. Fin pp r nc t 3 months. 199
2 ap is prone to pin-cushioning due to wound contrac-
tion. When this occurs, it usually resolves with time,
massage, and intralesional corticosteroids. o reduce
the chance o trapdoor de ormity, the surrounding tissue
should be widely undermined to allow or the second-
ary motion o the skin to atten the ap. T e ap must
also be care ully sized and slightly inset which occurs
naturally due to the tension on the ap that occurs with
advancement. Buried vertical mattress sutures can be
help ul in bringing the pedicle below the level o the sur-
A rounding skin. Although undersizing the ap can mini-
mize trap-dooring, the ap should instead be sized to ll
the de ect when it is located near a ree margin. When
the primary movement o the ap is toward the de ect
along the ree margin, secondary movement in the oppo-
S
sition direction can produce anatomic distortion. Some
c
XZ
t
Z
i
X A A authors advocate squaring o the de ect rather than
o
n
B
B rounding o the tip o the ap, as an angulated ap may
2
Y WY
W create less pin-cushioning.4
:
:
Flap mobility is dependent on the vertical restraint o
B the pedicle as well as the skin laxity. O ten, the leading
S
u
edge (1–3 mm) and tapered tail (distal 1/3 o ap) must be
r
g
i
reed to remove any tethering restraints on the ap. When
c
Figure 18-10 Modi c tion to th h ic dv nc m nt
p. A. Incision m d through nd through th s in. mobilized properly, V-to-Y aps can traverse a much
S
B. Z p sty t th obu to pr v nt r duction in th siz greater distance than other types o advancement aps
i
o th obu .
s
that are hindered by their cutaneous attachments.

exeCUTION OF V-TO-Y Fl a P (Figs. 18-11

v -t o -Y Fl a p (Is l a n d nd 18-12)
ped Ic l e Fl a p, KIt e Fl a p) 1. Remove excess tissue rom the wound base to ensure
adequate depth to accommodate the ap
V-to-Y aps di er rom other advancement aps in that 2. Design a triangular ap adjacent to the de ect, with
they have no epidermal or dermal connection to the sur- the base o the triangle being the edge o the de ect.
rounding tissue. Rather, a triangular island o tissue is cre- T e height o the triangle should be roughly two
ated with a deep pedicle to the underlying subcutaneous to three times the width o the de ect and ap. T e
at and muscle. Due to their rich blood supply rom the tapered tail should be suf ciently long that, once
underlying vessels rather than the dermal plexus, V-to-Y the ap is advanced, closure o the secondary de ect
aps are less prone to ap necrosis than classic advance- will not cause ree margin or other anatomical
ment aps. T e classic island pedicle ap denotes a V-to-Y distortion. For example, when repairing an upper
ap harvested rom a particular arterial supply. lip de ect with a V-to-Y ap, be sure to extend the
V-to-Y aps may be a use ul reconstructive option apex o the triangle below the lateral commissure to
when excessive tension prevents side-to-side closure o minimize the risk o pulling the ree margin o the
the de ect and/or when volume restoration is required at lip upward. T e angle between the two limbs should
site o tissue loss. T e V-to-Y ap is also tissue-sparing and be about 30 degrees. Incise the two limbs through
eliminates the need or standing cone resection altogether. the epidermis and dermis to the subcutaneous plane.
wo-dimensionally, one o the cones in a linear closure is i. Modi cation: T e tapered tail can be gently curved
advanced into the surgical de ect. T e secondary de ect is to rest on the adjacent cosmetic junction line.
then repaired in a side-to-side ashion. T e triangular geo- 3. Undermine widely in the surrounding subcutaneous
metric shape o the repair may at times become conspicu- plane. Slightly undermine the leading edge and
ous. Because o this tendency, the V-to-Y ap is classically tapered tail o the ap to allow adequate mobility.
used or superior lip de ects, as one or more limbs o the 4. Undermine the ap itsel with blunt, vertical
ap can be hidden in existing cosmetic junction lines, undermining to liberate it along its muscular
namely the lip margin and nasolabial old. T e incisions pedicle. Elevate it and move it into the de ect. Free
should have an angle o approximately 30 degrees between any tethered subcutaneous restraints as needed to
them, to avoid standing cone removal, and the height o allow adequate movement.
the triangle should be roughly 2 to 3 times the width o the i. Modi cation: T e ap can be rotated on its
ap and de ect. Proper design, undermining, and impec- pedicle, with care, as much as 180 degrees be ore
cable suture placement are o utmost importance to mini- insetting.
mize a kite-shaped, unnatural scar. 5. Inset the ap with buried (vertical mattress) sutures.
V-to-Y aps are ideal or repairing deep de ects as they 6. rim excess tissue i needed to slightly undersize
have a thick base o subcutaneous and muscular tissue. the ap to minimize “pin-cushioning.” Consider
200 I oversized or i adjacent tissue is not undermined, this squaring o the de ect rather than rounding the tip.
 2
x

2–3x 30˚

A
A

C
h
p
t
r
1
8
:
:
R
n
d
o
m
P
t
t
r
n
B C D

F
p
s
Figure 18-11 A. V to Y dv nc m nt p.

7. Close the secondary de ect and approximate the minimal muscular base, making it ideal or large de ect
epidermal margins. closures on the lower extremity.5,6 Unlike primary clo-
sures that can cause undue tension to the wound and
depression in the scar, the Keystone ap tends to main-
KeYs t o n e Fl a p tain the natural convexity o the skin due to its thick
pedicle base and standing tissue cone avoidance. T e
A modi cation to the V-to-Y ap, the Keystone ascio- keystone ap is also superior to skin gra ting, which
cutaneous ap, is designed as a curvilinear trapezoidal tends to create atrophic and hypopigmented wounds
shape with a broader pedicle o subcutaneous at and a with poorer overall survival.

A B C

D E

Figure 18-12 V to Y dv nc m nt p. A. Tri ngu r p d sign ith incision m d through th pid rmis nd d rmis
to th subcut n ous p n . B. e v t th p by r ing ny v rtic r str ints to ib r t it ong its muscu r p dic .
S ight y und rmin th ding dg nd t p r d t i to m imiz mov m nt. C, D. Mov nd ins t th p into th d ct
ith buri d sutur s. E. Fin ound c osur . 201
2 exeCUTION OF keYSTONe Fl a P (Fig. 18-13) 3. Incise along the entire keystone ap through the
epidermis and dermis to the subcutaneous at.
1. o design the keystone ap (Fig. 18-13A, B) Dissect bluntly and vertically down to the ascia to
a. Draw a classic ellipse around the de ect. On the ree any tethered subcutaneous brous attachments,
extremities, the orientation o the two cones is care ully sparing any vascular bundles. Undermine
usually along the vertical axis o the limb (distal along the surrounding tissues on the opposing side
and proximal) o the de ect.
b. o create the keystone shape – draw parallel 4. Close the tip o the keystone rst to advance the ap
curvilinear lines adjacent to and usually into the primary de ect (Fig. 18-13D).
posterior to the ellipse, displaced rom the de ect 5. Place sutures as diagrammed to align the ap,
by a distance approximately that o the de ect ollowed by buried and then epidermal sutures
width. (A larger ap can be created i signi cant (Fig. 18-13E).
tension is anticipated). T e corners o the 6. Redundant tissue cones tend to be quite large or
keystone shape should be designed at an angle this ap and at the superior and in erior ends o
o 90 degrees. the ap are oriented almost perpendicular to the
S
2. Excise the elliptical shape around the de ect and direction o advancement and greatest tension.
c
t
i
remove excess tissue rom the wound base to extend Excising these cones helps to trans er ap tension
o
n
the depth through the subcutis. (Fig. 18-13C) and ensures good tissue contours (Fig. 18-13F).
2
:
:
S
u
r
g
i
c
S
i
s
x x

A B C

Excis e

Excis e

D E F

Figure 18-13 k yston F p. A, B. k yston sh p d sign ith th idth o th p ppro im t y th t o th d ct.

Th corn r o th yston sh p shou d b 90 d gr s. C. e cis th iptic sh p round th d ct nd incis ong
th yston p to th subcutis. Und rmin ong th surrounding tissu to mobi iz th p. D, E. C os th tip o th
yston rst to dv nc th p th n p c y sutur s to ign th p. F. e cis r dund nt tissu con s t th sup rior
202 nd in rior nds o th p. continued
 2

C
h
p
t
r
1
G

8
H

:
:
R
n
d
o
m
P
t
t
r
n
F
p
s
I J K

Figure 18-13 Continued G, H. Fin ound c osur . I. Sutur r mov t2 s. J, K. Fin pp r nc t 3 months. Not
r stor tion o th n tur contour o th c .

r o t a t Io n Fl a ps at the pivot point. Several actors a ect pivotal restraint:

inelasticity o the skin, as in scalp skin; poorly arced rota-
tions and broadly based aps, especially when the inci-
Rotation aps rotate along an arc rom the donor site to
sions are not long enough to provide adequate movement;
an adjacent recipient area around a pivot point. T ese
and highly arced rotations which shorten the e ective
broadly based aps have an ample blood supply and are
length o the ap. A ap that rotates 45 degrees results in a
ideally suited or locations with an abundant surrounding
5% reduction in length; a 90 degrees rotation creates a 15%
tissue reservoir that may be lacking in tissue laxity. T e
reduction in length (Fig. 18-14A). o minimize tip tension,
superior viability o these aps makes them particularly
the rotation arc design may need to be oversized and o -
use ul or repairing large de ects when tissue sparing is
set (Fig. 18-14B).7 Undermining deeply beneath the pivot
important, such as along the lateral cheek and scalp. T e
point relieves pivotal restraint and improves ap mobility,
curved incision lines hide well along naturally curvilinear
as does a backcut into the ap. Caution must be taken not
cosmetic boundaries, relaxed skin tension lines, and the
to compromise the vascular supply o the ap pedicle with
hairline.
either o these two maneuvers.
T ere are several disadvantages to a rotation ap. While
the tension vector is distributed along the curvilinear line
o the closure, the tension vector is greatest along the ap u n Il a t er a l r o t a t Io n Fl a p
tip. Signi cant tension placed at the tip may cause undesir-
able secondary motion, especially near a ree margin. T is Several general rules are help ul in the design o a rota-
is compounded by pivotal restraint, de ned as the inher- tion ap. First, the circular de ect can be converted to a
ent sti ness o the tissue that limits the ap’s movement triangular de ect with at least a 2:1 height to width ratio. 203
2 90° Rota tion
(15% re duction in le ngth)

45° Rota tion 135° Rota tion

(5% re duction in le ngth) (25% re duction in le ngth)
Tr
u e
a

rc
0° X
S
180° Rota tion
c
(40% re duction in le ngth)
t
i
o
A
n
2
:
:
S
u
r
g
i
c
S
i
s
B

Figure 18-14 A. Rot tion p d monstr ting pivot r str int. So id in d not s tru s micircu r
rc. D sh in d monstr t s th ctu p th o th rot tion p s it rot t s round th pivot point
“x”. a s th p rot t s into p c , its f ctiv ngth short ns. Th gr t r th rot tion, th short r
th p ngth. B. Th high st t nsion is ong th tip o th p. To r duc t nsion, p m yn d
to b ov rsiz d to comp ns t or its pr dict b short ning.

T is avoids the need to remove an additional standing which minimizes wound closure tension and secondary
cone at the base o the triangle. Next, the length o the motion (Fig. 18-15).8 Removal o the Burow’s triangle is
ap should be designed along natural skin tension lines. not limited to the tail o the arc; rather, it can be excised
A long- ap incision is usually required to maximize anywhere along the length o the ap that is cosmeti-
movement and minimize tension. T e ap length is gen- cally suitable. Redundant tissue can also be evened out by
erally at least our times the height o a triangular de ect applying the “rule o halves” (Fig. 18-16).
on the ace and at least six times the height o a de ect
on the scalp.
Narrow rotation aps with a more acute arc o rota- BIl a t er a l r o t a t Io n Fl a ps
tion have decreased pivotal restraint but a tendency or a n d o -t o -Z Fl a ps
wider secondary de ects and increased secondary tension.
Wider aps with a broader arc o rotation create more piv- Bilateral rotation aps are required when there is insu -
204 otal restraint but reduce the size o the secondary de ect, cient tissue reservoir and/or laxity or a unilateral ap.
 De cre a s e s e conda ry te ns ion
2

Broa d a rc P ivota l re s tra int

Le ngth ~4×
Incre a s e prima ry te ns ion

×
Incre a s e s e conda ry te ns ion

30°

C
2–3×

h
p
t
Na rrow a rc

r
1
8
:
:
P ivota l re s tra int
De cre a s e prima ry te ns ion

R
n
d
Figure 18-15 Th ro o rot tion rc d sign on pivot r str int nd s cond ry t nsion. a bro d rc o rot tion cr t s bro d r

o
b s d p ith incr s d pivot r str int hich r duc s prim ry mov m nt o th p. This r su t in sm r s cond ry d ct

m
nd d cr s d s cond ry t nsion. On th oth r h nd, mor cut rc o rot tion cr t s n rro b s d p ith r duc d

P
pivot r str int nd incr s d prim ry mov m nt, but r su ts in id r s cond ry d ct nd incr s d s cond ry t nsion.

t
t
r
n
F
p
Locations with limited skin mobility, such as the scalp, ap mobilizes redundant adjacent tissue along the lat-

s
o ten bene t rom utilizing bilateral tissue reservoirs. eral cheek and temple. o prevent ectropion, all tension
Bilateral rotation aps can be designed along one rota- at the de ect site is directed horizontally. Vertical tension
tion arc (classically along the mental crease, Fig. 18-17) or is prevented by creating a ap that arcs superolateral to
opposing arcs as in an O-to-Z rotation ap (o ten used on the lateral canthus and is anchored there to support the
the scalp, Figs. 18-18 and 18-19). lower lid. As the ap rotates into place, pivotal restraint
shortens it. Extending the curvilinear design superior to
mu s t a r d e r o t a t Io n Fl a p the lateral canthus prevents the shortening o the ap that
inevitably occurs due to pivotal restraint as it rotates into
Described speci cally or large mid-to-lateral cheek place (Fig. 18-20). T e ap should be elevated above the
and lower eyelid de ects, this laterally based rotation orbicularis oculi muscle medially and in the super cial

A A

A A

A
× S ta nding cone ca n be ta ke n
a nywhe re a long the le ngth of the a p

A 2–3×

A A

A A

Figure 18-16 Rot tion p d sign. R dund ncy c n b r mov d ith b c cut or st nding con ny h r ong th
ngth o th p. 205
2
S
Figure 18-17 Bi t r rot tion p d sign d ong on rot tion rc. Not th curvi in r d sign o th rot tion p
c
hid s nic y ong th m nt cr s .
t
i
o
n
2
subcutaneous at along the temple to prevent damage to 50% o the lower lid. A semicircular ap is designed at the
:
:
the temporal branch o the acial nerve. Patients should lateral canthus curving superolaterally to the temple (Fig.
S
u
be warned o the possibility o in raorbital edema or 18-21). o prevent ectropion, the ap should be designed
r
g
several weeks due to obstruction o the laterally draining with generous vertical height to support the lower lid. A
i
c
lymphatic channels. attened ap will likely pull the lid downward. A lateral
S
canthotomy and a lower cantholysis are usually required
i
exeCUTION OF THe MUSTa RDe Fl a P to slide the lateral portion o the lid medially and to
s
maximize the movement o the ap. T e canthotomy is
1. T e ap incision is made at the superior aspect
per ormed by creating a slightly superiorly directed hori-
o the de ect laterally along the lower eyelid.
zontal incision along the lateral canthal tendon down to
Beginning at the lateral canthus, this vector extends
its periosteal insertion at Whitnall’s tubercle. T e in erior
superolaterally toward the temple. T e incision then
cantholysis is then achieved by severing the lower crus o
curves downward laterally just in ront o the hairline
the tendon. Finally, it is important to anchor the ap along
and ear.
the periosteum o the lateral orbital rim to recreate the
2. T e ap is elevated just above the orbicularis oculi
lateral canthus.
muscle medially and in the subcutaneous and supra-
SMAS zone everywhere else.
3. I a large cheek and temple rotation ap is required, med Ia l l Y Ba s ed r o t a t Io n Fl a ps
a periosteal suspension suture placed along
the lateral orbital rim may be use ul to prevent In eromedially based aps recruit tissue rom the lower
ectropion. cheek and nasolabial old and are help ul or repairing
smaller de ects along the medial lower lid and nasal side-
wall. T e arc o rotation is drawn in erior to the de ect
t en Zel s emIc Ir c u l a r r o t a t Io n Fl a p along the nasal sidewall and in erior cheek, starting
rom the in eromedial aspect o the de ect and ending in
Similar to the Mustarde ap, the enzel ap rotates adja- the nasolabial old. Once undermined in the subcutane-
cent temporal skin to ll de ects on the lower eyelid mar- ous plane and elevated, the ap is “hung” at the supero-
gin. It is most use ul when a de ect spans approximately medial aspect o the de ect, o ten suspended rom nasal

A
A
B
B A
A
B

206 Figure 18-18 Bi t r rot tion p O to Z p sty d sign d on opposing rot tion rcs.
 2

A B C

C
h
p
t
r
1
8
D E F

:
:
Figure 18-19 Bi t r rot tion p O to Z p sty or rg d ct on th sc p. A. Post Mohs d ct. B. Th in sticity

R
o th sc p s in n c ssit t s rg bro d y b s d rot tion p d sign. Signi c nt und rmining is r quir d to mobi iz

n
d
th p. C, D, E. Fin ound c osur . F. Fin pp r nc t 3 month o o up.

o
m
P
t
t
r
n
F
p
s
A B

C D E

Figure 18-20 A. l t r y b s d ch rot tion p Must rd p . Th prim ry mov m nt is dir ct d horizont y. a

curvi in r d sign sup rior to th t r c nthus supports th o r id. B. Post Mohs d ct. C. Fin ound c osur . a
sm s in gr t s p c d m di y to r duc t nsion to th p. D. Sutur r mov t 1 . E. Fin pp r nc t 1
month ith minim r sidu in r orbit d m . Th r is minor bbing to th m di c nthus hich r so v d ith tim
nd m ss g . Occ sion y Z p sty m y b r quir d to corr ct mor t nsiv m di c nth bbing. 207
2

A B
S
c
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2
:
:
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g
i
c
S
i
s
C D

E F G

H I J

Figure 18-21 T nz s micircu r rot tion p. A. Post Mohs d ct on th o r y id m rgin. B. l t r c nthotomy to

m imiz mov m nt o th p. C. a s micircu r incision is m d rom th t r c nthus, curving sup ro t r y to th
t mp . Und rmin id y to th d pth o th sup r ci t mpor is sci , c r u not to d m g th t mpor br nch
o th ci n rv . D. R mov th r dund nt con o tissu ong th o r id. E. C osur o th prim ry d ct ong th
o r id. Using 6 0 si sutur , th id m rgin shou d b r ppro im t d in v rtic m ttr ss shion to v rt th dg s.
F. C osur o th s cond ry d ct ong th t mp . G. Fin ound c osur . Th sutur ong th id m rgin shou d b
t ong nd t p d do n ith st ri strips to void cont ct ith th corn . H. Sutur r mov t 1 . Th r is s ight id
notching not d. I, J. On month o o up ith r so ution o th id notching. No ctropion is not d ith th “Y n t st”
– s th p ti nt to op n his mouth nd oo up.

208
or in raorbital periosteum. A redundant cone o tissue
is created and removed along the lower eyelid crease
his/her mouth and eyes and look upward (the “Yawn
test”). Vertical tension on the lower eyelid necessitates
2
lateral to the de ect. (Fig. 18-22A) Because the primary replacement o the suspension suture. A crescentic
tension vector is directed vertically, the key stitch in this modi cation o this ap places the incision line along
ap is a tacking or suspension suture which is critical to the melolabial old and naso acial sulcus, avoiding the
prevent ectropion.9 Evaluation or ectropion should be need to remove a standing cone on the in erior cheek
per ormed during the repair by having the patient open (Fig. 18-22B).10

C
h
p
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r
1
8
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n
d
o
m
P
t
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r
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F
p
s
A

Figure 18-22 M di y b s d ch rot tion p or short but id d cts. a s th prim ry

t nsion is v rtic y ori nt d, t c ing sutur to th intr orbit p riost um is o t n r quir d
to pr v nt ctropion. A. C ssic d sign. B. Cr sc ntic modi c tion to hid incision ong th
n so bi o d nd void r mov o r dund nt con . continued 209
2

C D E
S
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2
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F G H

Figure 18-22 Continued C. Post Mohs surgic d ct. D. Pr op r tiv d sign o o ing Mohs surg ry. E, F. Fin ound
c osur . G, H. Sutur r mov t 1 . Not th m jority o th incision in hid s ong th n so bi o d nd o r
id cr s .

rim to avoid tip elevation due to ap shortening with rota-

n a s a l s pIr a l Fl a p tion. However, some authors have reported good success
repairing a ull-thickness alar de ect with the use o this
For small de ects on the mid ala, a spiral ap designed ap.13 T e dorsal nasal ap is designed along the entire
along the alar groove allows closure o small de ects nasal dorsum/sidewall extending to the glabella. A backcut
involving no more than 50% o the anterior ala with per- along the glabella results in a V-to-Y advancement, allow-
ectly matched skin. T is ap prevents distortion o the ing the ap to drop in eriorly. T e ap should be thinned
alar rim and hides the incision along the lateral alar crease aggressively where it attaches to the thinner medial can-
(Fig. 18-23). As its name implies, the ap rotates (spirals) thus to avoid mismatch to the ap’s thicker glabellar skin.
upon itsel at the tip to ll the de ect.11 Some authors pre er the use o a Z-plasty at the glabella
Similarly, a superiorly based spiral ap along the in ero- because it helps to maintain interbrow distance while still
lateral nasal dorsum just above the alar crease is use ul or allowing or ap movement in eriorly (Fig. 18-25). Even
small- to medium-sized de ects along the nasal ala and with the use o a backcut, slight nasal tip elevation with
alar groove (Fig. 18-24).12 T is ap prevents blunting o this ap is common. Undermining is carried out at the
the natural concavity o the alar groove and convexity o level o the perichondrium and periosteum, making this
the ala. By rotating the tip o the ap upon itsel , the con- a robust ap with abundant per usion rom the underly-
tour o the alar groove is recreated. ing nasal musculature. T e key advantages o the dorsal
nasal ap are that it is a single stage procedure and that it
d o r s a l n a s a l r o t a t Io n Fl a p uses adjacent skin with good color, texture, and thickness
match. T e scar is usually well hidden along the glabella,
(r eIGer /Ha t c He t Fl a p) naso acial sulcus and alar crease.
T e dorsal nasal rotation ap is a modi ed rotation ap
that takes advantage o the robust reservoir o tissue in the
exeCUTION OF THe DORSa l Na Sa l ROTa -
glabellar area. T is ap is best used or nasal de ects less
TION Fl a P (Figur 18-25)
than 2.5 cm in width on the lower 2/3 o the nose, and can 1. Design a ap based ipsilateral to the de ect to
be contemplated when a de ect on the distal third o the maximize ap rotation. Draw a curvilinear line
nose is too large or a bilobed ap and too small to warrant rom the in erior edge o the de ect laterally to the
an interpolation ap. Ideally, the de ect should be midline naso acial sulcus, extending upward to a point
210 or paramedian and several millimeters away rom the alar at least 5 mm medial to the medial canthus and
 2

B
A

C
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1
8
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R
C D E

n
d
o
Figure 18-23 Spir p o th nos . A. a b s d spir p or sm d cts on th . Th incision hid s ong

m
th r cr s . B. Mohs d ct. C. Fin ound c osur . D. On sutur r mov . E. On month o o up.

P
Th r is mi d hyp rtrophic sc rring pr s nt th t r so v d on its o n ov r tim . Occ sion y, d rm br sion or

t
t
s r r sur cing m y b r quir d to smooth out th sc r.

r
n
F
p
into the glabellar crease. A backcut toward the the tension vector or closure into a more desirable loca-

s
contralateral medial canthus will improve ap tion within the secondary de ect. Closure o the secondary
mobility while hiding the scar in the glabellar crease. de ect e ectively pushes the ap into the primary de ect,
2. T e ap should be elevated in a submuscular plane leaving it relatively tension ree. T us, the main advantage
above the periosteum and perichondrium on the o a transposition ap is displacement o the tension vec-
nose to ensure a robust vascular supply. However, tor to a more acceptable location with mobilization o a
in the glabellar region, the ap should be harvested noncontiguous adjacent skin reservoir or closure. Due to
above the muscle and should include only skin, their geometric design, transposition aps create multidi-
subcutaneous at and a minimum o muscle. Further rectional scars that may be less noticeable than the longer
thinning o the ap may be necessary to prevent lines o rotation and advancement aps. However, trans-
discrepancies in skin thickness, especially i the thick position aps are more likely to produce a trap door de or-
glabellar skin trans ers to the medial canthal area. mity. T is can be minimized with wide undermining o the
3. T e ap is broadly undermined across the entire de ect and surrounding skin to create counterbalancing
nasal dorsum to the contralateral side prior to contractile orces that can help to atten the ap.
insetting. T e surrounding tissue is also undermined Several important points should be considered when
to allow or secondary movement, especially at designing a transposition ap. First, these are pivotal aps,
the nasal sidewall and the de ect site. Minimal much like rotation aps, and one must there ore keep in
undermining occurs over the alar rim. mind the decrease in e ective ap length that occurs with
4. T e donor site in the glabella should be closed rst greater tissue movement. Lengthening o the ap may be
by V-to-Y advancement or Z-plasty. T is will allow required to account or this pivotal restraint. At the same
the ap to drop in eriorly into the de ect. time, one must avoid insetting oversized or bulky aps,
5. Re-drape the ap and anchor it into place with deep which are prone to pin-cushioning. T e ap pedicle should
sutures, making certain that there is no asymmetry ideally be oriented in an in erior direction to improve
or distortion o the nasal tip. T erea ter, inset the lymphatic drainage and reduce edema. Furthermore, the
rest o the ap with buried sutures ollowed by secondary de ect should be closed rst to reduce direct
epidermal sutures. tension on the ap, to minimize ree margin distortion,
and to allow the ap to be pushed into the primary de ect.

t r a n s po s It Io n Fl a ps
r Ho mBIc Fl a p
ransposition aps utilize a tissue reservoir adjacent to
but not contiguous with the primary de ect. By de ni- T e classic Limberg rhombic ap redirects the tension
tion, the ap is li ted or transposed over a segment o vector by 90 degrees and creates a secondary de ect per-
intervening normal skin, and redirects and redistributes pendicular to the primary de ect. Several variations o 211
2
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A
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A B
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C D

Figure 18-24 Sup rior y b s d spir p ong th t r n s dorsum or d cts invo ving th
nd r groov . A, B. D sign o th spir p. a t rn tiv s inc uding bi ob d p r consid r d but
u tim t y spir p s chos n. C. Fin ound c osur . D. Sutur r mov 1 .

rhombic aps have been described, including the Du our- lateral canthi. Large de ects along the cheek and jawline
mental and Webster aps. T e classic Limberg ap starts can also be repaired with rhombic aps (Fig. 18-27).
with a rhombus-shaped de ect with opposing tips at 60
degrees and 120 degrees. T e ap is designed by extend-
ing a line rom the short axis o the rhombus at a length mo d IFIc a t Io n s t o
o equal distance to the short axis. A second line is then t He r Ho mBIc Fl a p
drawn parallel to the side o the rhombus, creating a ap
with a 60 degree tip. Closure o the secondary de ect o Pivotal restraint limits movement o a rhombic ap and
the ap redirects the tension vector 90 degrees rom the may create undue tip tension (Fig. 18-28A). T is can be
primary de ect. With any rhombic ap, our possible ap overcome by lengthening the leading edge o the ap to
designs can be created along the short axis (Fig. 18-26). compensate or pivotal shortening (Fig. 18-28B). Alterna-
T e optimal ap design must take into account the local tively, reducing the rotational arc o the ap also reduces
tissue reservoirs, ree margins, and relaxed skin tension pivotal restraint. T e Du ourmental modi cation is
lines. T ese aps are versatile and can be used in repairing designed by bisecting the angle between the extension o
212 de ects along the nasal sidewalls, temple, and medial and the short axis and the side o the de ect to create the rst
 2
30–45°

0.5 cm me dia l
to ca nthus

A B C

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8
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d
G

o
D E F H

m
P
Figure 18-25 Dors n s rot tion R ig r/h tch t p. A. Sch m tic dr ing. Dott d in d not s option Z p sty

t
t
t th g b . B. Post Mohs d ct. C. D sign o th dors n s p ith incision m d rom th in rior dg o th

r
d ct t r y to th n so ci su cus, t nding up rd ong th n so ci su cus to th g b . a b c cut ong

n
F
th g b o s th p to drop in rior y. D. e v tion o th p in submuscu r p n bov th p riost um nd
p richondrium on th nos . E. Fin ound c osur . F. Sutur r mov 1 . G, H. Fin r su t t 1 month. Th r is minor

p
s
hyp rtrophic sc r pr s nt by th m di c nthus th t r so v d on its o n ov r tim . Occ sion y, d rm br sion or s r
r sur cing m y b r quir d to smooth out th sc r.

Te ns ion ve ctor if re cons tructe d limb o the ap (Fig. 18-28C). T e second limb is then cre-
a s prima ry clos ure
ated parallel to the long axis o the rhombus. By reduc-
B
ing the arc o rotation, the ap more easily transposes into
place with less tip tension (Fig. 18-29). However, the ten-
sion vector is no longer redirected at 90 degrees, rather
more tension must be shared between the primary and
A secondary de ect. Z-plasties can be used at the base o
A B
the rhombic ap to acilitate movement and closure o the
60°
secondary de ect (Figs. 18-30 and 18-31).
Te ns ion ve ctor re dire cte d by 90°
with rhombic clos ure

n o t e Fl a p
B

A modi cation to the rhombic ap, the note ap resembles

B the design o an eighth note. A tangential line is drawn rom
A A the primary de ect with length 1.5 times the diameter o the
de ect. A second line is drawn at a 60 degree angle with a
1 s t s titch he re to length equal to the diameter o the de ect (Fig. 18-32).
clos e s e conda ry
de fe ct

Tips :
BIl o Bed Fl a p
x • De s ign fla p off the s hort a xis
of the de fe ct Most commonly used or de ects on the distal anterior
x x • All s ide s of the tria ngle a nd
pa ra lle logra m s hould be nose, the bilobed ap utilizes adjacent skin laxity at the
120° 60° e qua l in le ngth nasal sidewall and dorsum. It works well or de ects less
than 1.5 cm along the distal nasal sidewall, medial ala and
nasal tip. It is also use ul or larger de ects on the lateral
cheeks, temples, chin and submandibular area. T e stan-
Figure 18-26 C ssic l imb rg rhombic p. dard bilobed ap rotates along a 180 degree arc, while 213
2

A B
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s
Figure 18-27 C ssic rhombic p on th n s dorsum nd t r ch .

Te ns ion
ve ctors

60°

60°

Figure 18-28 Modi c tions to th rhombic p to comp ns t or pivot r str ints. A. C ssic y d sign d p cr t s
pivot r str int nd cr ting tip t nsion. B. l ngth ning th p comp ns t s or p short ning. C. Du ourm nt modi
214 c tion r duc s th rc o rot tion nd tip t nsion, but ch ng s th t nsion v ctor s .
 2

A B C D

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8
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R
F G

n
d
Figure 18-29 T o mp s o Du ourm nt modi c tion to th rhombic p. A, E. Post Mohs d ct. B, F. Fin ound

o
m
c osur . C nd G. Sutur r mov t 1 . D, H. On month o o up.

P
t
t
r
n
the Zitelli modi cation only rotates along a 90 degree T e bilobed ap can be thought o as a double transpo-

F
arc, which places the ap under less tension. (Fig. 18-33) sition ap, which allows the surgeon to borrow tissue rom

p
s
T e advantages o the Zitelli modi cation include reduc- the loose skin o the proximal nasal dorsum and trans er
tion o pivotal restraint on the ap and incorporation o it to the less mobile nasal tip. T e ap’s primary lobe is
the Burow’s triangle into the ap design. T e bilobed ap transposed to cover the primary surgical de ect. T is in
o ers signi cant advantages over other closures because it turn creates a secondary de ect, which is covered by the
is a single-stage ap with per ect skin match and predict- secondary lobe. T e tertiary de ect is closed primarily. By
able viability. Proper design is critical, as small alterations closing the tertiary lobe rst, the ap is e ectively mobi-
in design can result in signi cant asymmetry and distor- lized and rotated into place. Each lobe is designed at an
tion o the nose. Meticulous suture technique is essential, approximately 45 degree angle o rotation.
as the curved incision lines do not always hide well within Several important tips can reduce asymmetry o the
the sebaceous skin o the nose. nasal ala and tip when the bilobed ap is per ormed. Slight

Te ns ion
ve ctor

60°

60°
90°
60°
60°
90°

Figure 18-30 Z p sty to th rhombic p to ci it t mov m nt o th p nd c osur o th s cond ry d ct. 215

2

A B
S
c
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2
:
:
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g
i
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C D E
S
i
Figure 18-31 a rg d ct r p ir d ith tr nsposition p. This r p ir c n b conc ptu y r g rd d s rhombic
s
p ith t o Z p sty or tri ob d p. Z p sty t th b s o th p ci it t mov m nt nd c osur o th s cond ry
d ct. A. Post Mohs d ct. B. Incision o th p. C. Und rmining in th subcut n ous p n . D. Fin ound c osur .
E. Sutur r mov t 2 s.

tip depression and alar displacement can o ten occur on de ect. Care ul thinning o the in erior edge o the primary
the ipsilateral side o the ap due to minor lengthening lobe reduces bulkiness o the ap and the tendency or the
o the ap in a Z-plasty type manner as it is transposed ala to be pushed downward. T e Burow’s triangle should
into place. T is “bulldozing” depression e ect is more there ore be angled superiorly, to place it in less sebaceous
apparent when dealing with thicker sebaceous skin and tissue. A more horizontally placed Burow’s triangle will
only occurs when the ap is oversized with respect to the exaggerate the Z-plasty e ect o the bilobed ap.14

x
1.5x
60°
x

B C D

216 Figure 18-32 Not p. A. F p d sign. B. Post Mohs d ct. C. Fin ound c osur . D. On month o o up.
 B 1s t s titch he re to
the secondary lobe should be 80% to 85% o the primary
lobe.15 On thick sebaceous skin, however, the size ratio
2
clos e te rtia ry de fe ct
o the lobes should be closer to 1:1. T e length o each
B B B B
B A lobe should also equal the length o the de ect, especially
A A
in sebaceous or less elastic skin. As the ap rotates and
P ivota l re s tra int
A A transposes into place, pivotal restraint will result in minor
A shortening o the e ective ap length. At the same time,
care must be made to not oversize the lobes as this can
result in trap-door de ormity.
1s t s titch he re
Proper placement o the secondary lobe is also critical in
reducing asymmetry. When possible, the axis o second lobe
90° should be oriented perpendicular to the alar rim. As the pri-
mary tension vector o the ap is along the tertiary de ect,
a closure oriented perpendicularly will result in the small-
est amount o alar distortion.16 I the second lobe cannot be

C
h
Figure 18-33 Bi ob d p. A. Tr dition 180 d gr placed along the perpendicular axis, a trilobed ap can be

p
bi ob d p ith signi c nt pivot r str int. B. Zit i 90 created to place a tertiary lobe along the vertical axis.17

t
r
d gr modi c tion.

1
exeCUTION OF THe BIl OBeD Fl a P (Figs.

8
18 34 nd 18-35)
On the other hand, the alar margin can be displaced

:
:
superiorly i the primary ap is undersized and does 1. Design o the ap

R
not adequately cover the de ect, resulting in secondary a. Place the Burow’s triangle at the base o the

n
d
upward motion. In general, the width o the primary lobe primary lobe. It should be angled superiorly and

o
m
should be 90% to 100% o the primary de ect diameter and placed along the alar crease.

P
t
t
r
n
F
p
s
A B C

D E F

Figure 18-34 Bi ob d p. A. Post Mohs d ct. B. Und rmining in submuscu r p n bov th p riost um nd
p richondrium. C, D. Fin ound c osur . E, F. a pp r nc t 3 months. 217
2
S
c
t
i
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2
:
:
S
u
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c
S
i
s
Figure 18-35 Bi ob d p. A. Post Mohs d ct. B, C. Fin ound c osur . D, E. a pp r nc t 3 months.

b. Determine the placement o the second lobe. 2. Sharply incise the ap at a 90 degree angle down to
In most cases, it should be 90 degrees rom the submuscular plane below the nasalis muscle.
the de ect and oriented perpendicular to the 3. Undermine widely in a submuscular plane above
alar margin to prevent alar distortion. Draw the periosteum and perichondrium on the nose to
a line rom the tip o the Burow’s triangle to ensure a robust vascular supply.
the center o the de ect. Draw a second line to 4. Remove the Burow’s triangle prior to placement o
the center o the proposed second lobe. Draw the ap to reduce pivotal restraint.
a third line to bisect the two lines. T e classic 5. Close the tertiary de ect rst to allow the ap to
Zitelli bilobed ap should create angles at drop in eriorly into the de ect.
approximately 45 degrees and 90 degrees. I the 6. While securing the ap in place, ensure that there
angles are signi cantly wider than this, consider is no asymmetry or distortion o the nasal tip. Inset
changing the placement o the Burow’s triangle the ap with buried vertical mattress sutures and
or the second lobe, or consider the use o a approximate the epidermal margins.
trilobed ap.
c. Measure the distance rom the tip o the Burow’s
triangle to the center o the wound and the tip Ba n n er Fl a p
o the de ect. Mark these distances along the
45 degree and 90 degree lines, then draw two As its name implies, the banner ap is a long, thin triangle
parallel arcs based on these points. T ese arcs (“banner”) shaped ap (Figs. 18-36 and 18-37). Its width
represent the tip and originating points o the is equal to the width o the de ect and its length is equal
lobes. T is ensures that the lengths o the lobes to the distance rom the pivot point to the length o the
are equal to that o the de ect. de ect. T e nasolabial transposition ap is a type o ban-
d. Measure the width o the de ect and design the ner ap utilizing redundant skin along the nasolabial old
primary lobe to be 90% to 100% o this width. or de ects along the nasal sidewall and ala. Although this
T e secondary lobe should be 80% to 85% o the is a one-stage ap with a good skin texture match, it o ten
primary lobe. On more sebaceous skin, the ratio blunts the sidewall and alar subunits. Banner aps rom
o the lobe to the de ect should be close to 1:1. the pre- or postauricular area are use ul or closure o
218 e. Extend the second lobe into a triangular shape. de ects on the superior helical rim.
 P ivot c o n c l u s Io n
2
point
When properly designed and executed, random pattern
x x aps are an ideal reconstructive option or a wide variety
o de ects. An understanding o the anatomy, blood supply,
y y
and tissue quality surrounding the de ect will aid the sur-
geon in weighing the possible reconstructive options. It is
P ivot important to be thought ul and consider all options rom
point simple closure to complex aps, as there is o ten more
than one reconstructive alternative or any one de ect. It
x is also critical to remember that the main principles o
x
y reconstructive surgery must be obeyed or a success ul
y aesthetic and unctional repair, including avoiding distor-
tion o anatomic landmarks and ree margins, maintain-

C
ing shape and symmetry, respecting cosmetic boundaries,

h
Figure 18-36 B nn r p d sign. Th idth o th p hiding incisions along skin tension lines, repairing de ects

p
t
shou d b qu to th idth o th d ct. Th ngth with skin o similar characteristics and minimizing tissue

r
o th p shou d b t st th dist nc rom th tip o trauma. It is up to the surgeon to design and execute the

1
8
pivot point to th tip o th d ct.
closure that will provide the patient with the best possible
aesthetic and unctional outcome.

:
:
R
n
d
o
m
P
t
t
r
n
F
p
s
A
B

C D

Figure 18-37 M o bi tr nsposition p is on mp o b nn r p. A. D sign o th p or d ct invo ving

th nd n s sid . a t rn tiv s inc uding bi ob d p r consid r d but u tim t y m o bi p s
chos n. B. Fin ound c osur . C, D. Sutur r mov 1 . Th n so bi incision in is imp rc ptib , but th r is
oss o th r groov hich is common ith this p. Th r is so u n ss o th t n s sid sup rior to th r
groov . This tr pdoor f ct is not uncommon in tr nsposition ps on th nos . In som c s s, th pin cushioning m y
r gr ss ith tim , nd m ss g m y h p r so v cong stion rom ymph tic nd v nous obstruction. Dir ct inj ction
o intr sion corticost roid usu y tri mcino on c tonid 10–20 mg/cc v ry 4–6 s m y so t n contr ctur
o th sc r nd improv th tr p door f ct. Occ sion y, p rsist nt d ormity m y r quir surgic corr ction to thin
th p. 219
2 r eFer en c es
9. Honda K, Reichel J, Odland P. Anchored rotation ap or in ra-
orbital cheek reconstruction. Dermatol Surg. 2007;33:516–520.
10. Hussain W, an E, Salmon PJM. In eriorly based crescentic
1. Moody BR, Sengelmann RD. Standing cone avoidance via sliding cheek aps or the reconstruction o paranasal surgical
advancement ap modi cation. Dermatol Surg. 2002;28: de ects. Dermatol Surg. 2012;38:249– 255.
632–635. 11. Humphreys R. Use o the “spiral” Flap or closure o small
2. Kau mann AJ. Helical rim advancement aps or reconstruc- de ects o the nasal ala. Dermatol Surg. 2001;27:409– 410.
tion. Dermatol Surg. 2008;34:1229– 1232. 12. Mahlberg MJ, Leach BC, Cook J. T e spiral ap or nasal alar
3. Saleh DB, an J, Mohammed P, Majumder S. T e lobular reconstruction: our experience with 63 patients. Dermatol
transposition ap: a use ul adjunct to reconstruct helical Surg. 2012;38:373– 380.
de ects. J Pla st Reconstr Aesth Surg. 2012;65:963– 965. 13. Wentzell JM. Dorsal nasal ap or reconstruction o ull-
4. Braun M. T e island pedicle ap. Dermatol Surg. 2005;31: thickness de ects o the nose. Dermatol Surg. 2010;36:1171–1178.
995– 1005. 14. Cook JL. Reconstructive utility o the bilobed ap: lessons rom
5. Behan F. T e Keystone design per orator island ap in recon- ap successes and ailures. Dermatol Surg. 2005; 31:1024–1033.
structive surgery. ANZ J Surg. 2003;73:112– 120. 15. Moy RL, Gross eld JS, Baum M, Rivlin D, Eremia S. Recon-
6. Hu M, Bordeaux JS. T e Keystone ap or lower extremity struction o the nose utilizing a bilobed ap. Int J Dermatol.
de ects. Dermatol Surg. 2012;38:490– 493. 1994;33:657– 660.
S
7. Goldman GD. Rotation aps. Dermatol Surg. 2005;31: 16. Cook JL. A review o the bilobed ap’s design with particular
emphasis on the minimization o alar displacement. Derma-
c
1006–1013.
t
i
8. Buckingham ED, Quinn FB, Calhoun KH. Optimal design tol Surg. 2000;26:354– 362.
o
n
o O-to-Z aps or closure o acial skin de ects. Arch Facial 17. Albertini JG, Hansen JP. rilobed ap reconstruction or dis-
2
Pla st Surg. 2003;5:92– 95. tal nasal skin de ects. Dermatol Surg. 2010;36:1726– 1735.
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220
 Ch a p t e r Axial Pattern and

19 Interpolation Flaps
C s p J. M ll , J s p F. S ba k , & J G. Alb

In t r o d u c t Io n c Ar t Il Ag In o u s f r Ame w o r k
o f t he no se
Facial symmetry correlates highly with acial attractive-
ness.1 T e symmetry o midline structures has the great- Cartilage orms the nasal skeleton external to the pyri orm
est impact on perception o beauty.2 As the nose occupies aperture. T e nasal cartilages determine nasal projection
the most central location on the ace, its complex, sym- and support the airways. In contrast to the immobile bony
metrical contours play a key role in how we perceive other skeleton, the exible cartilaginous ramework is vulnera-
people’s aces. Observers normally ocus their gaze on the ble to distortion and compression, which can alter appear-
central triangle o the eyes, nose, and mouth.3 Asymmet- ance and impair breathing. T e external nasal ramework
ric noses are perceived as less attractive, de ormed noses consists o three primary structures: (1) the septal car-
attract excessive attention,1,3 and even small nasal lesions tilage; (2) the paired upper lateral cartilages; and (3) the
are considered dis guring, bothersome, and important to paired lower lateral cartilages. T e septal and paired upper
repair.4 When local aps are insu cient or coverage o a lateral cartilages are anchored to bone and there ore pro-
complex nasal de ect, the surgeon may need to consider vide more resistance to compression.
staged repair with a orehead or cheek interpolation ap. T e quadrilaterally shaped septal cartilage is rigid and
Similarly, the ear may require a postauricular interpolation at, gaining stability through its articulations with the
ap (PIF) to repair a larger de ect in an aesthetic ashion. ethmoid bone, vomer, maxilla, and nasal bone. Its caudal
Staged interpolation aps present unique technical chal- margin slopes rom the anterior nasal spine to the anterior
lenges. T is chapter will discuss the planning and execution septal angle, which is palpable at the supratip superior to the
o : (1) the paramedian orehead ap or nasal reconstruc- alar cartilage domes. T e septal cartilage determines nasal
tion; (2) the melolabial interpolation ap (MIF) or alar projection and rotation, separates the two nasal cavities,
reconstruction; and (3) the retroauricular interpolation ap and orms the medial boundary o the internal and external
or ear reconstruction. nasal valves. Surgical removal or compression o its distal
aspect alters nasal projection. Septal deviation can compro-
mise breathing by decreasing the size o the nasal valves.
An At o my o f T e paired upper lateral cartilages support the lateral
nasal sidewall and are relatively stable, due to articulation
t h e ex t er n Al n o s e with the septum medially, attachment to the nasal bone’s
undersur ace superiorly, and attachment to the pyri orm
T e nose has subtle convexities and concavities resulting aperture laterally. T e upper lateral cartilage’s caudal
rom the complex anatomy o the bone, cartilage, and so t aspect orms the lateral border o the internal nasal valve,
tissue. T e surgeon’s task is to recreate or simulate the nor- and attaches to the superior aspect o the lower lateral car-
mal anatomy, restore the complex nasal topography and tilages in a region termed the “scroll.”
maintain airway patency. T is section will ocus on those T e lower lateral cartilages, or alar cartilages, provide
aspects o external nasal anatomy essential to planning structure to the nasal tip, contribute to its projection, and
and executing the paramedian orehead ap and the MIF. support the external nasal valve. T ey are subdivided into
the medial, intermediate, and lateral crura. T e medial
crus stabilizes the ala and in uences columellar appear-
Bo n y f r Amew o r k o f t h e n o s e ance and projection. T e intermediate crus orms the alar
dome and de nes anterior tip projection. T e lateral crus
T e pyri orm aperture demarcates the boundary between projects laterally and provides support to the alar lobule
the external and internal nasal cavities. It provides a stable and external nasal valve.
rame or the cartilaginous ramework o the nose and T e alar cartilages are vulnerable to compression. Unlike
anchors most o the muscles o acial expression. T e the central septal and paired upper lateral cartilages, they
paired nasal bones orm the superior border o the pyri- do not articulate directly with bone, but derive their sup-
orm aperture, merging in the midline and projecting out- port rom attachments to the septal and upper lateral
ward as the nasal dorsum. T e maxilla orms the lateral cartilages, each other, and the pyri orm aperture.5 T e oot-
and in erior borders o the pyri orm aperture. T e ante- plate o the medial crus attaches to the septal cartilage. Its
rior nasal spine at the maxillary midline orms the most cephalic portion attaches to the upper lateral cartilages at
prominent in erior bony projection o the nose. the scroll. T e interdomal ligament links the lower lateral
2 cartilages at the midline. T e lateral crus attaches to the
pyri orm aperture by the sesamoid complex ligament.5,6
tip, and dorsal nasal ridges. T e dorsum and sidewalls have
planar sur aces. Scars placed in the shadows o concavities
T e upper and lower lateral cartilages gain strength rom or re ections at the peaks o the convexities are requently
the pyri orm ligament, which extends rom the maxillary inconspicuous, but preserving nasal contour is even more
periosteum to the anterior nasal spine, and provides ur- important in optimizing the aesthetic result.13
ther stability to the nasal tip.6 T e nasal skin has varying textures and thickness, which
also contribute to its topography. T e dorsum and sidewalls
have a thin dermis and ew sebaceous glands. T e midline
s o f t t Is s u e An At o my o f t h e n o s e dorsum has a scant layer o at over the transverse nasalis
aponeurosis. On the sidewall, a subcutaneous at layer adds
T e so t tissue o the external nose supports the underly- volume over the transverse nasalis muscle. T e tip and alae
ing cartilage and adds to the subtle nasal sur ace contours. have a thick dermis and dense sebaceous glands. T e nasal
Except at the alar lobule, there are ve distinct nasal so t root has a thick dermis, dense sebaceous glands, and a layer
tissue layers: the skin, subcutaneous at, super cial mus- o at over the procerus. T e dermal thickness and pilose-
culoaponeurotic system (SMAS), deep areolar layer, and baceous unit density are greater on the nose than in other
S
perichondrial or periosteal layer.7 T e SMAS is composed acial areas, but the paramedian orehead and nasolabial
c
o the nasal muscles and ascia and is continuous with the olds are similar in color, thickness, and texture.14
acial SMAS.7 Sharp dissection reveals the connection o
2
the SMAS to the skin and cartilage, adhesions that add
t h e ex t er n Al An d In t er n Al
:
stability to the nasal ramework and provide support to
:
the skin, and help to preserve airway patency. Excluding n As Al VAl Ves
S
u
the alar groove and lobule, subcutaneous dissection easily
g
separates the skin rom the underlying SMAS. T e anatomic eatures o the nose help to serve its primary
c
a
At the alar groove and lobule, the SMAS inserts into the unction: regulating air ow. Eighty- ve percent o adults
l
S
pre erentially breathe through the nose, except when exer-
k
dermis without a distinct subcutaneous layer. T is con-
l
cising or speaking.15 T e external and internal nasal valves
l
nection between the muscle and dermis provides support
s
to the external nasal valve; sharp dissection is necessary to are critical regulators o air ow and resistance, and are vul-
separate the two. Dissection deep to the SMAS is also ef ort- nerable to collapse rom excessive tension, compression or
less or most areas on the nose, except at the internal valve, loss o integrity. Nasal resistance is inversely proportional
where the SMAS inserts, and the alar groove and lobule. to the nasal passage radius raised to the ourth power
T e anatomic layers o the alar lobule are unique. It does (resistance = [viscosity × length]/radius4).16 T us, small
not contain cartilage, consisting o skeletal muscle and at changes in nasal valve con guration, including removal or
enveloped by dermis and epithelium on both sides.8,9 T e displacement o any individual component, can exponen-
lack o an intrinsic ramework and the absence o support tially increase resistance to breathing, leading to airway
at its ree margin make it particularly susceptible to distor- compromise.16
tion. T e dilator naris vestibularis muscle inserts directly T e external valve controls air passage through the distal
into the dermis o the external and vestibular epithelia; nostril, and is bounded by the upper lateral cartilage supe-
sharp dissection is necessary to separate the two.10 riorly, the alar attachment o the lateral crus laterally, the
T e muscles ensheathed by the SMAS animate the nose septum and columella medially, and the nasal sill in eriorly.8
and maintain airway patency.10,11 T ey can be divided into T e shape, size, and strength o the lower lateral cartilage
our groups: the elevators, the depressors, the dilators, and determine the risk o external valve collapse. Patients with
the compressors. T e elevators include the procerus, the a exible nasal tip, or whose ala collapses on orced inspira-
levator labii superioris alaeque nasi, and the anomalous tion, or whose breathing improves with lateral alar distrac-
nasi, which rotate the tip in a cephalic direction and dilate tion are at higher risk or collapse.
the nostrils. T e depressor muscles include the alar nasalis T e internal valve is located above the external valve,
and the depressor septi, which lengthen the nose and dilate and its risk or collapse usually stems rom septal devia-
the nostrils. T e dilator naris anterior is a pure nasal dila- tion or caudal compression or weakening o the upper lat-
tor. T e compressor muscles include the transverse nasalis eral cartilage.
and the compressor narium minor, which rotate the tip in T is ow-limiting segment contributes approximately
a caudal direction and narrow the nostrils. T e muscles at 50% o the total combined upper and lower airway resis-
the alar groove (i.e., the dilator naris anterior, the levator tance.15 T e angle between the septal and upper lateral car-
labii superioris alaeque nasi, and the dilator naris vestibu- tilages is 10 to 15 degrees in Caucasians, and more obtuse
laris) and alar- acial sulcus (i.e., the alar part o the nasalis) and there ore more resistant to collapse in ethnic A rican
determine the shape o this landmark and contribute to Americans and Asians.16
airway patency.10 T e caudal part o the transverse nasalis
de nes the contour o the alar groove, which is challenging
to recreate i the muscle is removed.
t h e PAr Amed IAn f o r eh eAd f l AP
T e nasal skin topography re ects its underlying struc-
ture. Its shadows and re ections de ne its subunits: the tip, As s es s In g t h e d ef ec t
dorsum, sidewalls, alae, and so t triangles.12 Its concavities
include the slight break at the supratip, the alar groove, the Lo CAt io n . T e paramedian orehead ap has su -
aint shadow at the so t triangles, and occasionally, bi dity cient length and a robust enough blood supply to
222 o the nasal tip. Convex sur aces include the lobule, nasal repair nearly any nasal de ect, although de ect location
in uences both pedicle length and the risk o airway com-
promise. Distal de ects lie urther rom the donor site and
de ect size may make donor site closure more di cult. It
also may increase pedicle length and the likelihood that
2
require a longer pedicle, potentially leading to the pres- the donor site will involve hair-bearing scalp.
ence o scalp hair on the ap. T ese de ects also pose a De ect enlargement ollows a ew simple principles.
risk o airway compromise and are more likely to require Horizontal scars across subunits are conspicuous; extend-
cartilage gra ts or support. More proximal de ects o the ing the de ect hides the scar at the ree margin. I the de ect
nasal root, dorsum, and sidewall less commonly threaten involves the alar lobule or nasal tip, it should be extended
airway unction, as the septum and upper lateral cartilages distally to the ree margin. Vertical scars on the ala tend
gain support rom their bony attachments. T e paired to heal inconspicuously. I the de ect does not involve the
lower lateral nasal tip cartilages provide only moderate ull alar height, its vertical aspect may be extended with-
resistance to compression and distortion. T e lobule is out hesitation. Caution must be observed with horizontal
especially vulnerable, requently requiring nonanatomic extension, because recreating the convex are o the ala
cartilage to brace its rim against contraction and maintain can be challenging. Even i cartilage gra ts are placed, at-
external valve patency. tening o the alar margin (best seen rom the swimmer’s
view) is common. As midline scars heal well, one may con-

C
sider extending the de ect to a “hemi-tip” subunit, rather

a
As s es s In g t h e An At o mIc d ePt h o f

p
than the entire tip, i it involves only one side. T e smaller
t h e d ef ec t An d In d Ic At Io n s f o r sur ace area will acilitate donor site closure with little

1
c Ar t Il Ag e g r Af t In g

9
or no compromise o the nasal scar (Fig. 19-1). Correct
contour is more important than placing scars in subunit

:
:
De ect depth in uences the required ap thickness and lines.13 When the bene ts o de ect enlargement are uncer-

A
airway integrity. In general, so t-tissue loss without dam- tain, the ocus should instead be on optimizing contour.

x
age to cartilage poses little risk or airway compromise.10

a
l
P
However, de ects involving alar skin and muscle require

a
special consideration because o the risk o airway com-
promise rom de ect instability or anticipated scar con-
d es Ig n In g t h e f l AP

a
traction, o ten requiring cartilage gra ts or repair. De ects
mAk In g t h e t emPl At e

d
involving cartilage increase the complexity o reconstruc-

i
tion, as nasal projection may be decreased and airway sta-
bility compromised. Missing cartilage is usually replaced Once the nal nasal de ect has been created, the surgeon

p
to restore nasal contour and projection and stabilize the must make a template that matches it exactly. It is there ore

l
a
airway. Preexisting cartilage should not be removed or its critical to heed the adage, “measure twice and cut once.”
attachments violated unless absolutely necessary. An oversized template will result in a bulky ap with poor

F
Full-thickness nasal de ects present the greatest chal- contour and occurs most commonly when the nasal wound

l
a
has a sur ace area greater than that o the skin removed.

p
lenge, as they require repair o mucosal lining, cartilage,

s
and skin. Such de ects are most common on the lobule Expansion occurs to a greater degree on the dorsum and
and so t triangle, where ull-thickness excision is required sidewalls, where the skin is looser, and to a lesser degree
i tumor involves the ree margin. Such de ects usually on the tip and ala, unless the wound is deep or ull thick-
require a three-staged orehead ap or aesthetic repair ness, or cartilage integrity has been damaged. No matter
and recreation o the mucosal lining.17,18 the location, the template should re ect the sur ace area
o the tissue removed, not the size o the expanded wound.
T e contralateral side o the nose, i intact, can serve as a
Pr In c IPl es o f Aes t h e t Ic d es Ig n : re erence i estimating the true size o the removed tissue
d ec Id In g w h en t o en l Ar g e is di cult.
t h e d ef ec t An undersized template will produce a orehead ap
under excessive tension, and usually occurs when the tem-
Although the surgeon cannot control the location, size, plate ails to re ect the three-dimensional sur ace o the
or depth o the de ect, he or she may modi y its size and de ect’s concavities and convexities. o avoid this error,
depth to achieve a more aesthetic design. As noted above, it is use ul to create the template with a exible material
so t-tissue de ects not involving the ala or alar groove less that is stif enough to retain a three-dimensional shape.
commonly threaten the airway. T ere ore, removing so t Many surgeons use the aluminum oil o a suture pack-
tissue to the level o the perichondrium or periosteum age. Others create a so t cast o the nose by placing steri-
may be advantageous. T e cartilaginous ramework will strips over the wound and surrounding skin, then cutting
appear more natural beneath a orehead ap o appropri- out a precise template. Regardless o the material used,
ate thickness, and the inset ap will have a better contour the surgeon will need to convert the three-dimensional
with decreased bulk. As the nasal lining lies immedi- template to a two-dimensional sur ace. T e authors use
ately beneath muscle on the alar lobule, deepening the a surgical marking pen to trace the de ect’s borders,
de ect here requires caution to avoid an unnecessary ull- then apply a nonstick gauze or suture package over it to
thickness de ect. con orm to its three-dimensional contour. T e resulting
Enlarging a de ect’s breadth may also be desirable at imprint allows precise determination o the wound edges.
times or better scar camou age. T e surgeon must weigh T e template is cut out at the inside margin o the imprint
the bene ts o de ect extension against the risks o airway and trans erred back to the wound to con rm that the t
compromise and added donor site morbidity. Increasing is precise. 223
2
S
c
2
A B
:
:
S
u
g
c
a
l
S
k
l
l
s
C

Figure 19-1 A. D c v lv g l m pa dc m g su ac a a
l w la al ca lag . B. t w u d was pa d as a m p subu , a
a x d g d c v lv asal p subu . App a a c a
pa am d a ad ap. n a d s was g p ma y cl su .
C. App a a c 6 m s p s p a v ly. t m dl sca s mp c p bl , d m -
s a g a plac m c sm c subu s always c ssa y. t
small p w u d a ad d s as al d acc p ably; vs was
p m d.

the ala, distal sidewall, or hemitip, the surgeon will usually

t r An s f er r In g t h e t emPl At e t o place the template on the ipsilateral orehead. T e ap will
t h e f o r eh eAd d o n o r s It e then require less length to reach the wound and will be less
likely to contain scalp hair. For laterally based wounds o
A ter nalizing the template, the surgeon must identi y a the medial canthus and proximal nasal sidewall, contralat-
suitable donor site. T e proposed site must be inspected eral aps have less torque and still reach the de ect without
or concerning lesions be ore surgery, so that these may di culty. Midline nasal wounds can use either side as the
be appropriately addressed. Previous surgery or trau- donor site.
matic scars can alter the ap’s blood supply, so the sur- A ter determining the side on which to base the ap, the
geon must also look or scars that could threaten ap surgeon maps the supratrochlear artery (S A), whose path
viability. determines template placement. Although the ap has axial
Determining the side on which to base the ap depends ow rom the S A, it also has blood ow rom the angular,
224 primarily on de ect location. For laterally based wounds o dorsal nasal, and supraorbital arteries via anastomoses in
the superior orbital plexus.19 A thorough understanding o
anatomy helps to plan the ap appropriately. T e S A is a
2
terminal branch o the ophthalmic artery that exits the
orbit by piercing the orbital septum at the superomedial
orbital rim, travels super cial to periosteum and the cor-
rugator supercilii muscle, then pierces the orbicularis oculi
and rontalis muscles, and reaches the at just above the
eyebrow. On average, it reaches the subcutaneous plane 1
cm above the supraorbital rim.20 On the lower orehead and
brow, the artery and its branches may be ound in the at
super cial to the rontalis muscle.20 On the superior third o
the orehead, the artery runs in the at and continues in this
plane beyond the junction o the sagittal and coronal sutures
at the top o the skull.19 Although its pulse is palpable in
many patients, a Doppler probe can also be used to locate it

C
and trace its path. I a probe is not available, the surgeon can

a
p
use topographic landmarks to identi y it. T e most promi-
nent glabellar rown line corresponds to the junction o the

1
9
medial corrugator and procerus muscles, and can be accen-
tuated by pushing the lateral orehead toward the midline.

:
:
T e S A is located anywhere rom this glabellar rown line

A
to 6 mm laterally.21 T e pedicle base should there ore be

x
a
wide enough to include these landmarks.20

l
P
Once the S A is mapped, the surgeon trans ers the

a
template to the orehead. o orient it accurately, the 180
degree direction o ap rotation must be anticipated. We

a
recommend placing the template on the nasal wound,

d
then rotating it 180 degrees toward the side on which the

i
ap will be based. T e template is placed in line with the Figure 19-2 A mpla asal d c as b
S A so that the portion corresponding to the distal wound a s d ad d s a -

p
lies just in erior to the hairline. Some patients have promi- l .t pa sup a c l a a y (St A) as b

l
a
nent vellus hairs on the upper orehead, and the template mapp d w a D ppl d v c , a d ap p d cl s
may there ore be placed lower to avoid hair trans er to the bas d a u d St A. t p d cl bas as a w d

F
nose, assuming the pedicle has adequate reach. I the ap 1.2 cm a d a s u m mpla d p

l
a
p
will not reach the de ect, the template can be placed trans- ap. As d c s l ca d m dl , sd

s
versely instead, aiming at the contralateral orehead in e- ad w uld s v as a su abl d s .
rior to the hairline. Even without an axial blood supply,
the ap will have su cient per usion via the subdermal
plexus.19 l If t In g t h e f l AP
Distal de ects o the in ratip and columella and patients
with low hairlines present the greatest challenges or ap
design. Ensuring adequate length is another instance where Id eAl An At o mIc Pl An es t o
it pays to “measure twice and cut once.” o avoid raising d et er mIn e f l AP t h Ic k n es s An d
a ap that is not long enough, a gauze pad simulating its Pr es er Ve Bl o o d s u PPl y
reach can be stretched rom the most proximal part o the
pedicle to the distal part o the template near the hairline. T e anatomic plane in which the ap is li ted determines
A surgical marking pen can be used to indicate the exact its thickness and blood supply. T e layers o the mid to
point at which the gauze meets the template’s distal aspect. superior orehead include skin, subcutaneous at, ron-
Keeping the gauze pressed against the pedicle base, its dis- talis muscle, loose connective tissue, and periosteum.
tal end is rotated 180 degrees toward the midline, avoiding At the medial brow and suprabrow, the anatomy is more
excessive tension, so as not to overestimate pedicle length. complex, including the skin, subcutaneous at, orbicularis
I the marked area does not reach the distal de ect, the ap oculi, rontalis, and corrugator muscles, at deep to the
may not be long enough. T e surgeon should then place the corrugator, and periosteum.22,23 T is discussion addresses
template more superiorly on the orehead or extend the base dissection o the ap in three separate regions: (1) the dis-
more proximally toward the medial canthus. A ter assuring tal ap (2) the mid-pedicle, or the mid- orehead portion
adequate length, the surgeon can nalize the design. T e o the ap, and (3) the base, or the most proximal portion
template is situated at its precise orehead location, and its at the medial brow. Each region requires unique strate-
border outlined, with the proximal pedicle centered on the gies, but or all three, it is crucial to maintain exquisite
S A. A width o 1.1 to 1.4 cm sa ely includes the S A and hemostasis to maximize visibility and accuracy, as well as
minimizes torque during ap trans er. T e ap’s template to improve the patient’s physical and psychological com-
portion is usually wider than its base. o optimize its blood ort. When per orming this ap under local anesthesia,
supply, the narrow portion should widen progressively bleeding ushes anesthesia rapidly, raising anxiety or the
until it meets the templated portion (Fig. 19-2). patient and the operating team. 225
2 DiSSeCt in G t h e t eMPLAt eD Po r t io n o F distal template outlines. At the lateral margins, the inci-
t h e FLAP. T e plane o dissection o the templated por- sion should be vertical. Distally, a beveled angle can be
tion o the ap depends on whether it has been planned as used i the ap must match the thin skin o the columella,
a two-stage or a three-stage process. wo-stage orehead in ratip, so t triangle, or alar rim. Sharp dissection can
aps are indicated or partial-thickness de ects or when proceed subdermally or 2 to 3 mm to match the thin nasal
cartilage gra t placement is possible during the initial stage. skin. An incision is then made through the at to reveal the
T ree-stage aps are indicated when there is a ull-thick- rontalis muscle bers or galea. Full-thickness orehead
ness nasal tip de ect requiring nasal lining and delayed car- skin usually provides a good match or the proximal ala
tilage gra ting, or when the de ect has complex contours and nasal tip.
that may require sculpting o the ap at an intermediate At this point, the surgeon can inspect the distal and
stage. lateral incision margins to identi y the precise depth o
the S A branches coursing through the at. T ese vessels
provide a visual landmark that guides the rest o the dis-
d Is s ec t In g t h e t emPl At ed section. T e dissection should proceed immediately
super cial to rontalis or most, and pre erably all, o the
S
Po r t Io n o f t h e f l AP f o r A remaining templated portion o the ap (Fig. 19-3). As long
c
Pl An n ed t w o -s t Ag e as the dissection cleanly separates at rom rontalis, the
f o r eh eAd f l AP S A branches, and there ore the ap’s blood supply, will
2
remain intact.20 An accidental incision into the base o the
:
:
For two-stage aps, the thickness o the templated por- at can transect the vessels and compromise blood supply.
tion should be a nearly per ect match or the de ect, since With the surgeon at the head o the operating table (bird’s-
S
u
aggressive thinning during pedicle division and inset may eye view), skin hooks at the distal ap can be held by an
g
compromise blood supply. A two-stage ap that is too assistant to provide rm countertraction as the scalpel or
c
a
l
thick will require revision, which may be challenging due scissors gently separates subcutaneous at rom rontalis.
S
k
to brosis and scar contraction. T e tissue plane should separate ef ortlessly with almost
l
l
s
T e templated portion o the ap should match the no bleeding. I the wound or the ap undersur ace demon-
varying thicknesses o the nasal so t tissue. An incision is strates excessive bleeding or scalloped ridges correspond-
rst made through dermis and at along the lateral and ing to passes o the blade or cuts rom the scissors, ap

A B

Figure 19-3 A. t cs slm d mpla d p ap m m z bl d g. B. F

s pla d w -s ag ap, mpla d p s l va d sup f c al al s muscl .
226 t abs c bl d g a ap bas d ca s a sup a c l a v ss ls a ac .
viability may be compromised and the surgeon should nd
a more precise dissection plane.
primary concept behind the three-staged ap is that mini-
mal brosis occurs i the galea or rontalis muscle remains
2
I the incision extends through rontalis or galea be ore intact. T e at is then easier to manipulate during the
reaching the proximal 10% to 20% o the templated por- intermediate procedure, and li ting the ap is ef ortless.17
tion o the ap, the ap will usually have more volume than T e indications or a planned three-stage ap include ull-
the nasal de ect. At the time o division and pedicle inset, thickness de ects requiring distal ap turnover to recreate
ef orts to excise muscle rom the proximal ap will risk lining; complex, multi-subunit de ects requiring consider-
compromise to the blood supply. T e ap should there ore able contouring to restore symmetry; patients with a tenu-
be dissected rom the muscle at the time o harvest, which ous blood supply; and de ects requiring delayed cartilage
requires intimate knowledge o the tissue planes. Although gra ting. Unplanned three-stage aps may be necessary i
novice surgeons may pre er to li t a ap with rontalis bers primary inset o an intended two-stage ap is too bulky.
intact to protect the vessels in the at, ap dissection at the However, brosis a ter rontalis removal may make con-
desired level presents multiple advantages.20 De ning tis- touring more di cult.
sue planes is easier when skin tension provides counter- Dissection o the templated portion o a planned
traction. When ap thickness is precisely de ned rom the three-stage ap is straight orward. T e incision proceeds

C
beginning, less manipulation is required at division and through galea and rontalis, and the ap is li ted in the

a
p
inset, and its blood supply will be optimized. Finally, i ten- plane deep to the muscle. T e loose connective tissue cre-
sion on the orehead prevents primary donor site closure, ates excessive bulk so the ap should not include it. T e

1
9
the intact rontalis will accelerate second intention healing ap thickness usually exceeds that o the de ect, making it
o the orehead wound. di cult to inset within the distal nasal skin. T e ap edge

:
:
may then be beveled to acilitate insetting.

A
x
d Is s ec t In g t h e t emPl At ed

a
d Is s ec t In g t h e mId -Ped Ic l e

l
P
Po r t Io n o f t h e f l AP f o r

a
A Pl An n ed t h r ee-s t Ag e Once the templated portion o the ap is elevated, the dis-
f o r eh eAd f l AP section should proceed through rontalis and continue in

a
the plane o the loose connective tissue (Fig. 19-4). A scal-

d
i
T e three-stage orehead ap includes an intermediate pel or blunt-tipped scissors dissects the tissue away rom
stage, usually 3 weeks a ter the primary inset, to li t and muscle with minimal ef ort. T is dissection strategy poses

p
contour the ap. Per ect ap thickness at the time o pri- no risk to the S A and does not vary between a two-stage

l
a
mary inset is there ore neither necessary nor expected. T e ap versus a three-stage ap.

F
l
a
p
s
A B

Figure 19-4 A. A l va g mpla d p ap sup f c al al s, muscl s c s d a d d s-

s c p c ds d ply l s c c v ssu . t s f gu s ws su g ’s v w m ad abl
w l cs g ug al s muscl . B. t m d-p d cl s l va d d p muscl l s c c v ssu . t
a s su g cal pla s s v s bl ap u d su ac a d a bas ad w u d. 227
2 d Is s ec t In g t h e BAs e
horizontal incisions may be made across the rontalis at its
undersur ace to gain additional movement, being care ul
o f t h e Ped Ic l e to avoid transecting the S A by inadvertently extending
the incisions into at. Intraoperative stretching o the ped-
As dissection o the mid-pedicle approaches the brow, icle by an assistant while closing the donor site can also
the surgeon will see yellow at deep to the corrugator. At provide some “tissue creep.”
this point, an incision should be made through the at to
periosteum. T e periosteum should not be incised, as it
provides no lengthening o the ap and hemostasis may be In s et t In g t h e f l AP
complicated i a deep vein is transected.
Dissection at the pedicle base proceeds deep to the corru- Pr ImAr y In s e t o f A t w o -s t Ag e
gator. Cotton-tipped applicators can be used to push away
the corrugator muscle bers without causing bleeding o f o r eh eAd f l AP
the superior orbital plexus (Fig. 19-5). Vessels deep to the
corrugator should be le t intact, but can be precisely elec- I the template has been sized precisely and the ap and
S
trocauterized i necessary. Flap length should be assessed de ect thickness match, inset should be straight orward.
c
by rotating the ap toward the midline and stretching it For a two-staged ap, cartilage gra ts should be placed
toward the nasal wound. I it reaches the de ect without prior to inset. For a three-staged ap, they may be delayed
2
tension, urther dissection at the base can be avoided. until the nasal lining has been secured. Di culty insetting
will occur i the ap is undersized or oversized. Under-
:
:
I the ap does not reach the distal de ect, dissection
can be carried proximally beyond the orbital rim. Inci- sized aps risk nasal cartilage compression and are di -
S
u
sions at the lateral edges o the pedicle are carried through cult to x. An oversized ap will result in poor contour,
g
the orbicularis oculi, rontalis, and corrugator muscles; but the recovery is easier, since the ap can be trimmed to
c
a
decrease its size.
l
a cotton-tipped applicator is used to push all so t tissue
S
T e main objectives during ap inset are to align the
k
away rom the periosteum. T is blunt dissection should
l
templated portion with its corresponding nasal de ect
l
s
be deliberate and carried out with precise hemostasis. By
carrying the dissection proximally, the ap gains consider- site. Undermining the de ect margins prior to inset may
able length. I the ap still does not reach the nasal de ect, help prevent pin-cushioning. T e distal ap is anchored to
the nasal wound; suturing proceeds proximally along its
lateral aspects. For aps that barely reach their intended
site or cover asymmetric de ects, the surgeon may secure
the proximal ap edges to the skin overlying the upper lat-
eral cartilages to prevent upward or lateral displacement
o the lower lateral cartilages. T e surgeon should make
sure that the ap undersur ace con orms properly to the
base and eliminates dead space. For complex de ects, quilt-
ing sutures can be used to recreate nasal concavities (Figs.
19-6 and 19-7). Some authors use cutaneous sutures alone
or ap inset. We pre er to use a ew deep sutures to pre-
vent wound-edge inversion.

In t er med IAt e s t Ag e o f A t h r ee-

s t Ag e f o r eh eAd f l AP f o r
c o n t o u r In g An d s ec o n d Ar y
f l AP In s et
T e intermediate stage o a three-stage ap provides the
opportunity to improve contour (Figs. 19-8–19-10). Approx-
imately 3 weeks a ter inset, the templated portion is incised
and li ted in the plane beneath galea or rontalis. Cartilage
gra ts may be placed and the brotic tissue at the wound
base sculpted, i needed. T e elevated ap has a robust blood
supply and can be thinned more aggressively than during
primary inset, removing rontalis or galea and at.17 T e con-
toured ap is sutured into place as described be ore.

Figure 19-5 W y ll w a d p c uga

muscl b c m s v s bl , blu d ss c s us d pus c l o s In g t h e f o r eh eAd d o n o r s It e
muscl f b s away m p s um. t St A u s
sup f c al c uga , s cs ug p s- T e donor site is undermined in the loose connective tissue
um s c ssa y p c . Ac - pp d appl - and closed in layers. De ect closure at the base and mid-
228 ca s us d p d cl bas m p s um. pedicle is usually straight orward. However, there may be
 2

C
a
p
1
9
:
:
A
x
a
A B

l
P
a
a
d
i
p
l
a
F
l
a
p
s
C D

Figure 19-6 A. D s al asal d c v lv g ala l bul , asal s d wall, a d p max lla y c k.

B. i a p a v p s w g au cula ca lag g a supp g ala ma g a d
c k adva c m p v blu g as ac al sulcus. C. App a a c a p ma y s
a pla d w -s ag pa am d a ad ap. t ack g su u s m ap bas bas
w u d w us d c a ala g v .t c cav y m ack g su u s s v s bl .
D. App a a c 1 w k a p ma y s . n d p g v c a d by ack g su u s. ed ma
a u d su u s s c mm .

signi cant tension superiorly. I the wound is under tension, ically acceptable (Fig. 19-1). Ef orts to close the orehead
but closure is possible, excising the rontalis and loose con- site with rotation aps or gra ts lengthen the procedure,
nective tissue may be help ul. Excising a standing cone on increase discom ort, and provide ew long-term cosmetic
the scalp is usually necessary. Any area too tight to close bene ts. I the orehead scar is unsatis actory, serial exci-
primarily should be le t to granulate. T e shiny scar rom a sions spaced several months apart will usually permit direct
wound le t to heal by second intention will o ten be aesthet- closure. 229
2
S
c
2
Figure 19-7 P s p a v app a a c pa m F gu 19-6 10 m sa d vs a d s w -
:
:
s ag pa am d a ad ap. t pa as a d c cav y al g l ala g v as a sul ack g
S
su u s. n vs was p m d.
u
g
c
a
l
S
k
d IVIs Io n An d In s et
l
dissected rom the de ect’s proximal aspect. T e exact
l
s
de ect margin is o ten not visible until the ap is elevated;
o f t h e Ped Ic l e it can be reshened by removing 1 to 2 mm o skin to the
level o the perichondrium or periosteum. T e reshened
Once the ap is ully integrated with the nasal blood sup- edge provides a target or sizing the ap in the horizon-
ply, the S A is no longer needed or its survival. Some tal and vertical dimensions. T e pedicle’s severed end is
authors success ully divide the pedicle as early as 1 week draped over the reshened proximal edge o the de ect and
a ter primary inset.24 However, most surgeons divide and trimmed. T e proximal aspect o the ap is sculpted with a
inset the pedicle 3 weeks later, especially i cartilage gra ts scalpel or tissue scissors to match the nasal skin thickness
are used, the patient smokes, the ap is under tension, or (Fig. 19-11). I the ap was too bulky at the time o inset,
i cosmesis would be optimized by re nement at pedicle reshaping may be necessary. Because excessive thinning or
division. ap elevation risks interruption o its newly ormed blood
o begin the process, the ap’s mid-pedicle is incised supply, sculpting should be limited to the ap’s proximal
and hemostasis achieved on both ends. T e cut end can be 10% to 20%. In most cases, the surgeon will need to remove
retracted with a skin hook and its proximal aspect bluntly any muscle le t proximally at its base.

A B C

Figure 19-8 A. D c v lv g asal p, ala, a d caudal ma g s la al c u a b s d s. B. i a p a v

p sd m s a gd c la g m clud p subu . t w small ca lag g a s av b su u d
caudal m a s la al c u a. C. A p ma y s a pla d -s ag pa am d a ad ap,
230 bulky ap lacks c u.
 2

C
a
p
1
9
:
:
A B

A
x
a
Figure 19-9 A. App a a c 3 w ks a p ma y s . t ap ma s bulky, sp c ally a s

l
P
p x mal w - ds. B. i a p a v p ap g 3 w ks a p ma y s . t p x -

a
mal p ap as b l va d, a d a 15 blad scalp l s b g us d xc s al s
muscl a d sculp ap d s d ck ss. el va ap was c ssa y
s cas . t d ap was subs qu ly su u d back s .

a
d
i
p
l
a
F
l
a
p
s
Figure 19-10 App a a c 6 m sa d vs a d s -s ag d ap. C u s muc mp v d.

A B C

Figure 19-11 Su g ’s v w m ad b d. A. t p d cl as b d v d d a d blu - pp d sc ss s a b g

us d l va ap m p x mal d c . B. r m a s al s muscl a d f b us ssu a v s bl d p
subcu a us a . A scalp l s us d xc s al s muscl a d f b us ssu m bas subcu a us a . 231
C. A w dg al s a d f b a y ssu as b xc s d. t p x mal ap w as app p a ck ss s .
2
S
c
A B C
2
Figure 19-12 A. t p d cl s w -s ag ap as b d ss c d p x mally ug b w av d a a s
:
:
s . B w a mus b u d s symm y. B. i v d V-s ap d su u l mm d a ly a d vs
S
u
p d cl a d s b w a . C. App a a c 4 m sa d vs a d s . Symm y b w a as b
g
s d. ecc ym s s s s m a sculp g v s p c du 1 w k p v usly.
c
a
l
S
k
T e corners o the proximal de ect require special atten- cutaneous sutures approximate the epidermis, ideally with
l
l
s
tion. T e pedicle’s ree edges have already begun to con- eversion.
tract and reepithelialize. T e nasal de ect is typically most
brotic at its corners, where the ap could not be sutured.
A scalpel is used to remove the newly epithelialized skin
c o mmo n PIt f Al l s
and reshen the ap’s edges. T e brotic tissue is excised An d s o l u t Io n s
and the ap is trimmed and sutured into place. T ere
should be no tension on the wound; a single layer o cuta- Each o the previous sections addresses common pit alls
neous sutures may be adequate. Strategically placed der- and solutions, so this section will brie y review key points.
mal sutures may help to minimize scar inversion. Excessive First, the surgeon must take care to ashion a template that
eversion should be avoided. exactly ts the nasal de ect contours. An undersized or
oversized ap must be avoided. Second, it is important to
Ad d r es s In g t h e d o n o r s It e: map the S A’s path, including the precise location at which
it pierces the orbital septum. Care ul mapping will increase
In s e t t In g t h e BAs e o f t h e Ped Ic l e the likelihood that the blood supply will remain intact,
especially i the pedicle is dissected rom the orbital rim to
Insetting the pedicle at the brow begins by retracting its
gain su cient length to reach the nasal de ect. T e donor
severed portion and bluntly dissecting the ap to reveal the
site is less likely to include scalp hair when the surgeon can
edges o the wound, which will be in the shape o an upside
mobilize the pedicle with con dence. T ird, during pri-
down “V.” T e lateral margins o the pedicle base have con-
mary inset o a two-stage ap, one should aim to match
tracted and reepithelialized. A scalpel is used to excise the
the thickness and contour o the nasal de ect. A bulky
epithelialized skin and to reshen its edges. Fibrotic tissue at
ap requently prevents per ect contouring at the time o
the wound base should also be excised. T e proximal ped-
pedicle division and inset. Fourth, meticulous hemostasis
icle is now rectangular. T e severed end is draped over the
is critical to decrease the risk o postoperative bleeding, as
proximal de ect edge and cut to match the inverted “V” at
well as to improve accuracy, e ciency, and patient com ort
the edge o the donor site. T e pedicle is usually too thick,
and con dence. Fi th, the surgeon should be patient with
primarily due to brosis below the corrugator muscle. T e
donor site repair. I the tension is too great or primary clo-
brotic tissue can be excised, and the ap base sculpted to
sure, the wound may heal by second intention. A subopti-
match the wound thickness at the donor site.
mal orehead scar can usually be revised later.
T e surgeon must pay care ul attention to the position o
the eyebrow hairs. I the pedicle base was carried through
the brow to increase ap reach, the hairs may have been mel o l ABIAl
pulled in eriorly and medially. o maintain symmetry, the
surgeon may want to realign them, or tailor the wound at In t er Po l At Io n f l AP
the donor site (Fig. 19-12). I insetting the hairs is not neces-
sary, it may be possible to excise the base o the pedicle and T e MIF is a random pattern pedicle ap based upon the
repair the wound with a linear closure. Residual muscle at muscular per orators branching rom the acial, superior
the ap base increases the risk o contraction. A care ully labial, and angular arteries in the nasolabial old.25 T e
232 placed deep suture layer prevents pin-cushioning while old provides a generous tissue reservoir with an excellent
color and texture match or the ala. Previous authors have
described multiple variants, such as a banner-type ap 26 and
margin make it particularly susceptible to distortion. Loss
o muscle decreases alar support, so de ects involving
2
an interpolated paranasal ap rom the hairless naso acial more than 50% o the distal lobule usually require cartilage
sulcus.27 In most cases, we pre er the traditional design.28,29 gra ts to brace against contraction, support the airway,
Compared to one-stage melolabial aps, the two-stage MIF and provide convexity to the ala, to optimize cosmesis and
has the advantage o preserving the alar- acial sulcus, the unction.18 T e concave antihelical cartilage at the lateral
apical triangle, and the narrow isthmus between the melola- conchal bowl produces a C-shaped strut that preserves the
bial old and alar lobule. are o the lobule and provides a scaf old or the ap. With
cartilage supporting the external valve and restoring alar
projection, internal valve patency is ensured and air ow
As s es s In g t h e d ef ec t obstruction is minimized.

l o c At Io n Pr In c IPl es o f Aes t h e t Ic d es Ig n :
d ec Id In g w h en t o en l Ar g e t h e

C
T e MIF is most suitable or reconstructing partial-thick-
ness de ects limited to the ala or the alar component o a d ef ec t

a
p
de ect involving multiple cosmetic subunits.12 T e natural
contraction o the ap reliably recreates the alar convex- Circum erential scar contraction, known as “pin-cushion-

1
9
ity, especially when the scar’s boundaries con orm to the ing” or “trapdooring,” recreates the alar structure when the
alar groove and distal ree margin. T e MIF may also repair MIF is used or total alar de ects. It is so predictable that

:
:
columellar de ects. While small tip de ects can be resur- nearly all partial alar de ects may be expanded to the alar

A
aced with an MIF, the blood supply to the distal portion o crease superiorly and the ree margin o the rim in eriorly.

x
a
the ap is unpredictable. T e paramedian orehead ap is However, horizontal expansion should be executed with

l
P
a better choice or larger tip de ects or multi-subunit nasal caution and avoided i it risks external valve weakening

a
de ects. T e MIF can be turned over on itsel to repair or attening o the alar are. T e alar base should be pre-
small ull-thickness alar rim de ects involving 2 to 3 mm served, as its three-dimensional projection orms the alar

a
o vestibular skin, but the orehead ap provides a better oundation.30 T e lateral alar- acial sulcus is especially di -

d
option or ull-thickness de ects with larger de ects o the cult to repair, so 1 to 2 mm o the ala should be preserved

i
vestibular lining. i possible.
As the MIF is best applied to the ala, portions o the

p
de ect beyond it may require separate closure. o identi y

l
As s es s In g t h e An At o mIc d ePt h o f

a
the precise alar boundaries, the surgeon marks the cos-
t h e d ef ec t An d In d Ic At Io n s f o r metic junction lines bilaterally and makes a template o the

F
c Ar t Il Ag e g r Af t In g de ect and the contralateral ala (Fig. 19-13). De ect com-

l
a
p
ponents on the adjacent sidewall or extending onto the tip

s
T e alar lobule does not contain cartilage.8,9 Its lack o beyond the MIF’s reach are best repaired separately. Super-
an intrinsic ramework and the absent support at its ree cial paranasal de ects do not necessarily preclude MIF

A B

Figure 19-13 A. C sm c subu s av b d f d b la ally. As d c x ds b y d c sm c subu

ala l bul , c ala al ala s us d c a a mpla ma c p d c c sp d g
ala l bul . B. t l mpla m c ala al ala subu as b a s d d s m l lab al
ld. 233
2 repair, because the muscular per orators that supply blood
to the ap will still be intact. o avoid ablating the alar-
acial sulcus and apical triangle, paranasal cheek de ects
are best allowed to heal by second intention i small, or can
be repaired at the time o takedown with remnants rom
the pedicle. T e alar crease heals well by second intention.
A thinned ap margin can also be basted with curvilinear
quilting sutures to recreate this concavity.31,32 When the
paranasal de ect is large, other options may be pre erable
to avoid ablation o the alar- acial sulcus.33

d es Ig n In g t h e f l AP
mAk In g t h e t emPl At e Figure 19-15 A a a mc ca lag ga as
S
b su u d bas d c.
c
T e majority o alar de ects large and deep enough to
require a MIF will also demand a cartilage strut. T e sur- replaced, trimmed i needed, and sutured. A bolster may
2
geon must prepare templates or the cartilage gra t and be placed or additional hemostasis. T e cartilage gra t is
:
:
the MIF. T e cartilage template is designed rst. T e ideal then secured to the de ect (Fig. 19-15). Using the scalpel or
S
donor site is the ipsilateral conchal bowl-antihelix junc- the tips o a scissors, pockets between the alar muscle and
u
tion, which af ords the patient a pain- ree contralateral vestibular mucosa are created along the de ect margins to
g
c
ear and cheek on which to rest. T is cartilage maintains its allow insertion o the gra t ends. T e cartilage may require
a
l
elasticity, and rarely develops solar induced calci cation or additional trimming. Care must be taken to secure the gra t
S
k
ossi cation, and its C-shape supports the MIF by recapitu- in eriorly to support the alar rim. A common mistake is to
l
l
s
lating the alar are. T e template is trans erred to the ear set it too superiorly, which results in insu cient bulk and
and the best matching location marked. T e gra t’s verti- risks contraction, shortening the vertical height o the ap.
cal height should be 1/3 to 1/2 the alar height (generally Gra ts less than 5 mm in height can be di cult to suture
5– 8 mm), as it provides su cient support and allows easy without racturing. One or two 5-0 absorbable sutures can
suturing. T e horizontal gra t dimension may be longer be lassoed around these narrow gra ts to secure them; 6-0
than the de ect’s horizontal axis to allow insertion o the sutures can be passed through larger gra ts without rac-
long ends o the cartilage into so t-tissue pockets, particu- turing. One must care ully pass the needle along its curva-
larly at the alar base. ture to avoid racturing the cartilage; it should pass through
A ter determining the appropriate gra t size, an inci- the de ect base without interrupting the mucosal sur ace.
sion is made along the antihelical rim, and the skin is dis- Once the cartilage gra t is in place, attention is turned to
sected of the perichondrium. T e template is trans erred making the MIF template. T e subunit (or de ect) borders
to the donor site to ensure appropriate size. T e carti- are inked; light pressure imprints the outline. T e goal is
lage gra t is excised with care (Fig. 19-14). Narrow donor to trans er the ink without attening the template, which
de ects can be reapproximated, but generally the skin is would underestimate the three-dimensional size o the ala.

A B

Figure 19-14 A. A g usly s z d ca lag g a as b av s d m

c c a va a a l cal c s . Ca lag m s l ca as a a u al cu -
va u a s mula s mal c u ala l bul . B. t au cula c s
s su u d w a lay u g cu a us su u s. Qu l g su u s a b ls
234 d ss g may b lp ul duc d ad spac a d d c as sk ma ma.
 2

C
a
p
A B

1
9
Figure 19-16 A. A t l a pad as b us d mak a mpla ala subu .

:
:
t d c w ll b la g d b u da s subu p ap a s .

A
B. t mpla as b a d la ally a d a s d m l lab al

x
ld d s .t us m d s g s c mpl d by d aw g a Bu w’s a gl

a
l
ac s d mpla d p ap.

P
a
a
I the de ect precludes accurate alar sizing, the contralateral triangles should be long enough that their apical angles are

d
ala should be used or the template, which is then trans- 30 degrees or less.

i
posed to the ipsilateral de ect to de ne the subunit borders, It can be help ul to mark the skin overlying the ap’s
retaining the three-dimensional shape and mirror image. planned blood supply to ensure that dissection does not

p
extend too ar proximally during its elevation.34 T e axis

l
a
o rotation lies at the base o the superior dog-ear, which
t r An s f er r In g t h e t emPl At e is later excised. A triangular pedicle MIF is pre erred over
t o t h e d o n o r s It e

F
a banner con guration or this reason. T e ormer design

l
a
p
reduces torque, as removing the superior dog-ear rees the

s
T e melolabial old is traced with a marking pen prior to proximal margin to move laterally as the distal end rotates
injecting anesthesia. T e cheek skin superolateral to the into the alar de ect. Reducing torque on the ap base
melolabial old is inspected or lesions or scars. In general, decreases tension and optimizes blood ow.
the donor site is located at the midpoint o the melolabial
old between the alar sill and labial commissure.
T e donor location must allow su cient length to reach l If t In g t h e f l AP
the de ect. o assess ap length, a 4˝ × 4˝ gauze is opened,
rolled into a tube shape to approximate the MIF’s caliber,
and held at the planned pedicle base lateral to the ala. Id eAl An At o mIc Pl An es t o
T e gauze is rotated 110 to 120 degrees superomedially, d et er mIn e f l AP t h Ic k n es s An d
simulating the anticipated ap rotation, and placed on the Pr es er Ve Bl o o d s u PPl y
de ect, where it is soiled with blood. I its stain is aint, a
surgical pen may be used to mark the point at which the T e MIF is incised through the skin into the super cial
gauze crosses the de ect margins. T e gauze is rotated back at. T e in erior dog-ear may be retained until a ter ap
to the donor area; the template location correlates with elevation, so that any length insu ciency can be accom-
the marked areas on the gauze. T is assessment should modated. T e ap is elevated rom its distal to proximal
be repeated, with care not to stretch the gauze so the ap aspect, and includes the layer o at immediately adherent
length will not be underestimated. to the underside o the dermis. T is plane is ound most
T e template is placed onto the cheek donor site, relaxed, reliably along the melolabial old. T e angular artery lies
attened, and outlined (Fig. 19-16), its orientation corre- deep to the zygomaticus major and levator labii superioris,
sponding to the exact shape o the de ect when the ap is and is protected by dissecting at the junction o the subcu-
in place. We recommend placing the template directly on taneous at and lip elevators.35 While elevating the lateral
the alar wound, then rotating it 110 to 120 degrees later- aspects o the ap, the surgeon must avoid the tendency to
ally. Its superior edge will lie against the melolabial old dive into the nasolabial at pad.36 Inclusion o the at pad
with its anterior edge on the cheek. A ter ensuring proper will result in excessive ap thickness and bulky contour.
orientation, the template margins are traced, and the Once the distal 80% to 90% o the ap has been dis-
usi orm design completed by drawing Burow’s triangles sected, the dissection transitions to a plane in the deeper
along the melolabial old and the naso acial sulcus. T e at, with care to preserve the per orators at the base. T e 235
2

A B
S
Figure 19-17 A. i a p a v p d m s a g l va p x mal a d d s al a ms ap a u d
c
c al muscula p d cl . t au cula ca lag g a as al ady b su u d ala d c . B. t ap ly
a s wa d d c . t p x mal a d d s al paddl s ap a l k l c p blad s a u d p d cl .
2
:
:
proximal ap should have the base o a nger-width over I the ap extends over the groove, horizontal mattress
S
u
the paranasal per orators, and the dissection is per ormed quilting sutures oriented along the alar crease will bend the
g
with blunt scissor tips held parallel to the ap’s long axis ap to con orm to the concavity at the in erior margin o
c
a
l
and spread 3 to 4 mm apart with a gentle orward pressing the lower lateral cartilage (Fig. 19-19). T e template or pre-
S
k
motion. T is technique loosens the brous septae while cise measurements should be used to ensure symmetry. T e
l
l
s
preserving the vessels. One continues proximally until the ap is trimmed distally only a ter the alar crease and rim
ap can move reely into the de ect. T e same technique is are repaired and recreated. issue characteristics and ap
used at its superior and lateral margins, although there are dynamics requently dictate that ap length is either shorter
brous connections along the alar crease and isthmus that or longer than measured, despite meticulous planning.
may need sharp scissor dissection in the plane above the
muscle. Dissection continues until the ap reely rotates
without tension or torque (Fig. 19-17). t Ak In g d o w n t h e f l AP
T e thickness o the ap is evaluated. I the initial dissec-
tion was too deep and the ap is bulky, the at is thinned, A ter 1 week, cheek and ear donor site sutures are removed.
being care ul to preserve the dermal plexus. More at can T e alar sutures can be removed a ter 1 to 2 weeks, with
be retained i bulk is required, but deep de ects will likely crease sutures retained or longer. Mid-pedicle compression
require a cartilage gra t to ll this void. As cheek and alar allows assessment o blood supply; the ap should remain
thickness, texture, and sebaceous quality almost always pink by the third week. akedown is accomplished by divid-
match, and the ap tends to develop a convex structure, 2 ing the pedicle and excising the base as an ellipse in the
to 3 mm o retained at will likely produce a natural appear- melolabial old and repairing with standard layered closure.
ance. Rarely, i ever, does a MIF require additional bulk, T e proximal ap must be inset with appropriate tension
although it may occasionally need thinning at takedown or to prevent pin-cushioning or excessive bulk. A template
later revision. T e outer edges o the donor site are under- based upon the contralateral ala is used to de ne the exact
mined to the degree needed or closure. Undermining is lateral crease. T e ap is gently stretched and incised along
especially vital in the hairless triangle and paranasal areas, this mark. Using a skin hook and sharp dissection, at and
and is per ormed just under the dermis and above the brotic tissues are thinned rom the ap base to match the
muscle. T is af ords a broad-based pedicle o muscle at the alar thickness. It is important to retain bulk at the alar base,
origin o the MIF, with robust vascularization. as it is a structural landmark. Generally, thinning is per-
ormed along the ap rather than within the de ect. T e ap
is sutured into the alar crease with simple or mattress cuta-
In s et t In g t h e f l AP neous sutures, allowing the true margin to heal secondarily
to recreate the concavity (Fig. 19-18). At the superior margin,
T e ap should be inset with the tension that exists natively the crease can be deepened with a V-shaped partial to ull-
to prevent pin-cushioning or necrosis. T e margins o the thickness excision ollowing a symmetric arc (Fig. 19-19).
nasal de ect are undermined above the lower lateral carti-
lage or super cial to the vestibular mucosa. T e ap is inset
using 5-0 buried sutures, most importantly at the nasal tip/ c o mmo n PIt f Al l s
alar junction and the alar base. T e rim requires only epider-
mal sutures. 6-0 sutures are placed along the ap margins, An d s o l u t Io n s
with extra eversion along the ree margin to prevent notch-
ing. o promote concavity, the crease is allowed to heal sec- T e most signi cant complication o the MIF is necrosis.
ondarily or cutaneous guiding sutures are placed. Eversion Overly aggressive thinning o the pedicle base threatens
236 should be avoided along the alar groove (Fig. 19-18). survival. In our experience, necrosis more requently
 2

C
A B

a
p
1
9
:
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A
x
a
l
P
a
a
d
i
p
l
a
C

F
l
a
Figure 19-18 A. M l lab al p la ap mm d a ly a plac m a a a mc ca -

p
lag g a a d p ma y s ap. t g al d c x d d b y d l bul ala

s
g v .n a ala c as as b all w d al by s c d , a a abla g
g v w ap. B. App a a c mm d a ly a d vs a d s ap. t c kd s
as b pa d w a lay d cl su . t ala - ac al sulcus as b all w d al by s c d -
c a d p, a u al c cav y. C. App a a c 6 m sa d vs a d s .t ap
as s d symm y ala subu s a d s c d al g as c a d ala g v .

A B C

Figure 19-19 A. M l lab al p la ap a plac m ca lag g a a d p ma y ap s . V cal ma -

ss su u s a p – ala ju c acc ua v s . Qu l g su u s a d s c d al g p duc v -
s al g ala g v . B. i a p a v p du g d v s a d s .t c kd s as b pa d. A
scalp l s us d sculp ala c as , a d ala - ac al sulcus s l al by s c d p m v s .
C. App a a c 6 m sa d vs a d s d m s a gg dc u a d mp c p bl sca s.

237
2 results rom an excessively thick pedicle, whose torque
restricts blood ow. T is torque is exacerbated by inad-
comprising the lower one-third o the ear consists o adi-
pose tissue enveloped by skin and devoid o cartilage.
equate undermining, especially in the paranasal sulcus. Ligaments and muscles connect the external ear to the
Flap elevation that is carried out too proximally or too skull. It projects slightly rom the sides o the head with
deeply can sever vital per orating vessels. Overly conser- the superior portion slightly more visible than the in erior
vative elevation or ap design with a pedicle that is based one rom an anterior view,40 and connects to the middle
too in eriorly can cause ap buckling and inability to reach and inner ear via the external auditory canal. Patency o
its intended site. A base designed too ar laterally on the the canal during reconstruction is paramount as constric-
cheek can compromise blood supply and requires exces- tion can compromise hearing.
sive length to reach the de ect. In our experience, even the ributaries o the external carotid system, including the
banner ap will have restricted movement and require a postauricular artery and the super cial temporal artery,
more challenging inset procedure. deliver blood to the ear. While the postauricular artery
Asymmetry is another common problem, o ten result- supplies the posterior sur ace, the anterior aspect is sup-
ing rom excessive size in any dimension relative to the plied by anastomosing vessel connections, which allow the
normal ala. Intralesional steroid injections at concentra- ear to remain vascularized i one o the arterial systems is
S
tions o 5 to 20 mg/cc are help ul or mild to moderate pin- sacri ced.41 In addition, occipital artery branches deliver
c
cushioning starting about 1 month a ter takedown and blood to the posterior auricle and adjacent mastoid skin.
repeated monthly as needed. Edge irregularities, common Because o this robust blood supply, helical rim and ante-
2
in sebaceous skin, can be smoothed with dermabrasion 4 rior de ects are o ten repaired with postauricular skin, as
:
:
to 8 weeks a ter division and inset. Deepening o the alar it possesses an easily mobilized subcutaneous layer and its
crease can also be improved in this manner. Flap height surgical scars are inconspicuous.
S
u
may be reduced by excising tissue along the superior alar
g
crease, and ap width reduced by excising tissue along the
c
As s es s In g t h e d ef ec t
a
l
lateral alar crease. T e rim may be thinned by excising
S
k
excess bulk via an incision at the alar margin, while ap
l
l
Success ul auricular reconstruction preserves contour.
s
volume may be reduced by sharply debulking the bro atty
tissue along the alar crease. T ese revisions are usually Because the ears cannot be appreciated simultaneously,
per ormed 2 to 4 months a ter division and inset, when minor height discrepancies rarely af ect aesthetic out-
the scar tissue has stabilized. comes.42 Likewise, minor alterations to sur ace topogra-
For aps that lack bulk or develop a notched or unstable phy are not likely to distract rom the lateral or anterior
alar rim, cartilage struts can be placed. A stab incision can pro les. Ear positioning is important. Distances greater
be made at the so t triangle or alar base to create a tunnel than 2 cm between the upper helix and temporal skin
into which is placed a small cartilage gra t. A ap can be may be perceived as abnormal.43 Malpositioning can arise
raised to allow easier placement, but excessive elevation when aps cause ear shortening or “cupping,” which can
should be avoided to reduce the risk o necrosis. be avoided with distal tissue trans er in the orm o a skin
gra t or interpolation ap.
T e depth, site, and size o an ear de ect de ne the
t h e Po s t Au r Ic u l Ar approach to its repair. Medial anterior de ects may granu-
late i perichondrium is intact. Granulation on the helical
In t er Po l At Io n f l AP rim may be possible or shallow de ects, but can lead to
notching with deeper ones. Less than 2 cm helical rim or
An At o my anterior sur ace de ects may be repaired with aps, gra ts,
or wedge resections.44 Flaps mobilized rom adjacent skin
T e external ear is a topographically complex structure do well or de ects less than 2 to 2.5 cm, but rarely is there
that projects rom the head at a 30 degree angle aligned a su cient tissue reservoir or larger de ects. Attempts at
between vectors drawn rom the lateral eyebrow and the wedge repair or random ap closure can shorten the ear
alar base.37,38 It contains concavities and convexities that or de orm its contour. Skin gra ts may be an option i peri-
possess varying degrees o skin thickness and sebaceous chondrium is preserved.
gland density. Some subunits vary widely in size and shape, T e PIF is an ideal reconstructive option or most
such as the antihelix, concha, scapha, and lobe, whereas medium- to large-sized cutaneous de ects o the heli-
others, like the helical rim and postauricular sur aces, cal rim and anterior ear, and provides su cient tissue to
vary less. cover large de ects without distortion. Its abundant ran-
Cartilage provides unique structural nuances to the dom pattern blood supply allows or reliable coverage o
ear. A cross-sectional view o the upper two-thirds o the de ects with exposed cartilage, and allows or reconstruc-
ear reveals an elastic cartilage substructure enveloped by tion o composite de ects. Cartilage gra ts rom the con-
skin. T e thin anterior skin rmly adheres to the peri- tralateral ear can restore the structural ramework and
chondrium without subcutaneous tissue interposed, and preserve contour, and are necessary i the antihelical or
contains a high density o sebaceous glands, particularly helical cartilages have been sacri ced (Fig. 19-20). Because
in the scaphoid and conchal regions. T e posterior skin is conchal bowl cartilage does not contribute to overall ear
thicker and more loosely adherent, contains a 1 to 3 mm shape and size, cartilage gra ts are usually not required or
thick adipose layer, and is less sebaceous. A curl in the car- reconstruction in this location.39 T e plenti ul reservoir o
tilage and a roll o subcutaneous tissue contribute to the skin that PIFs provide also allows or repair o large lobular
238 size and shape o the helical rim.39 A reely hanging lobule de ects, with or without cartilage placement.
 2

C
a
p
A B

1
9
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:
A
x
a
l
P
a
a
d
i
p
l
a
F
l
a
p
s
C D

Figure 19-20 A. C mp s d c sk a d ca lag al g m d l cal m. B. A ca -

lag g a as b av s d m ps la al a l x. t d s as b su u d w
u g cu a us su u s. t ca lag g a as b su u d d c . C. App a a c
p s au cula p la ap mm d a ly a p ma y s . n a c v s a -
a dp s su ac s ca lag p m z bl d supply. D. App a a c 1 m a
d vs a d s d m s a g s d l cal m c u.

corresponding to the height o the PIF. A more challeng-

d es Ig n In g t h e f l AP ing task is to precisely measure the horizontal dimension,
dictated by whether the de ect involves the rim or extends
Once it has been determined that the PIF may repair a to the anterior or posterior sur ace. In these scenarios,
particular de ect, one must decide whether cartilage sup- the ap must reach the most anteromedial portion o the
port is necessary. I the ear’s structural integrity or the de ect without tension. I the de ect involves the helical
helical rim convexity has been compromised, cartilage rim and anterior ear, length must be added to account
gra ting should be considered. A PIF repair or helical or or the skin curving or bending around the rim into the
antihelical composite de ects without cartilage can pro- scaphoid ossa. Incorrect ap design can lead to excessive
vide coverage but may not recreate the auricular contour. tension or inability to reach the anteromedial aspect o the
A contralateral conchal strut provides strength and a de ect. Anteriorly rotated ears or large antihelical de ects
longitudinal substructure or the PIF, and is typically per- challenge the surgeon to develop a ap traversing the span
ormed immediately prior to PIF trans er. rom scalp to ear without excessive tension. acking the
For both skin and composite de ects, PIF design should posterior ear to the mastoid area above and/or below the
precisely match the de ect dimensions. Appreciation o position o the anticipated ap bridge secures and pins
the de ect’s three-dimensional nature will allow or suc- back the pinna, reducing both the ef ective de ect length,
cess ul repair. First, the vertical height must be measured, and its required length. 239
2 Marking the template will vary based upon the de ect’s
anteromedial aspect. ypically, or de ects restricted to
I the PIF extends over the scaphoid ossa, one may
consider using horizontal mattress quilting sutures ori-
the helical rim, the leading edge can be drawn within the ented along the scaphoid ossa to recreate its concavity
postauricular sulcus, its vertical dimension mirroring (Fig. 19-21).45 For large antihelical de ects sparing the
the de ect’s vertical dimension. As the template extends rim, a modi ed PIF may be chosen, per orming a usi orm
toward the mastoid, these horizontal lines may be wid- excision o cartilage along the scaphoid ossa concavity,
ened slightly and Burow’s triangles added to increase ap through which the PIF can be pulled to preserve the heli-
movement. Placing the ap’s leading edge in the sulcus or cal rim.46 T ere are instances in which postauricular skin
de ects extending medially onto the antihelix may not pro- may not be su cient to resur ace a large anterior de ect.
vide su cient reach. In these cases, postauricular skin can T e surgeon should consider using skin gra ts or an inter-
be used. T e vertical ap is drawn as previously noted but polated preauricular ap or these cases.
its leading edge marked to the posterior angle o the heli- A ter the PIF is sutured into place, Xero orm gauze
cal rim. For wide de ects extending onto the postauricular is generally placed around the raw pedicle and changed
sur ace, the ap’s leading edge may actually begin at the weekly. Excessive compression should be avoided. Insert-
de ect’s posterior edge, which allows the PIF to be brought ing gel oam or Merocel nasal packing into the pocket
S
medially with minimal tension and ensures a width- ap behind the PIF can minimize the risk o bleeding.47 T e
c
ratio less than 3:1. A general guide or ap length can be patient should limit compression o this site by sleeping on
estimated by pushing the ear against the mastoid skin. T e their back or contralateral side.
2
proximal PIF base should stop just short o hair-bearing
:
:
skin to avoid trans erring hair to the ear.
t Ak In g d o w n t h e f l AP
S
u
g
l If t In g t h e f l AP
c
At 1 week, sutures are removed and the Xero orm gauze
a
l
replaced. Mid-pedicle compression allows assessment o
S
k
T e PIF is incised along the rectangular markings to the the distal blood supply. akedown is usually per ormed
l
l
s
level between the subcutaneous tissue and ascia and ele- a ter 3 weeks, but delaying division or an additional week
vated beginning at the leading edge o the ap. I template or two can improve the blood supply. A cotton-tipped
design begins on the postauricular sur ace, the ap should applicator may be inserted in the pocket behind the PIF and
be raised at the level o perichondrium; dissection contin- mastoid skin to provide counterpressure and a scalpel used
ues to the posterior sulcus, where there is a transition to to divide the pedicle. Judicious selection o the incision site
mastoid ascia. T e dissection is carried as ar as needed ensures that enough postauricular skin will be mobilized to
to reach the distal de ect. I necessary, Burow’s triangles the recipient area. A conservative approach may be taken
may be removed at the proximal base to assist in distal ap by incising the vertical length o the ap at its base near the
movement. Undermining should be per ormed but does hairline. T e additional skin can be thinned to match the
not tend to mobilize mastoid skin signi cantly. auricular thickness. I the de ect extends to the postauricu-
Because the PIF is not an axial ap, the surgeon must lar sur ace the excess ap skin is wrapped around the helical
preserve its subcutaneous at. T e preserved subcutane- rim, and the proximal aspect sutured in a layered ashion.
ous tissue not only increases ap viability but also provides Postauricular de ects are sometimes too wide to be ully
bulk to recreate the helical rim convexity. Even i cartilage covered by the PIF, but are out o view and have healthy
has been placed, bulky aps rarely present a problem, as granulation tissue by the time o takedown. T e PIF may
they can be recontoured later. When the ap is in place, there ore be wrapped around the postauricular sur ace as
a small open pocket remains behind the ear, an issue ar as tension allows and sutured into place. T e remaining
because the mastoid ascia has per orators that can cause de ect may granulate without aesthetic penalty.
postoperative bleeding. Besides compromising ap viabil- T e skin edges o the mastoid de ect should be resh-
ity, limited access may require ap take-down to allow ened. T is tissue may be mobilized and advanced to the
hemostasis. o avoid this complication, hemostasis must postauricular sulcus. A layered repair may be per ormed i
be obtained be ore insetting. it reaches the sulcus. I the skin cannot be mobilized, the
area may be le t to heal or closed partially. Skin gra ts are
usually not necessary because o the hidden location and
In s et t In g t h e f l AP reliable cosmesis o second intention healing.

T e preceding steps should ensure that the ap is raised

with su cient subcutaneous tissue and can reach the c o mmo n PIt f Al l s
de ect with minimal tension. Posteromedial displacement
o the ear toward the mastoid during inset can also decrease An d s o l u t Io n s
tension. T e anterior ear skin is so thin that dermal suture
placement can be di cult, although the more generous Complications are rare and can usually be avoided by
so t tissue at the helical rim can provide an anchor or bur- proper ap design and gentle tissue handling. o avoid
ied sutures. Exaggerated eversion at the helical rim will postoperative bleeding, patients should have all nonessen-
decrease the risk o notching. T e ap should reach with- tial anticoagulants discontinued preoperatively. T e ap
out tension and can be approximated with a single layer should be wrapped care ully with light pressure a ter the
o sutures, which may be le t in place or 2 weeks to gain procedure. In certain instances, a hematoma may arise,
240 additional strength. which can compromise viability and cause ap necrosis.
 2

A B

C
a
p
1
9
:
:
A
x
a
l
P
a
Figure 19-21 A. La g d c sup l cal
m a d p s su ac a . B. App a a c

a
p s au cula p la ap a p ma y s .

d
t l ad g dg ap was ld d c a

i
scap d ssa. i d d su ac d c .t
p s p was l al by s c d . C.

p
App a a c 3 m sa d vs a d s .t ap as

l
C

a
s dc u al g l cal m.

F
l
a
p
s
A common error is to underestimate the distance that the
PIF must travel to reach the anteromedial aspect o the
c o n c l u s Io n
de ect. T is can be avoided by marking its leading edge
on the postauricular sur ace rather than within the sul- “Form and function are a unity, two sides of one coin.
cus. Necrosis can also occur i the ap is raised without In order to enhance function, appropriate form must
subcutaneous at or thinned too much at trans er. Rais- exist or be created.”
ing the PIF at the mastoid ascia- at junction and avoiding
Ida P. Rolf
excessive thinning at takedown will help optimize viabil-
ity. In ection and chondritis can complicate PIFs, usually Optimal acial reconstruction realizes the dual goals o
presenting 3 to 5 days a ter ap trans er. Material available restoring both natural appearance and normal unction.
or culture should be sent or speciation and sensitivities, One needs master ul knowledge o acial anatomy, techni-
and patients may be placed on antibiotics. Nonsteroidal cal pro ciency and artistic creativity. Staged aps like the
anti-in ammatory agents can minimize pain and in am- paramedian orehead ap, MIF, and PIF to repair complex
mation. de ects o the nose and ear serve as per ect examples o
wo common aesthetic complications seen with the PIF this undamental tenet.
include helical rim notching and scaphoid ossa blunting.
T e ormer may result rom inadequate skin trans er. T e
surgeon must care ully measure the de ect and ensure that r ef er en c es
the ap markings on the postauricular sur ace are correct.
T e incision made at takedown should occur close to the 1. Roxbury C, Ishii M, Godoy A, et al. Impact o crooked nose
rhinoplasty on observer perceptions o attractiveness. Laryn-
hairline to provide more bulk i necessary. I large com- goscope. 2012;122(4):773– 778.
posite de ects are not supported with cartilage prior to 2. Springer IN, Wannicke B, Warnke PH, et al. Facial attrac-
PIF trans er, notching or decreased helical rim projection tiveness: visual impact o symmetry increases signi cantly
can result. Notching may also occur i the wound edges towards the midline. Ann Pla st Surg. 2007;59(2):156– 162.
are not everted when the ap is sutured into place. Verti- 3. Godoy A, Ishii M, Byrne PJ, Boahene KD, Encarnacion CO,
Ishii LE. T e straight truth: measuring observer attention to
cal mattress sutures may be o some help. Scaphoid ossa the crooked nose. Laryngoscope. 2011;121(5):937– 941.
blunting can be prevented with quilting sutures at PIF 4. Godoy A, Ishii M, Byrne PJ, Boahene KD, Encarnacion
trans er. CO, Ishii LE. How acial lesions impact attractiveness and 241
2 perception: dif erential ef ects o size and location. Laryngo-
scope. 2011;121(12):2542– 2547.
24. Somoano B, Kampp J, Gladstone HB. Accelerated takedown
o the paramedian orehead ap at 1 week: indications, tech-
5. Han SK, Lee DG, Kim JB, Kim WK. An anatomic study o nique, and improving patient quality o li e. J Am Acad Der-
nasal tip supporting structures. Ann Pla st Surg. 2004;52(2): matol. 2011;65(1):97– 105.
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6. Rohrich RJ, Hoxworth RE, T ornton JF, Pessa JE. T e pyri- struction o alar de ects. Br J Pla st Surg. 1978;31(2):79–92.
orm ligament. Pla st Reconstr Surg. 2008;121(1):277– 281. 26. Pharis DB, Papadopoulos DJ. Superiorly based nasolabial
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system: surgical applications in rhinoplasty. Arch Facial Pla st 27. Fisher GH, Cook JW. T e interpolated paranasal ap: a novel
Surg. 2008;10(2):109– 115. and advantageous option or nasal-alar reconstruction. Der-
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tional anatomic study o the relationship o the nasal car- 28. Fosko SW, Dzubow LM. Nasal reconstruction with the cheek
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1998;108(7):1025–1032. 587.
9. Ali-Salaam P, Kashgarian M, Davila J, Persing J. Anatomy o the 29. Fader DJ, Baker SR, Johnson M. T e staged cheek-to-nose
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266; discussion 7– 71. lobule. J Am Acad Dermatol. 1997;37(4):614– 619.
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c
anatomical pro le o the nasal musculature: dilator naris ves- determinants o aesthetically success ul nasal reconstruction: a
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2
Clin Anat. 2011;24(2):162– 167. 31. Zitelli JA. Secondary intention healing: an alternative to sur-
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num. Pla st Reconstr Surg. 2001;108(5):1118– 1126. 32. Zitelli JA. Wound healing by secondary intention. A cosmetic
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S
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struction. Pla st Reconstr Surg. 1985;76(2):239– 247. 33. Fader DJ, Wise CG, Normolle DP, Johnson M. T e multidis-
g
13. Rohrich RJ, Gri n JR, Ansari M, Beran SJ, Potter JK. Nasal ciplinary melanoma clinic: a cost outcomes analysis o spe-
c
a
reconstruction– beyond aesthetic subunits: a 15-year review cialty care. J Am Acad Dermatol. 1998;38(5 Pt 1):742– 751.
l
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o 1334 cases. Pla st Reconstr Surg. 2004;114(6):1405– 1416; 34. Karsidag S, Ozcan A, Sumer O, Ugurlu K. Single-stage ala
k
discussion 17– 19. nasi reconstruction: lateral nasal artery per orator ap. J Cra-
l
l
s
14. Rahman M, Jef erson N, Stewart DA, Oliver R, Walsh WR, niofac Surg. 2010;21(6):1887– 1889.
Gianoutsos MP. T e histology o acial aesthetic subunits: 35. Smit JM, Ruhe PQ, Acosta R, Kooloos JG, Hartman EH. T e
implications or common nasal reconstructive procedures. J nasolabial old as potential vascular receptor site: an ana-
Pla st Reconstr Aesthet Surg. 2010;63(5):753– 756. tomic study. J Reconstr Microsurg. 2009;25(9):539– 543.
15. Lane AP. Nasal anatomy and physiology. Facial Pla st Surg 36. Rohrich RJ, Pessa JE. T e at compartments o the ace:
Clin North Am. 2004;12(4):387–395, v. anatomy and clinical implications or cosmetic surgery. Pla st
16. Lee J, White WM, Constantinides M. Surgical and nonsurgi- Reconstr Surg. 2007;119(7):2219– 2227; discussion 2228– 2231.
cal treatments o the nasal valves. Otolaryngol Clin North Am. 37. Allison GR. Anatomy o the auricle. Clin Pla st Surg. 1990;
2009;42(3):495– 511. 17(2):209– 212.
17. Menick FJ. A 10-year experience in nasal reconstruction 38. Scla ani AP, Mashkevich G. Aesthetic reconstruction o the
with the three-stage orehead ap. Pla st Reconstr Surg. auricle. Facial Pla st Surg Clin North Am. 2006;14(2):103– 116,
2002;109(6):1839– 1855; discussion 56– 61. vi.
18. Burget GC, Menick FJ. Nasal support and lining: the mar- 39. Park SS, Hood RJ. Auricular reconstruction. Otolaryngol Clin
riage o beauty and blood supply. Pla st Reconstr Surg. North Am. 2001;34(4):713– 738, v– vi.
1989;84(2):189– 202. 40. Brodland DG. Auricular reconstruction. Dermatol Clin.
19. Reece EM, Schaverien M, Rohrich RJ. T e paramedian 2005;23(1):23– 41, v.
orehead ap: a dynamic anatomical vascular study veri y- 41. Park C, Lineaweaver WC, Rumly O, Buncke HJ. Arterial
ing sa ety and clinical implications. Pla st Reconstr Surg. supply o the anterior ear. Pla st Reconstr Surg. 1992;90(1):38–
2008;121(6):1956– 1963. 44.
20. Yu D, Weng R, Wang H, Mu X, Li Q. Anatomical study o 42. Farkas LG. Vertical location o the ear, assessed by the Leiber
orehead ap with its pedicle based on cutaneous branch o test, in healthy North American Caucasians 6– 19 years o
supratrochlear artery and its application in nasal reconstruc- age. Arch Otorhinolaryngol. 1978;220(1– 2):9– 13.
tion. Ann Pla st Surg. 2010;65(2):183– 187. 43. Adamson JE, Horton CE, Craw ord HH. T e growth pattern
21. Vural E, Batay F, Key JM. Glabellar rown lines as a reliable o the external ear. Pla st Reconstr Surg. 1965;36(4):466–470.
landmark or the supratrochlear artery. Otolaryngol Head 44. Shonka DC Jr, Park SS. Ear de ects. Facial Pla st Surg Clin
Neck Surg. 2000;123(5):543–546. North Am. 2009;17(3):429– 443.
22. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. 45. Johnson M, Fader DJ. T e staged retroauricular to auricular
T e anatomy o the corrugator supercilii muscle: part II. direct pedicle (interpolation) ap or helical ear reconstruc-
Supraorbital nerve branching patterns. Pla st Reconstr Surg. tion. J Am Acad Dermatol. 1997;37(6):975– 978.
2008;121(1):233– 240. 46. Mellette JR, Ho DQ. Interpolation aps. Dermatol Clin.
23. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. 2005;23(1):87– 112, vi.
Anatomy o the corrugator supercilii muscle: part I. Corruga- 47. Justiniano H, Eisen DB. Pearls or per ecting the mastoid
tor topography. Pla st Reconstr Surg. 2007;120(6):1647– 1653. interpolation ap. Dermatol Online J. 2009;15(6):2.

242
 Ch a p t e r

20 Skin Grafting
Hi ry Johnson J h ngir & Kir Minkis

In t r o d u c t Io n a n d and are typically placed into a wound to provide structural

support ( able 20-1).2
Ba c kg r o u n d
T e origin o skin gra ting dates back approximately 3000 Wo u n d Hea l In g
years ago, when autologous gra ts were used to repair
mutilated noses, ears, and lips in India.1 In the era o mod- T e survival o a skin gra t is dependent upon establish-
ern medicine, the rst reports o success ul skin gra ting ment o an adequate blood supply rom the recipient site.
date rom the mid to late 19th century, with Reverdin’s Gra t wound healing takes place through three phases.
report in 1869 presenting the use o pinch gra ts to accel- T e rst phase, plasmatic imbibition, takes place 24 to 48
erate healing o granulating wounds. Currently, there are hours a ter placement. During this phase, brin acts as an
a multitude o applications utilizing skin gra ting. T ese adhesive to help attach the gra t to the recipient bed.3 T e
include reconstruction ollowing surgery, tissue replace- gra t is then able to absorb exudate rom the recipient bed
ment in burn victims and patients with epidermolysis bul- and becomes edematous, with its weight increasing up to
losa, treatment o chronic ulcers, and hair transplantation. 40%.4 T is allows gra t hydration, provides a nutrient sup-
Free skin gra ts are pieces o skin o variable thickness ply, and helps to temporarily preserve gra t vessel patency.
and size that are completely detached rom their origin With time, granulation tissue replaces brin in the wound
(donor site) to cover a de ect (recipient site). Skin gra ts bed, allowing permanent attachment.
can be subdivided into our types, including ull-thickness Inosculation ollows 48 to 72 hours a ter gra ting and
skin gra ts (F SGs), split-thickness skin gra ts (S SGs), is a process o revascularization. During this phase, vas-
composite gra ts (CG), and ree cartilage gra ts (FCG). cular anastomoses are ormed between the recipient bed
F SGs are composed o the entire epidermis and the ull and pre-existing vessels in the dermis o the gra t.5 Neo-
thickness o dermis, including adnexal structures such as vascularization and vascular proli eration constitute the
hair ollicles and sweat glands. S SGs are composed o nal stage o gra t survival, consisting o blood vessel bud-
the ull epidermis and partial dermis that vary by overall ding and sprouting in the gra t and the wound bed and
thickness. CGs are composed o at least two di erent tis- the development o vascular connections allowing blood
sue types, usually skin and cartilage in cutaneous surgery. f ow between them. T e “bridging phenomenon” also
FCGs consist o cartilage with its overlying perichondrium allows or inosculation to occur in small avascular wound

Ta bl e 20-1
c mp is S i g t yp s u s i r s i

g B f s r is s
FTSG Fu thickn ss skin Optim cosm sis, unction, nd D ct siz imit d y donor tissu v i i ity
h ing or m ny d cts R quir s v scu r gr t d du to high m t o ic
d m nd
STSG P rti thickn ss Gr t r surviv on v scu r gr t Su optim cosm sis
skin d du to ow r m t o ic d m nd Contr cts mor s it h s
Gr t r donor tissu v i i ity Donor sit gr nu tion nd cosm sis
p rmits cov r g o rg r d cts
CG Skin–c rti g –skin On st g r p ir o u thickn ss or Gr t st m t o ic d m nd c n imit surviv nd siz o
d p r r d cts r quiring c rti g d ct (<2 cm)
Donor sit s imit d, mor dif cu t to r p ir, possi
donor sit p in nd chondritis
C rti g incr s s risk o in ction or gr t disp c m nt
FCG C rti g Structur / unction support or som Possi donor sit p in nd chondritis
p richondrium r, h ic rim, or ow r y id d cts C rti g incr s s risk o in ction or gr t disp c m nt
2 beds through vascular reanastomoses that derive exclu-
sively rom the wound edges.6 Revascularization requires
Ta bl e 20-2
adequate, healthy microvasculature in the recipient site. ch is i s f d i i Ft Sg d Si s
Within 4 to 7 days, ull circulation is restored to the gra t, Co or
the rate o which is determined by gra t thickness as well
as recipient bed vascularity. By 7 days, lymphatic circula- T xtur
tion is also restored.7 Reinnervation o the gra t may begin Thickn ss
in approximately 2 to 4 weeks, but recovery o ull sen-
S c ous qu ity o th surrounding skin
sation may require months to years or may never return
completely. V scu r p tt rn
Establishment o a stable vascular supply is essential History o sun xposur
or gra t survival. Factors that can decrease gra t survival
include prolonged ischemic periods as a result o disrup- a i ity to c mouf g donor sc r
tion o vascular connections, usually due to mechanical
shearing orces, seroma, hematoma, or in ection. T e
S
most common in ectious agents associated with gra t ail-
c
and clot ormation and gauge the potential success o skin
t
i
ure include coagulase-positive staphylococci, β-hemolytic
o
gra ting. Important questions that help predict challenges
n
streptococci, and Pseudomona s species. T e latter are
2
or intraoperative hemostasis or postoperative bleeding
especially common on the ears or near the eet since Pseu-
include anticoagulant medications, blood thinning herbal
:
:
domona s ourishes in moist locations as normal ora or
supplements, a history o bleeding tendencies, and hyper-
due to associated nosocomial in ection.8
S
tension.9 Questions regarding the patient’s general medi-
u
In addition, patient actors such as nicotine intake,
r
g
cal health may highlight actors that could impair wound
i
nutritional de ciencies, and diabetes mellitus can limit
c
healing due to a limited vascular supply. Compliance
gra t nutrient or vascular supply. Moreover, certain medi-
S
with postoperative wound care instructions is essential
k
cations may slow wound healing including corticosteroids,
i
to gra t survival. Physical activities or gra t site manipu-
s
chemotherapeutic agents, immunosuppressive medica-
lation resulting in shearing orces between the gra t and
tion, and anticoagulants. A proper preoperative patient
its recipient bed may result in gra t ailure. A discussion
evaluation is, there ore, essential, as are meticulous opera-
regarding postoperative expectations including healing
tive technique and postoperative wound care.
time, surgical scars, and potential complications is impor-
tant or increased patient compliance and optimization o
Fu l l -t HIc kn eSS SkIn g r a Ft S surgical outcomes.

F SGs are most commonly used to reconstruct acial de ects d o n o r SIt e Sel ec t Io n
a ter skin cancer excision. While F SGs are more prone to
necrosis than S SGs due to greater nutritional require- T e selection o an F SG donor site depends on optimal
ments, F SGs tend not to contract as much and also display matching o donor tissue to recipient site tissue based on
a superior color and texture match. T e main requirements the ollowing characteristics: color, texture, thickness,
or use o F SGs include a recipient bed with a suf cient sebaceous quality o the surrounding skin, vascular pat-
vascular supply or neovascularization and nutritional sup- tern, and history o sun exposure ( able 20-2).7 F SGs
port o the gra t, as well as broblasts to supply collagen obtained rom sun-exposed areas above the shoulders pro-
or gra t adherence. T e success o gra ting avascular areas vide an optimal match or most acial de ects. T e thick-
depends on the depth and vascular integrity o the recipi- ness o the desired gra t is one actor that determines the
ent site as well as the size o the area, with small avascular site o gra t harvesting ( able 20-3). T e thinnest gra ts
areas less than 1 cm in diameter allowing reestablishment are usually harvested rom the upper eyelid or the post-
o the blood supply through the bridging phenomenon.6 auricular sulcus. T e preauricular and cervical regions
F SGs may lack a suf cient blood supply i their wound bed can provide donor tissue or medium-thickness gra ts.
eatures larger areas o avascular tissue (exposed cartilage, T icker gra ts can be taken rom the supraclavicular or
bone, nerve, or tendon lacking overlying perichondrium, clavicular region, conchal bowl, orehead, or nasolabial
periosteum, perineurium, or peritenon, respectively). old. However, patient variability in skin thickness, tex-
F SGs contain epidermis and ull-thickness dermis, ture, sun exposure, and color preclude strict guidelines or
making them good reconstructive options or repair o
acial de ects owing to their intact adnexal structures and
superior color, texture, and thickness matches compared Ta bl e 20-3
with partial-thickness gra ts. Facial areas in which F SGs Ft Sg s d Si s B s g f t hi ss
are particularly use ul include the lower eyelid, ear, or
nasal sites (tip, dorsum, ala, or lateral sidewall). Thinn st gr ts Upp r y id or th post uricu r
su cus

Pr eo Per a t Iv e a SSeSSmen t M dium thickn ss gr ts Pr uricu r nd c rvic r gions

Thick st gr ts Supr c vicu r or c vicu r
As with any cutaneous surgery, a comprehensive preoper- r gion, conch ow , or h d,
or n so i o d
244 ative patient evaluation can help assess the risk o bleeding
 Ta bl e 20-4
provide a source or skin gra ting the sebaceous distal
nose. Perichondrial cutaneous gra ts consisting o epi-
2
Po ia d o or Si s for Ft Sg Bas o dermis, dermis, scant subcutaneous tissue, and the thin
l o a io of d f
perichondrium have been reported to result in less wound
D f ct oc tion Pot nti donor sit oc tion retraction and to provide greater lasting thickness and
possibly reduced necrosis.17 T e success o conchal F SGs
l ow r y id R dund nt upp r y id skin
without perichondrium has also been demonstrated; the
ey id nd uricu r d f cts Post uricu r skin donor site is allowed to heal secondarily.16 T ese gra ts
N s d f cts Pr uricu r skin (gr ft shou d
should be slightly undersized to minimize bulkiness due
o t in d from th h ir ss to “trapdoor” or “pin-cushioning” e ects.
r tw n th tr gus nd T e supraclavicular region or lateral neck may be poten-
th t r ch k) tial donor sites or repair o larger de ects on sun-damaged
skin, such as the orehead and vertex scalp. Other areas
ey rows or must ch r H ir ring skin of th
that may be used as donor sites or F SGs include areas
t mporop ri t r gion or
with thin redundant skin including the upper inner arms,

C
pr uricu r rd

h
orearms, and inguinal area, although these tend to have a

p
N s tip N so i fo ds or for h d suboptimal color and texture match or acial skin.

t
skin

r
2
0
Dist nos Conch ow
t ec Hn Iq u e

:
:
l rg r d f cts on sun Supr c vicu r r gion or t r
d m g d skin (for h d n ck, inn r upp r rm

S
Multiple di erent techniques or per orming F SGs

k
nd v rt x sc p)

i
exist.2,7,16,18,19 o plan or harvesting an F SG, a template

n
G
o the recipient de ect may be used to recreate the dimen-

r
sional needs or coverage, particularly when the de ect’s

f
t
i
n
depth or contour requires accommodation (Fig. 20-1A–

g
selection o donor sites. Rather, individual patients need G). Any exible material, including paper, gauze pads, or
to be examined care ully and their location or ideal gra t aluminum oil, can be used . T e periphery o the de ect is
harvesting will be determined by the characteristics o the marked with a sterile marking pen. T e material is pressed
recipient bed and donor tissue. against the recipient site in order to outline the border
Obtaining a gra t rom skin in close proximity to the drawn with the pen, thus creating a template that can be
recipient site may potentially provide the best tissue used to harvest an appropriate F SG. T e template can
match or a given de ect ( able 20-4). Redundant upper then be used to mark the donor site prior to injection o
eyelid skin can be used to gra t lower eyelid de ects, thus anesthetic to avoid sizing error resulting rom tissue dis-
providing an optimal textural and color match. Using tortion. In many cases, the F SG will have suf cient tissue
upper eyelid skin as donor tissue has the additional stretch to properly cover the de ect. Sometimes the F SG
advantage o leaving an inconspicuous donor site scar.10– 12 may be resized to be larger than the template to allow or
Lax tissue adjacent to a acial de ect can also be used a contraction and shrinkage o the gra t a ter harvesting.
Burow’s triangle as a partial F SG. T is usually occurs When de ects approach a ree margin such as the lower
when there is suf cient skin mobility to permit partial eyelid or over joint sur aces, gra ts should be oversized to
closure o the wound, thereby allowing the adjacent skin avoid excess tension and dys unction that may occur due
to resur ace the remaining de ect. Postauricular skin pro- to gra t contraction. In addition, concave wounds and sur-
vides ample donor tissue or repair o eyelid and auricular aces with complex sur ace contours require special siz-
de ects, and donor site scars in this area can be camou- ing considerations to prevent tenting o the gra t in the
aged easily, which can be advantageous. However, this concavities o the recipient bed.2 Standard surgical prepa-
skin may be a poor color match or sun-exposed acial ration using local anesthetic and application o antisep-
de ects because it is relatively less actinically damaged. tic soap is per ormed. Epinephrine may be used without
Preauricular skin can be used or repair o many nasal adversely impacting gra t survival. During the harvesting
de ects, owing to its thickness, numerous sebaceous o the F SG, the recipient bed should be kept moist and
glands, and similar degree o sun exposure.13,14 One must may be covered with saline-soaked gauze.
take care to avoid harvesting preauricular hair-bearing T e donor skin is excised to the level below the der-
skin to avoid unwanted hair growth within the gra t, par- mis and placed in a sterile container with normal saline
ticularly on the nose. T e gra t should be obtained rom while hemostasis o the donor site is achieved. T e gra t
the hairless area between the tragus and the lateral cheek, is usually used within 1 to 2 hours but may be used up to
and all ollicles should be trimmed rom the underlying 24 hours a ter harvesting i re rigerated or kept on ice.
subcutaneous at to ensure their removal. Conversely, i Minimally delaying gra t placement is optimal, however.
hair growth is desired within a gra t, such as or repair T e gra t may need to be de atted prior to placement
o the eyebrows or mustache area in men, a gra t may be by trimming super uous at with sharp, curved, or ser-
harvested rom the hair-bearing skin o the temporopari- rated scissors rom the dermal aspect o the gra t until
etal region or preauricular beard. T e nasolabial olds or the undersur ace has a white, shiny appearance (Fig.
orehead skin can be used as donor sites to repair small 20-1C). T is step can improve direct contact between the
de ects o the nasal tip, although the donor scar may be gra t dermis and recipient bed or nutritional require-
somewhat conspicuous.15,16 T e conchal bowl can also ments, establishment o anastomoses between blood 245
2

A B
S
c
t
o
n
2
:
:
S
u
r
g
c
S
k
s
C D

E F

Figure 20-1 P c m nt o u -th ckn ss sk n gr t. A. a

d ct o th ow r nt r or r s pr s nt t r r mov o
s c c rc nom w th Mohs m crogr ph c surg ry. a
post ur cu r donor s t prov d d th st t ssu m tch n
th s c s . B. a t mp t o th d ct s m d rom t
p d y pr ss ng t g nst th d ct. Th r su t ng out n
o th ood-st n d p d s rv s s gu d to cutt ng
pr c s t mp t . C. Th gr t s c r u y d tt d so th t
on y th wh t , g st n ng sur c o th d rm s r m ns. D,
E. Fu -th ckn ss sk n gr t s wn nto p c w th 6-0 st -
sor ng gut sutur s. F. X ro orm™ o st r s wn nto p c
G
ov r u -th ckn ss sk n gr t w th 5-0 po ypropy n t -
ov r sutur s. G. On -w k o ow-up.

246
vessels, and new vessel growth. T e dermis may be ur-
ther trimmed i indicated to con orm to beveled wound
through the central portion o the gra t to the level o the
recipient bed and back up to the gra t sur ace; they may
2
edges or di erences in recipient site depth, or to recre- also extend through the ull thickness o the recipient bed
ate normal sur ace contours. Prior to gra t placement, to the opposing epidermal sur ace and back to the gra t
some authors advocate that the recipient site be urther sur ace in locations such as the pinna. Some authors rec-
prepared. T e recipient site edges o the de ect may be ommend placement o the basting sutures prior to ully
undermined to minimize postoperative pin-cushioning, securing the perimeter o the gra t to allow or direct
promote uni orm wound contracture, and improve epi- visualization and to avoid injury to underlying structures
dermal approximation o the recipient site and F SG. such as blood vessels. Less commonly, enestrations or
However, undermining o the recipient site is not uni- small slits puncturing the gra t may be placed to allow or
orm practice and may not be necessary. Care ul hemo- drainage i there is concern or impending uid collection
stasis o the recipient site should be obtained to prevent beneath the gra t.
any barrier to good contact between the gra t and its
nutrient supplying bed. Caution to avoid excessive char-
ring is also needed. Particularly when gra ting auricular Sec u r In g t He g r a Ft

C
h
de ects, portions o cartilage that are not needed or

p
structural support should be removed to increase the raditionally, the gra t is immobilized with a tie-over bol-

t
ster dressing that serves to keep the gra t in place through

r
chance o gra t survival; this may be particularly use ul

2
application o direct, constant pressure (Fig. 20-1F). Bol-

0
or auricular de ects, and may be accomplished using a
punch device.18,20,21 stering the gra t promotes neovascularization, prevents

:
:
T e F SG is then positioned in the recipient bed. ormation o hematoma or seroma, and prevents patient
manipulation o the gra t. A generous amount o emol-

S
o ensure adequate wound healing, F SGs must make

k
lient such as petrolatum is rst applied over the gra t. A

n
direct contact with the underlying wound bed and should

G
be immobilized in the immediate postoperative period nonadherent contact layer may be applied with a prod-

r
to prevent gra t separation. Various methods accomplish uct such as petrolatum-impregnated gauze (Xero orm™

t
gauze: bismuth tribromophenate-petrolatum-impreg-

n
anchoring o the F SG, including perimeter sutures,

g
basting sutures, support dressings, or a combination nated gauze, Kendall; N- er ace, Win eld Laborato-
o these (Fig. 20-1E,F). Perimeter sutures reapproxi- ries, Dallas, X; Adaptic, Johnson & Johnson Medical).
mate the edges o the gra t with those o the recipient An anchoring stent can be made o a variety o materi-
site. A ter the gra t is placed in the recipient bed with als (petrolatum-impregnated gauze, cotton balls, oam
the dermal side down, it may be secured with anchoring rubber, sponges, plastic beads, or disks) and is normally
sutures so that apposing skin edges may be approximated sutured into place. Staples, adhesive wound closure tapes,
(Fig. 20-1D). Suturing the ull length o the skin edges or Steri-Strips™can be used as an alternative. In a clas-
can be carried out using a variety o suture materials, sic tie-over bolster, nonabsorbable sutures are placed
matching the caliber o the suture to the skin thickness. on opposite sides o the periphery o the gra t, cut long
Absorbable sutures such as 6-0 ast-absorbing gut or 5-0 (3 to 6 cm), and tied tightly over the bolster to secure it in
mild chromic gut have the advantage that they dissolve place. T e number o sutures placed should be suf cient
over several days to weeks and thereby reduce the poten- to prevent tangential movement o the bolster materials.
tial or gra t disruption during suture removal. Sutures Subsequently, a light dressing consisting o nonstick gauze
are placed with the needle rst passing through the gra t and stretchable bandage tape ( el a pad and Hypa x tape;
side and exiting rom the adjacent recipient tissue. T e Smith & Nephew, Inc., Largo, FL) may be placed. T e
sutures should be placed deeply enough to approximate donor site can be dressed with a standard pressure dress-
the epidermis, papillary dermis, and reticular dermis. ing. T e utility o bolster dressings is a subject o debate
Very super cial placement o sutures has been impli- and they may not be strictly necessary; no di erence in
cated as a potential etiology o gra t pin-cushioning and gra t survival has been reported with or without use o a
hematoma ormation, as well as a more depressed, prom- bolster dressing.22,23
inent scar.12 Sutures placed slightly higher in the dermis
on the gra t side and slightly deeper in the dermis o the
recipient side, modestly insetting the gra t relative to Po St o Per a t Iv e c a r e
the recipient skin edges, may prevent gra t edge tenting
and enhance gra t– recipient bed contact.19 T e ull gra t Pressure dressings rom both donor– recipient and gra t–
periphery may be sutured to the recipient de ect using recipient sites may typically be removed in 24 to 48 hours.
simple interrupted sutures placed a ew millimeters Following removal o these, the donor site as well as the
apart or by placement o interrupted sutures at opposite area surrounding the bolster dressing can be cleansed
edges o the gra t periphery ollowed by a simple running once or twice daily with hydrogen peroxide and a petro-
suture (Fig. 20-1E). Additional gra t trimming as needed latum-based emollient generously applied. T e bolster
during this stage generates an ideal shape. dressing remains in place or 1 week. A ter removal o the
Additional sutures, termed basting sutures, can be bolster dressing and all tie-over sutures at about 1 week,
placed centrally, particularly or large or concave sur- the gra t may not necessarily appear pink and well-vas-
aces, to increase contact between the gra t and recipient cularized and the patient should be counseled to expect
bed (Fig. 20-2A). T ese sutures are use ul or gra ts over this prior to suture removal to avoid alarm. T e ideal gra t
concave sur aces to prevent tenting or or larger gra ts should be light pink in color, but may be yellowish or range
to minimize movement. Basting sutures o ten extend in color rom dark pink to blue or purple, which may be 247
2
S
c
t
o
n
2
:
:
S
u
r
g
c
S
A B
k
s
C D

Figure 20-2 A. FTSG or r p r o n r d ct. Not mu t p qu t ng, or st ng, sutur s. B–D. FTSGs t t m o sutur
r mov . Wh gr ts d y r p nk wh n th o st r s r mov d, th y c n v ry ng sh d s o p nk, y ow, u , or
v n purp , du to th pr s nc o cchymos s or crust ng. (F gur s 20-2b–D us d w th p rm ss on o D s r R tn r, MD.)

secondary to ecchymosis (Fig. 20-2B– D). A gra t that is as well as actors that could induce circulatory overload or
black or white in color may be an indication o necrosis swelling o the gra t, such as excessive physical activity, or
and gra t ailure. However, despite the possibility o epi- several additional weeks.
dermal necrosis, the gra t dermis and appendages may
remain viable and the necrosed epidermis can serve as
a natural biologic dressing. For this reason, the eschar
SPec Ia l c o n SId er a t Io n S
should not be debrided, but rather le t to protect any
remaining viable dermis and to allow or second-intention d eFec t SIz e r ed u c t Io n
healing in the event o gra t death.
Following suture removal, the gra t can be cleansed I easible, a purse-string suture may be placed around
gently with hydrogen peroxide to remove all crusts and the periphery o the de ect to make it smaller. T e purse-
loose debris, ollowed by a layer o emollient. It is also string suture is commonly a nonabsorbable mono lament
important to counsel patients that the vascular supply o that is placed subcuticularly around the skin edges or a
the gra t remains ragile or weeks. Patients should, there- period o 3 weeks. A ter care ully cinching and tying the
248 ore, avoid trauma, such as direct shower water to the area, suture, the horizontal dimensions o the de ect may be
 2

A B

C
h
p
t
r
2
0
:
:
S
k
n
G
r
t
Figure 20-3 A. l rg sc p d ct o ow ng Mohs r s c-

n
g
t on o n ccr n c rc nom , xt nd ng pr nc p y to
th p r ost um, w th w sm r s o xpos d on .
B. a purs -str ng sutur o 3-0 po ypropy n w s us d
to d cr s th s z o th d ct s gn f c nt y, nd n
FTSG t k n rom th nn r upp r rm w s th n p c d. C.
C Sutur r mov t 1 w k. (F gur s us d w th p rm ss on o
D s r R tn r, MD.)

evenly reduced in size depending on the surrounding tis- act as tissue ller. Small “pinch” dermal gra ts can be used
sue laxity (Fig. 20-3A– C).24 or larger strips may be harvested and placed in a grid-like
pattern along the de ect base.26
Hinge aps o er another approach to lling sizeable
d eeP Wo u n d S de ects by making use o nearby deep tissue. Subcutane-
ous hinge and myocutaneous hinge aps both help to cre-
o gra t deep de ects that cannot be e ectively covered ate a recipient bed that is well-vascularized and allow or
by F SGs, several strategies can be undertaken. T ese immediate repair o deep wounds with an F SG. T ese
include delayed gra t placement to allow or granulation aps borrow subcutaneous adipose and/or muscle tis-
tissue growth over the recipient site base, dermal gra ting, sue that lies adjacent to the de ect. T e borrowed tissue is
and hinge aps. Delaying gra t placement by 12 to 14 days hinged like the page o a book into the primary de ect, thus
may increase gra t survival over areas with poor recipient reducing the depth o the de ect, and resur acing its base
bed vascularity such as de ects o the nasal tip and ala with with vascular tissue. T e F SG can then be placed directly
denuded cartilage. A prospective trial o immediate versus over the hinge ap.27– 29 T e galeal hinge ap is a unique
delayed F SGs o the nasal tip and ala with denuded car- method or extending the partial thickness o adjacent
tilage showed improved gra t survival, decreased contrac- galea aponeurotica on the scalp to cover exposed bone
tion and decreased gra t depression with delayed F SGs (Fig. 20-4A–C).28 Yet another strategy or repair o deep
as opposed to immediate F SGs.25 nasal alar de ects is the use o the “drumhead” gra t repair.
Dermal gra ting is another method used to ll deep T is gra t was designed to prevent gra t depression and the
de ects prior to placement o F SGs. Dermal gra ts are inward collapse o the nasal vestibule due to surgical loss o
autologous and are generated by removing the epidermis tissue. T e gra t involves application o an overlying rigid
and subcutaneous at rom harvested skin. One common plastic suspension coupled with an undersized gra t.30
source or these gra ts consists o the Burow’s triangles Perichondrial cutaneous gra ts (PCCGs) may also be
rom the F SG donor site or other primary de ect closure. used in the repair o deep nasal tip and alar de ects, particu-
A ter harvesting this tissue, the epidermis is meticulously larly in de ects with exposed cartilage. T ese skin gra ts are
removed to prevent epidermoid cyst ormation and the CGs harvested rom the conchal bowl, and are composed
subcutis is also removed. T e remaining dermis can then o epidermis, dermis, a small amount o subcutaneous tis-
be inserted as a dermal gra t under any contour irregulari- sue, and underlying perichondrium. However, they do not
ties in the recipient site or to ll in a deep recipient site to include the cartilage. PCCGs are thicker, may o er better 249
2

A B
S
c
t
o
n
2
:
:
S
u
r
g
c
S
k
s
Figure 20-4 A. Sc p d ct o ow ng Mohs r s ct on o
rg s c c rc nom , xt nd ng to on . B. G
h ng ps h rv st d rom th dj c nt sc p t ssu w r
p c d to cov r th xpos d on . C. a n FTSG h rv st d
C rom th nn r upp r rm sk n w s p c d th r t r.
(F gur s us d w th p rm ss on o D s r R tn r, MD.)

survival under conditions o vascular compromise, and have triangles (Fig. 20-5A,B). T e advantage o a Burow’s gra t
a decreased tendency or contraction compared to F SGs.31 is that it provides skin with a more closely matched color,
texture, and thickness compared to gra ts obtained rom
distant donor sites. Additional advantages include the
Bu r o W’S g r a Ft S proximity o the donor site to the recipient site, requiring
a single bandage or the two, and the use o these gra ts in
T e Burow’s gra t is an F SG whose donor site is the hair-bearing areas given the close match o the type and
skin adjacent to a wound, usually consisting o Burow’s direction o the hair with the recipient site hair. T ere are

A B

Figure 20-5 A. l rg d ct o c ntr or h d t r Mohs surg ry. Th r w s su c nt t ssu x ty to c os s gn f c nt

port on o th wound. B. a burow’s FTSG rom on o th burow’s tr ng s w s us d to r p r th c ntr port on o th
250 d ct, wh ch cou d not c os d pr m r y. (F gur s us d w th p rm ss on o D s r R tn r, MD.)
several variations o the Burow’s gra t.12 T e classic tech-
nique consists o excising two Burow’s triangles on either
at higher risk or in ection. When given, the antibiotics
should cover Staphylococcus and Streptococcus species;
2
side o the wound. Primary linear closure o the ends o or auricular gra ts, anti-pseudomonal coverage may be
the wound results in narrowing o the central portion. necessary.
T e remaining wound is gra ted with one or both o the Hematoma and seroma ormation can be avoided by
the Burow’s triangles as described above or F SGs. One meticulous intraoperative hemostasis, pressure dress-
variation help ul in areas to avoid bidirectional length- ings, and postoperative avoidance o physical activity,
ening o the scar (i.e., to avoid crossing cosmetic bound- bending, and li ting or the rst ew weeks a ter surgery
aries) is to use a single Burow’s gra t. Again, primary to minimize shearing orces o the gra t over its bed.
closure o the excised Burow’s gra t side o the wound Preoperative avoidance o anticoagulants, pending con-
causes narrowing o the de ect to a teardrop-shape, sultation with the patient’s cardiologist or primary care
which is then gra ted using the Burow’s triangle as above. provider, is advisable only i these agents are not neces-
A similar variation or wounds with immobile margins is sary or management o coagulopathy or prevention o
the use o a larger Burow’s triangle that results in a gra t blood clots and their sequelae. Nicotine-induced vaso-
as wide as the original wound. Finally, a variation or constriction is also associated with an increased risk o

C
h
wounds extending onto two cosmetic units makes use o gra t ailure, and patients should, there ore, be encouraged

p
one Burow’s triangle as the F SG or one cosmetic unit to decrease cigarette or nicotine consumption or several

t
r
while the second portion o the de ect is closed by tissue days prior to and ollowing surgery.

2
0
advancement.12 Long-term complications o F SGs consist o cosmetic
and unctional problems. Extensive preoperative coun-

:
:
seling is important in alleviating patient’s postoperative
Ha Ir -Bea r In g g r a Ft S

S
concerns regarding gra t appearance ollowing surgery. It

k
n
should be stressed that it may take 6 months or longer or

G
Although used less commonly than aps in hair-bear- gra ts to heal and reach their ultimate cosmetic outcome.

r
ing areas, gra ts can be used in these areas with some F SGs may be depressed initially, but this depression

t
special considerations. One important consideration is

n
tends to improve within 4 to 6 weeks. Camou age make-

g
that the gra t should be obtained rom a location with up and sunblock can usually be applied 3 to 4 weeks a ter
hair characteristics similar to those o the recipient site, gra t placement, thereby minimizing erythema and tex-
namely hair o the same caliber and density. It is impor- tural irregularities. Spot dermabrasion or laser resur acing
tant to anticipate a patient’s propensity or developing o the gra t and the surrounding complete cosmetic unit
androgenetic alopecia when determining the location can lead to improvement in color, consistency and eleva-
rom which to har vest an F SG rom the scalp. T e tion.32 T is can be per ormed at any time a ter 6 weeks
occipital and temporal regions o the scalp are com- to 6 months, although it is best per ormed 6 to 8 weeks
monly used donor sites as these sites are less likely to ollowing gra ting. Hyperpigmentation o the gra t can be
develop androgenetic alopecia; however, these would treated with a brie course o topical hydroquinone and/
not be ideal or gra ting o the vertex scalp in a patient or tretinoin combined with sunblock and usually resolves
with androgenetic alopecia, as the gra ted skin would completely.
likely retain terminal hairs whereas the hairs in the sur- Functional complications o F SGs occur primarily as
rounding skin would miniaturize. When har vesting and a result o wound contraction. T e degree o wound con-
preparing the hair-bearing F SG, the gra t should be traction depends in part on thickness o the F SG and
minimally de atted, as the hair bulbs are contained in in part on location o the gra t, with gra ts applied to the
the subcutis and extensive de atting can result in loss o periorbital or nasal areas contracting more than those
ollicles. De atting, there ore, should only be per ormed applied to the scalp and temples. T ere ore, gra ts placed
between the hair bulbs, i at all. In addition, proper in de ects with lax ree margins (such as eyelids, lips, nasal
orientation o the gra t, taking into consideration the ala) should be oversized to account or gra t contraction.19
direction o hair growth, is important to maintain a uni- Gra t contraction usually increases as the thickness o the
orm direction o hair sha ts within the gra t and the gra t decreases. I poor unctional or cosmetic outcomes
surrounding skin. result rom wound contraction, secondary revisional sur-
gery may be needed.
POSTOPeRa TiVe COMPl iCa TiONS. T e com-
plications o ull-thickness gra ting can be divided into
two categories: short-term problems o gra t ailure and c o mPo SIt e g r a Ft S
long-term problems o poor unctional outcomes and cos-
metic de cits. O utmost importance in gra t survival is CGs are simply modi ied F SGs composed o two or
uninterrupted direct contact between the gra t and the more tissue layers. ypically, within the scope o der-
recipient bed, which is key to neovascularization. Short- matologic surger y, these two layers are skin and carti-
term causes o gra t ailure include in ection, hematoma, lage, although they can likewise be composed o skin
seroma, and shearing orces o the gra t over the wound and perichondrium, or skin and adipose tissue.31,33– 35
bed.19 Although in ection is rare in gra ts, care should be Scenarios in which the use o CGs is most bene i-
taken when handling the gra t and electrocautery o the cial include repair o de ects that require recreation
recipient bed should be avoided to minimize the pres- o structural integrity such as ull-thickness alar rim
ence o devitalized tissue. Antibiotics are not given rou- de ects and nasal tip de ects with cartilage loss (Fig.
tinely but may be considered in selected patients that are 20-6A– F).36 251
2

A B
S
c
t
o
n
2
:
:
S
u
r
g
c
S
k
s
C D

E F

Figure 20-6 A. D p p rt -th ckn ss d ct o r ght n s t r Mohs surg ry or s c c rc nom . B. Compos t

gr t t k n rom r ght h c crus s wn nto p c w th 6-0 st sor ng gut sutur s. C. R ght h c donor s t c os d
pr m r y. D. Fo ow-up v w 4 y rs postop r t v y (s d v w). E. Fo ow-up v w 4 y rs postop r t v y ( ront v w).
F. V w o th donor s t 4 y rs postop r t v y. (Us d w th p rm ss on o D s r R tn r, MD. R produc d w th p rm s-
s on rom K por s HG, C rucc Ja . R p r o d ct on th . in: R tn r DS, Coh n Jl , brod nd DG, ds. Reconstructive
Conundrums in Dermatologic Surgery: The Nose. Ox ord: W y b ckw ;2014. Copyr ght © 2014 a m r c n Soc ty or D r-
m to og c Surg ry.)

Cartilage contributes signi cantly to maintaining the valve dys unction. Alar notching is a potential problem
anatomic structure and unction o the nose and ears. In associated with deep wounds o the nasal ala. Contrac-
instances when cartilage must be excised, a unctional and tion o a de ect close to the rim can result loss o the
structural de cit results, which necessitates repair with smooth, continuous contour o the alar- ree margin.
either a composite skin gra t or an FCG. Repair o ull-thickness alar rim de ects may involve a
Rein orcement o structural integrity o the nose layered skin– cartilage– skin CG “sandwich” versus a
252 using cartilage helps prevent alar notching and nasal combination o composite or FCGs with overlying ap
reconstruction.2,19 Alar and alar crease de ects can also
cause nasal valve dys unction. T e nasal valve lies at the d o n o r SIt e Sel ec t Io n
2
upper end o the lateral crus o the alar cartilage. It pro-
vides resistance that controls the speed and volume o T e ear can typically serve as the donor site or CGs since
inspired air so that the nasal passages are kept patent. it eatures multiple areas with variable cartilaginous con-
Problems with nasal valve unction can result rom loss tours with overlying skin. T e most commonly used area
o alar tissue or cartilaginous support, causing the pas- o the ear or repair o nasal alar de ects is the crus o the
sage o air to become occluded during inspiration with helix; other areas that can be used include the helical rim,
symptoms o reduced nasal air ow. T is occurs when tragus, antitragus, and concha.36 T e thin overlying skin
the remaining nasal tissue collapses inward toward the and subcutis o the ear may provide a good tissue match
nasal septum due to lack o structural support. Cartilage or the alar skin, except or the most sebaceous areas in
can be used as part o the gra t to reestablish the struc- certain patients, typically located on the distal third o the
tural integrity o the ala, thereby reducing alar collapse nose. Repair o a highly sebaceous nasal tip is best per-
during inspiration. Delayed nasal valve obstruction can ormed using an auricular FCG in combination with a
also occur i a cartilage gra t is not placed when needed, better matched F SG or local skin ap instead o a CG.

C
I a CG is deemed use ul, the more sebaceous, thicker

h
as scar contracture o existing cartilage can also cause a
cartilaginous aspect o the concha serves as the pre erred

p
unctional nasal obstruction.37 Similarly, loss o cartilage

t
donor site. T e concha can also be used or reconstruc-

r
rom the ear canal may require replacement to maintain

2
tion o nasal sidewall, columella, and larger alar nasal

0
ear canal patency.
Other locations in which CGs are commonly utilized de ects.42– 44 Repair o donor sites on the ear varies by loca-

:
:
include the nasal sidewall and columella. Deeper nasal tion. Helical rim donor sites are typically repaired with
wedge excision; de ects involving the crus o the helix

S
de ects arther rom the alar rim, particularly with exposed

k
can be closed either linearly or by use o a local ap; and

n
cartilage, can be repaired with either conchal bowl CGs

G
using skin and cartilage or PCCGs, consisting only o skin de ects o the triangular ossa, scapha, conchal bowl, or

r
and perichondrium.31 cymba heal well by secondary intention. Removal o con-

t
chal cartilage with a small punch (2– 3 mm) can also help

n
g
with more rapid secondary intention healing rom the
Pr eo Per a t Iv e c o n SId er a t Io n S opposing dermal tissue.

Sur vival o CGs depends on rapid revascularization.

CGs have greater metabolic demands than simpler t ec Hn Iq u e
skin gra ts and are dependent upon the bridging phe-
nomenon or sur vival, as revascularization takes places A ter appropriate surgical decontamination, scar tissue
through direct vessel anastomoses between the sub- at the recipient site should be evaluated and debrided, i
dermal plexus o the gra t and the subdermal plexus o necessary, to optimize blood supply or the CG. A template
the wound edge. Unlike F SGs, in which reestablish- con orming to the recipient site is prepared and the donor
ment o blood low occurs through direct contact o site marked using the template. T e CG should be approxi-
the gra t base with the underlying wound bed, the pri- mately 5% to 10% larger than the de ect in order to compen-
mar y establishment o CG circulation relies on wound sate or the natural shrinkage o the gra t that occurs during
edge vascular supply, which, there ore, limits the size o healing.2 Both the cutaneous boundaries o the donor site
these gra ts. CGs or de ect diameters greater than 2 cm as well as what will become the cartilaginous wings ram-
are contraindicated due to an increased risk o central ing the gra t should be drawn out. A ter the marking is
necrosis. he ideal maximum size o CGs is, there ore, complete, the areas may be anesthetized with 1% lidocaine
1 to 2 cm with no more than 0.5 to 1 cm between any with epinephrine. T e CG is harvested by incising perpen-
point o the gra t and the wound edge.34,38– 40 Areas o dicular to the sur ace o the skin, with the rst pass o the
limited size with a rich vascular supply, such as the ear scalpel blade cutting through the skin and the second pass
or the nose, are the most use ul sites or use o CGs. through the cartilage. T e harvested CG is thus excised en
Surgical strategies to re urbish the recipient vascular bloc as a skin–cartilage or skin–cartilage– skin “sandwich,”
bed include use o hinge laps rom the margins o the depending on the coverage needs. T e donor site can then
de ect or delayed gra ting or optimal granulation tis- be closed by the most appropriate method, as mentioned
sue growth.41 Delay allows the de ect to heal by second previously. During this time, the recipient site should be
intention or several weeks with wound contraction and kept moist and the gra t may be stored in saline.
ormation o granulation tissue that can better support T e CG should be handled delicately to prevent any dis-
a gra t with a high nutritional demand. I this approach ruption o vasculature or detachment o skin or adipose
is undertaken, however, one must monitor or exces- tissue rom the cartilage. For a typical CG, the cartilage
sive wound contraction that can lead to unctional or may be secured using sutures o 5-0 polyglactin. T e cuta-
aesthetic impairment. he higher nutritional require- neous wound edges are reapproximated using 5-0 or 6-0
ments o CGs may hamper wound healing, especially absorbable or nonabsorbable sutures. Meticulous suturing
in patients with suboptimal health. here ore, patients technique helps to minimize strangulation o blood ves-
who have underlying risk actors or poor wound heal- sels and acilitates anastomoses between gra t and recipi-
ing such as smokers, diabetics, and patients with vaso- ent vascular beds.
occlusive disease, would not be ideal candidates or o prepare a CG or placement near a ree margin,
such repair options. a design using interlocking cartilaginous pegs may be 253
2 considered to enhance gra t adherence without the need
or placement o sutures within the cartilage. T e skin over-
Due to their high nutritional demands, CGs can also ail.
Revision can be accomplished using a two-stage melo-
lying the cartilaginous wings o the gra t may need to be labial interpolation ap or by attempting a second CG
trimmed. T e remaining cartilaginous pegs with overlying procedure.
perichondrium rame the lateral aspects o the gra t.2 T e Potential complications at the donor site include pain
recipient site is prepared by undermining pockets using a and an increased risk o bleeding rom conchal bowl donor
hemostat or scissors parallel to the alar or helical rim on sites healing by secondary intention. T ere ore, auricular
each side o the de ect. T e cartilaginous pegs are care ully donor sites should be covered both anteriorly and posteri-
inserted into these pockets so that the gra t interlocks with orly with a pressure dressing. Addition o hemostatic oam
its recipient bed. T e interlocking o the gra t with its recipi- can also be considered. Another potential complication
ent bed aids in increasing the sur ace area or revasculariza- o surgery involving the ear results rom its propensity
tion as well as minimizing shearing orces. Once the gra t toward in ection with Pseudomona s spp. Measures that
is interlocked, the intranasal and cutaneous skin edges are can be undertaken to decrease this risk include cleansing
sutured into place; the cartilage does not require suturing.45 the area with dilute vinegar solution, applying topical gen-
Finally, a dressing is placed, which can consist o sup- tamicin ointment, or prophylactic oral uoroquinolone
S
port in the nasal vestibule using petrolatum-impregnated antibiotics.8 Perichondritis or chondritis due to either car-
c
t
dressing and antibiotic ointment with an overlying non- tilaginous in ammation or in ection (suggested by addi-
o
n
stick dressing placed on the external sur ace o the gra t. tional presence o ever or purulent drainage) can occur at
2
Given the high rate o colonization o the nares with bac- the surgical site, causing redness and pain. I an in amma-
:
:
teria, oral antibiotics are typically prescribed. Sutures are tory etiology is suspected, use o NSAIDs as indicated may
removed in 1 week. Postoperatively, the patient should be reduce the symptoms.46
S
u
advised to apply ice packs to the area or several days.
r
g
c
Fr ee c a r t Il a g e g r a Ft S
S
c o mPl Ic a t Io n S
k
s
FCGs are used to restore structural or unctional de cits
Similar to other types o gra ts, CGs may incur textural, due to tissue loss, particularly near ree margins o the
color, and contour irregularities. T ese can be treated i nose, ears, or eyelids (Fig. 20-7A– C).2,35,47 While most
desired using spot dermabrasion or laser resur acing. commonly per ormed along the alar rim, cartilage gra ts

A B

Figure 20-7 A. D ct o t r o ow ng Mohs surg ry. B.

a c rt g gr t w s p c d to st z th r m rg n o
C th r. C. a FTSG w s th n s wn ov r th d ct. (F gur s
254 us d w th p rm ss on o D s r R tn r, MD.)
are also used at times in repairing de ects o the distal
nasal tip, lower eyelid margin, or along the helical rim to
mined, the skin overlying the donor site is sharply incised,
then undermined to expose the perichondrium.2,35 I only
2
optimize both cosmetic and unctional results.35 In the a strip o cartilage is needed, a curvilinear incision may
context o dermatologic surgery, FCGs derive most com- be per ormed. For larger-sized FCGs, greater access to
monly rom the elastic auricular cartilage as it is more pli- the bulk o the conchal bowl can be obtained by li ting a
able, and o ten more easily accessible, than nasal septum curved ap o skin rom the conchal bowl skin via an ante-
or rib cartilage.2,35 rior approach.52 T e desired shape o the cartilage gra t is
Removal o a sizable portion o the conchal bowl carti- then outlined and incised with a scalpel blade, a ter which
lage can be achieved without signi cant aesthetic or unc- the cartilage with its overlying perichondrium is care ully
tional compromise at the donor site. Antihelical cartilage removed by sharp dissection. T e FCG should be placed
gra ts can also serve as use ul alternatives and tend to in a sterile moist environment, such as sterile saline, until
be less brittle.48 Potential complications o FCGs include ready or use. Buried sutures to reapproximate the carti-
donor site morbidity such as chondritis, in ection, hema- lage or dermal wound edges are not required at the donor
toma, or distortion o the helical rim. FCGs are avascular site. T e cutaneous sur ace o the donor site may be reap-
and depend on a nutrient supply rom the subdermal vas- proximated simply using a variety o super cial suturing

C
h
cular plexus o their recipient bed wound edges. Patients techniques; a running locked suture may be help ul i

p
who are smokers or have an impaired vascular supply are bleeding risk is a concern.2

t
r
at higher risk or cartilage gra t ailure. Gra t displace- Several techniques may be used to secure the FCG. One

2
0
ment or resorption is thought to be more likely ollowing o the most commonly used techniques involves creating
mechanical trauma or unmet nutritional demand. a pocket in the recipient bed by undermining medially and

:
:
Placement o a at strip o cartilage, also termed a batten, laterally beneath the skin edges, tucking the peripheral

S
along the nasal alar rim or supra-alar crease can provide edges o cartilage into these so t-tissue pockets sequen-

k
n
a rigid ramework or prevention o nasal valve collapse, tially, and securing the cartilage with absorbable sutures

G
maintaining airway patency and protecting against con- to the underlying so t tissue.2,53 T is pocket increases the

r
traction during healing.49–51 issue loss resulting rom exci- gra t contact with the rich vascular network o the recipi-

t
n
sional surgery on the nasal ala or supra-alar crease can cause ent bed. Buried polyglactin sutures encircling the cartilage

g
unctional obstruction due to nasal valve collapse. During strip may also be used to secure it to the underlying so t
inspiration, the remaining nasal tissue is pulled inward tissue. Larger gra ts may require absorbable suture place-
toward the septum, creating airway obstruction. A delayed ment through or around the ull thickness o the cartilage
nasal valve obstruction can also occur rom scar contrac- to optimize their inset. Once the gra t is secured, an F SG
ture and stenosis i a cartilage gra t is not placed or i an or ap can be per ormed to complete the wound closure
existing gra t is resorbed. When FCGs are combined with (Fig. 20-8A– C).2,54 Given its vascularity, it is possible that a
aps and F SGs, the risk o scar contraction and airway ap’s additional blood supply may help to enhance surviv-
collapse is greatly reduced. Be ore and a ter FCG place- ability o the FCG.
ment, airway patency can be tested and con rmed by com- In those circumstances when a less complex repair is
paring the patient’s ability to inspire through the a ected pre erred, FCG placement with secondary intention heal-
nostril with inspiration on the contralateral side. ing therea ter can yield acceptable, although perhaps
not aesthetically ideal, wound healing or nasal wound
de ects.55,56 Likewise, correction o lower eyelid retrac-
d o n o r SIt e Sel ec t Io n tion may involve placement o an FCG with secondary
intention healing on the conjunctival sur ace to provide
Several di erent donor sites can be used or harvesting structural support, or a conchal bowl-derived chondrocu-
FCGs including the conchal bowl, antihelix, nasal septum, taneous CG to urther enhance the contour o the cutane-
or ribs.35 Conchal and antihelical cartilage more closely ous sur ace.57,58
approximate the contours and elasticity o nasal cartilage Conchal cartilage is commonly used to repair helical
and serve most readily as donor sites.2,35,52 Cartilage that is rim de ects. A partial wedge closure o the helical rim
in amed or diseased should not be harvested.8 de ect may be used to decrease the size o the cartilage
gra t required, and can help to minimize the helical rim
collapse that can occur with wound contraction. T e FCG
t ec Hn Iq u e is then secured with sutures as mentioned previously, and
may be covered with a pedicled retroauricular advance-
Di erent techniques or harvesting conchal cartilage have ment ap.
been described, including both anterior and posterior
approaches.2,52 o obtain the gra t, the area is rst prepped
in a sterile ashion and local anesthesia is achieved with Po St o Per a t Iv e c a r e
in ltration o both the anterior and posterior aspects o
the donor site to ensure that removal o the gra t is pain- Appropriate postoperative care is imperative or the success
less.2 First, the amount o cartilage desired is estimated o cartilage gra ts.2,9 A bolster dressing may be applied to
by measuring the length o the surgical de ect at the ree the wound sur ace at the discretion o the surgeon. A non-
margin and adding an extra 2 to 5 mm on either side to adherent pressure dressing is typically used to give added
provide enough excess tissue to interlock with the periph- support and help prevent bleeding complications. Using
eral edges o the de ect.53 T e width o the ree cartilage intermittent ice packs or the rst 2 to 3 days a ter surgery
batten may range rom 3 to 6 mm. Once the size is deter- can help to minimize edema and may help to increase 255
2

A B
S
c
t
o
n
2
Figure 20-8 A. Mohs surg c d ct o th t n s tp
nd so t tr ng xt nd ng c os to th r r m. B. a c r-
:
:
t g strut w s p c d n th pr ur cu r FTSG to st -
S
z th r r m. C. a r r m n p r ct pos t on 6 months
u
r
t r surg ry. Th gr t shows good co or nd t xtur m tch
g
w th th surround ng sk n. (Us d w th p rm ss on o D s r
c
R tn r, MD. R produc d w th p rm ss on rom Cook J.
S
k
R p ro n r d ct. in: R tn r DS, Coh n Jl , brod nd
DG, ds. Reconstructive Conundrums in Dermatologic
s
C Surgery: The Nose. Ox ord: W y b ckw ; 2014. Copyr ght
© 2014 a m r c n Soc ty or D rm to og c Surg ry.)

gra t survival.2 Prescription o postoperative broad-spec- ceous glands. S SGs can range in thickness rom 0.125
trum oral antibiotics is variably practiced and lacks speci c mm to 0.75 mm. ypically thinner gra ts rom 0.3 to 0.4
evidence-based guidance. While topical antibiotic applica- mm are used in the head and neck region whereas 0.5 to
tion has not generally been shown superior to petrolatum 0.6 mm gra ts are used on the trunk.9
in routine wound care, it is possible that its use near the T ere are many advantages to using S SGs. S SGs
nares may help to reduce the risk o impetiginization.59 are able to cover very large de ects. T ey heal aster and
can survive better than F SGs, especially in areas o vas-
cular compromise as these thinner gra ts have reduced
c o mPl Ic a t Io n S nutritional requirements compared to F SGs.2,9 rophic
ulcers on the lower legs are a good example o an instance
As with any skin surgery, risks o in ection are present at in which an S SG can cover a large de ect and survive
both the donor and the recipient sites. Gram-negative bac- despite the poor vascularity o the recipient bed.7,9,61
teria are commonly the culprit at auricular donor sites.46 Since they are thin and semitransparent, S SGs allow or
I any exudate is present, empiric uoroquinolones can be improved surveillance or recurrence o high-risk tumors.2
considered while wound culture is in progress. I the patient S SGs can also be enestrated to enable a smaller gra t to
is not improving with antibiotics, a ungal culture should cover a larger de ect. T eir donor sites do not require pri-
be considered.2 Chondritis at auricular donor sites presents mary closure and heal secondarily.
as erythema, edema, and tenderness without an exudate.60 T e most recognized disadvantage o S SGs is their
reatment o ten requires several weeks to months o cold suboptimal color and texture match with the surround-
compresses and nonsteroidal anti-in ammatory drugs.2,19 ing skin, which is partly due to their lack o adnexal
Late complications that might require surgical revision structures.2,7 Another disadvantage o S SGs is that har-
include gra t resorption or extrusion, which can lead to vesting them requires specialized equipment. T e donor
de ormation o the site.2,35 Securing a cartilage gra t o the site wound requires urther care and tends to heal with a
appropriate thickness and sti ness is important.35 o avoid noticeable outline. Finally, S SGs may contract as much
complications, it is critical to minimize trauma to the site as 70%, and i placed near the ree margins o the eyelids,
or movement o the gra t with respect to its recipient bed. oral commissures, or nasal alae, such contraction can lead
to both unctional and cosmetic compromise.7
S SGs are harvested rom broad areas o skin that are
SPl It -t HIc k n eSS Sk In g r a Ft S hidden by clothing, whether manually with a reehand
device, or with a power-driven dermatome.62 Many donor
S SGs contain the entire epidermis and variable amounts sites are possible, including the thighs, upper arms, inner
o dermis. Unlike F SGs, they usually lack adnexal struc- orearms, lower back, and abdomen, with the anterome-
256 tures including hair ollicles, eccrine glands, and seba- dial thigh being the most common. Large gra ts needed to
 desired gra t thickness, although there is a learning curve
associated with use o these devices as well (Fig. 20-9).2
2
Several recent studies have advocated harvesting
S SGs rom the posterior scalp as a donor site due to its
rapid wound healing, low risk o complications, and excel-
lent cosmetic results.65,66 T e scalp is thought to contain a
large number o epidermal stem cells due to its signi cant
number o hair ollicles, which may explain why it tends
to heal so well. In addition, the color and texture o scalp
S SGs tend to match those o acial recipient sites more
closely, leading to improved cosmesis.65,66

Ha r v eSt In g t He St Sg

C
A ter the donor site is anesthetized and prepped in a sterile

h
Figure 20-9 W ck d .

p
ashion, a reehand S SG can be per ormed with a #10 or

t
#15 blade by orienting the blade parallel to the skin, and

r
2
gently harvesting the gra t by making super cial incisions

0
cover a substantial de ect should be harvested rom broad, just below and parallel to the epidermis (Fig. 20-10A–C).2

:
:
at sur aces, usually with a power-driven dermatome. A Weck blade can also be used or harvesting o S SGs.
Smaller gra ts can be quickly harvested with a reehand T e presence o pinpoint bleeding rom the donor site is

S
k
#10 or #15 scalpel blade rom a variety o di erent donor generally a good indication that the gra t is the appropriate

n
G
sites, including the mastoid processes and upper lateral thickness, and that the papillary dermis has been reached.67

r
arms.2,63 T e dif culty in harvesting S SGs manually lies Multiple blades may be required to harvest a single S SG,

t
in obtaining a gra t with uni orm dermal thickness, which as they tend to dull quickly during harvesting.19

n
g
is highly technique dependent.64 A Weck blade can pro- For power-driven dermatomes, it is important to lubri-
vide a solution to this problem; these are reehand blades cate the skin with mineral oil or normal saline to enable
with templates that allow the physician to choose the the dermatome to glide gently over the skin sur ace. T e

A B

Figure 20-10 P c m nt o sp t-th ckn ss sk n gr t. A.

a nt r or r d ct o ow ng Mohs m crogr ph c surg ry.
C B. M nu h rv st ng o STSG w th #15 d . C. STSG
sutur d nto p c . 257
2 handpiece is then held at a 30 degree angle with steady
pressure oriented downward and orward.7,67 An assis-
ailure o engra tment can otherwise ensue. Once the gra t
is placed on its recipient site, anchoring sutures should be
tant applies traction to create a at, even sur ace while the placed along its periphery with 6-0 ast absorbing gut or
surgeon applies pressure to the dermatome as it starts to 5-0 chromic gut. A bolster or pressure dressing can then
cut. In the absence o adequate surrounding traction and a be applied once the gra t has been sutured in place, which
broad at sur ace or harvesting, it is likely that an uneven will act to protect the gra t rom outside orces and aid in
gra t will result. T e gra t is then gently removed rom the decreasing in ection and hematoma ormation.2,7,9 Basting
pocket area o the dermatome with orceps. It is then placed sutures may also be placed to acilitate gra t adherence to
on sterile saline-soaked gauze or directly onto the recipient the wound bed, and a bolster is requently sewn over the
site, at which point it can be trimmed to match the de ect.2 gra t.9,68 A ter the gra t is secured, a pressure dressing may
It is important to remember that the S SG will tend to curl be applied i desired.
on itsel , which helps the surgeon to distinguish between A newer method or securing S SGs was recently
the dermal and epidermal sur aces, and minimizes the described using the tissue adhesive N-butyl-2-cyanoacry-
risk o the gra t being placed upside down. I the edges o late.69 Applying the adhesive was ound to be aster than
the gra t are not per ectly approximated with the wound suturing, cheaper than suture material ($2.00 per appli-
S
edges, the overlapping skin will slough without a ecting cation), and seemed to have no higher rates o in ection
c
t
the cosmetic outcome. T e donor site is later covered with than securing a gra t with sutures. T e adhesive is simply
o
n
mupirocin 2% ointment, petrolatum ointment, gel oam, or applied to the periphery o the gra t, and allowed 60 sec-
2
a nonadherent dressing o the surgeon’s choice.68 onds to ully set. A terward a bolster may be applied.
:
:
Power-driven dermatomes are used to harvest large For the donor site, a moist occlusive dressing with pet-
S SGs, which may be up to 4 in wide, and can easily cre- rolatum is recommended.2,70 Moist dressings decrease
S
u
ate gra ts with a uni orm dermal thickness, up to 0.75 mm postoperative pain and promote re-epithelialization.70,71
r
g
thick.2 An adjustable dial allows the operator to increase T e donor site usually heals over 1 to 3 weeks, although
c
or decrease the thickness o the gra t, enabling gra ts postoperative erythema at the site may last or months
S
k
between 0.05 and 0.76 mm thick to be easily harvested.68 be ore ading. Ultimately, a hypo- or hyperpigmented
s
Another distinct advantage o S SGs is their ability to be donor site scar will likely result.2
enlarged with a meshing device, which can increase their
coverage by 25% to 35%.2 Most meshing devices compress
S SGs on a plastic grid with a steel roller, thereby creating Po St o Per a t Iv e c a r e a n d
uni orm enestrations. T e enestrations allow the gra t to
increase its coverage size, and allow or drainage o sero- c o mPl Ic a t Io n S
sanguinous material that could inhibit gra t healing. For
larger gra ts, a meshing device can be quite help ul, while Despite meticulous wound care, complications can some-
simple enestrations can be made with a #11 or #15 blade times occur. Early complications o S SGs include ail-
in smaller gra ts to increase their size.2 ure o engra tment, which can result rom hematoma or
seroma ormation, in ection, or trauma to the gra t site.
Within the rst day or two a ter placing the gra t, a large
Sec u r In g t He St Sg S amount o serosanguinous uid can accumulate beneath
it, potentially compromising its survival. Placement o
Be ore securing the S SG, it is important to prepare the a bolster dressing can help to minimize this risk. I this
recipient bed to receive the gra t. Hemostasis must be complication does occur, the uid should be drained with
achieved be ore attaching the gra t, since a hematoma and a sterile needle and syringe, and a new pressure dressing

A B

Figure 20-11 A. Thr -month o ow-up o STSG p c d on sc p t r rg sc p rot t on p or rg or h d nd

ront on d ct o ow ng m nom r s ct on. Not th hypop gm nt t on nd smooth, sh ny, h r ss sur c o
th STSG n contr st to th h r- r ng sc p. B. On -y r o ow-up o STSG p c d on sc p t r r s ct on o rg SCC.
258 Not th poor co or nd t xtur m tch w th th surround ng sk n. (F gur 20-11b us d w th p rm ss on o D s r R tn r, MD.)
applied. Patients should be educated to avoid trauma to
their gra ts, especially in the early healing phase.
10. Kau man AJ. Adjacent-tissue skin gra ts or reconstruction.
Dermatol Surg. 2004;30(10):1349– 1353.
2
11. Silapunt S, Peterson SR, Alam M, Goldberg LH. Clinical ap-
Late complications typically include color and tex-
pearance o ull-thickness skin gra ts o the nose. Dermatol
ture mismatch or unctional problems with the gra t Surg. 2005;31(2):177– 183.
itsel .2,19 Once S SGs have healed, their color may var y 12. Zitelli JA. Burow’s gra ts. J Am Acad Dermatol. 1987;17(2 Pt
signi cantly, but they rarely match the surrounding skin 1):271– 279.
(Fig. 20-11A,B). Some remain er ythematous to light 13. Breach NM. Pre-auricular ull-thickness skin gra ts. Br J Pla st
Surg. 1978;31(2):124– 126.
pink, whereas others may become hyperpigmented,
14. Corwin R, Klein AW, Habal MB. T e aesthetics o the
hypopigmented, or largely depigmented. o minimize preauricular gra t in acial reconstruction. Ann Pla st Surg.
the risk o hyperpigmentation, especially in darker- 1982;9(4):312– 315.
skinned individuals, patients should limit sun exposure 15. Beare RL, Bennett JP. T e naso-labial ull thickness gra t. Br J
and wear sunscreen. Other S SG complications include Pla st Surg. 1972;25(3):315– 317.
16. Rohrer E, Dzubow LM. Conchal bowl skin gra ting in nasal
gra t scaling and dr yness, likely due to the presence o
tip reconstruction: clinical and histologic evaluation. J Am
decreased adnexal structures resulting in decreased Acad Dermatol. 1995;33(3):476– 481.
sweating and desquamation, but this problem can be

C
17. Stucker FJ Jr, Shaw GY. T e perichondrial cutaneous gra t.

h
reduced with requent emollients. A 12-year clinical experience. Arch Otolaryngol Head Neck

p
Functional problems with the gra ts are another late Surg. 1992;118(3):287– 292.

t
18. Palkar VM. Full-thickness skin gra ting. J Surg Oncol.

r
complication. T ese problems are usually due to S SG

2
2000;73(1):31.

0
contraction, which can cause joint contractures i placed 19. Ratner D. Skin gra ting. From here to there. Dermatol Clin.
near or overlying a joint, ectropion near the ree eyelid 1998;16(1):75– 90.

:
:
margin or upper cheek, eclabium near the ree margin 20. Hill G. Contouring o donor skin in ull-thickness skin gra t-

S
o the lip, or distortion o the nose i placed near the ree ing. J Dermatol Surg Oncol. 1987;13(8):883– 888.

k
21. Mellette JR Jr, Swinehart JM. Cartilage removal prior to skin

n
margin o the alar rim. Signi cant hypertrophic scarring
gra ting in the triangular ossa, antihelix, and concha o the

G
o gra t sites and donor sites has also been reported.2 I

r
ear. J Dermatol Surg Oncol. 1990;16(12):1102– 1105.
recognized early, this complication may be success ully 22. Langtry JA, Kirkham P, Martin IC, Fordyce A. ie-over bol-

t
n
treated with intralesional steroids. I it persists, treatment ster dressings may not be necessary to secure small ull thick-

g
with the pulsed dye laser may be help ul. ness skin gra ts. Dermatol Surg. 1998;24(12):1350– 1353.
23. Shimizu I, MacFarlane DF. Full-thickness skin gra ts
may not need tie-over bolster dressings. Dermatol Surg.
2013;39(5):726– 728.
c o n c l u SIo n S 24. Brady JG, Grande DJ, Katz AE. T e purse-string suture in a-
cial reconstruction. J Dermatol Surg Oncol. 1992;18(9):812–
As the incidence o skin cancers continues to rise, and the 816.
25. Robinson JK, Dillig G. T e advantages o delayed nasal ull-
population continues to age, an increasing number o skin thickness skin gra ting a ter Mohs micrographic surgery. Der-
gra ts will be required to repair a variety o acial and non- matol Surg. 2002;28(9):845– 851.
acial de ects. A working knowledge and complete under- 26. Meyers S, Rohrer , Grande D. Use o dermal gra ts in recon-
standing o the indications, donor site considerations, structing deep nasal de ects and shaping the ala nasi. Derma-
techniques, and complications o all types o skin gra ts is, tol Surg. 2001;27(3):300– 305.
27. Fader DJ, Wang S, Johnson M. Nasal reconstruction uti-
there ore, essential or the practicing reconstructive surgeon. lizing a muscle hinge ap with overlying ull-thickness skin
gra t. J Am Acad Dermatol. 2000;43(5 Pt 1):837– 840.
28. Halpern M, Adams C, Ratner D. Galeal hinge aps: a use ul
r eFer en c eS technique or immediate repair o scalp de ects extending to
periosteum. Dermatol Surg. 2009;35(1):127– 130.
1. Hauben DJ, Baruchin A, Mahler A. On the history o the ree 29. Johnson M, Baker S, Brown MD, Nelson BR. Utility o the
skin gra t. Ann Pla st Surg. 1982;9(3):242– 245. subcutaneous hinge ap in nasal reconstruction. J Am Acad
2. Adams DC, Ramsey ML. Gra ts in dermatologic surgery: Dermatol. 1994;30(3):459– 466.
review and update on ull- and split-thickness skin gra ts, 30. Draper BK, Wentzell JM. T e “drumhead” gra t repair o deep
ree cartilage gra ts, and composite gra ts. Dermatol Surg. nasal alar de ects. Dermatol Surg. 2007;33(1):17– 22.
2005;31(8 Pt 2):1055– 1067. 31. Gloster HM Jr, Brodland DG. T e use o perichondrial cuta-
3. Converse JM, Smahel J, Ballantyne DL Jr, Harper AD. Inos- neous gra ts to repair de ects o the lower third o the nose.
culation o vessels o skin gra t and host bed: a ortuitous en- Br J Dermatol. 1997;136(1):43– 46.
counter. Br J Pla st Surg. 1975;28(4):274– 282. 32. Nehal KS, Levine VJ, Ross B, Ashino R. Comparison o
4. Converse JM, Uhlschmid GK, Ballantyne DL Jr. “Plasmatic high-energy pulsed carbon dioxide laser resur acing and
circulation” in skin gra ts. T e phase o serum imbibition. dermabrasion in the revision o surgical scars. Dermatol Surg.
Pla st Reconstr Surg. 1969;43(5):495– 499. 1998;24(6):647– 650.
5. Clemmesen , Ronhovde DA. Restoration o the blood-sup- 33. Geyer AS, Pasternack F, Adams C, Ratner D. Use o a skin-
ply to human skin autogra ts. Scand J Pla st Reconstr Surg. at composite gra t to prevent alar notching: an alternative to
1968;2(1):44– 46. delayed postoperative repair. Dermatol Surg. 2005;31(5):602–
6. Gingrass P, Grabb WC, Gingrass RP. Skin gra t survival on 607.
avascular de ects. Pla st Reconstr Surg. 1975;55(1):65–70. 34. Haas AF, Glogau RG. A variation o composite gra ting or
7. Johnson M, Ratner D, Nelson BR. So t tissue reconstruction reconstruction o ull-thickness nasal alar de ects. Arch Der-
with skin gra ting. J Am Acad Dermatol. 1992;27(2 Pt 1):151– matol. 1994;130(8):978– 980.
165. 35. Otley CC, Sherris DA. Spectrum o cartilage gra ting in
8. Unal S, Ersoz G, Demirkan F, Arslan E, utuncu N, Sari A. cutaneous reconstructive surgery. J Am Acad Dermatol.
Analysis o skin-gra t loss due to in ection: in ection-related 1998;39(6):982– 992.
gra t loss. Ann Pla st Surg. 2005;55(1):102– 106. 36. Field LM. Nasal alar rim reconstruction utilizing the crus o
9. Ratner D. Skin gra ting. Semin Cutan Med Surg. 2003; the helix, with several alternatives or donor site closure. J
22(4):295–305. Dermatol Surg Oncol. 1986;12(3):253– 258. 259
2 37. Robinson JK, Burget GC. Nasal valve mal unction resulting
rom resection o cancer. Arch Otolaryngol Head Neck Surg.
or de ects on the distal nose. J Drugs Dermatol. 2012;11(1):
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1990;116(12):1419– 1424. 56. van der Eerden PA, Verdam FJ, Dennis SC, Vuyk H. Free
38. Mc LC. Composite ear gra ts and their blood supply. Br J cartilage gra ts and healing by secondary intention: a viable
Pla st Surg. 1954;7(3):274– 278. reconstructive combination a ter excision o nonmelanoma
39. Ruch MK. Utilization o composite ree gra ts. J Int Coll Surg. skin cancer in the nasal alar region. Arch Facial Pla st Surg.
1958;30(2):274–275. 2009;11(1):18– 23.
40. Weisberg NK, Becker DS. Repair o nasal ala de ects with 57. Marks MW, Argenta LC, Friedman RJ, Hall JD. Conchal car-
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41. eltzrow , Arens A, Schwipper V. One-stage reconstruction 58. Matsuo K, Hirose , akahashi N, Iwasawa M, Satoh R. Lower
o nasal de ects: evaluation o the use o modi ed auricular eyelid reconstruction with a conchal cartilage gra t. Pla st Re-
composite gra ts. Facial Pla st Surg. 2011;27(3):243–248. constr Surg. 1987;80(4):547– 552.
42. Keck , Lindemann J, Kuhnemann S, Sigg O. Healing o com- 59. Campbell RM, Perlis CS, Fisher E, Gloster HM Jr. Gentami-
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113(2):248– 253. 60. Kaplan AL, Cook JL. T e incidences o chondritis and peri-
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43. Meade RJ. Composite ear gra ts or construction o columel- chondritis associated with the surgical manipulation o au-
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ties associated with cle t lip and other congenital and post- 62.
o
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traumatic de ciencies o the columella. Pla st Reconstr Surg 61. Anderson JJ, Wallin KJ, Spencer L. Split thickness skin
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Transplant Bull. 1959;23(2):134– 147. gra ts or the treatment o non-healing oot and leg ulcers
44. Raghavan U, Jones NS. Use o the auricular composite gra t in in patients with diabetes: a retrospective review. Diabet Foot
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u
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46. Cummings CW, Flint PW, Haughey BH, et al., eds. In ections 35.
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o the external ear. Chapter 137. Otolaryngology: Head & Neck 63. Snow SN, Sti M, Lambert D, soi C, Mohs FE. Freehand
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Surgery. 5th ed. Philadelphia, PA: Mosby Elsevier; 2010. technique to harvest partial-thickness skin to repair super -
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47. Andreassi A, Bilenchi R, Biagioli M, D’Aniello C. Classi ca- cial acial de ects. Dermatol Surg. 1995;21(2):153– 157.
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tion and pathophysiology o skin gra ts. Clin Dermatol. 2005; 64. Johnson , Ratner D. Skin gra ts. In: Ratz J, ed. Textbook of
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51. oriumi DM, Josen J, Weinberger M, ardy ME Jr. Use o alar 67. Foroozan M, Pouaha J, ruchetet F. Simple method or
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skin gra t overlying a separately harvested auricular cartilage Dressing the split-thickness skin gra t donor site: a random-
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260
 Ch a p t e r

21 Surgical Scar Revision

L M. Mill r & S v r L. Soon

In t r o d u c t Io n summarizes scar characteristics, possible etiologies, and

recommended approaches to revision.
Scar ormation is vital to the wound healing process. As
surgeons, we spend much o our day creating wounds t ImIn g
in the skin, and as a result, scarring is an inherent real-
ity o surgical practice. Many patients may present with Once the decision is made to proceed with surgical scar
reconstructive challenges, resulting in scars that are cos- revision, the surgeon should wait until the appropriate time
metically or unctionally unsatis actory to the patient, to act. In general, scar revision should be de erred until the
physician, or both. As such, a comprehensive understand- nal phase o wound healing (6–12 months), when mature
ing o scar revision and the various modalities by which collagen makes up most o the scar bed.2– 6 In the meantime,
scars may be managed is essential. While a plethora o patients should continue to practice good wound care and
techniques are available to improve both unctional and may begin massaging their scar 1 month postoperatively to
cosmetic outcomes, this chapter ocuses speci cally on minimize scar hypertrophy and contracture. A ew excep-
“cold steel” surgical scar revision techniques. With proper tions exist to this general rule. First, scars perpendicular
preoperative analysis o the scar and surrounding tissue, as to RS L or that cross the boundary between adjacent cos-
well as skilled execution o an appropriately planned surgi- metic subunits are obvious and o ten lead to de ormity dur-
cal revision, optimal results may be consistently attained. ing animation. T is de ormity tends to worsen with time,
and should there ore be corrected earlier to re-establish
proper anatomic contours and margins.2,3 Second, derm-
Pr ev en t Io n abrasion and debulking o hypertrophic aps should be
considered at 6 to 9 weeks due to the greater intrinsic
Proper planning and attention to detail during the initial broblastic activity during this time rame.3,6 In contrast,
reconstruction may obviate the need or scar revision when considering surgical revision in a child, the surgeon
in many cases. T is goal is attained by adhering to basic should wait as long as possible, as childhood scars are likely
principles o surgical reconstruction, speci cally avoiding to improve substantially over time.2
unnecessary trauma to the surrounding tissues, success-
ully accessing available tissue reservoirs, care ul planning
o reconstruction to camou age incision lines along junc- o Pt ImIz a t Io n
tions o cosmetic subunits and within relaxed skin ten-
sion lines (RS L), and awless suturing technique with o ensure the best result the surgeon must optimize the
meticulous reapproximation, eversion, and avoidance o patient’s healing ability, which includes assuring that
epidermal strangulation. When success ul, reconstructive the patient is receiving good nutrition, has discontinued
surgeons may achieve their goal o creating a scar that is medications that may adversely a ect healing, avoiding
nearly imperceptible. T is scar is level with and similar in surgery in heavily irradiated areas and controlling acute or
texture and color to the surrounding skin, is under mini- chronic in ammatory skin conditions. Insuf cient caloric
mal tension, ollows underlying structural contours, aligns intake or nutritional de ciencies in vitamin A, vitamin C,
with RS L or the junctions o cosmetic subunits, and is errous iron, and zinc may ultimately retard the skin’s
not straight, but avorably broken up to scatter re ected ability to heal by decreasing protein production, collagen
light. T ese eatures minimize any negative unctional or synthesis, or impairing the immune system. Likewise,
aesthetic impact o the scar. medications such as systemic corticosteroids, immuno-
modulators, and chemotherapy may alter healing either
via a direct antimetabolic e ect or by immune alteration.
Sc a r c l a SSIf Ic a t Io n I possible, these medications should be withheld dur-
ing the period o surgical scar revision. issues receiving
As wound repair and new collagen ormation proceed, the greater than 50 Gy o radiation may display basilar brosis,
a orementioned criteria may be compromised, and result dermal plexus obliteration, atrophy o the subcutaneous
in an unsatis actory scar. T ere are our main ways in which and sur ace epithelium, and loss o dermal appendages, all
this may occur, conveniently dividing scars into the ollow- o which may adversely a ect the healing potential o the
ing etiologic categories: (1) traumatic; (2) poor design; skin. However, patients who have received less than 50 Gy
(3) poor healing; and (4) disease-related.1 able 21-1 o radiation and who are otherwise healthy may predictably
2 Ta bLe 21-1
S a ii s S i t a pp s 1,5

S i c i
S a i e i t i s a t pi s
el v t d Poor pproxim tion o wound R xcision Intr l sion l st roids
dg s Sh v xcision D rm r sion
exc ss wound t nsion Sc lp l sculpting L s r r sur cing
Ov rsiz d gr ts or ps
D pr ss d D p sh v iopsy R xcision So t tissu ugm nt tion
el ctrod sicc tion/cur tt g Su cision/ L s r r sur cing
In d u t wound dg v rsion Su d rm l und rmining
Prior h m tom or in ction
S
Hyp rtrophic sc rs/ exc ss in mm tion (in ction, R xcision Intr l sion l immunomodul tors
c
t
K loids or ign ody r ction, tc.) Sh v xcision R di tion
i
o
n
exc ss t nsion sc lp l sculpting Cryosurg ry
2
G n tic pr disposition L s rs
Compr ssion th r py
:
:
Wid n d sc rs exc ss t nsion (in d u t R xcision L s rs
S
u
und rmining)
r
g
Poor suturing t chni u
i
c
l
Long str ight sc rs L c r tion Z pl sty D rm r sion
S
k
Poor surgic l pl nning: W pl sty
i
l
l
s
Crossing RSTL or dj c nt cosm tic G om tric rok n lin closur
su units R positioning
Distortion o r m rgins
Long lin r d sign
Poor suturing t chni u
(l ck o v rsion, in d u t
pproxim tion, tc.)
Contr ct d sc rs/ Tr v rsing conc viti s Z pl sty Intr l sion l st roids
w ing
Fr m rgin d vi tion Poor surgic l pl nning Z pl sty L s rs
Proximity to r m rgins V–Y dv nc m nt
Ic pick/Pitt d sc rs Prior cn Punch xcision Punch gr ting
Tr um D rm l pock t gr ting
D rm r sion
boxc r sc rs Prior cn Punch xcision L s rs
V ric ll Punch l v tion
Rolling sc rs Prior cn Su cision So t tissu ugm nt tion
L s rs

undergo success ul surgical scar revision.2 Finally, avoid-

ing unnecessary cutaneous in ammation assists in the exc ISIo n a l t ec h n Iq u eS
healing process. For instance, i an area is actively in ected,
treatment with systemic antibiotics and delaying surgery r e-exc ISIo n
or at least 6 weeks should allow or the in ammation to
subside.2 Patients with chronic in ammatory skin condi- Perhaps the simplest orm o scar revision is to remove
tions may bene t substantially rom appropriate medi- the abnormal scar in its entirety. T is is accomplished by
cal therapy; or example, surgical candidates with active excising the existing scar with narrow margins and care-
acnei orm or eczematous eruptions should receive appro- ully reapproximating each layer o the normal surround-
priate medical therapy to optimize the outcome o their ing tissues with attention paid to wound-edge eversion
scars. Finally, the importance o skin hygiene to minimize and tension. Re-excision o scars is particularly use ul or
in ammation should be emphasized to patients. aking relatively small irregular or hypertrophic linear scars that
the preceding actors into account while planning or sur- are aligned within 30 degrees o the surrounding RS L.1,2
gical scar revision will increase the likelihood o superior Buried vertical mattress sutures will help achieve adequate
262 patient outcomes. wound-edge eversion (Fig. 21-1). As with any standard
 2

A B C

C
h
Figure 21-2 M Pl sty. A. Th M Pl sty is us ul t ch

p
t
ni u th t short ns th l ngth o th incision. Th tr di

r
tion l 30 d gr p x in riorly nd th tip r inv rt d

2
1
B or th M pl sty t th sup rior tip. B. Th xc ss tissu
is xcis d, r v ling n “M sh p d” wound t th sup

:
:
Figure 21-1 buri d v rtic l m ttr ss sutur . A. Th sutur rior p x. C. Th wound dg s r r pproxim t d nd

S
is pl c d such th t th r nds xit th d rmis on th un sutur d in pl c .

u
r
g
d rmin d sur c o th wound. B. Onc ti d, this sutur

i
c
t chni u promot s wound dg v rsion.

l
S
c
r
R
lenti orm excision, the angles o the apices o the excised as a base onto which deep tissues may be anchored, but

v
i
s
tissue should not exceed 30 degrees to avoid standing cone also to add bulk to ll the depressed area o the scar. T is

i
o
n
de ormities. I the angle o the apex exceeds 30 degrees may be accomplished using either bilateral or unilateral
and there is insuf cient tissue to lengthen the scar, one tissue mobilization resembling a tongue in groove struc-
may consider M-plasty revision (Fig. 21-2). Although re- ture (Fig. 21-4A,B). In either case, the scar is rst de-epi-
excision may be e ective, patients should be in ormed thelialized. In the unilateral mobilization technique (Fig.
that the re-excised scar will be longer than the original 21-4A), a ull-thickness incision is made along only one
(Fig. 21-3A,B). side o the de-epithelialized scar tissue. T e skin is then
Surgical incisions under tension or in areas o high undermined in one direction, away rom the bed o scar
mobility, particularly on the trunk and proximal extremi- tissue. T e resultant ap edge is then thinned to match
ties, o ten spread over time, resulting in a wide, depressed the depth and width o the bed o scar tissue. T e thinned
scar. T ese scars are amenable to re-excision; however, skin edge is then advanced over the bed o scar tissue
to avoid a similar problem in the uture, one may con- and the deep portion o the skin edge is anchored to the
sider leaving a plate o scar tissue behind to serve not only scar tissue while the two skin edges are reapproximated

A B

Figure 21-3 R xcision. A. D pr ss d sc r o th n s l supr tip. Dott d outlin shows pl nn d r o und rmining to
su ci ntly mo iliz tissu . B. R xcision r sults in long r sc r nd mor sth tic contour o th n s l tip. (Photos
r print d y p rmission o Nicol M. a nn st, MD, MS.) 263
2

A
S
c
t
i
B
o
n
Figure 21-4 R xcision with nchoring to sc r tissu or r vision o d pr ss d sc rs. A. Unil t r l t chni u :
2
ull thickn ss incision is m d on on sid o th sc r nd p is und rmin d unil t r lly. Th sc r is d pi
:
:
th li liz d nd th und rsid o th p is thinn d to m tch (crossh tch d r s r r mov d). Th d p
sutur is th n pl c d rom th d pith li liz d sc r to th corr sponding loc tion on th d p sur c o
S
u
th p. This d p sutur uri s th t nsion, nchoring th p nd llowing or n r pproxim tion o th
r
g
i
pid rm l dg s. B. bil t r l t chni u : ull thickn ss incisions r m d on ith r sid o th sc r nd oth
c
sid s r und rmin d. a r und rmin d should t l st twic th width o th d ct or sc r. Th sc r is
l
S
d pith li liz d y r moving its top portion (crossh tch d). Th two sid s r nchor d to th d o sc r
k
i
l
tissu using uri d v rtic l m ttr ss sutur pl c d through th sc r tissu . Th sc r m y v ri ly thinn d
l
s
d p nding on th n d or ulk.

with a subcuticular suture to avoid suture marks.2,7 For

the bilateral mobilization technique (Fig. 21-4B), the scar t ISSu e ex Pa n SIo n
is de-epithelialized in a similar ashion. A ull-thickness
incision is then made along both sides o the bed o When there is insuf cient surrounding tissue to excise
scar tissue. T e skin edges are undermined bilaterally, and close the de ormity in one session, a staged excision
advanced, and anchored to the bed o scar tissue. T e technique or use o a tissue expander may be considered.5
mobilized skin overlying the scar tissue may or may not issue expanders consist o a high-grade silicone bag with
need to be thinned, depending on the amount o tissue a rein orced backplate, and may have an injection port
needed to correct the depressed component o the scar. within the wall, or a remote injection port connected via a
emporary ullness may develop, although it generally silicone tube. T ese devices are implanted in the skin adja-
attens with pressure and time.2 cent to the area to be excised and slowly lled to gradually
Several surgical pearls may be help ul in context where expand the normal surrounding tissues, taking advantage
re-excision may be appropriate. For example, to reduce o the viscoelastic properties o the skin. In areas where tis-
tension on the revised surgical incision, the wound sue mobility is limited and excellent tissue match is impor-
margins should generally be undermined to a distance tant, such as the scalp, a tissue expander may expand the
at least twice the width o the scar and the subsequent adjacent tissue reservoir to provide per ect tissue texture
de ect (Fig. 21-4B). For cases in which the de ect will and color match.
close, but is under some tension, a slight “S” shape or wavy issue expanders o er the ability to predictably repair
ellipse will close more easily with a smaller standing tis- large de ects with excellent match o tissue color and tex-
sue cone de ormity.2 In order to maintain the curvature ture by increasing the available reservoir o surrounding
o the S-shaped excision, it is help ul to suture rom the normal tissues. However, their use is raught with unique
ends rst, working toward the middle to avoid sewing out disadvantages, including the need or multiple stages and
the curvature, as would occur by using the rule o halves. requent visits or reinjection. Patients also experience
Re-excision and repositioning is use ul or scars aligned progressive de ormity during expansion. Each injection
parallel to a distinct RS L or near the boundary between may be accompanied by discom ort. ypically this is
cosmetic subunits, and consists o excising normal tis- minimal and limited to the rst 24 to 48 hours ollowing
sue between the scar and the desired location o scar injection.8 Finally, as with any surgery, tissue expanders
placement within the RS L or at the junction between may be subject to such complications as in ection, hema-
cosmetic subunits. T e surgeon can use this technique toma, pressure-induced necrosis, wound dehiscence, and
to move scars to areas that camou age the scar, such as exposure or per oration o the implant.
the hairline, nasolabial old, preauricular crease, glabellar During consultation, the area to be removed should
264 crease, or orehead rhytides.3 be measured and the tissue expander should be sized to
 2

A B

Figure 21-5 Tissu xp nd r. A. L rg surgic l d ct ollowing Mohs xcision o d rm to ros rcom pro
tu r ns. B. Tissu xp nd rs ins rt d il t r lly dj c nt to th surgic l wound nd volumiz d such th t th

C
h
pic l circum r nc is two to thr tim s th width o th d ct. (Photos r print d y p rmission o R ch l

p
L. Moor , MD.)

t
r
2
1
:
:
match. T e expander should be capable o holding enough device, and should be le t intact whenever possible as it

S
volume to reach an apical circum erence two to three times improves the blood supply and viability o the ap, and

u
r
the width o the planned de ect to allow suf cient tissue

g
provides a strong oundation to hold buried sutures.

i
c
to cover the de ect and the donor area (Fig. 21-5A,B).8

l
T e device is implanted and lled minimally with sterile

S
Kel o Id S

c
saline. Once the wound has healed suf ciently, the device

r
R
is slowly expanded by injecting sterile saline on a weekly
In those patients prone to hypertrophic or keloid scarring,

v
basis ( requency may range rom 3 to 10 days depending

i
s
one must proceed with caution. Although adjuvant treat-

i
on location and tolerability). T e volume injected at each

o
ments such as intralesional steroids, topical imiquimod,

n
visit will depend on the overlying skin tension, wound
or postoperative radiotherapy may minimize an exuberant
strength, and patient discom ort. I the overlying skin
scarring response, this process may recur and result in a
blanches ollowing injection, some saline should be with-
similar or possibly worse outcome. Excisional techniques
drawn to avoid ischemic necrosis and subsequent expo-
should be avoided when dealing with keloid scars in high-
sure o the tissue expander, which is the most common
tension areas. Persistent sources o in ammation should
complication.8 As the dermis expands, neovascularization
be removed as these may promote exuberant scarring.
occurs around the device, resulting in a bluish discolor-
ation that resolves ollowing nal reconstruction. Once an
apical circum erence two to three times the de ect width Sc u l Pt In g
is reached, the surgeon drains the saline, removes the
tissue expander, and per orms the nal reconstruction, SHa Ve a ND Fea THeRING TeCHNIq UeS.
which may consist o a primary closure, broad-based rota- A shave excision may address elevated or pedunculated
tion, advancement, or “jigsaw puzzle” design. During the scars, using a exible razor blade or a #15 blade to shave
process o tissue expansion, a capsule orms around the the elevated portion o the scar level with the surrounding

A B

Figure 21-6 A. exophytic compon nt o tr nsposition p sc r sh v d ush with dj c nt skin using xi l l d .

B. F th ring th wound with #15 sc lp l l d ppli d p rp ndicul r to th skin sur c minimiz s th lin o d m r
c tion. (Photos r print d y p rmission o S v r L. Soon, MD.) 265
2 skin, and the resulting wound is allowed to heal by second-
ary intention. T is procedure will not remove the deeper
portion o the scar, but will remove the exophytic com-
ponent and its associated shadowing, resulting in sub-
stantial bene t in properly selected situations. T e deep
portion may be excised later i necessary. Dermabrasion A B C D
may also be considered or such cases, but o ten entails
longer set-up times and relative biohazards.9 For irregular Figure 21-7 Punch xcision t chni u . A. Sm ll circul r
scars with a depressed component, the proper sculpting sc r. B. Const nt t nsion is ppli d p rp ndicul r to th
r l x d skin t nsion lin s with th nondomin nt h nd.
plane is determined by selecting the skin height midway
C. Th sc r is r mov d vi punch xcision. D. a s t nsion
between the plane o the surrounding skin and the low- is r li v d, th d ct is ound to ori nt d p r ll l to th
est plane o the abnormality, in an e ort to remove the r l x d skin t nsion lin s.
elevated portions and create a homogeneous plane that
blends into the surrounding skin. Once the bulk o a scar
is removed and is level with the surrounding tissue, the
S
edges can be eathered to blend the scar by scraping a #15
c
t
i
blade perpendicularly across the skin’s sur ace to remove procedure, the punch is sized to match the diameter o the
o
n
the epidermis to the level o the super cial papillary der- deepest portion o the scar. T e deepest portion is then
2
mis, with the clinical endpoint being pinpoint bleeding incised, li ted slightly with orceps, and xed in place with
:
:
(Fig. 21-6A,B).9 medical grade skin adhesive.1
T e surgeon must exercise caution when considering
S
u
scalpel sculpting or eathering in abnormal skin, such
r
g
d er ma l Po c Ket g r a f t In g
i
as that subjected to prior radiation therapy or steroid
c
l
therapy, or skin with extensive sun damage or atrophy.
S
Dermal pocket gra ting may be used to correct depressed
k
In general, shave and eathering techniques are use ul or
i
l
l
rolling or boxcar acne scars, as well as deep rhytides, using
s
correcting discrepancies in contour, but will do little or
other scar abnormalities. In addition, one must re rain postauricular dermal donor tissue. In this technique, the
rom excessively deep sculpting to avoid surpassing the desired site o correction should be undermined approxi-
regenerative properties o the scar tissue, which may be mately 10 to 14 days be ore. At the time o the procedure,
limited.9 the donor site is rst dermabraded to de-epithelialize the
tissue. T e dermal tissue is then harvested as punches or
strips. T e autologous dermal gra ts are placed into der-
Pu n c h t ec h n Iq u eS mal or subdermal pockets in the desired location to assist
in elevating the depressed tissue. Advantages to this tech-
nique include reliability, long-lasting e ect, and the ability
Pu n c h exc ISIo n a n d el e va t Io n to tailor the tissue or a precise correction.5

For small boxcar or ice-pick scars, a punch excision may be

considered. In this case, a small punch is used to remove Su bc ISIo n
the entire scar. I tension is applied perpendicular to the
RS L while the lesion is excised, the result is an elliptical Subcision is a use ul technique or depressed scars, par-
de ect oriented parallel to the RS L, which will acilitate ticularly o the rolling type, as seen in acne scars. T e area
closure (Fig. 21-7A– C). Another option or treatment o is anesthetized locally and an 18 gauge needle or other
depressed or boxcar scars is the punch elevation. In this suitable blade is inserted into the super cial subcutaneous

A B

Figure 21-8 A. a n 18 g ug su cision n dl is us d to su cis d pr ss d sc r on th n s l dorsum rom d p sh v

iopsy. B. F nning su cision in multipl dir ctions llows or d u t tissu s p r tion o th d pr ss d sc r rom th
266 und rlying d rmis. (Photos r print d y p rmission o S v r L. Soon, MD.)
tissue at a shallow angle. T e needle or blade is then anned
out as it is advanced and retracted. T e tissue is stabilized
tissue concavities or in sites o ree margin deviation.
Incisions are sometimes placed un avorably across RS L
2
with the opposite hand, while the underlying brous adhe- due to other concerns at the time o reconstruction. As
sions are released (Fig. 21-8A,B). mentioned previously, scars less than 30 degrees rom
the RS L may be re-excised. However, when scars cross
Sc a r Ir r eg u l a r Iz a t Io n RS L at angles greater than 30 degrees simple re-exci-
sion is no longer easible.10 T e Z-plasty o ers the abil-
ity to easily reorient such scars. In addition, the Z-plasty
Noticeable scars o ten disturb the normal acial con-
results in a relative recruitment o tissue laterally, culmi-
tours, resulting in an undesirable appearance. Scars that
nating in lengthening along the original axis o the scar
are long and straight o ten cross adjacent cosmetic sub-
and removing tension on adjacent tissue concavities and
units, distort anatomic relationships, or cause webbing.
ree margins (Figs. 21-9A– C and 21-10A,B). Many cos-
In such situations, one must devise a plan to break up or
metic and/or unctional de ormities rom suboptimal
irregularize the scar in an e ort to make the de ect less
scars may be ameliorated by reorientation, lengthening,
noticeable. T ese irregularization techniques may be ol-
or creating irregular scar lines, which may all be accom-

C
lowed by adjunctive scar treatment techniques such as

h
plished with a Z-plasty.
ractionated laser or dermabrasion to optimize the nal

p
o per orm the Z-plasty, the original healed incision line

t
result.5 It must be noted that while these procedures have

r
is marked. T e central limb o the Z-plasty is placed within

2
the potential to improve the nal outcome, they are time

1
or parallel to the long axis o the scar. Alternatively, the scar
consuming and i not precisely executed, may worsen a
may be excised with narrow margins with the new usi orm

:
scar’s appearance.

:
de ect serving as the central incision o the Z-plasty.11 wo

S
parallel limbs are then drawn, each originating rom oppo-

u
r
z -Pl a St y

g
site ends o the original incision. For any given Z-plasty, there

i
c
are two ways in which the limbs may be oriented. Generally

l
S
Although conceptually dif cult, the Z-plasty may be con- one o the arrangements will blend more naturally into the

c
sidered a workhorse o surgical revision or contracted RS L, which results in a less noticeable scar (Fig. 21-11A).

r
R
or misoriented scars. Scar contracture places tension o conceptualize the approximate nal orientation, one may

v
on adjacent tissue, and results in either webbing across simply leave the orientation o the limbs unchanged and

i
s
i
o
n
A

B C

Figure 21-9 Z pl sty. A. Sc r contr ctur ollowing right m st ctomy nd xill ry lymph nod diss ction r sults in d
cr s d m xim l duction o th right rm. B. S ri l Z pl sty r vision ori nt d to l ngth n th long xis o th xill ry
sc r contr ctur . C. Succ ss ul l ngth ning o th xill ry sc r vi s ri l Z pl sty r vision r sults in su st nti l incr s in
r ng o motion. (Photos r print d y p rmission o Jyoti a ry , MD.) 267
2 A

A B

B B
A
S
e
c
t
i
o
n
2
:
:
C
S
u
r
g
i
c
a
l
S
k
i
l
l
s
B D

Figure 21-10 Z-plasty to correct alar elevation. A. Postop-

erative elevation o the right alar rim, with Z-plasty revi-
sion designed to depress the ree margin by lengthening
the longitudinal axis o the scar. B. Following Z-plasty revi-
sion, right alar margin assumes a more anatomic position.
(Photos reprinted by permission o Nicole M. Annest, MD.)

E
connect the ree tips o the two limbs with a new imaginary
A
central incision (Fig. 21-11B).11 Once the appropriate “Z” is
determined, incisions are placed along these lines. T e two
triangular aps and surrounding skin are undermined and
elevated. As tension is applied to the tips o the “Z,” the tri-
angular aps are transposed and sutured into position (Fig.
21-11C–E). o optimize results, the triangles must be com-
pletely released and the surrounding tissues must be widely
undermined to maximize ap movement.
Varying the angle o the diagonal limbs o the Z has F B
substantial ef ect on tissue recruitment and the degree o Figure 21-11 Classic 60 degree Z-plasty. A. For any scar
lengthening along the original axis. Classically a 60 degree running rom A to B, there are two orientations in which
angle results in a 75% increase in length along the origi- any Z-plasty may be planned. Orienting the two limbs par-
nal axis (Fig. 21-11F). As the angle between the diagonal allel to the RSTL is desirable (green). B. The two limbs are
limbs and the original axis becomes more acute, less lat- drawn at a 60 degree angle with respect to the central limb
eral tissue is recruited, such that a 45 degree angle results and with the same length as the central limb. Although not
in a 50% increase in length and a 30 degree angle results geometrically accurate, one can visualize the approximate
in a 25% increase in length along the original axis.11 T ese orientation o the nal outcome by connecting the ree
calculations are based upon theoretical and mathemati- ends o the two limbs with an imaginary new central limb
(blue line). C–E. The Z is incised, undermined, and the two
cal models; the actual gain in length in vivo is less than
f aps are elevated. As gentle tension is applied to the ends
these theoretical gains due to tissue elasticity.10 Variations o the original scar, the two f aps are transposed, all into
o the Z-plasty, including the double-opposing Z-plasty, place naturally, and the original scar (A–B) is lengthened.
the unequal triangle Z-plasty, the our- ap Z-plasty, the F. The f aps are sutured into place, and the nal outcome
planimetric Z-plasty, and the compound Z-plasty provide o a classic 60 degree Z-plasty results in a 75% increase in
distinct advantages. For longer linear scars, the compound the distance rom A to B (the original scar axis) while reori-
268 Z-plasty is use ul, as the larger aps o a single Z-plasty enting the central limb o the Z.
 2

A
B

C
A B C

h
C

p
t
r
Figure 21-12 Multipl Z pl sty. A. Origin l sc r. B. Multipl Figure 21-13 W pl sty. A. a p tt rn o 5 to 8 mm int r

2
1
Z pl sti s m rk d. R d lin isol t s on Z pl sty or d mon locking “Ws”is m rk d on ith r sid o th sc r. C r must
str tion purpos s. C. Th ps r tr nspos d nd sutur d t k n not to xc d 30 d gr s t th pic s in ord r

:
:
into pl c . Incr s o 75% in th origin l xis l ngth. to void tissu r dund ncy. B. Th sc r with its p tt rn o

S
“Ws” is xcis d. C. Th int rlocking p tt rns r sutur d

u
into pl c .

r
g
i
c
may result in additional distortion o surrounding cosmetic

l
S
subunits. In this technique, the scar is divided into seg-

c
W-plasty may become more noticeable as scar length

r
ments and multiple smaller Z-plasties are linked together increases.2,10 Rather than interlocking “Ws,” GBLC is

R
along the length o the scar (Fig. 21-12A– C). Hove et al.11 composed o a random pattern o interlocking geometric

v
i
published an excellent review o Z-plasty techniques that

s
shapes (triangles, squares, and semicircles) on each side o

i
o
details the bene ts o the variations listed earlier.

n
the scar (Fig. 21-14A– C). Each excised geometric shape
should range rom 3 to 7 mm in size and may extend 3 to
W-Pl a St y 6 mm rom the margin o the wound.1 While technically
more dif cult, the GBLC is thought to have enhanced abil-
Both the W-plasty and the Geometric Broken Line Clo- ity to camou age the scar, particularly in cases where the
sure (GBLC) rely on the principle that an irregular line is scar crosses the RS L at angles greater than 30 degrees.
less visible than a straight line. T e W-plasty is a use ul Apex angles less than 30 degrees (Fig. 21-13A) and wide
technique to break up a long, linear scar with relatively undermining are necessary or optimum cosmetic result
consistent width that may cross RS L. T is technique is with both the W-plasty and the GBLC.
particularly well-suited to assist in camou aging those
scars on convex sur aces.2 o per orm a W-plasty, the
original scar is narrowly excised with a pattern o inter-
locking “Ws” on each side (Fig. 21-13A– C). Ideally, hal
o the limbs should be aligned with the RS L. In addition,
the limbs should be approximately 5 to 8 mm in length
with angles o 60 to 90 degrees to allow or adequate tissue
interposition, optimal vascularity with minimal tip edema,
and crosslinking o healed tissues to resist tension and con-
tracture.2 Deep sutures should principally be used to avoid
tip ischemia and venous congestion. issue tapes may be
help ul or up to 6 weeks.2 In contrast to the transposi-
tion component characteristic o the compound Z-plasty,
the W-plasty is composed o interposition aps. T us,
there is no added length or decrease in wound tension as
observed in a compound Z-plasty. In act, this procedure
will increase tension slightly as a small amount o normal
tissue is excised rom either side o the wound, which must A B C
be considered in areas with minimal tissue laxity.
Figure 21-14 G om tric rok n lin closur (GbLC). A.
a p tt rn o r ndomly rr ng d int rlocking g om tric
g eo me t r Ic br o Ken l In e c l o Su r e sh p s r nging rom 3 to 7 mm in siz is m rk d on ith r
sid o th sc r. B. Th sc r nd p tt rn on ith r sid r
T e GBLC is a variant o the W-plasty more suited to xcis d. C. Th two p tt rns r int rpos d nd sutur d
long, irregular scars, as the regular zigzag pattern o the into pl c . 269
2 v –y a d va n c emen t f l a P
T e V–Y advancement ap, ormerly re erred to as the
island pedicle ap, is another means by which the surgeon
can lengthen a contracted scar. T is technique is particularly A B C
use ul to correct retraction along tissue- ree margins, such
as the lip or the eyelid. Although the Z-plasty and the V–Y Figure 21-15 V–Y dv nc m nt p. A. a “V” is m rk d
advancement ap share the same end goal o lengthening the on th f ct d r m rgin. B. Th incisions r m d nd
de orming scar, the two techniques achieve their results via th l ding dg , tr iling tip, nd th surrounding tissu s
di ering tissue mechanics. T e V–Y advancement ap tech- r und rmin d without compromising th v scul r
nique displaces tissue linearly, in contrast to the Z-plasty, p dicl . Th V sh p d isl nd is th n dv nc d on its v s
which relies on transposition to recruit tissue laterally. cul r p dicl , corr cting th d ormity. C. Th n w d ct
is th n clos d lin rly.
S
c
t
i
o
n
2
:
:
S
u
r
g
i
c
l
S
k
i
l
l
s
A B

C D

Figure 21-16 Fl p r vision. A. bulky, protu r nt sc r ollowing p r m di n or h d p r p ir on th right n s l tip. B.

bulky p is incis d long th pr vious sc r lin nd r ct d to xpos xc ss ro tty tissu . C. exc ss ro tty tissu
is xcis d to llow or mor n tomic contour. D. Th p is r s t nd sutur d in pl c . (Photos r print d y p rmission
270 o S v r L. Soon, MD.)
 o per orm this technique, a V-shaped incision is placed,
and the surrounding tissues are undermined widely. T e
be minimized by proper sizing o the ap, wide under-
mining, squaring the edges o the de ect, and meticulous
2
skin edges o the ap may then be undermined with care so surgical technique.4,12 Despite these precautions, trapdoor
as to avoid compromising the vascular supply rom the base. de ormity may still occur and must be corrected to achieve
T e V is then displaced along its central axis, and the newly the optimal cosmetic outcome.
created de ect rom the displaced tip o the V is closed in a I the ap is mildly hypertrophic and the incision scar
linear ashion (Fig. 21-15A–C). T is technique is generally blends into the surrounding tissue, intralesional cortico-
restricted to smaller corrections, as movement is limited by steroid injections may provide improvement. However,
the deep tissues that provide the vascular supply to the tis- or cases o moderate-to-severe hypertrophy or or those
sue being advanced.4 T is technique may also be reversed to with ap hypertrophy and a recessed incision scar, surgi-
shorten the length o a scar as the Y-V advancement ap.12 cal correction may be indicated.12
A ter the area is anesthetized, a portion o the ap is
f l a P r ef In emen t reincised. I the original incision is depressed or retracted,
the scar may be excised narrowly, leaving precise,
squared-o edges. T e entire incision need not be rein-

C
f l a P h yPer t r o Ph y/t r a Pd o o r

h
cised, only that part o it which is necessary to gain access

p
d ef o r mIt y to the hypertrophied area. Generally the surgeon should

t
r
choose the most uneven, raised, or spread section o the

2
1
T e trapdoor de ormity is a relatively common complica- incision that provides the necessary exposure.4 T e ap is
tion that tends to occur in rounded aps on noses charac- then re ected to gain access to the area o hypertrophy,

:
:
terized by highly sebaceous skin. T e trapdoor e ect can and both the ap and/or the wound base can be debulked

S
u
r
g
i
c
l
S
c
r
R
v
i
s
i
o
n
A B

Figure 21-17 D rm r sion. A. D pr ss d surgic l sc r

on th n s l supr tip nd or h d ollowing p r m di n
or h d p r p ir. B. Postd rm r sion d y 3 d mon
str ting sup r ci l rosions nd h morrh gic crust long
th ntir cosm tic su unit o th n s l tip nd th or
h d sc r. C. Thr months ollowing d rm r sion th
surgic l sc rs r l ss ind nt d nd l nd mor s ml ssly
C
with dj c nt skin. (Photos r print d y p rmission o
Hoom n Khoor s ni, MD.) 271
2 o excess bro atty tissue. T e goal is to remove a uni orm
disc o excess tissue, attening the ap and correcting the
surgeons, it is important to keep patients’ expectations in
mind. Patients should be counseled prior to any attempt
de ormity. T e newly thinned ap may require additional at revision that a scar can never be completely removed,
trimming o redundant skin rom the edges to precisely t but rather modi ed to achieve a more aesthetic and unc-
the de ect, and is then sutured into place (Fig. 21-16A– D). tional result. Although any scar with suboptimal appear-
ance can be revised, the greatest satis action is achieved
in those patients with realistic expectations. T ere ore it
Po St o Per a t Iv e c a r e is critical to be honest with patients regarding the level
o possible improvement. With thorough planning and
Following surgical scar revision, proper wound care will meticulous execution, we can improve many o the unac-
optimize outcomes. T e area should be kept well-hydrated ceptable scars encountered in surgical practice, thereby
with topical emollients. Regular sunscreen use may pre- positively in uencing our patients’ quality o li e.
vent postin ammatory hyperpigmentation. Massage is
encouraged a ter approximately 1 month to aid collagen
ber realignment and to prevent adhesions to deeper
r ef er en c eS
S
c
structures.3,10 Following repair, sur ace taping at bedtime
t
1. Batra RS. Surgical techniques or scar revision. Skin T erapy
i
o
or 3 to 6 months, may help to smooth scar lines. Lett. 2005;10(4):4– 7.
n
2. Horswell BB. Scar modi cation: techniques or revision and
2
camou age. Atla s Oral Ma xillofac Surg Clin North Am. 1998;
a d j u va n t t r ea t men t
:
6(2):55– 72.
:
3. T omas JR, Prendiville S. Update in scar revision. Facial Pla st
S
u
Surg Clin North Am. 2002;10(1):103– 111.
Following surgical scar revision, subtle irregularities may
r
g
4. Lee KK, Mehrany K, Swanson NA. Surgical revision. Derma-
i
remain. T ese may be amenable to a variety o adjuvant
c
tol Clin. 2005;23(1):141–150.
l
techniques such as dermabrasion, chemical peels, and 5. Kaplan B, Potter , Moy RL. Scar revision. Dermatol Surg.
S
k
laser resur acing as described elsewhere in this text (Fig. 1997;23:435– 442.
i
l
l
6. Brenner MJ, Perro CA. Recontouring, resur acing, and scar
s
21-17A– C). Most adjuvant techniques should be per-
revision in skin cancer reconstruction. Facial Pla st Surg Clin
ormed approximately 4 to 12 weeks ollowing the surgical North Am. 2009;17:469– 487.
revision.2,6 Although cumbersome or the patient, silicone 7. Wilson AL. Widening o scars: oe coaxed into a riend? T e
sheeting on a daily basis or 2 to 6 months promotes bro- Millard technique revisited. Pla st Reconstr Surg. 2000;106(7):
blast modi cation through wound hydration and may help 1488–1493.
improve color, texture, thickness, and size.6,13 Patient edu- 8. Roenigk RK, Wheeland RG. issue expansion in dermato-
logic surgery. Dermatol Clin. 1987;5(2):429– 436.
cation and individualization o their postoperative wound 9. Snow SN, Sti MA, Lambert DR. Scalpel sculpturing tech-
care regimen based on their ability and competence will niques or gra t revision and dermatologic surgery. J Derma-
ensure consistent compliance. tol Surg Oncol. 1994;20:120– 126.
10. Shockley WW. Scar revision techniques: z-plasty, w-plasty,
and geometric broken line closure. Facial Pla st Surg Clin
c o n c l u SIo n North Am. 2011;19(3):455– 463.
11. Hove CR, Williams EF, Rodgers BJ. Z-Plasty: a concise review.
Facial Pla st Surg. 2001;17(4):289– 294.
T ere are a variety o “cold steel” surgical techniques that 12. Isenhath SN, Swanson NA, Lee KK. Scar revision. In:
may be use ul in revising unsatis actory scars. A work- Robinson JK, Hanke CW, Siegel DM, Fratila A, eds. Surgery
of the Skin: Procedural Dermatology. 2nd ed. Philadelphia, PA:
ing knowledge o these techniques is essential to obtain Elsevier Mosby; 2010:chap 20.
the best aesthetic and unctional results or our patients. 13. Chang CW, Ries WR. Nonoperative techniques or scar man-
Although much o the end result relies on our skill as agement and revision. Facial Pla st Surg. 2001;17(4):283– 288.

272
 Ch a p t e r

22
Nail Surgery
Joshua W. Trufant, John A. Carucci, Nathaniel Jellinek, &
Chris G. Adigun

extreme care must be taken to minimize trauma. Proce-

An At o my dures af ecting the proximal matrix, responsible or up to
80% o the nail plate, are more likely to result in noticeable
Nail procedures require a detailed knowledge o the anat- postoperative split-nail de ormity.2
omy and physiology o the distal digit. A thorough under- T e matrix makes up the in erior and proximal portion
standing o nail unit structures and their unctions will o a cul-de-sac rom which the nail plate emerges. T e
allow the surgeon to maximize diagnostic and therapeutic superior portion or “roo ” o the cul-de-sac is ormed by
results while minimizing patient discom ort and postop- the proximal nail old (PNF). Its ventral aspect, in contact
erative de ormity. A comprehensive anatomic review is with the nail plate, is o ten re erred to as the eponychium.
beyond the scope o this text, but a brie primer will allow T e most distal aspect o the PNF is the cuticle, a trans-
or better understanding o the procedures described lucent rim o stratum corneum that seals the proximal
subsequently. old to the nail plate, thereby preventing microorganisms
T e nail unit is composed o the nail matrix, nail bed, and irritants rom entering the cul-de-sac. T e sides o
nail plate, and their bordering structures (Fig. 22-1). T e the nail plate are bordered by the lateral nail olds (LNF),
nail matrix is the germinative epithelium that produces which are anatomically similar to the PNF but do not
the keratinized nail plate on the dorsal aspect o the dis- orm a cuticle.
tal digit.1 A portion o the matrix is visible through the Abutting the matrix and comprising the majority o
proximal nail plate as the pink– white, semicircular lunula. the base o the nail plate is the nail bed. Characterized
T e lateral horns o the crescent-shaped matrix extend by linear, parallel rete ridges, this highly vascular tis-
approximately 6 mm proximally rom the visible edge o sue lends a pink color to the nail. T e nail bed is rmly
the nail plate. T e proximal portion o the matrix orms adherent to the plate, to which it may contribute a small
the dorsal – or most super cial – portion o the nail plate, number o cells.2,3 T e bed extends rom the lunula to
while the distal portion produces the ventral portion (Fig. the hyponychium, which seals the potential subungual
22-2). As the predominant germinative structure, the nail space and is the point at which the nail separates rom
matrix is an irreplaceable component o the nail unit, and the underlying epithelium. T e distal nail groove marks

Figure 22-1 Anatomy of the nail. (Reproduced with permission from Dave Klemm. © 2007
Dave Klemm.)
2 Orig in o f nail laye rs Key As pec t s o f
S upe rficia l (dors a l) S ublingua l ke ra tin
pr eo per At iv e evAl u At io n
na il pla te (ve ntra l na il)
T e preoperative evaluation should in orm the surgi-
Eponychium
cal approach and allow or better anticipation and/or
preemption o surgical and postoperative complica-
tions. Occasionally, it may reveal contraindications or
surgery. Important items in the past medical history
include: actors predisposing to in ection, such as a his-
tory o diabetes or other immunocompromised states, as
P roxima l well as the presence o arti cial heart valves, joints, or
ma trix De e p Lunula Na il be d
(s te rile prostheses; bleeding diatheses or coagulopathies; a his-
Inte rme dia te na il
ma trix la ye r ma trix) tory o coronary artery disease, arrhythmias, hyperten-
sion, peripheral vascular disease, Raynaud’s disease, or
S
e
c
other vasospastic disorders; connective tissue diseases;
t
Figure 22-2 Origin o nail la ers. (Used with permission
i
o
arthritides; and psychological disorders that may a ect
n
rom P. Kechijian, MD.)
the patient’s ability to tolerate a procedure. For patients
2
with multiple comorbidities or advanced age, it may be
:
:
advisable to request preoperative clearance rom a pri-
S
the convex distal edge o the hyponychium, separating mary medical doctor.
u
r
it rom the ngertip. T e nail bed dermis sits directly A thorough medication history must be completed, with
g
i
c
atop the periosteum o the distal phalanx without any special emphasis on agents that may increase bleeding risk
a
l
inter vening subcutaneous tissue. Flexor and extensor (antiplatelet and anticoagulant agents, particularly when
S
k
used in combination),4 predispose to in ection (chemother-
i
tendons cross the distal interphalangeal (DIP) joint
l
l
s
and attach to the distal phalanx, while lateral tendons apeutic, steroidal, or other immunosuppressive agents),
attached to the distal ungual process urther stabilize inhibit wound healing (corticosteroids), or inter ere with
the joint. anesthesia or analgesia (anxiolytics, opiates, or other anal-
T e blood supply to the nail unit is provided by the gesics). T ere are no data concerning the e ect o herbals
proper dorsal and palmar digital arteries, which course or vitamins on intra- or postoperative bleeding in the der-
down the lateral aspects o each digit and anastomose to matologic literature, and studies o the e ects o nonsteroi-
orm an arcade o smaller vessels and capillaries (Fig. 22-3). dal anti-in ammatory drugs (NSAIDs) are equivocal.5,6 In
T ey are branches o the common palmar digital arteries general, antithrombotic agents should not be stopped prior
radiating rom the super cial palmar arch, with the excep- to dermatologic procedures, despite an increased risk o
tion o the radial artery o the lateral index nger and the bleeding. Any urther consideration o stopping prescribed
princeps pollicis artery o the thumb, which branch rom medications perioperatively should be discussed with the
the deep palmar arch. Venous drainage generally mirrors patient’s primary doctor or appropriate specialty physician.
arterial architecture, with the exception o collecting veins Medication allergies – particularly to anesthetics, antibiot-
in the LNF that orm an arch over the PNF.3 Innervation ics, or analgesics – must also be documented care ully.
o the nail apparatus is provided by the dorsal and ventral Key aspects o the social history include substance use,
lateral digital nerves, which course alongside the blood employment, and social support network. Casual alco-
vessels. hol users may be counseled to abstain rom consuming
alcoholic beverages prior to surgery due to its vasodila-
tory and blood-thinning e ects, although there is no data
to support this. For misusers, abstaining rom alcohol at
Dors a l digita l least 1 month be ore elective surgery has been shown to
ne rve S upe rficia l a rca de decrease postoperative morbidity.7 Patients who smoke
Exte ns or P roxima l a rca de should be made aware o tobacco’s detrimental e ects on
te ndon wound healing and composite gra t survival ollowing dig-
Dis ta l a rca de ital amputation.8,9 It is also important to be amiliar with
a patient’s living situation and potential care givers, as
well as their orm o employment. Procedures temporarily
a ecting ambulation or use o a hand may be particularly
burdensome or those whose jobs involve manual labor,
computers, or prolonged standing or walking. As the vast
P rope r majority o nail procedures are nonemergent, it is advis-
digita l a rte ry able to delay surgery until the patient can arrange or time
o rom work or home responsibilities.
La te ra l te ndon
In addition to close inspection o all 20 nails, preop-
Pa lma r digita l ne rve erative physical examination should include palpation o
Figure 22-3 Vessels, nerves, and tendons o the nail unit. peripheral pulses and assessment o vital signs. Plain lms
(Adapted with permission rom Fleckman P, Allan C. Surgi- help to de ne the extent o any underlying bony abnor-
274 cal anatom o the nail unit. Dermatol Surg. 2001;27:257.) malities. Magnetic resonance imaging (MRI) provides
optimal tumor localization or select neoplasms (glomus
tumors, myxoid cysts), but is rarely necessary.10
cryogen spray applied or 1 to 2 seconds immediately
prior to needle insertion also lessens the pain o injec-
2
tion.19 Bu ering lidocaine– epinephrine mixtures with 7%
to 8% sodium bicarbonate in a 5:1 or 10:1 ratio has been
An x io l ys is reported to reduce the burning sensation associated with
administration, as has the use o room-temperature anes-
Adequate management o patient discom ort involves thetic.22,23 Patients should always be placed in a reclined or
more than local anesthesia, particularly when per orming supine position during administration to prevent negative
surgeries on ully conscious patients. Patients with a prior sequelae in the event o a vasovagal reaction.
history o anxiety disorder may require preoperative dos- T ere are several e ective approaches to anesthetizing
ing o anxiolytics. Even those without a history o anxiety the nail unit. T e two most commonly used techniques are
may be apprehensive about nail procedures. In addition to the proximal and distal (or “wing”) blocks. T e traditional
being unpleasant or the patient, anxiety may also cause proximal digital block is considered less pain ul, but requires
elevated blood pressure and heart rate, potentially result- up to 10 minutes or complete anesthesia. In addition, it is
ing in greater intra- and postoperative bleeding. During contraindicated in the setting o bacterial in ection.24 T e

C
h
the surgical consultation visit, the physician should inquire proximal block is achieved by two injections laterally at the

a
p
directly about any anticipated emotional discom ort, and a base o the involved nger or toe (Fig. 22-4). T e hand is

t
e
prescription or an anxiolytic agent to be taken preopera-

r
typically laid at, palm down, with ngers spread. T e oot

2
tively should be o ered when appropriate. Oral midazolam

2
is also approached dorsally, but in a neutral position with
has been demonstrated to be help ul in both pediatric the patient’s leg extended. A ter cleaning the injection site

:
:
and adult patients undergoing dermatologic surgery.11,12 with an alcohol pad, the needle is inserted tangentially at

N
Patients who elect to premedicate with an anxiolytic must the web space on either side o the proximal bony phalanx,

a
i
be reminded to bring a companion who is able to escort or between the metacarpophalangeal (or metatarsophalan-

l
S
drive the patient home ollowing the procedure. On the day

u
geal) joints and the proximal interphalangeal (PIP) joints,

r
g
o the surgery, patients should be seated com ortably in a and advanced into the subcutaneous at. A ter pulling back

e
r
reclined or supine position. Attention to ambient tempera- brie y on the syringe to ensure no blood re ux, between
ture, lighting, and background noise will help to ensure a 1 and 2 mL is administered with each injection. T e use
more com ortable experience or patient and surgeon. o greater than 5 mL risks creating a tourniquet e ect that
could cause ischemia. Similarly, a “ring-block,” in which
multiple injections are used to create a tumescent ring o
An es t h es iA anesthetic encircling the base o the digit, is unnecessary
and may be associated with increased risk o digital necro-
Lidocaine is the most commonly used local anesthetic sis.16 I the anticipated scope o the procedure involves only
agent in nail procedures due to its low allergenicity, rapid one side o the nail unit, a block o the ipsilateral nerve only
onset, and 1 to 2 hours’ duration o action. Bupivacaine or may be used. T e surgeon should allow 10 minutes or the
prilocaine may be used or longer procedures or in par- anesthetic to take ull e ect. Additional injections may be
ticularly pain-sensitive patients.13 raditionally, the addi- required, depending on the length o the procedure.
tion o epinephrine or hemostasis was not recommended T e distal “wing” block has the advantage o being
in hand and nger surgeries due to concerns or digital nearly instantaneous. T e rapid e ect likely has more to
necrosis. However, more recent studies do not support do with tumescence than with chemical properties o the
this long-held surgical dogma. A retrospective study o lidocaine itsel . Hemostasis resulting rom tumescence
1111 cases and another prospective study o 3110 cases may be su cient to preclude the need or epinephrine or
o hand or nger surgeries employing 1% lidocaine with
epinephrine (typically 1:100,000) ound no instances o
Pro ximal dig ital blo c k
digital ischemia or tissue loss.14,15 Earlier reports impli-
cating epinephrine in digital gangrene have since been
attributed to other causes such as the use o older anes-
thetic compounds (many o which had an abnormally low
pH), excessive tourniquet pressure, “ring-block” tech-
nique, high-volume injection, and thermal burns rom hot
soaks.14,16 On the contrary, by enhancing and prolonging
the e ects o lidocaine, epinephrine may decrease the
number o lidocaine injections required, prolong post-
procedure pain relie , and decrease the need or a digital
tourniquet.16– 18 Some authors advise caution when using
epinephrine in patients with hyperthyroidism, severe
Do rs al Vie w Vo lar Vie w
hypertension, cardiac disease, Raynaud’s disease, periph-
eral vascular disease, or tobacco use.17,19 Recently, some
have proposed the use o ropivacaine as a long-acting, Figure 22-4 Pro imal digital block. (Reproduced with
rapid-onset anesthetic that may have some inherent vaso- permission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller
constrictive properties.20 AS, Le ell DJ, Wol K. Fitzpatrick’s Dermatology in General
o minimize patient discom ort, anesthesia should Medicine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-2. Cop -
be administered slowly via a 30 gauge needle.21 opical right © McGraw-Hill Education LLC.) 275
2 Dis tal dig ital blo c k
as well.24 Care should be taken to limit injections to the
dorsal hal o the digit, as the pulp o the volar sur ace o
the digit could serve as an unintended reservoir or the
injected anesthesia. Additional injections o the distal
digit may rarely be needed. A total o 1 to 3 mL o anes-
thetic is typically required to anesthetize the dorsal digital
tip, which should appear blanched upon completion.
In an alternative medial approach to the distal wing
block, the needle is introduced at a 30 degree angle
between the DIP joint and PNF, then angled toward one
junction o the PNF and LNF. Approximately 1 to 2 mL
o anesthetic is slowly injected.26 T e procedure is then
repeated using the same insertion point but with the
needle pointing to the opposite LNF. A simpli ed, single-
injection median distal administration may also be used
S
e
or procedures involving only the proximal hal o the
c
t
i
nail unit. In this technique, the needle is introduced at
o
Figure 22-5 Distal digital block. (Reproduced with per-
n
a 30 degree angle into the middle o the PNF, and anes-
2
mission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller AS,
Le ell DJ, Wol K. Fitzpatrick’s Dermatology in General Medi- thetic is injected slowly but continuously as the needle
:
:
cine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-3. Cop right © is advanced distally through the so t, subcutaneous nail
plate, the matrix, and the proximal nail bed.24
S
McGraw-Hill Education LLC.)
u
Other less commonly used techniques include the
r
g
i
transthecal digital block, in which 2 mL o anesthetic
c
a digital tourniquet.25 T e wing block has been reported
a
l
to be more pain ul than the proximal block, but the use o is injected into the potential space o the exor tendon
S
k
sheath at the level o the palmar exion crease.27 Although
i
topical cryogen spray can signi cantly lessen patient dis-
l
l
s
com ort.19 T e needle is rst inserted super cially into the some advocate its use in selected procedures involving
super cial PNF, 2 to 4 mm in erolaterally rom the junc- the middle three ngers, this method has been shown to
tion o the PNF and LNF (Fig. 22-5). A dermal wheal is be no more e ective, and yet signi cantly more pain ul,
created by the injection o a small amount o anesthetic. than volar subcutaneous single-injection techniques or
Additional anesthetic is then slowly injected, creating a the traditional two-injection proximal digital block.26,28– 31
gradual blanching o the LNF that resembles the un old- Both volar injection techniques may risk inadequate anes-
ing o a wing (Fig. 22-6). T e process is then repeated at thesia o the dorsal digit, particularly in surgeries o the
the opposite lateral edge o the PNF. Some authors advise thumb and little nger.29 Wrist blocks are rarely used or
repositioning the needle without withdrawing a ter the nail procedures, except in cases involving extensive ap
rst injection and injecting transversely across the PNF reconstruction.

po s t o per At iv e An Al g es iA
Postoperative pain a ter nail surgery can be signi cant, and
the surgeon should not shy away rom prescribing strong
analgesics when appropriate. It is advisable or the patient
to take an analgesic agent immediately a ter surgery in
anticipation o increased pain when the anesthesia wears
o .32 Although data are scarce in the dermatologic litera-
ture, one randomized controlled trial comparing postoper-
ative analgesia regimens a ter Mohs micrographic surgery
(MMS) ound that the combination o acetaminophen and
ibupro en provided better pain control than acetamino-
phen alone or acetominophen plus codeine.33 T is regi-
men was also better tolerated and associated with ewer
side e ects, including bleeding, than the other regimens.
Importantly, studies rom other surgical specialties have
similarly shown that NSAIDs, in combination with other
analgesics, provide superior postoperative pain control and
are not associated with an increased risk o bleeding.5,33
For smaller procedures, acetaminophen alone may provide
adequate pain relie . T e addition o codeine or oxycodone
to acetaminophen prolongs relie o acute postopera-
tive pain, but may also increase the incidence o adverse
events such as gastrointestinal distress.34,35 As mentioned
earlier, the use o longer-acting bupivacaine anesthesia
276 Figure 22-6 Wing block anesthesia. may lessen the need or analgesics in the rst 24 hours
postoperatively, during which time pain tends to peak.33
Regardless o the choice o analgesic, the patient should be
disadvantage o epinephrine is that its vasoconstrictive
e ects may mask inadequate hemostasis until a ter the
2
educated about the intensity, quality, and duration o pain patient has le t the surgeon’s o ce. T e tumescent e ect
to be expected, as well as signs o a potential complication. o lidocaine alone during a distal digital block may pro-
Pulsating pain that develops 36 to 48 hours a ter nail sur- vide su cient hemostasis or smaller procedures. T ere
gery may indicate an in ection.24 are several digital tourniquet options, should the use o
one be deemed necessary. An adjustable metal ring with
a screw that is turned to regulate pressure may be applied
s u r g ic Al pr epAr At io n , at the base o the digit. A at Penrose drain or catheter
in s t r u men t s An d s u t u r e wrapped around the digit and clamped may also serve
as an improvised tourniquet. Perhaps the best solution
o pt io n s , h emo s t As is , is the use o a sterile surgical glove with the tip o the
involved nger cut o and then rolled back to the base o
po s t o per At iv e d r es s in g s the digit, as mentioned earlier. Studies have shown that
this technique provides sa e, e ective, steady pressure.40– 42

C
h
Nail surgery is ideally per ormed under sterile conditions. Prolonged tourniquet time (i.e., >30 minutes) should be

a
p
T e involved hand or oot is cleansed with an antiseptic avoided, although studies evaluating digital tourniquet

t
e
such as chlorhexidine, isopropyl alcohol, or povidone–

r
time sequelae are lacking. Pressure may be applied manu-

2
iodine solution, or a combination o several agents. For

2
ally over the proper digital arteries at the sides o the digit
ngernail procedures, a sterile surgical glove with the cor- as needed. Although pressure alone usually proves to be

:
:
responding ngertip cut o is then placed over the hand su cient, in rare cases, electrosurgery, erric subsul ate
and the glove nger rolled down to the base o the digit.36

N
(Monsel’s solution), or oxidized cellulose (Gel oam) may

a
T is technique serves the dual purpose o a sterile surgi-

i
be used prior to wound closure.

l
S
cal eld and an e ective tourniquet. Some authors advise

u
r
g
preoperative antiseptic oot soaks to reduce bacterial col-

e
po s t o per At iv e d r es s in g s

r
onization, although it is unclear whether decreased ora
leads to a reduction in clinically signi cant postoperative
in ections.37,38 At the least, soaking so tens the nail plate A pressure dressing applied by the surgeon can help to
and acilitates cutting a thickened nail plate. Antibiotic reduce postoperative throbbing pain and bleeding. How-
prophylaxis is generally not recommended in dermato- ever, care should be taken not to apply the dressing too
logic surgery, although there is a paucity o large-scale, tightly to allow or anticipated postoperative edema and
prospective studies. A recent advisory statement incor- to prevent the ormation o a postoperative tourniquet.
porating American Heart Association recommendations Petrolatum or antibiotic ointment is rst applied to the
provides help ul guidance.39 wound, ollowed by a nonadherent dressing and a bulky
Most instruments required or nail procedures can be gauze wrap to protect against incidental trauma. T e nail
ound on a standard dermatologic surgery tray, with a ew plate is sometimes used as a biologic dressing or splint
notable exceptions. A Freer septum elevator or dental ollowing avulsion or nail bed punch biopsy.43 An alterna-
spatula is use ul or nail avulsion and or protecting the tive, novel technique or splinting ollowing nail avulsion
matrix during nail old biopsies. An English anvil-action is the use o a piece o aspiration tubing cut to t the nail
nail splitter, or rarely a bone rongeur, is help ul or par- bed.44 A bolster dressing sutured to the surgical site may be
tial nail avulsion. A dual-action nail clipper is a versatile used a ter more complex repairs involving aps or gra ts.
instrument or cutting through hard nail plate. Frequently Elevation o the operated extremity reduces pressure on
used standard instruments include ne skin hooks, the surgical wound and urther decreases pain and bleed-
pointed curved scissors, small-nosed hemostats, #11 and ing. Wearing a sling on the operated arm or 48 hours
#15 scalpel blades, a ne-tipped needle holder, and punch serves this purpose, although this is usually not necessary.
biopsy tools. Mono lament, nonresorbable 5-0 or 6-0 Patients undergoing toenail procedures should be advised
sutures are typically used or closure. It is also advisable to to wear open-toed sandals on the day o the surgery. A
have 6-0 resorbable suture material available or nail bed meta-analysis o other postoperative interventions a ter
closure or vessel ligation i necessary. ingrown toenail surgery – such as the use o antibiotics,
honey, or para n dressings – did not show any decrease in
the risk o postoperative in ection, pain, or healing time.45
h emo s t As is
A bloodless eld is essential or success ul nail surgery.
t ec h n iq u es in n Ail s u r g er y:
raditionally, intraoperative hemostasis was achieved n Ail Bed An d mAt r ix ex po s u r e
with a digital tourniquet, although in practice this is
rarely necessary. Standard surgical teaching prohibited
o pt io n s
the use o epinephrine or hemostasis in hand and nger
surgeries due to isolated reports o digital necrosis. How- t o t Al Av u l s io n
ever, as mentioned previously, more recent studies have
challenged that traditional wisdom and demonstrated Avulsion, the process o removing all or a portion o the
the relative sa ety and advantages o using standardized nail plate, is one o the most undamental nail proce-
mixtures o lidocaine with epinephrine.14,15 One potential dures. It is also one o the most traumatic, and should be 277
2 per ormed only when absolutely necessary or diagnosis
or treatment o disease. Avulsion acilitates visualization
T e proximal approach may be the less traumatic o the
two classic total avulsion techniques, particularly i there
o the nail bed and matrix, allowing or matrix biopsies is very tight adhesion between nail plate and bed at the
and other more complex procedures. raditionally, the hyponychium.26 It is also employed i there is no distal nail
total nail plate was avulsed by either distal or proximal edge due to dystrophy. Proximal avulsion begins similarly
approach to maximize exposure o underlying structures, to the distal approach with the septum elevator inserted
but partial transverse or longitudinal avulsion o ten pro- between the PNF and nail plate and moved gently back
vides su cient exposure and results in less trauma.43 otal and orth. However, rather than reinserting at the hypo-
avulsion eliminates important counterpressure provided nychium, the tip o the elevator is kept in place while the
by the nail plate, which can result in nail bed hypertro- handle o the instrument is rotated end-over-end toward
phy and distal embedding o the new nail plate.46 It may the patient’s wrist, gently re ecting the PNF. T e nail plate
also be complicated by postoperative paronychia and is then li ted at its proximal edge with the elevator or a
increased throbbing pain. Some authors suggest that total hemostat. I necessary, the elevator can be advanced dis-
avulsion may increase physiological transverse nail plate tally beneath the nail plate to sever any remaining attach-
curvature, predisposing to pincer-nail de ormity, a condi- ments to the nail bed.50 In practice, the proximal approach
S
e
tion that avulsion was once proposed to treat.47 However, is only rarely used and is a more traumatic and less elegant
c
t
i
there are de nite indications or total avulsion, such as technique.
o
n
large tumors, rank melanoma or squamous cell carci-
2
noma (SCC), and onychomatricomas that project into the
pAr t iAl An d t r Apd o o r Av u l s io n s
:
:
nail plate.
In distal total nail avulsion, the Freer septum eleva-
S
u
tor or a dental spatula is rst inserted between the PNF As noted earlier, partial avulsion provides adequate expo-
r
g
i
and nail plate and moved rmly with a li ting– lower- sure or many nail procedures and may be associated with
c
a
less postoperative morbidity. Importantly, it preserves
l
ing motion to disrupt attachments (Fig. 22-7).48 T is is
S
k
repeated across the entire proximal old to completely some o the counterpressure provided by the nail plate
i
l
l
that is lost with total avulsion. Partial avulsion also acili-
s
ree the dorsal nail plate. T e instrument is then rein-
serted at the hyponychium between the ventral nail tates replacement o the removed portion o the nail plate
plate and nail bed and advanced toward the proximal when histologic evaluation is not required. T e avulsed
edge o the nail plate. A sudden decrease in resistance segment can be sutured or secured with Steri-Strips to act
signals proximity to the matrix; urther advancement as a biological dressing to protect the de ect and promote
increases the risk o trauma and residual nail dystrophy. healing. T ere are a variety o partial avulsion techniques,
At this point the plate should be easily removed with the well described in a recent review, and several o these may
elevator, or i needed, by gently pulling and rotating a be e ective or a given clinical indication. In selecting the
hemostat clamped to the distal nail plate. Some authors most appropriate approach, the surgeon must consider
maintain that use o the straight mosquito hemostat lesion size, localization, and suspected anatomic origin,
alone is pre erable or avulsion, as recommended in ear- as well as the overall surgical objective (i.e., biopsy vs.
lier surgical textbooks.49 removal o the whole lesion).43
Partial distal plate avulsion is use ul or investigating
lesions involving the distal nail bed or hyponychium. It
may also acilitate the topical treatment o distal subungual
onychomycosis or allow drainage o subungual purulent
Dis tal and pro ximal nail avuls io n material in the setting o acute bacterial in ection. A ter
A anesthesia, the nail plate is transected with a nail clipper
B
or English nail splitter and then avulsed using a septum
elevator or hemostat. Soaking the nail in warm water prior
to the procedure can ease cutting. Partial lateral avulsion
may be per ormed to evaluate a neoplasm, oreign body,
or hematoma abutting the LNF. It also has a role in the
treatment o chronic paronychia (CP) and ingrown nails
prior to chemical matricectomy. A longitudinal incision is
made using an English nail splitter (with the at, anvil-like
portion beneath the nail plate), and the lateral portion o
the nail plate avulsed by one o the approaches described
previously.
When examination o the proximal matrix is required,
as in cases o longitudinal melanonychia (LM), a partial
Figure 22-7 A. Distal nail avulsion. B. Pro imal nail avul- proximal nail plate avulsion can be per ormed (Fig. 22-8).
sion. (Reproduced with permission rom Goldsmith LA, T e PNF is rst incised obliquely at its lateral aspects,
Katz SI, Gilchrest BA, Paller AS, Le ell DJ, Wol K. Fitzpat- then undermined with a Freer elevator and re ected
rick’s Dermatology in General Medicine. 8th ed. McGraw- using either ne skin hooks or sutures. An English nail
Hill, Inc.; 2012. Fig. 245-5A and B. Cop right © McGraw-Hill splitter is then inserted rom the lateral edge o the nail
Education LLC.) plate and a transverse cut is made approximately 4 mm
278
 2

C
h
a
A

p
t
e
r
2
2
:
:
N
a
i
l
S
u
r
g
e
r
B

Figure 22-8 A. Partial avulsion o the pro imal nail plate. B. Resulting e posure o the distal matri and pro imal nail bed.
(Reproduced with permission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Le ell DJ, Wol K. Fitzpatrick’s Dermatol-
ogy in General Medicine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-6A and B. Cop right © McGraw-Hill Education LLC.)

rom the ormer site o the cuticle. A hemostat is used to trapdoor avulsion involves the use o a #11 blade to cut
remove the proximal portion o the nail plate, which can three sides o a small “window” in the nail plate that is then
be reinserted a ter the procedure. I the lesion o interest elevated to expose underlying nail bed. T is technique is
is con ned to the lateral nail unit, the lateral plate curl use ul in the case o small, well-demarcated lesions, or-
technique also provides exposure o the proximal matrix. eign bodies, or to allow drainage o blood or purulent
A ter oblique incision and re ection o the involved LNF, material. Alternatively, a ourth cut can be made and the
a hemostat or Freer elevator is inserted beneath the lateral entire “window” removed, or a circular window can be
ree edge o the nail plate and advanced proximally with created with a punch biopsy tool.
steady dorsal pressure on the ventral sur ace o the plate.
Once reed, the lateral plate is grasped with a hemostat
and rolled or peeled medially, exposing the underlying
n o n s u r g ic Al Av u l s io n
nail bed, nail old, and proximal matrix. At the close o
the procedure, the plate may be rolled back and sutured
Ablative carbon dioxide (CO 2) laser treatment is e ec-
to the LNF.43
tive but potentially damaging to the nail bed and matrix,
Another alternative to total avulsion is the “trapdoor”
and should only be per ormed i total matricectomy is
technique, which exposes the distal matrix, nail bed, and
planned.51 Chemical avulsion with 40% urea paste or
hyponychium without removing the nail plate.43 In this
nail lacquer may be use ul in the treatment o onycho-
approach, the Freer elevator or a hemostat is inserted
mycosis.52
between the ree nail edge and nail bed and advanced
proximally to the lunula. T e nail plate is then re ected
superiorly in trapdoor ashion rom the distal edge. wo
oblique incisions o the lateral PNF a ord greater proxi- n Ail u n it Bio ps ies An d exc is io n s
mal exposure i needed. T is approach can be used to
avulse the ull width o the nail plate, or only the lateral INDICATIONS. Biopsies o the nail unit are per-
or medial segments by rst longitudinally incising with ormed to diagnose neoplastic, in ectious, or in am-
an English nail splitter. An abbreviated version o the mator y conditions that cannot be diagnosed by history,
279
2 Bio ps y te c hnique s invo lving the late ral nail fo ld
PNF heal well by second intention, with an exaggerated,
lengthened nail plate as a sequela.

NAIL BED BIOPSIES AND ExCISIONS. Punch

biopsy is a versatile technique or diagnosis o nail bed
and plate lesions. A 3 mm punch typically provides an ad-
equate tissue sample and is less likely to result in residual
dystrophy than larger diameter punches.19 Soaking the
digit in warm water or 10 minutes prior to the procedure
will so ten the plate and acilitate cutting. T e punch tool
may be used to score the sur ace o the nail plate to con rm
optimal localization. It is then advanced by simultaneously
applying downward pressure and twisting the circular
P unch biops y S ha ve biops y blade. For diagnosis o proximal onychomycosis or evacu-
ation o subungual hematomas, local anesthesia is not al-
S
Eliptica l biops y
e
ways required. T e punch tool is advanced only as ar as the
c
t
i
ventral portion o the plate, signaled by a decrease in resis-
o
n
Figure 22-9 Nail old biopsies. (Reproduced with per- tance. T e severed disk o nail plate may be removed with
2
mission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller ne-tipped scissors or a #11 blade and submitted or pe-
:
AS, Le ell DJ, Wol K. Fitzpatrick’s Dermatology in General
:
riodic acid-Schi (PAS) staining i indicated. T e surgeon
Medicine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-15.2. should also take care to examine the punch be ore discard-
S
u
Cop right © McGraw-Hill Education LLC.) (E-Figure on
ing it, as the sample may remain attached to the blade.
r
g
AccessMedicine).
i
I a nail bed sample is desired, as in the diagnosis o
c
a
l
neoplasms or in ammatory conditions such as lichen
S
k
clinical examination, or routine mycology.1 In the case planus or psoriasis, punch or elliptical biopsy techniques
i
l
l
s
o smaller lesions or subungual hematomas, the proce- may be used (Fig. 22-11). Elliptical biopsy necessitates at
dure may also be therapeutic. T e most commonly used least partial avulsion o the overlying nail plate by one o
techniques are punch, elliptical, longitudinal, and shave the techniques described previously. A longitudinal usi-
biopsies. T e nail unit is rst anesthetized as described orm incision through to the periosteum is then made
previously, and the biopsy technique and orientation around the lesion with a #11 blade. Resorbable sutures
tailored to the anatomic structure involved. T e goal, are used to close de ects larger than 3 mm.1 Avulsion may
as with all nail procedures, is to maximize diagnostic or be per ormed prior to punch biopsy, or, alternatively, the
therapeutic e ect while causing as little pain and residu- punch may be advanced through the plate and nail bed
al nail dystrophy as possible. until bone is reached. T e punch is then withdrawn, and
the sample extracted gently using ne-tipped scissors or
NAIL FOLD BIOPSIES. Lesions o the PNF and LNF #11 blade. Forceps tend to damage the tissue and are not
may be biopsied using a shave, punch, or elliptical tech- recommended. T e punch should be care ully examined
nique in a similar ashion to other cutaneous biopsies to ensure that a part or all o the sample has not been
(Fig. 22-9). Small spindle-shaped excisions are particu- retained. A variation on this technique involves the use o
larly well-suited to this region. A Freer elevator with the a larger, 6 mm punch to remove the overlying nail plate,
curved tip angled ventrally can be inserted under the nail ollowed by a 3 mm or 4 mm punch biopsy o the nail bed
old during PNF biopsies to protect the underlying ma- (Fig. 22-12). T is acilitates visualization o the nail bed
trix rom trauma (Fig. 22-10).1 Even large de ects o the and eases extraction o the tissue sample while avoiding
the discom ort and morbidity associated with total avul-
sion.43 I needed, hemostasis may be assured with Monsel’s
solution or Gel oam. Sutures are not required. I not o

Hyponychium

Na il be d
3 mm punch

Longitudina l
e llips e

Figure 22-11 Nail bed biopsies. (Adapted with permis-

Figure 22-10 Punch biops o pro imal nail old, with sion rom Rich P. Nail biops : indications and methods.
280 elevator to protect matri . Dermatol Surg. 2001;27:229.)
 2
6 mm 3 mm or
punch 4 mm punch

A B

C
Excis e d na il

h
a
pla te

p
t
e
r
2
2
:
:
N
C

a
i
l
S
u
r
Figure 22-12 Telescope “two-punch” technique or punch biops o nail bed. A. 6 mm punch device

g
e
through nail plate onl , and this portion o plate is set aside B. A 3 or 4 mm punch device is used to sample

r
the nail bed through the de ect in the nail plate created b the 6 mm punch device C. The removed 6 mm
portion o the nail plate is then used to cover the de ect. (Adapted with permission rom Richert B. Basic nail
surger . Dermatol Clin. 2006;24:313. Cop right © Elsevier.)

diagnostic importance, the avulsed nail plate is replaced horns extend more laterally, the second excision should
over the resulting de ect. T e nail bed typically heals with- be made 1 to 2 mm beyond the LNF to ensure complete
out scarring, although a small ocus o onycholysis may excision.54 Drawing the planned incisions with a surgical
persist a ter surgery.53 marker will help to ensure an adequate specimen. Dissec-
tion can be completed using ne scissors, and the sample
NAIL MATRIx BIOPSIES AND ExCISIONS. inked or orientation during processing and histologic
T e primary indication or nail matrix biopsy is to rule out interpretation. T e de ect is then closed by reapproximat-
malignant melanoma in a patient with a pigmented nail le- ing the skin edges and using resorbable simple interrupted
sion. Longitudinal nail excision and punch, elliptical, and
shave biopsies all have a role in diagnosis (Fig. 22-13). T e
surgeon’s chosen approach must be in ormed by a thor-
ough history and physical examination. Proximal matrix
biopsies in particular carry a high risk o permanent post-
operative split nail, and less traumatic approaches may be
indicated or less clinically concerning lesions. However,
excisional biopsy is recommended when clinical suspicion C
B
or melanoma is high. An excision that reduces matrix A
length will generally result in a thinner nail plate, while one
that reduces matrix width will result in a narrower plate.
Lateral longitudinal excision is most use ul or diagno-
sis o LM o the lateral one-third o the nail. Partial avul-
sion may be per ormed rst, but is not required and may
alter the histologic appearance o the specimen. Following
local anesthesia, an incision to bone is made beginning
at the distal crease o the dorsal DIP joint. It is then car-
ried distally through the PNF, matrix, nail bed, and plate
Figure 22-13 Nail matri biopsies. A. Punch biops ma
(i not previously avulsed) 1 to 2 mm parallel to the LNF, be used or pigmented bands less than 3 mm in diameter.
ending at a point 2 to 3 mm beyond the hyponychium.54 B. Transverse biops o distal nail natri ma be used or pig-
An English nail splitter may be used or cutting through mented bands in the middle o the nail plate. C. Longitudinal
particularly resistant nail plate. A second incision is then nail biops ma be used or lateral pigmented nail lesions.
made through the LNF. Complete excision o the lateral (Adapted with permission rom Braun RP, Baran R, Le Gal FA,
matrix horn prevents ormation o postoperative spicules et al. Diagnosis and management o nail pigmentations.
or cysts.55 In cases involving the great toe, whose matrix J Am Acad Dermatol. 2007;56:835. Cop right © Elsevier.) 281
2 Re fle c te d pro ximal nail fo ld

(1)
(2)
S
e
c
t
i
o
Figure 22-15 Matri shave biops . (1) Partial Lateral Avul-
n
2
sion (2) Re ection o the dorsal old with f ne skin hooks.
(Reproduced with permission rom Goldsmith LA, Katz SI,
:
:
Figure 22-14 Punch biops o longitudinal melanon chia. Gilchrest BA, Paller AS, Le ell DJ, Wol K. Fitzpatrick’s Derma-
tology in General Medicine. 8th ed. McGraw-Hill, Inc.; 2012.
S
u
Fig. 245-10. Cop right © McGraw-Hill Education LLC.)
r
g
i
c
a
or horizontal mattress sutures passed rom skin to nail to side, exposing the proximal matrix and allowing identi -
l
S
k
recreate the LNF.54,56 T is “back-stitch” technique helps to cation o the origin o melanonychia. Using a #15 blade,
i
l
l
avoid implantation o nail plate ragments in the nail bed, the surgeon scores 1 to 2 mm margins around the ori-
s
which can result in keratin granuloma ormation. Biped- gin and then shaves the lesion tangentially (Figs. 22-15
icle ap or partial closure with second intention healing and 22-16). Although resulting specimens are less than
o the remaining de ect may be employed in cases o high 1 mm thick, this technique has been shown to yield ade-
tension. quate tissue or histologic diagnosis and to have excel-
Punch biopsy, with or without preceding avulsion, lent aesthetic outcomes.60,61 Placement o the specimen
can also be used to evaluate matrix lesions.25 Following on a piece o wet paper or cardboard will prevent it rom
re ection o the PNF, a 3 mm punch excision is made curling, which can complicate subsequent processing.56
perpendicularly to the skin through to the underlying o repair the de ect, the proximal nail plate and nail old
periosteum (Fig. 22-14). T e punch should be immedi- are laid back in place. rimming the ree lateral edge o
ately inspected to see i it contains the sample. I not, the avulsed plate by a ew millimeters will help prevent
ne-tipped scissors are then gently inserted around the lateral embedding.57 T e plate can then be secured with a
specimen to snip at the base.57 Forceps should not be used horizontal mattress suture. Alternatively, sutures closing
due to the risk o crush arti act. Sutures are not required the oblique incisions o the PNF may be su cient to hold
or matrix de ects o 3 mm or less. wo 3 mm punches or it in place.
a single larger punch can be per ormed or larger lesions,
but are requently associated with residual nail dystro-
phy. Although technically more demanding, elliptical or
crescentic matrix biopsy may have improved cosmetic
outcomes or larger lesions. Following proximal nail avul-
sion, transverse crescentic or usi orm incisions are made
around the origin o pigmentation with 1 to 2 mm mar-
gins, paralleling the distal curvature o the lunula. De ects
larger than 3 mm are closed with 6-0 resorbable sutures.
A midline/paramedian longitudinal excision may also
be per ormed to evaluate the origin o LM in the middle
third o the nail, but this technique is more likely to result
in split-nail de ormity or other residual dystrophy i the
resulting de ect is not properly repaired.58 Several nail
matrix aps have been described to address these surgi-
cal challenges.
Another use ul approach or diagnosing LM wider
than 3 mm with minimal residual dystrophy is the tan-
gential matrix excision or matrix shave biopsy.56 I
the PNF or cuticle is pigmented, a shave biopsy o the
involved area can be per ormed prior to obliquely incis-
ing and re ecting the PNF.56,57,59 A proximal nail plate Figure 22-16 Matri shave biops ollowing partial pro i-
282 avulsion is then per ormed and the plate re ected to one mal nail plate avulsion and retraction o pro imal nail old.
 d es t r u c t iv e t ec h n iq u es :
2
mAt r ic ec t o my An d t o t Al
n Ail ABl At io n
reatment o recalcitrant nail hypertrophy or extensive
benign and malignant neoplasms may necessitate matri-
cectomy or total ablation o the nail unit. T ere are a
variety o techniques at the surgeon’s disposal. I histopath-
ologic examination is required, surgical excision must be
per ormed. Otherwise, chemical, laser, or electrocautery
ablation are acceptable and e ective destructive methods.

MATRICECTOMy. T e rst steps in surgical matri-

cectomy are oblique lateral incision and re ection o the

C
h
PNF, ollowed by avulsion o the proximal one-third o

a
p
the nail plate (Fig. 22-17). T e nail bed is then incised 1

t
e
r
to 2 mm distal to the lunula and the matrix care ully dis-

2
2
sected rom the periosteum with blunt-tipped scissors. Figure 22-18 Chemical matricectom o the lateral matri
Incomplete excision o the matrix lateral horns will result horn. (Adapted with permission rom Haneke E. Controver-

:
:
in postoperative cysts or spicules.55 Care should be taken sies in the treatment o ingrown nails. Dermatol Res Pract.

N
to avoid trauma to the extensor digitorum tendon, which 2012;2012:783924. Cop right © 2012 Eckart Haneke.)

a
i
l
inserts in the distal phalanx just proximal to the matrix.

S
u
T e ventral epithelium o the PNF is tangentially excised

r
g
as well, completely eliminating all germinative lining o

e
r
the nail cul-de-sac. tissue necrosis.62 T is technique is commonly used or
I no histologic specimen is required, chemical matri- treatment o ingrown nails. Following proximal plate
cectomy is e ectively and sa ely carried out using liq- avulsion, 88% phenol solution is vigorously applied to the
ue ed phenol, a protein-denaturing alcohol that causes entire matrix – paying particular attention to the lateral
horns – using a cotton-tipped swab (Fig. 22-18). Success
rates generally exceed 98%, although recommendations
Matric e c to my or the necessary application time to achieve permanent
e ect vary rom 2 to more than 4 minutes.63,64 Adjoining
nail structures can be protected using petrolatum, and
P roxima l La te ra l
A Na il ma trix na il fold na il fold
the destructive action o phenol neutralized with isopro-
pyl alcohol. Recent data suggest that trichloroacetic acid
Cuticle
and 10% sodium hydroxide show promise in chemical
matricectomy.65,66
Hyponychium CO 2 laser or curettage with electrocautery are also
e ective options or partial or complete matricectomy.
T e CO 2 laser has the advantage o creating a bloodless
eld, and may be associated with less postoperative pain
and aster healing times.67,68

TOTAL NAIL ABLATION. otal nail ablation, also

Na il pla te known as “en bloc” excision, is an alternative to ampu-
B Na il be d tation or the treatment o malignant neoplasms o the
Lunula nail unit (Fig. 22-19). Avulsion is not necessary, but i
per ormed, some authors recommend staining the ma-
trix with methylene blue to allow or better visualization
during dissection.69 A ter anesthesia, an incision to bone
is made around the periphery o the nail unit. T e most
proximal transverse cut should be made approximately
three-quarters o the distance rom the cuticle to the dor-
sal DIP joint, a point proximal to the matrix but distal to
the insertion o the extensor digitorum tendon.70,71 T e
transverse incision is continued to the midlateral line o
Figure 22-17 Surgical matricectom . (Reproduced with the digit on each side, then carried longitudinally paral-
permission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller leling the LNF and across the ngertip, 2 to 5 mm rom
AS, Le ell DJ, Wol K. Fitzpatrick’s Dermatology in General the hyponychium. Proceeding in a distal-to-proximal di-
Medicine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-12.1A rection, the tissue is care ully dissected rom the perios-
and B. Cop right © McGraw-Hill Education LLC.) (E-Figure teum using blunt-tipped scissors. Complete excision o
on AccessMedicine). the matrix lateral horns prevents postoperative cysts or 283
2 Nail ablatio n
improvise and tailor the chosen approach to the speci c
needs o each individual patient.

A P roxima l La te ra l PROxIMAL NAIL FOLD REPAIRS. Smaller PNF

Na il ma trix na il fold na il fold Lunula de ects resulting rom trauma or surgical excisions can
Cuticle o ten be closed primarily. However, wider de ects may
require relaxing incisions to acilitate wound closure
(Fig. 22-20). A midline or paramedian de ect can be eas-
Hyponychium ily closed by rst making incisions at each side o the
nail old, then undermining the nail old to the level o
the nail plate. T e PNF aps are then rotated toward the
midline and sutured without tension. For particularly
wide medial de ects, aps employing skin rom the later-
al digit can be mobilized by creating two arcing incisions
Na il rom the midlateral line o the digit to the medial cuticle.
S
pla te
e
B In both cases, the relaxing incisions are le t to heal by
c
Na il be d
t
i
second intention. For more lateral de ects, the creation
o
De fe ct to he a l by s e conda ry inte ntion,
n
gra fting, or cros s -finge r fla p o one or two relaxing incisions on the contralateral side
2
ollowed by undermining achieves a similar e ect.61
:
:
NAIL MATRIx REPAIRS. Matrix de ects are associ-
S
u
ated with a high risk o permanent nail dystrophy, and the
r
g
i
surgeon must make every e ort to repair them meticu-
c
a
l
lously while minimizing wound tension. Second intention
S
k
healing is a less than optimal choice given that any scarred
i
l
l
s
tissue will be incapable o producing normal nail plate.
T e inelastic quality o the dermal matrix makes primary
Figure 22-19 Total nail ablation. (Reproduced with per- closure o de ects more challenging than in other cutane-
mission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller ous surgeries. In some cases, thorough yet delicate under-
AS, Le ell DJ, Wol K. Fitzpatrick’s Dermatology in General mining o surrounding tissue enables primary repair, but
Medicine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-12A and a ap is o ten required to close matrix de ects to achieve
B. Cop right © McGraw-Hill Education LLC.)
avorable cosmetic outcomes.
A number o reconstruction techniques have been
spicules.55 T e surgical de ect may be allowed to heal by suggested or midline de ects involving the matrix
second intention or repaired with a skin gra t, described (Fig. 22-21).58 Wide undermining ollowed by primary
in greater detail in the ollowing paragraphs. closure, also known as the Schernberg ap, is requently
associated with residual midline nail dystrophy.72,73 T e
bilateral distal rotation ap involves creating two curvilin-
n Ail d ef ec t r epAir s ear incisions down to the bone at the distal tip o the de ect
and carrying each to the lateral sulci. T e aps are then
T e repair o surgical and traumatic nail unit de ects reed by care ul undermining above the periosteum, back
ranges in complexity rom healing by second intention to the level o the proximal tip o the de ect, resulting in
to skin gra ts and aps. T ere is no one correct repair greater mobilization toward the midline o the digit.74 T e
or each type o de ect. As with all other nail procedures, wound can be closed with minimal tension using simple,
repairs call upon the surgeon’s detailed knowledge o the absorbable sutures. T e A-to- bilateral advancement ap
anatomy and physiology o a ected structures, amiliar- similarly involves mobilization o lateral aps, but with
ity with previously described approaches, and ability to undermining o the proximal matrix and preservation o

A B C
Figure 22-20 Pro imal nail old repairs. A. Small medial de ect repair acilitated b lateral rela ing incisions. B. Lateral
de ect depair acilitated b two contralateral rela ing incisions. C. Larger medial de ect repaired with bilateral rotational
284 aps.
 2

A B C

Figure 22-21 Matri de ect repairs. A. Bilateral distal rotation ap. B. A-to-T bilateral advancement ap. C. Bilateral
bipedicle ap. (Adapted with permission rom Collins SC, Cordova KB, Jellinek NJ. Midline/paramedian longitudinal matri

C
h
e cision with ap reconstruction: alternative surgical techniques or evaluation o longitudinal melanon chia. J Am Acad

a
p
Dermatol. 2010;62:627. Cop right © Elsevier.)

t
e
r
2
2
:
:
the matrix– nail bed junction. A ter re ecting the PNF, subungual malignancy. Second intention healing is a

N
arcing incisions are made down to the bone beginning viable option, but may require several months to restore

a
i
at the midline o the de ect at the most proximal point o unctionality. Full-thickness skin gra ting, probably the

l
S
u
the matrix and carried to the LNF sulci. T e aps are then most common technique, is associated with good unc-

r
g
sharply undermined above the periosteum, completely tionality and acceptable cosmesis.70,76,77 Gra ts are typi-

e
r
reeing the proximal matrix and acilitating midline clo- cally harvested rom the inner arm or groin, and may be
sure with absorbable sutures.58 per ormed immediately or delayed until a nal pathol-
T e widest medial de ects involving the nail matrix and ogy report con rms complete excision.78,79 A bolster
bed can be repaired using a ap or gra t. T e bipedicled dressing sutured to the surgical site and le t in place or
bilateral matrix advancement ap exploits the relative 1 week helps promote apposition and protects the heal-
laxity o skin rom the lateral digit.58,75 Deep relaxing inci- ing wound rom injur y. A less requently used technique
sions are made longitudinally at both sides o the PNF, is the reversed dermal gra t, in which a donor gra t is
in line with the LNF. T e matrix aps are then sharply stripped o its epidermis and sutured into place on the
undermined with a scalpel at the level o periosteum de ect upside-down, allowing the richly vascularized
in a medial-to-lateral direction, taking care to preserve super cial dermis to improve the chances or success ul
the proximal and distal attachments. T e medial edges take. T e exposed deep dermis is le t to heal by second
o the aps can then be approximated and sutured in a intention or split-thickness skin gra t.61 Split-thickness
tension- ree ashion. Alternatively, a ree matrix gra t skin gra ts alone do not provide much protection or
employing a thin slice o matrix harvested rom the intact the distal digit, and color and texture matching can be
big-toenail can be placed in the de ect.61 I the recipient problematic.70 Split-thickness toenail bed gra ts, ree
nail plate has been totally avulsed, the toenail plate can nail gra ts and ree vascularized nail trans ers, more
be trimmed down and placed in the recipient nail bed to
act as a splint.
Narrow lateral de ects o the nail matrix and bed can
be closed with a Schernberg ap, but, or larger de ects,
a bipedicled lateral nail wall ap may result in better cos-
mesis and unctionality (Fig. 22-22).61 T is technique is
most use ul a ter lateral longitudinal excision or excisional
biopsy o erythro- or melanonychia. T e lateral wall o
the de ect is rst undermined and dissected rom bone. A
relaxing incision is then made in the pulp o the ngertip
to acilitate greater movement o the ap into the de ect.
Back-stitches (passed rom nail bed to nail plate) are used
to raise the ap above the remaining nail plate, thereby
reconstructing the lateral nail wall. T e secondary de ect
heals by second intention.61

l Ar g er d ef ec t s o f
t h e d is t Al d ig it
T e surgeon has several options or reconstruction
o the distal digit ollowing conservative excision o Figure 22-22 Bipedicled lateral nail wall ap. 285
2 commonly described in the plastic surger y literature or
repair o congenital or traumatic de ects, require con-
Tre atme nt o f partial he mato ma

siderable technical expertise and are associated with

signi cant donor-site morbidity and variable success
rates.80– 82
ransposition aps, although potentially more time-
intensive and intimidating to both the patient and the
surgeon, are associated with good unctional and cos-
metic outcomes. T e cross- nger ap is the most com-
monly used by dermatologic surgeons or thumb and
index nger de ects.70,83,84 It is typically per ormed as a
two- or three-staged interpolation ap procedure. A ull-
thickness ap o appropriate size is incised in the volar
aspect o an adjacent digit. It is le t in place or up to 10
days to “train” the ap, and then transposed to cover the
S
e
primary de ect. akedown o the pedicle is per ormed 2
c
t
i
to 3 weeks a ter the transposition, and a ull-thickness
o
n
skin gra t used to repair the secondary de ect.61 T e ag
2
Figure 22-23 Trephination o subungual hematoma. (Repro-
ap 85 and Foucher island ap 86 are single-stage proce-
duced with permission rom Goldsmith LA, Katz SI, Gilchrest
:
:
dures avored by some hand surgeons or distal digit BA, Paller AS, Le ell DJ, Wol K. Fitzpatrick’s Dermatology in
reconstruction.
S
General Medicine. 8th ed. McGraw-Hill, Inc.; 2012. Fig. 245-14.
u
r
Cop right © McGraw-Hill Education LLC.)
g
i
c
a
l
in d ic At io n s f o r s u r g er y o keratin ragments in the nail bed, which may result in
S
k
granuloma ormation.
i
l
l
s
T e most common indications or surgery o the nail
unit are to diagnose and treat benign or malignant neo- in f ec t io n s An d pAr o n yc h iA
plasms, to relieve patient discom ort and to improve cos-
mesis. T e nail unit is a compact anatomical space bound Nail unit in ections are requently preceded by trauma
on one side by a relatively hard, keratinized nail plate. to the nail old or cuticle, which enables microorganism
Any space-occupying lesion, particularly o the nail bed, inoculation. Acute paronychia, an in ammatory reaction
can be extremely pain ul and lead to de ormity o the o the nail olds, is most commonly caused by Staphylococ-
nail plate by exerting pressure on the matrix or the plate cus species. Incision and drainage is indicated i an abscess
itsel . is present. rephination or partial avulsion can help to
relieve pain and allow drainage o in ections unresponsive
to oral antibiotics alone.88 A culture should be per ormed
t r Au mA An d h emo r r h Ag e to guide oral antibiotic coverage, i indicated. wice-daily
antimicrobial soaks are also recommended.
Subungual hematomas resulting rom injury to the CP is o ten associated with nail dystrophy. It is com-
nail bed appear as red to purple or black discolorations monly seen in people whose jobs involve wet work, such as
beneath the nail plate. ypically, the patient can provide dishwashers, launderers, and bartenders. Candida species
a history o recent trauma. Hematomas can be exquisitely may be isolated rom the nail, but their role in the patho-
pain ul in the acute setting. rephination, the creation o genesis o CP is unclear.89,90 In one double-blind study,
a small opening in the nail plate to relieve pressure and topical steroids were ound to be a more e ective treat-
allow escape o subungual material, is the treatment o ment than systemic anti ungals, suggesting that CP may
choice (Fig. 22-23). A #11 blade or small punch may be be more correctly thought o as a type o hand dermatitis
used or this purpose. For more chronic discolorations, caused by environmental exposures rather than a orm o
particularly those that do not travel with the nail as it onychomycosis.91 Intralesional corticosteroids may also be
grows, melanoma or other malignancy must be ruled bene cial.19 En bloc excision o the PNF with nail avulsion
out. T e presence o subungual blood does not necessar- is an e ective treatment or recalcitrant cases.92
ily exclude a concurrent melanoma.87 Larger hematomas rue onychomycosis is caused by dermatophyte in ec-
may require total avulsion to allow or investigation o the tion. It is requently characterized by subungual hyper-
extent o nail bed injury. T ey should also prompt radio- keratosis, onycholysis, dystrophy, and dyschromia o the
graphs to rule out racture. nail plate. A simple nail clipping with subungual keratotic
Foreign bodies can cause signi cant discom ort and material submitted or PAS staining is the most sensitive
may be associated with in ammation, granulation tis- diagnostic test.93 Occasionally, partial avulsion or punch
sue, secondary in ection, and nail dystrophy. Plain radio- biopsy may be required or diagnosis o more proximal
graphs can help to con rm the presence o a suspected in ections. opical treatment is extremely challenging, and
radiopaque object. Partial nail plate avulsions are use ul avulsion does not appear to improve success rates.94 Dark
or exploring and extracting well-localized oreign bodies brown to black pigmentation due to pigmented myco-
in the nail bed.43 T e surgeon must take care when sutur- ses or reactive melanocytes occasionally mimics the LM
286 ing the nail plate not to implant oreign bodies in the orm caused by melanoma or benign melanocytic neoplasms.
 in f l AmmAt o r y d is eAs es
La te ra l ma trix horn
2
Intralesional corticosteroid injections are an e ective treat-
ment or nail dystrophy associated with in ammatory con-
ditions like psoriasis, lichen planus, and CP.95 A 30 gauge
needle is introduced into the PNF, angled toward the nail
plate, and 0.05 to 0.1 mL o corticosteroid (usually triamcin-
olone, 2.5–10 mg/mL) is injected to create a dermal wheal
over the matrix. T is may be repeated two or three times Na il
Na il s picule
per nail to cover the entire PNF. T e use o a re rigerant s picule
spray immediately be ore injection reduces patient discom- S wolle n dis ta l portion
of la te ra l na il wa ll
ort.19 Injections are continued monthly or a ew months A B
until normal nail begins to orm, then tapered in requency.
Figure 22-24 Distal–lateral ingrowing nail. A. Nail spicule

C
embedded in swollen distal lateral nail old B. Nail spicule

h
in g r o w n n Ail s

a
almost completel engul ed b swollen lateral nail old

p
t
tissue. (Adapted with permission rom Haneke E. Contro-

e
r
Ingrown nails, also known as onychocryptosis, are a com- versies in the treatment o ingrown nails. Dermatol Res

2
2
mon problem, particularly among adolescents and young Pract. 2012;2012:783924. Cop right © 2012 Eckart Haneke.)
adults. T e most common variety is the “distal– lateral”

:
:
ingrowing nail, in which the obliquely-trimmed lateral a narrowing o the nail plate (Figs. 22-18 and 22-26). Phenol

N
edges o the nail plate become embedded in the distal– matrix cauterization, described in detail previously, may be

a
i
more e ective than excision in preventing recurrence.101,102

l
lateral nail grooves (Fig. 22-24). T is results in a oreign

S
u
body reaction characterized by in ammation, granulation Particular care must be taken to completely excise or

r
g
destroy the lateral matrix horns to prevent recurrence or

e
tissue, and secondary in ection. T e choice o treatment

r
depends on the degree o in ammation and induration nail spicule ormation. Isolated reports o high rates o
o the LNF.96 aping the LNF is a common conservative in ection and other complications associated with pheno-
approach e ective in mild cases, but requires excellent lization have not been supported by meta-analysis.45 Par-
patient adherence.97 Surgical tape is applied obliquely in tial matricectomy by CO 2 laser ablation, with or without
a proximal– lateral direction to the LNF, thereby pulling concomitant LNF vaporization, is an increasingly popular
it away rom the lateral edge o the nail plate (Fig. 22-25). treatment modality, although reported recurrence rates
Packing the lateral nail groove with a small wisp o cotton vary widely.67,103,104 Other surgeons eschew matricectomy
is another conservative modality or separating the LNF in avor o resection o the overgrown lateral borders o
and nail plate.98 T e “gutter treatment,” per ormed under the nail.105 Proponents o this technique, which leaves the
local anesthesia, entails the placement o a piece o sterile nail width unaltered, cite improved cosmesis and ewer
plastic tubing, cut lengthwise, over the entire length o the complications.106 However, this approach may be associ-
lateral nail margin.99 T e tubing is secured with stitches, ated with higher recurrence rates, perhaps due to a ailure
tape, or acrylic glue and le t in place or 6 to 12 weeks. to address the primary etiology o the ingrowing nail.64,96
Steel, plastic, or alloy nail braces to atten the nail plate
are sometimes used by podiatrists, based on the theory s pl it n Ail s
that over-curvature is a major etiologic actor.96,100
Surgical treatment o ingrown nails is generally asso- Split-nail de ormity most commonly results rom sharp or
ciated with lower recurrence rates, particularly in more blunt trauma to the matrix, resulting in a scarred segment
severe cases.45 T e prevailing approach is excision or unable to produce normal nail plate.107 Neoplasms o the
chemical destruction o the lateral matrix, which results in distal phalanx, nail bed, matrix, or plate may also lead to

Wis p of cotton pa cke d

S wolle n la te ra l unde r la te ra l corne r of
S wolle n la te ra l
na il fold the na il pla te to ke e p
na il fold
it away from the na il
groove

Na il s picule Na il s picule
A cut away B cut away C

Figure 22-25 Conservative management o ingrown nails. A. Taping. B. Cotton packing. C. Gutter treatment. (Adapted
with permission rom Haneke E. Controversies in the treatment o ingrown nails. Dermatol Res Pract. 2012;2012:783924.
Cop right © 2012 Eckart Haneke.) 287
2

Toe na il trimme d to s ize

A of finge rna il cove rs gra ft
a nd re cipie nt na il be d
S
e
c
t
i
o
n
2
:
:
S
u
r
g
B Ma trix s ca r
i
c
a
Figure 22-26 Surgical management o ingrown nails. Fre e ma trix gra ft
l
S
A. Selective lateral matri horn resection. B. Reduction B ha rve s te d from big toe
k
i
l
o the lateral nail old b usi orm incision. (Adapted
l
s
Figure 22-27 A. Classical method o split nail repair. B.
with permission rom Haneke E. Controversies in Free matri gra t rom the big-toenail ma be used or
the treatment o ingrown nails. Dermatol Res Pract. wider de ects.
2012;2012:783924. Cop right © 2012 Eckart Haneke.)

a split nail, as can biopsy or other iatrogenic manipulation nail unit such as exostoses or cysts.47 Recurrence ollowing
o the matrix. An understanding o the speci c etiology o surgical or conservative treatment is all but assured i the
the de ormity in each case is absolutely essential to reduce underlying abnormality is not corrected. Plain radiographs
the risk o recurrence. Optimal surgical repair, described can be help ul in identi ying causative bony anomalies.
in more detail previously, hinges on care ul excision o One e ective surgical approach involves bilateral partial
the scarred portion o matrix and meticulous reconstruc- avulsion o the nail plate ollowed by permanent excision
tion (Fig. 22-27). T e narrowest matrix de ects may be or chemical destruction o the lateral matrix horns.19,47
closed primarily with absorbable sutures. However, the T is may also be achieved with CO 2 laser.51 T e nail plate
creation o matrix aps may be necessary to eliminate is then shortened to allow dissection o the nail bed rom
tension on the wound and reduce the risk o additional the phalanx and removal o osteophytes with a bone ron-
scarring.58 Wide undermining o the nail bed just above geur prior to closure. Reverse-tie sutures in the LNF help
the periosteum acilitates reapproximation and suturing
o the bed and the two remaining nail plate ragments (i
not avulsed). For wider de ects on the ngernail, a ree
Width of the na il tip
matrix gra t rom the big-toenail can be per ormed.61
I the recipient nail plate has been totally avulsed, the
trimmed toenail plate or a piece o surgical tubing can be
He ight of
used as a splint. the na il tip

pin c er n Ail s Width of the

na il root
Pincer-nail de ormity describes a transverse over-curva-
ture o the nail plate most requently a ecting the toenails
o young adults. In the “common” variety, the aperture o the
curving nail narrows distally, pinching the underlying nail
bed and causing in ammation and o ten severe pain (Fig.
22-28). Symmetric congenital pincer nails are due to inher- Norma l na il P ince r na il de formity
ited anomalies o the distal phalanges, while acquired disease Figure 22-28 Pincer-nail de ormit . (Adapted with per-
is commonly due to de ormation o the oot with deviation mission rom Muta M, Suna M, Isk D. A new surgical tech-
o the phalanges due to ill- tting shoes, chronic conditions nique or the correction o pincer nail de ormit . Ann Plast
288 such as psoriasis and osteoarthritis, or neoplasms o the Surg. 2007;58:496.)
to stretch the nail bed. An alternate, matrix-preserving
approach includes total avulsion ollowed by insertion
destruction is indicated to relieve pain, improve cosme-
sis, and prevent recurrence o the de ormity. T e surgical
2
o dermal gra ts under the lateral edges o the dissected approach will depend upon the nail structure(s) involved.
nail bed and matrix to widen and atten the nail unit.108 Benign tumors o the nail olds can generally be excised by
T e use o a modi ed ve- ap Z-plasty technique to cor- the same approaches used in other cutaneous surgeries.
rect the nail bed shape has also been described.109 In most Small spindle-shaped excisions per ormed in this region
instances, simple lateral matrix horn chemical matricec- heal well by second intention. When excising PNF tumors,
tomy is used, with predictable success. a Freer elevator inserted under the nail old can protect
the underlying matrix rom trauma.1 Excision o nail bed
and matrix tumors is more challenging. A ew o the more
o n yc h Au xis An d o n yc h o g r yph o s is commonly encountered benign neoplasms o the nail bed
are glomus tumors, periungual warts, pyogenic granulo-
Onychauxis, or thickening o the nail plate, and onychog- mas, epidermal cysts, myxoid cysts, onychopapillomas,
ryphosis, or gross hyperkeratosis coupled with increased bromas, and exostoses. Rarer tumors include enchon-
curvature o the nail, are common among the elderly. T ey dromas and osteochondromas. Some benign tumors, like

C
are requently associated with neglect, poor nail groom-

h
pyogenic granulomas, can mimic subungual melanoma.113

a
p
ing, and ill- tting ootwear, as well as trauma, onychomy- Periungual warts may be impossible to distinguish clini-

t
e
cosis, and psoriasis. Idiopathic, congenital, and acquired

r
cally rom SCC. Plain radiographs can aid in the diagnosis

2
cases involving the toenails are not uncommon. Fingernail

2
o bony neoplasms, whereas MRI may help to di erenti-
involvement is rare. Periodic nail grinding can provide ate so t tissue and cystic lesions and better de ne the con-

:
:
symptomatic relie , but recurrence is common. T e most tours o a tumor prior to surgery.10 Partial and trapdoor
e ective, lasting treatment o nail thickening that origi-

N
avulsions are help ul conservative techniques that acili-

a
nates in the matrix is surgical shortening o the matrix

i
tate treatment o localized nail bed tumors. Punch biopsy

l
S
length. Following proximal avulsion, the distal one-third

u
is o ten su cient to remove smaller lesions, whereas ellip-

r
o the matrix is removed with a crescentic excision that

g
tical, crescentic, or wedge excisions may be required or

e
parallels the curvature o the lunula.110 Severe onychogry-

r
larger lesions. A bone rongeur is use ul or removal o
phosis may require complete matricectomy.111 bony or cartilaginous tumors. Repair o associated de or-
mities such as split nails, pincer nails, or ingrown nails
r Ac q u e t n Ail s may be required. Destructive modalities such as CO 2 laser
and cryotherapy should be used with caution as they do
Racquet nails, or brachyonychia, is an autosomal-dom- not permit histopathologic exclusion o malignancy.
inant inherited de ormity characterized by wide nail
plates. It most commonly a ects the thumbs in women,
and may be associated with conditions such as the Rubin-
n o n mel An o mA s Kin c An c er s
stein– aybi syndrome.112 Surgical treatment options
SCC and Bowen’s disease are the most common malig-
are similar to those or other causes o ingrown nails:
nancies a ecting the nail olds, hyponychium, and most
partial matricectomy to narrow the plate or resection o
commonly, nail bed. Clinically, SCC may be indistin-
the LNFs.
guishable rom HPV-associated periungual and sub-
ungual warts, which can delay diagnosis or years i
Ben ig n t u mo r s destructive treatment modalities are repeated without
biopsy (Fig. 22-29).114 Subungual tumors may also pres-
Benign tumors o the nail unit can cause nail de or- ent with er ythronychia, leukonychia, melanonychia,
mity and signi cant discom ort. Surgical excision or hyperkeratosis, paronychia, mild onycholysis, or nail

A B

Figure 22-29 Periungual SCC (A) be ore and (B) a ter e cision. 289
2 plate destruction. Most cases are invasive at the time
o diagnosis, including up to 60% o longstanding cases
shave techniques have been described. Each o these
techniques may be used to excise the lesion completely
with bony involvement requiring amputation o the dis- at the time o biopsy or complete histopathologic evalu-
tal phalanx.115,116 Un ortunately, the sensitivity o radio- ation. Punch or shave biopsies may be associated with
graphic evaluation or bony involvement is unclear.117,118 less residual nail dystrophy.56,57
MMS, one o the pre erred treatment modalities, may Current trends in the surgical management o nail mel-
reduce amputations by enabling histopathologic exami- anoma avor conservative, tissue-sparing approaches over
nation o the deep and peripheral margins o a tumor.119 traditional wide surgical excision or amputation when
Reported cure rates with MMS approach 96% or possible. “En bloc” excisions and MMS are most com-
tumors not involving the bone.120 However, long-term monly per ormed or nail melanoma in situ (MIS). Recom-
ollow-up data is lacking, and reported recurrence rates mendations or appropriate margins in “en bloc” excisions
approach 20% (compared to 3% or other cutaneous vary rom 2 to 10 mm around all nail structures.70,76 MMS
SCC).114 I MMS is not available, wide surgical exci- has the advantage o complete margin analysis, but is not
sion is associated with a low risk o relapse.116 Radiation as well-studied.83,130 Amputation at the PIP or DIP joint
therapy has been proposed as a possible alternative to (or interphalangeal joint o the thumb) is still the pre-
S
e
distal phalanx amputation, but experience and ollow- dominant treatment or invasive nail melanoma, but some
c
t
i
up is limited.121– 123 Data is also lacking on the e cacy o authors have begun to cast doubt on any survival bene t
o
n
photodynamic therapy (PD ) and topical therapies such over local excision.70,85,131– 133 In every case, but particu-
2
as 5- uorouracil and imiquimod. larly in those with tumors located on the thumb and index
:
:
Basal cell carcinoma (BCC), the most common malig- nger, a detailed discussion o treatment options, includ-
nancy worldwide, is exceedingly rare in the nail unit. It ing digit-sparing versus amputation surgeries, should be
S
u
requently presents with ulceration, but like SCC, may initiated with the patient and amily. Excision with clear
r
g
i
clinically resemble a number o benign neoplasms, margins remains the most important goal o surgery, and
c
a
l
in ammatory conditions, and in ections.124 Shave patients must guide the surgeon’s decision, with an under-
S
k
biopsy is typically adequate or diagnosis.125 MMS is the standing o the pros and cons o each technique, as well as
i
l
l
s
most common treatment modality. Repairs described postoperative sequelae.
in the literature include second intention healing and
ull-thickness skin gra ts.126 Other rare malignancies o
the nail unit include Kaposi’s sarcoma, Merkel cell carci-
noma, and metastases, most commonly rom lung, kid- c o mpl ic At io n s
ney, and breast cancers. In nearly hal o reported cases,
subungual metastases were the presenting sign o the Complications o nail surgery are in requent, but similar
primar y malignancy.127 Once con rmed by biopsy, exci- to those associated with other dermatologic surgeries,
sion may theoretically be per ormed or symptomatic namely pain, bleeding, in ection, scarring, and recur-
solitar y lesions. However, metastases typically involve rence. A recent patient survey identi ed sensory distur-
the bone, a ect multiple digits, and portend a very poor bance, including paresthesias and cold intolerance, as a
prognosis. potentially under-recognized complication.134 Reports
o digital necrosis due to epinephrine, well-enshrined in
surgical lore, are exceedingly rare to nonexistent in more
mel An o c y t ic l es io n s An d recent large-scale retrospective studies.14,15 Preopera-
l o n g it u d in Al mel An o n yc h iA tive and postoperative hygienic soaks or ingrown toe-
nail surgery, while commonly practiced, are o unclear
Subungual melanoma is a rare orm o acral lentiginous bene t in reducing postoperative in ection, and oral
melanoma arising rom the nail matrix. It makes up less antibiotics are not routinely indicated, except in immu-
than 4% o all melanoma subtypes, but up to 20% o nosuppressed patients or those with arti cial heart
melanomas in Black, Asian, and Native American popu- valves or prosthetic joints.39,45
lations.76 It is also associated with a poorer prognosis Nail dystrophy caused by iatrogenic trauma is a
than melanoma o other sites, likely due to delays in unique aspect o nail surgery. Biopsy and treatment o
diagnosis. Subungual melanoma most commonly pres- nail matrix, and less requently, nail bed lesions can
ents as LM, a sign with a broad di erential diagnosis result in scarring o the matrix, rendering it unable to
that also includes benign melanocytic lesions as well as produce normal nail plate. One study o nail procedures
subungual hemorrhage, mycotic or bacterial in ection, cited a 22% rate o residual scarring and dystrophy.135
and Bowen’s disease.56 Pigmentation o the nail old, or Split nails, pincer nails, hooked nails, or misaligned nails
Hutchinson’s sign, should heighten clinical suspicion have all been reported.55 Surgical corrections o these
or melanoma, but is also a relatively nonspeci c nd- de ormities are discussed previously. Nail dystrophy can
ing.59 Several algorithms exist to guide the dermatolo- cause signi cant psychological distress, which may be
gist in the management o pigmented nail lesions (Fig. lessened by preoperative discussion o risks and patient
22-30).57,128 However, it is also worth noting that any- expectations.135,136
where rom 15% to 65% o subungual melanomas are Incomplete excision or destruction o the lateral matrix
amelanotic.129 Dermoscopy can enhance clinical exami- horns during matricectomy can result in postoperative
nation, but a biopsy is required i there is the least clini- spicules or cysts.55 T is risk is increased in cases involv-
cal suspicion or malignancy. Longitudinal, punch, and ing the big toe, where the matrix horns extend more
290
 2
Longitudina l me la nonychia
(< 6 mm wide )

His tory a nd phys ica l exa mina tion

De rmos copy a nd e nd-on de rmos copy

C
h
a
Be nign findings

p
De cis ion: biops y or not biops y
a nd no biops y

t
e
r
2
2
:
:
Evolving or worris ome findings

N
a nd biops y

a
i
l
S
u
r
g
e
r
High like lihood of
La te ra lly loca te d pigme nt
inva s ive me la noma

La te ra l longitudina l excis ion P igme nt loca te d ne a r midline Full-thickne s s excis ion

or biops y

Dors a l pla te pigme nt Ve ntra l pla te pigme nt (dis ta l

(proxima l ma trix) ma trix) (ma jority of ca s e s )

≥ 3 mm wide < 3 mm wide ≥ 3 mm wide < 3 mm wide

3 mm punch excis ion 3 mm punch

Ma trix s have Ma trix s have
or ma trix s have excis ion
biops y biops y
biops y

Figure 22-30 A proposed algorithm or approach to biops o longitudinal melanon chia. (Adapted with permission
rom Jellinek N. Nail matri biops o longitudinal melanon chia: diagnostic algorithm including the matri shave biops .
J Am Acad Dermatol. 2007;56:803. Cop right © Elsevier.)

laterally.54 Phenol cauterization has rarely been associated

with excessive tissue necrosis, persistent exudative drain-
c o n c l u s io n
age, and periostitis.137 Other potential surgical complica-
Surgical procedures are an essential component o the
tions include injury to the extensor tendon during en bloc
diagnosis and treatment o neoplastic, in ectious, and
nail excision, which can be avoided i the surgeon is aware
in ammatory conditions o the nail unit. A detailed
o its relationship to the proximal matrix.70 Excess thermal
understanding o nail anatomy, thorough preoperative
damage to the nail matrix or bed rom a CO 2 laser can
evaluation, and thought ul attention to patient com ort
cause the same nail dystrophies as the cut o a scalpel.
allow the surgeon to maximize results while minimizing
291
2 postoperative de ormity and dys unction. Procedures
involving the germinative matrix must be approached
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papillomavirus type 35 RNA in the digital tumor and axillary 134. Walsh ML, Shipley DV, de Berker DA. Survey o patients’
lymph node metastases. J Am Acad Dermatol. 1996;34:1080. experiences a ter nail surgery. Clin Exp Dermatol.
116. Dalle S, Depape L, Phan A, Balme B, Ronger-Savle S, T omas 2009;34:e154.
L. Squamous cell carcinoma o the nail apparatus: clinico- 135. de Berker DA, Dahl MG, Comaish JS, Lawrence CM. Nail
pathological study o 35 cases. Br J Dermatol. 2007;156:871. surgery. an assessment o indications and outcome. Acta
117. Peterson SR, Layton EG, Joseph AK. Squamous cell carci- Derm Venereol. 1996;76:484.
noma o the nail unit with evidence o bony involvement: a 136. Alam M, Moossavi M, Ginsburg I, Scher RK. A psychomet-
multidisciplinary approach to resection and reconstruction. ric study o patients with nail dystrophies. J Am Acad Der-
Dermatol Surg. 2004;30:218. matol. 2001;45:851.
118. Dika E, Piraccini BM, Balestri R, et al. Mohs surgery or 137. Gilles GA, Dennis KJ, Harkless LB. Periostitis associated with
squamous cell carcinoma o the nail: report o 15 cases. Our phenol matricectomies. J Am Podiatr Med Assoc. 1986;76:469.

294
 Ch a p t e r

23
Ear Piercing and Ear Lobe Repairs
Steven S. Greenba m, Charles H. Greenba m, &
Josh a M. Greenba m

T e external ear is made up o the pinna or auricle, and inward in comparison to the surrounding parts o the ear.
the auditory canal, or meatus. T e pinna serves to col- In “meso”- ear types both the helix and anti-helix protrude
lect the sound waves that travel through the air, and the rom the head, the lower helix and lobule evert rom the
meatus guides these vibrations to the middle ear. T e head at an angle slightly less than the horizontal angle o
concave outer sur ace o the pinna consists o a series o the hypo-type, and the tragus and anti-tragus are in an
depressions and convexities that result rom the olding intermediate position.2
o its brocartilaginous structure. Speci cally, the lobule Understanding di erent ear types can aid in more accu-
(commonly known as the ear lobe), located below the rate and aesthetic auricular reconstruction. A study con-
antitragus, is composed o tough areolar and adipose tis- ducted at ulane University compared speci c attributes
sue, and lacks the developed structure o the rest o the o the human ear observed among 67 Caucasian men and
pinna1 Fig. 23-1. 120 A rican American men, both living and deceased. In
T e auditory canal or meatus, extends approximately analysis o the measurements o total ear length, ear width,
1 inch rom the bottom o the concha to the tympani or ear base, and concha length and width, it was observed
middle ear. T e meatus orms an S-shaped curve and is com- that Caucasians generally have long, narrow ears and
posed o cartilage, membrane and bone, and is lined by skin.1 Americans o A rican descent have shorter, broader ears.
In analyzing the aesthetic variations o the ear, it is T e average length and width o the ear respectively were
important to understand the anatomic variations o the 64.18 mm and 37.19 mm or Caucasian men, and 58.58 mm
human ears. Ears may be categorized into speci c types, and 37.43 mm or A rican American men. Americans o
“hyper-,” “hypo-,” and “meso-”based on their appearance. A rican descent had minimal-to-no hair on the ear in com-
In “hyper”- ear types, the helix is pressed down toward the parison to Caucasian ears. T e helix was observed to be
head, the anti-helix protrudes beyond the helix, the lower broader in A rican Americans, whereas the antihelix was
helix and lobule bend toward the head, and the tragus and more prominent in Caucasians.2 As the blending o races,
anti-tragus protrude and turn outward. In “hypo”- ear cultures, and ethnicities has become more common, such
types, the helix is protruding, the anti-helix is pressed in di erences have become less pronounced. When doing
toward the head, the lower helix and lobule point outward surgery on a given individual, there is no better compari-
almost horizontally, and the tragus and anti-tragus press son than the contralateral ear!

Hype r e ar type Hypo e ar type Me s o e ar type

Figure 23-1 Variations in the basic str ct re o the external ear.

2 Ea r l o bE piEr c in g a downward tilt, which may be aesthetically unacceptable.
I the hole is placed too ar anteriorly, the earlobe symme-
try may be disrupted, and the diameter o the earring that
Many individuals have their initial ear piercing done in a
the patient can wear may be limited due to reduced space.
non-medical setting, such as a shopping mall, by relatively
Once the necessary discussion has occurred, the physician
untrained personnel under varying conditions. T ere are
can mark the mutually agreed upon location.
people who pre er to have their piercing done in a more con-
Be ore doing this, the ear should be cleaned. Although
trolled environment such as a physician’s o ce. Sometimes,
in ection is extremely rare, meticulous preparation can
this is or the initial piercing but in many cases it is a ter
reduce this risk even urther. We typically use chlorhexi-
a prior complication. Certainly, many patients and physi-
dine gluconate due to its antiseptic, antimicrobial, and bac-
cians pre er that a physician per orm a secondary piercing
tericidal e ectiveness, although other antibacterial agents
i there has been previous earlobe surgery. T ere are many
can be used. Once the ear has been cleaned, marking can
advantages o doing earlobe piercings in a doctor’s o ce,
proceed, typically with a ne point surgical pen. Alcohol
most notably its sterile, controlled environment. Precise
pads should be available to remove the marking i it is
hole placement can be discussed and the procedure can be
deemed unacceptable. For initial piercings, the marking is
S
done care ully and skill ully. Although the vast majority o
e
straight orward. I there has been prior surgery on that ear
c
t
piercings done in a commercial setting occur without com-
i
or the contralateral one, this must be taken into account.
o
n
plications, bleeding, vasovagal response, equipment mal-
Similarly, i there is already one hole in the lobule and the
2
unction, improper positioning, and in ection are possible.
patient desires a second piercing, care ul evaluation o the
T e medical o ce environment is prepared to handle these
:
:
appropriate location is paramount. T e new ostium should
possibilities. As with any technique or procedure, there are
be placed ar enough away rom the prior hole so as not to
S
many approaches and methods. We describe the technique
compromise the strength or integrity o either piercing site.
r
g
that we have ound to be e ective, sa e, and reproducible
i
Once the rst ear has been marked, attention is shi ted
c
a
over a period o many years.
l
to the other side. As earlobes are not identical even in the
S
k
same person, strictly measuring or a location can be inad-
i
l
l
s
equate. Aesthetic evaluation to ensure that the eventual
St Ep 1: c o n Su l t a t io n w it h t h E appearance will be pleasing is critical. Open communica-
pa t iEn t tion is especially important during this phase. Once the
sites have agreed upon and the other ear has been simi-
Consultation with the patient is o paramount impor- larly cleansed, it can be marked. T e patient is given the
tance. A discussion regarding the exact location in which opportunity to view both markings be ore piercing.
the piercing (s) will be placed is critical. T ere is an inher-
ent advantage i the ears have not been previously pierced.
Ideally, the patients’ desired location and the physician’s St Ep 3: a n ESt h Et iz in g t h E Ea r a n d
idea o optimum position intersect. I not, the rami ca- u t il iz in g a 30 g a u g E n EEd l E a S a
tions o “improper” placement should be explained to g u id E
the patient. I the physician is not com ortable with the
patient’s desires, an impasse may be reached and the doc- A ter marking has been satis actorily accomplished, the
tor may not eel com ortable proceeding. Fortunately, this ears must be anesthetized.3 ypically we use 1% lido-
is rare as most patients respect the judgment o the doctor caine mixed with epinephrine 1:200,000. T e procedure
with whom they have chosen to consult. is so quick that epinephrine is not required, but there
In deciding upon the proper location, the patient should may be an advantage to having its hemostatic e ect. As
be handed a large mirror so that an interactive, in ormed so little anesthetic is used, any adverse e ect is negligible.
discussion can take place. Each individual’s ear lobes have A 30 gauge needle attached to a 1.0 cc luer lock syringe
a slightly di erent size and shape. Although most people or a 1.0 cc tuberculin syringe is utilized. An additional
are relatively symmetrical this is not invariably the case. I 30 gauge needle is placed on the surgical tray. A ter the
signi cant variation between the ears exists, it is incum- lobes have been anesthetized, the additional needle is used
bent upon the physician to discuss this with the patient to pierce the lobe on the anterior sur ace directly in the
be ore marking the proposed sites. center o the marked spot (Fig. 23-2). It is important that
the needle penetrate the lobule perpendicular to the skin
rather than at an angle to ensure that the nal piercing is
St Ep 2: Ma r k in g t h E Ea r l o bES also perpendicular and that the earring will not be tilted
bEf o r E piEr c in g upward or downward relative to the skin sur ace. T e
30 gauge needle will act as a guide over which an 18 gauge
With the patient holding a mirror, the physician should dis- needle will later be slid to create the ostium.
cuss the patient’s piercing pre erences be ore making any
marks on the lobe. ypically, the ideal position is in the mid-
dle o the lobule. T e most common mistake is placing the St Ep 4: Sl id in g t h E 18 g a u g E
hole too ar in eriorly toward the ree margin o the lobule. n EEd l E o v Er t h E 30 g a u g E g u id E
As there will be less bulk, this o ten results in an increased t o c r Ea t E t h E o St iu M
chance or the piercing to elongate or tear. In addition,
heavier earrings will not have the so t-tissue support to Once the 30 gauge needle has been used to puncture the
296 allow them to lay perpendicular to the lobe, resulting in lobule rom anteriorly to posteriorly, the positioning should
 2

C
h
a
Figure 23-2 A ter the lobes have been anesthetized the Figure 23-4 The post o the earring (m st be smaller

p
t
e
additional needle is sed to pierce the lobe on the anterior than the l men o the 18 ga ge needle) is placed into the

r
s r ace directly in the center o the marked spot. l men o the 18 ga ge needle.

2
3
:
:
E
a
once again be checked. A sterile 18 gauge needle can then not to bring a hoop or an earring with a ne wire post

r
P
be slid over the tip o the 30 gauge needle that protrudes because these are more likely to cause damage to the lobe.

i
e
rom the posterior sur ace o the lobe. Care must be taken It should be determined prior to the procedure whether

r
c
i
to avoid needle sticks while sliding the larger needle over the earring post ts inside the lumen o the 18 gauge nee-

n
g
the smaller needle. Once this has been accomplished, the dle. I the post is too thick a slightly lower gauge must

a
n
18 gauge needle should be advanced rom posterior to be used.

d
E
anterior as the 30 gauge needle is withdrawn (Fig. 23-3).4 T e post should be placed into the lumen o the

a
r
Care must be taken not to withdraw it too quickly, as its 18 gauge needle while holding the ear and the needle

L
o
guidance will then be lost. T e 18 gauge needle should steady (Fig. 23-4) to minimize the chance o an inadvertent

b
e
per orate the skin perpendicular to the lobe’s sur ace and needle stick. Once the post is inserted, the earring is gently

R
e
through the center o the mark drawn on the anterior sur- pushed rom anterior to posterior as the 18 gauge needle

p
a
ace o the ear. is simultaneously withdrawn rom the posterior sur ace.

i
r
s
A slow synchronous movement is desired so that the ear-
ring emerges rom the posterior lobe at the same time
St Ep 5: in SEr t io n o f t h E Ea r r in g that the tip o the 18 gauge needle is removed (Fig. 23-5).
Once the earring has been positioned, its backing can be
ypically, we ask the patient to bring an earring with placed. Care should be taken not to press too tightly, as
them, speci ying that it be a “stud” made o gold, sterling the lobule may be swollen rom the anesthesia and could
silver, stainless steel, titanium, or other material unlikely swell even more in the ensuing hours i manipulation is
to cause an allergic reaction. We speci cally ask them excessive.

Figure 23-3 The 18 ga ge needle is gently and precisely Figure 23-5 The earring is slowly p shed rom anteriorly
p shed anteriorly as the 30 ga ge g ide needle is sim lta- to posteriorly as the 18 ga ge needle g ides it thro gh
neo sly slowly p lled o t o the lob le. the osti m. 297
2 St Ep 6: po St o pEr a t iv E w o u n d c a r E
Once the earring(s) have been placed, wound care
instructions are given. ypically the new ostium will epi-
thelialize within 6 to 10 weeks, although there is some
variability. Patients should be instructed to cleanse the
area once or twice a day with soap and water, alcohol or
hydrogen peroxide. It is important that the patient not
over manipulate the earring or remove it prematurely.
We advise gentle periodic rotation o the earring to mini-
mize the possibility o adherence to the inner lining o the
ostium, using small amounts o Vaseline or lubrication.
T ere is no need or antibiotic ointment as these agents
Figure 23-6 Beaver handle and blade— se l or deli-
can cause hypersensitivity and allergic contact dermatitis.
cate, precise s rgical control.
S
e
We advise the patient that they may change their earring
c
t
in 6 to 8 weeks barring any un oreseen complications, and
i
o
n
to call i any pain, swelling, redness, drainage, or other
2
symptoms arise. St Ep 2: pu n c h o u t t h E l in in g o f
t h Eo l d h o l E
:
:
Ea r l o bE r Epa ir
S
Once the area is anesthetized we select the size o the
r
g
punch to be used. We stretch the skin in the direction per-
i
c
a
Ear lobes can sustain injury in many ways.5– 9 T ey can be pendicular to the long axis o the dilated hole. In this way,
l
S
lacerated due to trauma or as a consequence o piercing.
k
we create a more elliptical wound, which will be easier to
i
l
A hoop-shaped earring can pull through the ear causing
l
close, and minimize standing cone de ormities (Figs. 23-7
s
a ull split or leading to elongation o the ostium. Keloids and 23-8). A tongue blade or chalazion clamp can be used
may develop due to piercing or an inf ammatory process. to stabilize the lobe and act as a “backstop” or the punch
Improper healing may lead to tissue overgrowth that can as it pierces the skin. A combination o pressure and rota-
extend signi cantly beyond the actual piercing site. As the tion are used to create as precise a cut as possible, mini-
ear protrudes rom the side o the head and the lobe itsel mizing tissue raying and irregular edges.
is unique, this site is di cult to reconstruct. T e paucity o
appropriate adjacent donor tissue in this location limits the
options or repair. St Ep 3: r Epa ir in g t h E w o u n d
I the wound is small and under minimal tension, simple
d il a t Ed o r St r Et c h Ed interrupted sutures can be placed. We use nylon or poly-
Ea r r in g h o l E propylene because rapidly absorbable suture may lose
its integrity be ore the wound gains su cient strength.
We commonly leave the sutures in or 10 days. I they
A dilated or stretched hole usually results either rom an are placed properly and are not under undue tension,
acute injury, as when an earring is pulled partially through suture marks rarely occur. We utilize the smallest cali-
the lobule, or rom chronic stress on the ostium rom ber suture on the smallest needle to minimize additional
heavy earrings. Inappropriate ostium placement, espe- trauma, which can be especially important in patients
cially in eriorly, can exacerbate the problem. In either prone to keloid ormation. I the wound is signi cantly
event patients may seek repair. larger than a typical earring hole, consideration must be
Depending on the location o the piercing as well as the given to using buried sutures. When the wound is small
extent o stretching, several approaches are available.10– 14 I we close it entirely rather than closing part o it to main-
the dilated hole is in the center o the lobule it may be pos- tain an opening or a newly placed earring. I the wound
sible to de-epithelialize the ostium and repair it. A scalpel is larger, or the tear more complete, we can leave part o
can be used to incise around the old hole, although this the wound open, while placing an earring at the time o
can be technically challenging because o ten the area to be surgery to save the step o re-piercing later (Fig. 23-9).
incised is quite small. Sometimes a Beaver blade and han-
dle can be utilized (Fig. 23-6). In other instances a round
or elliptical surgical punch can be used. A punch slightly r Epa ir in g a pa r t ia l t Ea r
larger than the hole is appropriate.
St Ep 1: d E-Epit h El ia l iz a t io n o f
St Ep 1: a n ESt h Et iz E t h E Ea r t h E t Ea r
We numb the ear be ore selecting our punch as the size o Once anesthesia has occurred the lobe should be stabi-
the ostium changes rom the turgor o the anesthetic. We lized in preparation or removal o the opposing epithe-
typically wait several minutes be ore initiating surgery so lium (Fig. 23-10). Depending on the de ect’s location and
298 that the bene cial e ects o the epinephrine occur. extent, extending the tear to completion is o ten pre erred,
 2

C
h
a
p
t
e
r
2
3
:
:
Figure 23-7 Drawing demonstrating “p nch techniq e” in repairing a dilated hole while preserving an opening at the

E
a
s perior aspect o the incision or an earring. (Reprod ced with permission rom Amer M, Greenba m S, Lask GP, Parish

r
P
LC. Ear piercing and repair. In: Parish LC, Lask GP, eds. Aesthetic Dermatology. New York: McGraw-Hill;1991:187. Copyright

i
e
© McGraw-Hill Ed cation LLC.)

r
c
i
n
g
as reapproximation o the opposing edges o a ully split closure and add strength to the repair. I the wound

a
lobule is easier than opposing those o a partially split one. appears almost to close on its own without tension, this

n
d
Prior to de-epithelialization and conversion o the partial step can be eliminated and the wound can be repaired

E
a
tear to a ull tear, the lobe must be stabilized. We employ simply with cutaneous sutures. We typically use 6-0

r
L
one o two methods. A tongue blade can be placed posterior nylon or polypropylene sutures and leave them in or 7 to

o
b
to the lobule by the “non-cutting” hand o the surgeon, who 14 days.18,19 We recommend that the patient cleanse the

e
R
can then manipulate the lobe with that hand, or by a surgical area twice a day with hydrogen peroxide and apply a

e
p
assistant, although it can be di cult to have too many hands thin coating o Vaseline as needed until the sutures are

a
i
in this con ned space (Fig. 23-11). Alternatively, a chalazion removed to keep the wound moist and acilitate healing.

r
s
clamp can be utilized (Fig. 23-12). T e advantage o this We do not recommend that patients bandage the ear as it
approach is that it rees the surgeon’s hands and provides may be di cult to dress and over manipulation can dis-
compression hemostasis.15 Once the lobule is stabilized the rupt the repair.
edges o the ostium can be de-epithelialized, usually with a
scalpel (Figs. 23-13 and 23-14). Alternatively, a scissors, car-
bon dioxide laser or other modality may be used.16–17 r Epa ir in g a c o Mpl Et E t Ea r
Complete ear lobe tears can occur anywhere although
St Ep 2: Su t u r in g t h E d Ef Ec t they tend to be centrally located. As trends and ashions
change, some individuals choose to have multiple pierc-
Depending on the size o the de ect either one or two ings. A complete tear can occur at any o these sites, but
absorbable (and in certain instances nonabsorbable) repair o all o these tears is similar (Figs. 23-15 to 23-17).
buried sutures may be used to take tension o the nal

Figure 23-8 P nch being sed to de-epithelialize the Figure 23-9 Res lt showing repaired enlarged hole with
lining o the dilated osti m. earring in place. 299
2
S
e
Figure 23-10 Dilated (partially torn) earring hole with
c
t
posteriorly placed tong e blade being sed or stabiliza- Figure 23-13 Scalpel positioned s ch that it is being
i
o
tion and ease o incision. p lled toward the operator or best control o incision.
n
2
:
:
S
r
g
i
c
a
l
S
k
i
l
l
s
Figure 23-11 Conversion o partial tear to complete tear. Figure 23-14 F lly de-epithelialized wedge.

Figure 23-12 Example o chalazion clamp positioned

allowing or stabilization and hemostasis. Figure 23-15 Ear lobe with m ltiple complete tears.

300
 2

Figure 23-16 Techniq e showing repair o alternate Figure 23-17 Follow- p showing healing o the repaired

C
h
de ects. Attempts to x all tears at the same time can be tears be ore xing the remaining ones.

a
p
technically di c lt and can also leave several thin, poorly

t
e
vasc larized f aps that can have ten o s healing.

r
2
However, we o ten use a nonabsorbable suture. As a

3
repaired laceration only regains at most 85% o its original

:
:
strength there will always be inherent weakness along the
St Ep 1: St a bil iz E t h E l o bu l E

E
suture line. T is may be unimportant i another piercing

a
r
hole is not planned along the line o closure.20 However, in

P
A ter the earlobe has been anesthetized, a waiting period

i
e
patients with small lobes or multiple piercings in the same

r
ensues to allow the epinephrine to take e ect. As dis-

c
lobe, it may be necessary to re-pierce in essentially the

i
n
cussed previously, we stabilize the lobe be ore incising it to

g
same location as the original hole and thus along the line
allow or more precise surgery. Depending on the de ect’s

a
o closure. In these cases a buried permanent suture not

n
position, we either use a tongue blade placed posteriorly

d
only gives prolonged strength to the wound but i placed

E
to act as a backstop or the scalpel, or a chalazion clamp,

a
properly can also provide a supportive sling under a newly

r
which is available in various sizes. I the clamp is too small,

L
pierced hole. o accomplish this, the buried suture must

o
it can get in the way and make surgery awkward. For this

b
be located slightly in erior to where the new piercing site

e
reason we tend to use the larger clamp sizes.

R
would be. We use polypropylene due to its relative inert-

e
p
ness and ease o use. Although it may eventually degrade,

a
i
St Ep 2: in c iSio n o f t h E Epit h El ia l

r
it gives prolonged strength to the wound. We typically

s
Ed g ES place the suture with the needle oriented vertically rather
than horizontally to keep the suture “buried” in the lobule
With the earlobe stabilized, the lobe is incised by pull- and arther rom the skin sur ace, thereby minimizing the
ing the scalpel superiorly rom the ree edge o the lobule chance o suture “spitting” and palpability. We also leave
toward the vertex o the de ect. I the surgeon chooses to an approximately 1 mm tag a ter cutting it to help mini-
incise in the opposite direction, he or she must be posi- mize the chance o the knot untying. I multiple intrader-
tioned so as to “pull” the scalpel toward them rather than mal sutures are needed we o ten use one permanent suture
“pushing” it away. As little normal tissue as possible is to act as the sling among the other absorbable sutures to
removed when de-epithelializing the split, because the less decrease the chance o a granulomatous reaction causing
tissue removed, the greater the symmetry with respect to added earlobe bulk.
the contralateral side. Sometimes it is more e ective to Once the buried suture(s) have been placed the skin
begin the incision with a scalpel and complete it with ne may be closed. T e most important consideration is to
scissors. In either case the tissue to be discarded should be ensure that the opposing edges are properly aligned to
grasped with orceps to reduce trauma to the remaining give continuity to the smooth, even contour o the lob-
tissue. ule’s sur ace. A ter placement o the buried sutures the
lobe should be relatively well aligned, although we typi-
cally place a key suture at its in erior aspect to guarantee
St Ep 4: Su t u r in g t h E d Ef Ec t that this is the case. We also try to achieve good wound-
edge eversion with this suture to minimize the chance o
Once incision o the edges is complete the clamp is notching or developing a groove along the incision line.
removed to acilitate approximation o the wound edges. I we cannot achieve proper eversion with an interrupted
We also minimize thermal injury to optimize the cos- suture we may elect to place a vertical mattress suture
metic result. As there are no major blood vessels in the instead. T e selection o suture material varies depend-
lobe, signi cant bleeding is rarely a problem; simple pres- ing on the wound size, the lobe size, and the skin texture.
sure is o ten all that is needed. Once hemostasis has been Use o nonabsorbable suture allows us to control how long
obtained the actual repair can begin. the sutures remain in place. Rapidly absorbable gut suture
In nearly all instances at least one buried suture is nec- can be used but typically loses tensile strength quickly and
essary to give prolonged strength to the wound. radition- does not maintain the same degree o integrity as a non-
ally, absorbable sutures have been used or this purpose. absorbable suture. We utilize a running suture or multiple 301
2 closely spaced interrupted sutures to enhance eversion.
I more “ ne-tuning” o lobe contour is needed, multiple
As this technique requires great precision we utilize a
Beaver blade and handle. T e ne blade and ergonomi-
interrupted sutures may be more appropriate. In most cally designed handle enable removal o the thin tissue
instances both the anterior and posterior sur aces align strips required. Flap symmetry is paramount. I a 5 mm
readily. However, in a minority o cases there may be a wide strip is removed rom the le t f ap, then an equally
slight discrepancy between the anterior and posterior sur- sized reciprocal strip must be removed rom the right f ap
aces. In these cases it is important to rst align the ante- or proper approximation.
rior sur ace as it is most visible. I a Burow’s triangle needs Because each f ap is only one-hal o the thickness o
to be removed it should be done rom the posterior aspect the lobe, placement o buried sutures becomes more di -
to optimize the nal result. We leave the sutures in place cult. T e smallest caliber suture should be used. T e knots
or 7 to 10 days depending on the age o the patient and should be secure. More than the necessary knot number
their skin type and texture. Wound care includes clean- increases the likelihood o suture “spitting” and palpability.
ing twice a day, typically with hydrogen peroxide, water T e super cial layer o sutures should not be placed too ar
or isotonic saline. T e area is then blotted dry and coated rom the incision edge. Each needle bite should penetrate
with a thin layer o Vaseline. We rarely utilize antibiotic the overlying and underlying complementary f aps to ensure
S
e
ointments and have ound the incidence o postsurgical stability and to prevent sliding o the f aps during healing.
c
t
i
in ection to be extremely low. I an in ection develops we It is o ten technically more di cult to align the ree mar-
o
n
manage it with appropriate systemic antibiotics. gin o the lobe when utilizing this repair method because
2
more sur aces must be approximated, adding to the com-
:
:
plexity o the closure. Again, care ul attention is paid rst
t o n g u E a n d g r o o v E c l o Su r E to the ree margin o the lobule, as even a minor step-o is
S
o f t h E Ea r l o bE readily apparent. I done properly this repair can elegantly
r
g
i
lead to a strong wound that can more con dently be
c
a
l
re-pierced along its incision line.
S
T e tongue and groove closure is a modi cation o the
k
i
l
standard side-to-side closure.21– 23 It is technically more
l
s
di cult and requires greater precision. T e inherent f ix in g a t t a c h Ed (pix iE) Ea r
beauty o this technique, and thus its main advantage, is
that it allows or avoidance o a ull-thickness de ect along l o bES
the line o closure. By creating two overlapping “tongues”
o tissue, each f ap maintains 50% o its bulk (Fig. 23-18). Occasionally, a dermatologic surgeon may be consulted
T is advantage becomes particularly valuable when a re- regarding complications resulting rom previous surgery.
piercing is planned along the line o closure. It is, there ore, important to be amiliar with the many
T e preoperative evaluation and anesthesia remain ways o treating scars, hypertrophic scars, and keloids.
unchanged. When designing the repair it must be decided Not all complications can be avoided nor do they neces-
which side o the split will be the overlying f ap and which the sarily indicate improper or poorly per ormed surgery.
underlying f ap. Once this has been decided the surgery can A ter a rhytidectomy, a combination o scar contraction
begin. Again stabilization o the lobe with a tongue blade or and aggressive skin excision can sometimes cause the
a chalazion clamp acilitates the procedure. Simply put, hal healing tissue to pull the earlobe taut and downward. T is
o each f ap’s bulk is removed. On one f ap, the anterior hal contributes to ormation o a “pixie” ear, which is a tell-tale
is removed. For the complementary f ap the posterior hal sign o cosmetic acial surgery, at times providing an aes-
is removed. When the two f aps are brought together they thetically displeasing result.24,25 As the ree f oating lobule
interlock to give the line o closure 100% o its needed bulk. is converted to a stretched, tight, elongated, xed lobe, it

Figure 23-18 Drawing showing “tong e and groove”method o ear lobe repair. (Reprod ced with permission rom Amer
M, Greenba m S, Lask GP, Parish LC. Ear piercing and repair. In: Parish LC, Lask GP, eds. Aesthetic Dermatology. New York:
302 McGraw-Hill;1991:188. Copyright © McGraw-Hill Ed cation LLC.)
 St Ep #3: Su t u r in g t h E
2
SEc o n d a r y d Ef Ec t
■ T e secondary de ect needs to be sutured as meticu-
lously as possible, although it may also be allowed to
granulate. However, unless healing proceeds per ectly,
a widened scar can result. For this reason we usually
choose to suture the wound.
■ I the wound edges are not at 90 degree angles to one
another, they are modi ed to enable optimal wound-
edge apposition, leading to a less perceptible scar.
■ ypically we use 5-0 buried absorbable suture to
decrease wound tension as much as possible. We then
Figure 23-19 Pixie ear de ormity prior to s rgery. use a running 6-0 nylon or polypropylene suture or 6-0

C
h
ast absorbing gut.

a
p
t
e
r
r Ej u v En a t io n o f t h E

2
appears unnatural and at times unusual. T e repair o such

3
a problem can make a di erence in how the individual
a g in g Ea r l o bE

:
views their overall cosmetic result (Figs. 23-19 and 23-20).

:
E
a
T e ears are typically sun-exposed and o ten as sun-dam-

r
St Ep #1: a n ESt h Et iz E t h E Ea r a n d

P
aged as the rest o the ace. T e lobe is the only part o the

i
e
Su r r o u n d in g a r Ea

r
ear with a substantial adipose and connective tissue com-

c
i
n
ponent. Due to its unique composition the lobe can age

g
We typically use enough anesthetic to render the lobule

a
■
similarly to the rest o the ace, developing rhytides, len-

n
insensate but not so much as to distort the anatomy.

d
tigines, and sagging due to intrinsic and extrinsic aging.

E
We also anesthetize the cheek tissue that directly abuts Individuals who are less consistent in applying sunscreen

a
r
the lobule.

L
to the ears can exacerbate this problem. When cosmetic

o
b
surgery is per ormed on the aging ace and neck it does

e
not usually address the ear lobes. o render the appear-

R
St Ep #2: f r EEin g t h E Ea r l o bE

e
ance o the ear lobes consistent with the newly rejuvenated

p
a
ace and neck the surgeon can utilize several approaches.

i
r
An incision is made at the junction o the taut, elon-

s
■

gated lobule where it joins the ace. T e incision pro-

ceeds superiorly rom the anterior sur ace o the lobe in #1: CHEMICAL PEELING. Chemical peels have
an in erior direction toward the bottom o the lobule. It been utilized or many years to rejuvenate the aging, sun-
then sweeps posteriorly and superiorly with care taken damaged ace.26,28 T e same technique is use ul when ap-
to keep the blade and the incision parallel to the ante- plied to the ear lobes. Super cial peeling agents such as
rior incision. T is will create wounds o equal lengths glycolic acid, salicylic acid and dilute trichloroacetic acid
that can be approximated without the need or stand- can be applied to the lobes when the ace is treated. With
ing cone de ormity repairs or other “ ne-tuning.” super cial peeling the results are less dramatic and mul-
■ Detaching the lobule rom its attachment along the tiple, sequential treatment sessions are needed.
ace creates a secondary de ect. Minimizing this de ect, Deeper peeling agents such as more concentrated tri-
to the extent possible, will enhance cosmesis. chloroacetic acid and phenol can restore the lobes to a
more youth ul appearance. As is the case when using
these agents on any type o skin, care must be taken to
avoid creating an injury deep enough to cause visible
scarring. Injuries extending into the lower one-third o
the dermis have a signi cant chance o causing such scar-
ring. It is also possible, and o ten recommended, to treat
di erent parts o the ear with di erent peeling agents.
Since the lobule is endowed with a greater blood sup-
ply and looser connective tissue, it may be treated with
a deeper peeling agent while the rest o the ear is peeled
more conservatively.

#2: LASER RESu RFACING. T e morphologic

changes that occur in the aging ear lobe can be addressed
with lasers as well to create a depth o injury commensu-
rate with the degree o photodamage. T e ability to use
lasers in a controlled ashion may be easier or some sur-
Figure 23-20 Pixie ear de ormity ollowing revision. geons than applying a chemical that must be neutralized 303
2 or is sel -neutralizing.28– 31 Fully ablative carbon dioxide
and erbium YAG lasers were once utilized or resur ac-
ing. More recently the advent o ractionated ablative and
nonablative lasers has given dermatologic surgeons a larg-
er repertoire o tools rom which to choose. T e primary
principle behind use o these techniques is awareness o
the depth o injury being created. T e ractionated lasers
leave interstices o normal tissue between the columns o
lasered skin. As the entire skin sur ace is not destroyed,
wound repair and reepithelialization occur more rapidly.
Caution must still be utilized as scarring is possible. As
with chemical peeling, the surgeon can use lasers to de-
stroy tissue to di erent depths on di erent regions o the
ear. o e ectively reduce deeper rhytides on the lobe, the
depth o injury should be carried at least into the mid der- Figure 23-21 Extensive ear lobe keloid.
S
e
mis. Not only will the rhytides be improved but the tissue
c
t
i
contraction will enhance the skin’s appearance as well.
o
n
hyaluronidase should be kept in mind, especially or those
2
#3: FILLING AGENTS. Prolonged exposure to ultra- just gaining experience with ear lobe rejuvenation.35,36
:
violet irradiation can lead to solar elastosis with dermal
:
thinning as well as atrophy o the underlying adipose tissue,
S
which contributes to wrinkled, sagging, def ated ear lobes. t r Ea t MEn t o f Ea r l o bE k El o id S
r
g
T e same tenets that allow us to utilize dermal “ llers” on
i
c
a
the ace hold true or the ear lobe.32– 34 I a eather pillow
l
Keloid, a term derived rom the Greek word or crab-claw-
S
k
loses too many o its eathers, the pillowcase that once was like, re ers to an abnormal response o the skin to trauma.
i
l
l
taut becomes large, wrinkled, and creased. T e same anal-
s
T e response consists o an aggressive proli eration o
ogy holds true with the ear lobe. o give the overlying skin brous connective tissue at the site o trauma, with exten-
a tighter appearance, some skin has to be removed, or more sion beyond the immediate area. Keloids, unlike hypertro-
volume has to be put into the lobe. It is simpler, more e ec- phic scars, rarely regress spontaneously, and o ten recur
tive, and more conservative to plump up the lobe with a ll- a ter treatment (Fig. 23-21).
ing agent. Many o the newer agents are composed mainly Simple excision o keloids results in a recurrence rate o
o hyaluronic acid, which tends to last signi cantly longer 55%, while irradiation with heavy ltration ollowing surgery
than older collagen derived materials. In addition, there is a lowers the recurrence rate by 70% to 90%.37 With decreased
smaller chance o developing an allergic reaction. use o radiation or benign lesions, other adjuvants to sur-
Hyaluronic acid or similar agents are injected deep gery have been studied. It is known that intralesional corti-
into the adipose tissue o the earlobe. Injections are done costeroids decrease collagen synthesis and inhibit broblast
slowly, initially as a bolus. Once a signi cant amount has proli eration. Intralesional corticosteroid injection a ter sur-
been injected it is massaged rmly to evenly distribute gery, repeated every 2 weeks or ve injections, accompa-
it. As these agents are hydrophilic some normal swelling nied by topical application o a steroid ointment twice daily
will occur. A ter observing the site or several minutes or 6 months, yielded a 14.3% recurrence rate over a study
it can be decided whether it is necessary to inject more period o 24 to 57 months. Side e ects included reversible
ller. It is o ten surprising about how much needs to purpura (100%), atrophy (50%), and telangiectasia. A num-
be injected to achieve the desired degree o correction. ber o chemotherapeutic agents, known or their ability to
T e amount required varies according to the amount o suppress broblastic activity, have also been studied, with
damage the ear lobes have sustained. T e varying size signi cant reduction o recurrences. Surgery with adjuvant
o lobes amongst individuals is also a determining ac- therapy remains the treatment o choice.
tor. Care should be taken to not over inject, which could Ear lobe keloids are a source o annoyance and rustra-
lead to vascular compression, decreased blood f ow and tion or patient and surgeon alike. T ey are a cosmetic
possible necrosis. It is always easier to add ller than to issue as well as symptomatic, and can be susceptible
remove it. to cyst ormation and in ection. T ey can present a sig-
As the ear lobe is injected and the skin becomes more ni cant challenge not only in their removal and repair
taut, piercing sites will be a ected. A hole that was slightly but perhaps more importantly their risk o recurrence
dilated can become tighter as the lobe becomes “volu- (Fig. 23-21). For all o these reasons patients seek the
mized.” Whereas the hole itsel does not become smaller, attention o a dermatologic surgeon.7,37,38
its e ective size is smaller as the ller compresses the In the initial consultation it is important to stress the
ostium circum erentially. Similarly, a piercing site located need or realistic expectations. Several key points as the
too in eriorly can be supported by injecting ller beneath ollowing should be emphasized:
the hole, thus bolstering the tissue supporting the earring.
emporary lling agents such as poly-L lactic acid and ■ Nonsurgical approaches should be tried rst.39– 43
calcium hydroxylapatite are used in a similar ashion. As ■ Surgery has limitations
the ear lobes are static, in contradistinction to mobile areas ■ Per ection is nearly impossible to achieve

on the ace, the llers tend to persist or a longer period o ■ Recurrence is common and typically not caused by

304 time. T e act that hyaluronic acid can be dissolved using aulty surgical technique or poor wound management
 ■ Although symmetry and complete eradication are
the primary goals o keloid surgery, both may be di -
2
cult i not impossible to achieve.
■ Postsurgical treatment is critical to prevent recurrence.
I the patient is unwilling to return it is incumbent
upon the surgeon to reconsider whether surgery is
appropriate because recurrence rates ollowing surgery
alone are high.44– 49
■ As many patients who seek surgical treatment or keloids
are minors, it is important that a clear understanding o
the procedure and subsequent treatment exists between
surgeon, patient, and parent. T e parent must be willing
to support the process to achieve optimal results.

As is the case with almost all surgery, the best type o

C
h
surgery is no surgery at all. I a patient presents with an

a
Figure 23-22 Posterior lob le “marble”-type keloid, pre-

p
incipient keloid or hypertrophic scar, it should be managed

t
e
sa cerization removal.

r
nonsurgically i possible. T is is especially true or keloids

2
3
that are small and rather so t. Conservative approaches
such as high-potency intralesional corticosteroid injec-

:
:
tions should be o ered. As keloids are by nature hyper-

E
trophic, the side e ect o atrophy works to the patient’s

a
One o the most common types o keloids is the “mar-

r
advantage. T e anti-inf ammatory attributes o the steroid

P
ble” type, which typically presents as a round, rm keloid

i
e
are also advantageous. We typically start with intralesional

r
on the anterior or posterior sur ace o the lobule. T e

c
i
triamcinolone acetonide at a minimum concentration o

n
etiology o the keloid can to a certain extent determine

g
20 mg/cc. As keloidal tissue is rm and di cult to inject, its morphology. I it is the direct result o piercing, the

a
n
instead o using a 30 gauge needle in a tuberculin syringe keloid can extend onto the anterior and posterior sur aces

d
we use a 27 gauge needle attached to a 1.0 cc luer-lock

E
o the lobe. In these instances the tract or ostium is usu-

a
r
syringe. I a “slip” type o needle/syringe combination is ally involved and can act as a conduit through which the

L
o
used the needle and syringe may disconnect during injec- keloid develops. I a keloid is the result o an inf ammatory

b
e
tion due to retrograde pressure, posing signi cant danger lesion such as a cyst, it may be con ned to one sur ace or

R
to the surgeon, assistants, and patient. In addition, the

e
the other.

p
spraying o steroid and blood is to be avoided.

a
i
r
s
We typically inject directly into the keloid to optimize
the therapeutic bene ts o the injection. Because the “Ma r bl E”-t ypE k El o id
injected material seeks the point o least resistance there is
a tendency or it to f ow around the keloidal tissue rather T e simplest type o keloid to remove is the posterior
than into it. T is may lead not only to ine ective treatment sur ace “marble”-type that does not extend into a pierc-
but may also lead to unintended atrophy o the surround- ing ostium (Fig. 23-22). In these cases, there are several
ing tissue. I injection is di cult it can be aborted or in approaches that can be utilized:
some instances acilitated by spraying the injection site and
keloid with f uoroethyl to ease injections and minimize dis-
com ort. ypically we inject the keloid approximately 5 to
po St Er io r Su r f a c E
10 seconds a ter spraying the area. I injection is attempted in v o l v EMEn t o n l y
too early, it can be even more di cult due to the rmness
o the ormed “ice-ball.” We stress to the patient that mul- 1. I a ter palpation o the keloid and lobe it is elt that
tiple injections over time are the rule rather than the excep- there is “normal” tissue between the base o the
tion, and typically space them at 4 week intervals. I we see keloid and the anterior sur ace o the ear, a simple
no improvement a ter two to three sessions, we abandon keloidectomy can be per ormed (Figs. 23-23 to 23-27).
the approach. I the patient is noncompliant in returning, 2. A scalpel, scissors, electrosurgical cutting current,
we seriously evaluate whether they will comply with post- or a cutting laser can be used to dissect the keloid
surgical instructions and postoperative steroid injections. ree rom the surrounding tissue (Figs. 23-25 and
23-26). It is wise in these instances to extend the
dissection 1 to 2 mm lateral to the keloid so as not
Su r g ic a l a ppr o a c h t o to inadvertently leave behind any keloid that could
serve as a nidus or recurrence. Each modality o
k El o id r EMo va l removal has its advantages. Electrosurgery or a laser
creates a bloodless surgical eld, improving visibility
No two keloids are exactly the same. However, there are and o ten obviating the need or postsurgical
certain patterns o keloid development that are more hemostasis (Figs. 23-28 and 23-29). Whether or not
common than others. T e type o repair and the options the heat generated in the tissue can act as su cient
available depend to a certain degree on the morphology o trauma to induce recurrence is unclear. Cold steel
the keloid.50– 53 surgery such as a scalpel or scissors allows or direct 305
2
S
e
c
t
i
o
n
2
:
:
S
r
g
i
c
a
l
S
k
i
l
l
s
Figure 23-23 Incision aro nd the base o the keloid into Figure 23-25 Dissecting scissors being sed to remove
atty tiss e. the keloidal mass rom the nderlying tiss e.

Figure 23-24 Skin hook being sed to grasp the keloid

306 or better s rgical manip lation and control. Figure 23-26 Keloid being completely removed.
 2

C
Figure 23-29 Posterior s r ace o lobe immediately ol-

h
lowing carbon dioxide laser removal.

a
p
t
e
r
2
3
possible lobe asymmetry. As the posterior sur ace

:
:
o the ear is not visible, second intention healing in

E
these cases is o ten a good option, as it o ers the

a
r
least manipulation o the skin. As the wounds heal,

P
i
e
they can be injected with corticosteroids to retard

r
c
collagen ormation and possibly reduce the chance

i
n
g
o recurrence. Once the wound is healed, close

a
n
ollow-up and sequential corticosteroid injections

d
are advised to prevent new keloid growth. We advise

E
Figure 23-27 Res ltant de ect a ter al min m chloride

a
patients to be meticulous in their wound care. As

r
was applied to the base o the wo nd or hemostasis.

L
o
applying a bandage to the area may be logistically

b
di cult, we advise patients to recoat the base o the

e
R
wound with Vaseline multiple times during the day

e
p
tactile “ eel” o the tissue, which can in certain to acilitate reepithelialization.

a
i
instances help guide the surgeon more precisely. It

r
3. I the original keloid was small but deep, it may be

s
is typically thought best to remove all, or as much pre erable to simply suture the wound. In these cases,
as possible, o the keloid. In many cases there will as ew buried sutures as possible should be used.
be a variably sized layer o tissue separating the Suturing may lead to a more aesthetically pleasing
base o the dissection rom the anterior sur ace cosmetic outcome.
o the ear. T e greater the thickness o that layer,
the less contraction will occur i the wound is le t
to heal secondarily. I the surgical de ect is wide a n t Er io r Su r f a c E
and deep, contraction can lead to distortion with
in v o l v EMEn t o n l y
When the anterior sur ace o the lobe is the only area
involved, the cosmetic consequences o removal and
repair are more critical. Care should be taken to utilize an
approach that maximizes the chance o success ul removal
and aesthetic healing and minimizes recurrence.
1. T e width o the base o the keloid is critical in
determining an approach. I the pedicle is relatively
thin, and the keloid sessile, an excellent approach is
to incise the ear lobe in a “V” ormation extending
rom the base o the keloid into the lobe itsel . T e
operator should palpate the keloid to determine the
angle o incision so as to remove the entire base.
2. Once the keloid has been removed, the de ect is
closed using buried absorbable suture and a 6-0
rapidly absorbable or nonabsorbable cuticular stitch.
3. I the base o the keloid is too wide to make this
approach possible, there are several alternatives.
Figure 23-28 Posterior s r ace ear lobe keloid prior to T e wound can be le t to heal by second intention.
carbon dioxide laser removal. T e results can be good although in darker 307
2 skin, the tendency is or the healed wound to be
hyperpigmented with a more irregular texture
than the surrounding skin. Again, postoperative
intralesional corticosteroids help to minimize the
chance o recurrence. I the secondary de ect is
deep and broad a “purse-string” can be utilized.54– 57
In this scenario, an absorbable material such as 5-0
or 6-0 Monocryl or a similar permanent material
can be utilized to close the wound. We pre er
Monocryl to other absorbable materials or this
purpose because it is a mono lament, and creates
minimal inf ammatory response. T e surgeon should
be aware that knot security is decreased with this
type o suture as its coe cient o riction is less,
and it may be necessary to add an extra “throw” to
S
e
maintain the integrity o the closure.
c
Figure 23-31 Wedge excision o keloid.
t
i
o
n
Another possibility in dealing with “marble”-type keloids
2
on the anterior or posterior sur ace o the ear is to “shell”
anterior ear toward the ree margin o the lobe and then
:
:
them out.54,58–60 With this approach, the surgeon dissects
onto the posterior sur ace o the ear, o ten close to the
the keloid ree while creating a super cial f ap, which is then
S
location o the intended ostium. T e width o this semi-
used to repair the resultant de ect. We typically incise along
r
g
lunar band o tissue can vary (Figs. 23-30 to 23-32). T e
i
the base o the keloid in an arc o 180 to 220 degrees. We pre-
c
a
thinner it is, the easier the repair.
l
er cold steel to laser or electrosurgery or these dissections.
S
k
Depending on the size o the keloid, either a #15 scalpel blade 1. I the width o the band is narrow and the lobe large,
i
l
l
s
or a Beaver blade is used to dissect it ree rom the overlying the band may be excised as a wedge, cutting through
skin, which is peeled rom the underlying keloid to be used the lobule to create a de ect that can be easily closed.
as a f ap. We leave the f ap intact and only trim it once we see Depending on the exact location o the de ect we can
the size o the de ect. At that point, the f ap is laid over the repair it as i we were repairing a traumatically torn or
wound and trimmed to size with a sharp scissors. It should enlarged piercing. Buried absorbable or nonabsorbable
be cut precisely to minimize tension, and should not be over- suture is used to close the subcutaneous tissue
sized because when normal wound contraction occurs, it ollowed by closure o the skin edges.
will not lay f at. Once the f ap has been loosely but precisely 2. As the width o the band increases and or the
laid over the wound, it is sutured into place using either 6-0 size o the lobe decreases, there is more o a
nylon or polypropylene sutures or 6-0 rapidly absorbable gut. disparity in lobe symmetry. However, it may still be
We typically do not employ buried sutures here. I nonab- advantageous to use this approach because rarely are
sorbable sutures are used, they are removed in 7 days. both lobes viewed simultaneously.

r EMo va l o f in f Er io r l y r EMo va l o f Mo r E c o Mpl ic a t Ed

po Sit io n Ed SEMi-l u n a r k El o id S k El o id S
Sometimes, especially a ter an in eriorly placed piercing, Un ortunately, many keloids are neither o the “marble” or
a keloid can develop in such a way as to extend rom the “semi-lunar band” types, and can assume many sizes and
shapes. As the keloid becomes larger and involves a greater

Figure 23-30 Semi l nar in eriorly based keloid prior to

308 s rgery. Figure 23-32 Closed wo nd.
 2

C
h
a
p
Figure 23-33 In the case o complex keloids, it is o ten Figure 23-35 Res lt at 3 months ollowing initial s rgery

t
e
necessary to combine m ltiple techniq es to achieve the be ore repairing large posterior lobe keloid.

r
2
best res lt.

3
:
:
including wedge excision, a “shelling out” approach, or

E
portion o the ear, the challenge or the surgeon increases

a
saucerization. For complex keloids, it is o ten necessary to

r
accordingly. Sometimes the keloid can occupy a large por-

P
combine techniques to achieve the best result (Figs. 23-33

i
e
tion (i not all) o the ear lobe. In these cases, preservation

r
to 23-37). As the keloid extends rom the lobule onto sur-

c
i
o as much normal tissue as possible is required to acilitate

n
rounding structures, it is even more critical to preserve as

g
reconstruction. Creativity and an artistic sense are needed

a
much tissue as possible. Once the helical rim is a ected,

n
to orm a lobule that appears “normal” and is as similar

d
through and through removal carries with it reconstruc-

E
as possible to the contralateral side. As described previ- tive challenges. Decreasing the size o the rim appreciably

a
r
ously, there are multiple methods o removing keloids, will lead to asymmetry. In these cases, we o ten will try

L
o
b
to shell out the keloid as described previously, maintain-

e
ing as much o the overlying uninvolved covering as pos-

R
e
sible. In certain instances, this additional tissue may be

p
a
utilized to reconstruct portions o the ear that had to be

i
r
s
sacri ced in removing the keloid. T ere is no “cookbook”
ormula or algorithm to removal and repair, and it is help-
ul to have an image o the opposite ear as a guideline or
comparison. Perhaps the simplest way to do this is to take
a photograph o the opposite ear using 1:1 magni cation,
which can be printed and placed near the surgical eld or
easy re erence. I the a ected ear is the “right” ear, a photo
can be taken o the normal “le t” ear using a 1:1 magni-
cation lens. T at image can be f ipped horizontally in a
photo editing program and printed out to make the image

Figure 23-34 S perior component o the keloid has been

removed. “Normal” skin overlying the keloid has been pre-
served a ter shelling o t the keloid and is sed to cover
the de ect and help recreate a more normal appearing rim. Figure 23-36 Posterior view o lob le keloid. 309
2
S
e
c
t
Figure 23-37 Res lts ollowing staged repair o complex Figure 23-38 Prea ric lar s b nit closed primarily (blue
i
o
arrows). Ear lob le recreated tilizing a “ oldover f ap”
n
keloid.
2
(green arrow).
:
:
appear as i it is the “right” ear or use as a template or visible. When it is larger, the punch technique becomes
S
model or reconstruction. T e ability to do this is built less practical. We utilize the smallest incision possible
r
g
i
into most photo-editing so tware programs, although the overlying the cyst, which is then carried deeper into the
c
a
l
details vary rom program to program. As surgery itsel lobe in a pyramidal ashion. T e cyst is dissected ree rom
S
k
is a risk actor or keloids, we try to do as much as pos- the surrounding stroma using scissors. Once it has been
i
l
l
s
sible during the initial surgery to minimize the necessity isolated, we o ten use a hemostat to grasp the cyst wall
or subsequent revisions. As has been stressed previously, to optimize control. I grasped indelicately, the cyst can
return visits or intralesional corticosteroid injections are rupture, making complete removal more di cult and the
o ten necessary to minimize the chance o recurrence. chance or recurrence greater. I the cyst is large and has
T e patient may inquire about re-piercing the ear a ter been present or a long time the “tissue expansion” that
lobe repair. Although it is best to discourage this as pierc- has occurred over it will leave excess skin. T e size o the
ing may induce keloid ormation, sometimes patients are overlying ellipse should vary accordingly.
insistent. Rather than have them do it in a poorly controlled Common skin tumors such as basal cell, squamous cell
environment, we will o er to do it in our o ce. Our hope carcinoma, and melanoma can occur on the ear lobe. I the
is that care ul surgical technique and sterile conditions will lesions are small, primary closure may be easily accom-
minimize the chance o keloid ormation due to re-pierc- plished. I they occupy a larger portion o the lobule, recon-
ing. We stress to the patient that this cannot be guaranteed struction becomes more challenging. Adjacent periauricular
and that they are taking a risk by having the lobe re-pierced. skin can sometimes be used to recreate portions o the lobe
(Figs 23-38 to 23-40). Full-thickness or split-thickness skin
gra ts are seldom used, although the posterior lobule can
t u Mo r S o f t h E Ea r l o bE be an excellent donor source or small ull-thickness gra ts.
Depending on the size and shape o the recipient de ect a
T e ear lobes are subject to various benign and malignant “punch” gra t may be the best option. T e donor de ect on
growths in addition to keloids. Cysts o various types are the lobe can be sutured or le t to heal by second intention.
common due to the density o sebaceous and apocrine
glands. When they are relatively new, intralesional cor-
ticosteroids can be utilized in an attempt to obviate the
need or surgery. When this approach is unsuccess ul, sur-
gery is indicated. Whenever possible, removing the cyst
via a posterior approach is pre erable, most signi cantly
to conceal the incision. When cysts are 1.0 to 3.0 mm in
size, a punch excision may be easiest. When utilizing this
technique, the cyst should be immobilized with the thumb
on the posterior sur ace and the second and third ngers
spanning the cyst anteriorly. T e punch is then pushed
directly into the lobe surrounding the cyst. Care should
be taken not to inadvertently per orate the skin on the
anterior sur ace. A chalazion clamp can also be utilized
or stabilization, although a disadvantage to this tech-
nique is that the operator loses direct tactile sensation o
the size, location, and relative position o the cyst. I it is
relatively close to the posterior skin sur ace, the stretching
310 and compression rom the clamp can make the cyst readily Figure 23-39 S t red in ra-tragal s b nit and lobe f ap.
 8. Murray JC. Scars and keloids. Dermatol Clin. 1993;11:
697– 707.
2
9. Nemeth AJ. Keloids and hypertrophic scars. J Dermatol Surg
Oncol. 1993;19:738– 746.
10. Nikko A, Hsu S, Quan L , Greenbaum SS. Surgical pearl:
repair o partially torn earlobes—punch technique versus
conversion to complete tear. J Am Acad Dermatol. 2000;43:
99– 101.
11. Niamtu J. Eleven pearls or cosmetic earlobe repair. Derma-
tol Surg. 2002;28:180– 185.
12. Zilinsky I, essone A, Winkler E, Mendes D, Alon L. Par-
tially torn ear lobe repair using a cross-stitching technique.
Dermatol Surg. 2009;35:987– 989.
13. Kalimuthu R, Larson BJ, Lewis N. Earlobe repair: a new
technique. Pla st Reconstr Surg. 1984;74:299– 300.
14. Pardue AM. Repair o torn earlobe with preservation o
the per oration or an earring. Pla st Reconstr Surg. 1973;51:

C
472– 473.

h
15. Smith C, Glaser DA. Surgical pearl: repair o split or

a
Figure 23-40 Res lt at s t re removal.

p
de ormed ear lobe with a tongue depressor blade or sta-

t
e
bilization during surgery. J AM Acad Dermatol. 1998;38:

r
2
990– 991.

3
16. Dessy KA, Buccheri EM. Modi ed punch technique or
As the lobule is relatively thick, signi cant gra t thinning incomplete earlobe cle t repair. Aesthetic Pla st Surg. 2006;30 :

:
:
731– 732.
will be required be ore suturing it into position.

E
17. Robinson JK. Split earlobe repair. In: Robinson JK, Arndt

a
“Friends, Romans, countrymen—lend me your ears.”1

r
KA, LeBoit PE, Wintroub BU, eds. Atla s o Cutaneous Sur-

P
Our external ears are valuable or a number o reasons. gery. Philadelphia, PA: W.B. Saunders; 1996:207– 209.

i
e
r
T e outer ear helps to collect sound waves and unnel 18. Greco JF, Stanko CS, Greenbaum SS. Use o a deep poly-

c
i
propylene suture during earlobe repair: A method to provide

n
them toward the inner ear, where they can be processed.

g
permanent rein orcement in the prevention o recurrent ear-
Because the ears are among our most prominent acial

a
lobe tract elongation. Dermatol Surg. 2005;31:1442– 1443.

n
eatures, they may be a source o adornment rom a

d
19. Bennett RG. Selection o wound closure materials. J Am

E
very early age. Piercing and placement o jewelry on the Acad Dermatol. 1988;18:619– 637.

a
r
ears are meant to call attention to them. When they are 20. Zoltie N. Split earlobes: a method o repair preserving the

L
o
mal ormed, torn, asymmetrical or a ected by disease, hole. Pla st Reconstr Surg. 1987;80:619– 621.

b
e
21. Argamaso RV. T e lap-joint principle in the repair o the
the ears can be a source o consternation and sel -con-

R
cle t earlobe. Br J Pla st Surg. 1978;31:337– 338.

e
sciousness. Whether the task is to pierce an ear, remove a

p
22. Amer M, Greenbaum SS, Lask GP, Parrish LC. Aesthetic

a
keloid, x a laceration or reconstruct a de ect o the skin Derma tology. New York, NY: McGraw-Hill; 1991:187– 188.

i
r
s
and cartilage a ter tumor removal, the outcome is o ten 23. Harahap M. Repair o split earlobes. A review and a new
o great importance to the patient. It is incumbent upon technique. J Dermatol Surg Oncol. 1982;8:187–190.
24. Mowlavi A, Meldrum DG, Wilhelmi BJ, Russell RC, Zook
us to use our skills as dermatologic surgeons in such
EG. T e “pixie”ear de ormity ollowing ace li t surgery
a way as to meet or exceed our patients’ expectations, revisited. Pla st Reconstr Surg. 2005;115(4):1165– 1171.
and to provide them with the best possible aesthetic and 25. Man D. Reducing the incidence o ear de ormity in aceli t.
unctional results. Aesthet Surg J. 2009;29(4):264–271.
26. Rubin MG. Manual o Chemical Peels Superf cial and
Medium Depth. Philadelphia, PA: JB Lippincott Co; 1995.
1
27. Brody HJ, Monheit GD, Resnik SS, Alt H. A History o
Shakespeare, William. Julius Caesar. Act III, scene II. chemical peeling. Dermatol Surg. 2000;26:405– 409.
28. Kauvar AN, Dover JS. Facial skin rejuvenation: Laser resur-
acing or chemical peel: choose your weapon. Dermatol
Surg. 2001;27:209– 212.
29. Reddy KK, Brauer JA, Geronemus RG. Evidence or rac-
r Ef Er En c ES tional laser treatment in the improvement o cutaneous
scars. J Am Acad Dermatol. 2012;66(6):1005– 1006.
1. Gray H. Organs o special sense: T e ear. In: Gray’s Anatomy. 30. Brightman LA, Brauer JA, Anolik R, et al. Ablative and rac-
15th ed. New York, NY: Barnes & Noble Books; 1995:830– tional ablative lasers. Dermatol clin. 2009;27(4):479– 489.
834. 31. Greenbaum SS, Rubin MG. Surgical pearl: T e high-energy
2. Bean RB. Some ears and types o men. American Anthro- pulsed carbon dioxide laser or immediate scar resur acing.
pologist 1915;17:529– 533. J AM Acad Dermatol. 1999;40:988– 990.
3. Greenbaum SS, Greenbaum CH. Aesthetic Dermatology. 32. zikas L. A 52-Month summary o results using calcium
New York, NY: McGraw- Hill; 1991:19– 29 hydroxylapatite or acial so t tissue augmentation. Derma-
4. Amer M, Greenbaum SS, Lask GP, Parrish LC. Aesthetic tol Surg. 2008;34:S9–S15.
Dermatology. New York, NY: McGraw-Hill; 1991:185– 189. 33. Alam M, Gladstone H, Kramer EM, et al. ASDS Guidelines
5. Hwang K, Hwang PJ. Which type o earring and which o care: Injectable llers. Dermatol Surg. 2008;34:S115–S148.
piercing point is sa est with regards to tearing through the 34. Redbord KP, Busso M, Hanke CW. So t-tissue augmentation
ear by an external orce? Dermatol Surg. 2012;38:772– 777. with hyaluronic acid and calcium hydroxyl apatite llers.
6. Hendricks WM. Complications o ear piercing: treatment Dermatol T er. 2011;24:71– 81
and prevention. Cutis. 1991;48:386– 394. 35. Lee A, Grummer SE, Kriegel LD, Marmur E. Hyaluronidase.
7. Wol ram D, zankov A, Pulzl P, Piza-Katzer P. Hypertro- Dermatol Surg. 2010;36:1071– 1077.
phic scars and keloids—a review o their pathophysiology, 36. Brody HJ. Use o hyaluronidase in the treatment o granu-
risk actors, and therapeutic management. Dermatol Surg. lomatous HA reactions or unwanted hyaluronic acid mis-
2009;35:171– 181. placement. Dermatol Surg. 2005;31:893– 897. 311
2 37. Vivas AC, ang JC, Maderal AD, Viera MH. Hypertrophic
scars and keloids, part 1: conventional treatments. Cos Der-
scars: a 10 year ollow-up study. Br J Pla st Surg. 1992;45:
374– 379.
matol. 2012;25:309– 316. 48. Berman B, Bieley HC. Adjunct therapies to surgical manage-
38. Sha er JJ, aylor SC, Cook-Bolden F. Keloidal scars: a review ment o keloids. Dermatol Surg. 1996;22:126– 130.
with a critical look at therapeutic options. J Am Acad Der- 49. Alster S, Williams CM. reatment o keloid scars with
matol. 2002;46:S63–S97. 585 nm f ashlamp-pumped pulsed-dye laser. Lancet.
39. ziotzios C, Pro yris C, Sterling J. Cutaneous scarring: 1995;345:1198–1200.
pathophysiology, molecular mechanisms, and scar reduc- 50. Park H, Seo WS, Kin K, Chang CH. Earlobe keloids: clas-
tion therapeutics: part II. Strategies to reduce scar orma- si cation according to gross morphology determines proper
tion a ter dermatologic procedures. J Am Acad Dermatol. surgical approach. Derm Surg. 2011;38:406–412.
2012;66:13–24. 51. Music EN, Engel G. Earlobe keloids: a novel and elegant sur-
40. Atkinson JA, McKenna K , Barnett AG, McGrath DJ, Rudd gical approach. Dermatol Surg. 2010;36:395– 400.
M. A randomized, controlled trial to determine the e cacy 52. Rosen DJ, Patel M, Freeman K, Weiss P. A primary protocol
o paper tape in preventing hypertrophic scar ormation in or management o ear keloids: results o excision combined
surgical incisions that traverse Langer’s skin tension lines. with intraoperative and post-operative steroid injections.
Pla st Reconstr Surg. 2005;116:1648– 1658. Pla st Reconst Surg. 2007;120:1395–1400.
41. Shih R, Waltzman J, Evans GR. Review o over-the-coun- 53. Lee Y, Minn K, Baek R, Hong J. A new surgical treatment
S
ter topical scar treatment products. Pla st Reconstr Surg. o keloid: keloid core excision. Ann Pla st Surg. 2001;46:
e
2007;119:1091–1095. 135– 140.
c
t
i
42. Morganroth P, Wilmot AC, Miller C. Over-the-counter 54. Greenbaum SS, Radonich MA. T e purse-string closure.
o
n
scar products or postsurgical patients: disparities between Dermatol Surg. 1996;22:1054– 1056.
2
online advertised bene ts and evidence regarding e cacy. 55. Brady JG, Grande DJ, Katz AE. T e purse-string suture in acial
J Am Acad Dermatol. 2009;61:e31– e47. reconstruction. J Dermatol Surg Oncol. 1992;18:812–816.
:
:
43. Mustoe A, Cooter RD, Gold MH, et al. International clini- 56. Vujevich J, Obagi. Repair o partial earlobe cle t using a
cal recommendations on scar management. Pla st Reconstr “purse-string”repair. Derm Surg. 2006;32:969– 971.
S
Surg. 2002;110:560– 571. 57. Kontos AP, Ozog DM. (2006), Use o purse-string suture
r
g
44. Berman B, Flores F. Recurrence rates o excised keloids technique in closure o f esh tunnel de ects o the bilateral
i
c
a
treated with postoperative triamcinolone acetonide injec- earlobes. Dermatologic Surgery, 32:1070– 1071
l
S
tions or inter eron al a-2b injections. J Am Acad Derm. 58. Qi Z, Liang W, Wang Y, et al. X”-shaped incision and keloid
k
1997;5:755– 757. skin-f ap resur acing: a new surgical method or auricle
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l
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45. Fulton JE. Silicone gel sheeting or the prevention and man- keloid excision and reconstruction. Dermatologic Surgery.
agement o evolving hypertrophic and keloid scars. Derma- 2012;38:1378– 1382.
tol Surg. 1995;21:947– 951. 59. Field LM. Subtotal keloid excision – a pre erable preventa-
46. Klumpar DI, Murray JC, Anscher M. Keloids treated with tive regarding recurrence. Dermatol Surg. 2001;27:323– 324.
excision ollowed by radiation therapy. J Am Acad Dermatol. 60. Kim DY, Kim ES, Eo SR, Kim KS, Lee SY, Cho BH. A surgical
1994;31:225– 231. approach or earlobe keloid: keloid llet f ap. Pla st Reconstr
47. Darzi MA, Chowdri NA, Kaul SK, Khan M. Evaluation Surg. 2004;113:1668– 1674.
o various methods o treating keloids and hypertrophic

312
 Ch a p t e r Surgical Complications and

24 Their Management
Milène K. Crispin, Erik S. Cabral, & Sumaira Z. Aasi

In t r o d u c t Io n study by McGinness and Goldstein, in which all surgical

sites were identi ed correctly with a preoperative biopsy-
site photograph. Without the photograph, 16% o patients
Complications, de ned as any adverse and unexpected
and 5.9% o physicians incorrectly identi ed the site, and
events, are inevitable in surgery. T e recent increase in
in 4.4% o cases, both the patient and physician incorrectly
the number o outpatient surgical procedures has led to
identi ed the site despite having access to the pathology
a critical appraisal o its sa ety. Yet several studies have
report listing the anatomic site.7 Once the surgical site
demonstrated the overwhelming sa ety o dermatologic
has been identi ed with a prebiopsy picture, the physician
surgery.1,2 In a 10 year prospective study o o ce-based
should have the patient mark the site to con rm the area
surgeries in Florida, where there is mandatory reporting
with a pen and mirror.
o surgical complications, there were 309 reported adverse
incidents, out o which dermatologists accounted or just
1.3% o all complications (no deaths).3 T e rst comprehen- Pa c ema k er s
sive prospective study documenting the relative incidence
o postoperative complications in dermatologic surgery, It was previously thought that the use o electrosurgical
speci cally Mohs surgery, ound the overall incidence devices in dermatologic surgery could cause pacemaker
to be 1.6%.4 In a recent multicenter prospective study o and implantable cardiac de brillator (ICD) mal unction;
20,821 Mohs procedures, there were 149 adverse events however, it is now known that patients with these devices
(0.72%), including our serious events (0.02%), and no have a low overall risk o cardiac complications in derma-
deaths reported.5 T e most common adverse events were tologic surgery,8 and that the types o inter erence reported
in ections (61.1%), dehiscence and partial or ull necrosis have not led to any signi cant morbidity or mortality.9 It is
(20.1%), and bleeding and hematoma (15.4%). T is chapter recommended that these devices be kept on during der-
will review some common complications associated with matologic surgery, and that surgeons exercise precautions
dermatologic surgery and provide strategies or the preven- to minimize inter erence such as utilizing short bursts o
tion, assessment, and management o these complications. less than 5 seconds, using minimal power, avoiding the
area directly around the device, using bipolar orceps, and,
i necessary, true electrocautery to achieve hemostasis.
Pr eo Per a t Iv e a s s es s men t
Preoperative assessment, particularly o pre-existing a l l er g Ies
medical conditions and medications, can help the surgeon
identi y patients at higher risk or intra- and postopera- A history o allergies is important to obtain in dermato-
tive complications such as bleeding, in ection, and poor logic surgery, particularly allergies to local anesthetics,
wound healing. A preoperative evaluation, discussed thor- topical antibiotics, cleansers, tape/adhesives, and latex.
oughly in other parts o this text, includes guidelines on Allergic reactions include type I (IgE-mediated, causing
identi ying the correct surgical site, reviewing pertinent anaphylaxis) and type IV (delayed-type) hypersensitivities.
medical history, prior surgeries including any problems Local anesthesia typically used in dermatologic surgery
with wound healing, medications (including anticoagu- includes esters and amides, and amides are almost univer-
lants), allergies, social history (including the use o tobacco sally tolerated. When an allergy is reported, it is usually
and alcohol), and anticipating the postoperative care o the to the preservative compounds such as methylparaben,
wound in the patient’s particular social supportive setting. and not the anesthetic compound itsel . Some patients
mistakenly believe that they have an “allergy” to epineph-
rine due to the physiological side e ect o palpitations and
Id en t If yIn g t h e c o r r ec t rapid heartbeat. Education and reassurance regarding this
s u r g Ic a l s It e side e ect o ten allays any misapprehension. Regardless, a
care ul history o any “allergic” episode to local anesthe-
Identi ying and con rming the correct surgical site prior sia should be elicited and clari ed, and in the rare cases
to surgery is axiomatic. In a survey that included 300 Mohs o true allergy to local anesthetics a re erral to an allergist
surgeons, wrong-site surgery was the most requent cause prior to surgery would be prudent.
o medical lawsuits.6 A photograph o the prebiopsy site is T e most common allergy to topical antibiotics is a type
crucial or avoiding wrong-site surgery, as evidenced in a IV hypersensitivity to neomycin (15%). O note, bacitracin
2 be ore and 1 week a ter surgery. Surgeons should minimize
undermining in the deep subcutaneous plane and limit tis-
sue dissection during the procedure, and avoid large f ap
reconstructions, i possible. In cases necessitating f aps, a
delayed f ap may have an improved outcome.12

bl eed In g a n d h ema t o ma
Bleeding is usually the rst postoperative complication
that occurs in dermatologic surgery, and it can o ten initi-
ate the other dreaded complications: wound tension and
necrosis, in ection, and dehiscence. Increased intraopera-
S
tive and postoperative bleeding can be multi actorial in
e
c
nature. Abnormal hemostasis can occur due to an acquired
t
i
o
or inherited bleeding disorder, thrombocytopenia, platelet
n
dys unction, or pharmacologic inter erence. Assessment
2
o anticoagulants and medical comorbidities can help a
:
:
surgeon identi y patients at higher risk or adverse events
S
such as bleeding and hematoma.
u
r
g
i
c
a
a n t Ic o a g u l a t Io n
l
S
k
i
l
l
Dermatologic surgeons used to routinely recommend the
s
discontinuation o anticoagulation and antiplatelet thera-
pies prior to surgery in order to avoid bleeding complica-
Figure 24-1 Ecchymosis: Extensive bruising developed
bilaterally in erior to the surgical site on this patient’s ace. tions. Prospective and meta-analysis studies have shown
the relative paucity o serious complications with the
continuation o multiple antiplatelet and anticoagulant
medications.13 Otley et al.14 ound the rate o serious com-
can cross-react with neomycin and it is generally rec- plications in anticoagulated patients to be 1.6% as com-
ommended to use topical mupirocin or erythromycin i pared with 0.7% or controls. Moreover, Billingsley et al.15
a topical antibiotic is pre erred. Eliciting allergies to oral studied the bleeding risk with Mohs micrographic surgery
antibiotics is important in the event that the patient needs in a prospective ashion and showed that there was no
pre- or postsurgical antibiotic prophylaxis or develops a signi cant increase in postoperative hematoma, although
postsurgical wound in ection. there was a slight increase without statistical signi cance
An allergic contact dermatitis (ACD) may result rom in anticoagulated patients. In the largest prospective
preservatives in emollients or bacitracin or neomycin, study o Mohs micrographic surgeries, most bleeding and
which are key components o over-the-counter antibiotic wound-healing complications occurred in patients receiv-
ointments such as Polysporin or rom any components o ing anticoagulation therapy5; however, the incidence o
the wound dressing. T e morphology o an ACD is typi- complications related to bleeding and wound healing was
cally bright erythema surrounding the wound with dis- very low (0.11% and 0.14%, respectively) and none o the
crete margins, ref ecting the distribution in which the bleeding complications were li e-threatening. Despite the
o ending agent came into contact with the skin. An ACD insigni cantly increased risk o bleeding in patients on
with a geometric shape is suggestive o an allergy to a tape anticoagulants, ironically, a study showed that when der-
adhesive component such as colophony. T e patient will matologic surgeons were blinded to the use o anticoagu-
o ten complain o pruritus in an ACD rather than pain, lants in their surgical patients, they were unable to identi y
which is more commonly associated with in ection. which patients were taking them.16
Although there is no o cial consensus statement
regarding the discontinuation o anticoagulant and anti-
t o ba c c o platelet therapy prior to dermatologic surgery, it is now
generally accepted that patients should continue these
Smoking tobacco has been associated with a higher inci- medications i they are being used or primary stroke
dence o postoperative complications including in ections, prevention. T ere have been several reports o li e-threat-
impaired wound healing, wound dehiscence, and gra t/ ening adverse events such as ischemic strokes in patients
f ap necrosis.10 Case series have shown a higher rate o who have discontinued their anticoagulants prior to der-
f ap ailure in smokers who smoked even one pack per day matologic surgery.17– 20 As there have been no reports
compared with those who smoked ewer cigarettes and o li e-threatening hemorrhagic events in the setting o
abstainers.11 T e consensus recommendations or smok- anticoagulant therapy, anticoagulation therapy used or
ing cessation be ore dermatologic surgery are to stop or primary prevention may be continued be ore and a ter
314 decrease (as much as possible) smoking at least 2 weeks dermatologic surgery.
 2

C
h
a
p
t
e
r
2
4
:
:
S
u
r
g
i
c
a
l
C
o
m
B

p
A

l
i
c
a
t
Figure 24-2 A. Hematoma: This patient developed a hematoma and persistent oozing rom her surgical

i
o
wound on the lip and chin. B. Hematoma resolved without any unctional or aesthetic consequences.

n
s
a
n
d
T
h
T e most commonly used anticoagulants are aspirin, Patients will o ten ail to report nonprescription medi-

e
i
clopidogrel, NSAIDs, war arin, and heparin. Aspirin and cations and may even be hesitant about reporting herbal

r
M
clopidogrel irreversibly inhibit platelet unction by inacti- remedies. Because o the growing list o herbal products

a
n
vating cyclooxygenase (COX). It is recommended to dis- that a ect hemostasis, it is important to speci cally ques-

a
g
continue these medications 10 to 14 days prior to surgery tion a patient about all nonprescription medications and

e
m
i they are not being taken or primary prevention. NSAIDs supplements as well. It is generally recommended that

e
also inhibit COX, but reversibly. T ese can be substituted these herbal supplements be discontinued 10 to 14 days

n
t
with acetaminophen i taken or pain control, and should prior to surgery.
also be discontinued 10 to 14 days prior to surgery. War a-
rin inhibits the synthesis o serum anticoagulation proteins
II, VII, IX, and X, and is thought to increase thrombotic med Ic a l c o mo r bId It Ies t h a t
risk in the setting o discontinuation by its compensatory a f f ec t h emo s t a s Is
increase in the synthesis o proteins C and S. War arin
inter eres with wound healing by inhibiting the orma- Preoperative assessment should include a screening or
tion o a brin plug, which typically occurs 72 to 96 hours bleeding disorders, including prior surgeries and amily
post surgery. It is recommended to check a patient’s inter- history. I the patient’s personal or amily history is sus-
national normalized ratio (INR) be ore surgery i a large picious or a bleeding disorder, the surgeon should check
surgical procedure such as a complex two-staged f ap is the platelet count, a unctional in vitro bleeding time assay,
anticipated. T e INR should ideally be kept between 2 and P (extrinsic pathway) and aP (intrinsic pathway). A
3. wo newer anticoagulants approved or the prevention review o medical comorbidities should include assessing
o systemic emboli are dabigatran (Pradaxa) and rivaroxa- or chronic hepatic or renal disease, which can a ect clear-
ban (Xarelto). Both o these medications inhibit the coagu- ance o local anesthesia, bleeding risk, and coagulation
lation cascade; dabigatran is a direct thrombin inhibitor compromise. Hypertension is also a risk actor or bleed-
whereas rivaroxaban is a direct actor Xa inhibitor. T ere ing complications,24 and blood pressure measurement is a
have been reports o bleeding complications with both o vital component o the preoperative visit and immediately
these drugs.21 Multiple studies have compared the overall prior to surgery. Finally, alcohol consumption has been
risk o bleeding between multiple agents. T e risk o com- shown to inhibit platelet unction, decrease coagulation,
plications was higher in patients taking war arin rather and increase brinolysis.25 T ere ore, it is crucial or der-
than aspirin as compared with controls.22 In terms o anti- matologic surgeons to elicit history o alcohol consump-
platelet agents, clopidogrel posed a higher complication tion and advise patients to abstain rom alcohol at least 48
risk than aspirin monotherapy.23 hours prior to and ollowing surgery. 315
2 by manual pressure, chemical agents such as aluminum
chloride or erric subsul ate, or cauterization (electrodesic-
cation, electrocoagulation, or disposable heat cautery). For
deeper or muscular oozing, the a orementioned methods
o manual pressure and cautery may be used. In addition,
absorbable hemostatic agents or drains may be used i the
persistent oozing and bleeding cannot be controlled, so as
to prevent the development o a hematoma. Hemostatic
agents include gelatin oams (Gel oam®), oxidized cellulose
(Oxycel®, Surgicel®), and micro brillar collagen (Avitene®,
Collastat®).27 O note, the application o excessive oxidized
cellulose has been shown to result in a postsurgical or-
eign body granulomatous reaction, and caution should be
used with this agent.28 opical thrombin can also be used
to promote a more rapid coagulation cascade at the site o
S
e
bleeding/oozing.
c
t
i
Placement o a drain should be considered or persis-
o
n
tent oozing or with large, complex repairs more likely to
2
be associated with dead space and subsequent ormation
:
:
o hematomas. Drains are classi ed into open and closed
systems. T e most commonly used open system in derma-
S
u
tologic surgery is placement o a Penrose drain, whereby
r
g
i
gravity allows or the passive movement o f uid through
c
a
l
a simple enestrated drain or collection in a gauze dress-
S
k
ing. It should be removed a ter 24 to 48 hours to avoid
i
l
l
s
in ection, and when the risk or hematoma ormation is
minimal. A closed system includes a draining tube that
connects the wound’s interior to an outer, sealed container,
creating a vacuum with suction, allowing or collection o
Figure 24-3 Surgical wound in ection on the cheek dem- f uid generated inside the wound. Examples o a closed
onstrates redness, swelling, and increased tension upon system include the Jackson–Pratt drain and the mini-f ap
the super cial sutures. The patient complained o increas- wound suction drain.29
ing pain despite analgesics.

Po s t o Per a t Iv e bl eed In g a n d
h ema t o ma
In t r a o Per a t Iv e bl eed In g
Postoperative bleeding most requently occurs within the
T e addition o epinephrine to the local anesthetic rst 24 hours, and usually within the rst 6 hours a ter
causes local vasoconstriction and helps minimize intra- surgery (Fig. 24-1). During this period, epinephrine dis-
operative bleeding. Managing intraoperative bleeding sipates, and the subsequent vasodilation can lead to ooz-
e ciently involves proper patient positioning, adequate ing or bleeding o small vessels (Fig. 24-2). Newly ormed
lighting, and meticulous surgical technique. Vessels and clots are also sensitive to movement, and can be easily
nerves can be damaged or severed during undermining. dislodged. Minimizing the risk o postoperative bleeding
Although adequate undermining is crucial or decreas- and hematoma ormation begins in the surgical suite, with
ing wound tension, it does increase the risk o bleeding the application o an adequate pressure dressing and clear,
and creates potential spaces or hematoma ormation detailed patient instructions. T e pressure dressing is usu-
and thus should not be excessive. With any surgical pro- ally kept in place or at least 24 hours and should provide
cedure, a care ul, methodical inspection underneath pressure without causing ischemia. T e dressing typically
all wound edges using skin hooks be ore the wound is includes ointment with an overlying nonadherent contact
sutured is good practice. Once the source vessel has been lm ( el a®, Release®), ollowed by at least one absorbent
identi ed, electrosurgery is appropriate or achieving layer o cotton, sponges, or gauze. It should be secured by
hemostasis o small arteriolar and venular hemorrhages, an outer layer o adhesive tape and/or a stretchable cover-
whereas ligation is pre erred or large vessels. A horizon- ing (Ace Wrap®,Coban®).
tal gure-o -eight tie with an absorbable suture is pre er- Written and verbal instructions should be provided to
able or vessel ligation. Absorbable sutures should also be the patient to minimize bleeding, as well as what to do i
used to close potential dead space to minimize the risk o bleeding or hematoma ormation occurs. T ese instruc-
hematoma ormation. tions include avoidance o movement, bending over, or
O ten, oozing rather than rank bleeding occurs at the li ting weight heavier than 10 lb. Patients should also
surgical site. Goldman 26 has described the approach to avoid alcohol or at least 48 hours. I the surgical site is
intraoperative oozing, and o ers varying approaches or perioral, the patient should minimize talking, eat so t
the management o super cial (dermal) oozing and deep oods, and take precautions when inserting or removing
316 (musculature) oozing. Super cial oozing may be managed dentures. Patients should also be counseled about the
 2

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t
A B C

e
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2
4
Figure 24-4 A. Increased tension on the distal portion o this bilobed transposition f ap caused super cial necrosis and
dehiscence. B. With conservative wound management, the dehisced area heals by second intention. C. The bilobed f ap

:
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has healed without signi cant scarring.

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inevitable development o ecchymoses ollowing surgery. A later stage hematoma, in the gelatinous or organized

o
T ese bruises can extend beyond the surgical wound, stage, o ten cannot be easily extracted without opening

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especially onto dependent areas o the ace, and patients the wound. I a gelatinous or organized hematoma is not

l
i
c
should be counseled to minimize alarm as well as to di - expanding, evacuation can be delayed until 7 to 10 days

a
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i
erentiate this rom postoperative bleeding. postoperatively, when the hematoma is in the lique active

o
n
stage and can be evacuated with simple needle aspiration.

s
a
In many instances, a nonexpanding gelatinous hematoma

n
ma n a g emen t o f h emo r r h a g e o r

d
will lique y and be resorbed by the body and does not nec-

T
h ema t o ma f o r ma t Io n

h
essarily need evacuation.

e
i
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M
When a hematoma occurs, the patient o ten experiences

a
a n t IbIo t Ic Pr o Ph yl a x Is a n d

n
increasing pain or pressure at the site. I the patient is

a
g
concerned about persistent bleeding or hematoma orma-

e
Wo u n d In f ec t Io n s

m
tion, he/she should be instructed to remove the pressure

e
dressing and visualize the wound to ascertain whether

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there is a speci c area that is the source o bleeding. T e T e e cacy o prophylactic oral antibiotics in dermato-
patient should apply direct pressure or 15 to 20 minutes, logic surgery is unclear, and the current guidelines are not
while watching a clock. In many cases, minor postopera- based on multiple, large-scale, prospective trials.31 It is
tive bleeding or oozing will cease with this intervention. generally accepted that patients at high risk or developing
However, i bleeding persists then the patient needs to be in ective endocarditis or a joint in ection (as de ned by
evaluated by the surgeon. the American Heart Association and American Academy
A hematoma is a localized collection o blood and its o Orthopaedic Surgeons, respectively) who are under-
evolution can be divided into our stages: early (stage I), going dermatologic surgery involving the breach o a
gelatinous (stage II), organized (stage III), and lique action mucosal barrier or in ected skin should receive antibiotic
(stage IV).30 Within the rst 48 hours o surgery, the sur- prophylaxis. T e guidelines and rationale are discussed in
geon is con ronted with early stage or expanding hema- the chapter on preoperative evaluation.
tomas. T ese have the potential to cause wound ischemia Most surgical wounds in dermatologic surgery are cat-
and necrosis, and are a nidus or in ection. I an early or egorized as clean or clean-contaminated. In general sur-
expanding hematoma is ound on evaluation, the surgeon gery, where sterile technique is practiced in all aspects o
should reanesthetize the wound (with or without epi- surgery, the risks o in ection or these wounds are +/− 2%
nephrine), evacuate the hematoma, visualize the source(s) and 10%, respectively. In cutaneous surgery, the rates are
o bleeding, achieve hemostasis, and irrigate the wound much lower than expected, and are estimated at less than
bed. I a source cannot be ascertained or oozing persists, 1% to 3%.32– 34 T ese rates are even lower in Mohs micro-
a drain may be placed. T e wound may be le t open to heal graphic surgery (0.44%–0.91%), a ter which wounds o ten
by secondary intention or partially sutured or completely may be le t open or prolonged periods o time and sterile
reclosed, depending on the surgeon’s con dence that ade- technique may only be practiced during reconstruction.5,35
quate hemostasis has been achieved. Due to the increased Not surprisingly, more complex repairs such as f aps
risk o in ection in this case, many surgeons advocate ini- have been associated with the highest risk o in ection
tiating a course o empiric antibiotics. (2.4%– 2.67%).34 In a study o 5091 skin surgery cases, there 317
2 de ects on the lips, ears, or below the knee.34 Hemorrhagic
complications in both simple and complex dermatologic
surgeries are independent risk actors or in ection.32,36

Pr e v en t Io n o f s u r g Ic a l s It e
In f ec t Io n s
Preventive measures such as antibiotic prophylaxis and the
use o sterile surgical gloves have been shown to correlate
with ewer postoperative in ections in some studies, but
these measures have not been shown to be causative.5,37
Most Mohs surgeons use sterile gloves during reconstruc-
tion, but not during the removal o Mohs layers.5 In addi-
tion, preoperative cleansing with one or more antiseptics,
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including alcohol, iodophors, and chlorhexidine, is recom-
c
t
i
mended or prevention o in ection. Alcohols are used less
o
n
requently due to their f ammability. Iodophors provide
2
antimicrobial protection, but are inactivated by serum or
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:
blood. T ey should not be used in patients with iodine or
shell sh allergies. Chlorhexidine provides broad-spectrum
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antibiotic activity, but should be used with caution around
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the eyes and ears due to potential corneal irritation and
c
a
ototoxicity. Shaving the skin has been shown to increase
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k
the risk o in ection,38 and surgeons should clip hair in lieu
i
s
o shaving when possible.

Figure 24-5 Extensive suture reaction causing a dehis

t r ea t men t o f s u r g Ic a l s It e
cence. In f ec t Io n s
Although postoperative in ections are rare in dermatologic
was an overall in ection rate o 1.47%, with increased risk surgery, they will typically present 4 to 7 days ollowing sur-
in speci c sites, including below the knee (6.92%), groin gery with symptoms o increasing pain, swelling, warmth,
area (10%), wedge excisions o the lip and ear (8.57%), and erythema, and/or purulent drainage (Fig. 24-3). When an
gra ts (8.7%).32 In contrast, the Mohs micrographic surgery in ection is suspected, a wound culture should be obtained
prospective studies showed no increase in the rate o in ec- and empiric antibiotics initiated that are appropriate to
tion in cases involving skin gra t repairs, or having surgical the surgical site ( able 24-1) and probable microorganism.

TAbl E 24-1
a ibi i m P i I i a i mi i / s i si

a r i d i mi i /s i
Cepha exin 250–500 mg PO bID QID 7–10 d S. aureus, rst ine agent
Dic oxaci in 250–500 mg PO bID QID 7–10 d S. aureus, rst ine agent
Azithromycin 250 mg 2 ta s on day 1 and 1 ta on S. aureus, rst ine a ternative in penici in
days 2–5 a ergic patients
Amoxici in/ 500 mg PO TID or 875 mg 7–10 d S. viridans coverage or ora mucosa site, rst
C avu anate PO TID ine agent
Ciprof oxacin 500 mg PO bID 7–10 d S. aureus and Pseudomonas coverage or ear or
genitourinary site
C indamycin 300 mg PO QID 7–10 d S. aureus and S. viridans coverage or skin or
ora surgery
Erythromycin 500 mg PO bID 7–10 d S. viridans coverage or ora mucosa site,
second ine agent
Trimethoprim/ 1 DS ta PO bID 7–10 d S. aureus and E. coli coverage or skin and
Su amethoxazo e genitourinary sites

Source: Reproduced with permission rom Wood l D, Warner NM, bi ings ey EM. In ectious comp ications o dermato ogic procedures. Dermatol
318 Ther. 2011;24:558–570.
Depending on the severity o in ection and the amount o
purulence, some, i not all, o the percutaneous sutures
should be made to care ully plan a closure that is appro-
priate to the surgical site. I it becomes apparent that the
2
should be removed to allow or drainage and healing by closure is burdened by excessive tension, the surgeon can
secondary intention. Abscesses always require drainage. attempt to alleviate this by placing relaxing incisions 2 to 3
In rare cases, i patients report ever or other worsening cm rom the wound bed, using tissue expanders, or opting
systemic symptoms, hospital admission and intravenous or a partial closure with healing by secondary intention,
antibiotics may be indicated. Most surgical site in ections depending on the site o the surgical de ect.
result rom the presence o bacteria on the patient’s skin Flaps and gra ts are subject to relative ischemia and are
and accordingly, their requency is as ollows, in descend- there ore more susceptible to necrosis and in ection. Com-
ing order: Staphylococcus aureus, coagulase-negative plications o f aps can arise rom a variety o causes: poor
staphylococci, enterococcus spp., Escherichia coli, Pseu- reconstructive design, traumatic tissue handling, inappro-
domona s aeruginosa and streptococci. Certain pathogens priate dog-ear correction at the vascular base o the f ap,
ollow a time course o presentation ollowing cutaneous aggressive control o bleeding, and excessive wound tension.
surgery. Streptococcal in ections usually present early, Gra ts are especially vulnerable in certain sites with poor
in the rst 1 to 2 days a ter surgery, and typically appear blood supply such as exposed bone, exposed cartilage, and

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as rapidly spreading, pain ul erythema. Staphylococcal at sites o previous radiation. Adequate contact between the

a
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in ections appear 2 to 5 days postoperatively and are usu- gra t and the wound bed must be established, as poor place-

t
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ally associated with a collection o purulent material. In ment or accumulation o blood may lead to inadequate con-

2
4
the later postoperative period, such as 2 to 4 weeks a ter tact. Methods to maximize gra t viability include achieving
surgery, in ections with Mycobacterium can present with a balance between adequate hemostasis while minimizing

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nonhealing ulcers and recurrent papulonodules. Surgeons electrocautery o the wound bed and proper apposition o

S
should also be aware o the prevalence o methicillin-resis- gra t to the wound bed. Fenestrations in the gra t can mini-

u
r
tant S. aureus (MRSA) and initiate appropriate antibiotic

g
mize the accumulation o blood or a seroma and a pressure

i
c
therapy i there is a high suspicion or a MRSA in ection dressing can help keep the gra t in place, minimizing shear-

a
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prior to return o the culture results. Viral, ungal, and ing orces over the wound bed. Neither a necrotic gra t

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mycobacterial in ections are much less common but when nor a f ap should be removed or debrided, unless there is

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they do occur, the culprit is usually HSV-1, HSV-2, Can- an obvious in ection. In many instances, the necrotic tis-

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dida species, and multiple species o Mycobacterium.39 sue serves as a biologic dressing, and avoiding aggressive

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O note, contact allergies and inf ammatory response to debridement may lead to an unexpected amount o tissue

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sutures o ten mimic in ection in their presentations. survival beneath the necrotic areas. Reassuring the patient

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and seeing them regularly throughout the healing process,

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however, is critical.
t Is s u e Is c h emIa a n d n ec r o s Is

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d eh Is c en c e

M
issue ischemia and necrosis occur due to inadequate

a
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blood supply, o ten in relation to other complications such

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as edema, increased wound tension secondary to bleeding Wound dehiscence can occur due to excessive tension,

e
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or poor operative design and execution, in ection, under- in ection, hematoma, or necrosis (Fig. 24-5). It typically

e
lying medical conditions that impair wound healing, or occurs at the time o suture removal, but can occur at any

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patient noncompliance, such as inappropriate postopera- time in the rst ew months ollowing surgery. T e tensile
tive physical activity. issue ischemia can lead to wound strength o scar tissue is approximately 80% o the tensile
necrosis and even dehiscence (Fig. 24-4). In order to avoid strength o the uncut skin, and 2 weeks ollowing surgery
ischemia and necrosis, surgeons should minimize direct it is 10% or less than normal.40 It is there ore important
tissue injury and excessive wound tension intraoperatively. to instruct patients regarding which activities should be
Direct tissue injury can occur intraoperatively due to avoided a ter surgery (exercise, no li ting more than 10 lb
traumatization o wound edges. Surgeons and their assis- o weight, stair climbing, long walks) and to verbally rein-
tants should take care not to crush the wound edges when orce the lack o tensile strength o the wound. I dehis-
handling them with skin hooks or orceps, or grasp them cence occurs due to a complication such as in ection or
or excessive periods o time. Sutures should not be tied hematoma, those conditions should be treated. I dehis-
too tightly, especially super cial sutures. Excessive elec- cence occurs without evidence o in ection, necrosis, or
trocautery can also cause direct tissue injury, and charred hematoma, it may be appropriate to resuture the wound
and necrotic tissue can serve as a nidus or in ection a ter as long as there is no excessive tension.
wound closure. Vascular compromise o the wound can
also occur i blood vessels are traumatized either by elec-
trocautery or excessive undermining. t r a Pd o o r d ef o r mIt y
Excessive wound tension not only leads to wound necro-
sis, but can also result in wound dehiscence, scar widening, ransposition f aps with curvilinear borders and V-Y
and an undesirable cosmetic result. Excessive tension can advancement f aps become susceptible to trapdoor de or-
be avoided by adequate undermining, proper placement o mity. rapdoor de ormity may also result rom f ap lymph-
buried sutures to avoid sur ace tension, and the appropri- edema, excess subcutaneous at beneath the f ap or a ailed
ate use o f aps and gra ts to minimize tension when surgi- connection between the f ap base and the recipient bed.
cal de ects cannot be repaired linearly. As excessive wound Scar tissue around the border o the f ap contracts in a con-
tension is o ten the result o poor design, every e ort centric ashion. T is concentric contractile orce pushes the 319
2 skin o the f ap upward and leads to a pin-cushion appear-
ance. Properly sizing the f ap as well as wide undermining
point, which is located 6 cm below the mastoid process
or 2 to 3 cm above the clavicle, along the border o the
to create an even plate o scar contraction that extends sternocleidomastoid muscle. T e spinal accessory nerve
beyond the f ap help to minimize the risk o trapdoor provides motor innervation to the sternocleidomastoid
de ormity.41 Some o the trapdoor appearance o the f ap and trapezius muscles, and injury results in winging o
may improve with time. Steroid injection into the scar and the scapula, adduction o the arm and inability to elevate
subcutaneous tissue or scar revision helps in those cases the shoulder.
that do not resolve.

s u t u r e g r a n u l o ma
n er v e In j u r y
Suture reactions may take the orm o small granulomas or
In dermatologic surgery, there is a risk o motor or sen- abscesses. Anticipatory guidance regarding the time rame
sory nerve injury, which may or may not be reversible. or suture absorption should be provided to patients or
During the preoperative evaluation, the surgeon should suture granulomas. Dermal sutures may emerge rom the
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per orm a ocused neurologic examination to identi y any deep layer and break through the epidermis 4 to 6 weeks
c
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pre-existing de cits or asymmetries, and make the patient a ter surgery as a result o oreign body reaction to the
o
n
aware o such anatomical variations. T e types o nerve absorbable sutures. Protruding sutures can be removed
2
injury that occur include neurapraxia, axonotmesis, and with orceps or le t to dissolve i the surrounding tissue
:
neurotmesis. Neurapraxia is the least severe orm o nerve is riable. Removing the extruding suture can acilitate
:
injury, and occurs when there is a temporary interruption wound healing. Deeper placement o buried sutures usu-
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o nerve conduction due to compression or ischemia. ally helps to prevent suture granuloma ormation.
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Axonotmesis occurs when there is structural damage to
c
a
the axon and its myelin sheath, with preservation o the
l
k el o Id s a n d h yPer t r o Ph Ic
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k
encapsulating tissue, epineurium, and perineurium, and
i
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l
restoration o nerve conduction requires axon regenera- sca r s
s
tion. T is type o injury usually occurs due to crushing
trauma or severe stretching o the nerve. Neurotmesis
Keloids and hypertrophic scars are dreaded, poorly under-
is transection o the nerve and is the most severe orm
stood complications or both patients and surgeons. T ey
o nerve injury. T is disruption in the architecture o the
have a predilection or the extremities, neck and trunk,
nerve makes recovery rom this type o injury the least
and are thus thought to occur secondary to increased
likely o all.
wound tension in areas with constant dynamic movement.
Injury to super cial cutaneous sensory nerves is com-
T ey are more common in higher Fitzpatrick skin types
mon, and may result in hypoesthesia, anesthesia, pares-
and individuals o Asian descent. A hypertrophic scar is
thesia, or dysesthesia. Dysesthesia and hypoesthesia are
characterized as a rm, smooth, elevated scar at the site o
extremely common at sites o primary closure or over
cutaneous surgery or injury, whereas a keloid is a smooth
gra t sites. T e digits, orehead, and scalp are most suscep-
elevated scar that extends beyond the site o injury or sur-
tible to sensory nerve injury. Motor nerve injury results
gery. Both hypertrophic scars and keloids can be treated
in de cits that correspond to the associated proximal
with multiple rounds o intralesional corticosteroids with
nerve root. I motor or sensory nerve injury occurs a ter
varying success.
surgery, the surgeon should counsel the patient that the
nerve injury is o ten temporary, and that unction may
return in a matter o days to months. Patients should wait c o n c l u s Io n
at least 9 to 12 months prior to seeking cosmetic or unc-
tional repair.
Even the most scrupulous surgeon will encounter opera-
T ere are well-known anatomic “danger zones” that
tive complications. Fortunately the overall incidence and
are at higher risk or nerve injury, and the dermato-
morbidity o complications in dermatologic surgery are
logic surgeon should exercise caution when per orming
low. Many complications can be anticipated and avoided
surgery at these sites. T e temporal branch o the acial
by per orming a comprehensive preoperative assessment,
nerve is most super cial where it crosses the zygomatic
as well as thought ul operative design and meticulous
arch in the temporal region. T e anterior branches supply
execution. Recognizing and appropriately managing com-
the rontalis, orbicularis oculi, and corrugator supercilii,
plications early can o ten minimize adverse long-term
and the temporal branch serves as the e erent limbs o
surgical outcomes.
the corneal ref ex. Injury results in the inability to raise
the eyebrows on the a ected side, resulting in f attening
o the orehead. T e marginal mandibular branch o the r ef er en c es
acial nerve is located at the mid-mandible, approximately
2 cm posterior and in erior to the oral commissure. It 1. Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. T e
supplies the muscles o the lower lip and chin, including sa ety o Mohs surgery: a prospective multicenter cohort
the depressor labii in erioris, the depressor anguli oris, study. J Am Acad Dermatol. 2012;67(6):1302– 1309.
2. Elliott G, T om GA, Litterick KA. O ce based dermato-
and the mentalis. Injury results in drooping and inward logic surgery and Mohs surgery: a prospective audit o surgi-
retraction o the mouth on the a ected side. Finally, the cal procedures and complications in a procedural dermatol-
320 spinal accessory nerve is most vulnerable to injury at Erb’s ogy practice. Australa s J Dermatol. 2012;53:264– 271.
 3. Starling JS, T osani MK, Coldiron BM. Determining the
sa ety o o ced-based surgery: what 10 years o Florida
22. Lewis KG, Du resne RG Jr. A meta-analysis o complications
attributed to anticoagulation among patients ollowing cuta-
2
Data and 6 years o Alabama data reveal. Dermatol Surg. neous surgery. Dermatol Surg. 2008;34(2):160– 164.
2012;38:171– 177. 23. Cook-Norris RH, Michaels JD, Weaver AL, et al. Com-
4. Cook JL, Perone JB. A prospective evaluation o the inci- plications o cutaneous surgery in patients taking clopi-
dence o complications associated with Mohs micrographic dogrel-containing anticoagulation. J Am Acad Dermatol.
surgery. Arch Dermatol. 2003;139(2):143– 152. 2011;65(3):584– 591.
5. Alam M, Ibrahim O, Nodzenski M, et al. Adverse events 24. Straith RE, Raju DR, Hipps CJ. T e study o hematomas in
associated with Mohs micrographic surgery. JAMA Der- 500 consecutive ace li ts. Pla st Resconstr Surg. 1977;59(5):
matol. 2013;149(12):1378– 1385. doi:10.1001/jamaderma- 694– 698.
tol.2013.6255. 25. Salem RO, Laposata M. E ects o alcohol on hemostasis. Am
6. Perlis CX, Campbell RM, Perlis RH, Malik M, Du resne RG Jr. J Clin Pathol. 2005;123(suppl):S96–S105.
Incidence o and risk actors or medical malpractice lawsuits 26. Goldman G. Surgical complications and optimizing out-
among Mohs surgeons. Dermatol Surg. 2006;32(1):79– 83. comes. In: Bolognia JL, Jorizzo JL, Scha er JV, eds. Derma-
7. McGinness JL, Goldstein G. T e value o preoperative tology, 3rd ed. China: Elsevier Limited; 2012:2464.
biopsy-site photography or identi ying cutaneous lesions. 27. Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Sha-
Dermatol Surg. 2010;36(2):194– 197. piro ML, Lawson JH. A comprehensive review o topical

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8. Matzke J,Christenson LJ,Christenson SD,Atanashova N,Otley hemostatic agents. Ann Surg. 2010;251:217– 228.

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CC. Pacemakers and implantable cardiac de brillators in der- 28. Billingsley EM, Maloney ME. Considerations in achieving

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matologic surgery. Dermatol Surg. 2006;32(9):1155–1162. hemostasis. In: Robinson JK, Arndt KA, Leboit PE, Win-

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9. El-Gamal HM, Du resne RG, Saddler K. Electrosurgery, troub BU. Atla s of Cutaneous Surgery. Philadelphia, PA: WB

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2
pacemakers and ICDs: a survey o precautions and compli- Saunders; 1996:67–73.

4
cations experienced by cutaneous surgeons. Dermatol Surg. 29. Nasser NA. T e use o the Mini-Flap wound suction drain
2001;27(4):385– 390. in maxillo acial surgery. Ann R Coll Surg Engl. 1986;68(3):

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10. Gill JF, Yu SS, Neuhaus IM. obacco smoking and dermato- 151– 153.

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logic surgery. JAMA Dermatol. 2013;68:167– 172. 30. Nguyen H, Erickson QL. Hemostasis. In: Robinson JK,

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11. Goldminz D, Bennett RG. Cigarette smoking and f ap Hanke CW, Siegel DM, Fratila A, eds. Surgery of the Skin,

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and ull-thickness gra t necrosis. Arch Dermatol. 1991; 2nd ed. New York, NY: Mosby Elsevier; 2010:225– 238.

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127(7):1012– 1015. 31. Wright I, Baddour LM, Berbari EF. Antibiotic prophylaxis

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12. Reus WF 3rd, Colen LB, Straker DJ. obacco smoking and in dermatologic surgery: advisory statement 2008. J Am

o
complications in elective microsurgery. Pla st Reconstr Surg. Acad Dermatol. 2008;59:464– 473.

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1992;89(3):490– 494. 32. Futoryan , Grande D. Postoperative wound in ection rates

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13. Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, Fu P, in dermatologic surgery. Dermatol Surg. 1995;21:509– 514.

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a
Maloney ME. Prospective evaluation o dermatologic 33. Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospec-

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surgery complications including patients on multiple tive study o wound in ections in dermatologic surgery in

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antiplatelet and anticoagulant medications. J Am Acad the absence o prophylactic antibiotics. Dermatol Surg.

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Dermatol. 2011; 65(3):576– 583. 2006;32:819– 827.

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14. Otley CC, Fewkes JL, Frank W, Olbricht SM. Complications 34. Rogues AM, Lasheras A, Amici JM, et al. In ection control

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o cutaneous surgery in patients who are taking war arin, practices and in ectious complications in dermatological

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aspirin, or nonsteroidal anti-inf ammatory drugs. Arch Der- surgery. J Hosp Infect. 2007;65:258– 263.

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r
matol. 1996;132(2):161– 166. 35. Maragh SLH, Brown MD. Prospective evaluation o surgical

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15. Billingsley EM, Maloney ME. Intraoperative and postopera- site in ection rate among patients with Mohs micrographic

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tive bleeding problems in patients taking war arin, aspirin, surgery without the use o prophylactic antibiotics. J Am

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and nonsteroidal anti-inf ammatory agents. A prospective Acad Dermatol. 2008;59:275– 278.

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study. Dermatol Surg. 1997;23(5):381– 383. 36. Amici JM, Rogues AM, Lasheras A, et al. A prospective

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16. West SW, Otley CC, Nguyen H, et al. Cutaneous surgeons study o the incidence o complications associated with der-

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cannot predict blood-thinner status by intraoperative visual matological surgery. Br J Dermatol. 2005;153:967– 971.

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inspection. Pla st Reconstr Surg. 2002;110(1):98– 103. 37. Xia Y, Cho S, Greenway H , Zelac DE, Kelley B. In ection
17. Schanbacher CF, Bennett RG. Postoperative stroke a ter stop- rates o wound repairs during Mohs micrographic surgery
ping war arin or cutaneous surgery. Dermatol Surg. 2000; using sterile versus non-sterile gloves: a prospective ran-
26(8):785–789. domized pilot study. Dermatol Surg. 2001;37(5):651– 656.
18. Alam M, Goldberg LH. Serious adverse vascular events asso- 38. Cruse PJ, Foord R. A ve-year prospective study o 23,649
ciated with perioperative interruption o antiplatelet and surgical wounds. Arch Surg. 1973;107:206– 210.
anticoagulant therapy. Dermatol Surg. 2002;28(11):992– 998. 39. Wood LD, Warner NM, Billingsley EM. In ectious com-
19. Kovich O, Otley CC. T rombotic complications related to dis- plications o dermatologic procedures. Dermatol T er.
continuation o war arin and aspirin therapy perioperatively or 2011;24:558– 570.
cutaneous operation. JAMA Dermatol. 2003; 48(2):233–237. 40. Stasko . Complications o cutaneous procedures. In: Roe-
20. Kimyai-Asadi A, Jih MH, Goldberg LH. Perioperative pri- nigk RK, Roenigk HH Jr, eds. Dermatologic Surgery Prin-
mary stroke: is aspirin cessation to blame? Dermatol Surg. ciples and Practice. 2nd ed.. New York, NY: Marcel Dekker;
2004;30(12 Pt 2):1526– 1528. 1996:149– 175.
21. Schmitt AR, Zender CA, Bordeaux JS. A new oral antico- 41. Kau man AJ, Kiene KL, Moy RL. Role o tissue undermining
agulant in the setting o dermatologic surgery. J Am Acad in the trapdoor e ect o transposition f aps. J Dermatol Surg
Dermatol. 2013;68(5):869–870. Oncol. 1993;19(2):128– 132.

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 Sect ion
Sk T o s
3
ch a pt er

25 Benign Subcutaneous Tumors

Paul X. Benedetto & Allison T. Vidimos

Ov er v iew CLin iCa L pr eSen Ta TiOn

T ere are a variety o benign dermal and subcutaneous Lipomas present as so t or rubbery nodules or masses
tumors that present to the procedural dermatologist or located within the subcutaneous tissue. T ey are poorly
management. We provide an overview o the epidemiol- de ned and reely mobile, unless trapped beneath skel-
ogy, clinical presentation, di erential diagnosis, histopa- etal muscle or galea, which limits their lateral mobility.
thology, and surgical management o each o these tumors, T e overlying epidermis appears clinically unremarkable.
and discuss the surgical management o these lesions. Lipomas commonly present as slow-growing tumors with
a size range o approximately 1 to 10 cm. T ey are most
o ten con ned to the hypodermis but may achieve sub-
Fa T Tu mOr S stantial mass i le t intact or many years. Most lipomas
are painless and asymptomatic, but anatomic locations
LipOma (a n d va r ia n TS) with restricted room or expansion (e.g., orehead and
scalp), and histologic subtype (e.g., angiolipoma) may pre-
Lipomas are a common benign neoplasm composed pre- dispose the patient to developing pain with these lesions.
dominantly o lobules o mature adipocytes and brous Common anatomic locations include the back, shoulders,
stroma.1 T ey are ound most o ten in the subcutane- neck, and proximal upper and lower extremities.3,4 Lipo-
ous tissue and less requently in internal organs. T ey mas that occur on the orehead are o ten buried under-
are o ten delineated rom surrounding normal hypoder- neath the rontalis muscle or galea.5
mis by brous septa. T ere are numerous subtypes o Lipomas most o ten present as a solitary lesion, but
benign lipomas. At the malignant end o the spectrum is multiple lesions can occur in certain circumstances,
the liposarcoma, which likely arises de novo, rather than such as amilial lipomatosis and genodermatoses such as
rom malignant trans ormation o benign lipomas.2 Spe- Gardner’s syndrome, Proteus syndrome, neuro bromato-
ci c variants o benign lipomas (e.g., angiolipoma, spindle sis, Cowden syndrome, Bannayan– Riley– Ruvalcaba syn-
cell lipoma, lipoblastoma, brolipoma, adenolipoma) are drome, and others.6
largely histopathologic distinctions, as their clinical pre- Furthermore, certain lesions can mimic lipomas. In
sentations are o ten quite similar. For the purposes o some cases, the alternative diagnosis may not be known
surgical management, these lesions will be considered or suspected until the tumor is assessed intraoperatively.
together, with special mention made o any identi ying or For example, a liposarcoma may be brighter yellow and
exceptional eatures. greasier than a typical lipoma. A lesion that elt rubbery
and was clinically consistent with a lipoma, may have the
appearance o a vascular tumor intraoperatively. In such
epid emiOLOg y cases, it may be advisable to remove a smaller biopsy
sample, terminate the case prematurely, and plan a more
Lipomas are the most common so t tissue tumor, occur- de nitive approach once the results o histopathology are
ring in between 0.1% and 1% o the population.3 known. Certain unexpected tumors, such as a liposarcoma
3 or dermal metastases, may require preoperative imaging
with C or MRI scans to assess the extent o involvement
important. Antiplatelet and anticoagulant therapy obviously
increases the patient’s bleeding risk, but it is not advisable to
o underlying tissue prior to surgical excision. stop these medications or minor surgery in most cases.12,13
Likewise, a review o all over-the-counter medications,
herbal supplements, and vitamins is important because o
HiSTOpa THOLOg y the clinically signi cant side e ect pro le o many o these
medications.14
Lipomas appear histologically as sheets o adipocytes Regarding contraindications to surgery, active in ection
orming at lobules o varying sizes dissected by brous overlying or near the surgical site should be considered
septa and o ten enclosed by a thin brous capsule within an absolute contraindication or routine elective surgery.
the subcutaneous space. Varying degrees o angiogenesis Although pregnancy does not absolutely preclude sur-
may be appreciated, with angiolipomas displaying numer- gical excision o benign lipomas, the excision will need
ous small- to medium-sized blood vessels throughout to be conducted with plain lidocaine, as epinephrine is
the lobules and septa. Lipomas with relatively increased pregnancy category C. Proceeding with excision during
brous tissue are re erred to as brolipomas. Adenoli- pregnancy should be reserved or smaller or problem-
S
e
atic lesions, or or lesions or which the diagnosis is not
c
pomas are a rare variant with prominent eccrine glands.
t
i
entirely clear.
o
Spindle cell, sclerotic, ossi ying bromyxoid, and chon-
n
drolipomas are other rare variants that have been charac-
3
terized histologically.7
Su r g iCa L pLa n n in g
:
:
S
k
Tr ea Tmen T/Su r g iCa L T e next step in planning the excision involves the evalu-
i
n
T
ation o the lesion itsel , and any anatomic or unctional
ma n a g emen T OF LipOma S
u
m
considerations that may impact the procedure.
o
When marking the overlying skin to plan the surgical
r
s
reatment o lipomas is undertaken or a variety o rea- removal, it is help ul to palpate the tumor and mark out
sons, and most o ten is achieved surgically. umors that the clinically perceived peripheral margins. T is will give
grow unabated warrant excision and histopathologic a rough estimate o the overall size o the lesion. Depend-
examination. T e clinical diagnosis o a lipoma cannot ing on the size o the tumor, and how long it has been
always be made with complete certainty, and excision or present, the overlying epidermis may exhibit varying
the purpose o histologic examination is a reasonable step amounts o redundancy. For smaller nodules, or lesions
in the diagnosis. Removal o lipoma variants such as an without excessive overlying skin, a linear incision may
angiolipoma may be necessitated by patient discom ort be planned over the center o the lipoma a ter care ully
or pain. marking out the borders (Fig. 25-1). For larger lesions, or
or tumors that have expanded the overlying skin creat-
ing signi cant redundancy, it is help ul to draw out a con-
pr eOper a Tiv e a SSeSSmen T servative ellipse overlying the tumor to remove some o
the excess skin. As with any excision, the ellipse should be
As with any other surgical excision, care ul preoperative oriented in the direction o the relaxed skin tension lines.
planning will result in the most optimal surgical outcome. Once the surgical site is marked with ink, anesthetized
It is important to conduct a review o the patient’s past with local anesthetic, and prepped with a surgical scrub
medical and surgical histories, social history including such as chlorhexidine or betadine, the initial incision can
tobacco use and alcohol intake, current medications and be made.
allergies, and obvious contraindications to surgery.8
Regarding the medical history, it is critical to review
comorbidities that may impact the surgical procedure.
Hypertension may lead to intraoperative or postoperative
bleeding. Diabetes may contribute to suboptimal wound
healing or higher risk o postoperative in ection. Patients
may have underlying conditions associated with pro-
longed bleeding times, such as hemophilia, or abnormal
coagulation, such as actor V Leiden de ciency.9
A review o the patient’s surgical history may uncover
issues previously encountered with other surgical proce-
dures, such as keloid ormation or hypertrophic scarring,
allergies or sensitivities to local anesthetic or epinepherine,
allergies or irritation rom bandage adhesive, and a history
o postoperative in ection. A patient who actively smokes
tobacco should be warned o the risks o poor wound heal-
ing and skin necrosis, especially with larger excisions or tight
closures.10 Heavy alcohol consumption may decrease plate-
let aggregation and increase the risk o developing a hema- Figure 25-1 Lipoma with peripheral margin and central
324 toma.9,11 A thorough review o the patient’s medication list is incision marked.
 3

Figure 25-3 Penrose drain placed after lipoma excision.

C
h
a
p
Figure 25-2 Squeezing lipoma through a small incision.

t
e
r
d iSTa n T in CiSiOn

2
5
Su r g iCa L r emOva L

:
:
In the case o a lipoma located in a more conspicuous

B
anatomic location (e.g., orehead), or one approximat-

e
n
T e incision should be carried down through the epider- ing a cosmetic unit, the surgical incision can be planned

i
g
mis and dermis into the subcutaneous plane. At this point, remote rom the actual site o the tumor.18 T e incision

n
S
rm pressure can be applied circum erentially around the can be made up to several centimeters rom the site o the

u
b
incision site to gently express the lipoma through the skin lipoma, and the dissection care ully carried out around the

c
u
sur ace. In the event o a small, super cial lipoma without tumor mass, so that the scar will be hidden (e.g., within

t
a
the hairline or a orehead lesion). T e surgeon is cautioned

n
many brous adhesions, this technique may su ciently

e
that such a removal is technically more di cult, and care-

o
deliver the tumor through the skin sur ace, where it may

u
ul technique is required to minimize excess trauma and

s
be cut away rom the surrounding adipose tissue with the

T
bleeding. Knowledge o the local surgical anatomy is para-

u
operating scissors. (Fig. 25-2).15,16 T is technique has been

m
reported to be success ul a varying percentage o the time, mount and meticulous hemostasis is imperative.

o
r
s
but is most use ul or lipomas o the extremities with ade-
quate overlying so t tissue, and in which the underlying
muscle is not involved.3 LipOSu CTiOn TeCHn iq u e
However, in the event o a larger lipoma, or one with
more abundant brous adhesions, skin hooks may be used Liposuction may be considered a reasonable alternative to
to open the incision and expose the depth o the surgi- surgical excision or the removal o lipomas. T is method
cal wound. Using a blunt-tipped, curved surgical scissors may be advisable in the case o very large lipomas that
(e.g., curved Metzenbaums), the lipoma with its associ- may produce excessive surgical scars, lesions that have
ated brous septa can be dissected rom the surround- grown in conspicuous anatomic locations, or in special
ing adipose tissue. T e at lobules and adherent brous situations, such as in the case o benign symmetric lipo-
stroma can o ten be palpated between the surgeon’s index matosis.19 T e bene ts o suction lipectomy relate to its
nger and thumb, helping to delineate the borders o the improved cosmesis or smaller surgical scars and overall
tumor. Once the lipoma is dissected rom the surround- diminished trauma rom less invasive surgical technique.20
ing adipose tissue and the dissection is carried to a plane T e obvious drawback is the signi cantly higher rate o
beneath the lipoma, the tumor can be sharply transected recurrence, owing to the act that the brous septa are not
at the base with the operating scissors. Some authors have always su ciently removed with this technique. However,
described techniques to use tumescent anesthesia to help some cases may warrant the risk o a higher rate o recur-
hydrodissect the lipoma rom the surrounding adipose tis- rence to obtain a signi cantly diminished scar line. Some
sue, acilitating surgical removal.17 authors have also described techniques or removing the
Removal o a large lipoma may result in a de ect with brous capsule through the small liposuction incision
signi cant dead space. T is problem must be addressed as well.21
to prevent the ormation o a postoperative seroma or
hematoma. One technique that is help ul is to plicate the
base o the wound with deep sutures in successive layers CySTS
o broadipose tissue and deep reticular dermis be ore
placing dermal sutures to approximate the skin. In the epid er ma L in CLu SiOn CySTS
event that the plicating sutures do not keep the at well
approximated, or i the dead space is too large, placement Epidermal inclusion cysts (a.k.a. sebaceous cysts, epi-
o a surgical drain, such as a Penrose drain, or several dermoid cysts, wens) are common benign dermal nod-
days a ter the procedure can help prevent f uid collection ules that requently present or removal. T ese lesions
(Fig. 25-3). consist o a cystic wall composed o strati ed squamous 325
3 epithelium.7 As the epithelium di erentiates and matures,
sloughed skin cells and proteinaceous debris are trapped in
the cystic cavity and enlarge the cyst. T is may requently
result in rapid enlargement, cyst rupture into the dermis, a
local inf ammatory reaction, and rarely, in ection. Patients
o ten present or management o their cysts during these
periods o inf ammation. It is, however, advisable not to
excise the cysts at this time, as the inf ammatory reac-
tion will obscure the borders o the cyst and make com-
plete removal di cult. Inf amed cysts can be managed
with injection o a small amount o intralesional steroid
and warm compresses, or incision and drainage plus oral
antibiotics in the case o a potentially in ected cyst. Once
the inf ammatory reaction has resolved, the patient can
be scheduled or de nitive excision. As long as the entire
S
e
cystic structure is removed, the chance o recurrence is
c
t
Figure 25-4 Cyst wall visualized.
i
very small. It is important to note that some authors have
o
n
argued that it is more economical, and produces less mor-
3
bidity, to excise acutely inf amed cysts preemptively.22
cyst wall to the deep margin. Once all adhesions between
:
:
Rare development o squamous cell carcinomas arising in
the lateral cyst wall and the surrounding tissue have been
epidermal inclusion cysts has been reported.23 It is, there-
S
removed, a cut may be made at the base to transect the
k
i
ore, advisable to send all excised specimens or histologic
n
cyst rom the underlying broadipose tissue.
T
examination.
u
I the cyst should rupture during the procedure, the
m
cavity should be f ushed with sterile normal saline. I the
o
r
pLa n n in g THe exCiSiOn
s
keratinous debris is le t in the wound upon closure, it will
provoke an inf ammatory reaction in the dermis that will
inhibit wound healing and may lead to a delayed in ection
In most cases, the surgical removal o an epidermal inclu-
o the surgical site.
sion cyst is a airly straight orward procedure. Once the
area is cleaned with alcohol, one can mark out the clini-
cally palpable borders o the cyst with a marking pen and a LTer n a Tiv e TeCHn iq u eS
draw out an ellipse over the center o the lesion. For small
cysts, the ellipse may be drawn around the entire nodule,
In situations that require minimization o the scar, one
but or larger cysts, the ellipse overlies the center o the
may use a punch removal technique. A ter marking out
lesion. It is important to draw the ellipse around the cen-
the peripheral borders o the cyst and identi ying the
tral punctum, as ailure to remove the punctum may leave
overlying punctum, a small (3– 4 mm) punch incision can
remnants o the epithelium in the dermis and result in a
be made directly into the cyst. T is will allow the surgeon
recurrence o the cyst. T e area can then be anesthetized
to collapse the cyst by extruding the contents with gen-
with local anesthetic such as lidocaine, and prepped with a
tle manual pressure on either side o the incision. Once
surgical scrub such as chlorhexidine or betadine.
the cyst contents have been removed, it is o ten possible
to remove the cyst wall with a 2 to 3 mm curette, or by
exCiSin g THe CyST grasping the wall with a small hemostat and gently pulling
it away rom the surrounding dermis and subcutis.24 Once
Smaller epidermal inclusion cysts can be excised in toto,
either by removing an ellipse around the entire cyst, or by
doing a larger punch excision that encompasses the cyst.
However, or larger nodules, the ellipse is drawn over the
center o the lesion. T e scalpel incision may be carried
down to the mid dermis until the cyst wall is visualized,
taking care not to rupture the cyst during the excision
(Fig. 25-4). At this point, the use o surgical hooks to
retract the skin edges is help ul to better visualize the
eld. T e ellipse and super cial skin overlying the cyst
may be grabbed with Brown-Adson orceps, or a curved
hemostat. Alternatively, a suture can be placed through
the super cial skin paddle overlying the cyst, so that it
can be manipulated easily without obstructing the view o
the surgical eld (Fig. 25-5). T e dissection is then carried
down around the cyst using a curved pair o surgical scis-
sors, such as curved iris or small Metzenbaum scissors.
T is will allow or sharp dissection o the brous adhesions Figure 25-5 Suture tied to skin paddle overlying cyst to
326 tethering the cyst, as well as blunt dissection around the aid manipulation of the cyst.
the cyst is removed, the cavity will need to be f ushed with
a generous amount o normal saline. When this technique
3
works properly, the cyst removal can be conducted very
quickly through a small incision and can lead to a very
nice cosmetic outcome. T is technique should not be
used in cases o larger cysts in which there is overlying
skin laxity, as it will likely not remove a su cient amount
o redundant skin.

piLa r CySTS
Pilar cysts (a.k.a. trichilemmal cysts) are benign growths
that commonly occur on the scalp in areas o dense hair
ollicle distribution. In contrast to epidermal inclusion

C
cysts, the epithelium that makes up pilar cysts resembles

h
a
that o the outer root sheath o the hair ollicle and under-

p
t
e
goes more rapid trichilemmal keratinization. T e strati-

r
2
ed squamous epithelium lacks a granular cell layer, and

5
the rapidly produced keratin is more compact within the

:
:
cyst giving a more rm structure to the cyst itsel .7 Fur-
thermore, there is no punctum connecting the cyst to

B
e
the overlying epidermis. T is lack o punctum and rm

n
i
g
cystic structure o ten allows or the cyst to be extracted

n
intact through a small incision overlying the cyst. Given

S
u
the common scalp location o most pilar cysts, and the

b
c
u
act that the underlying skull does not permit much tissue

t
a
expansion or the cyst, the pressure exerted by the cyst on

n
e
the overlying scalp and hair ollicles requently produces a Figure 25-7 Large pilar cyst with overlying alopecia.

o
u
localized area o alopecia overlying the cyst.

s
T
u
m
scalp circum erentially around the cyst. I the cyst does
exCiSin g a piLa r CyST

o
not release easily, it can be grasped with an Allis clamp

r
s
or Adson– Brown orceps and extracted through the small
Planning the excision o a pilar cyst o ten depends on the incision with gentle pressure and blunt undermining with
clinical appearance o the scalp overlying the lesion. Rel- curved tissue scissors.
atively small cysts that do not have signi cant overlying In the case o larger or longer-standing cysts that have
skin laxity or alopecia can be removed through a small lin- clinically signi cant alopecia overlying the cyst, the redun-
ear incision over the center o the cyst (Fig. 25-6). Because dant skin will likely need to be removed to achieve an
there is no punctum connecting the cyst to the skin sur- acceptable cosmetic outcome (Fig. 25-7). In such cases, a
ace, its wall is rm and resistant to rupture, and there are small ellipse may be excised overlying the lesion to reduce
relatively ew brous adhesions tethering it to the sur- the area o alopecia and redundant skin (Fig. 25-8). Once
rounding so t tissue, o ten the cyst can be extracted in toto the excision is carried out through the ull thickness o the
through a small incision by applying gentle pressure to the dermis and subcutis, the cyst should be easily extracted.

Figure 25-8 Ellipse drawn over pilar cyst to remove alopecic

Figure 25-6 Healing linear incision from pilar cyst extraction. redundant skin. 327
3 T e only other consideration that requently com-
plicates these excisions is the scalp’s tendency to bleed.
5. Worle B, Kunte C, Schaller M, Konz B. Lipoma o the ore-
head. Hautarzt. 2000;51(9):661– 665.
6. Spitz J. Genodermatoses: a Clinical Guide to Genetic Skin Dis-
Achieving adequate hemostasis is made more di cult by
orders. 2nd ed. Lippincott Williams and Wilkins; 2005.
the retraction o the thick brous scalp skin due to the 7. Weedon D. Weedon’s Skin Pathology. 3rd ed. Churchill Livingstone
underlying action o the scalp muscles, which holds open Elsevier; 2010.
the per orating vessels. Waiting a ull 10 to 15 minutes or 8. Otley CC. Perioperative evaluation and management in der-
the epinephrine to work, and using a running locked stitch matologic surgery. J Am Acad Dermatol. 2006;54(1):119– 127.
9. Bunick CG, Aasi SZ. Hemorrhagic complications in dermato-
in the wound closure, as well as applying an adequate pres-
logic surgery. Dermatol T er. 2011;24(6):537–550.
sure dressing or 24 to 48 hours can help provide the nec- 10. Delaney A, Diamantis S, Marks VJ. Complications o tissue isch-
essary hemostasis. emia in dermatologic surgery. Dermatol T er. 2011;24 (6):551–557.
11. Salem RO, Laposata M. E ects o alcohol on hemostasis. Am
J Clin Pathol. 2005;123(suppl):S96–S105.
12. Otley CC. Continuation o medically necessary aspirin and war-
COn CLu SiOn S arin during cutaneous surgery. Mayo Clin Proc. 2003; 78(11):
1392–1396.
S
In this chapter, we present some o the more common 13. Kovich O, Otley CC. T rombotic complications related to
e
discontinuation o war arin and aspirin therapy periopera-
c
benign dermal tumors, and several approaches to their
t
i
tively or cutaneous operation. J Am Acad Dermatol. 2003;
o
surgical management. When planning excisions o cysts
n
48(2):233– 237.
3
and lipomas, as with any condition, it is important to give 14. Dinehart SM, Henry L. Dietary supplements: altered coagula-
preoperative consideration to the di erential diagnosis, tion and e ects on bruising. Dermatol Surg. 2005;31(7 Pt 2):
:
:
actors that may complicate the surgery, and alternative 819– 826; discussion 826.
15. Rao SS, Davison SP. Gone in 30 seconds: a quick and simple
S
methods o management. It is also important to recognize
k
technique or subcutaneous lipoma removal. Pla st Reconstr
i
n
that even lesions that are presumed to be classic examples Surg. 2012;130(1):236e– 238e.
T
u
o benign tumors have the capacity to surprise the clini- 16. Kenawi MM. ’Squeeze delivery’ excision o subcutaneous lipo-
m
cian when the tissue is examined histologically. Lesions ma related to anatomic site. Br J Surg. 1995;82(12):1649– 1650.
o
r
17. Capriotti K, Humphreys R. A novel technique or the extrac-
s
that are clinically presumed to be lipomas or epidermal
tion o larger lipomas. Dermatol Surg. 2009;35(3):493– 495.
inclusion cysts may turn out to be liposarcomas, desmo- 18. Funayama E, Minakawa H, Oyama A. Forehead lipoma re-
plastic melanomas, proli erating trichilemmal tumors or a section via a small remote incision using a surgical raspatory.
variety o other tumors masquerading as benign lesions. J Am Acad Dermatol. 2007;56(3):458– 459.
As such, it is advisable to send any surgical specimen or 19. Coleman WP 3rd. Noncosmetic applications o liposuction.
histopathologic examination. J Dermatol Surg Oncol. 1988;14(10):1085– 1090.
20. Pinski KS, Roenigk HH Jr. Liposuction o lipomas. Dermatol
Clin. 1990;8(3):483– 492.
21. Al-basti HA, El-Khatib HA. T e use o suction-assisted sur-
r eFer en CeS gical extraction o moderate and large lipomas: long-term
ollow-up. Aesthetic Pla st Surg. 2002;26(2):114– 117.
1. Mentzel , Fletcher CD. Lipomatous tumours o so t tissues: 22. Jun GB, Qi H, Golap C. One-stage excision o inf amed seba-
an update. Virchows Arch. 1995;427(4):353– 363. ceous cyst versus the conventional method. S A r J Surg. 2010;
2. Weiss SW, Goldblum JR, eds. Enzinger and Weiss’s So t issue 48(4):116– 118.
umors. 5th ed. Mosby Elsevier; 2008. 23. Anton-Badiola I, San Miguel-Fraile P, Peteiro-Cancelo A,
3. Rydholm A, Berg NO. Size, site and clinical incidence o li- Ortiz-Rey JA. Squamous cell carcinoma arising on an epi-
poma. Factors in the di erential diagnosis o lipoma and sar- dermal inclusion cyst: a case presentation and review o the
coma. Acta Orthop Scand. 1983;54(6):929– 934. literature. Acta s Dermosif liogr. 2010;101(4):349– 353.
4. ruhan AP, Garden JM, Caro WA, Roenigk HH Jr. Facial and 24. Yang HJ, Yang KC. A new method or acial epidermoid cyst
scalp lipomas: case reports and study o prevalence. J Derma- removal with minimal incision. J Eur Acad Dermatol Venereol.
tol Surg Oncol. 1985;11(10):981– 984. 2009;23(8):887– 890.

328
 Ch a p t e r Mohs Micrographic Surgery:

26 Indications and Technique

Nichol s B. Countrym n & C. Willi m H nk

In t r o d u c t Io n Chemosurgery in 1967, the college’s rst meeting was held

that year, and consisted o 23 attendees o the American
Academy o Dermatology Annual Meeting.2
Developed by a meticulous, pioneering general surgeon
Chemical xation used in the initial chemosurgery posed
and re ned by a host o orward-thinking dermatologists,
several challenges, namely the time consuming nature o the
Mohs micrographic surgery (MMS) represents the stand-
standard 24 hour xation, the pain associated with chemi-
ard o care today or treatment o many cutaneous tumors.
cal xation, and the limited reconstruction options ollowing
With cure rates unparalleled by standard destructive and
the nal excision o tissue. T ese were all overcome upon the
excisional surgeries and the innate ability to preserve
development o the resh tissue technique using horizontal
healthy surrounding tissue, MMS should be considered or
rozen sections without zinc chloride xation. Although Dr.
large, aggressive, or recurrent carcinomas as well as those in
Mohs rst used the technique in 1953, a presentation by
unctionally or cosmetically sensitive areas. In utilizing the
Dr. T eodore romovitch at the American College o Che-
serial staged excisional process as illustrated subsequently,
mosurgery Annual Meeting in 1970 reporting his success
the Mohs surgeon is able to immediately repair ensuing
using the resh tissue technique changed the uture o the
wounds as necessary. Due to the sa ety and cost-e ective
specialty.3,4 With the evolution o the use o rozen section
nature o the procedure, MMS appropriately represents the
pathology, the title o the procedure, Mohs’ chemosurgery,
gold standard or treatment o many cutaneous tumors.
was altered, and became “microscopically controlled exci-
sion” (MCE). Other names suggested at the time included
a mnemonic by Dr. Walter Shelley who suggested MOHS,
HIs t o r y a n d Ev o l u t Io n microscopically oriented histographic surgery.5
T ere are several advantages to the technique o MCE. T e
As a sophomore medical student at the University o Wis- main advantage is the decreased pain with elimination o the
consin, Frederic Mohs, while experimenting with the injec- zinc chloride paste. T e usual 24 hour paste xation caused
tion o zinc chloride and other chemicals into rat tumors, signi cant pain, which o ten required narcotic management.
noted excellent preservation o the microscopic eatures o With repeat excisions, pain o ten increased. With the advent
the treated tissue. A ter shaving the tumor nodules hori- o MCE, the pain o the zinc chloride paste was exchanged
zontally with respect to the skin sur ace, he made the obser- or the brie discom ort associated with the injection o local
vation that zinc chloride acted as an in situ xative. T e in anesthetic. MCE is also aster and allows or multiple layers
situ xation along with the concept o horizontal section- o tissue to be removed in a single day. T e nal and unex-
ing initiated a series o experiments that has eventually led pected advantage is that once the borders o the wound are
to modern MMS. In 1936, the rst patients were treated tumor ree, the resh wound can be closed by any number
with chemosurgery, and in 1941, Dr. Mohs reported suc- o surgical reconstructive methods. With the classic chemo-
cess using microscopic surgery on 440 patients.1 Initially surgery wound, approximately 7 to 10 days were required
termed “chemosurgery” to indicate that the tissue was or the remaining xed tissue to slough. T e patient would
chemically treated and surgically excised, early chemosur- then wait or healing by second intention or a split thickness
gery procedures were initiated by the application o a paste skin gra t could be applied. T e new technique has encour-
composed primarily o zinc chloride applied to malignant aged the development o reconstruction options, many o
tissue. A ter a period o 4 to 24 hours, saucerized surgi- which have been advanced by Mohs surgeons.
cal excision ensued ollowed by microscopic examination In their 8 year retrospective study, Stegman and ro-
o the horizontal sections. Accordingly, Mohs con rmed movitch reported an overall cure rate o 98.4% or basal
tumor removal or precisely identi ed remaining tumor, cell carcinoma (BCC), con rming that the modi ed tech-
repeating the staged excision as necessary. nique is capable o achieving results comparable to those
raditional medicine proved slow to adopt Mohs’ reported with zinc chloride paste chemosurgery.6,7 More
chemosurgery technique. T e early days o the proce- recent literature con rms similarly high cure rates or pri-
dure were met with great skepticism and hostility. With mary BCC.8 MMS or recurrent BCC reveals slightly lower
meticulous records and eventually adequate patient data but still superior cure rates when compared to those stan-
revealing extremely high cure rates, chemosurgery began dard excisional surgery.9 In addition, squamous cell car-
to gain acceptance. Despite being trained as a general cinoma (SCC), both primary and recurrent, is amenable
surgeon, Dr. Mohs recognized that dermatologists repre- to MMS with cure rates superior to all other methods o
sented the most interested group o physicians in his tech- removal.10 Dr. Mohs success ully documented high cure
nique. T us, ollowing the creation o American College o rates using chemosurgery or melanoma11 and current
3 evidence has con rmed that modern MMS can also be
success ul in the treatment o melanoma.12
States each year.23 In general, cutaneous tumors with
aggressive histologic subtypes, that are recurrent, located
In the rst randomized trial concerning MMS, Muller et in unctionally or cosmetically sensitive areas, located in
al. demonstrated that it is a tissue-sparing treatment. T e areas known to have higher rates o recurrence or metas-
median area o the surgical de ect ollowing surgical exci- tasis, tumors in immunocompromised patients or in areas
sion was 1.6 times that o the de ect obtained a ter MMS.13 o previous radiation, should be considered or MMS.
T e smaller de ect size subsequently allowed or the sim- BCC and SCC comprise greater than 95% o all NMSC.
plest repair, which o ten consisted o healing by second A review o long-term cure rates o over 10,000 cases o
intention. A recent study o national Mohs surgery prac- primary BCC treated with standard excision and tradi-
tices ound that 18% o Mohs de ects are allowed to heal tional margin assessment as opposed to MMS showed a
by second intention.14 Primary closure techniques can also 10.1% recurrence rate or standard excision compared to
be utilized to repair a signi cant number o MMS de ects, 1.0% or MMS.8 Similarly, the long-term recurrence rate
minimizing the need or more complex aps and gra ts. utilizing MMS or recurrent BCC was 5.6% compared to
In addition to the advantages o providing the highest 9.8% or radiation therapy and 17.4% or standard surgical
cure rates and having an inherent tissue-sparing nature, excision.9 Another review o treatments or SCC revealed
S
MMS is also sa e and cost-e ective. Recent evidence con- equally superior results or MMS when compared to stan-
c
t
i
rms anecdotal accounts that MMS is an extremely sa e dard surgical excision. MMS yielded a long-term recur-
o
n
outpatient procedure per ormed under local anesthesia rence rate o 3.1% while standard surgical excision yielded
3
with extremely low complication rates.15 Despite the staged a 10.9% recurrence rate. Similarly superior results or
:
:
nature and length o MMS, documented rates o surgical recurrent SCC were noted with MMS resulting in a 10.0%
site in ections with MMS are equal to or below those o recurrence versus a 23.3% recurrence rate with standard
S
k
similar procedures per ormed in operating rooms.16 Several surgical excision.24
i
n
T
studies also illustrate the cost-e ective nature o MMS. It is Another indication or MMS is lentigo maligna (LM) or
u
m
lower in cost than surgical excision, which o ten includes an melanoma in situ (MIS). T e incidence o MIS continues to
o
ambulatory surgery center (ASC) acility ee.17,18 MMS has increase with an estimated 55,560 cases to be newly diag-
r
s
high intrinsic value, which is cost-e ective in comparison nosed in 2012.25 Although considerable controversy per-
to traditional surgical excision.19 Cost-e ectiveness analy- sists in relation to the use o MMS or melanoma and MIS,
sis demonstrating the outcomes based ef ciency o MMS ample evidence suggests that it is sa e and e ective.26 MMS
are critical in the current health care climate, as heightened may be particularly use ul to conserve tissue or melanomas
sensitivity to nancial pressures and declining reimburse- on the head, neck, hands, or eet or or melanomas with
ments may challenge patients’ ability to receive optimal indistinct clinical margins.12 Many Mohs surgeons now use
treatment or nonmelanoma skin cancer (NMSC). immunohistochemical staining (see below) to optimally
In 1985, the term “micrographic surgery” was rst used visualize melanoma on rozen section histology.27,28
to indicate unambiguously the use o the microscope and Superior cure rates utilizing MMS compared to standard
the drawing o maps to achieve complete MCE.20 T at same excision or other rare cutaneous tumors have also been
year, the American College o Chemosurgery decided to demonstrated. T ese include dermato brosarcoma protu-
change the name o the procedure to Mohs micrographic berans (DFSP),29 sebaceous carcinoma,30 atypical broxan-
surgery and the name o the organization to American Col- thoma (AFX),31 malignant brous histiocytoma (MFH),32
lege o Mohs Micrographic Surgery and Cutaneous Oncol- microcystic adnexal carcinoma (MAC),33 extramammary
ogy (ACMMSCO). More recently, this name was changed Paget’s disease (EMPD),34 leiomyosarcoma,35 desmoplas-
to the American College o Mohs Surgery (ACMS). Until tic trichoepithelioma,36 angiosarcoma,37 mucinous carci-
the recent transition to the American Council or Gradu- noma,38 and Merkel cell carcinoma (MCC).39
ate Medical Education (ACGME), the ACMS served as In 2012, a consensus statement was published address-
the accreditation organization or ellowship training in ing the appropriate use o MMS or cutaneous tumors.40
MMS. Fellowship training in MMS currently consists o T is statement did not compare MMS with other treat-
a 1 to 2 year training program encompassing teaching o ments; rather it provides a ramework to assess the appro-
MMS, cutaneous oncology, and reconstructive surgery priateness o MMS or individual cutaneous tumors. Use
in addition to other dermatologic surgery and procedural o MMS in various clinical scenarios was rated as appro-
dermatology.21 As o 2012, the ACGME had accredited 56 priate, uncertain, or inappropriate. As pointed out in this
procedural dermatology ellowship training programs.22 statement, uncertain indications o ten require individual
T e ACMS continues to approve a small number o inter- physician judgment and understanding o the patient and
national programs. Completion o an accredited ellow- other clinical actors to better determine the appropriate-
ship quali es applicants or membership in the ACMS. ness o MMS or a particular scenario. T e authors note
that the ranking o uncertain should not be viewed as limit-
ing the use o MMS or patients and in appropriate settings.
In d Ic a t Io n s reatment o tumors with an uncertain ranking with MMS
should be reimbursable when determined appropriate by
MMS is a technique or the removal o complex or ill- the clinician. ables 26-1 to 26-3 summarize the recom-
de ned skin tumors. NMSC represents the vast majority mendations o this statement or the use o MMS or BCC,
o cutaneous tumors treated with MMS. In the United SCC, and LM/MIS. In this consensus statement, area “H”
States in 2006, there were an estimated 3.5 million NMSC includes the central ace and eyelids including inner and
diagnosed, and it is projected that there will be nearly outer canthi, eyebrows, nose, lips, chin, ear and periauricu-
330 4 million new cases o NMSC diagnosed in the United lar skin, temple, genitalia including perineal and perianal
 Ta bl e 26-1 Ta bl e 26-3
3
S mmary from a c o s s s Stat m t S mmary from a c o s s s Stat m t
Addr ss g t Appropr at u s of MMS Ar a Addr ss g t Appropr at u s of MMS
“h ” c ompr s g t c tral Fa a d ey l ds, Ar a “L” i l d g t Tr k a d extr m t s
i l d gi r a d O t r c a t , ey brows, ex l d g Pr t b al S rfa , h a ds, F t, n a l
n os , L ps, c , ear a d P r a r lar Sk , u ts, a d A kl s
T mpl , G tal a i l d g P r al a d
P r a al R g o s, h a ds, F t, n a l u ts, Ar a L Appropr at u rta
A kl s, a d n ppl s a d Ar ola
bCC R curr nt: Prim ry:
Ar a h Appropr at u rta a ggr ssiv , nodu r a ggr ssiv ≤0.5 cm,
Prim ry: nodu r 1.1–2 cm,
bCC Prim ry or r curr nt: a ggr ssiv ≥0.6 nodu r (IC) 0.6–1 cm,
a ggr ssiv , nodu r, cm, nodu r >2 cm, sup rf ci (IC) ≥1.1 cm
sup rf ci nodu r (IC) ≥1.1 cm

C
SCC Prim ry or r curr nt:

h
SCC Prim ry or r curr nt: R curr nt: In situ/bow n’s
a ggr ssiv , non ggr ssiv ,a

p
a ggr ssiv , Ka typ Prim ry 1.1–2 cm: Non

t
v rrucous, Ka typ , in situ/ (IC) ≥0.6 cm ggr ssiv ,a in situ/

r
2
bow n’s R curr nt: Non bow n’s

6
l M nd MIS Prim ry or r curr nt: ggr ssiv ,a Ka typ Prim ry ≤1 cm: Non

:
Prim ry >2 cm: Non ggr ssiv a (IC)

:
l ntigo m ign ,
m nom in situ a ggr ssiv ,a In situ/ Prim ry 0.6–1 cm: In situ/

M
bow n’s bow n’s

o
h
a
SCC without ggr ssiv tur s, <2 mm d pth without oth r d f n Prim ry ≥1.1 cm: Non Prim ry ≤0.5 cm:

s
M
ing tur s, ≤C rk v III; ist d indic tions r or oth h thy nd ggr ssiv ,a Ka typ , Ka typ (IC)

i
immunocompromis d (IC) p ti nts, nd tumors o ny siz un ss

c
in situ/bow n’s (IC)

r
o
oth rwis sp cif d.

g
Source: Modif d with p rmission rom Conno y SM, b k r DR, l M nd R curr nt: l ntigo Prim ry: l ntigo

r
MIS m ign , m nom m ign , m nom in

p
Co diron bM, t . a a D/a CMS/a SDSa /a SMS 2012 a ppropri t Us

h
Crit ri or Mohs Microgr phic Surg ry: a R port o th a m ric n in situ situ

i
c
a c d my o D rm to ogy, a m ric n Co g o Mohs Surg ry,

S
u
a
a m ric n Soci ty or D rm to ogic Surg ry a ssoci tion, nd th SCC without ggr ssiv tur s, <2 mm d pth without oth r d f n

r
g
a m ric n Soci ty or Mohs Surg ry. J Am Acad Dermatol. 2012; ing tur s, ≤C rk v III; ist d indic tions r or oth h thy nd

r
immunocompromis d (IC) p ti nts, nd tumors o ny siz un ss

y
67(4);531–550. Copyright e s vi r.

:
oth rwis sp cif d.

I
n
Source: Modif d with p rmission rom Conno y SM, b k r DR,

d
i
c
Co diron bM, t . a a D/a CMS/a SDSa /a SMS 2012 a ppropri t Us

t
Crit ri or Mohs Microgr phic Surg ry: a R port o th a m ric n

i
o
a c d my o D rm to ogy, a m ric n Co g o Mohs Surg ry, a m ri

n
s
c n Soci ty or D rm to ogic Surg ry a ssoci tion, nd th a m ric n
Ta bl e 26-2

n
Soci ty or Mohs Surg ry. J Am Acad Dermatol. 2012;67(4);531–550.

d
Copyright e s vi r.

T
S mmary from a c o s s s Stat m t
addr ss g t Appropr at u s of MMS

c
h
Ar a “M” i l d g t c ks, For ad, S alp,

n
i
n k, Jawl , Pr t b al S rfa

q
regions, hands, eet, nail units, ankles, and nipples and are-

u
olae. Area “M” includes the cheeks, orehead, scalp, neck,
Ar a M Appropr at u rta jawline, and pretibial sur ace. Area “L” indicates the trunk
bCC Prim ry or r curr nt: a ggr ssiv , Prim ry: and extremities excluding pretibial sur ace, hands, eet, nail
nodu r, sup rf ci (IC) Sup rf ci units, and ankles.
Prim ry: Sup rf ci ≥0.6 cm ≥0.6 cm In the consensus statement, MMS was also deemed
appropriate or adenocystic carcinoma, adnexal carcinoma,
SCC Prim ry or r curr nt: a ggr ssiv ,
apocrine/eccrine carcinoma, AFX, DFSP, EMPD, leiomyo-
non ggr ssiv ,a v rrucous,
Ka typ , in situ/bow n’s sarcoma, MFH (undi erentiated pleomorphic sarcoma),
MAC, also known as sclerosing sweat duct carcinoma,
l M nd Prim ry or r curr nt: l ntigo mucinous carcinoma, and sebaceous carcinoma in all loca-
MIS m ign , m nom in situ tions regardless o patient type. MCC was determined to be
a
SCC without ggr ssiv tur s, <2 mm d pth without oth r d f n appropriate in areas “H” and “M” with MMS as monother-
ing tur s, ≤C rk v III; ist d indic tions r or oth h thy nd apy. Angiosarcoma in all locations, desmoplastic trichoepi-
immunocompromis d (IC) p ti nts, nd tumors o ny siz un ss thelioma in areas “H” and “M,” and MCC in area “L” were
oth rwis sp cif d. deemed uncertain.
Source: Modif d with p rmission rom Conno y SM, b k r DR,
Co diron bM, t . a a D/a CMS/a SDSa /a SMS 2012 a ppropri t Us
Crit ri or Mohs Microgr phic Surg ry: a R port o th a m ric n
a c d my o D rm to ogy, a m ric n Co g o Mohs Surg ry, a m ri
Tec h n iq u e
c n Soci ty or D rm to ogic Surg ry a ssoci tion, nd th a m ric n
Soci ty or Mohs Surg ry. J Am Acad Dermato . 2012;67(4);531–550. Today, MMS is a technique or the removal o complex
Copyright e s vi r. or ill-def ned skin cancers with histologic examination o 331
3 100% o the surgical margins. It is a combination o surgi-
cal excision and surgical pathology that requires a single
physician to act in two integrated but separate and distinct
capacities: surgeon and pathologist. T e Mohs surgeon
removes the tumor tissue, prepares a map, and divides the
tumor specimen into pieces. Each piece is embedded into
an individual tissue block or histopathologic examina-
tion. An outline o the technique o MMS is depicted later.
Achieving superior cure rates utilizing MMS in the
removal o cutaneous tumors requires a standardized,
precise, and exacting technique. Appropriate staf ng with
capable assistants trained in surgical technique as well as
proper local anesthesia is paramount in creating an opti-
mal patient and surgeon experience. Virtually all MMS is
per ormed under local anesthesia utilizing the resh tissue
S
technique. A ter in ormed consent is obtained, the area
c
t
i
is marked with a surgical marker to delineate the edges
o
n
o the tumor to be treated. T e patient is positioned in a
3
prone position with unobstructed access to the operative
:
:
site. T e area is sterilely prepped and is anesthetized most
commonly with 1% lidocaine with 1:100,000 epinephrine
S
k
i
bu ered with sodium bicarbonate. I necessary, the tissue
n
T
to be removed may be remarked with gentian violet i pre-
u
m
operative markings are obscured.
o
Figure 26-1 Photogr ph d monstr t s symm tric sup r-
Many Mohs surgeons utilize debulking o the obvious
r
s
f ci l nicking o pid rmis to ori nt Mohs l y r. P ti nt h s
tumor to decrease alse positives as well as to better delin-
n inf ltr ting b s l c ll c rcinom on th l t t mpl .
eate the extent o the tumor. Methods include curettage
or sharp scalpel debulking. Removal o central tumor by
any method allows or thinner, more exible specimens.41 tissue is excised is an alternative approach to orienting the
Many surgeons pre er curettage although sharp debulking tissue. Other methods include stapling, wooden grids, and
with a scalpel blade may be more e ective in morphea orm digital or Polaroid photographs.43– 46 Forty- ve-degree inci-
BCC and other sclerotic cutaneous tumors that are not as sions have traditionally been used to easily allow or the
amenable to curettage. Both methods are dependent on the excised tissue to be attened and processed into horizontal
ability o the surgeon to see or eel the di erence between rozen sections, as they allow lateral and deep edges to be
cancerous and noncancerous skin. Many Mohs surgeons examined in one section. Some have re erred to these sec-
eel that debulking represents an unnecessary step and tions as oblique rather than tangential, horizontal, or bev-
move directly to removing the rst layer o tissue. An added eled.47 Others have advocated 90 degree sections during
bene t o debulking the tumor is that the debulked tissue removal o the rst layers o tissue to minimize de ect size
can be processed. Although processing this tissue may and spare normal tissue, although this presents challenges
add a small amount o time, it serves several purposes: It in sectioning the entire tissue specimen.42 Figure 26-2 illus-
helps in veri ying the location o the tumor, provides visual trates the typical 45 degree-angle lateral incisions through
cues as to the histology o the tumor being excised and can the epidermis, dermis, and into the super cial at typically
justi y reimbursement when the tumor is cleared on the employed during the rst layer o MMS. Once the incisions
rst stage. Disadvantages o processing the debulked tis-
sue include the potential con usion o stray tumor that can
attach to other specimens and the act that handling more 45°
tissue can increase processing time and expense. Overly
vigorous debulking may also necessitate an unnecessarily
deep or wide stage.42
T e rst layer o tissue is most commonly removed using
a #15 scalpel blade. Exceptionally large cutaneous tumors
or those on the trunk or extremities may be more amenable
to removal with a #10 blade. Generally, the rst layer o tis-
sue encompasses a 2 to 3 mm margin o normal appearing
skin around and underneath the visible tumor or deb-
ulked area. Orienting the tissue in relation to the patient
is accomplished using one o several di erent methods.
T e most common is super cial asymmetric nicking o the
skin including the excised tissue. For example, two hatch
marks at the 12 o’clock epidermal margin and one at the
6 o’clock margins are shown in Figure 26-1. Additional Figure 26-2 Di gr m showing two-dim nsion l vi w o
hatch marks are added as per need or large specimens typic l 45 d gr ngl c rri d out in th f rst Mohs l y r.
332 (e.g., at 3 o’clock and 9 o’clock). Marking with gentian vio- In this circumst nc , th f rst st g tr ns cts th symm tric
let or other inks on the patient in the area rom which the tumor pictur d by th d rk bl ck r .
on the lateral margins o the tissue are made, the rst layer
is completed by incising the tissue in a horizontal plane,
3
generally through the super cial at with either the scalpel
blade or sharp tissue-cutting scissors.
Once the tissue has been removed, pinpoint hemostasis
is obtained and the patient is bandaged and returned to the
reception area during processing o the tissue. Long-acting
anesthetics or topical anesthetics (such as a compound o
lidocaine, epinephrine, and tetracaine) may be employed
to extend the local anesthetic e ect and improve patient
com ort.48 Depending on tissue processing time, the anes-
thetized area will remain numb during the waiting period
and require less anesthesia on subsequent Mohs layers
and during reconstruction, thereby minimizing the risk o
lidocaine toxicity. T is is particularly essential when treat-

C
h
ing large cutaneous tumors.

p
Accurate mapping and inking o the excised tissue rep-

t
r
resents the next step in the process. Using stock body dia-

2
6
grams encompassing the involved area, a two-dimensional
map approximating the shape and size o the excised tissue

:
:
is drawn or uture re erence. Figure 26-3 shows a map o the Figure 26-4 excis d tissu rom f rst Mohs l y r is tr ns-
port d to th l bor tory nd shown h r on “4 × 4”g uz

M
excised tissue rom the rst Mohs layer. Although various

o
in p tri dish with th two h tch m rks t 12 o’clock ink d
methods are employed to maintain orientation o the tissue,

h
with blu nd th singl h tch m rk t 6 o’clock ink d

s
use o 2- to 4-color tissue marking inks is most o ten used.

M
with r d. Notic how th m p rom Figur 26-3 pr cis ly

i
Commonly used ink colors include red, blue, green, yellow,

c
m tch s th ink d tissu .

r
o
and black. Every Mohs surgeon uses various conventions to

g
r
accomplish appropriate mapping. wo-ink systems are su -

p
cient in virtually all cases as seen in Figure 26-4. Alterna- A ter mapping and inking the tissue, the tissue is taken to

h
i
c
tives exist but are not as readily used.49 T e hand-drawn map the CLIA certi ed laboratory and the histotechnician (H )

S
u
is likewise marked to represent the location o the various prepares the tissue or processing. Most H s pro cient

r
g
tissue inks or orientation when interpreting the histologic in sectioning excised tissue rom MMS require extensive

r
training and mentoring. T ough ormal training is available,

y
specimens, as shown by the dotted and solid circles around

:
I
the 12 o’clock and 6 o’clock hatch marks in Figure 26-3. most o the training takes place on the job. T e rst step in

n
d
processing the tissue is grossing. T e purpose o grossing

i
c
tissue or MMS is to trans orm a three-dimensional piece

t
i
o
S ta ge o tissue rom the patient into two dimensions on the slide

n
Color code s

s
S pe c # thus providing complete margin control. T is is accom-

n
Blue = plished using relaxing incisions when necessary. Depending

d
La b In
on the size and shape o the tissue, it may be necessary to

T
La b Out Re d =

c
subdivide it into sections to allow or horizontal sectioning.

h
n
HT T e next step is to mount and embed the tissue. T is

i
q
amounts to placing the tissue upside down on an appro-

u
priately sized cryostat chuck and embedding in OC com-
pound (Optimum Cutting emperature: issue- ek, Miles
Inc., Diagnostics Division, Elkhart, IN). Figure 26-5 shows
the embedded tissue mounted on the cryostat chuck.
Again, numerous methods exist to accomplish this step.
Some o the most commonly utilized include the Floating
Method and Cryomold.50,51 Embedding larger specimens
with a membrane and vacuum system embedding machine
may enhance ef ciency.52 T ese various techniques all aim
to expose the lateral and deep margins o the tissue in a
two-dimensional plane or cutting.
Once embedded, the tissue is rozen and mounted in
the cryostat where the tissue is sectioned horizontally in
4 to 8 µm sections. A ter mounting on slides, the tissue
is stained. Hematoxylin and eosin (H&E) staining is the
most commonly used stain or this application. Although
less requently used, toluidine blue is another simple, use-
Figure 26-3 M p corr sponding to tissu xcis d during ul stain, with an ability to metachromatically stain the
th f rst Mohs l y r. a s th l g nd indic t s, th dott d mucopolysaccharide stroma o BCC a characteristic pink
lin round th two h tch m rks t 12 o’clock corr sponds or magenta color. T is signals the Mohs surgeon to care-
with blu ink nd th solid lin round th h tch m rk t ully inspect the corresponding area or tumor. It is also a 333
6 o’clock corr sponds with th r d ink. more rapid stain.53
3 S ta ge
Color code s
S pe c #
Blue =
La b In
La b Out Re d =
HT

Figure 26-5 Mohs l y r is mount d on cryost t chuck

S
mb dd d in OCTcompound r dy or horizont l s ctioning.
c
t
i
o
n
3
T e use o immunohistochemical staining is de nitely
:
:
on the rise, particularly in cases o LM and malignant
S
melanoma. Immunostains can be an e ective method o
k
i
n
enhancing the accuracy o assessing the surgical margins
T
u
o common and rare tumors, thereby maximizing tissue
m
sparing and minimizing recurrence. T e use o rozen
o
Figure 26-7 Using th h tch m rks nd tissu ink or ori-
r
tissue provides a template in which antigen preservation
s
nt tion, th Mohs surg on us s r d p ncil on th Mohs
is maximized, allowing or better staining and improved
m p to indic t wh r p rsist nt tumor is s n on histo-
localization o tumor.54,55 Disadvantages and limitations logic int rpr t tion o slid .
o incorporating immunohistochemistry into a Mohs
surgery practice include the additional processing time
and cost involved, as well as more time-consuming slide extirpation during MMS. Extensive mentoring during an
interpretation. T e antibodies most commonly used in ACMS certi ed training program with at least 500 cases
conjunction with MMS are HMB-45 (50% o laboratories), o proctored MMS cases a ords the Mohs surgeon the
S-100 (42%), and Melan-A and Mel-5 (42%) or mela- expertise to accurately interpret rozen section histol-
noma; antikeratin or BCC and SCC (42%); and anti-CD34 ogy.59 Numerous pit alls in interpreting horizontal rozen
or DFSP (33%).56 Antikeratinocyte immunoperoxidase sections exist. Missed microscopic tumor cells can lead
stains contain antikeratin cocktails use ul in identi ying to higher recurrence rates. Alternatively, misinterpreta-
carcinoma obscured by a dense lymphocytic in ltrate, tion o benign entities as malignant leads to inappropriate
nerve, or vessel.57,58 In the case o EMPD, immunostaining removal o noncancerous tissue and unnecessarily large
with cytokeratin 7 can be help ul in delineating disease.34 de ects.10,60 Utilizing the hatch marks and ink in the sec-
As immunohistochemical stains improve, the use o these tions, microscopic ndings o residual tumor are marked
stains in MMS will continue to improve ef ciency and cost on the corresponding map with red ink in preparation or
and will likely become more widespread. subsequent stages. Figure 26-6 shows a representative slide
T e nal step is the interpretation o the stained slides. rom the rst Mohs layer. A ter histologic interpretation
High-quality rozen section slides and accurate interpre- by the Mohs surgeon, the corresponding map as seen in
tation by the Mohs surgeon provide the core o tumor Figure 26-7 is marked with red pencil indicating persistent

Figure 26-6 R pr s nt tiv slid rom f rst Mohs l y r d monstr ting th horizon-
334 t l s ction ncomp ssing th ntir l t r l nd d p m rgin.
 S ta ge
Color code s
3
S pe c #
Blue =
La b In
La b Out Re d =
HT

C
h
p
t
r
2
6
:
:
M
o
h
s
M
Figure 26-9 a t r xcision o th s cond Mohs l y r,

i
c
m p corr sponding to th xcis d tissu is dr wn. a g in,

r
o
r d nd blu tissu inks r mploy d to ori nt th tissu

g
r
during histologic int rpr t tion.

p
h
i
c
S
u
tumor a ter the rst and subsequent stages. In Figure

r
g
Figure 26-8 Using th m p rom th f rst Mohs l y r, n 26-8, the patient is marked encompassing a 2 mm margin

r
y
around the area rom the rst Mohs layer that contained

:
r ncomp ssing th p rsist nt tumor with 2 mm

I
n
m rgin is m rk d indic ting th tissu to b xcis d in th persistent tumor. T is represents the tissue to be excised

d
i
during the second Mohs layer. Again, a super cial hatch

c
s cond Mohs l y r. Not th h tch m rk m d c ntr lly

t
on th tissu nd p ti nt th t will b us d or ori nt tion mark centrally on the excised tissue and carried onto the

i
o
n
should urth r tissu n d to b xcis d. patient assists in orientation. Ninety-degree incisions on

s
subsequent stages are acceptable in most cases as the

n
trans ormation rom three-dimensions to two is more

d
T
tumor. T e hatch marks and tissue ink are employed to easily accomplished during embedding. Figure 26-9 shows

c
precisely map the persistent tumor.

h
the hand-drawn map corresponding to the excised tissue

n
During subsequent excisions, the entire area should be rom the second Mohs layer. A slide showing stained verti-

i
q
u
anesthetized to ensure that the patient remains as com- cal sections rom a representative second Mohs layer can
ortable as possible between stages and to minimize total be seen in Figure 26-10. In this ashion, by utilizing the
anesthetic used during the entire procedure. Subsequent map and hatch marks on the patient, persistent tumor on
Mohs stages are removed only around precisely mapped the patient is marked and excised serially until the section

Figure 26-10 R pr s nt tiv slid rom th s cond Mohs l y r d monstr ting th

horizont l s ction g in ncomp ssing th ntir l t r l nd d p m rgin o th
xcis d tissu . 335
3 S ta ge
Color code s
aggressive tumors, large and recurrent tumors, and tumors
in cosmetically sensitive and unctionally important loca-
S pe c #
La b In
Blue = tions should be considered or treatment with MMS.
La b Out Re d =
HT r EFEr En c Es
1. Mohs FE. Chemosurgery, a microscopically controlled
method o cancer excision. Arch Surg. 1941;42:279– 295.
2. Mohs FE. History o Mohs micrographic surgery. In: Roenigk
RK, Roenigk HH, eds. Dermatologic Surgery: Principles and
Practice. New York: Marcel Dekker; 1989:783– 789.
3. romovitch A, Stegman SJ. Microscopically controlled exci-
sion o skin tumors. Arch Dermatol. 1974;110(2):231– 232.
4. Swanson NA, aylor WB, romovitch A. T e evolution o
Mohs surgery. J Dermatol Surg Oncol. 1982;8:650– 654.
5. Shelley WB. Mohs: microscopically oriented histographic
S
surgery. Arch Dermatol. 1978;114(7):1097– 1098.
c
t
6. Stegman SJ, romovitch A. Modern chemosurgery-
i
o
n
microscopically controlled excision. West J Med. 1980;132:7–12.
3
7. Mohs FE. Chemosurgery or skin cancer. Arch Dermatol.
1976;112:211– 215.
:
:
8. Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates
in previously untreated (primary) basal cell carcinoma:
S
k
implications or patient ollow-up. J Dermatol Surg Oncol.
i
n
1989;15:315– 336.
T
u
9. Rowe DE, Carroll RJ, Day CL Jr. Mohs surgery is the treat-
m
ment o choice or recurrent (previously treated) basal cell
o
Figure 26-11 a r d p ncil lin dr wn through th Mohs carcinoma. J Dermatol Surg Oncol. 1989;15:424– 431.
r
s
m p indic t s th t th m rgins on th s cond Mohs l y r 10. Mohs FE. Chemosurgery: Microscopically Controlled Surgery for
w r r o p rsist nt tumor. Th p ti nt c n now b pr - Skin Cancer. Spring eld, IL: Charles C. T omas; 1978:1–356.
p r d or r construction o th wound. 11. Mohs FE. Chemosurgery or melanoma. Arch Dermatol. 1977;
113:285– 291.
12. Zitelli JA, Brown C, Hanusa BH. Mohs micrographic surgery
or the treatment o primary cutaneous melanoma. J Amer
con rms clear margins. Once histologic interpretation Acad Dermatol. 1997;37(2):236– 245.
con rms clear margins, a red pencil line drawn through 13. Muller FM, Dawe RS, Moseley H, Fleming CJ. Randomized
the Mohs map as seen in Figure 26-11 indicates that the comparison o Mohs micrographic surgery and surgical exci-
tumor has been removed and the patient can be prepared sion or small nodular basal cell carcinoma: tissue-sparing
outcome. Dermatol Surg. 2009;35(9):1349– 1354.
or repair o the wound. T e average number o Mohs
14. Casey AS, Kennedy CE, Goldman GD. Mohs micrographic
stages is approximately 1.76 stages per case.18 surgery: how ACMS ellowship directors practice. Dermatol
aking Mohs layers rom speci c locations at times Surg. 2009;35(5):747– 756.
provides additional challenges. One particular challenge 15. Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. T e
arises when the perichondrium o the ear is involved by an sa ety o Mohs sugery: a prospective multicenter cohort study.
J Am Acad Dermatol.2012;67(6):1302– 1309.
overlying cutaneous tumor. In these situations, a Goulian
16. Rogers HD, Desciak EB, Marcus RP, Wang S, MacKay-Wig-
kni e with a Weck blade can be utilized to remove an ade- gan J, Eliezri YD. Prospective study o wound in ections in
quate layer o tissue while sparing as much o the una - Mohs micrographic surgery using clean surgical technique in
ected cartilage as possible.61 the absence o prophylactic antibiotics. J Am Acad Dermatol.
Once the tumor has been cleared microscopically, the 2010;63(5):842–851.
17. ierney EP, Hanke CW. Cost e ectiveness o Mohs micro-
Mohs surgeon evaluates the wound or reconstruction
graphic surgery: review o the literature. J Drugs Dermatol.
options. As previously mentioned, due to the tissue- 2009;8(10):914–922.
sparing nature o MMS, many wounds can appropriately 18. Rogers HW, Coldiron BM. A relative value unit-based cost
be allowed to heal by second intention. Alternatively, the comparison o treatment modalities or the nonmelanoma
wound may require more advanced reconstruction with skin cancer: e ect o the loss o the Mohs multiple sur-
gery reduction exemption. J Am Acad Dermatol. 2008;61:
primary closure, aps, or gra ts. T ese repairs are generally
96– 103.
undertaken immediately ollowing MMS and per ormed in 19. Cook J, Zitelli JA. Mohs micrographic surgery: a cost analysis.
the outpatient setting, again under local anesthesia. Excep- J Am Acad Dermatol. 1998;39(5):698– 703.
tionally, patients are re erred to consulting specialists or 20. Hanke CW, emo eew RK, Miyamoto R , Lingeman RE.
reconstruction. Postoperative wound care, antibiotics, and Chemosurgical report: basal cell carcinoma involving the
external auditory canal—treatment with Mohs micrographic
pain management vary depending on the reconstruction
surgery. J Dermatol Surg Oncol. 1985;11(12):1189– 1194.
that is executed. 21. Brodland DG, Amonette R, Hanke CW, Robins P. T e history
and evolution o Mohs micrographic surgery. Dermatol Surg.
2000;26(4):303–307.
c o n c l u s Io n 22. ACGME. American Council or Graduate Medical Education
reports by program. Chicago, IL; 2012. http://www.acgme.org/
adspublic/. Accessed August 15, 2012.
Its cost-e ective and sa e nature, superior cure rates and 23. Rogers HW, Weinstock MA, Harris AR, et al. Incidence esti-
tissue-sparing properties make MMS the gold standard or mate o nonmelanoma skin cancer in the United States, 2006.
336 the treatment o many cutaneous tumors. Histologically Arch Dermatol. 2010;146(3):283– 287.
24. Rowe DE, Carroll RJ, Day CL. Prognostic actors or local
recurrence, metastasis, and survival rates in squamous cell
American Society or Mohs Surgery. J Am Acad Dermatol.
2012;38(10):1582– 1603.
3
carcinoma o the skin, ear, and lip. Implications or treatment 41. Ratner D, Bagiella E. T e ef cacy o curettage in delineating
modality selection. J Am Acad Dermatol. 1992;29:976–990. margins o basal cell carcinoma be ore Mohs micrographic
25. Society AC. Cancer Facts and Figures 2012. Atlanta, GA; 2012. surgery. Dermatol Surg. 2003;29:899– 903.
http:// www.cancer.org/acs/ groups/ content/ @epidemiology 42. Davis DA, Pellowski DM, Hanke CW. Preparation o rozen
surveilance/documents/document/acspc-031941.pd . Accessed sections. Dermatol Surg. 2004;30:1479– 1485.
August 15, 2012. 43. Cottel WI, Proper S. Mohs surgery, resh-tissue tech-
26. Zitelli JA, Moy RL, Abell E. T e reliability o rozen sections nique: our technique with a review. J Dermatol Surg Oncol.
in the evaluation o surgical margins or melanoma. J Am 1982;8:576– 587.
Acad Dermatol. 1991;24:102– 106. 44. Larson PO. Staple and double-stable method o tissue orien-
27. Kelley LC, Starkus L. Immunohistochemical staining o tation in Mohs micrographic surgery. J Dermatol Surg Oncol.
lentigo maligna during Mohs micrographic surgery using 1987;13:732– 734.
MAR -1. J Am Acad Dermatol. 2002;46:78– 84. 45. Lang PG Jr. Mohs micrographic surgery: resh-tissue tech-
28. Bricca GM, Brodland DG, Zitelli JA. Immunostaining mela- nique. Dermatol Clin. 1989;7:613– 626.
noma rozen sections: the 1 hour protocol. Dermatol Surg. 46. Alcalay J. Digital computerized mapping in Mohs micro-
2004;30:403– 408. graphic surgery. Dermatol Surg. 2000;26:692– 693.

C
29. Ratner D, T omas CO, Johnson M, et al. Mohs micro- 47. Rapini RP. Comparison o methods or checking surgical mar-

h
graphic surgery or the treatment o dermato brosarcoma gins. J Am Acad Dermatol. 1990;23(2 Pt 1):288– 294.

p
protuberans: Results o a multiinstitutional series with an 48. Albertini J. Mohs micrographic surgery pearls. Semin Cut

t
analysis o the extent o microscopic spread. J Am Acad Der- Med Surg. 2004;23:184– 195.

r
2
matol. 1997;37(4):600– 613. 49. Grabski WJ, Salasche SJ. Mapping and orienting tissue during

6
30. Ratz JL, Duong SL, Kulwin DR. Sebaceous carcinoma o Mohs micrographic surgery: an alternative approach. J Der-
the eyelid treated with Mohs surgery. J Am Acad Dermatol. matol Surg Oncol. 1991;17:865– 868.

:
:
1986;14:668– 673. 50. McCulloch M, Geddis C, Hetzer MR, et al. Embedding tech-

M
31. Ang GC, Roenigk RK, Otley CC, Kim Phillips P, Weaver AL. niques. In: Fish FS, ed. Manual of Frozen Section Processing

o
More than 2 decades o treating atypical broxanthoma at for Mohs Micrographic Surgery. Milwaukee, WI: American

h
Mayo Clinic: what have we learned rom 91 patients? Derma- College o Mohs Surgery; 2008:601.

s
M
tol Surg. 2009;35:765– 772. 51. Leshin B, Cook SR, Frye D. Cryomold: echnique or tissue

i
c
32. Hollmig S , Kirkland EB, Henderson M , ang JY, Glad- embedding in Mohs micrographic surgery. J Dermatol Surg

r
o
stone HB. T e evolving conception and management chal- Oncol. 1991;17:234–236.

g
r
lenges o malignant brous histiocytoma. Dermatol Surg. 52. Hanke CW, Leonard AL, Reed AJ. Rapid preparation o high-

p
2012;38(12):1922– 1929. quality rozen sections using a membrane and vacuum system

h
33. Fleischmann HE, Roth RJ, Wood C, Nickolo BJ. Microcys- embedding machine. Dermatol Surg. 2008;34(1):20– 25.

i
c
tic adnexal carcinoma treated by microscopically controlled 53. odd MM, Lee JM, Marks VJ. Rapid toluidine blue stain or

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u
excision. J Dermatol Surg Oncol. 1984;10:873– 875. Mohs micrographic surgery. Dermatol Surg. 2005;31:244–

r
g
34. O’Connor WJ, Lim KK, Zalla MJ, et al. Comparison o Mohs 245.

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micrographic surgery and wide excision or extramammary 54. T osani MK, Marghoob A, Chen CS. Current progress o

y
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Paget’s disease. Dermatol Surg. 2003;29:723– 727. immunostains in Mohs micrographic surgery: a review. Der-

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35. Starling J, Coldiron BM. Mohs micrographic surgery or the matol Surg. 2008;34(12):1621– 1636.

d
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treatment o cutaneous leiomyosarcoma. J Am Acad Derma- 55. Kader El al A, Abrou AE, Sti MA, Mehregan DA. Immu-

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tol. 2011;64(6):1119– 1122. nostaining in Mohs micrographic surgery: a review. Dermatol

i
o
36. Behroozan DS, Goldberg LH, Glaich AS, Kaplan B, Kaye Surg. 2010;36:275– 290.

n
s
VN. Mohs micrographic surgery or deeply penetrating, 56. Robinson JK. Current histologic preparation methods or Mohs
expanding benign cutaneous neoplasms. Dermatol Surg. micrographic surgery. Dermatol Surg. 2001;27:555–560.

n
d
2006;32(7):958–965. 57. Jimenez FJ, Grichnik JM, Buchanan MD, Clark RE. Immu-

T
37. Goldberg DJ, Kim YA. Angiosarcoma o the scalp treated nohistochemical techniques in Mohs micrographic surgery:

c
h
with Mohs micrographic surgery. J Dermatol Surg Oncol. their potential use in the detection o neoplastic cells masked

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1993;19(2):156–158. by in ammation. J Am Acad Dermatol. 1995;32:89– 94.

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q
38. Marra DI, Schanbacher CF, orres A. Mohs micrographic 58. Zachary CB, Rest EB, Furlong SM, Arcedo PN, McGeorge

u
surgery o primary cutaneous mucinous carcinoma using BC, Kist DA. Rapid cytokeratin stains enhance the sensitivity
immunohistochemistry or margin control. Dermatol Surg. o Mohs micrographic surgery or squamous cell carcinoma. J
2004;30(5):799–802. Dermatol Surg Oncol. 1994;20:530– 535.
39. O’Connor WJ, Roenigk RK, Brodland DG. Merkel cell carci- 59. Murphy ME, Brodland DG, Zitelli JA. Errors in the interpre-
noma: comparison o Mohs micrographic surgery and wide tation o Mohs histopathology sections over a 1-year ellow-
excision in 86 patients. Dermatol Surg. 1997;23:929– 933. ship. Dermatol Surg. 2008;34(12):1637–1641.
40. Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ 60. Leshin B, White WL. Folliculocentric basaloid proli eration.
ASDSA/ASMS 2012 Appropriate Use Criteria or Mohs Arch Dermatol. 1990;126:900– 906.
Micrographic Surgery. A Report o the American Academy 61. Countryman NB, Leshin B. Use o a Goulian kni e and Weck
o Dermatology, American College o Mohs Surgery, Ameri- blade or Mohs layers when tumor extends to the perichon-
can Society or Dermatologic Surgery Association, and the drium o the ear. Dermatol Surg. 2012;38(4):670– 672.

337
 Ch a p t e r Practical Management of

27 Atypical Nevi
Jun J. Pa k, Cla a Cu l-L wand wsk , & Ca l n C. K m

In t r o d u c t Io n clinically atypical (ABCD) eatures. In 1980, the term dys-

plastic nevus syndrome (DNS) was termed to describe the
association o sporadic DN with non amilial melanoma.5
Atypical nevi (AN) are melanocytic nevi that may exhibit
ABCD eatures similar to those o melanoma, and patients
with AN have an increased risk o developing melanoma. EpId EmIo l o g y
Since their rst description over 30 years ago, con usion
persists about the de nition, as well as the clinical and sur- Clinically, AN have been reported in up to 17% o the Cau-
gical management, o AN. Patients with AN account or a casian population.6 Histopathologically, DN are reported
signi cant percentage o patients seen in general derma- at a prevalence o approximately 10%.7,8 AN are reported at
tology practices and specialized pigmented lesion clinics, a much higher requency ranging rom 34% to 59% among
as well as in dermatologic surgical clinics or excision. It is, patients with a history o melanoma.9– 12 T e prevalence o
there ore, imperative that all general and procedural der- AN is positively associated with air-skinned populations,
matologists understand the complexities o this diagnosis presence o common melanocytic nevi,13 and chronic sun
and the challenges o care or these patients. T is chapter exposure. A decrease in prevalence is seen with increas-
will review the diagnosis, clinical evaluation, approach or ing age.14 AN typically appear in childhood and can appear
management and skin biopsies, and uture directions in throughout adulthood.15
the care o patients with AN, including advanced imaging
technologies.
pa t h o ph ys Io l o g y
Ba c kg r o u n d AN can be inherited or occur sporadically. Molecularly,
AN have been shown to exhibit altered gene expression
In 1978, Wallace H. Clark and colleagues rst reported the patterns including p16 and p53, a higher proli eration
AN (termed “B-K” nevus by Clark) as a clinicopathologic index, and greater microsatellite instability compared to
entity and described particular nevi on individuals at risk benign nevi.16 Clark originally described AN as part o a
or melanoma.1 Several names are used in the literature to tumor progression lineage toward melanoma.1 However,
re er to such nevi, including AN, dysplastic nevus (DN), and as opposed to models o dysplasia progressing to carci-
Clark’s nevus. In 1992, the US National Institutes o Health noma in other diseases such as colon cancer, there is no
Consensus Con erence recommended that AN re er to clini- evidence that AN progress to melanoma at a rate greater
cally atypical appearing nevi, while “nevus with architectural than that o common nevi. Multiple studies have investi-
disorder” be used or pathologically evaluated nevi with dys- gated pathologic associations between melanoma and pre-
plasia. o date, some clinicians use the terms AN and DN existing nevi and have suggested similar rates o melanoma
interchangeably. For the purpose o this chapter, we will use associated with preexisting banal nevi as with preexisting
the term AN or clinically AN, and DN or lesions that have DN.17– 21 T is would suggest that DN in general have no
been biopsied with pathologically con rmed dysplasia. greater risk o malignant trans ormation than banal nevi
Several de nitions and criteria or the Familial Atypi- and may not need to be treated more aggressively.17– 21
cal Mole and Melanoma (FAMM) syndrome have been Although AN is primarily sporadic in etiology, when
proposed, including one by the a orementioned 1992 inherited, the mode o inheritance o AN is thought to be
con erence that de ned it by (1) occurrence o melanoma autosomal dominant. Germline mutations in three genes
in one or more rst- or second-degree relatives, (2) large have been linked to melanoma-prone amilies: CDKN2A,22
numbers o moles (o ten greater than 50), some o which CDK4,23 and CMM1.24 Up to 40% o FAMM harbor a
are atypical and o ten variable in size, and (3) moles that mutation in the CDKN2A locus, exhibiting altered gene
demonstrate certain distinct histologic eatures o dys- expression or p16 and ARF tumor suppressor proteins.25
plasia de ned by the consensus con erence. In addition,
others have proposed FAMM syndrome as the presence
o two or more amily members with AN and at least one r Is k f o r mEl a n o ma In pa t IEn t s
amily member with melanoma.2 T e atypical mole syn- WIt h a t ypIc a l n Ev I
drome has also been described as the presence o 503 to
1004 or more melanocytic nevi including one or more 8 AN identi y patients at slightly increased risk or mela-
mm or larger in greatest diameter and one or more with noma. While the risk or melanoma in the general
population is around 1.93%, patients with AN have been
estimated to have a two old to 12 old increased relative Ed u c a t In g t h E pa t IEn t
3
risk depending on the number o nevi.26,27 Furthermore,
patients with atypical mole syndrome have been reported Patients’ knowledge regarding AN may range rom lack o
to have a 10 year cumulative risk o 10.7% or develop- awareness to extreme anxiety surrounding a ear o mela-
ing melanoma.28 However, as described earlier, there is noma and the need or numerous surgical excisions. Provid-
no evidence that individual AN progresses to melanoma ing education during visits is crucial in the care o patients
any more requently than common nevi. T e majority o with AN. Patients should be educated about the nature o
melanomas—around 75%—develop de novo.19,29 Removal AN, and o ered reassurance that the great majority o lesions
o AN as a means o preventing melanoma is not a viable are not pre-cancerous, and, there ore, are not destined to
approach, and biopsy o every atypical mole should not progress to malignant melanoma (MM). However, patients
be considered the standard o practice. Patients with AN should be aware o the need to be alert or any new or pre-
need to be monitored closely or suspicious lesions, given existing lesions that suddenly change to exhibit worrisome
their higher risk or melanoma, and the decision to biopsy eatures. Clinicians can teach patients the sel -skin examina-
an individual lesion is based on suspicion or melanoma tion including how to monitor their skin, the ABCDs o mel-

C
a ter a comprehensive and integrative evaluation o each anoma, and the identi cation o an “ugly duckling” lesion.

a
Patients should be amiliar with the warning signs o itching

p
individual patient.

t
and bleeding and know when to call or an urgent evalu-

2
ation. Clinicians can advise patients to use adequate sun

7
c l In Ic a l pr Es En t a t Io n protection (hats, cover-ups, sunscreen with sun protective

:
:
actor 30 or higher, shade, and avoiding mid-day sun). T e
ollowing acts concerning AN should be considered when

P
Clinically, AN have been described as melanocytic

a
lesions measuring 5 mm or more in diameter with vari- discussing the clinical relevance o this entity with patients:

c
t
c
able pigmentation, poorly de ned borders, and asym- AN are a kind o nevus associated with a slightly

a
■

l
metry.12 T ey are typically larger than banal nevi, and increased risk o developing melanoma.

M
a
their pigmentation can vary rom pink and tan, to dark T e majority o melanomas arise de novo; although

n
■

a
brown with patients o ten having their own particular it is important to ollow one’s nevi or any suspicious
“signature patterns” o one or more di erent types o changes, it is also very important to monitor or new

m
AN.30 AN may clinically exhibit the ABCDs described or suspicious lesions arising in the normal skin.

n
melanoma (Asymmetry, Border irregularity, Color var-

t
■ AN can be monitored clinically and do not need to
iegation, and larger Diameters), and, there ore, can look

f
be removed unless there are changes concerning or

A
suspicious or melanoma. Although ultraviolet rays may

t
melanoma.

p
a ect the distribution o AN, with a higher prevalence ■ Systematic removal o AN has not been shown to decrease

c
in sun-exposed areas, AN can occur anywhere on the

a
one’s risk o melanoma; there ore, the goal o management

l
N
body including sun-protected areas.31 One can generally is care ul and close observation instead o a “molectomy.”

v
diagnose AN based on the a orementioned eatures, but ■ T e “ugly duckling” rule o melanoma or sel -monitor-
there can be discordance between the clinical impression ing: look or any outlier pigmented lesions that display
o atypia and histopathologic dysplasia.32,33 T ere ore, i eatures not seen in other AN.
symptoms concerning or melanoma arise, including ■ T e importance o sun protection and the sel -skin
pruritus, bleeding, growth, or other worrisome clinical examination.
changes, one should consider removal to exclude the
possibility o melanoma with minimal clinical eatures.
T e correlation between clinical atypia and histologic c l In Ic a l Ex a mIn a t Io n
dysplasia has been reported to be 27% or small nevi
(3~5 mm) and 70% or larger nevi (greater than 5 mm) Some patients may have a ew AN, whereas others may
in one study.33 have hundreds. When evaluating AN, the primary goal
is to rule out melanoma. I the clinical and dermoscopic
eatures o a lesion display symmetry and homogeneity o
ma n a g EmEn t pigmentation, and lack dermoscopic warning signs, the cli-
nician can choose to monitor the lesion by documenting
Early detection o melanoma while minimizing unnec- its measurements, any particular clinical/dermoscopic ea-
essary biopsies is the primary goal o dermatologists or tures, and/or photograph it or short-term monitoring. T e
patients with AN. o date, most dermatologists rely on patient should also be asked to ollow the lesion on sel -skin
their clinical impression alone to di erentiate AN versus examinations and to noti y the clinician o any changes.
melanoma. In several instances, the diagnosis o AN can
be made clinically, without the need or a biopsy, using
the characteristics described earlier. Many dermatologists c l In Ic a l Ex a mIn a t Io n o f pa t IEn t s
use dermoscopy (epiluminescence microscopy) or total WIt h n u mEr o u s a t ypIc a l n Ev I
body photography ( BP) to assist in their clinical exami-
nation o patients with AN, which will be discussed later. For patients with numerous AN, a systematic approach
When possible, clinicians should per orm an excisional becomes very use ul. One technique that has been described
biopsy o any pigmented lesion with eatures suspicious is similar to the way in which a pathologist evaluates a slide.
or melanoma. T e clinician can rst screen the patient at “low power” to 339
3 assess that patient’s typical mole patterns and their “signa-
ture” nevi, noting typical size, shape, and color ranges o
the gold standard or diagnosing melanoma. I easible, an
excisional biopsy is pre erred so as to provide the patholo-
those nevi.34 Any pigmented lesions not tting into these gist with the complete lesion or histologic evaluation, and
patterns (ugly ducklings), or o concern to the patient or cli- to avoid sampling error that could lead to a missed mela-
nician or any other reason can then be urther evaluated at noma, while also allowing or accurate microstaging in the
“higher power” through dermoscopic evaluation.30 case o a melanoma.45 Furthermore, complete removal o
an AN with an excisional biopsy avoids concerns about
recurrence and potential upgrading in atypia, described as
c u r r En t t o o l s f o r Eva l u a t Io n “pseudomelanoma.”46 Another consideration or per orm-
o f a t ypIc a l n Ev I ing an excisional biopsy is to remove suspicious lesions in
areas that are dif cult or the patient to sel -monitor.
Der Mo SCo Py. Dermoscopy is a technique that uses Methods o biopsy include scoop/shave biopsy, punch
a handheld luminescing magni er lens to visualize deep biopsy, and elliptical excisions; their indications vary
pigmentation and stromal and vascular structures below based on the clinical judgment and pre erence o the
clinician. A previous study has shown that melanocytic
S
the skin sur ace. It is the most widely used diagnostic tool
lesions may microscopically extend laterally as much
c
to examine a melanocytic lesion in vivo.35 raditional der-
t
moscopy contains a nonpolarized light source and requires as 1.2 mm.47 T ere ore, when per orming an excisional
n
biopsy o a DN, clinicians should aim or biopsies with
3
direct skin contact with a liquid interphase to cancel out
light re ecting rom the skin sur ace. Modern dermoscopy 1– 2 mm peripheral margins i easible regardless o the
:
:
dispenses polarized light to allow inspection o subsur ace technique used.
Depending on the size o the pigmented lesion, punch
S
structures. Dermoscopy is use ul in examining underly-
k
and elliptical excisions can allow or 1– 2 mm clinically
n
ing pigment patterns, ruling out malignant eatures, and
T
clear lateral margins and will extend to the subcutis,
u
monitoring AN clinically over time. T e ability to diagnose
m
melanoma accurately improves signi cantly when trained thereby removing the entire depth o the lesion in ques-
dermatologists use dermoscopy as opposed to the naked tion. For lesions that are highly suspicious or melanoma,
s
eye.36– 39 Accuracy has been shown to decrease when der- this method ensures that one does not transect the mela-
moscopy is used by untrained care providers.40 It is, there- noma and allows or the most accurate microstaging. It
ore, recommended that clinicians seek training and cours- is important to be orward-thinking and to design the
es to properly learn dermoscopy, thereby optimizing the closure o the excisional biopsy along skin tension lines
results o implementing this technique in clinical practice. (parallel to the length o limbs or arms and legs, or
example) in case a wider excision is needed. I scoop shave
To TAL Bo Dy Dig iTAL Ph o To g r APh y. BP excisional biopsies are per ormed, in addition to aim-
is another tool currently used to aid in the management ing or 1– 2 mm peripheral margins, one should aim or
o patients with AN. A series o total body photographs a depth o at least 1 mm and perhaps deeper depending
in standardized positions to maximize viewing o nevi are on the clinical lesion to avoid transecting the lesion and
taken o patients by a pro essional photographer trained to allow or complete histologic removal. Shallow shave
in this technique. Close-up and dermoscopic photographs biopsies should be avoided in lesions concerning or the
o individual nevi o concern may also be per ormed. diagnosis o melanoma.29 Scoop/shave biopsies have been
During subsequent ollow-up visits, clinicians are able shown to be associated with a higher recurrence rate o
to examine patients’ skin with the ability to re erence the DN, suggesting that it may be more dif cult to achieve
baseline photographs to assess or clinical stability o nevi histologic clearance o a lesion with the shave technique.29
and any new or concerning changes. BP is particularly In addition, because o a higher incidence o transecting
use ul or patients with numerous, clinically complex AN, melanomas with shave procedures, shave biopsies have
or patients who are at a high risk or melanoma, as BP also been associated with higher rates o sentinel node
has been shown to identi y early, subtle changes or the procedures due to uncertain de nitive tumor depths at
detection o early melanoma.41 In addition, BP has been the time o initial biopsy.48 However, shave/scoop biopsies
shown to reduce the number o unnecessary biopsies42,43 may be pre erred under certain circumstances. Clinicians
and to reduce patient anxiety.44 Some challenges to BP may consider shave/scoop procedures or lesions without
include the cost and logistics o setting up imaging tech- worrisome atypical eatures, lesions that are at and large,
nology and increased time in per orming complete skin lesions in anatomic locations under high skin tension that
examinations. However, BP can greatly enhance the may not close well, and lesions on patients who may not
management o particularly complex and/or anxious AN tolerate more invasive procedures.29
patients. Even without having BP in their own practices,
clinicians can educate patients about BP, re er them to
clinics that utilize BP, and collaborate with those clinics h Is t o pa t h o l o g Ic a s s Es s mEn t
in the management o these high-risk individuals.
a n d ma n a g EmEn t o f
d ys pl a s t Ic n Ev I
BIo ps y
Histologically, DN are characterized by architectural
I the clinician identi es a lesion concerning or mela- disorder and cytologic atypia that include a basilar pro-
340 noma, a biopsy should be per ormed, as histopathology is li eration o atypical melanocytes in a lentiginous or
epithelioid-cell pattern associated with at least two o
the ollowing criteria: (1) the presence o lamellar bro-
moderately DN; however, large-scale studies are needed to
develop data-driven guidelines or DN management.
3
sis or concentric eosinophilic brosis, (2) neovascular-
ization, (3) in ammatory response, and (4) usion o rete
ridges.49 Reporting o biopsied DN varies depending on f o l l o W-u p
the individual pathologist and/or institution. Some der-
matopathologists di erentiate high-grade (severe) DN Existing AN and new lesions should be care ully moni-
only, while others will grade the degree o dysplasia as tored by the clinician or concerning eatures during
mild, moderate or severe, or levels in between (i.e., mild- ollow-up and by the patient regularly between visits. T e
moderate, moderate- ocal severe, etc.). Because grading risk o melanoma remains li elong; regular sel -skin exam-
o DN has a signi cant subjective component depending inations and examinations by a dermatologist are impera-
on the pathologist’s interpretation o the biopsy specimen, tive. T e requency o ollow-up usually varies rom every
substantial discordance amongst pathologists has been 6 to 12 months based on the complexity o nevi, the
reported in grading.49 For challenging melanocytic lesions, patient’s history, and their level o risk or melanoma.
it is not uncommon or second opinions to be requested

C
o dermatopathologists experienced in interpreting mela-
f u t u r E d Ir Ec t Io n s o f

a
p
nocytic lesions.

t
ma n a g EmEn t o f a t ypIc a l n Ev I:

2
7
r E-Exc Is Io n s EmEr g In g t Ec h n o l o g IEs

:
:
P
When DN are biopsied and removed with clear histologic Multispectral imaging is an advanced technology that may

a
margins, no urther re-excision is needed since there are be considered in the management o pigmented lesions.

c
t
no data to suggest that ully excised DN can evolve into Multispectral imaging utilizes di erent wavelengths o

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a
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melanoma. However, some clinicians may recommend re- light (400– 1000 nm) to produce images o a pigmented

M
excision o severely DN with 5 mm margins so as to treat lesion at di erent depths below the skin sur ace, up to

a
n
them as malignant melanoma in situ (MMIS). T is stems 2 mm deep. wo multispectral imaging devices or spec-

a
rom the act that grading o DN can di er rom patholo- trophotometric intracutaneous analysis, SIAscope (devel-

m
gist to pathologist and o ten there can be discrepancies oped by Astron Clinica, o t, Cambridgeshire, UK, and

n
about what constitutes a severe DN vs. MMIS. Until ur- marketed by Biocompatibles since 2009) and MelaFind

t
ther studies are per ormed addressing appropriate mar- (MELA Sciences, Inc., Irvington, NY), are available. SIA-

f
A
gins or severely DN, and markers are identi ed to predict scope emits eight di erent wavelengths o light between

t
400 to 1000 nm to obtain in ormation regarding a lesion’s

p
which severe DN have malignant potential, many insti-

c
tutions are erring on the side o caution and re-excising color, epidermal and dermal melanin, blood, and collagen

a
l
them. that is then interpreted by the clinician.35 A preliminary

N
T e clinical management o DN biopsied with posi- investigation per ormed by Moncrie et al. ound that the

v
tive histologic margins varies, as there are currently no presence o dermal melanin, collagen holes, and blood
ormal guidelines or re-excision o DN. Some clinicians displacement with erythematous blush correlated with an
may choose to per orm a re-excision o DN with posi- 83%sensitivity and 80%speci city or melanoma detection
tive margins to rule out sampling error and avoid recur- in a study.52 Glud et al.53 per ormed a prospective study
rence, depending on the degree o dysplasia noted. A examining SIAscope’s utility in diagnosing melanoma
recent survey o 101 Chicago dermatologists50 showed compared to dermoscopy in 2009. T e authors ound that
that the decision to re-excise or observe nevi depended the sensitivity o dermoscopy was 92%, compared to 100%
on the histologic grade o dysplasia and margin status. or SIAscopy, while the speci city o dermoscopy was 81%
wenty-one percent o those surveyed reported that they compared to 59% or SIAscopy. T e authors concluded
would re-excise mild DN with positive biopsy margins, that, overall, dermoscopy remains the best approach to
81% would re-excise moderately DN, and 95% would diagnosing pigmented lesions, but SIAscope could pro-
re-excise severely DN. With biopsy margins that were clear, duce dermoscopic images and thereby help train clini-
9% would re-excise moderately DN, and 55% reported cians to recognize speci c lesions. MelaFind, which is
re-excising severely DN. However, given that recent stud- FDA-approved, emits 10 di erent wavelengths between
ies suggesting AN and common banal nevi have similar 430 and 940 nm. By using a lesion classi cation algorithm,
rates o recurrence a ter biopsy and a similar risk o pro- it provides a binary output o whether a pigmented lesion
gression to melanoma, it is unclear whether re-excision o has a high or low degree o disorganization, which helps
incompletely biopsied mild and moderately DN is neces- determine whether to biopsy a lesion.35 o assist in making
sary to prevent melanoma.29,51 A ew studies have exam- this decision, MelaFind compares the lesion’s eatures to
ined the role o observation o mild and moderately DN a pigmented lesion database and uses a lesion classi ca-
with positive margins. One study showed no evolution tion algorithm that has been shown to have a sensitivity
to melanoma in a small study sample (26 DN) ollowed o greater than 95% or melanoma detection.54 MelaFind
or a mean ollow-up time o 6.12 years, and low rates o is not currently designed to evaluate amelanotic lesions,
clinical recurrence (3.6% o 195 DN compared to 3.3% lesions on certain anatomical sites (acral, mucosal, sub-
o 61 benign nevi) with at least 2 years’ ollow-up.29,51 ungual), lesions within areas o scarring, and pigmented
T ese data suggest that observation can be a sa e alter- lesions <2 mm in diameter. Preliminary studies utiliz-
native to re-excision or incompletely removed mild and ing MelaFind or melanoma diagnosis ound that it had 341
3 a sensitivity ranging rom 98% to 100%, and speci city
ranging rom 44% to 85%.55,56 Most recently, a 2010 pro-
6. Munro DD. Multiple active junctional naevi with amily his-
tory o malignant melanoma. Proc R Soc Med. 1974;67(7):
594– 595.
spective, multicenter, blinded study comparing MelaFind
7. Steijlen P, Bergman W, Hermans J, Sche er E, Van Vloten
to clinician per ormance in detecting melanoma ound WA, Ruiter DJ. T e ef cacy o histopathological criteria
that MelaFind had a biopsy sensitivity o 98.4%, while cli- required or diagnosing dysplastic naevi. Histopathology.
nicians’ biopsy sensitivity was 78%.57 MelaFind’s biopsy 1988;12(3):289– 300.
speci city was 9.9%, compared to the clinicians’ speci c- 8. Piepkorn MW, Barnhill RL, Cannon-Albright LA, et al. A mul-
tiobserver, population-based analysis o histologic dysplasia
ity o 3.7%. T e authors concluded that MelaFind may be
in melanocytic nevi. J Am Acad Dermatol. 1994;30:707– 714.
a use ul device or dermatologists evaluating pigmented 9. Augustsson A, Stierner U, Rosdahl I, Suurküla M. Common
lesions and that urther studies are warranted to investi- and dysplastic naevi as risk actors or cutaneous malignant
gate its speci c applications in patient care. melanoma in a Swedish population. Acta Derm Venereol.
Other emerging technologies include con ocal micros- 1991;71:518– 524.
10. Grob JJ, Gouvernet J, Aymar D, et al. Count o benign mela-
copy, which provides high-resolution horizontal section
nocytic nevi as a major indicator o risk or non amilial nodu-
images o tissue using point illumination; optical coher- lar and super cial spreading melanoma. Cancer. 1990;66:
ence tomography, which provides sagittal section images
S
387– 395.
o tissue using in rared light; electrical impedance, which 11. Garbe C, Buttner P, Weiss J, et al. Risk actors or developing
c
t
detects electrical di erences in malignant and benign cutaneous melanoma and criteria or identi ying persons at
n
risk: multicenter case-control study o the Central Malignant
cell/tissue structure58; and epidermal genetic in orma-
3
Melanoma Registry o the German Dermatological Society. J
tion retrieval, which allows noninvasive sampling o stra- Invest Dermatol. 1994;102:695– 699.
:
:
tum corneum with adhesive tape stripping.59 Ultrasound, 12. ucker MA, Halpern A, Holly EA, et al. Clinically recognized
magnetic resonance imaging, dynamic in rared imaging, dysplastic nevi: a central risk actor or cutaneous melanoma.
S
k
photoacoustic microscopy, and other advancements are JAMA. 1997;277:1439– 1444.
n
13. Piepkorn M, Meyer LJ, Goldgar D, et al. T e dysplastic mela-
T
expected to be incorporated or earlier and more accu-
u
nocyric nevus: a prevalent lesion that correlates poorly with
m
rate detection o melanomas.35 Although many o these clinical phenotype. J Am Acad Dermatol. 1989;20:407– 415.
technologies are still undergoing investigation, an ideal 14. Lasithiotakis KG, Kokolakis A, Giannikaki E, Krasagakis K,
s
diagnostic modality would improve clinicians’ sensitivity osca A. Factors associated with the prevalence o atypical
and speci city or melanoma detection while also being a nevus in a Mediterranean pigmented skin lesion clinic. Mela-
noma Res. 2011;5:469– 473.
practical and cost-ef cient bedside tool that could easily
15. Halpern AC, Guerry D IV, Elder DE, rock B, Synnestvedt
be integrated into clinical practice. M, Humphreys . Natural history o dysplastic nevi. J Am
Acad Dermatol. 1993;29:51– 57.
16. Du y K, Grossman D. T e dysplastic nevus: rom histori-
c o n c l u s Io n cal perspective to management in the modern era: Part II.
Molecular aspects and clinical management. J Am Acad Der-
matol. 2012;67:19e1– 19e12.
AN are melanocytic nevi that may exhibit ABCD eatures 17. Skender-Kalnenas M, English DR, Heenan PJ. Benign mela-
similar to those o melanoma and identi y patients who nocyric lesions: risk markers or precursors o cutaneous mel-
may be at an increased risk or developing melanoma. It is anoma? J Am Acad Dermatol. 1995;33:1000– 1007.
imperative that all general and procedural dermatologists 18. Sagebiel RW. Melanocytic nevi in histologic association with
understand the complexities o this diagnosis in order primary cutaneous melanoma o super cial spreading and
nodular types: e ect o tumor thickness. J Invest Dermatol.
to educate patients about the signi cance o AN as well 1993;100:322– 325.
as the need or regular monitoring to provide them with 19. Bevona C, Gogins W, Quinn , Fullerto J, sao H. Cuta-
optimal care. Future investigations on imaging technology neous melanomas associated with nevi. Arch Dermatol.
or patient monitoring and surgical management o AN, 2003;139:1620– 1624.
including biopsy techniques and re-excisions, will urther 20. Lucas CR, Sanders LL, Murray JC, Myers SA, Hall RP, Grich-
nik JM. Early melanoma detection: nonuni orm dermoscopic
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21. Goodson AG, Florell SR, Boucher KM, Grossman D. A
r Ef Er En c Es decade o melanomas: identi cation o actors associated
with delayed detection in an academic group practice. Der-
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MH, Van Horn M. A study o tumor progression: the precur- ment o a locus or amilial melanoma, MLM, to chromosome
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Hum Pathol. 1984;15:1147–1165. 23. Nobori , Miura K, Wu DJ, Lois A, akabayashi K, Carson DA.
2. Greene MH, Clark WH Jr, ucker MA, Kraemer KH, Elder Deletions o the cyclin-dependent kinase-4 inhibitor gene in
DE, Fraser MC. High risk o malignant melanoma in mela- multiple human cancers. Nature. 1994;368(6473):753– 756.
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40. Binder M, Puespoeck-Schwarz M, Steiner A, et al. Epilumines- MelaFind: a prospective multicenter study. Arch Dermatol.
cence microscopy o small pigmented skin lesions: short-term 2011;147:188– 194.

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343
 Ch a p t e r Surgical Management of

28 Melanoma
Peter L. Mattei, Elizabeth K. Jones, & Hensin Tsao

In the past several decades, the incidence o melanoma the disease extends to regional nodes however, survival
has steadily risen. In the United States, as o 2012, it is rates decrease by hal .
estimated that 76,250 new cases o melanoma will develop
and 9,180 patients will die o the disease.1 Data rom 2006
to 2008 projects that 1 in 36 males and 1 in 55 emales Bio ps y o f A pr imAr y
will develop invasive melanoma during their li etime.1
T e median age o diagnosis is 59 years. Furthermore, the mel An o mA
projected increase in the incidence o melanoma may be
underestimated due to unreported outpatient treatments T e rst step or de nitive diagnosis o a cutaneous mela-
o super cial and in situ melanomas. Melanoma is one o noma is to obtain a biopsy. A biopsy may be incisional
the leading cancers in terms o average years o li e lost and sample part o the lesion or excisional and encom-
per death rom disease.2 Melanoma has higher incidence pass the entire lesion. I melanoma is suspected, the most
rates in lightly pigmented Caucasians than in Hispanics, appropriate approach is a narrow excisional biopsy with
Asians, and A rican Americans.2 Estimates indicate that 1 to 3 mm margins. Most atypical melanocytic lesions
82% to 85% o patients present with localized disease, are cleared by this approach.4 T e goal o a narrow exci-
10% to 13% with regional disease, and 2% to 5% with dis- sional biopsy is to achieve clinically negative margins
tant metastatic disease.3 Melanoma is responsible or the and an adequate depth while avoiding transection o the
majority o skin cancer-related deaths but is o ten cured specimen. Wider margins should be avoided to allow sub-
when detected early. Outcome depends on the stage at sequent wide local excision and accurate lymphatic map-
presentation. ping by sentinel lymph node biopsy (SLNB) i necessary.2,3
Strong evidence supports three histologic eatures o Elliptical, disk, or punch excisions are o ten employed. A
the primary tumor to be o high prognostic value: tumor partial shave biopsy should generally be avoided and only
(Breslow) thickness, the presence or absence o micro- used when the suspicion or melanoma is low, as tangen-
scopic ulceration, and mitotic rate. All three are required tial removal may result in transection o the tumor and
components o the biopsy specimen’s pathology report.4 complicate determination o the true Breslow depth.
Maximum Breslow thickness is measured rom the gran- An incisional biopsy is best reserved or cosmetically sen-
ular layer o the epidermis or the base o a super cial sitive or anatomically di cult locations (palm/sole, digit,
ulceration to the deepest depth o invasion by malignant ace, or ear), and is also appropriate in cases o exception-
cells to the nearest 0.1 mm, excluding extension into the ally large lesions, a low clinical suspicion or melanoma, or
adnexal adventitia. Microscopic ulceration is de ned as diagnostic uncertainty. An incisional biopsy should encom-
tumor-induced ull-thickness epidermal loss with subja- pass the ull thickness o the skin to the level o the adi-
cent dermal tumor and reactive dermal changes. Mitotic pose tissue and should be taken rom the darkest or most
rate is measured as the number o dermal mitoses per elevated portion o the lesion. Partly due to the di culty
square millimeter. in clinically predicting the thickest portion o the lesion,
In 2010 the American Joint Committee on Cancer an incisional biopsy is less likely to guarantee accurate
(AJCC) de ned an updated staging system in which representation o the lesion’s Breslow depth and a repeat
tumor (Breslow) thickness and mitotic rate were iden- biopsy may be required.4 I the incisional biopsy indicates
ti ed as the two major actors that predict melanoma a cutaneous melanoma <1 mm thick and a clinically appar-
survival in tumors ≤1 mm in thickness.4 T is change ent lesion remains, a narrow margin excisional biopsy
stemmed rom the nding that a dermal mitotic rate ≥1 should ollow. T is subsequent narrow excisional biopsy
mitosis/mm 2 is independently associated with a worse allows microstaging i the patient requires SLNB, as well as
disease-speci c survival. As a result, in the 2010 AJCC histologic evaluation or upstaging, which could result in
staging guidelines, the dermal mitotic rate was used to a change in treatment plan.2 In one study o lesions with
upstage patients with melanoma ≤1 mm rom stage IA to ≥50% residual tumor postincisional biopsy, about one- th
stage IB, replacing the anatomic (Clark) level o invasion. were upstaged and one-tenth required SLNB.5 T ere is no
T e impact o tumor thickness on prognosis is under- evidence that incisional biopsy o a primary melanoma can
scored by variations reported in survival outcomes. In “seed” tissue and negatively impact survival.2 Regardless o
patients with localized disease and primary tumors ≤1.0 the biopsy approach, a ter the histologic con rmation o a
mm in thickness, over 90% o patients achieve 5 year cutaneous melanoma, a wider and deeper excision is usu-
survival. For patients with localized melanomas thicker ally warranted. Melanoma cells can extend several millime-
than 1.0 mm, survival ranges rom 50% to 90%.3 When ters to centimeters beyond the clinically detectable lesion.4
A His t o r ic Al per s pec t iv e o n signi cantly impact local and regional recurrence or long-
term survival compared to narrow (1 cm) margins.
3
s u r g ic Al mAn Ag emen t o f
mel An o mA exc is io n mAr g in s f o r t u mo r s
l es s t HAn o r eq u Al t o 1.0 mm
Despite research e orts toward nonsurgical management
o primary melanomas, surgery continues to be the stan- Limited data exist on excision o primary invasive mela-
dard or primary lesions. Until the 1970s, surgical dogma noma ≤1.0 mm in thickness. Wide excision with a 1 cm
opted or an aggressive approach with wide surgical mar- margin to the level o the ascia is recommended based
gins extending 5 cm beyond the primary lesion.6 Despite on the WHO randomized trial.4,6 T e WHO trial stud-
this historical, rather than evidence-based approach, an ied 612 melanoma patients with tumors ≤2.0 mm (305
increasing incidence o melanoma established the need patients with 1 cm margin vs. 307 with ≥3 cm margins).
or better-de ned surgical guidelines, early diagnosis, and T is trial ultimately concluded that thin melanomas
identi cation o prognostic actors. Subsequent clinical tri- (≤1.0 mm thick) could be sa ely excised with a 1 cm mar-

C
als led to the evolution o a more tailored approach linked

h
gin (vs. a 3 cm margin). T e use o a 1 cm margin in these

a
to prognostic actors and risk o recurrence.6 T e identi-

p
tumors provides a good cosmetic outcome and unction-

t
e
cation o tumor thickness as a prognostic actor greatly ality without adversely impacting therapeutic e cacy. In

r
2
inf uenced the evolution o narrower excision margins. melanomas thicker than 1.0 mm, the WHO trial demon-

8
Studies in the 1980s suggested that narrower excision mar- strated a trend toward increased incidence o local recur-

:
:
gins were acceptable in many cases, particularly or thin rence in the narrow excision group. T is trend was not
melanomas, and did not adversely a ect survival. Studies

S
statistically signi cant due to the small number o observed

u
also indicated that narrow margins used in the treatment

r
events.7,8 As a result, the WHO trial did not reach a de ni-

g
i
o thicker tumors o ten led to increases in local recurrence

c
tive conclusion or melanomas thicker than 1.0 mm.

a
l
rates. Data rom retrospective studies in the 1980s and

M
1990s continued to weigh the inf uence o narrow mar-

a
n
gins versus primary tumor characteristics on outcome. exc is io n mAr g in s f o r t u mo r s 1

a
g
Ultimately, researchers determined that local recurrence t o 2 mm in t Hic k n es s

e
m
is both a unction o biologic actors and the extent o

e
n
excision.6 A paradigm emerged that dictated that wider T e margin recommendations or melanomas 1 to

t
o
margins were necessary or higher risk or thicker lesions.6 2 mm in thickness are implemented based on conclusions

M
T ese conclusions led to the conduction o various pro- rom the WHO Melanoma Program and the Intergroup

e
l
spective randomized trials to establish more de nitive Melanoma Surgical rial (IMS ).9 T e IMS was initi-

a
n
guidelines or treatment.

o
ated as a randomized controlled trial in the early 1980s to

m
Current surgical margin recommendations are based assess the margin approach to patients with intermediate-

a
largely on conclusions rom randomized controlled trials thickness melanomas (1– 4 mm).6,9– 11 T e study random-
and consensus opinion. An algorithm to guide the manage- ized 740 patients with melanomas 1 to 4 mm thickness
ment o cutaneous melanoma is available in Figure 28-1.2 into (a) 486 patients with melanomas on the trunk or
proximal extremity to compare outcomes o 2 versus
4 cm margins and (b) 272 patients with melanomas on
BAs ic c o n c ept s f o r exc is io n the head, neck, or distal extremity who underwent a 2 cm
excision. Overall, 28 patients (3.8%) experienced a local
o f pr imAr y mel An o mA recurrence associated with a high mortality rate, with a
5 year survival rate o 9% ( rst relapse) or 11% (any time)
T e goals o excision or a primary cutaneous melanoma versus 86% survival or patients who did not experience
are to achieve negative margins on histology and prevent a local recurrence (p < 0.0001). Comparing 2 versus 4 cm
recurrence caused by residual disease. Wide excision is margin outcomes, no signi cant di erence in 10 year
the standard o surgical therapy or primary cutaneous survival (70% vs. 77%, respectively), incidence o local
melanoma.4 T is practice is based on early ndings that recurrence, or risk o in-transit disease was observed
a wider excision is associated with a reduced risk o local between treatment arms. T is report indicated that sur-
recurrence due to disease persistence despite histopatho- vival o intermediate-thickness tumors (1– 4 mm) was not
logically con rmed tumor- ree margins.2,4 Outcomes o inf uenced by the extent o excision (2 vs. 4 cm).11 A 2 cm
wide and narrow excision in the treatment o melanoma margin o excision was concluded to be sa e or tumors
continue to be assessed. 1 to 4 mm in thickness.
o determine appropriate surgical margins or tumors Guidelines or 1 to 2 mm thickness tumors have been
less than 2 mm thick, the French Cooperative Group, the established by ndings o the IMS and WHO trials in
World Health Organization, and the Swedish Melanoma this subset o melanomas. As noted earlier, the WHO trial
Study Group conducted various trials in the late twenti- detected a trend toward an increased incidence o local
eth and early twenty- rst century. T ese trials varied in recurrence in the narrow excision group (1 vs. 3 cm mar-
regard to sample size, margin width, and tumor thickness gin). However, the IMS reported a lower incidence o
cuto or patient inclusion, yet they ultimately reported local recurrence in 1.0 to 2.0 mm thickness lesions com-
similar conclusions.6 Collectively, they demonstrated that pared to the WHO trial (0.6% vs. 4.5%) and no advantage
in tumors less than 2 mm thick, wider margins did not in local control or survival with a 4 versus 2 cm margin. 345
3 Ge ne ral g uide line alg o rithm fo r the tre atme nt o f c utane o us me lano ma

S us pic io us primary le s io n

Excis iona l biopsy (pre fe rre d) Incis iona l biopsy (la rge le s ion
or low s us picion for me la noma )

Me la noma <1 mm <1 mm but typica lly >0.75 mm 1.01–2.0 mm >2 mm

in s itu thick with fe a ture s a s s ocia te d with a highe r thick thick
proba bility of a pos itive S LNBa
S
e
c
0.5–1.0 cm 1.0 cm 1.0 cm 1.0–2.0 cm 2.0 cm
t
i
o
ma rgin ma rgin ma rgin ma rgin ma rgin
n
3
:
:
S urve illanc e Cons ide r S LNB, if a ppropria te
S
k
i
n
T
u
m
o
r
CLND a nd s ta ging s tudie s Co ns ide r inte rfe ro n-
s
S us pic io us no dal FNA or ope n
(e.g., CXR, s e rum LDH, CT; α 2b o r clinic al trial
dis e as e biopsy
MRI; P ET vs . o bs e rvatio n

S us pic io us fo r dis s e minate d

dis e as e

CT-guide d FNA or ope n biopsy S urve illanc e

S olita ry or limite d Dis s e mina te d

Obs e rve a nd No
Co ns ide r re s e c tio n
re pe a t s ca n cha nge

Targ e te d the rapy (e .g ve murafe nib,

dabrafe nib, trame tinib) bas e d o n
Progre s s ion tumo r g e no type (BRAF) and/o r
immuno the rapy (e .g . IL-2, ipilimumab)

Figure 28-1 General guideline algorithm or the treatment o cutaneous melanoma. a Ulceration, extensive vertical
regression to at least 1 mm thick, young patient age, high mitotic rate, especially in younger persons, shave biopsy with
positive deep margin, presence o angiolymphatic invasion, and Clark level IV. CLND, completion lymph-node dissection;
CNS, central nervous system; CT, computed tomography; CXR, chest X-ray; FNA, ne-needle aspiration; LDH, serum lactate
dehydrogenase; MRI, magnetic resonance imaging; PET, positron emission tomography; and SLNB, sentinel lymph node
biopsy. A minus sign indicates no evidence o disease, and a plus sign evidence o metastasis. Patients who are candidates
or SLNB should be re erred to a surgeon experienced in per orming the procedure so that the bene ts and complications
can be ully discussed. (Reproduced with permission rom Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Lef ell DJ, Wolf
K. Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York, NY: McGraw-Hill, Inc; 2012. Fig. 124-18. Copyright ©
McGraw-Hill Education LLC.)

346
O note, the IMS detected a trend toward 10 year dis-
ease-speci c survival seen in the wider margin group.11
s u mmAr y o f c u r r en t
3
Regardless, consensus opinion agrees that according to r ec o mmen d At io n s
these ndings, in tumors 1 to 2 mm thick, i 2 cm margins
are comparable to 4 cm margins, no additional advantage Evidence or thin melanomas (≤1.0 mm) does not suggest
would be gained with a 3 cm margin.6 that margins greater than 1 cm o er an improvement in
Many experts recommend a 2 cm margin as the stan- survival or local recurrence rate. Accordingly, the current
dard o care or tumors 1 to 2 mm in thickness whenever recommendation or stage IA melanoma (≤1.0 mm thick-
anatomically easible. No study to date has directly com- ness) is wide excision with a 1.0 cm margin.
pared 1 with 2 cm surgical margins in these lesions.6 His- For thicker melanomas, the current recommendation or
torically, the use o a 1 cm margin or 2 mm thick lesions a surgical margin or invasive melanoma is at least 1 cm to
has been met with resistance by some surgeons and der- no more than 2 cm around the primary tumor. Several large
matologists. T e overall survival data rom prospective randomized controlled trials have ailed to demonstrate a
clinical trials demonstrate no apparent bene t or a wider di erence in survival rates or local recurrence between nar-
excision.6 Following this guideline, a margin ranging rom row (1–2 cm) versus wide (3–5 cm) margins.2,7,11– 17 Over-

C
h
1 to 2 cm may be adjusted or unctional or cosmetic rea- all, greater than 2 cm margins or a primary melanoma

a
p
sons or lesions up to 2 mm thick. o any thickness have not been shown to improve overall

t
e
r
survival or local recurrence.4 For 1.01 to 2.0 mm in thick-

2
8
ness, wide excision with a 1.0 to 2.0 cm margin as large
as anatomically possible is recommended. For melano-

:
exc is io n mAr g in s f o r t u mo r s 2

:
mas greater than 2.0 mm in thickness, wide excision with
t o 4 mm in t Hic k n es s

S
2.0 cm margins is recommended. Despite well-de ned

u
r
g
recommendations, the surgical approach must be decided

i
c
For thick primary melanomas, 2 to 4 mm thick, most on an individual basis. Margins may be modi ed according

a
l
studies have ailed to show a bene t o surgical margins

M
to anatomic or cosmetic considerations, and a 1 to 2 cm

a
greater than 2 cm.4 T e United Kingdom Melanoma Study margin may be acceptable in certain circumstances where a

n
a
Group (UKMSG) rial randomly assigned 900 patients 2 cm margin is di cult to achieve anatomically. Nonethe-

g
e
with melanomas 2.0 mm or thicker to two groups with less, reconstruction concerns are secondary to achieving

m
excision margins o 1 and 3 cm. T e study showed no

e
tumor clearance. raditionally, the recommended depth o

n
signi cant di erence in the rate o local recurrence or in

t
a therapeutic excision extends to muscle ascia when pos-

o
overall survival between the groups, although the group sible.4 Many experts believe that in regions with a thicker

M
with 1 cm margins had more combined locoregional adipose layer, extension to deep adipose tissue is adequate.

e
l
a
recurrences. T is nding provides evidence against use

n
o
o a 1 cm margin or lesions o 2 to 4 mm thickness, and
mel An o mA in s it u

m
does not support a bene t o 3 versus 2 cm margins. In

a
addition, the IMS data determined that a 4 cm margin
is not superior to a 2 cm margin and ultimately estab- T e appropriate excision margin or melanoma in situ
lished the adequacy o a 2 cm margin or 2 to 4 mm thick remains an area o controversy. Clinical trials on this topic
lesions. Summarizing the conclusions rom both trials are lacking. As a result, margin recommendations or mel-
or tumors 2 to 4 mm thickness, i a 4 cm margin is not anoma in situ are based on consensus o available experi-
superior to a 2 cm margin, it ollows that a 3 cm margin ence. T e current consensus is to per orm a wide excision
would not con er superiority. o date, no survival di er- with a 0.5 to 1.0 cm margin or melanoma in situ, nonlen-
ences have been demonstrated with greater than 2 cm tigo maligna subtype.4 With these margins, most in situ
margins or thick tumors. T is holds true or tumors melanomas are completely and easily excised and repaired
thicker than 4 mm as well. A recent retrospective series with a primary closure.
o 632 patients with tumors greater than 4 mm showed Recently, the adequacy o a 0.5 cm margin or excision o
that patients with histopathologic margins 16 mm or melanoma in situ has been challenged. A prospective study
less had worse local disease- ree survival (HR, 2.41; p = o 1072 patients with 1120 melanomas in situ compared
0.01) than those with histopathologically determined pri- excision by Mohs micrographic surgery using 6 versus
mary tumor excision margins greater than 16 mm (i.e., 9 mm margins and determined a clearance rate o 86% and
corresponding to a 2 cm surgical margin), suggesting 98.9% respectively (p < 0.001).18 Investigators ultimately
that a 2 cm surgical margin is both necessary and likely recommended 9 mm margins or standard excision o mel-
su cient or local control o thick melanomas.12 As a anoma in situ and deemed 5 mm margins to be inadequate.
result, current recommendations hold that primary mela- Care ul consideration o the primary lesion’s de ning
nomas greater than 2 mm in thickness should undergo a characteristics must be taken into account. For example, the
wide excision with 2 cm margins. O note, the large clini- melanoma in situ, lentigo maligna subtype, warrants concern
cal trials to date have demonstrated a trend toward sur- or large subclinical extension o atypical junctional mela-
vival avoring wide excisions. Due to lack o power in trial nocytic hyperplasia.3 In this subtype, histologically posi-
design, these trends have not demonstrated signi cance. tive margins may be encountered, necessitating sequential
In the uture, larger clinical trials are required to address excisions to clear the margins histopathologically.6 Larger
the evolving hypothesis o equivalence between wide and lesions on the head and neck may also require wider than
narrow excision rather than the traditional hypothesis o 0.5 cm margins. Examination by Wood’s lamp may be o
the in eriority o the latter. bene t in identi ying subclinical disease.3 347
3 in -t r An s it met As t As is
A variety o treatment approaches are available or patients
with Stage III, or in-transit metastasis. When possible,
regional in-transit or satellite disease should be surgically
excised with histologically con rmed clear margins, partic-
ularly in patients with one or a small number o in-transit
metastases. O note, in-transit metastases con er NM
staging status o N2c in the absence o metastatic lymph
nodes and con er NM staging status o N3 when present
in conjunction with metastatic lymph nodes.19
Nonsurgical options tend to be considered or a greater
number o in-transit metastases or multiple dermal
lesions. Isolated limb per usion (ILP) can be considered
S
or control o this type o disease when it is limited to an
e
c
t
extremity. ILP allows chemotherapy to be delivered in
i
o
high doses to the limb, reducing systemic toxicity.2 Mel-
n
3
phalan is the typical chemotherapeutic agent used in ILP
under hyperthermic conditions in patients with a risk o
:
:
substantial morbidity; the goal is to achieve locoregional
S
disease control rather than to improve overall survival.2
k
Figure 28-2 Lentigo maligna and lentigo maligna mela-
i
n
noma (LMM). Lentigo maligna (in situ) displays prominent For patients ineligible or ILP, a newer, less invasive, and
T
u
asymmetry, poorly de ned irregular borders, and pigment simpler alternative with demonstrated e cacy is isolated
m
variegation. (Reproduced with permission rom Goldsmith limb in usion (ILI) with melphalan and actinomycin D.2,20
o
r
LA, Katz SI, Gilchrest BA, Paller AS, Lef ell DJ, Wolf K. Fitz-
s
patrick’s Dermatology in General Medicine. 8th ed. New
York, NY: McGraw-Hill, Inc.; 2012. Fig 124-4A. Copyright ©
McGraw-Hill Education LLC.)
r eg io n Al n o d Al r ec u r r en c e
Regional nodal recurrence should be con rmed with FNA
Lentigo maligna melanoma (LMM) in situ and invasive biopsy. T e diagnostic workup involves FNA biopsy (pre-
LMM can be particularly di cult to manage because o erred) or lymph node biopsy, chest radiograph and/or C ,
their predilection or the ace and scalp and their tendency LDH, and pelvic C i inguino emoral nodes are clinically
to exhibit extensive clinical and microscopic extension positive. Abdominal/pelvic C , MRI o the brain, and PE
(Fig. 28-2). Per orming a complicated f ap on such lesions, scan may be indicated depending on clinical presentation.3
only to later discover that the margins are positive, is not Patients who have not yet undergone prior lymph node
ideal or the surgeon or the patient. As a result, accurate dissection should undergo a complete lymph node dissec-
delineation o the clinical and histologic margins to the tion. I a complete lymph node dissection has already been
greatest degree possible is essential prior to closure. per ormed, excision o the recurrence to achieve clear mar-
gins is appropriate. In patients with completely resected
nodal recurrence and additional risk actors, the risk o
l o c Al r ec u r r en c e urther regional nodal recurrences may be decreased by
postoperative adjuvant radiotherapy. Patients with distant
T e risk o local recurrence has important implications or recurrence are treated similarly to patients with stage IV
ollow-up surveillance. I detected, treatment is required, metastasis.3
and the nature o that treatment depends on the nature
o the recurrence. Local recurrence may occur as a result
o persistence o the primary lesion due to inadequate f o l l o w -u p
primary excision, or rom underlying dermal lymphatic
disease near the excision scar despite apparently adequate Follow-up depends on a patient’s individual risk actors,
primary excision. Re-excision o a persistent primary including recurrence risk, amily history, and previous pri-
lesion portends a better prognosis and should be per- mary melanoma. Patient disposition, skin type, dysplastic
ormed according to the Breslow depth o the tumor. nevi, and history o other skin cancers also have an impact
T e prognosis o a recurrence due to dermal lymphatic on the recommended ollow-up regimen. Most recurrences
disease is akin to that o recurrent regional disease. Base- are detected within the rst 5 years a ter treatment o the
line imaging is utilized or urther evaluation and stag- primary melanoma. Nonetheless, recurrence greater than
ing. Lymphatic mapping and sentinel node biopsy may 10 years ollowing the initial treatment is not uncommon.
be per ormed i dermal lymphatic disease is suspected, T e li etime risk or developing a second primary mela-
and should be considered on an individual basis since the noma is 4% to 8%.3 According to expert opinion, li etime
anatomy may have been altered by prior surgery. A ter dermatologic surveillance or melanoma patients is recom-
excision o the recurrence, observation or adjuvant treat- mended and justi ed.3 Closer surveillance may be pre era-
ments, such as inter eron-alpha or other agents adminis- ble or patients at risk o regional recurrence who have not
348 tered through clinical trials, may be employed.3 undergone sentinel node biopsy or or those with a positive
lymph node who have not undergone a complete lymphad-
enectomy. Skin examination and surveillance at least once
unnecessary re-excision o inadequately excised tumor.
During this waiting period, the patient can be covered
3
a year is recommended or all patients with melanoma, with a temporary hydrocolloid dressing. Pharmacologic
including those with in situ melanoma. Patients with stage management o lentigo maligna with topical imiquimod
IA melanoma should be evaluated every 3 to 12 months or has also been utilized in elderly patients and in poor sur-
5 years and annually therea ter as indicated. Patients with gical candidates. T is is currently controversial with vari-
stage IB to stage IV melanomas and no urther evidence able response rates in published studies and should be
o disease should undergo ollow-up every 3 to 6 months approached with caution.
or 2 years, every 3 to 12 months or 3 years, and annually
therea ter.3 For patients with low and even intermediate
risk tumors, routine radiographic and blood tests are con- s pec iAl Bo d y s it es
sidered low yield and generally not recommended. I a care-
ul review o systems reveals a localizing symptom or sign, Although the guidelines or the excision o primary mela-
targeted evaluation with C s or MRIs may be warranted. noma o varying thickness are usually airly straight orward
In patients with high-risk disease (e.g., greater than stage on body sites such as the trunk, adequate excision with

C
h
IIC), medical oncology ollow-up is usually indicated.3,4 acceptable cosmetic impact may be less easily achieved

a
p
on other body sites, including the head, perineum, and

t
e
r
acral sites. T ese areas require special considerations and
s pec iAl mel An o c y t ic l es io n s

2
8
necessitate particular techniques.
As discussed earlier, melanomas o the ace may be di -

:
:
Aside rom common melanoma pathologic categories, cult to manage as they may be near, or involve, vital

S
atypical melanocytic lesions are not in requently encoun- structures. T e cosmetic implications o lesions involving

u
r
tered. T ey may represent a diagnostic and management the eyes, nose, ears, and mouth require extensive planning

g
i
c
dilemma as these lesions may demonstrate a natural history and a specialized reconstructive e ort. Standard excisional

a
l
that is di erent rom typical melanoma lesions. Whenever removal o such lesions to achieve an optimal aesthetic result

M
a
pathologic uncertainty exists, conservative management may result in less than ideal margins and adjuvant radio-

n
a
according to the pathologic impression with the worst therapy may be indicated in such cases. Mohs micrographic

g
e
prognosis is the rule. surgery can be a use ul technique or lentigo maligna on

m
Desmoplastic melanoma is one atypical melanoma

e
the ace when combined with rush permanent sections or

n
variant that displays some special characteristics. T ese

t
immunohistochemistry. T e delicate ear area can be man-

o
lesions have a di erent natural history relative to other aged with wedge excision or smaller lesions with excellent

M
melanomas o the same Breslow thickness. T ey are more cosmetic results (Fig. 28-3). More extensive lesions may

e
l
a
common in males and o ten are initially interpreted as necessitate partial or ull amputation (Fig. 28-4).

n
o
benign at rst biopsy. T ese lesions also clinically do not

m
exhibit classic eatures o melanoma such as asymmetry,

a
border irregularity, and color variation. Clinical and patho-
logic di culty in recognition o desmoplastic melanoma
may account or the increased thickness o these lesions
at the time o diagnosis. Despite the requently observed
higher thickness o these lesions, they do not have as high
a rate o regional lymph node metastasis at initial presen-
tation as do typical melanomas o similar thickness. T ese
lesions do, however, have a higher rate o local recurrence,
particularly lesions that demonstrate perineural inva-
sion.21 Such neurotropism is more requently observed in
lesions o the head and neck. Lesions demonstrating neu-
rotropism may bene t rom adjuvant radiation therapy.
Once the clinically apparent lesion has been excised,
rozen section processing does not accurately examine the
margin o these lesions, as there may be a lack o melano-
cyte cytoplasmic vacuolization as well as other tissue xa-
tion arti acts. In addition, these lesions requently occur
on a background o severely photodamaged skin that may
contain baseline atypical melanocytes, making border
delineation more di cult. o ensure complete removal,
reconstruction can be delayed until ormal pathologic
evaluation can be completed utilizing para n embed-
Figure 28-3 Nodular melanoma (NM). Amelanotic NM,
ded tissue, o ten with special stains such as immunohis- Breslow depth 2.37 mm, 32 mitoses/mm 2, vertical growth
tochemistry. Studies using rush permanent slides22,23 and phase, ulceration present. (Reproduced with permission
immunohistochemistry24 have demonstrated very low rom Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Lef ell
recurrence rates (0%– 1.2%) and this practice is pre er- DJ, Wolf K. Fitzpatrick’s Dermatology in General Medicine.
able to rozen sections or melanocytic lesions. Although 8th ed. New York, NY: McGraw-Hill, Inc.; 2012. Fig 124-3C.
this may result in a slower staged excision, it may save an Copyright © McGraw-Hill Education LLC.) 349
3
S
e
c
t
i
o
n
3
:
:
S
k
Figure 28-4 Lentigo maligna and lentigo maligna mela- Figure 28-6 Acral lentiginous melanoma (ALM). Classic
i
n
noma (LMM). Amelanotic LMM with nodular component ALM demonstrating asymmetry, border, color, diameter/di -
T
u
initially suspected to be a basal cell carcinoma, nose, erence, elevation/evolving (ABCDs), le t oot, Breslow depth
m
Breslow depth 2.2 mm, 5 mitoses/mm 2, ulceration present. 1.72 mm, ulceration present. (Reproduced with permission
o
r
(Reproduced with permission rom Goldsmith LA, Katz rom Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Lef ell DJ,
s
SI, Gilchrest BA, Paller AS, Lef ell DJ, Wolf K. Fitzpatrick’s Wolf K. Fitzpatrick’s Dermatology in General Medicine. 8th ed.
Dermatology in General Medicine. 8th ed. New York, NY: New York, NY: McGraw-Hill, Inc.; 2012. Fig 124-5A. Copyright
McGraw-Hill, Inc.; 2012. Fig 124-4C. Copyright © McGraw- © McGraw-Hill Education LLC.)
Hill Education LLC.)
Acral sites present a particular challenge because o per ormed on the toes, amputation o ngers (especially
their geometry and unctional implications. When the dis- the thumb) carries a more signi cant unctional de -
tal digits are a ected by melanoma, adequate margins can cit. Melanomas o the distal thumb may be treated with
be o ten achieved by amputation. While this is requently amputation proximal to the distal interphalangeal joint to
maintain unction i possible (Fig. 28-5). Adequate so t-
tissue excision is usually achievable in proximal areas o
the ngers.
Melanomas o the oot may present di erent types o
dilemmas based on whether they involve weight-bearing or
non– weight-bearing areas (Fig. 28-6). Non– weight-bear-
ing sites are usually adequately closed with a split-thickness
gra t. However, weight-bearing areas may require ull-
thickness skin gra ting in order to maintain viability and
unction o tissue.

s en t in el l ympH n o d e Bio ps y
(s l n B)
A ull discussion o the utility and practice o lympho-
scintography/selective lymphadenectomy (i.e., SLNB)
is beyond the scope o this chapter. Furthermore, in the
United States, the procedure is most commonly per ormed
by nondermatologic surgeons. T ere ore, only the rudi-
ments o this procedure will be discussed in this chapter.
Figure 28-5 Subungual acral lentiginous melanoma
In addition to the body site involved, a common man-
(ALM). Extensive involvement o periungual skin (Hutchin-
son’s sign) with dystrophy and loss o the nail plate sec- agement consideration is whether to per orm a SLNB.
ondary to the tumor. (Reproduced with permission rom SLNB is a valuable prognostic tool and the presence
Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Lef ell DJ, o melanoma in the lymph nodes draining the primary
Wolf K. Fitzpatrick’s Dermatology in General Medicine. 8th tumor site is the strongest predictor o overall survival
ed. New York, NY: McGraw-Hill, Inc.; 2012. Fig 124-6A. and risk o recurrence.25,26 Despite the prognostic value o
350 Copyright © McGraw-Hill Education LLC.) SLNB, removal o the regional lymph nodes among which
 TABLE 28-1
3
r mm ati s ti l ymph n Bi p y19,46

s ti l ymph s ti l ymph n s ti l ymph n Bi p y

n Bi p y n t Bi p y s h u b sh u B di u a
g ui i r mm c i of
2011 AAD Stage 0 Stage IB (0.76–1 mm) >1 mm Breslow depth
Stage IA
Stage IB (≤0.75 mm unless
angiolymphatic invasion, + deep
margin, young age)
NCCN Guideline Stage IA with adverse features Stage IA with adverse features Stage IB
version 1.2013 to (lymphovascular invasion, (lymphovascular invasion, Stage II

C
4.2014 ulceration, >0.75mm, mitosis >0.75 mm, young age) Stage III (with resectable solitary in

h
a
>1/mm 2) transit disease)

p
t
e
2012 ASCC/SSO <1 mm (without ulceration or <1 mm (with ulceration, 1–4 mm

r
2
mitosis) mitosis >1/mm 2, 0.75–0.99 >4 mm (may recommend for staging

8
mm) and local disease control)

:
:
S
u
r
g
i
c
a positive node has been ound has not been shown to lymph node positivity rates (8.7% or ≤1 mm and 12.3% ≥

a
l
improve outcomes in patients with melanoma. 0.76 mm).39 For this special subgroup o thin melanomas,

M
a
Prior to development o the SLNB technique, elective SLNB may be more seriously considered. In addition, lym-

n
a
lymph node dissection was commonly per ormed in the phovascular invasion has also been implicated with a greater

g
e
anatomic site predicted to be most likely to drain a par- likelihood o sentinel lymph node positivity.42 T e utility o

m
ticular lesion. T is practice o ten resulted in signi cant SLNB is a matter o debate in thick (≥ 4 mm) melanomas as

e
n
morbidity and did not of er any survival bene t. SLNB well. Some believe that the high risk o occult disease at the

t
o
was developed in 1990 using radio-labeled colloid, which time o presentation makes SLNB less use ul because o an

f
M
could be injected at the tumor site.27 T e advantage o this overall poor prognosis.43 Others assert the utility o SLNB

e
l
a
technique is its ability to identi y the af erent lymph node even in thick melanoma, citing statistically signi cant dif er-

n
o
that would be predicted to rst receive lymphatic drainage ences in 5 year overall survival rates in positive versus nega-

m
rom the tumor site. T is concept presumes orderly spread tive SLNB o melanomas greater than 4 mm.44

a
rom the primary site to an af erent lymph node and does T e 2010 AJCC guidelines recommend SLNB or greater
not account or hematogenous spread. When per ormed than 4 mm melanomas without radiographic evidence o
by an experienced team, SLNB of ers greater than 95% regional lymph node involvement. T ese guidelines rec-
probability o identi cation o the sentinel lymph node.28,29 ommend SLNB or patients with melanomas less than or
When identi ed, melanoma in a sentinel node is a equal to 1 mm i ulcerated or with one or more mitoses
strong predictor or poor outcome.30,31 In act, a recent per millimeter squared.45 A summary o the guidelines or
study examining disease con ned to sentinel lymph nodes SLNB recommendations can be ound in able 28-1.
versus extension to nonsentinel lymph nodes prognos- In summar y, melanoma is an increasingly common
ticated better outcomes in patients with sentinel lymph tumor that is usually best managed surgically. Wide
node involvement only.32 Despite this prognostic value, local excision is the pre erred initial management or
removal o positive sentinel lymph nodes and their asso- primary tumors and is dictated by depth o invasion.
ciated basin does not appear to carry overall survival Special body sites and tumor types may require modi -
bene t compared to patients undergoing wide local exci- cation o standard techniques, and Mohs micrographic
sion alone.33– 35 Generally, patients with clinically negative surgery can be a use ul technique or lentigo maligna
nodes and primary melanomas with Breslow thickness when combined with rush permanent sections or immu-
greater than 1 mm are routinely of ered SLNB. T is rea- nohistochemistr y to enhance the delineation o periph-
soning derives rom observed risk o sentinel lymph node eral tumor margins. Although SLNB is use ul or staging
metastases based on Breslow depth. and prognosis, it con ers no therapeutic survival bene t
As a result o the low positivity rate in primary melanomas and should be of ered only when clinically appropriate.
o less than 1 mm, SLNB is not routinely recommended or
thin lesions.36 Among thin melanomas, primary tumors o
Breslow thickness less than or equal to 1 mm have a less than r e er en c es
5% nodal metastasis rate, and those less than 0.76 mm have
a less than 2% nodal metastasis rate.36–41 However, there are 1. Siegel R, Naishadham D, Jemal A. Cancer statistics. CA Can-
certain subgroups among these thin melanomas that may be cer J Clin. 2012;62(1):10– 29.
2. Bailey EC, Sober AJ, sao H, Mihm MC Jr, Johnson M. Cutane-
at higher than expected risk based on actors other than the ous melanoma. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller
Breslow thickness. For example, tumors with a mitotic rate AS, Lef ell DJ, Dallas NA, eds. Fitzpatrick’s Dermatology in
greater than zero have been associated with higher sentinel General Medicine. 8th ed. New York, NY: McGraw-Hill; 2008. 351
3 3. Coit DG, Andtbacka R, Anker CJ, et al. Melanoma. J Natl
Compr Canc Netw. 2012;10(3):366– 400.
26. Slinglu CL Jr, Stidham KR, Ricci WM, Stanley WE, Seigler HF.
Surgical management o regional lymph nodes in patients with
4. Bichakjian CK, Halpern AC, Johnson M, et al. Guidelines o melanoma. Experience with 4682 patients. Ann Surg. 1994;
care or the management o primary cutaneous melanoma. 219(2):120–123.
American academy o dermatology. J Am Acad Dermatol. 27. Morton DL, Wen DR, Wong JH, et al. echnical details o
2011;65(5):1032– 1047. intraoperative lymphatic mapping or early stage melanoma.
5. Karimipour DJ, Schwartz JL, Wang S, et al. Microstaging Arch Surg. 1992;127(4):392– 399.
accuracy a ter subtotal incisional biopsy o cutaneous mela- 28. Morton DL, Cochran AJ, T ompson JF, et al. Sentinel node
noma. J Am Acad Dermatol. 2005;52(5):798– 802. biopsy or early-stage melanoma: accuracy and morbid-
6. Ross MI. Excision o primary melanoma. In: Balch CM, ity in MSL -I, an international multicenter trial. Ann Surg.
Houghton AN, Sober AJ, Soong SJ, eds. Cutaneous Melanoma. 2005;242(3):302– 311; discussion 311– 313.
5th ed. St. Louis, MO: Quality Medical Publishing; 2009:251. 29. Stebbins WG, Garibyan L, Sober AJ. Sentinel lymph node
7. Veronesi U, Cascinelli N. Narrow excision (1-cm margin). A biopsy and melanoma: 2010 update part I. J Am Acad Derma-
sa e procedure or thin cutaneous melanoma. Arch Surg. 1991; tol. 2010;62(5):723– 734; quiz 735– 736.
126(4):438– 441. 30. Balch CM, Buzaid AC, Soong SJ, et al. Final version o the
8. Veronesi U, Cascinelli N, Adamus J, et al. T in stage I primary American Joint Committee on Cancer staging system or
cutaneous malignant melanoma. Comparison o excision with cutaneous melanoma. J Clin Oncol. 2001;19(16):3635– 3648.
S
margins o 1 or 3 cm. N Engl J Med. 1988;318(18):1159–1162. 31. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic actors
e
9. Balch CM, Urist MM, Karakousis CP, et al. E cacy o 2-cm analysis o 17600 melanoma patients: validation o the Amer-
c
t
i
surgical margins or intermediate-thickness melanomas (1 to ican Joint Committee on Cancer melanoma staging system.
o
n
4 mm). Results o a multi-institutional randomized surgical J Clin Oncol. 2001;19(16):3622–3634.
3
trial. Ann Surg. 1993;218(3):262–267; discussion 267– 269. 32. Reintgen M, Murray L, Akman K, et al. Evidence or a bet-
10. Karakousis CP, Balch CM, Urist MM, Ross MM, Smith J, ter nodal staging system or melanoma: the clinical relevance
:
:
Bartolucci AA. Local recurrence in malignant melanoma: o metastatic disease con ned to the sentinel lymph nodes.
long-term results o the multiinstitutional randomized surgi- J Surg Oncol. 2013;20:668– 674.
S
k
cal trial. Ann Surg Oncol. 1996;3(5):446– 452. 33. Nowecki ZI, Rutkowski P, Michej W. T e survival bene t to
i
n
11. Balch CM, Soong SJ, Smith , et al. Long-term results o a patients with positive sentinel node melanoma a ter comple-
T
u
prospective surgical trial comparing 2 cm vs. 4 cm excision tion lymph node dissection may be limited to the subgroup
m
margins or 740 patients with 1– 4 mm melanomas. Ann Surg with a primary lesion breslow thickness greater than 1.0
o
r
Oncol. 2001;8(2):101– 108. and less than or equal to 4 mm (p 2-p 3). Ann Surg Oncol.
s
12. Pasquali S, Haydu LE, Scolyer RA, et al. T e importance o ade- 2008;15(8):2223– 2234.
quate primary tumor excision margins and sentinel node biopsy 34. van Akkooi AC, Bouwhuis MG, de Wilt JH, Kli en M,
in achieving optimal locoregional control or patients with thick Schmitz PI, Eggermont AM. Multivariable analysis com-
primary melanomas. Ann Surg. 2013;258(1):152–157. paring outcome a ter sentinel node biopsy or therapeutic
13. T omas JM, Newton-Bishop J, A’Hern R, et al. Excision lymph node dissection in patients with melanoma. Br J Surg.
margins in high-risk malignant melanoma. N Engl J Med. 2007;94(10):1293– 1299.
2004;350(8):757– 766. 35. Morton DL, T ompson JF, Cochran AJ, et al. Sentinel-node
14. Krown SE, Chapman PB. De ning adequate surgery or pri- biopsy or nodal observation in melanoma. N Engl J Med.
mary melanoma. N Engl J Med. 2004;350(8):823– 825. 2006;355(13):1307– 1301.
15. Khayat D, Rixe O, Martin G, et al. Surgical margins in cutane- 36. Bleicher RJ, Essner R, Foshag LJ, Wanek LA, Morton DL. Role
ous melanoma (2 cm versus 5 cm or lesions measuring less o sentinel lymphadenectomy in thin invasive cutaneous mel-
than 2.1-mm thick). Cancer. 2003;97(8):1941– 1946. anomas. J Clin Oncol. 2003;21(7):1326– 1331.
16. Cohn-Cedermark G, Rutqvist LE, Andersson R, et al. Long 37. Rousseau DL Jr, Ross MI, Johnson MM, et al. Revised Ameri-
term results o a randomized study by the Swedish mela- can Joint Committee on Cancer staging criteria accurately pre-
noma study group on 2-cm versus 5-cm resection margins or dict sentinel lymph node positivity in clinically node-negative
patients with cutaneous melanoma with a tumor thickness o melanoma patients. Ann Surg Oncol. 2003;10(5):569– 574.
0.8– 2.0 mm. Cancer. 2000;89(7):1495– 1501. 38. Cascinelli N, Belli F, Santinami M, et al. Sentinel lymph node
17. Johnson M, Sondak VK. Melanoma margins: the impor- biopsy in cutaneous melanoma: the WHO melanoma pro-
tance and need or more evidence-based trials. Arch Derma- gram experience. Ann Surg Oncol. 2000;7(6):469– 474.
tol. 2004;140(9):1148– 1150. 39. Kesmodel SB, Karakousis GC, Botbyl JD, et al. Mitotic rate as
18. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins or a predictor o sentinel lymph node positivity in patients with
melanoma in situ. J Am Acad Dermatol. 2012;66(3):438– 444. thin melanomas. Ann Surg Oncol. 2005;12(6):449– 458.
19. National Comprehensive Cancer Network. NCCN clinical 40. Wright BE, Scheri RP, Ye X, et al. Importance o sentinel
practice guidelines in oncology (NCCN guidelines): melanoma; lymph node biopsy in patients with thin melanoma. Arch
Version v4.2014. Surg. 2008;143(9):892– 899; discussion 899– 900.
20. T ompson JF, Kam PC. Isolated limb in usion or melanoma: 41. Wong SL, Brady MS, Busam KJ, Coit DG. Results o sentinel
a simple but e ective alternative to isolated limb per usion. J lymph node biopsy in patients with thin melanoma. Ann Surg
Surg Oncol. 2004;88(1):1– 3. Oncol. 2006;13(3):302– 309.
21. Quinn MJ, Crotty KA, T ompson JF, Coates AS, O’Brien CJ, 42. Andtbacka RH, Gershenwald JE. Role o sentinel lymph node
McCarthy WH. Desmoplastic and desmoplastic neurotropic biopsy in patients with thin melanoma. J Natl Compr Canc
melanoma: experience with 280 patients. Cancer. 1998;83(6): Netw. 2009;7(3):308– 317
1128– 1135. 43. Balch CM. T e role o elective lymph node dissection in
22. Cohen LM, MCall MW, Zax RH. Mohs micrograhic surgery melanoma: rationale, results, and controversies. J Clin Oncol.
or lentigo maligna and lentigo maligna melanoma. A ollow- 1988;6(1):163– 172.
up study. Dermatol Surg. 1998;24:673– 677. 44. Gutzmer R, Satzger I, T oms KM, et al. Sentinel lymph node
23. Clayton BD, Leshin B, Hitchcock MG, Marks M, White WL. Util- status is the most important prognostic actor or thick (> or =
ity o rush para n-embedded tangential sections in the manage- 4 mm) melanomas. J Dtsch Dermatol Ges. 2008;6(3):198–203.
ment o cutaneous neoplasms. Dermatol Surg. 2000;26:671–678. 45. Balch CM, Gershenwald JE, Soong SJ, et al. Final version o
24. Bhardwaj SS, ope WD, Lee PK. Mohs micrographic surgery 2009 AJCC melanoma staging and classi cation. J Clin Oncol.
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Mel-5 immunostaining: University o Minnesota experience. 46. Wong SL, Balch CM, Hurley P, et al. Sentinel lymph node
Dermatol Surg. 2006;32:690– 696. biopsy or melanoma: American Society o Clinical Oncology
25. Garrison M, Nathanson L. Prognosis and staging in mela- and Society o Surgical Oncology joint clinical practice guide-
noma. Semin Oncol. 1996;23(6):725– 733. line. J Clin Oncol. 2012;30(23):2912– 2918.
352
 Ch a p t e r Management of Advanced

29 Nonmelanoma Skin Cancer

Ct i L T ,M M. T , & Tim t y S. W

In t r o d u c t Io n o blistering sunburns, history o tanning bed use,29 smok-

ing,19,30 and genetic conditions, such as basal cell nevus
syndrome (BCNS) and epidermolysis bullosa.17,18,29,31– 33 O
EpId EmIo l o g y o f n o n mEl a n o ma these, UV radiation is one o the most important causes
Sk In c a n c Er o BCC. In addition to the total radiation dose, the tim-
ing and mode o exposure also seem to contribute to BCC
Skin cancers are divided into two main groups: malignant development. Recent studies showed that acute, intense
melanoma (MM) and nonmelanoma skin cancer (NMSC). incremental UV exposure increases BCC risk more than
T e term “NMSC” encompasses a wide variety o skin similar doses o UV radiation delivered in a more chronic
cancers including basal cell carcinomas (BCC), cutaneous ashion over the same total period o time.26,34 T ere have
squamous cell carcinomas (cSCC), dermato brosarcoma also been studies suggesting that childhood and adoles-
protuberans (DFSP), cutaneous lymphomas, adnexal cence are critical periods or establishing adult BCC risk,
tumors, and Merkel cell carcinoma (MCC), and only thus highlighting the importance o early photoprotective
excludes malignancies involving melanocytes. BCC and measures to prevent the development o BCCs.16– 19,33– 35
cSCC comprise the vast majority o NMSC tumors (esti- Li estyle actors such as smoking have also been suggested
mated between 75% and 80% and 20% and 25%, respec- to contribute to the development o BCCs.19,30
tively)1,2 and their incidence is approximately 18 to 20 times Pathways involved in the growth, apoptosis, or di eren-
higher than that o MM.3 T is chapter will ocus on the tiation o keratinocytes,36– 39 as well as genes that in uence
management o advanced BCC, cSCC, DFSP, and MCC. immune response such as C LA140 also contribute to
T e incidence o NMSC is highest in Australia and the BCC development. Better understanding o these genetic
lowest in parts o A rica.4 abnormalities has led to a better understanding o BCC
In the United States, the total number o NMSC cases pathogenesis.
is reported to be higher than lung, breast, prostate, and
colon cancers combined.5 Over one million new cases o
NMSC are diagnosed each year in the United States alone, Mo LeCu La r Pa Th o g en eSIS o BCCs.
and this has continued to increase at a rate o approxi- Major advances in the understanding o the pathogen-
mately 3% to 8% since the 1960s.3,6 NMSCs are also widely esis o BCCs have come rom extensive studies o patients
believed to be the most commonly diagnosed malignancy with BCNS and the subsequent discovery o mutations in
worldwide.2,7 the tumor suppressor gene, P CH1. BCNS, also known
as Gorlin’s syndrome, is a rare, autosomal dominant syn-
drome, in which patients develop numerous BCCs start-
Ba Sa l c El l c a r c In o ma S ing in childhood, and are at risk o developing medullo-
blastomas and rhabdomyosarcomas.41,42 BCNS is caused
BCC In CId en Ce a n d r ISk a CTo r S. BCC by loss-o - unction mutations in the tumor suppressor
is the most common type o cancer worldwide.8 In the gene, human P CH1, on chromosome 9q22, which is the
United States, the estimated annual incidence is esti- primary inhibitor o Hedgehog (Hh) signaling.43,44 T e Hh
mated to be 0.1% to 0.5%.9 It is especially common in light- signaling pathway plays a critical role in embryonic growth
skinned populations, with the estimated li etime risk o and patterning, as well as in the maintenance o homeo-
developing BCC up to 30% in the United States white pop- stasis postembryonically through e ects on stem cells or
ulation.10 T e incidence is about 30% higher in men than progenitor cells in invertebrate and vertebrate organisms.45
in women,11– 13 and increases with age.14 Interestingly, the T is signaling pathway is constitutively repressed under
incidence o BCC among Americans younger than 40 years normal circumstances, and only activated by binding o Hh
o age, especially among women, seems to be increasing.15 ligand, such as Sonic hedgehog (SHH), Indian hedgehog
Both environmental and genetic actors play a role in the (IHH), and desert hedgehog (DHH), to the transmembrane
development o BCC: these include ultraviolet (UV) radia- receptor P CH1.46 When not bound by Hh ligand, P CH1
tion,16– 19 arsenic exposure,20– 22 history o radiation ther- receptor suppresses the activity o transmembrane protein
apy (R ),23– 25 immunosuppression ( rom various causes Smoothened (SMO). When the P CH receptor is bound
including solid organ transplantation, HIV in ection, by Hh ligand, the repression is released, thus permitting
or chronic steroid use secondary to autoimmune disor- SMO to transmit downstream signals, leading to produc-
ders),26,27 air skin,28 light-colored eyes, red hair, northern tion o Gli amily transcription actors (Fig. 29-1).47– 49 T is
European ancestry, older age, childhood reckling, history receptor ligand association is reversible and has eedback
3 Inac tive
P tch
Ac tive
P tch Hh
T e important role o epithelial– stromal interaction in
creating a avorable environment or tumor cell proli era-
S mo
tion has also been demonstrated. Stromal cells isolated
Hip Hip rom human BCCs express increased levels o gremlin 1,
S mo
? which antagonizes the pro-di erentiation actors, BMP2
Fus e d Fus e d
and BMP4.68,77
S ufu S ufu
Gli Gli
Tr ea TMen T o Ba Sa L CeLL Ca r CIn o Ma .
Appropriate treatment o BCC is necessary due to the
Gli locally invasive and destructive nature o this tumor. T e
Ta rge t ge ne s Ta rge t ge ne s majority o BCCs represent only local disease and carry
an excellent prognosis. T e goal o treatment is complete
tumor extirpation with maximal preservation o unction
Figure 29-1 M l c l p t sis b s l c ll c ci m . and cosmesis. Currently, the widely accepted treatment
modalities include: cryotherapy, electrodesiccation and
S
curettage (ED&C), surgical excision, Mohs micrographic
c
t
i
mechanisms to tightly control transcription and regulate surgery (MMS), topical and intralesional agents (5-FU,
downstream gene expression.50 T e possible regulation o imiquimod, resiquimod, ingenol mebulate, cyclooxygen-
3
Hh signaling by various molecular pathways, including Ras, ase-2 inhibitors, cyclopamine), radiation therapy (R ),
:
nuclear actor-κB, and estrogen receptor-α, which thereby
:
photodynamic therapy, and systemic chemotherapeutic
contributes to carcinogenesis, has also been postulated.46 agents (capecitabine, inter eron, EGFR inhibitors, GDC-
S
T is model demonstrates how either inactivating muta- 0449, LDE-225, vismodegib).74,78 Several actors deter-
i
T
tions in P CH or activating mutations in SMO can result mine the recurrence potential o BCC, including size,
m
in constitutive signaling o Gli and downstream target location (Fig. 29-2), histopathologic subtype, perineural
genes. In patients with BCNS, the inactivating mutation involvement, clinically indistinct borders, patient immune
s
o P CH1 leads to constitutive overexpression o SHH status, primary versus recurrent lesions, and history o
signal, which has been implicated in the development o radiation exposure to the a ected area. T ese risk actors,
BCCs via activation o the transcription actors Gli.51– 56 as well as a thorough understanding o the di erent treat-
Subsequent studies have demonstrated that approximately ment modalities, including their associated risks, compli-
one-third o sporadic BCCs have acquired P CH1 muta- cations, cosmetic outcome, and recurrence rates, should
tions.57,58 Besides UV exposure targeting P CH1,59 the be considered in order to make appropriate treatment
mechanisms involving SHH mutations in sporadic BCC choices.
are likely multi actorial, including activating mutations in Several studies have looked into various characteristics
the SMO gene, a reciprocal translocation between chro- o BCC to determine the risk o tumor recurrence.79–81 T e
mosomes 9q22.3 and 16p, and mutations in P CH2.60– 63 National Comprehensive Cancer Network (NCCN) guide-
Studies o other genetic syndromes associated with lines assess the risk actors or BCC recurrence, as well as
multiple BCCs, such as Bazex– Dupré– Christol syn- proposed primary treatments or low-risk and high-risk BCCs
drome,64 Rombo syndrome,65 cartilage– hair hypoplasia ( able 29-1, Fig. 29-3).82
syndrome,66 and xeroderma pigmentosum,67 have dem- T e majority o NMSC are low risk and can be suc-
onstrated other pathways, including DNA repair and cess ully treated by ED&C, surgical excision, cryotherapy,
telomere maintenance, that play an important role in photodynamic therapy, and topical agents. Patients with
BCC pathogenesis.68 Recent studies have elucidated other BCC who are not considered surgical candidates may be
molecular pathways that may contribute to its pathogen- re erred or radiotherapy, which has a 4 year locoregional
esis as well. T e Wnt pathway is known to play a critical control rate o 86%with a median time to recurrence o 40.5
role in normal hair ollicle development and cycling.68 A months.83 T e use o radiotherapy may be limited in patients
mediator o Wnt signaling, β-catenin, was shown to be with tumors located near the eyes or on the eyelids,84
increased in both human and mouse BCCs.69,70 Another which may be di cult to treat, and patients nearing their
study showed that active Wnt signaling is required or Hh-
driven hamartomas by demonstrating that overexpression
o the Wnt antagonist, Dkk1, in a mouse model, resulted
in the inhibition o hamartomatous growth.71
Some pathways induce BCC ormation by modulating Hh
signaling. T e epidermal growth actor receptor (EGFR)/
MEK/ERK pathway was shown to modulate Gli-dependent
transcription and induce oncogenic trans ormation o
human keratinocytes.68,72,73 Along with the P CH pathway
gene, the p53 tumor suppressor gene is another major target
o UV radiation.74 It plays a critical role in regulation o the
cell cycle and apoptosis, and mutations in it were ound to be
present in about 56% o BCCs.75 p53 can also in uence BCC
development via its in uence on the Hh pathway, as shown
in a study where complete loss o p53 resulted in upregula- Figure 29-2 h i is m s s c b s l
354 tion o SMO in the inter ollicular epidermis in mice.76 sq m s c ll c ci m .
 Ta BLe 29-1
3
r is f s Bc c r e e e

ch e is i l w r is Hi h r is
P im y vs. c t P im y r c t
B s W ll P ly
Imm s pp ssi n Ys
L c ti : ey li s, s, Siz <20 mm Siz ≥20 mm
s , lips, it ls, s, Siz <10 mm Siz ≥10 mm
tC s, , Siz <6 mm Siz ≥6 mm
sc lp, c
T , xt miti s

C
P t l y n l ,s p ci l a ssiv wt p tt

p
P i l i v lv m t n Ys

t
2
Sit p vi s i ti n Ys

9
t tm t

:
:
M
Prima ry tre a tme nt

m
of low-ris k BCC

t
a
v
c
S urgica l Ra dia tion

n
ca ndida te the ra py
No

m
l
Ye s

m
S
i
Curre tta ge a nd In ha ir-be a ring

C
e le ctrode s icca tion* re gion?
No

c
Ye s

Excis ion with

Fa t re a che d? pos tope ra tive
Ye s ma rgin a s s e s s me nt

Re -excis ion, Mohs

s urge ry or re s e ction
with comple te
No Ne ga tive circumfe re ntia l a nd
ma rgins ? de e p ma rgin
No
a s s e s s me nt with froze n
or pe rma ne nt s e ctions

Ye s

Re gula r follow-up

Figure 29-3 T tm t l it m b s l c ll c ci m . 355

3 maximum sa e li etime dose o radiation.85 Use o radio-
therapy is contraindicated in Gorlin’s syndrome86 as well
treatments, ollowed by radiotherapy, cryotherapy, and
photodynamic therapy.88 ED&C can be a cost-e ective
as in BCC that has recurred a ter prior radiotherapy.84 and appropriate treatment choice or low-risk tumors i
Certain BCCs are at higher risk or recurrence based three important actors are kept in mind 74,82:
on their size and location, as well as clinical and micro-
scopic actors. Evidence-based treatment options or 1. T is technique should not be used to treat lesions
BCC are ew because o the rarity o randomized, pro- in hair-bearing sites because o the risk o tumor
spective studies comparing di erent treatment modali- extending down hair ollicles;
ties and their recurrence rates. According to a large 2. I the subcutaneous layer is reached during the ED&C
systematic review that included studies with at least procedure, surgical excision should be per ormed;
50 patients and 5 years’ ollow-up, totaling 9930 pri- 3. I curettage is per ormed based on the clinical
mary BCC cases, MMS had the lowest rate o recur- appearance o tumor, a biopsy should be taken
rence, ollowed by surgical excision, cryosurgery, and to con rm that there are no high-risk pathologic
ED&C.87 T e authors suggested that MMS be used or eatures. Further guidelines and treatment
larger, morphea orm or recurrent BCCs located in dan- algorithms can be ound on the NCCN website:
S
ger zones (Fig. 29-4), and that surgical excision with http://www.nccn.org/.
c
t
i
4 mm margins around the clinical borders o the tumor
Although surgical and other destructive treatments are
be used or well-circumscribed nodular or super cial
3
considered the gold standard o therapy or localized BCC,
BCCs <2 cm in diameter, as well as or re-excision o low-
advancements in understanding BCC pathogenesis have
:
:
risk primary BCCs located on the trunk and extremities.
led to the development o targeted therapies or more
T ey recommended that other treatment modalities be
S
advanced disease. T ese treatments are valuable or
used in patients or whom surgery is contraindicated.74,87
i
patients with unresectable tumors as well as metastases.
T
A Cochrane review analyzing randomized controlled tri-
As discussed earlier, the Hh signaling pathway is now well
m
als examining BCC recurrence rates ound that MMS and
established as playing a critical role in BCC pathogenesis.
conventional surgical excision were the most e ective
s
Primary tre atme nt a Adjuvant tre atme nt

C&E:
• In nonha ir-be a ring a re a s
• If fa t re a che d, s urgica l
excis ion s hould
ge ne ra lly be pe rforme d Mohs or re s e ction with
CCP DMA
or
Re -excis ion with P OMA
or for a re a Le re gions
or
Pos itive RTc
Excis ion with P OMA:
Prima ry
• If le s ion ca n be excis e d
tre a tme nt of
with 4 mm clinica l S e e Follow-up
low-ris k ba s a l Ma rgins
ma rgins a nd s e conda ry (BCC-4)
ce ll s kin Ne ga tive
inte ntion, s ide -to-s ide
ca nce r a
re pa ir, or s kin gra ft b

or

RT c ,d for non-s urgica l

ca ndida te s

a
S e e Principle s of Tre a tme nt for Ba s a l Ce ll S kin Ca nce r (BCC-B). C&E = cure tta ge a nd e le ctrode s icca tion
b
Clos ure s like a dja ce nt tis s ue tra ns fe rs, in which s ignifica nt tis s ue re a rra nge me nt occurs , P OMA = pos tope ra tive ma rgin
a re be s t pe rforme d a fte r cle a r ma rgins a re ve rifie d. a s s e s s me nt
cS ee Principle s of Ra dia tion The ra py for Ba s a l Ce ll S kin Ca nce r (BCC-C).
CCP DMA = comple te circumfe re ntia l
d
RT gene ra lly re se rve d for pa tients over 60 y be caus e of conce rns a bout long te rm s eque lla e. pe riphe ra l a nd de e p ma rgin
e Are a a s s e s s me nt with froze n or
L = trunk a nd extre mitie s (S e e BCC-A). pe rma ne nt s e ctions

Note : All re comme nda tions a re ca te gory 2A unle s s othe rwis e indica te d.
Clinica l Tria ls : NCCN be lieve s tha t the be s t ma na ge me nt of a ny ca nce r pa tie nt is in a clinica l tria l. Pa rticipa tion in clinica l tria ls is
e s pe cia lly e ncoura ge d.

356 Figure 29-4 T tm t l it m i is b s l c ll c ci m .

In 1998, it was observed that lambs developed cyclopia
a ter maternal ingestion o corn lilies, which contain
and neck cancers.1,112,113 In the United States, the inci-
dence o SCC in men is 81 to 136 per 100,000 and 26 to
3
cyclopamine, a potent inhibitor o the Hh signaling path- 59 per 100,000 in women.114 T e risk actors or develop-
way by direct binding to SMO.89,90 Subsequent in vitro ing cSCCs include air skin, male gender, older age (>65
and in vivo studies demonstrated that the oral and topical years old), increased sun exposure, and immunosuppres-
administration o cyclopamine reduced BCC growth and sion such as solid organ transplantation.115 For the last
development in mice and humans.91,92 T ese observations several decades, the incidence o cSCCs has been rising.
led to the synthesis o a novel class o Hh antagonists T is is likely attributable to several actors including an
derived rom cyclopamine with improved pharmaceuti- expanding older population; the incidence o cSCC is
cal properties and in vitro potency.93 Vismodegib (GDC- three times higher or those over the age o 75 compared
0449), a SMO inhibitor, showed promising results in a to those between 50 to 55 years o age.116 Additionally,
phase I trial o patients with locally advanced or meta- there is a growing population o solid organ transplant
static BCC.94,95 recipients whose immunosuppression and longevity o
In a phase II clinical trial o vismodegib, investiga- transplant predispose these patients to numerous and
tors observed such promising results among patients high-risk cSCCs.15,113,114,117,118

C
with locally advanced or metastatic BCC96 and BCNS While the majority o cSCCs are minimally invasive in

p
patients with multiple BCCs that the Data Sa ety Moni- their early stages, the potential or metastasis exists115 with

t
toring Board recommended ending the placebo arm o an approximately 2% to 3% overall rate o regional metas-

2
9
the study.68 Vismodegib demonstrated a 30% response tasis to lymph nodes o the head and neck, primarily to
rate in patients with metastatic BCC (n = 33), and a 43% parotid lymph nodes.119 When cSCCs do metastasize, they

:
:
response rate in those with locally advanced BCC (n = account or 20% o all skin cancer-related deaths.120 T us,

M
63); 21% showed complete responses (CRs).97 More than with an increase in the geriatric population and longer li e
30% o patients reported adverse events including muscle expectancy o immunosuppressed patients, the incidence
spasms, alopecia, dysgeusia (taste disturbance), weight o cSCC will likely continue to rise.

m
loss, and atigue; seven deaths were noted. Acquired cSCC most requently develops on sun-exposed areas
resistance during continuous vismodegib therapy has o the skin.2,119 Up to 75% o NMSCs occur in the head

t
been reported in a case series in 21% o patients (n = 28) and neck region 121 with 68% o all cSCCs occurring on the
with advanced BCCs.98 T e novel use o vismodegib as a head and neck.122 Epidemiologic studies support the role

a
neoadjuvant to shrink a locally advanced BCC prior to o UV light in NMSC pathogenesis since increased rates

v
resection has been reported recently in a patient with are correlated with proximity to the equator 2,117,123 and are

c
Gorlin’s syndrome.99 also seen in areas o ozone depletion, such as Australia,
Potential challenges in the use o Hh signaling path- where the incidence o NMSC is approximately 1000 to

n
way antagonists exist. Studies show that a ter dramatic 2000 per 100,000 per year.1,2,4 Northern European coun-

m
reduction in tumor mass, a small population o residual tries have much lower rates o NMSC.122
tumor cells insensitive to Hh inhibition persist in both T e increased incidence o NMSCs ollowing trans-

l
the mouse model100 and in clinical trials o LDE225.68,101 plantation has been well documented.124– 128 One report

m
Another challenge is the development o resistance documented a three- to ve- old increase in cancer risk
caused by mutations in SMO and ampli cation o in the posttransplant population compared to the general

S
downstream genes including Gli2 and cyclin D1.102,103 population 129 with the incidence o de novo malignancy

i
C
Recently, an alternative SMO inhibitor, itraconazole, an in this population ranging between 6% and 18% in some
FDA-approved anti ungal agent, was ound to inhibit studies.127 Interestingly, the types and distributions o

c
Hh signaling pathway by binding SMO at a site di erent cancers that a ect this population are quite di erent rom
rom that o cyclopamine, delaying BCC development those o the general population.130 While the most com-
in a mouse model.104 Itraconazole is currently undergo- mon tumors in the general population are breast, pros-
ing a phase II study to evaluate its potential as a BCC tate, colon, and lung cancers, the most common types
treatment option. Given the common adverse e ects o o malignancies in transplant recipients are cSCC, BCC,
systemic SMO inhibitors, including loss o taste, muscle and non-Hodgkin’s lymphoma, with the most common
spasms, hair loss, atigue, and hyponatremia,105– 107 a topi- sites o involvement being on the head and neck.129– 131
cal ormulation o SMO inhibitor LDE224 was developed, T e cSCCs in immunocompromised patients are clini-
which produced a decrease in Hh gene expression in the cally aggressive; these patients tend to develop multiple
majority o treated tumors without treatment-related lesions with a higher rate o recurrence and a higher rate
side e ects.101 A number o inhibitors o the Hh signaling o metastasis.124 In particular, transplant patients have a
pathway with targets downstream o SMO, such as Gli 65 times greater risk o developing cSCCs compared to
transcription actors, or independent o SMO, are cur- age-matched controls.132
rently under investigation.108– 111
CLIn ICa L a n d h ISTo Lo g IC ea Tu r eS o
h Ig h -r ISk SCC
Sq u a mo u S c El l c a r c In o ma S S i . T e staging system most o ten used or
NMSCs is the American Joint Commission on Cancer
In CId en Ce a n d r ISk a CTo r S o cSCC. (AJCC) NM system. T e seventh edition o AJCC ( ables
Cutaneous SCC (cSCC) is the second most common type 29-2 and 29-3) includes the clinical and histologic eatures
o skin cancer in Caucasians a ter BCC, accounting or that should be taken into account to better ascertain the
one- th o all cutaneous malignancies and 90% o all head prognosis and natural history o cSCCs. 357
3 p h e esis. cSCC is thought to mani est as a spec- Ta BLe 29-3
trum o progressive changes, rom actinic keratoses (AKs)
S i Bs S s ce S i c e
to SCC in situ (SCCIS), invasive cSCC, and metastatic b p si His i g s
SCC.
According to the classic multistep model o carcino- p si g s St 0 Tis, n 0, M0
genesis, mutations in tumor suppressor genes may cause St I T1, n 0, M0
development o precursor lesions with increased genetic St II T2, n 0, M0
instability, and additional mutations in oncogenes permit St III T3 o r
the emergence o invasive carcinoma.133,134 In the case o Tis T3 wit n 1
St IV T4 o r
cSCC, the mechanism leading to genomic instability is
Tis T3 wit n 2 o r
likely due to UVB-induced inactivation o p53,135 as dem-
n3 o r
onstrated in a study where p53 knockout mice developed M1
increased numbers o AKs and cSCCs a ter UV-B expo-
sure,136 as well as a number o studies con rming the His i g e gX c t b ss ss
g1 w ll if ti t
S
presence o p53 mutations in majority o cSCCs.137– 139 In
g2 m t ly if ti t
c
addition to UV radiation induced signature mutations
t
i
g3 p ly if ti t
(CC→ and C→ ), aberrant activation o EGFR and
g4 if ti t
Fyn, an Src- amily tyrosine kinase, were shown to down-
3
regulate p53 in a c-Jun-dependent manner.140,141
:
:
S
i
T
m
Ta BLe 29-2
S i B s S s ce S i c e b Size/p ese e l hn e I v ve e
s
me s ses

Primary Tumor (excludes eSCC of eyelid)

Stage Def nition High-Risk Features
Tx C tb ss ss d pt >2 mm
Cl l v l ≥4
o – i b i lip
P ly t if ti t
T0 n vi c p im y t m
Tis C ci m i sit
T1 ≤2 cm <2 i is t s
T2 >2 cm o r s ≥2 i is t s
T3 I v s m xill , m ibl , bit, t mp lb s
T4 I v s xi l pp ic l s l t p i ls ll b s

re i l hn e I v ve e
Stage Def nition
nX Lymp sc tb ss ss
n0 n lymp m t st sis
n1 I v lv s si l lymp ≤3 cm
n2 ≥3 cm t ≤6 cm i si l lymp or
n 2b ≤6 cm i m ltipl ipsil t l lymp sor
n 2c ≤6 cm i bil t l c t l t l lymp s
n3 M t st sis >6 cm i lymp

d is me s sis
Stage Def nition
M0 n
M1 P s t

358
 UVB
EGFR
MEK inhibitors
3
BEZ-235 OP B-31121
Ra s S rc/Fyn ERK-1/2
P DK-1 STAT-3
p53 AKT
Ra f P KC δ S rca s m
MK-2206
GS K-690693 CP-31398
Ba x BAD
MEK
Ba k Ra s AKT Tyros ine kina s e s p53 p21

Bcl-XL CP-31398
ERK c-Jun Da s a tinib HDACs
APAF-1 Bcl-2 Erlotinib
mTOR Ge fitinib Notch 1
Cyclin D1 p21

C
Apoptos is
BEZ-235
s e ne s ce nce S urviva l

p
Ce ll

t
prolife ra tion Cyto s o l S6

2
Prone opla s tic Antine opla s tic

9
Nucle us
p53
Figure 29-6 Potential pathways that may be targeted

:
:
c-Jun
by small molecules to treat AKs and cSCCs. k y si l

M
i p t w ys ivi c t s pl si s w .
Sm ll m l c l s t t c p m t t pi mis
Figure 29-5 Key signaling pathways involved in the t t t s si li cits m y v t p tic p
formation of cSCC. M t ti s i c by u VB xp s

m
t ti l. a ws t stim l t y l ti s ips Tb s
c p t b m ltipl c ll l p t w ys, t by c t ib t i ibit y l ti s ips. (r p c wit p mis

t
ti l i t t m ti cSCC. T ic ws si m r t s y V, g b Md , h ic r , r i y TW, S y
si i y i c s c s i si li i SCC. r JT. m ti cyt t c c : t p t sis m

a
T b s i ic t i ibit y l ti s ips. li c t s sq m s c ll c ci m . J Clin Invest.

v
2012;122:464–472.)

c
n
Recently, ampli cation and activating mutations o Ras deep margin assessment (CCPDMA). Standard excision
is permissible or tumors greater than 2 cm on the trunk

m
oncogene, a amily o G P-binding proteins that activates
the Ra /Mek/Erk1/Erk2 kinase pathway, have been ound and extremities with no other high-risk actors, which

l
in SCCs and AKs.142– 145 T e Ras amily o proto-onco- can be excised with a 1 cm clinical margin with a primary
closure.81 In MMS, the surgeon per orms the complete

m
genes promotes cellular growth and proli eration, and
aberrant Ras activation can result in tumorigenic pheno- margin assessment whereas the pathologist per orms this

S
types.145 Interestingly, one study showed that activation o assessment in CCPDMA. Lower recurrence rates have

i
oncogenic Ras alone was not su cient to induce SCC, but been reported with MMS in a systematic review compar-

C
that it was necessary to couple Ras overexpression with ing MMS to standard excision.148 T e cure rate o primary

c
activation o the cell cycle progression mediator CDK4, cSCC with MMS (97%) is reported to be higher than
or to modulate NF-κB activity to bypass Ras-mediated that o standard excision (92%); similarly, the cure rate
G1 arrest and induce epidermal tumorigenesis (Figs. 29-5 o recurrent disease is reportedly higher ollowing MMS
and 29-6).134,146,147 (90%– 94%) than a ter standard excision (77%).148,149
R is another treatment option or cSCC but is reserved
Tr ea TMen T. T e approach to treating cSCC depends or tumors that that are di cult to treat surgically, par-
on its risk classi cation according to the NCCN. T e ticularly on the eyelids, lips, and ears.150 While radiation
NCCN characterizes high-risk cSCC as having any o the can be used as a primary treatment option or cSCCs, it is
ollowing risk actors: large diameter (>2 cm or >1 cm on important to note that reported cure rates are higher with
cheeks, orehead, scalp, or neck, or >6 mm on other areas surgical therapy, and that there are long-term cutaneous
o ace, genitalia, hands, eet), depth >4 mm or beyond risks o radiation and as well as short-term scheduling chal-
the papillary dermis, ill-de ned margins, recurrence a ter lenges.151 As monotherapy, radiation is generally reserved
de nitive treatment, immunosuppression, prior radia- or patients in whom surgery would lead to unacceptable
tion, chronic in ammation, rapid growth, neurological cosmetic or unctional impairment, patients with inoper-
symptoms, perineural or vascular invasion, moderately or able tumors, or in whom the risks o surgery outweigh the
poorly di erentiated histology, in ltrative or acantholytic bene ts. With high-risk cSCC, local control rates with R
pattern, or mucin production.81 For non high-risk cSCC, range rom 80% to 85%.152 When implemented in the right
the NCCN considers standard surgical excision adequate, context, R may match surgery in restoring oral unction
in which the margin assessment is made rom representa- and cure rates or lower lip cSCC.153 In cSCC with aggres-
tive tissue sections. For high-risk cSCC, complete mar- sive eatures, R has been reportedly used as adjuvant
gin analysis is advised by the NCCN either by MMS or therapy to surgery and chemotherapy with some degree
excision with complete circum erential peripheral and o e cacy.152,154,155 359
3 Chemotherapy as a treatment modality or meta-
static cSCC thus ar remains inconsistently e ective.
MCC has a 1 year survival rate o approximately 80%
and a 2 year survival rate o approximately 50%. It most
Combinations o cisplatin with 5- ourouracil (5-FU), commonly a ects the older Caucasian population with
doxorubicin, or bleomycin have been reported to yield adjusted incidence rates o 0.18 to 0.41 per 100,000 per-
some degree o e cacy, with a subset achieving CRs in son-years.169 In the United States, approximately 1500 new
some cases.155– 160 For distant metastatic disease or regional cases are diagnosed each year and the incidence contin-
recurrence, the NCCN recommends consideration o ues to be on the rise.162,170 MCC is more common in sun-
cisplatin-based chemotherapeutic regimens and par- exposed areas, such as the head, neck, and extremities.171
ticipation in clinical trials.158 Combination therapy with T e risk o MCC is signi cantly higher in patients who are
13-cis-retinoic acid and inter eron-alpha therapy, with immunosuppressed 172,173 and in those with other malig-
and without cisplatin, are in clinical trials or unresect- nancies, including multiple myeloma, chronic lympho-
able cSCC.159,161 With the recognition that some cSCCs cytic leukemia, and MM.174,175
overexpress EGFR, EGFR inhibitors have been used o
label in inoperable cases.162 T ere are currently our EGFR
inhibitors on the market: two are small molecules (erlo- Pr eSen Ta TIo n . Clinically, MCC lesions o ten
S
tinib and ge tinib) and two are antibodies (cetuximab and lack distinctive eatures and can present as a rapidly
c
t
growing, asymptomatic, esh-colored to bluish-red
i
panitumumab).163 In a phase II clinical trial, cetuximab has
shown some success as a monotherapeutic agent in con- dermal papule or nodule, clinically mimicking epider-
3
trolling inoperable or metastatic cSCC: a ter 6 weeks o mal inclusion cyst, BCC, or amelanotic melanoma. In
:
2008, Heath et al.176 proposed clinical characteristics o
:
treatment, 69% o enrolled patients were observed to have
some degree o disease control.164 MCC called “AEIOU eatures” obser ved in a series o
S
195 MCC cases over a period o 27 years: asymptom-
i
Combined radiotherapy and EGFR inhibition have
atic; expanding rapidly; immune suppression, older than
T
also shown promising results compared to monother-
m
apy alone. In an NEJM 2006 article, the authors demon- 50 years; and UV-exposed site on person o air skin.
strated that, in patients with locally advanced head and Maintaining vigilance and a high index o suspicion or
s
neck SCC, radiotherapy with cetuximab achieved 49.0 biopsy ollowed by histopathologic con rmation acili-
months median sur vival compared to 29.3 months a ter tates a timely diagnosis.
radiotherapy alone.153 A paper reviewing case reports
and a phase II trial concluded that cetuximab combined
with radiotherapy is superior to cetuximab alone; com-
STa g In g . Once the diagnosis is established, the tumor
is staged according to AJCC NM criteria ( ables 29-4 and
bination therapy showed a total response in 50% o
29-5).177 T e staging system was rst released in 2010; the
advanced SCC cases.165 As radiotherapy combined with
criteria and stage groupings are based on the analysis o
EGFR inhibition has gained traction or advanced cSCC
National Cancer Database data rom more than 4000 MCC
treatment, clinical trials are under way to elaborate the
patients with at least 5 years’ ollow-up. Figure 29-7 shows
cutaneous side e ects due to radiation versus cetux-
the signi cant di erence in survival rates ound between
imab in a large national prospective study in Germany
patients presenting with local, regional, and distant meta-
as o 2013.166 In ver y high-risk SCC, characterized by
static disease.178
lymphovascular or extracutaneous invasion, cetuximab
appears to con er an advantage in controlling disease in
combination with surger y and/ or radiation in a recent Pa Th o g en eSIS. Although the molecular patho-
retrospective study at an academic institution.167 genesis o MCC has not yet been completely elucidated,
Comparison studies o radiotherapy with adjunctive multiple actors appear to contribute to the development
cisplatin-based chemotherapy versus adjunctive EGFR o MCC, including immunosuppression, UV exposure
inhibition are sparse. One recent retrospective study and Merkel cell polyomavirus. T e relative risk o MCC
o patients receiving these combination interventions development increases signi cantly with immunosup-
shows the superiority o adjunctive cisplatin (n = 18) over pression, with a 13 old increase in the HIV population 172
adjunctive cetuximab (n = 29): 83% o patients achieved and a 10 old increase in solid organ transplant patients.173
a 3 year disease-speci c survival period in the cisplatin T ere are multiple reports to support the possible
group compared with 18% in the cetuximab group.156 important role o UV radiation exposure in the etiology
T e advent o EGFR inhibitors marks an exciting period o MCC. In one study o 195 cases o MCC, the lesions
o discovery o new molecular targets or treatment o were observed to arise in sun-exposed areas 81% o the
advanced cSCC. With novel molecules targeting alterna- time.176 In one population-based study o 425 cases o
tive pathways, including PI3 K-AK , ALK-1, NO CH1, MCC rom nine areas o the United States, the Surveil-
and Hh, new monotherapeutic or adjuvant agents promise lance, Epidemiology, and End Results (SEER) Program
new ways to control disease or at least overcome tumor database demonstrated that regional incidence rates o
resistance to EGFR inhibition.168 both cancers increased with increasing sun exposure as
measured by the UV-B solar index.179 One prospective
study o 1380 patients with psoriasis who were treated
mEr kEl c El l c a r c In o ma with oral psoralen and UV-A photochemotherapy
(PUVA) showed an increased risk o MCC development
ePId eMIo Lo g Y a n d r ISk a CTo r S. MCC is in the PUVA treated group compared to controls.180 In
a rare, aggressive neuroendocrine carcinoma o the skin, addition, a C-to- mutation, a typical UV-B induced
360 with a high risk o recurrence and metastasis. Overall, mutation, is ound in MCC cell lines, urther supporting
 Ta BLe 29-4 Ta BLe 29-5
3
S i me e c e c i p si S i me e c e c i

p i t Prognostic Groups St 0 Tis, n 0, M0

St Ia T1, pn 0, M0
Stage Def nition St IB T1, cn 0, M0
St IIa T2 T3, pn 0, M0
Tx C tb ss ss St IIB T2 T3, cn 0, M0
T0 n vi c p im y t m St IIC T4, n 0, M0
St IIIa Tis T4, n 1 , M0
Tis C ci m i sit St IIIB Tix T4, n 1b/n 2, M0
T1 ≤2 cm St IV M1

T2 >2 cm ≤5 cm Histologic Grade gX C t b ss ss

g1 W ll if ti t
T3 >5 cm g2 M t ly

C
T4 I v s m sc l s l t l st ct s g3 if ti t

p
P ly if ti t

t
re i l hn e I v ve e g4 u if ti t

2
9
Stage Def nition

:
nX Lymp sc tb ss ss

:
o MCC, the exact molecular pathogenesis has yet to be

M
pn X Lymp sc tb ss ss
p t l y elucidated ully.
cn 0 Lymp sc tb t ct cli ic lly

m
pn 0 n lymp m t st sis t ct Tr ea TMen T. Currently, the main treatment modalities
p t l y

t
or MCC are surgical resection and radiotherapy, although
n1 Mic m t st sis ( i s t s ti l much controversy exists regarding the speci c role o each

a
l ctiv lymp p t y) modality. T e ollowing are the updated NCCN consensus

v
recommendations or the treatment o MCC.
n 1b M c m t st sis (cli ic lly t ct bl

c
c m by bi psy t p tic
Wide local excision (WLE) o the primary tumor with
lymp p t y) negative margins is the standard treatment or newly diag-

n
nosed MCC patients without evidence o metastasis. T e
n2 I t sit m t st sis ( isti ct m ist l current recommendation or surgical margins depends on

m
t p im y l si b tw p im y l si
the clinical size o the tumor: a 1 cm margin or <2 cm

l
i i i l lymp )

d is me s sis

m
100

S
Stage Def nition

i
Mx C tb ss ss

C
80
M0 n
l
c
a
Lo c al
v
i
v
M1 I s i , s bc t s tiss ist t
r
u
lymp s 60
s
e
v
i
M1b I l s
t
No dal
a
l
e
r
M1c I t visc l sit 40
t
n
e
c
r
e
Me tas tatic
P
20

the role o sun exposure as a actor contributing to MCC

development.181 0
T e observation o clonal integration o polyomavirus 0 1 2 3 4 5
(MCPyV) in human MCC by Feng et al. in 2008 initiated Ye a rs from Dia gnos is
great interest in the study o viral tumorigenesis.182– 184
MCPyV is a nonenveloped, double-stranded DNA virus Lo c al 91% 80% 71% 67% 64%
(n = 2356)
with a reported prevalence in MCC lesions ranging rom
77% to 86%.182,185– 187 Notably, it is not exclusively observed No dal 75% 56% 48% 43% 39%
(n =937)
in MCC, but has also been detected in normal skin and
cSCC.188– 192 Some studies also attempted to demonstrate Me tas tatic 44% 26% 20% 18% 18%
(n = 277)
the association o improved survival with the presence o
MCPyV187,193; other studies were not able to show the prog- Figure 29-7 S viv l t s m p ti ts p s ti
nostic relevance o MCPyV.186,194 Although the emerging wit l c l, i l, ist t m t st tic M l c ll
role o MCPyV provides promising insights into the etiology c ci m . 361
3 tumors and 2 cm margins or >2 cm tumors.195 Almost
one-third o clinically node-negative patients have micro-
the usion gene COL1A1/PDGFB resulting rom the rear-
rangement o upstream regions o the COL1A1 gene in
scopic nodal disease; there ore, or untreated primary 17q21 to 17q22 and exon 2 o PDGF in 22q13.1. T is trans-
tumors, sentinel lymph node (SLN) biopsy is recom- location results in the deregulation o platelet-derived
mended at the time o WLE, examined by both hema- growth actor-beta (PDGFB) expression, thus producing
toxylin and eosin (H&E) and immunoperoxidase staining, continuous autocrine activation o tyrosine kinase PDGF
including CK20.177,178,196 I the SLNs are positive, comple- Receptor B (PDGFRB).215– 217 T is mechanism is thought
tion lymph node dissection with subsequent radiotherapy to be undamental to the development o DFSP, as this
o the basin is recommended.178 usion gene was observed to be present in nearly all cases
MCC has been shown to be a radiosensitive tumor, and o DFSP.215,218 T e usion gene product COL1A1/PDGFB
radiotherapy is currently used as an adjuvant therapy to provides a use ul molecular diagnostic test as well as a tar-
surgical excision in the majority o cases. In one study o get or new molecular therapeutic options.
1254 MCC patients, surgery combined with local radio-
therapy was shown to signi cantly decrease the incidence Tr ea TMen T. T e standard o care in the treatment o
o local and regional recurrence compared with a control patients with localized DFSP is complete resection with
S
group treated with surgery alone.197 Another study dem- negative margins. T e NCCN guidelines recommend some
c
t
i
onstrated improved survival in patients who underwent orm o complete histologic surgical margin evaluation
adjuvant R .198 In inoperable cases radiation monotherapy whenever possible, implementing di erent approaches
3
can provide an alternative therapeutic option.199,200 including: MMS; modi ed MMS (MMS technique with
:
an additional nal margin taken or permanent section
:
T e role o chemotherapy in MCC treatment remains
controversial. In general, MCC chemotherapy regimens assessment); CCPDMA; and 2 to 4 cm margins to invest-
S
ing ascia o muscle or pericranium with clear pathologic
i
are adapted rom those used or small cell carcinoma
margins, when clinically easible.219 Recent studies con-
T
o the lung. T e most common agents include a com-
m
bination o platinum-containing agents with etoposide, ducted in di erent parts o the world consistently show a
which are associated with signi cant morbidity and, signi cant decrease in the rate o recurrence (under 10%),
s
rarely, mortality.201 T ere have been no randomized compared to the recurrence rate o 20% to 60% reported
trials evaluating the e cacy o chemotherapy. Even in in older studies.206,211,220– 224 Especially in anatomically chal-
patients with locally advanced or distant disease show- lenging areas such as head and neck, MMS was shown to
ing initial response to chemotherapy, chemotherapy thus achieve a high cure rate, with the local recurrence rate
ar has not shown any survival bene t.202 Chemotherapy averaging approximately 1.5%.220,225– 233
is, there ore, used mostly as palliative treatment in dis- T e e cacy o R as primary therapy or DFSP is still
seminated disease rather than as primar y or adjuvant controversial given the scant data available.234,235 Cur-
therapy. rently, R is not indicated routinely and is mostly utilized
in the adjuvant setting when negative margins cannot be
achieved surgically.210,219,234– 238
d Er ma t o f IBr o Sa r c o ma DFSP metastasis to the lymph nodes is extremely rare.
pr o t u BEr a n S Although the management strategy is controversial,
lymphadenectomy is generally recommended or patients
ePId eMIo Lo g Y a n d Pr eSen Ta TIo n . DFSP with lymph node spread.239,240 In extremely rare cases o
is a rare, locally aggressive mesenchymal neoplasm with hematogenous metastases, the lungs are the most com-
a generally low malignant potential. Its incidence ranges mon site o involvement, ollowed by brain, bone, and
rom 0.8 to 4.5 cases per million people per year,203– 205 other so t tissues. For isolated, resectable metastatic dis-
accounting or 2% to 6% o all so t-tissue sarcomas diag- ease, resection is recommended.241,242
nosed in the United States206,207 It typically a ects middle- Systemic treatment is indicated or metastatic disease
aged individuals208 with males more commonly a ected and surgically unresectable cases. As discussed previously,
than emales (3:2 ratio),209 and presents as an erythematous the majority o DFSP tumors have the characteristic usion
to violaceous dermal plaque or exophytic tumor with sur- gene product, COL1A1/PDGFB, which is the molecular
rounding telangiectases.210 T e most commonly involved target o the small molecule tyrosine kinase inhibitors
anatomic sites include the trunk (47%), ollowed by the ( KI), such as imatinib, sunitinib, and sora enib. Imatinib,
lower extremity (20%), upper extremity (18%), and head a chemotherapeutic agent commonly used in the treat-
and neck (14%).211 T e lesions show an initial indolent ment o chronic myelogenous leukemia and gastrointesti-
radial growth pattern with satellite peripheral nodules; i nal stromal tumors, inhibits the PDGFR and other receptor
untreated, the lesion grows vertically, invading underlying tyrosine kinases, such as c-kit. T ere have been multiple
structures including subcutaneous tissue, ascia, muscle, studies, including large retrospective series and multi-
or bone with satellite nodules coalescing into a larger center prospective phase II trials, demonstrating that most
tumor to give it its “protuberant” appearance.212 T e diag- patients with advanced DFSP with this speci c transloca-
nosis is made by histologic evaluation, o ten con rmed by tion bene t rom imatinib therapy.217,243– 251 Interestingly,
immunohistochemistry, most notably by the presence o one case report in a patient with locally advanced DFSP
CD34, hyaluronate, and vimentin, and the absence o ac- with a negative 17,22 translocation by R -PCR showed
tor XIIIa and S100.203,213 a partial response to imatinib.252 T ese promising results
promoted interest in the use o imatinib in the neoadjuvant
Pa Th o g en eSIS. DFSP is characterized by a speci c setting or large unresectable or recurrent tumors. Early
362 cytogenetic abnormality. In 1997 Simon et al.214 identi ed studies have demonstrated potential bene ts, including
 3

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a decreased extent o excision and reconstruction and an with metastatic cutaneous squamous cell carcinoma o the

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improved rate o complete resection with negative mar- head and neck. Curr Opin Otolaryngol Head Neck Surg.
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 Ch a p t e r Skin Cancer in the Organ

30 Transplant Patient
S sh J nkins, M r n Cot s, & Fion Zw d

In t r o d u c t Io n ransplant recipients have a f ve- old increase in the

risk o MM, which accounts or 6.2% o posttransplan-
tation skin cancers in adults and 15% in children.7,13 T e
Advances in the management o solid organ transplanta-
mean time ollowing transplantation to the development
tion recipients (O R) have led to improved overall sur-
o melanoma is 5 years.4 O Rs also tend to have lower sur-
vival. However, patients ace many consequences o being
vival rates than immunocompetent patients.14
on long-term immunosuppression, including an increased
T e risk o skin cancers in the pediatric transplant pop-
risk o developing premalignant and malignant skin can-
ulation (<18 years old) is also increased compared to the
cers. T is is likely to pose an increasing challenge to der-
general pediatric population. In a Dutch pediatric kidney
matologists, as the number o patients receiving a solid
transplant recipient population, the standardized risk or
organ transplant continues to grow and the li e expec-
development o NMSC was ound to be 222 old higher
tancy o these patients continues to increase. Skin cancers
than in the general pediatric population.15 Skin cancers
are the most common malignancy posttransplantation,
typically arise 12 to 15 years a ter transplantation, at an
comprising almost 40% o posttransplant malignancies,
average age o 26 to 28 years.15 SCCs are also more com-
and tend to behave more aggressively than in nontrans-
mon than BCCs in pediatric O Rs. In one series, NMSC
plant patients.1 T e increased risk o skin cancer impacts
spread to lymph nodes was more common in pediatric
patient morbidity and quality o li e post transplantation,
transplant recipients compared to adults.16 In this same
and management o such cases places a signif cant burden
series, lip SCC occurred more requently in children than
on diminishing health care resources.
adults, and was associated with a higher rate o lymph
node metastases.16
EpId EmIo l o g y
Nonmelanoma skin cancers (NMSC) are the most requent r Is k Fa c t o r s a n d
cutaneous malignancies in O Rs, with squamous cell car-
cinomas (SCC) and basal cell carcinomas (BCC) repre-
pa t h o g En Es Is
senting about 90% to 95% o the total in multiple reported
cohorts.2,3 Although the incidence o both types o malig- UV radiation exposure is the primary carcinogen promot-
nancies is increased, the rate o SCC is disproportionately ing NMSC development in O Rs, which is easily appre-
higher. In the immunocompetent population, BCC is the ciated considering that these lesions occur with greatest
more common type o NMSC. However, in the transplant requency on sun-exposed sites. Increased total sun bur-
population the ratio is reversed with the ratio o SCC to den prior to transplant (as measured by Fitzpatrick skin
BCC o at least 4:1.4,5 Although the risk o BCC is increased type, latitude o residence, and occupational and leisure
10 to 16 old, SCC occurs at a requency 65 times that o sun exposure history) is correlated with an increased risk
the general population.1,6 O Rs are also at increased risk o skin cancer ollowing transplantation.5,17
or developing other premalignant and malignant cutane-
ous conditions, including actinic keratoses (AKs), Bowen’s
disease (SCC in situ), malignant melanoma (MM), Kaposi’s Ta bl e 30-1
sarcoma, Merkel cell carcinoma (MCC), atypical f broxan- ri F f d eve e fs i c e i
thoma (AFX), lymphoma, and angiosarcoma.7– 10 However, o t r e i ie
the incidence o SCC predominates in this population.
T e majority o transplant patients usually develop mul- Fitzp trick skin typ I to III
tiple SCCs. T e time period between transplantation and Incr sing g t tr nsp nt tion
development o a skin cancer varies rom a ew months to Dur tion nd v of immunosuppr ssion
up to 20 years, depending on the length o time a ter trans- Typ of org n tr nsp nt (h rt/ ung > kidn y > iv r)
plantation, the level o sun exposure, skin type, and other Pr vious tr nsp nt
risk actors predisposing to SCC ( able 30-1).1 About 25% Squ mous c c rcinom for tr nsp nt
o O Rs will develop a second SCC within 13 months and History of ymphom pr /posttr nsp nt
50% within 3.5 years o their f rst SCC.11 T e increased Pr tr nsp nt nd org n dis s ( .g., rh um toid rthritis,
incidence o SCC in O Rs is such that the diagnosis o a syst mic upus ryth m tosus, or utoimmun h p titis)
f rst SCC has been shown to be predictive o the develop- l iv r tr nsp nt r cipi nts with psori sis on pr vious io ogic
th r py/psor n p us u tr vio t a ight phototh r py
ment o additional NMSC within 5 years.12
 Male gender and age greater than 50 years at the time
o transplantation are associated with an early increase in
Immu n o s u ppr Es s Io n
3
NMSC number. Younger patients initially have a lower risk
O Rs require li elong immunosuppression to prevent
o developing a cutaneous neoplasm, but due to cumula-
potentially atal organ rejection and to preserve gra t
tive immunosuppression, their risk increases dramatically
organ unction. T is includes both initial and long-term
as they age.18 O Rs with a history o NMSC are at high risk
maintenance immunosuppression. Induction therapy
o developing a second skin malignancy and, there ore,
is an aggressive immunosuppressive regimen started
require requent skin screening examinations due to their
be ore, at the time o , or immediately ollowing transplan-
elevated risk.12,19
tation in order to deplete or modi y -cell responses at
Risk or the development o cutaneous malignancy is also
the time o initial allogra t antigen presentation. T erapy
related to the type, intensity, and duration o immunosup-
consists o treatment with either a lymphocyte-depleting
pression. Although individual immunosuppressive agents
agent (antithymocyte globulin, antilymphocyte globulin
act via di erent mechanisms to potentiate the e ects o
[OK 3], or muromonab CD3) or an IL-2 receptor antag-
photocarcinogenesis, studies have ailed to demonstrate
onist (basiliximab and daclizumab), and is intended to
a consistent correlation between individual agents and

C
reduce acute rejection rates and improve the e cacy o

h
overall risk o keratinocyte malignancy. Instead, it appears
subsequent immunosuppression.1 Increased rates o post-

p
that the intensity and duration o immunosuppression is

t
transplantation lymphoproli erative disorder and NMSC

r
more closely associated with increased risk. Patients on

3
are seen a ter induction with lymphocyte-depleting

0
triple therapy are more likely to develop skin cancer than
antibodies.26
those on dual or monotherapy.20

:
:
Maintenance immunosuppression is typically achieved
with a combination o immunomodulatory agents;

S
k
the goal o treatment is long-term prevention o gra t

i
n
u V Ex po s u r E a n d mo l Ec u l a r rejection and ongoing preservation o gra t unction. In

C
c h a n g Es

n
general, higher doses o immunosuppressive agents are

c
used during the immediate posttransplant period, ol-

r
T e role o UV radiation in the induction and promotion

i
lowed by dose reduction in stable patients to minimize

n
o cutaneous carcinogenesis is mani old; it is the major

t
toxicity.

h
mutagen causing keratinocyte DNA damage and also leads Immunosuppressive agents can compound the e ects

O
to suppression o antigen presentation by Langerhans cells

r
o UV exposure in O Rs and accelerate cutaneous car-
in the skin, thereby inducing tolerance to aberrant pho- cinogenesis independent o their role in depressing

n
todamaged cells. T e combination o decreased immuno-

T
immune surveillance. Cyclosporine A has been shown

r
surveillance and immunosuppressive medications leads to to promote the ormation o skin cancers via multiple

n
s
down-regulation o the host response against cutaneous

p
mechanisms, including increased secretion o GFβ,
neoplasms in O Rs.21 increased expression o vascular endothelial growth ac-

n
t
T e p53 tumor suppressor gene is the most commonly tor (VEGF), decreased p53-induced apoptosis, inhibition

P
mutated gene in skin cancer and is particularly sensitive

t
o nucleotide excision repair ollowing photodamage,

i
to UV-induced damage. p53 mutations are detected in

n
and tolerance o keratinocyte survival under conditions

t
up to 60% o NMSCs in O Rs, and the majority (78%) o increased genotoxic stress ollowing UV radiation
have UV-speci c C to transitions at dipyrimidine sites.22 via inhibition o mitochondrial permeability transition
Normal-appearing skin adjacent to known cutaneous car- pore opening.27– 32 Cyclosporine A has also been shown
cinoma in O Rs is ound to have aberrant p53 patches to induce A F3 production through inhibition o the
with greater requency than in matched, immunocompe- calcineurin/NFA pathway, resulting in inhibition o
tent controls. T ese patches represent microscopic pre- p53-dependent cellular senescence and uncontrolled
cursors o SCC and can serve as markers or increased tumor growth.33
SCC risk.23 T e active metabolite o azathioprine, 6-thioguanine, is
incorporated into keratinocyte DNA, resulting in abnor-
mal photosensitivity with decreased UV-A minimal
h pV erythema dose (MED-A) and accelerated photocarcino-
genesis.34,35 T e use o azathioprine has also been shown to
T e role o human papillomavirus (HPV) in ection in increase cellular susceptibility to mutagenesis via inhibi-
cutaneous carcinogenesis is less well de ned. Up to 90% tion o postreplicative DNA mismatch repair.36 It has also
o O Rs will develop HPV-induced verrucous lesions as been demonstrated that azathioprine exposure can lead to
a result o their immunosuppressed status. In addition, BCCs on nonphotoexposed skin with unusual G:C to A:
HPV DNA is detected in up to 75% o SCCs rom O Rs transitions in the P CH gene at nondipyrimidine sites.37
versus 37% o SCCs rom immunocompetent controls.24 Ho bauer et al.38 recently demonstrated the photosensi-
It is hypothesized that inactivation o cell cycle regula- tizing e ects o azathioprine in renal transplant patients,
tor y proteins p53 and pRb by viral oncogenes E6 and E7 by replacing azathioprine with mycophenolate mo etil
may act synergistically with UV-induced DNA damage and measuring the MED ollowing UV-A radiation. T e
to promote keratinocyte tumorigenesis.25 Additional mean MED response was much higher, demonstrating
study is needed to urther elucidate the role o HPV a marked reduction in photosensitivity in renal trans-
in ection in the promotion o NMSC in the transplant plant patients in whom the conversion to mycophenolate
population. mo etil occurred. 371
3 Vo r Ic o n a z o l E Ta bl e 30-2
F w-u I e v f t B s ki
Other nonimmunosuppressive agents commonly used in Ex i i f s i o t i
the treatment o O Rs with potential to increase risk o
posttransplant malignancy include voriconazole. Vori- I e v f t B
conazole, a second-generation triazole anti ungal used or s ki Ex i i
treatment and prophylaxis o invasive aspergillosis in lung p ie ri kF (n . f m h )
transplant recipients, has been shown to increase the risk
No skin c nc r/f d 12
o NMSC; a potential mechanism may be via a phototoxic
dis s
reaction in which the voriconazole N-oxide metabolite is
excited by radiation in the UV-B range. Predisposition to Fi d dis s 3–6
cutaneous toxicity is seen in individuals with genetic poly- On nonm nom skin 3–6
morphisms o the cytochrome p450 enzyme CYP2C19.39 c nc r
T ere have been multiple reports documenting aggressive
S
Mu tip nonm nom 3
and multi ocal SCCs in immunocompromised patients
c
skin c nc rs
t
undergoing treatment with voriconazole, and it has
i
o
n
recently been shown that a longer duration o treatment High risk squ mous c 3
3
leads to increased numbers o NMSCs, supporting its role c rcinom or m nom
in accelerated keratinocyte carcinogenesis.40– 43 In a study
:
:
M t st tic squ mous c 1–3
o lung transplant recipients on voriconazole, Zwald et al. c rcinom or m nom
S
k
determined that length o time a ter transplantation, age,
i
n
skin type I or II and months o exposure to voriconazole
T
u
were ound to be independent risk actors or the num-
m
o
ber o skin cancers a ter lung transplantation. Duration o
r
s
voriconazole exposure was ound to correlate with NMSC patient population with numerous and aggressive skin
number. All patients exposed to voriconazole should be cancers. Comprehensive and ef ective multidisciplinary
educated about their increased risk o skin cancer and dermatologic care o these patients is a necessity. Regard-
should have regular dermatologic ollow-up or skin less o clinic design, an organized and rmly established
cancer screening. Physicians caring or lung transplant clinic model to allow proactive and ongoing care or these
recipients should consider alternatives to voriconazole in patients is important or education, prevention, and early
patients at risk.43 intervention.45 Ideally, all patients should be seen prior
to transplantation or a total body skin examination to
evaluate and treat preexisting lesions, and this examina-
ma n a g EmEn t tion should be repeated in the immediate posttransplant
period. At the Emory ransplant Dermatology Clinic
pa t IEn t Ed u c a t Io n patients are strati ed according to risk actors, such
as prior history o skin cancer, cumulative li etime sun
Patient education regarding adequate sun protective exposure, duration o time posttransplant, skin type, and
measures and appropriate sunscreen application is the history o sunburns. Patients are scheduled or evalua-
most important tool in managing and preventing skin tion and ollow-up based on their individual risk actors.
cancer in solid O Rs. At the Emory ransplant Specialty All O Rs are, there ore, evaluated pre- and posttrans-
Dermatology clinic, patient education in sun protection plant as per protocol. T is system enables those patients
is integrated into the care o O Rs both pre- and post- at high risk to be evaluated in a more timely ashion
transplantation. Education includes counseling on sun ( able 30-2).46
protection, appropriate sunscreen and sun-protective Patients also receive in ormation about per orming sel -
clothing use, and strong recommendations against the skin examinations or suspicious lesions, and high-risk
use o tanning salons. Sun-associated behavior modi ca- patients with a known history o skin cancer are taught
tion posttransplant has been proven to reduce the risk how to per orm a pertinent lymph node examination. T e
o developing NMSC, even in patients with a history development o cutaneous malignancy negatively impacts
o prior SCC.44 Vitamin D de ciency is a consequence patients’ quality o li e ollowing transplantation, and
o aggressive photoprotection, and O Rs should be intervention with regular skin examinations not only less-
screened and supplemented accordingly. T e American ens morbidity associated with skin cancer but can improve
Academy o Dermatology recommends daily supplemen- overall quality o li e in the posttransplant period.47,48 In
tation with 1000 IU o D3 in adults who regularly and our practice we have established a system that autho-
properly practice photoprotection. rizes designated transplant coordinators to overbook
transplant patients with new or concerning lesions that
may occur between regularly scheduled ollow-up visits
pa t IEn t a c c Es s t o s pEc Ia l t y so that they may be evaluated in a more timely ashion.
t r a n s pl a n t d Er ma t o l o g y c l In Ic s T is arrangement is easily acilitated through the use o
electronic medical records. All o the a orementioned rec-
Specialty transplant dermatology clinics of er more timely ommendations allow or better utilization o diminishing
372 access to the care o O Rs, who represent a complex clinical resources.
 Ta bl e 30-3
3
c em w a i i
1. W sh ct d r ( ith r g or rm) with so p nd w t r.
2. a pp y thick co t o 5 f uorour ci (shou d whit ).
For th or rms, st rt on th dors h nd nd xt nd to
ow th ow.
For th ow r g, st rt on th mid oot nd xt nd to th
upp r c .
For oth r s, tr t circum r nti y, oth ct d nd
non ct d skin.
3. For th ow r g, pp y V s in g uz on th nt rior o
nk .
4. a pp y zinc impr gn t d g uz , such s (Unn p st ) with
50% ov r p ov r 5 FU.

C
h
5. Cov r with K r ix with minim ov r p.

p
6. Cov r with 6 in co n or s dh ring wr p.

t
7. P ti nt r mov s wr p t r 1 wk, w sh s r nd r turns

r
3
to c inic or r pp ic tion.

0
8. Continu s n c ss ry, usu y 4–12 wk.

:
:
S
k
i
n
is mediated by disruption o RNA synthesis as well as

C
via inhibition o thymidylate synthetase leading to de-

n
creased DNA synthesis.50,51 Despite its widespread use,

c
there are ew randomized controlled trials examining

r
i
n
the e icacy o 5-FU in O Rs. A single study per ormed

t
h
Figure 30-1 Fi d dis s on th dorsum o th h nd in in 2007 compared the use o methyl 5-aminolevu-

O
r n tr nsp nt r cipi nt. linate photodynamic therapy (MAL-PD ) with a typi-

r
g
cal 3 week course o twice daily application o 5-FU in

n
transplant recipients and ound that the 5-FU group

T
r
c o n c Ept o F FIEl d c a n c Er Iz a t Io n experienced only an 11% rate o complete clearance o

n
the treated ields, with a mean decrease in lesional area

s
p
otal body skin examination in O Rs can be challenging o 79%.52 his is in marked contrast to prior studies o

n
5-FU in immunocompetent hosts, where rates o com-

t
due to the presence o di use areas o photodamage with

P
“ eld cancerization” in which it can be exceedingly di - plete clearance o the treated ield as high as 90% have

t
been reported, likely secondar y to the background im-

i
cult to determine which o the many keratotic lesions may

n
munosuppression seen in O Rs.53

t
be an actual skin cancer (Fig. 30-1). AKs and verrucae are
associated with areas o actinic damage and represent clin- 5-FU can be used repeatedly in O Rs and no stud-
ical and subclinical lesions o epidermal dysplasia. Warts, ies to date have reported adverse e ects on gra t unc-
AKs, and porokeratoses should be treated aggressively at tion. Application under occlusion (chemowraps), applied
rst development, and i they are pain ul, have an atypi- weekly and le t in place or 5 to 7 days, may increase
cal appearance, are enlarging, or do not respond to usual e cacy and may be use ul or treating larger areas o
therapy, should be immediately biopsied or histological disease.54 able 30-3 provides an explanation o the
evaluation. chemowrap technique: in brie , topical 5-FU is applied
T e use o curettage and other destructive modalities is under occlusion to a ected areas on the orearms, dorsal
use ul in the treatment o individual lesions. T e implemen- hands, and/or lower extremities. T e patient returns or
tation o cyclical topical therapies has been added to tradi- weekly assessments by the dermatologist with care being
tional surgical approaches in the treatment o clinical and taken to avoid the occurrence o super cial in ection or
subclinical lesions in large, sun-exposed sites ( eld therapy), skin ulceration. At the end o treatment, any lesions that
with good success in reducing overall burden o premalig- remain should be biopsied to rule out invasive disease.
nant disease. Various modalities will be explored in greater Curettage o lesions prior to chemowrap application may
detail below and may be employed in repeated rotation or shorten duration o therapy.
the treatment o larger areas o eld cancerization.49
IMIq UIMOD 5% CRea M. Imiquimod is a mem-
ber o the imidazoquinoline group, possesses antiviral
t o pIc a l t h Er a pIEs and antitumor activities, and is approved by the FDA or
treatment o condyloma acuminata, AKs, and super cial
TOPICa l 5-Fl UOROURa CIl 5%. opical BCCs less than 2 cm on the neck, body, or extremities in
5-f uorouracil (5-FU) is an antimetabolite that has been immunocompetent adults. Its activity is thought to be me-
used or nearly 50 years in treating premalignant skin diated in part by interactions with oll-like receptor ( LR)
disease in the immunocompetent population and is 7 and stimulation o both innate and adaptive immune re-
commonly used or ield treatment in O Rs. Its e ect sponses.55– 57 A 2007 study examining the e cacy and sa ety 373
3 o topical 5% imiquimod in O Rs demonstrated reduced
cutaneous dysplasia with complete clearance rates o AKs
a c It r Et In
as high as 62%. No adverse e ects on gra t organ unction
Systemic retinoids, speci cally acitretin, have demonstrated
were noted during or ollowing treatment with imiquimod
utility in suppressing AK and SCC development in O Rs.67
on areas o 100 cm 2 three times per week over 16 weeks.58
T is is the result o multiple downstream e ects secondary
Combination with 5% 5-FU (imiquimod applied Monday,
to the binding o acitretin to the nuclear retinoid receptor,
Wednesday, and Friday and 5-FU applied twice daily on o
including promotion o cell maturation and di erentia-
days) may enhance e cacy o each individual agent and has
tion as well as down-regulation o proto-oncogene expres-
been used success ully to treat lower extremity SCC in situ
sion.68–70 Retinoids can be used both to prevent morbidity
in renal transplant recipients.59
rom multiple primary NMSCs as well as to decrease the
risk o mortality rom a single, high-risk tumor. Chemopre-
INg eNOl MebUTa Te. Ingenol mebutate is a re-
vention with acitretin should be considered in transplant
cently approved topical medication or the treatment o
recipients, particularly those developing multiple NMSCs
AKs on the scalp, trunk, and extremities. It is derived
annually (5– 10 per year), those with extensive actinic dam-
rom the milkweed plant, Euphorbia peplus, and is a
S
age and a history o multiple skin cancers, in those patients
hydrophobic macrocyclicditerpene ester. T e proposed
c
t
with a history o high-risk SCCs or metastatic SCC, and in
i
mechanism o action in immunocompetent hosts involves
o
n
patients with eruptive keratoacanthomas.71 It is important
rapid lesion necrosis and speci c neutrophil-mediated,
3
to recognize that this is a long-term therapy; cessation o
antibody-dependent cellular cytotoxicity.60 Clearance
treatment results in prompt recurrence and rebound e ect
:
:
rates with ingenol mebutate in immunocompetent hosts
o premalignant/malignant skin disease that can be di cult
are comparable to those achieved with topical imiqui-
S
k
to control.72,73
i
mod and 5-FU, with the major advantage being a short
n
T e side e ect pro le o acitretin therapy in O Rs is sim-
T
2 or 3 day treatment course. Adverse e ects are similar
u
ilar to that seen in the immunocompetent population and
m
to those seen with other topical treatments or premalig-
o
includes mucocutaneous xerosis, elevated serum lipids,
nant skin disease and include erythema, f aking, scaling,
r
s
and transaminitis. T ese e ects appear to be dose related.74
crusting, swelling, vesiculation, pustulation, erosions, or
Initiation o therapy at low doses (10 mg every other day)
ulceration.61 Ingenol mebutate has not yet been studied
and increasing at 10 mg increments at 2 to 4 week inter-
exclusively in O Rs or other immunosuppressed popula-
vals to a goal dose o 20 to 25 mg daily can minimize side
tions and it remains to be seen what role it will play in the
e ects by preventing sudden onset o severe mucocutane-
care o such patients.
ous symptoms. Baseline asting lipids, comprehensive met-
abolic panel and complete blood count should be obtained
ph o t o d yn a mIc t h Er a py and rechecked at 2 to 4 weeks and then at monthly intervals
or the rst 3 months o therapy. Acitretin is a teratogen
Several recent studies have examined the e cacy o PD and pregnancy category X and should never be used during
in the treatment o eld cancerization in O Rs. PD pregnancy. T e use o retinoids in women o childbearing
employs a topical photosensitizer ollowed by exposure age must be care ully weighed against these risks and regu-
to a noncoherent light source; light is absorbed by the lar pregnancy testing is critical. Other contraindications to
photosensitizing agent and subsequently generates reac- use include severe lipid abnormalities re ractory to stan-
tive oxygen species. MAL is a methyl ester o aminolevu- dard therapies.
linic acid (ALA) and is converted into photo-activated
porphyrin pre erentially in cancer cells.62 T ree separate c a pEc It a BIn E
studies evaluating the e cacy o topical PD with MAL
or AKs in O Rs demonstrated complete clearance rates Capecitabine is the rst FDA-approved oral chemo-
o 64% to 89% and a 71% to 76% decrease in number o therapeutic agent and was initially used in patients with
AKs. T ese studies all ollowed similar protocols, which metastatic breast cancer and later in patients with both
involved curettage o lesions prior to treatment, and use metastatic and primary colon cancer. In 2006, Peramiquel
o noncoherent red light.52,63,64 T e most notable adverse et al.75 reported inf ammation and regression o AKs in
e ect associated with PD is moderate to severe pain patients receiving capecitabine and shortly therea ter the
during treatment. use o this medication was explored in patients at high risk
A small study ollowed 12 high-risk O Rs who received or NMSC, including O Rs.
cyclic PD using 20% 5-ALA and blue light every 4 to Capecitabine is a prodrug o 5-FU and the nal step in
8 week intervals over 2 years and monitored development its conversion is mediated in peripheral tissues by thy-
o urther SCC compared to pretreatment; the median midine phosphorylase, which is expressed at greater lev-
reduction in invasive and in situ SCC at 12 and 24 months els in some carcinomas. Be ore starting therapy patients
posttransplant was 79% and 95% respectively, showing must be tested or activity o dihydropyrimidine dehy-
promise or this treatment modality.65 drogenase, an enzyme involved in uracil and thymine
PD has previously been demonstrated as a success ul metabolism as de ciency can lead to toxicity ollowing
therapy or BCCs in immunocompetent patients, and was exposure.
recently shown to be e ective or treating similar lesions wo retrospective reviews examined the use o low-
in the transplant population: MAL-PD was used to treat dose oral capecitabine in O Rs with recurrent NMSC.76,77
18 transplant recipients with BCCs with only one recur- In these studies patients were treated in repeated 3 week
374 rence at 26 months post treatment.66 cycles o 1 to 1.5 g/m 2 daily or 14 days, ollowed by 7 days
o no treatment. A smaller study, which included only
three patients, reported a dramatic decrease in the num- Ta bl e 30-4
3
ber o malignant skin lesions requiring excision in the 6 hi - i k Fe e f scc i o
months ollowing study onset compared to the 6 months
t p ie
immediately prior (only one lesion excised compared to a l r siz (>2 cm)
total o 35 excisions in the preceding 6 months). A study o Mu tip squ mous c c rcinom s
15 solid O Rs demonstrated a signi cant decrease in the Hi h risk oc tion ( r, ips, ov r p rotid nd, sc p, or
incidence o SCCs in 80% o treated patients. In addition, t mp )
40% o patients had reduction in the rate o BCC occur- In tr nsit m t st tic sion
rence, and 53.3% o patients had a decrease in number o R curr nc
AKs. No evidence o rebound a ter stopping therapy was Histo o y
reported. However, in this study 73% o patients eventu- Poor y dif r nti t d
ally developed grade 3 or 4 toxicities, most commonly P rin ur inv sion
atigue (40%), hand– oot syndrome (20%), and diarrhea D p inv sion
(20%), and 33% o patients had discontinued treatment by

C
h
1 year. No cases o gra t rejection were reported in either

p
publication.

t
r
T ese early reports o capecitabine use in O Rs suggest HIg H-RISK SCC. Features attributable to high-risk

3
0
that overall this is a relatively sa e treatment, especially at SCC include large size (>2 cm), location (ear, lips, scalp,
low doses, but urther prospective studies are needed to temple, over parotid gland), histology o the lesion (poor

:
:
characterize its long-term sa ety and ef cacy in the trans- di erentiation, perineural invasion or deep invasion), es-

S
plant population. Use o capecitabine in our institution is

k
pecially i occurring in an immunocompromised patient

i
n
per ormed in close collaboration with medical oncology ( able 30-4, Fig. 30-2).73 Patients with high-risk SCC

C
and the transplant team. should be treated and monitored aggressively given their

n
c
increased risk o developing metastases. In these patients,

r
MMS is recommended to achieve rapid and complete tu-

i
n
mor extirpation, especially or tumors located on the head

t
s u r g Ic a l t r Ea t mEn t

h
and neck. Alternatively, high-risk SCC can be removed

O
with a wider margin o at least 10 mm per NCCN guide-

r
ma n a g EmEn t o F Ba s a l c El l lines. Preoperative C /MRI or PE /C may be required

n
to evaluate or deep extension or nodal involvement in

T
c a r c In o ma

r
such lesions.

n
s
p
T e management o BCC in O Rs is similar to manage-

n
ment in immunocompetent patients. Although several

t
P
small case series have reported successes with treatments

t
such as PD and 5% imiquimod cream in O Rs,66,78 sur-

i
n
gical treatment remains the standard o care. T e AAD/

t
ACMS/ASDSA/ASMS 2012 Appropriate Use Criteria or
Mohs Micrographic Surgery (MMS) report deemed MMS
the appropriate therapy or immunocompromised patients
with BCCs o any size or histologic subtype on the ace,
neck, scalp, ears, genitalia, hands, eet, nail units, nipples/
areolae, ankles, and pretibial sur aces. MMS was elt to be
inappropriate or the same patient population with pri-
mary nodular BCCs ≤0.5 cm or primary super cial BCCs
≤1 cm on the trunk or extremities (excluding those areas
mentioned previously).79

ma n a g EmEn t o F s q u a mo u s c El l
c a r c In o ma
l OW-RISK SCC. T e treatment o low-risk SCC in
O Rs is similar to that in immunocompetent individuals
with use o standard excision with a minimum o 4 mm
surgical margins recommended per the National Compre-
hensive Network (NCCN) guidelines. In addition, cyclical
use o topical therapies, including 5-FU and imiquimod,
or use o PD is a necessity given the presence o eld
cancerization that can progress to SCC in situ and SCC.
Addition o a systemic retinoid should be considered in Figure 30-2 Hi h risk SCC on th t t mp in r n
patients at risk or developing multiple SCCs. tr nsp nt p ti nt. 375
3 Ta bl e 30-5
I i i f r i i t e i t e e
f scc i o t r e i ie
Nonsurgic c ndid t s
a djuv nt th r py for incomp t tumor r s ction
a djuv nt th r py for ymph nod invo v m nt
a djuv nt th r py for p rin ur tumor invo v m nt

Adjuvant therapy with either node dissection and/or

radiation therapy should also be considered, especially i
perineural invasion is present, even in the absence o clini-
cally palpable lymphadenopathy. Radiation therapy used
S
as a primary treatment option leads to lower cure rates
c
t
Figure 30-3 In tr nsit SCC in ung tr nsp nt p ti nt.
i
than surgical therapy, and should be reserved or patients
o
n
where tumors are inoperable or when the risks o surgery
3
outweigh the bene ts. T e use o radiation therapy in
:
transplant patients is outlined in able 30-5.73 recurrent tumor (Fig. 30-3). reatment o these lesions
:
Radiation therapy ollowing tumor removal has better must be individualized, but usually requires wide surgical
S
k
outcomes than surgery alone, according to nonrandom- excision ollowed by wide- eld AR .73,91
i
n
ized case series data.80 In patients with perineural invasion,
T
u
m
adjuvant radiation therapy (AR ) reduces the incidence o
s En t In El l ymph n o d E BIo ps y
o
local recurrence.81 Per NCCN guidelines, adjuvant radia-
r
s
tion should be used at the primary tumor site i substantial
Surgical staging o the primary nodal basin achieved by
perineural invasion is identi ed, de ned as “involvement o
sentinel lymph node biopsy (SLNB) has been shown to
more than just a ew small sensory nerve branches or large
be a prognostic actor in melanoma. T ere are emerg-
nerve involvement,” though in reality, its use is not always
ing data indicating that SLNB may have a role in high-
restricted to carcinomas involving large nerves.82 Salvage
risk SCC. Lymph node involvement rom high-risk SCC
radiation carries a higher risk o local, regional, and distant
has an increased risk o recurrence and death.92 SLNB
recurrence, but might be required in settings where there
may accurately detect subclinical lymph node metastasis
are positive margins ollowing MMS or excision.82,83
in patients, potentially allowing or the earliest possible
Head and neck SCC with disease metastatic to the lymph
therapeutic lymphadenectomy i the SLNB is positive.73,93
nodes portends a poor prognosis. reatment o these
Prospective studies are needed to determine which risk
patients may require re erral to EN surgery or paroti-
actors predict nodal and distant metastases, and thus
dectomy with or without neck dissection along with AR
which patients warrant a SLNB. A recent study by Kwon et
to improve local and regional control.73,84 T e addition o
al. analyzed the results o SLNB in 128 patients with high-
radiation therapy ollowing lymphadenectomy can result
risk SCC without nodal involvement clinically. A positive
in a 73% 5 year disease- ree survival.85 T e NCCN recom-
SLNB was ound in 14% o cases. O the high-risk cases,
mends AR in all head and neck SCC nodal metastases, and
SLNB had a negative predictive value o 97.8% and a alse
it should be considered in cases o SCC on the trunk and
negative rate o 15%. Despite the high negative predictive
extremities ollowing lymphadenectomy.82 Patients should
value, long-term ollow-up and close monitoring o these
be ollowed closely, with requent PE -C or MRI.
patients is recommended, as most o the data were derived
T e role o chemotherapy in treatment o high-risk SCC
rom studies with a short ollow-up period.94
remains unclear.73 Metastatic SCC may be treated with
cisplatin monotherapy or in combination with other sys-
temic agents, such as methotrexate, 5-FU, bleomycin, and ma n a g EmEn t o F o t h Er
doxorubicin, all with limited ef cacy data. Capecitabine,
the oral 5-FU prodrug, has been used as monotherapy as ma l Ig n a n c IEs : mEl a n o ma
well as in combination with subcutaneous inter eron, with
possible improved outcomes.86,87 T e use o capecitabine O Rs have a three- to ve- old increased risk or develop-
with cisplatin or paclitaxel in SCC o head and neck has ment o MM, with similar risk actors as those in the general
shown avorable outcomes in phase II trials.88,89 T erapy population.4 T ree main clinical scenarios arise; namely,
targeting epidermal growth actor receptors (EGFR), such pre-transplant MM, donor-transmitted MM, and de novo
as cetuximab, is being explored in treatment o SCC in MM occurring posttransplantation.95 T e management o
clinical trials, but is being used o -label currently to treat pre-transplant MM and de novo MM occurring posttrans-
SCC.90 T e NCCN guidelines recommend consideration plantation is the same as in immunocompetent individuals.
o cisplatin-based therapy and clinical trial participation MM in situ and thin melanoma (<1 mm) in the transplant
or metastatic disease or regional recurrence.82 population have recurrence and survival estimates similar
In-transit metastases o high-risk SCC in O Rs pres- to those in the general population. A minimum wait time o
ent as rapidly enlarging subcutaneous nodules with no 2 years prior to transplantation is suggested or MM with
376 epidermal extension in close proximity to the primary or a Breslow depth less than 1 mm and no clinical evidence o
metastasis. More advanced MM may have a more aggres-
sive course in transplant recipients. SLNB may be o addi-
T e patient’s transplant physician should make all deci-
sions regarding adjustment or reduction o immunosup-
3
tional prognostic bene t. Revision o immunosuppression pression, with dermatology acting in a consulting role.
in the management o de novo melanoma in collaboration T ere are several ways to achieve reduction in immu-
with the transplant team should be considered. Larger nosuppression. T e dosage o therapy may be lowered,
prospective studies utilizing uni orm staging criteria or, at or or patients on multidrug regimens, especially triple
minimum, Breslow depth, are required to assess true risk therapy, it may be possible to discontinue an agent with-
and outcome o MM in the immunosuppressed transplant out signi cantly impairing gra t unction. Another rea-
population. Emphasis remains on patient education and sonable strategy is conversion rom a calcineurin inhibitor
regular screening to provide early detection o MM.95 and antimetabolite-based immunosuppressant regimen to
one based on a mammalian target o rapamycin (m OR)
inhibitor (sirolimus or everolimus). Sirolimus is a potent,
mEr kEl c El l c a r c In o ma nonnephrotoxic immunosuppressant with both antitu-
mor and antiangiogenic properties. Several studies have
O Rs are also at risk or development o MCC, with an shown a signi cant decrease in the rate o de novo malig-

C
h
estimated relative risk o 5 to 10 compared to the general nancies in those patients treated with an m OR inhibitor

p
population.96 MCC tend to develop 7 to 8 years posttrans- as part o their immunosuppressive regimen, and it has

t
plant, and o ten arise on the head and neck.97 In O Rs,

r
been demonstrated to trigger regression o pre-existing

3
MCC behaves aggressively with rapid growth, ulceration,

0
NMSC in O Rs.98– 101 wo recent, multicenter, open label,
and a poor prognosis. reatment o MCC is based on extent controlled trials have been published examining the use o

:
:
o disease, with local disease requiring wide local excision sirolimus in renal transplant recipients with a history o
with 2.5 to 3 cm margins or MMS. SLNB with or without

S
NMSC.102,103 Patients were randomized either to continue

k
i
complete dissection, and AR , usually to the primary site

n
calcineurin inhibitor therapy or convert to sirolimus. One

C
and a ected lymph node, is recommended.97 Reduction o study demonstrated that yearly NMSC rates were signi -

n
immunosuppression should also be considered. cantly lower within the sirolimus group (this reduction

c
r
was seen in the rate o SCC development but not in that

i
n
o BCCs), and that a lower proportion o patients receiv-
a t ypIc a l FIBr o x a n t h o ma a n d

t
h
ing sirolimus developed new or recurrent NMSC or new
u n d IFFEr En t Ia t Ed pl Eo mo r ph Ic

O
SCCs compared with patients on other regimens. How-

r
s a r c o ma ever, discontinuation rates secondary to adverse events

n
were signi cantly higher with sirolimus.102

T
r
AFX and undi erentiated pleomorphic sarcoma (UPS) T e second study investigated the rate o survival ree

n
have a higher rate o local recurrence and metastasis in o new NMSC at 2 years o treatment and did not dem-

s
p
O Rs.9 reatment should be aggressive, with MMS or onstrate a signi cant di erence in the number o new

n
WLE (2 cm margins) ollowed by wide- eld AR .9 McCop- SCCs between sirolimus and calcineurin inhibitor in the

t
P
pin et al. describe their experience in O Rs and outline the intention to treat analysis; however, the length o disease-

t
value o MMS in the treatment o AFX in immunocom-

i
ree survival was signi cantly increased in the sirolimus

n
promised patients. Progression to UPS and a possible role group. Rates o drug-related adverse events were high, and

t
o immunosuppression are also discussed.9 23% o patients treated with sirolimus discontinued the
drug prior to study completion. T e authors did note that
patients on progressive conversion protocols (>7 day tran-
t h E r o l E o F r EVIs Io n o F sition rom calcineurin inhibitors to sirolimus) had lower
Immu n o s u ppr Es s Io n rates o discontinuation and serious adverse events than
those on rapid protocols.103
Patients who develop more than 5 to 10 high-risk SCCs per Despite its promising anticarcinogenic properties, siro-
year or those with a high risk o metastasis rom a cutane- limus is not appropriate therapy or patients within the
ous malignancy may bene t rom a revision o immuno- rst 6 months ollowing transplant due to its deleterious
suppression. A 2006 consensus survey by the International e ects on wound healing. Other reported adverse e ects
ransplant Skin Cancer Collaborative (I SCC) and the include hyperlipidemia, myelosuppression, proteinuria,
Skin Care in Organ ransplant Patients Europe (SCOPE) edema, pneumonitis, thrombotic microangiopathy, and
supports reduction/alteration o immunosuppression as an acnei orm eruptions.
adjuvant management strategy or patients with substan-
tial morbidity and mortality resulting rom MM or NMSC.
Multiple hypothetical scenarios were modeled by the con- EmEr g In g t h Er a pIEs
sensus group with the conclusion that more aggressive
revision o immunosuppression (weighed against the con- SCCs have an overexpression and ampli cation o EGFR.
comitant increased risk o allogra t ailure) was warranted Cetuximab, a monoclonal antibody to the EGFR receptor,
in those patients with higher-risk skin malignancies.71 has been used in metastatic SCC o the head and neck.
Multiple actors must be considered i contemplating a However, as mentioned earlier, the clinical use o this
reduction in immunosuppression, including patient age, treatment in cutaneous SCC is currently being evaluated
previous history o rejection, and type o allogra t. Patient in phase I and II clinical trials. Cetuximab is airly well
survival rom melanoma or NMSC must be balanced with tolerated, with the most common side e ect being acne-
survival and quality o li e related to their gra t unction. i orm eruptions. T e use o cetuximab in lung transplant 377
3 patients should be cautioned, given that there are a ew
case reports in the literature o atal alveolar hemor-
13. Hollenbeak CS, odd MM, Billingsley EM, Harper G, Dyer
AM, Lengerich EJ. Increased incidence o melanoma in renal
transplantation recipients. Cancer. 2005;104(9):1962– 1967.
rhage.104 A retrospective review comparing the treatment
14. Brewer JD, Christenson LJ, Weaver AL, et al. Malignant
o high-risk SCC versus very-high-risk SCC (de ned as melanoma in solid transplant recipients: collection o data-
perineural, parotid, cartilaginous, or bony invasion, in- base cases and comparison with surveillance, epidemiology,
transit metastasis, or regional or distant metastasis) in and end results data or outcome analysis. Arch Dermatol.
immunocompetent patients showed that patients with 2011;147(7):790– 796.
15. Euvrard S, Kanitakis J, Cochat P, Claudy A. Skin cancers
very-high-risk SCC treated with adjuvant cetuximab, or
ollowing pediatric organ transplantation. Dermatol Surg.
cetuximab and radiation, had a small bene t.105 Another 2004;30(4 Pt 2):616– 621.
case series described eight patients, our with SCC and 16. Penn I. De novo malignancy in pediatric organ transplant
our with BCC, treated with cetuximab with a 62.5% com- recipients. J Pediatr Surg. 1994;29(2):221– 226; discussion
plete remission. However, in the patients who achieved 227– 228.
17. erhorst D, Drecoll U, Stockf eth E, Ulrich C. Organ trans-
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plant recipients and skin cancer: assessment o risk actors
Future phase III trials need to be pursued to investigate with ocus on sun exposure. Br J Dermatol. 2009;161(Suppl
urther the role o chemotherapy in the treatment o SCC.
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3):85– 89.
18. MoloneyFJ, Comber H, O’Lorcain P, O’KellyP, Conlon PJ, Mur-
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phy GM. A population-based study o skin cancer incidence
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c o n c l u s Io n
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2006;154(3):498– 504.
19. Mackenzie KA, Wells JE, Lynn KL, et al. First and subse-
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quent nonmelanoma skin cancers: incidence and predictors
requires a multidisciplinary approach. Education o these in a population o New Zealand renal transplant recipients.
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k
patients and requent total body skin examinations are Nephrol Dial ransplant. 2010;25(1):300– 306.
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cal therapy, surgical excision, and use o adjuvant therapy a ter early cyclosporine withdrawal reduces the risk or can-
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intrapatient comparative study o 5-f uorouracil cream and Wolverton SE, ed. Comprehensive Dermatologic Drug T er-
topical photodynamic therapy. Br J Dermatol. 2007;156(2): apy. 2nd ed. Philadelphia, PA: Elsevier; 2007:275– 300.
320– 328. 75. Peramiquel L, Dalmau J, Puig L, Roé E, Fernández-Figueras
53. Pearlman DL. Weekly pulse dosing: e ective and com- M , Alomar A. Inf ammation o actinic keratoses and acral
ortable topical 5-f uorouracil treatment o multiple acial erythrodysesthesia during capecitabine treatment. J Am
actinic keratoses. J Am Acad Dermatol. 1991;25(4):665– 657. Acad Dermatol. 2006;55(5 Suppl):S119–S120.
54. Ritchie SA, Patel MJ, Miller SJ. T erapeutic options to 76. Endrizzi B , Lee PK. Management o carcinoma o the skin
decrease actinic keratosis and squamous cell carcinoma inci- in solid organ transplant recipients with oral capecitabine.
dence and progression in solid organ transplant recipients: a Dermatol Surg. 2009;35(10):1567– 1572.
practical approach. Dermatol Surg. 2012;38(10):1604– 1621. 77. Jirakulaporn , Endrizzi B, Lindgren B, Mathew J, Lee PK,
55. Sauder DN. Immunomodulatory and pharmacologic prop- Dudek AZ. Capecitabine or skin cancer prevention in solid
erties o imiquimod. J Am Acad Dermatol. 2000;43(1 Pt 2): organ transplant recipients. Clin ransplant. 2011;25(4): 379
S6–S11. 541– 548.
3 78. Vidal D, Alomar A. E cacy o imiquimod 5% cream or
basal cell carcinoma in transplant patients. Clin Exp Derma-
in a series o 21 patients. Dermatol Surg. 2004;30(4 Pt 2):
651– 655.
tol. 2004;29(3):237– 239. 92. Mullen J , Feng L, Xing Y, et al. Invasive squamous cell car-
79. Conolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ cinoma o the skin: de ning a high-risk group. Ann Surg
ASDSA/ASMS 2012 Appropriate use criteria or Mohs Micro- Oncol. 2006;13(7):902– 909.
graphic Surgery. J Am Acad Dermatol. 2012;67(4):531–550. 93. Ross AS, Schmults CD. Sentinel lymph node biopsy in cuta-
80. Jambusaria-Pahlajani A, Hess SD, Katz KA, Berg D, Sch- neous squamous cell carcinoma: a systematic review o the
mults CD. Uncertainty in the perioperative management o English literature. Dermatol Surg. 2006;32(11):1309– 1321.
high-risk cutaneous squamous cell carcinoma among Mohs 94. Kwon S, Dong ZM, Wu PC. Sentinel lymph node biopsy or
surgeons. Arch Dermatol. 2010;146(11):1225–1231. high-risk cutaneous squamous cell carcinoma: clinical expe-
81. Ross AS, Whalen FM, Elenitsas R, Xu X, roxel AB, Sch- rience and review o literature. World J Surg Oncol. 2011;
mults CD. Diameter o involved nerves predicts outcomes 9:80.
in cutaneous squamous cell carcinoma with perineural inva- 95. Zwald FO, Christenson LJ, Billingsley EM, et al. Mela-
sion: an investigator-blinded retrospective cohort study. noma in solid organ transplant recipients. Am J ransplant.
Dermatol Surg. 2009;35(12):1859– 1866. 2010;10(5):1297– 1304.
82. Miller SJ, Alam M, Andersen J, et al. Basal cell and squamous 96. Nghiem P, Jamies N. Merkel cell carcinoma in organ trans-
cell skin cancers. J Natl Compr Canc Netw. 2010;8(8):836–864. plant recipients. In: Otley CC, Stasko , eds. Skin Disea se in
S
83. Kwan W, Wilson D, Moravan V. Radiotherapy or locally Organ ransplantation. New York, NY: Cambridge Univer-
advanced basal cell and squamous cell carcinomas o the sity Press; 2008:190– 194.
c
t
i
skin. Int J Radiat Oncol Biol Phys. 2004;60(2):406– 411. 97. Poulsen M. Merkel-cell carcinoma o the skin. Lancet Oncol.
o
n
84. Stasko , Brown MD, Carucci JA, et al. Guidelines or the 2004;5(10):593–599.
3
management o squamous cell carcinoma in organ trans- 98. Kau man HM, Cherikh WS, Cheng Y, Hanto DW, Kahan BD.
plant recipients. Dermatol Surg. 2004;30(4 Pt 2):642– 650. Maintenance immunosuppression with target-o -rapamycin
:
:
85. Veness MJ, Morgan GJ, Palme CE, Gebski V. Surgery and inhibitors is associated with a reduced incidence o de novo
adjuvant radiotherapy in patients with cutaneous head and malignancies. ransplantation. 2005;80(7):883– 889.
S
k
neck squamous cell carcinoma metastatic to lymph nodes: 99. Yakupoglu YK, Buell JF, Woodle S, Kahan BD. Individualiza-
i
n
combined treatment should be considered best practice. tion o immunosuppressive therapy. III. Sirolimus associated
T
u
Laryngoscope. 2005;115(5):870– 875. with a reduced incidence o malignancy. ransplant Proc. 2006;
m
86. Cartei G, Cartei F, Interlandi G, et al. Oral 5-f uorouracil in 38(2):358– 361.
o
r
squamous cell carcinoma o the skin in the aged. Am J Clin 100. Fernandez A, Marcen R, Pascual J, et al. Conversion rom cal-
s
Oncol. 2000;23(2):181– 184. cineurin inhibitors to everolimus in kidney transplant recip-
87. Wollina U, Hansel G, Koch A, Köstler E. Oral capecitabine ients with malignant neoplasia. ransplant Proc. 2006;38(8):
plus subcutaneous inter eron alpha in advanced squa- 2453– 2455.
mous cell carcinoma o the skin. J Cancer Res Clin Oncol. 101. de Fijter JW. Use o proli eration signal inhibitors in non-
2005;131(5):300– 304. melanoma skin cancer ollowing renal transplantation.
88. Hitt R, Jimeno A, Rodriguez-Pinilla M, et al. Phase II trial Nephrol Dial ransplant. 2007;22(Suppl 1):i23– i26.
o cisplatin and capecitabine in patients with squamous cell 102. Campbell SB, Walker R, ai SS, Jiang Q, Russ GR. Ran-
carcinoma o the head and neck, and correlative study o domized controlled trial o sirolimus or renal transplant
angiogenic actors. Br J Cancer. 2004;91(12):2005– 2011. recipients at high risk or nonmelanoma skin cancer. Am J
89. Bentzen JD, Hansen HS. Phase II analysis o paclitaxel and ransplant. 2012;12(5):1146– 1156.
capecitabine in the treatment o recurrent or disseminated 103. Euvrard S, Morelon E, Rostaing L, et al. Sirolimus and sec-
squamous cell carcinoma o the head and neck region. Head ondary skin-cancer prevention in kidney transplantation. N
& neck. 2007;29(1):47– 51. Engl J Med. 2012;367(4):329– 339.
90. Clinical rials.gov. Phase III randomized study o adjuvant 104. Leard LE, Cho BK, Jones KD, et al. Fatal di use alveolar
intensity-modulated radiotherapy with versus without damage in two lung transplant patients treated with cetux-
cetuximab in patients with locally advanced resected squa- imab. J Heart Lung ransplant. 2007;26(12):1340– 1344.
mous cell carcinoma o the head and neck. Clinical rials. 105. O’Bryan K, Ratner D, eds. Evolving Paradigm for the Workup
gov identi er: NC 00956007. http://clinicaltrials.gov/show/ and Management of Very High Risk Cutaneous Squamous
NC 00956007. Accessed Aug. 6, 2014. Cell Carcinoma. Chicago, IL: American College o Mohs
91. Carucci JA, Martinez JC, Zeitouni NC, et al. In-transit metas- Surgery; 2012.
tasis rom primary cutaneous squamous cell carcinoma in 106. Kalapurakal SJ, Malone J, Robbins K , Buescher L, Godwin J,
organ transplant recipients and nonimmunosuppressed Rao K. Cetuximab in re ractoryskin cancer treatment. JCancer.
patients: clinical characteristics, management, and outcome 2012;3:257– 261.

380
 Sect ion
a s i
P
l s
s
4
ch a pt er

31 Cosmeceuticals and Topical Agents

Zoe Diana Draelos

In t r o d u c t Io n procedures. A healthy bio lm can be an asset to procedural

dermatology because there is a limit to how many bacte-
rial and ungal organisms can live in a square centimeter
opical agents are important in procedural dermatol-
o skin. Colonization with nonpathogenic organisms, such
ogy. T ey can prevent in ection, improve the skin barrier,
as Mala ssezia ur ur and Staphylococcus epidermidis, can
minimize pain, create an environment or wound healing,
limit the ability o pathogenic organisms, such as Candida
decrease scarring, and enhance skin appearance. T e most
albicans and methicillin-resistant Staphylococcus aureus
basic o topical agents important or skin health are cleans-
(MRSA), to grow. On the other hand, it has been suggested
ers designed to maintain a healthy bio lm key to the preven-
that inadvertent injection o bio lm organisms into the
tion o wound in ection. A specialized subset o cleansers
skin with llers has resulted in sterile granuloma orma-
are hand sanitizers used by physicians and patients alike, as
tion. Nevertheless, the bio lm must be controlled to pre-
the most accessible source o pathogens or wound in ec-
vent postprocedural in ections.
tion is the hands. Moisturizers are sometimes required due
T e main method o controlling the bio lm is through
to the overly aggressive e ects o cleansers and are use ul
cleansing. Cleansing temporarily removes the bio lm, but
in improving postprocedural skin appearance and creat-
recolonization occurs rapidly in a contaminated world. It
ing an environment or barrier repair and healing. Many
is thought that the pH o healthy skin is 5, but this is really
scar creams are specialized moisturizers with an impor-
the pH o the bio lm. T e slightly acidic bio lm pH lim-
tant subset considered as FDA 510(k) cleared prescription
its the growth o organisms and must be maintained. For
products. Some contain interesting new ingredients, such
this reason, it is important to understand the role o skin
as stem cell extracts and peptides, engineered to promote
cleansing in procedural dermatology.
healing with market crossover into the anti-aging market.
T is chapter discusses these technologies and their rel-
evance to procedural dermatology. Sk In c l ea n SIn g
Skin cleansing is an important mechanism or procedural
t h e Sk In BIo f Il m in ection prevention, and represents a complex interac-
tion between the skin sur ace, physical rubbing, and the
T e skin bio lm assumes great importance in procedural chemistry o the cleanser. Even though cleansing is a rou-
dermatology because it can become a source o organisms tine skin hygiene event, it is technologically pro ound. T e
resulting in postprocedural complications. T e bio lm cov- invention o soap ranks along with clean water and public
ers every inch o the skin and is composed o sebum, eccrine sewers as one o the major advances providing improved
and apocrine secretions, environmental dirt, cosmetics, health in the United States.
skin care products, bacteria, yeast, and ungal organisms. T ere are three types o traditional cleansers classi ed as
It can be diminished, but not eliminated. Even a ter aggres- soap: true soaps, syndets, and combars. rue soaps, such
sive skin cleansing, the bio lm begins to reappear almost as Ivory (Procter & Gamble) are composed o long-chain
immediately. T is begs the question as to whether the bio- atty acid alkali salts with a pH o 9 to 10. T ese true soaps
lm is an asset or hindrance to the success o dermatologic can alkalinize the skin bio lm, which some researchers
4 believe can contribute to irritation. I the bio lm is alkalin-
ized, healthy skin will rapidly regain its slightly acidic pH,
Quaternary ammonium compounds, such as benzal-
konium chloride or benzethonium chloride, represent
but this may not be the case in skin disease. rue soaps do another category o hand sanitizers. While the ethanol-
an excellent job o removing sur ace sebum, but can also based hand sanitizers are f ammable, the quaternary
remove the intercellular lipids. ammonium compounds are not and can be used around
T e need to remove only sur ace sebum, leaving the cautery and laser equipment. Quaternary ammonium
skin barrier undamaged, led to the development o syn- compounds adsorb to the cytoplasmic membrane o
thetic detergents, known as syndets. Syndets contain less microbes causing leakage o cytoplasmic contents. T ey
than 10% soap. It is or this reason that they can be used are bacteriostatic against gram-positive bacteria and some
requently or daily bathing without causing eczematous gram-negative bacteria and are also ungistatic. T ey are
disease in most individuals. Syndets also have a lower pH not active against nonenveloped viruses. It is interesting to
o 5.5 to 7, which is closer to natural neutral skin pH, result- note that some species o S. aureus carry a gene that allows
ing in less alkalinization o the skin. However, this point resistance to quaternary ammonium compounds. T ese
is somewhat controversial. T ere are people who design organisms are more likely to be antibiotic resistant as well.
cleansers that believe a pH as close to neutral as possible Quarternary ammonium compound hand sanitizers may
S
e
is desirable, as it does not alter the pH o the skin. T is is not be the best choice when MRSA is a concern.
c
t
i
in contrast to the Japanese, who believe that skin cleansers T e Center or Disease Control (CDC) considers hand
o
n
should be ormulated at a slightly acidic pH, because they sanitizers to be a mainstay in the prevention o worldwide
4
eel that bacterial killing occurs better in an acidic environ- disease transmission. Alcohol-based hand sanitizers have
:
:
ment. Others state that the cleanser pH does not matter, as become an international standard or hand hygiene and
healthy skin returns to its normal pH rapidly a ter cleans- are endorsed by the World Health Organization (WHO) as
A
e
ing. T e controversy has yet to be resolved. part o its Patient Sa ety Initiative.1 However, hand sanitiz-
s
t
h
T e most important cleansers rom a dermatologic pro- ers do not kill all organisms. For example, hand sanitizers
e
t
cedural standpoint are the combars. T ese are products are not e ective against Clostridium di cile, which has
i
c
a
that contain both soap and syndet cleansers, usually with become another antibiotic resistant organism. A study in
n
d
an added topical antibacterial, such as triclosan (Dial, Dial health care workers demonstrated better skin condition
L
with the use o hand sanitizers as opposed to requent hand
a
Corporation; Irish Spring, Colgate-Palmolive). riclosan is
s
e
chemically known as 2,4,4’-trichloro-2’-hydroxydiphenyl washing, attesting to their mildness when used repeatedly.2
r
P
ether. It is a chlorinated phenolic compound that is also
r
o
used as a surgical scrub. riclosan kills organisms by dam-
c
mo ISt u r Iz er S
e
d
aging the cell membrane, but has weak activity against
u
r
gram-negative bacteria, such as Pseudomonas. Recent FDA
e
s
concerns have been expressed regarding the widespread Skin cleansing is important to normalize the bio lm and
use o triclosan and its environmental impact, accompanied prevent in ection postprocedurally, but maintenance o
by concerns o possible growing bacterial resistance. Nev- the skin barrier is equally important to prevent in ection
ertheless, triclosan remains an important pre- and post- and promote healing. In viable epidermis, the nucleated
procedural cleanser to normalize the bio lm and prevent cells possess tight gap and adherens junctions with desmo-
in ection. somes and cytoskeletal elements that contribute to the bar-
rier. In the stratum corneum, the skin barrier is ormed by
protein rich intervening intercellular lipids that are synthe-
h a n d Sa n It Iz er S sized in the keratinocytes during epidermal di erentiation
and extruded into the extracellular domains. T ese lipids
Hand sanitizers represent a subset o cleansers with unique are composed o ceramides, ree atty acids, and choles-
importance to procedural dermatology. Not only are hand terol, which covalently bind to the corni ed envelope pro-
sanitizers used by dermatologists to clean the hands prior teins. Changes in these intercellular lipids and alterations
to surgery in some cases, but patients can also use hand in epidermal di erentiation lead to barrier de ects and
sanitizers to minimize in ection ollowing invasive proce- delayed postprocedural healing.
dures. In 2007, USA oday listed hand sanitizers as one Moisturizers that are medically relevant increase skin
o the 25 inventions, along with cell phones, that changed hydration and improve skin tactile characteristics. T ey
modern li e during the past 25 years. Hand sanitizers all do so by leaving a skin lm that creates an arti cial barrier,
into several categories on the basis o composition: alco- thereby decreasing evaporation o water rom the skin to
hols, quaternary ammonium compounds, and triclosan, the lower humidity atmosphere. Moisturizers do not mois-
discussed previously under antibacterial cleansers. turize the skin. In the strictest sense, the word “moistur-
T e largest category o hand sanitizers is based on alco- izer” is a misnomer, as moisturizers do not add water to the
hols. Alcohols have been used or disin ection or over 100 skin. Any water in a moisturizer ormulation is a vehicle
years and are highly e ective because they nonspeci cally that evaporates, possibly drying the skin urther, without
denature proteins. T e most e ective alcohol used in hand enhancing skin water content. T is explains why requent
sanitizers is ethanol, which is generally recognized as sa e application o moisturizers will urther damage xerotic skin
and e ective by the FDA. Ethanol has excellent killing due to repeated wetting and drying o the skin sur ace.
properties against both gram-positive and gram-negative Moisturizers hydrate the skin by decreasing transepi-
bacteria and ungal organisms, but is not e ective against dermal water loss ( EWL) and attracting water to the
bacterial spores and has variable e cacy in killing envel- dehydrated stratum corneum and epidermis. Substances
382 oped viruses. that reduce EWL are oily and occlusive ( able 31-1).
 TAbLe 31-1
has approved them as a 510(k) device. T e 510(k) device
approval process was originally developed to ensure the
4
m is izi g I g i s mi i izi g sa ety o equipment with an on/o switch. Lasers, light
t s pi W l ss devices, cardiac pacemakers, and insulin pumps repre-
sent equipment requiring this type o approval. Although
Silicon : dim thicon , cyclom thicon
creams are not traditionally thought o as “devices,” they
V g ta l oils: grap s d, orag , jojo a, s sam s d received approval because they induce a physical change
Alcohols: c tyl alcohol, st aryl alcohol in the skin. T is physical change was documented as an
increase in skin hydration resulting rom a decrease in
P trol um d rivativ s: p trolatum, min ral oil
EWL.
Much like the previously described moisturizers, bar-
rier repair products place a water impervious lm over the
Substances that attract water to the skin are known as
skin sur ace, which decreases EWL. EWL is elevated
humectants ( able 31-2). T e best moisturizers delivering
when the skin barrier is damaged, representing the physi-
skin hydration will contain both occlusive and humectant
ologic signal or barrier repair initiated by ceramide syn-

C
ingredients. T e sum o these skin e ects results in an

h
thesis. By decreasing EWL, barrier creams hydrate the

a
environment that is optimal or barrier repair and healing

p
skin and create an environment optimal or healing. T ere

t
in a postprocedural setting.

r
are a variety o di erent ormulations that presently have

3
1
510(k) approval and produce barrier repair by di erent
emo l l Ien t S a n d Sc a r c r ea mS mechanisms. T ese 510(k)-approved barrier creams are

:
:
reviewed next based on their unique active ingredient.

C
o
An interesting subset o moisturizers used postprocedure

s
m
are emollients and scar creams. As the wounded skin heals,
c er a mId e

c
the edges o the corneocytes old, creating an irregular skin

u
sur ace. T is irregular sur ace eels rough when stroked due

t
Ceramide synthesis is the rst step in healing a postpro-

i
c
to increased skin riction. Emollients, which are thin oily

a
cedure damaged skin barrier. Nine di erent ceramides

l
s
substances, deposit between the desquamating corneocytes

a
have been identi ed and many have been synthetically

n
and unction like glue to stick the corneocyte back onto the

d
duplicated or inclusion in moisturizer ormulations. T e
skin sur ace, decreasing riction and creating so t, smooth

T
o
ceramides are distinguished by their polar head group
skin. All o the substances listed in able 31-1 can also be

p
architecture, as well as by their hydrocarbon chain proper-

i
c
considered emollients and orm the basis or many over-

a
ties.3 A ceramide-dominant, triple-lipid barrier repair or-

l
the-counter (O C) scar creams. T e riction reducing abil-

A
mulation received 510(k) approval in April 2006 containing

g
ity o the emollient ingredients also allows easier massage
capric acid, cholesterol, conjugated linolenic acid and the

n
o the re-epithelialized skin, thereby increasing elasticity

t
s
EWL reducing agents candelilla wax and petrolatum.4
and possibly minimizing hypertrophic scarring. In addition
T e unique aspect o this cream is that the ratio o the triple
to emollients, scar creams may contain topical antibiotics
lipid combination mimics that o physiologic lipids. How-
and botanical anti-inf ammatories, such as onion extract.
ever, as o this writing, the product is temporarily unavail-
able due to patent issues (EpiCeram, Promius).5
Po St Pr o c ed u r a l
Ba r r Ier Pr o d u c t S h ya l u r o n Ic a c Id
A newer postprocedural moisturizer has been labeled as Another endogenous component o the skin necessary or
a barrier repair product. T is class o creams di ers rom the maintenance o hydration postprocedurally is hyal-
traditional nonprescription moisturizers because the FDA uronic acid, a glycosaminoglycan ound in the dermis.
Hyaluronic acid acts as a humectant and is a component o
the extracellular matrix. It is believed to stimulate neutro-
TAbLe 31-2 phil migration, broblast proli eration, and neoangiogene-
h m is izi g I g i s sis. Ivanov evaluated the e ect o a hyaluronic acid sodium
salt in the healing o episiotomy and cesarean section sur-
Glyc rin
gical wounds and ound a lower incidence o edema and
Sor itol decreased wound exudate.6
Propyl n glycol, thyl n glycol wo hyaluronic acid–containing products have received
510(k) approval (Bionect, Innocutis; Hylatopic, Onset
Hyaluronic acid T erapeutics). One contains 0.2% hyaluronic acid sodium
Sodium PCA salt, which unctions as a humectant, in combination with
other humectants, such as glycerol and a 70% sorbitol
Prot ins (collag n, k ratin), p ptid s, and amino acids
solution (Bionect). In addition to humectants, occlusive
Vitamins (A, D, e) ingredients are required to keep the water attracted by the
Ur a humectant rom evaporating into the environment. T ese
are oily substances, such as an emulsi ying wax, that physi-
Lactic acid
cally block EWL. Most good moisturizers use ingredients 383
4 with occlusive and humectant properties to increase skin
hydration. T e same hyaluronic acid sodium salt is com-
T ese oils are less greasy than petrolatum and possess bet-
ter aesthetic properties but are not as e cacious as petro-
bined in a oam ormulation with glycerin as an added latum in reducing EWL. Silicone originates rom silica,
humectant accompanied by dimethicone and petrolatum which is ound in sand, quartz, and granite. It derives its
as occlusives (Hylatopic, Onset T erapeutics). Both o properties rom the alternating silica and oxygen bonds,
these products are recommended by the manu acturer or known as siloxane bonds, which are exceedingly strong.
postprocedural use ollowing laser resur acing. T ese strong bonds account or the tremendous thermal
and oxidizing stability o silicone. Silicone is resistant to
decomposition rom ultraviolet radiation, acids, alkalis,
l Ic o r Ic e ex t r a c t ozone, and electrical discharges. T e silicone used in topi-
cal preparations is an odorless, colorless, nontoxic liquid,
Other 510(k) device barrier creams contain a variety o which is excellent at reducing riction and can be used to
botanical extracts designed to reduce postprocedural massage a wound to minimize hypertrophic scar orma-
inf ammation. One currently marketed product contains tion. o date there is no report o toxicity rom the use
glycyrrhetinic acid and Vitis vini era extracts (Atopi- o topical silicone.10 A combination o cyclomethicone,
S
e
clair, currently or sale). In addition, it contains allantoin, a cyclic higher viscosity silicone, and dimethicone are
c
t
i
used in barrier creams that are resistant to water removal
o
alpha-bisabolol, hyaluronic acid, and shea butter. Glycyr-
n
rhetinic acid is a licorice extract that was reported to be ( etrix, Valeant).11,12
4
sa e by the Cosmetic Ingredient Review, and has the abil- Silicone is also used to promote healing and minimize
:
:
ity to block gap junction intracellular communication and scarring in the orm o gel sheeting. T e gel sheets are
inf ammation.7 a xed to the re-epithelialized wound. Exactly how the gel
A
e
In addition to the anti-inf ammatory e ect o glycyrrhet- works has never been proven, but it can reduce EWL thus
s
t
h
inic acid, the Vitis vini era extract, derived rom grapes, and creating an environment conducive to wound healing.
e
t
i
the alpha-bisabolol, derived rom chamomile, also serve as
c
a
antioxidant, anti-inf ammatory ingredients. Finally, allan-
n
Pa r a f f In Wa x
d
toin, a heterocyclic organic compound, is a time tested
L
a
anti-inf ammatory as assessed by the Cosmetic Ingredient
s
e
Review.8 T e combination o various botanical anti-inf am- Another time-tested occlusive agent to decrease EWL
r
P
matories may be help ul in managing postprocedural ery- is para n wax. Liquid para n combined with para n
r
o
wax is the basis or another barrier cream designed to be
c
thema, although studies or this indication have not been
e
d
published. used in the management o super cial wounds, dermal
u
r
ulcers, donor sites, burns, and radiation dermatitis (Bia ne,
e
s
OrthoNeutrogena). T e wax provides an arti cial barrier
Pe t r o l a t u m that remains in place until healing can occur. In addition,
it was demonstrated that the ormulation was chemotactic
T e oldest wound care product and the very rst thera- or macrophages and increased the IL-1/IL-6 ratio in epi-
peutic moisturizer ever developed was petrolatum. Pet- dermal wounds in normal human volunteers.13 T is wax-
rolatum is a semisolid mixture o hydrocarbons obtained based ormulation also improved healing ollowing the
through the dewaxing o heavy mineral oils. Pure cosmetic treatment o actinic keratoses.14
grade petrolatum is practically odorless and tasteless.
Other hydrocarbon contaminants in lower quality petrola-
tum may account or a distinct chemical smell noted with t o PIc a l St em c el l S
some products. Petrolatum rst appeared in the US Phar-
macopoeia in 1880 and has been a widely used ingredient
a n d h ea l In g
in skin care products and topical pharmaceuticals ever
since. It is interesting to note that petrolatum has never Another topical trend in postprocedural healing is the use
been duplicated synthetically. Some barrier repair creams o stem cell technology. Although there is little scienti c
contain petrolatum as their primary ingredient (Eletone, dermatologic data to support the use o such products,
Ferndale). Petrolatum remains the gold standard or bar- their tremendous penetration into the boutique cosme-
rier repair ingredients because it is the substance closest ceutical marketplace makes them a worthwhile topic or
to the natural intercellular lipids and it can intercalate into discussion. Stem cells are pluripotent cells that can di er-
the intercellular spaces.9 It may be that the bene cial e ect entiate into many di erent structures. T e ability o stem
o topical antibiotics in postprocedural wound care is not cells to di erentiate and remain di erentiated is the key to
related to the bacitracin or neomycin, but rather to the pet- survival o complex multiorgan li e, such as humans. Once
rolatum vehicle. di erentiated, liver cells must remain liver cells, kidney
cells must remain kidney cells, and skin cells must remain
skin cells. T is is accomplished through epigenetic changes
d Imet h Ic o n e a n d that repress selected gene sequences that should no lon-
ger be transcribed. I these gene sequences are mistakenly
SIl Ic o n e g el Sh ee t In g available or transcription, cancer may occur. T ere is nev-
ertheless tremendous interest in stem cells as a source o
A newer alternative to petrolatum as a barrier repair materials or replenishing the aging body and also or pro-
384 ingredient is dimethicone, one o a amily o silicone oils. moting wound healing.
 St em c el l ex t r a c t S TAbLe 31-3
4
r spb ye c si s
T e majority o stem cells used in cosmeceuticals are
derived rom plants rather than animals. T is eliminates Ph nolic acids
the possibility o disease transmission and also keeps with F rulic acid
current industry standards o avoiding animal cruelty; how-
Caf ic acid
ever, it also raises the issue as to whether plant stem cells
can truly have an e ect on human physiology. In actuality, Protocat chuic acid
the stem cells are not used in the skin healing products, but Gallic acid
rather substances that are present in the stem cell extract.
T e stem cells are used as bioreactors to produce highly Coumaric acids
pure and re ned raw materials to include in cosmeceutical ellagic acid p ntos d rivativ s
ormulations.
ellagitannins
Some o the more popular stem cell extracts are derived

C
rom berries, such as raspberries, blueberries, and strawber- Flavonoids

h
a
ries, because they contain high levels o anthocyanins, rep-

p
Qu rc tin

t
resenting a new category o highly potent antioxidants with

r
Qu rc tin rhamnosid

3
anti-inf ammatory activity. T e anti-inf ammatory proper-

1
ties are elt to be bene cial in wound healing preparations. Qu rc tin glucosid

:
:
Stem cells used or extract preparation can be obtained
M thyl d rivativ o qu rc tin
rom berries, leaves, stems, twigs, or roots, but lea stem

C
o
cells are most commonly cultivated because they are the Ka mp rol glucosid

s
m
site o photosynthesis and require excellent oxidative stress Anthocyanins

c
protection yielding high quantities o antioxidants. T e

u
P largonidin
stem cells are cultured under controlled laboratory condi-

t
i
c
tions to obtain the purest extracts possible, which are ree

a
P largonidin glucosid

l
s
rom environmental contaminants including heavy met-

a
R sv ratrol glucosid

n
als, pesticides, and ungal toxins. When plant materials are

d
T
concentrated, so are the contaminants. Stem cell derived

o
p
materials also have greater consistency o contents. T e

i
c
a
plant materials are cultured under optimal conditions to is added to the wound healing product. An example o the

l
A
yield a more standard composition than those grown out- constituents o a raspberry extract obtained in this manner,

g
doors, which may vary based on actors such as weather, containing numerous antioxidants, is listed in able 31-3.15

n
t
soil condition, or ertilizer application. Consistency is the Stem cell technology is the rst step in standardizing

s
key to obtaining a reliable extract or reproducible results. botanical cosmetic ingredients and achieving dose consis-
tency and purity. However, stem cell technology does not
mean that plant cells can somehow interact with human
St em c el l c u l t Iva t Io n cells to promote wound healing or induce slowing o aging.
Stem cells are simply chemical actories to yield high-quality
Many dermatologists mistakenly think that the entire stem ingredients that might be bene cial in creating an environ-
cell is placed in the skin care product, but this is not the ment or wound healing. T is technology is in its in ancy and
case. T e stem cell is used to obtain the extract that is certainly will be an area to ollow or uture developments.
then placed into ormulation. It is not possible to maintain
live stem cells in cosmeceutical emulsions. Osmotic con-
ditions, lack o suitable growth media, and preservatives PePt Id eS a n d Wo u n d h ea l In g
make this impossible.
Stem cells are obtained rom the plant leaves a ter they Peptides are the cellular messengers o the body that allow
have been sterilized in 70% ethanol or 15 minutes and 1% the modulation o receptors, activate enzyme release, and
bleach or an additional 15 minutes ollowed by washing regulate the production o proteins. Peptides are present in
three times with sterile water. T e original plant material many o the new generation cosmeceuticals, but were origi-
or culture must come rom outdoors, but all contaminants nally developed or wound healing purposes. T ey are con-
must be removed or success ul culture. T e leaves are then sidered sa e when topically applied, as peptides are ingested
cut into thin 0.5 cm pieces and placed on an agar culture on a regular basis when consuming meat. Allergic reactions
plate containing plant growth hormones, such as kinetin, to topical peptide ormulations have not been reported to
an active agent advertised in dermatology to promote heal- date. T is discussion examines peptides and their role in
ing and decrease the appearance o aging. Plant callus is postprocedural skin care.
then ormed, and can be collected. T e callus is then cul- Peptides are ormed rom amino acids that are selected by
tured to orm single cells, which are recultured in a liquid the protein chemist to achieve a speci c unctional goal. T e
medium. T e cells are then ltered or removal rom the peptide amilies that have been identi ed thus ar are listed
media and homogenized. T e mixture is centri uged to in able 31-4. T e rst peptides introduced into the wound
remove the soluble components and lyophilized to obtain a healing marketplace were carrier peptides, which were
powder that represents the cosmeceutical ingredient, which then adapted to the anti-aging skin care market. From the 385
4 TAbLe 31-4
(soluble N-ethyl-maleimide-sensitive actor attachment
protein receptor) complex ormation. Acetyl hexapeptide-3
P p i f ii s is commercially known as Argireline (Centerchem). It sup-
Carri r p ptid s
posedly unctions topically to relax muscles, much like a
weak short-lived botulinum toxin, by inhibiting vesicle
Signal p ptid s docking through prevention o the SNARE complex or-
N urotransmitt r p ptid s mation. T is muscle relaxation reduces the appearance o
acial wrinkles.
enzym modulating p ptid s

en z yme-mo d u l a t In g PePt Id eS
carrier peptides, the next development was signal peptides
designed to mimic a natural body structure and turn on or Enzyme-modulating peptides directly or indirectly inhibit
o production o an endogenous protein. Neurotransmitter the unction o a key enzyme in some metabolic processes.
peptides were then developed that interrupted acetylcholine Many o these peptides are extracted rom botanical
S
release. Finally, enzyme-modulating peptides that directly sources rather than engineered through protein chemis-
c
t
i
or indirectly inhibit enzyme unctioning were produced. try. Soy proteins, already used in cosmeceuticals or the
o
n
reduction o postinf ammatory hyperpigmentation, pos-
4
sess another peptide that inhibits the ormation o prote-
c a r r Ier PePt Id eS
:
:
ases. Rice proteins possess a peptide that inhibits matrix
metalloproteinase (MMP) activity. T ese naturally occur-
A
T e rst commercialized peptides were carrier peptides. ring peptides are presently used in a number o marketed
s
t
T ese peptides were designed to hook to another ingredi-
h
cosmeceuticals.
ent and acilitate transportation o the agent to the active
t
It is important to recognize that peptide chemistry is
i
c
site. T e rst carrier peptide was designed to deliver cop-
a
still in its in ancy. Peptides hold the promise to modulate
n
per, a trace element necessary or wound healing. From a
d
skin healing and unctioning, but good studies remain elu-
L
wound healing application, a peptide known as GHK-Cu sive. T e dermatologist should closely watch this amily o
a
s
was commercialized into a line o skin care products to cosmeceutical ingredients, as their true potential has not
r
minimize the appearance o ne lines and wrinkles (Neu-
P
yet been ully realized.
r
o
trogena, J&J). GHK-Cu is composed o glycine, histidyl and
c
lysine hooked to copper and was ound to induce dermal
d
u
keratinocyte proli eration. GHK was originally isolated c o n c l u SIo n
r
rom human plasma and then synthetically engineered.
s
T ere are a variety o topical products worthy o discussion
SIg n a l PePt Id eS relevant to procedural dermatology. T ese include cleans-
ers and hand sanitizers that can restore a healthy bio lm ol-
T e largest peptide amily currently used in marketed cos- lowing skin injury rom ller injectables, chemical peeling,
meceuticals is the signal peptides. Signal peptides stimulate laser resur acing, or cancer removal with reconstruction.
collagen, elastin, bronectin, proteoglycan, and glycosami- A ter cleansing o the skin, a moisturizer is usually applied.
noglycan production, creating the appearance o younger T e moisturizer can improve the appearance o the skin by
looking skin. T e most popular signal peptide is palmitoyl smoothing scale in the area o the procedure, but also can
pentapeptide, commercially known as Matrixyl (Olay Rege- create an environment or optimal healing. Specialized scar
nerist, P&G). Palmitoyl pentapeptide, abbreviated Pal- and barrier repair creams are a subset o moisturizers using
K KS, is composed o the amino acids threonine, lysine, many o the same ingredients, but also incorporating new
and serine. It is a procollagen I ragment demonstrated to technologies. wo o the most interesting relevant technol-
stimulate the production o collagen I, III, and IV in vitro. It ogies are stem cell extracts and peptides. Over time, new
is used in a low concentration o our parts per million, as it topical agents with enhanced ormulations will be devel-
theoretically acts as a “signal,” by way o which one molecule oped, which will be likely to have increasing relevance and
has a cascading e ect. T e idea is to present the body with utility or the procedural dermatologist.
procollagen ragments that will down-regulate the produc-
tion o collagenase, thereby increasing dermal collagen.
r ef er en c eS
n eu r o t r a n SmIt t er PePt Id eS 1. Harbarth S, Pittet D, Grady L, et al. Interventional study
to evaluate the impact o an alcohol-based hand gel in im-
proving hand hygiene compliance. Pediatr Infect Dis J. 2002;
Neurotransmitter peptides unction by inhibiting the 21:489– 495.
release o acetylcholine at the neuromuscular junction. 2. Boyce JM, Kelliler S, Vallande N. Skin irritation and dryness
T ey are similar to botulinum toxin in that both selectively associated with two hand hygiene regimens. Infect Control
modulate synaptosome-associated protein o 25,000 Dal- Hosp Epidemiol. 2000;21:442– 448.
tons, more commonly known as SNAP-25. Botulinum toxin 3. Garidel P, Fölting B, Schaller I, Kerth A. T e microstruc-
ture o the stratum corneum lipid barrier: mid-in rared
A proteolytically degrades SNAP-25 while acetyl hexapep- spectroscopic studies o hydrated ceramide: palmitic acid:
tide-3, a neurotransmitter peptide, mimics the N-termi- cholesterol model systems. Biophys Chem. 2010;150(1– 3):
386 nal end o the SNAP-25 protein that inhibits the SNARE 144– 156.
4. Madaan A. Epiceram or the treatment o atopic dermatitis.
Drugs Today (Barc). 2008;44(10):751– 755.
10. Ruiz MA, Hernandez A, Llacer JM, Gallardo V. Silicone
chemistry. Cosmet Toilet. 1998;113:57– 62.
4
5. Sugarman JL, Parish LC. E cacy o a lipid-based barrier 11. Slade HB, Fowler J, Draelos ZD, Reece B , Cargill DI. Clinical
repair ormulation in moderate-to-severe pediatric atopic e cacy evaluation o a novel barrier protection cream. Cutis.
dermatitis. J Drugs Dermatol. 2009;8(12):1106– 1111. 2008;82(Suppl 4):21– 28.
6. Ivanov C, Michova M, Russeva R, Batashki I. Clinical applica- 12. Slade HB, Fowler J, Reece B , Cargill DI. Clinical sa ety
tion o bionect (Hyaluronic acid sodium salt) in wound care evaluation o a novel barrier protection cream. Cutis. 2008;
by cesarean section and episiotomy. Akush Ginekol (Sof ia). 82(Suppl 4):16– 20.
2007;46(Suppl 4):20– 26. 13. Coulomb B, Friteau L, Dubertret L. Bia ne applied on hu-
7. Eberlein B, Eicke C, Reinhardt HW, Ring J. Adjuvant treat- man epidermal wounds is chemotactic or macrophages
ment o atopic eczema: assessment o an emollient containing and increases the IL-1/IL-6 ratio. Skin Pharmacol. 1997;10
N-palmitoylethanolamine (A OPA Study). J Eur Acad Der- (5– 6):281–287.
matol Venereol. 2008;22(1):73–82. 14. Cohen JL, Jorizzo JL, Kircik LH. Use o a topical emulsion or
8. Becker LC, Berg eld WF, Belsito DV, et al. Final report o the wound healing. J Support Oncol. 2007;5(10 Suppl 5):1– 9.
sa ety assessment o allantoin and its related complexes. Int J 15. Barbulova A, ito A, Carola A, et al. Raspberry stem cell
Toxicol. 2010;29(Suppl 3):84S– 97S. extract to protect skin rom inf ammation and oxidative
9. Morrison DS. Petrolatum: a use ul classic. Cosmet Toilet. stress. Cosmet Toilet. 2010;125(7):38– 47.

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1996;111:59– 69.

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p
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:
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e
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e
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t
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s
a
n
d
T
o
p
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c
a
l
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g
e
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387
 Ch a p t e r

32 Chemical Peels
Christ ph r B. H rm n &T r k M. F kh uri

In t r o d u c t Io n Peel c l a s s If Ic a t Io n
Maintaining a youth ul appearance through the reha- Peels are classi ed based on the achievable depth o pen-
bilitation o photoaged skin is a topic o growing interest etration, which determines the clinical e ect o the agent.
among the general population. o meet this need, reju- Super cial peels (0.06 mm depth) lead to ex oliation and
venation techniques such as chemical peeling, dermabra- regeneration o the entire epidermis while very super cial
sion, and laser resur acing have been developed. O these, peels only a ect the stratum corneum. Medium-depth
chemical peeling has the longest record o sa ety and peels (0.45 mm depth) will destroy the epidermis and
e cacy while being an easily accessible modality to the induce inf ammation within the papillary dermis. Deep
clinician. Chemical peeling is also low in cost and has a peels (0.6 mm depth) will induce inf ammation into the
relatively quick recovery time.1 reticular dermis and induce new collagen production.7

Mec h a n Is M o f a c t Io n Pr o Per Pa t Ien t s el ec t Io n

As with any procedure, patient selection is key to opti-
Chemical peeling is the result o application o a chemi-
mizing outcomes and special attention should be paid to
cal agent to the acial skin to create an injury to a speci c
eatures o the patient’s history and physical examination
depth, thereby inducing rejuvenation via wound repair.
in attempt to identi y actors that may contribute to intra-
T e degree o tissue penetration and ensuing injury by
operative or postoperative problems. As a general rule, the
the peeling agent is dependent on several actors includ-
deeper the peel the more care must be exercised in patient
ing skin preparation, anatomic site, duration o peeling,
selection. Although patients o all skin types are o ten
and the strength o the compound.1 T e depth o the
able to tolerate super cial peels, medium and deep peels
injury is used to classi y chemical peels into several cat-
carry more risk. Patients with Fitzpatrick skin types III
egories. Super cial chemical peels cause epidermal injury.
to VI have higher risk o postoperative dyschromia than
Medium-depth chemical peels cause injury to the level o
patients o lighter skin types ( able 32-1).1,9
the upper dermis. Deep chemical peels cause injury that
Enquiry should be made regarding prior recent resur ac-
extends to the level o the mid-dermis.
ing procedures, ace-li t surgery, and isotretinoin therapy
within the past 6 months as these actors may increase the
risk o complications.10 A history o hypertrophic or keloi-
h Is t o r y o f u s e dal scar ormation is a relative contraindication to medium-
depth peels and a contraindication to deep peels. A history
Chemical peeling has been practiced since ancient times. o prior radiation treatment or photodynamic therapy must
Cleopatra was known to use an alpha hydroxyacid (AHA) also be care ully considered as they may impact the skin’s
(lactic acid) rom sour milk to smoothen her skin. O ability to repopulate the epidermis i signi cant numbers o
historical interest to dermatology, Unna rst described pilosebaceous units have been obliterated.11
the use o trichloroacetic acid ( CA), salicylic acid, res-
orcinol, and phenol in 1882. Mackee, in 1903, treated
acial scars with phenol and began publishing his results Ta Bl e 32-1
in 1952. In the 1940s, Eller and Wol summarized the t f i zp i c ii i s i t p
peeling ormulas available at that time and used phenol,
resorcinol, salicylic acid, and carbon dioxide (CO 2).2 In s i t p c r i s
the 1960s, Brown, Baker, and Gordon described a modi-
ed phenol solution with Septisol, croton oil, and water I V r whit , r ck d a w s burns
while Ayres began experimenting with CA.3– 6 T e II Whit Usu burns
work o Stegman in the 1980s characterized the histo-
III Whit t iv S m tim s burns
logic depth o many chemical cauterants and heralded
a controlled scienti c approach to chemical peeling.7 IV Br wn Rr burns
Van Scott’s work on AHAs in the 1970s and 1980s laid V D rk br wn Vr r r burns
the oundation or the most popular super cial peeling
VI B ck N v r burns
agent, glycolic acid (GA).8
 Ta Bl e 32-2
4
P gi g G p a i g G g c ii i

Mi M a v s v
(28 35 ) (35 50 ) (50 65 ) (60 75 )
l itt wrink ing r sc rring e r wrink ing; mi d sc rring P rsist nt wrink ing r m d r t S v r wrink ing, ph t ging,
cn sc rring gr vit ti n nd d n mic rc s
cting skin
N k r t s s S w c r with r ctinic Disc r ti n with t ngi ct si s a ctinic k r t s s ± skin c nc r
k r t s s nd ctinic k r t s s
l itt r n m k up l itt m k up W rs m k up w s W rs m k up with p r
c v r g

C
h
Patients with dermatologic disorders such as atopic bene t rom medium-depth chemical peeling whereas

p
dermatitis, rosacea, seborrheic dermatitis, and psoriasis individuals with severe photoaging need deep peeling or

t
r
may be at increased risk o postoperative complications resur acing plus cosmetic surgical intervention to improve

3
2
including disease exacerbation, prolonged erythema, gravitational changes.
contact hypersensitivity, and delayed healing. Individu-

:
:
als with rosacea and vasomotor instability may develop an

C
exaggerated inf ammatory response to the peeling agent s u Per f Ic Ia l Peel s

h
with prolonged postoperative erythema. A history o “cold

m
i
sores” can predispose to post-peel herpes simplex virus T e most common peeling agents or super cial peels

c
reactivation ollowing medium or deep peeling. Similarly, are AHA (e.g., GA), beta hydroxyacids (BHA) (e.g., sali-

P
cigarette smoking can delay healing o the treated area. cylic acid), Jessner’s solution (JS) (resorcinol 14 g, salicylic
acid 14 g, lactic acid 14 mL, and ethanol 100 mL), CO 2

s
T e Glogau system classi es the severity o photo-
damage, taking into account the degree o epidermal slush, and CA. Very light super cial peels injure only the
and dermal degenerative e ects ( able 32-2).12 T ese stratum corneum, causing ex oliation without necrosis.
categories are devised to project which patients need Agents used or very light peels include low concentra-
therapeutic intervention. Patients with mild photoaging tions o GA (10%– 40%), CA (10%– 20%), JS, and salicylic
are best treated with super cial chemical peeling in com- acid. Light super cial peels injure the entire epidermis
bination with a medical or cosmeceutical agent. Patients and are per ormed using GA 70%, CA (25%– 35%), or
with moderate or advanced photoaging achieve maximal solid CO 2 slush.1,13

s mp c f m
c o n s en t f o r c h eMIc a l Peel
I, _______________ r u st nd uth riz Dr. _____________ t p r rm ch mic p th skin in rd r t impr v th wing
c nditi n(s): ___________________________________________________________________________________________________
_____________________________________________.
I kn w th t th pr ctic m dicin nd surg r is n t n x ct sci nc ; th r r , r put b pr ctiti n rs c nn t pr p r
gu r nt th u it th r su ts r r d m r m c mp ic ti ns. I ckn w dg th t th n tur nd cts this pr c dur , risks
inv v d, s w s t rn tiv m th ds tr tm nt, h v b n xp in d t m t m s tis cti n.
B signing this c ns nt, I ckn w dg th t I und rst nd th wing cts b ut ch mic p ing:
1. Th r is n gu r nt th t th r su ts wi b s tis ct r t m .
2. Th r is s m disc m rt ss ci t d with th s pr c dur s. I m b giv n p in m dicin s pri r t th pr c dur .
3. Mu tip pr c dur s m b n c ss r t chi v th d sir d r su ts, sp ci with “ ight” ch mic p s c nsisting n
JS r TCa .
4. Th r is risk c mp ic ti ns such s, but n t imit d t , n th wing: d m (sw ing), h p rpigm nt ti n (incr s d
pigm nt ti n) th t might b b tch , h p pigm nt ti n (d cr s d pigm nt ti n) th t might b b tch , p rsist nt r th m
(r dn ss) in s m r s t r th pr c dur , in cti n, rgic r cti n, sc rring (this is v r r r c mp ic ti n).
5. exp sur t sun m incr s th p ssibi it sw ing nd r dn ss.
6. Ph t gr phs th ct d r s, b r , during, nd t r tr tm nt, sh b h d r ur m dic r c rds; un ss, in th
judgm nt th d ct r, m dic r s rch r sci nc wi b n t r m th ir us .
7. I und rst nd th t this pr c dur m b c nsid r d c sm tic v n th ugh it is th r c mm nd d pr c dur r m c nditi n.
I gr t p r this pr c dur nd wi b u r sp nsib r th s ch rg s in th v nt th t m insur nc d s n t c v r this
surg r .
8. Th stim t d c st this pr c dur is $_____________.

P ti nt:_______________________________ D t :____________
Witn ss:______________________________ D t :____________
389
4 INDICa TIo NS Fo R SUPeRFICIa l Peel S. was 50% CA. When used alone, this agent produced
acceptable results in ameliorating ne wrinkles and actinic
Super cial chemical peels can be used or comedonal
acne, postinf ammatory erythema or pigmentation, epi- damage.20 However, in strengths o 50%or higher, CA can
dermal melasma, and mild photoaging (Glogau I and II).14 result in increased risk o scarring and has since allen out
Multiple peeling sessions are necessary to obtain maximal o avor as a single agent chemical peel as a result. More
result and are usually per ormed on a weekly or biweekly recently, combinations o 35% CA with other chemical
requency.1 Results are enhanced by daily use o a retinoid and physical agents have been ound to be equally e ective
and, when used or pigmentary lesions, daily kojic acid in producing this level o controlled damage with a much
or hydroquinone may improve e cacy.15 Prior to initia- lower risk o scarring.19,21,22
tion o a treatment course or photoaging, the patient and Brody21 pioneered the use o solid CO 2 applied with ace-
physician must understand the limitations o that course. tone to the skin be ore the application o 35% CA. Freez-
T e improvement will be subtle and the e ect o multiple ing the skin sur ace prior to application o CA breaks
super cial peels will never equal the e ect o a medium- up the epidermal barrier and allows or more even penetra-
depth or deep peel. Super cial peels only a ect the epi- tion, and the penetration using this combination is deeper
than with 35% CA alone. Monheit 19 demonstrated similar
S
dermis and are unable to e ect improvement in dermal
results with the use o JS prior to application o 35% CA.
c
processes, such as deep rhytides.
t
i
JS destroys the epidermal barrier, allowing or deeper and
n
SUPeRFICIa l Peel PRo To Co l S. GA is an AHA more even penetration o the 35% CA. Coleman and
4
that is naturally present in sugar cane. GA can be obtained Futrell22 demonstrated similar e cacy and sa ety using the
:
:
in unbu ered concentrations o 50% to 70%. Following combination o 70% GA prior to the application o 35%
CA. se et al.23 compared the GA/ CA 35% and JS/ CA
a
degreasing with acetone, GA 70% is applied to the skin
35% medium-depth peels in the treatment o ne wrin-
s
evenly with a gauze pad or cotton swab. GA 70% will in-
t
h
duce epidermolysis in 3 to 7 minutes depending upon the kling, actinic keratoses (AKs), and lentigines. Although
t
both methods produced similar clinical responses and
i
patient. T e acid must be neutralized by rinsing with water
c
or 5% sodium bicarbonate once appropriate peeling has oc- had similar healing times, patients treated with GA/ CA
n
d
curred, typically 2 to 4 minutes a ter application. Mild ery- 35% experienced more pain than those treated with JS/
l
thema with scaling may occur or an hour post procedure.16 CA 35%. T e JS/ CA 35% peel produced a more intense
s
CA 10% to 35% can be used or very light to light inf ammatory response, and clinically post-peel erythema
r
P
super cial peels. CA should be ormulated using a was more prolonged. Although all three medium-depth
r
peel combinations have proven to be as e ective as the use
c
weight-in-volume method. For example, a 25% CA solu-
d
tion is made by adding 30 g o CA to enough water to o 50% CA with a greater sa ety margin, the JS/ CA 35%
u
r
make a 100 mL solution. Adding 25 g o CA to 100 mL combination enjoys widespread use and will be discussed
s
would produce a weaker concentration and is inappropri- later.
ate. Following degreasing with acetone, hexachlorophene,
or chlorhexidine gluconate, CA is applied with a gauze INDICa TIo NS Fo R MeDIUM-DePTH Peel S.
pad or cotton-tipped applicator. As with all peels, the CA Medium-depth chemical peels may be used to treat mild-to-
is applied to cosmetic units individually, beginning with moderate photoaging including pigmentary changes, len-
the thickest and most sebaceous skin and progressing to tigines, AKs, acne scarring, unwanted epidermal growths,
the thinnest and most delicate skin o the eyelids. T e dyschromias, and rhytides (Fig. 32-1).24 Although most o ten
CA is applied uni ormly and a an or ice pack may be per ormed or photoaging, the e cacy o medium-depth
used to alleviate the discom ort o areas that have come to chemical peels in the treatment o AKs is well substantiated.
a complete rost. Immediate erythema o the treated site Lawrence et al.25 compared the e cacy and sa ety o the
is ollowed by a rost that usually persists or less than an JS/ CA 35% medium-depth peel to that o 5% f uorouracil
hour.17 Ex oliation without vesiculation begins on postop- (5-FU) in the treatment o severe acial actinic damage.
erative day 2 and lasts rom 3 to 5 days. Both treatments reduced the number o AKs by 75% and
JS is used or very light or in combination with CA produced equivalent reductions in keratinocyte atypia,
or medium-depth peels. JS must be kept in a dark bottle, hyperkeratosis, parakeratosis, and inf ammation. T e
otherwise it will become an irritating solution that can majority o patients pre erred the peel to 5-FU because
discolor the ngernails. JS is applied similarly to CA with o the single application and less morbidity. Witheiler
wrung-out or wet gauze sponge application. Dilution is et al.26 compared the long-term e cacy and sa ety o JS/
not per ormed and neutralization is unnecessary. Addi- CA to 5-FU in the treatment o widespread acial AKs.
tional coats will increase the strength o the peel and the Both treatments resulted in an 80% decrease in AKs, and
patient’s response to the number o coats should be moni- the reduction in clinically apparent lesions was stable or
tored. T e number o coats is typically increased based on 1 year a ter treatment. However, the investigators noted
patient tolerability. JS has the advantage o being a single a sharp increase in the mean number o AKs between 12
solution that does not require dilution or timing o the and 32 months a ter both treatments, and these ndings
duration o application.18,19 indicate the importance o 12 to 18 month ollow-up vis-
its. In both studies, a single treatment o JS/ CA 35% was
compared to 3 weeks o 5-FU cream applied b.i.d.
Med Iu M-d ePt h Peel s
Co NTRa INDICa TIo NS. T ere are no absolute con-
Due to its low cost, ease o application, and e cacy, the traindications or medium-depth chemical peeling. How-
390 benchmark standard or medium-depth chemical peels ever, the risk/bene t ratio o a medium-depth chemical
 4

C
h
p
t
r
3
2
:
:
C
A B

h
m
i
c
P
s
Figure 32-1 A. P ti nt with ph t d m g pri r t J ss
n r’s p w d b a ccup 16%. B. F ur d s t r th
p th s r ntig n th right ch k is much impr v d.
C. eight d s t r th p th s r ntig n th right
ch k is b ginning t r pp r, which is t n th c s
with rg r si ns. (R pr duc d with p rmissi n r m
C
B um nn l , d. Cosmetic Dermatology. 2nd d. McGr w
Hi educ ti n; 2009. Figur s 20–16 t 20–18, Pg 159–160.)

peel may be un avorable in patients with dermatologic T e consent orm should be signed (see Sample Consent
disorders that koebnerize, a history o radiation or photo Form), and the patient is then given a prescription or val-
dynamic therapy or acne, recent isotretinoin use, a history cyclovir 500 to 1000 mg b.i.d. to t.i.d. or 14 days with in-
o hypertrophic scarring, or a darker skin phenotype. structions to begin taking this medication 1 day prior to
the procedure. Patients should also be instructed to pur-
PRePRo CeDURe eDUCa TIo N a ND PRePa - chase a jar o a petrolatum-based emollient or use a ter
Ra TIo N. Patients should be aware that the procedure the procedure.
requires application o a peeling agent to the skin that Skin preparation prior to medium-depth peeling is
will cause moderate pain, stinging, and burning. Methods important to avoid post-peel complications and increase
to alleviate this pain include: local anesthesia, pre- and in- e cacy ollowing the peel. Adjunctive agents should be
traoperative pain medications, and a an blowing cool air started 6 weeks prior to peeling, the most important o
on the treatment site. Normal postoperative expectations which is a topical retinoid. retinoin 0.025% to 0.1% is
include oozing o clear f uid, mild-to-moderate edema, er- used or its ability to decrease stratum corneum thickness,
ythema, and skin peeling. Patients must be in ormed o the increase the rate o epidermal turnover, and decrease cor-
possible complications including allergic reactions, scar- neocyte adhesion.20 Ex oliants such as AHAs can be used
ring, postoperative in ection, and pigmentary dyschromia. to stimulate epidermal growth by disrupting the stratum 391
4 corneum. Finally, broad-spectrum sunscreens and hydro-
quinone 4% to 8% are use ul in patients with dyschromias
INTRa o PeRa TIVe Sa FeTy Co NCeRNS. T e
major sa ety concern regarding the medium-depth chemi-
and those at risk or postprocedure inf ammatory dyspig- cal peel is eye injury rom the peeling agent or prep mate-
mentation. rials. T e physician should wear protective eyewear, damp
swabs containing JS or CA should never be carried over
the patient’s eyes, and care must be taken when applying the
Med Iu M-d ePt h Js /t c a 35% Peel peeling agent to the eyelids and periorbital regions. T e
Pr o t o c o l patient should be instructed to keep their eyes closed at all
times during the procedure. We apply the peeling agent to
TRay SeT UP a ND STo Ra Ge o F Ma TeRIa l S. the eyelids with a damp cotton-tipped swab. In addition
T e set up tray should include Septisol Soap, 4 oz.; acetone, to these precautions, it is prudent to have appropriate eye
8 oz.; JS solution, 4 oz.; and CA 35%, 1 oz.19,27 All o these lavage gear available.
chemicals are available rom Delasco Dermatologic Lab
& Supply, Inc (Delasco, Council Blu s, IA; tel. 800–831– PRo CeDURe TeCHNIq Ue. T e patient should
S
6273). Additional items include a midsized electric an, 1 L be positioned with the head elevated at 30 degrees and
c
prechilled normal saline, 2 × 2 gauze pads, 4 × 4 gauze pads, the eyelids closed. o remove oil and debris, acial skin is
t
i
and cotton-tipped swabs. Chemical components o the set scrubbed thoroughly with Septisol soap, 4 × 4 gauze pads
n
and water, then rinsed with water and dried. T is process
4
up tray are stored at room temperature and have a shel li e
o up to 2 years. Sta should review the chemical expiration may be repeated depending on the amount o oil and de-
:
:
dates to ensure quality. bris present. T e intent is to debride the skin o stratum
a
corneum and excessive scale.
PRo CeDURe PRePa Ra TIo N a ND a NeS-
s
Next, the skin sur ace is degreased by scrubbing with
t
h
THeSIa . Prophylactic valcyclovir 500 to 1000 mg b.i.d. 2 × 2 gauze pads dampened with acetone. T e cleansed
t
i
skin should be palpated to check or the presence o oil,
c
to t.i.d. should have been initiated 1 day prior to the pro-
cedure and should be continued or a total o 14 days. and i any is elt, degreasing should be repeated. T ree
n
d
Documentation is reviewed including the consent orm applications or emales and up to ve applications or
l
and the operative site ( able 32-3). Preoperative photo- males may be required. T orough degreasing is neces-
s
sary to ensure even penetration o the peel and uni-
r
graphs are taken and archived. Medium-depth chemical
P
orm results. T e an is switched on, pointed toward the
r
peels are usually per ormed with mild preoperative seda-
c
tion in combination with a nonsteroidal anti-inf amma- patient’s ace, and le t in this position or the duration o
d
tory drug (NSAID). Choices include 50 mg o i.m. or p.o. the procedure.
u
r
meperidine, 5 mg o p.o. diazepam, 5 mg o i.v. midazol- A ter degreasing, a single coat o JS is applied to the
s
am, 25 mg o p.o. vistaril, and p.o. aspirin 325 mg. Aspirin area using cotton-tipped swabs or 2 × 2 gauze pads. T e
can be continued 24 hours postoperatively i tolerated as orehead is treated rst, ollowed by the cheeks, then the
its anti-inf ammatory e ect is especially help ul in reduc- nose and chin, and nally the eyelids. T is process may
ing swelling and relieving pain.24 I given be ore surgery, be repeated to ensure complete and even coverage. Proper
that may be all that the patient requires during the post- application o the JS results in a aint rost that is super-
operative phase. imposed on a background o erythema (level I rosting).

Ta Bl e 32-3
P i
Pr ph ctic ntivir m dic ti n
In rm d c ns nt sign d
Ph t s t k n
Pr p r tiv m dic ti ns giv n
l i uid nitr g n tr tm nt t k r t s s i n d d
a pp s ptis
a pp c t n
Turn n n
a pp JS
a pp TCa
a pp c s in c mpr ss s
P st p r tiv instructi ns giv n
Pr c dur n t d cum nt d in ch rt
392
 s mp P p iv I i
4
Po s t c h eMIc a l Peel In s t r u c t Io n s (Med Iu M d ePt h )
Po s t o Per a t IVe c a r e
1. St rting t m rr w m rning
. S k th tr t d r r 15 minut s, ur tim s d using s uti n n t b sp n whit vin g r in n pint c
w t r n w shc th. a n sc bs pr s nt sh u d b g nt s k d i p ssib . Do No T PICKTo ReMo Ve Dea D SKIN o R
SCa BS.
b. a t r s king, p t th skin dr with t w nd pp r euc rin®cr m v r th ntir c . R pp wh n v r th skin
s dr .
2. S p n ur b ck with ur h d v t d n w pi ws r th rst w d s i th c is sw n.
3. a v id str nu us x rcis r 2 w ks t v id irrit ting th skin.
4. D n t xp s th skin t th sun r 2 w ks. a t r c mp t h ing, it wi b b t t r t sunscr ns. W r c mm nd Sh d
UVa Gu rd.

C
h
5. M st ch mic p s t d r supp m nt d b th us cr ms such s r tin ic cid (R tin a ), which c us c nst nt turn v r

p
th t p rs skin, urth r impr ving its int grit . y ur ph sici n wi instruct u wh n t r sum th ppr pri t str ngth

t
R tin a .

r
3
**D n t us a Ha r R tin a pr ducts unti dir ct d b ph sici n

2
:
:
Po s t o Per a t IVe eXPec t a t Io n s

C
h
1. Mi d/m d r t r dn ss is xp ct d r 7 d s t r th pr c dur nd wi d gr du v r 4t 6w k p ri d

m
2. o zing c r f uid r m th surgic sit m ccur r 3 t 7 d s

i
c
3. Mi d t m d r t sw ing is n rm nd m st 3 t 7 d s

P
s mp c mi P op iv n

s
c h eMeXf o l Ia t Io n o Per a t IVe n o t e

N m :_____________________
D t :______________________
Di gn sis:__________________

Pr c dur : 1. l c d structi n ______________________ si ns.

2. Ch m x i ti n th ____________________________ using _______________________________________
_______________________________________________________
Surg n:___________________
a ssist nt:__________________
D scripti n th pr c dur : Th individu si ns nd r s r ch mic r m v w r ut in d nd scrubb d with s ptis
nd c t n t d gr s nd r m v str tum c rn um. a r gi n b ck using th ___________________n rv with
_____________________________ n sth tic w s p r rm d. ________________
S uti n w s p int d v r th r unti r sting w s vid nt. Individu si ns w r d str d with ________________, nd th
r gi n r (s) th _______________ w r p int d c r u with c tt n tips unti r st d. a t r______________________, th r s
w r c v r d with s in s tur t d 4 × 4 g uz . Th p ti nt t r t d th pr c dur w .
Ph sici n:___________________
Sign tur :___________________

T e rosting rom JS is much lighter than that produced by Application o CA to the eyelids can be challenging due to
CA and produces a eeling o heat. the pro use tearing that accompanies coating o the sensitive
A ter the JS has completely dried, CA 35% is applied eyelid skin. Placing a dry cotton swab at the medial and lateral
with one to our cotton-tipped swabs or 2 × 2 gauze until canthi can soak up excess tears. By applying a slight amount o
a light rost appears. T e amount o CA delivered to the horizontal tension with the dry swabs, the eyelid skin can be
skin sur ace is dependent on the degree o saturation o delicately stretched, making it easier to evenly coat the area.
the swabs or gauze. More saturated gauze or swabs are Application o CA to the eyelids is best done by rolling the
applied with broad strokes over the orehead and cheeks. swab in the direction opposite to that o application.
wo moist swabs or a less saturated gauze pad are used to As with the application o JS, the orehead is treated
treat the lips and chin, and one semidry swab is used to rst, ollowed by the cheeks, then the nose, chin, and
carry the CA within 2 to 3 mm o the lid margin. nally the eyelids. T e white rost rom application o the 393
4 excessive manipulation such as rubbing or picking can lead
to scarring. A low-potency topical steroid may be used
in patients who complain o pruritus. Patients should be
in ormed that pre-existing pigmented lesions will darken
considerably and appear grayish-brown.
Patients will experience a variable degree o erythema
and edema. Edema peaks at 48 hours and may persist or
several days. T e patient should be instructed to sleep on
his or her back with head elevated or the rst ew days
i the ace is swollen. Patients should also avoid strenuous
exercise and not expose the treated skin to the sun or 4 to 6
weeks. T e erythema intensi es as desquamation becomes
complete within 4 to 5 days a ter the procedure. A ter 7
days the bright red color has aded to pink and has the
appearance o a sunburn. Frequent brie ollow-up visits are
S
important to ensure normal healing. We schedule visits on
c
t
i
postoperative days 1, 3, and 10. A ter re-epithelialization is
n
complete, 7 to 10 days postprocedure, sunscreen, cosmet-
4
ics, and retinoids may be restarted as tolerated. Patients
:
:
should be advised that a post-peel regimen o sunscreen,
retinoid, and an ex oliating agent, such as AHA, is neces-
a
sary to maintain the bene ts gained. Medium-depth chem-
s
t
h
ical peels should not be repeated or a period o 6 months.
t
Figure 32-2 Th whit r st pp rs 2 minut s t r
i
c
pp ic ti n s ic ic cid p . (R pr duc d with p r
d eeP c h eMIc a l Peel In G
n
missi n r m B um nn l , d. Cosmetic Dermatology. 2nd
d
l
d. McGr w Hi educ ti n; 2009. Fig 20–7, Pg 151.)
s
Patients with Glogau group III to IV photodamage may
r
require deep chemical peeling or laser resur acing to cor-
P
r
CA appears on the treated area within 30 seconds to 2 rect the dermal damage. Due to its unpredictability and risk
c
minutes. Be ore re-treating the area, at least 3 to 4 minutes o scarring, CA ≥45% is no longer used or deep chemi-
d
u
should elapse to ensure that rosting has reached its peak. cal peeling. T e Baker– Gordon peel, described in 1961,
r
produces reliable results and is the most commonly used
s
Additional applications o CA to previously treated areas
will increase the depth o penetration and the risk o com- ormula or deep chemical peeling.28 T e Baker– Gordon
plications. For this reason, CA should be care ully reap- peel ormula must be reshly prepared and stirred vigor-
plied to un rosted areas. Feathering o the solution into ously prior to application.29 T e two main variations o
the hairline and around the rim o the jaw and brow con- deep chemical peeling with the Baker– Gordon ormula
ceals the demarcation line between treated and untreated are occluded (with zinc oxide tape) and unoccluded.
areas. A ter the application o CA is completed, cool T e tape, placed directly a ter the phenol is applied to
saline compresses are applied to the entire ace to dilute each cosmetic unit, increases the penetration o the Bak-
the solution, and these should remain in place or at least er’s phenol solution and is help ul or very deep rhytides.
10 to 20 minutes with the an running. T e taped Baker– Gordon phenol peel creates damage to
Achieving level II to level III rosting will ensure desired the midreticular dermis and carries a signi cant risk o
e cacy. Most medium-depth peels use a level II rosting, scarring and overpenetration.24 T e unoccluded technique
which is de ned as white-coated rosting with erythema as modi ed by McCollough requires more skin cleansing
showing through (Fig. 32-2). T e zygomatic arch, bony and application o a greater amount o solution to achieve
prominences o the jaw line, and chin should only receive deep penetration.30 However, it does not produce as deep
up to a level II rosting as risk o scarring is high in these a peel as the occluded method.
areas. Level III rosting, de ned as solid enamel rosting
with aint background erythema, should be reserved or INDICa TIo NS Fo R DeeP CHeMICa l Peel -
areas o heavy actinic damage or thick skin. ING. Deep chemical peeling is indicated or patients with
severe photoaging (Glogau groups III and IV).
Po STPRo CeDURe Ca Re. T e patient should be
instructed to soak the treated area with 0.25% acetic acid Co NTRa INDICa TIo NS To DeeP CHeMI-
(one tablespoon white vinegar in one pint o warm water) Ca l Peel ING. Phenol is toxic to the kidneys and liver,
using a clean washcloth up to our times per day. A ter and may induce cardiac arrhythmias. It is, there ore, contra-
soaking, the area should be gently patted dry and a thin indicated in patients with a history o arrhythmia, who are
layer o emollient applied. A ter 24 hours, the patient can on pro-arrhythmic medications, or who have hepatic or re-
shower and clean gently with a mild nondetergent cleanser. nal disease. Deep chemical peeling should not be per ormed
Some oozing o clear f uid rom the treated area as well as within 6 months o using isotretinoin or having a medium
mild-to-moderate swelling are normal in postoperative or deep chemical peel.
ndings that may last 3 to 7 days. Patients should be ad- In addition, deep chemical peeling carries the risk o per-
394 vised that the peeled skin will look and eel tight and that sistent erythema and pigmentary disturbance. T is can be
particularly problematic or male patients and those with
Fitzpatrick skin types III to VI. Other relative contraindica-
kidneys and decreases the risk o arrhythmia. Intravenous
(IV) midazolam is titrated slowly at 1 mg per dose up to
4
tions to deep peeling include patients with a koebnerizing a maximum o 5 mg. IV entanyl citrate is given in 50 ug
condition, a history o radiation or photodynamic therapy doses to a maximum o 2 ug/kg over 90 to 120 minutes.
or acne, and a history o abnormal wound healing. T ese medications should be administered and monitored
by an anesthesiologist or anesthetist.
PRePRo CeDURe eDUCa TIo N a ND PRePa -
Ra TIo N. As with medium-depth chemical peeling, pa- INTRa o PeRaTIVe Sa FeTy Co NCeRNS. Phenol
tients who are undergoing deep chemical peeling should is systemically absorbed and is toxic to the liver, kidneys,
be aware that the procedure requires application o a peel- and heart.33 Intraoperative arrhythmia is the most eared
ing agent to the skin that will cause pain, stinging, and complication. Patients should be monitored closely and the
burning. T is pain is managed by preoperative sedation. peel must proceed slowly (10–15 minutes between cosmet-
Patients should be ully in ormed o the risks to the heart, ic units). Slow application o the phenol in conjunction with
liver, and kidneys and a thorough preoperative evaluation pre, intra, and postoperative IV hydration prevents serum
must be per ormed. A baseline electrocardiogram and phenol rom rising to toxic levels, thereby minimizing risk

C
h
baseline labs (liver unction tests, blood urea nitrogen, o renal toxicity and arrhythmia. As with medium-depth

p
creatinine, complete blood count, and electrolytes) should peels, deep-peeling agents should never be carried over the

t
r
be obtained and veri ed as normal. T e patient’s medica- eyes or introduced into the eye. Should this occur, f ush-

3
2
tions should be reviewed to ensure that an arrhythmogen- ing with mineral oil is necessary as water can increase the
ic medication is not present. strength o the phenol. I the phenol is accidentally spilled

:
:
Normal postoperative expectations include oozing o on sta or the patient, propylene glycol or glycerol can be

C
clear f uid, moderate-to-severe edema, erythema, and used to decontaminate the area.

h
skin peeling. Close ollow-up during epithelialization

m
is required and the patient must also be aware that it is PRo CeDURe TeCHNIq Ue. Following adequate se-

i
c
normal or postprocedure erythema to last up to 90 days. dation and monitoring the ace is cleansed and degreased

P
Patients must be in ormed o the possible complications with hexachlorophene (Septisol) with special attention to
including allergic reaction, scarring, postoperative in ec- sebaceous areas. I per orming an occluded peel, the acial

s
tion, persistent erythema (<90 days), and pigmentary hair is shaved to avoid discom ort during tape removal.
dyschromia. T e consent orm should be signed (see T e phenol ormula is then care ully applied with a cot-
Sample Consent Form), and the patient is then given a ton-tipped applicator to cosmetic units in this sequence:
prescription or valcyclovir 500 to 1000 mg b.i.d. to t.i.d. orehead, perioral area, right cheek, le t cheek, nose, and
or 14 days with instructions to begin taking this medica- periorbital area. A ter treatment o a cosmetic unit rost-
tion 1 day prior to the procedure. Patients should also be ing occurs rapidly and, i per orming a deep peel with
instructed to purchase a jar o a petrolatum-based emol- occlusion, the tape should be placed just a ter the phenol
lient or use a ter the procedure. has been applied. ape is applied in at least two layers over
all treated areas except the periorbital area and earlobes.
Micro oam tape is o ten used on the perioral area as it is
Ba ker –Go r d o n Peel Pr o t o c o l elastic. Waiting 15 minutes be ore treating the next cos-
metic unit is necessary to allow the body to clear any sys-
t r a y s e t u P a n d s t o r a Ge temically absorbed phenol and prevent toxicity. T e peel
may be extended just over the mandibular rim in order to
o f Ma t er Ia l s blend the treated and untreated areas. T e periorbital area
must be treated conservatively to avoid overpenetration
T e Baker– Gordon peel ormula must be prepared resh, and scarring.
and consists o 3 mL SUP liquid phenol 88%, 2 mL tap T e peeling agent creates an immediate burning sensa-
water, 8 drops o Septisol, and 3 drops o croton oil.5,24,28,30– tion or 15 to 20 seconds that subsides and then returns
32
Additional items include cotton-tipped applicators, a ter 20 minutes, persisting or up to 8 hours. Ice packs
waterproo zinc oxide tape cut into short strips (i per- and opioid analgesics are usually adequate or pain control.
ormed with occlusion), and ice packs. A short course o systemic steroids may be employed to
lessen the inf ammatory response. For unoccluded peels,
PRo CeDURe PRePa Ra TIo N a ND a NeS- petrolatum is applied and a biosynthetic dressing is placed.
THeSIa . Prior to administration o sedation and analge-
sics, the surgeon outlines the limits o the operative eld Po STPRo CeDURe Ca Re. Patients should return
with a surgical pen with the patient in a sitting position. on postoperative day 1 or encouragement and evaluation.
On the day o the procedure the patient should be NPO T e tape mask is easily removed at 48 hours due to the ac-
and skip break ast. Documentation is reviewed including tion o the wound exudate on the adhesive. Removal o the
the consent orm and operative site ( able 32-3). Preoper- tape mask may be per ormed at 24 hours i the patient is
ative photographs are taken. T e patient is then placed on very uncom ortable. Postoperative edema can be substan-
cardiac monitoring equipment, including a pulse oximeter tial and cause the eyelids to swell shut. T is can be allevi-
and automated blood pressure cu , and an in usion o lac- ated by sleeping, with the aid o hypnotics, in a sitting or
tated Ringer’s solution is begun. Administration o 500 mL elevated position.
o lactated Ringer’s be ore the procedure and 1 L during Wet to dry soaks with 0.25% acetic acid should be
and a ter the peel acilitates excretion o the phenol by the per ormed three to ve times daily. T e acetic acid has 395
4 antibacterial activity against gram-negative organisms
and Pseudomona s and is mildly debridant. Following
rom allergic or irritant contact dermatitis, exacerbation o
prior skin disease, or a genetic susceptibility to erythema.
soaks, the patient should apply bland emollients. Occlu- Persistent erythema is indicative o poor wound healing
sive salves prevent crusting and speed re-epithelialization. and the presence o excessive angiogenic actors, which
Milia may develop during re-epithelialization and may be can induce scarring. A ter ruling out in ectious agents, the
manually extracted i they do not resolve spontaneously. erythema can be treated with topical, systemic, or intrale-
Strict photoprotection is necessary until re-epithelializa- sional steroids i ocal thickening is present.24 Biosynthetic
tion occurs at 8 to 12 days. Pruritus may be managed with membranes (e.g., Vigilon, C.R. Bard, Inc., Covington, GA)
moisturizers, low-potency topical steroids, ice packs, and can provide a protective barrier and speed resolution o
NSAIDs. As with medium-depth peels, resumption o a this process. I thickening or scarring becomes evident,
skin care regimen that includes sunscreen and a retinoid is other measures that may be help ul include the daily use
necessary to maintain the results. Peak results can be seen o silicone sheeting and the 585 nm pulsed dye laser.34,35
3 to 4 months postoperatively and repeat peeling should With prompt intervention, scarring may be averted.
not be per ormed or at least 6 months postoperatively. Medium and deep peels carry the risk o scarring. A his-
tory o prior peel, dermabrasion, or isotretinoin use within
S
6 months may be risk actors or scarring. A personal or
c
c h eMIc a l Peel c o MPl Ic a t Io n s
t
i
amily history o hypertrophic scarring carries increased
n
risk. Postrhytidectomy ull-thickness skin sloughing may
4
Many o the complications seen with chemical peeling occur rom peels per ormed earlier than 3 months post
:
can be recognized early, and the surgeon should be well
:
procedure.33 Patients who have had a blepharoplasty
acquainted with the normal postoperative appearance and within 6 months are at risk o lower lid ectropion a ter
a
the normal time rame required or healing.33 Complica- deep peeling.33 Scars may be treated with topical or intra-
s
t
h
tions may arise intraoperatively or postoperatively. Intra- lesional steroids, silicon gel sheeting, pulsed dye laser, or
t
operative errors include incorrect peel pharmacology and simple massage.
i
c
solution misplacement. As described earlier, all solutions Patients with Fitzpatrick skin types I to III ordinarily
n
d
must be resh and at the proper concentration. Applica- have ew problems with pigmentation a ter peeling. ype
l
tion should be deliberate and systematic, and care must be IV skin can be peeled but may leave an obvious demarca-
s
taken to avoid spills or introduction o the solutions into tion between peeled and unpeeled skin. ype VI skin will
r
P
the eye. Saline and sodium bicarbonate should be pres- hyperpigment a ter peeling and may not return to normal
r
ent to dilute CA or neutralize GA. Mineral oil should or up to 2 years. In addition, type VI skin may heal with
c
be present or Baker– Gordon phenol peels. Postopera-
d
a visibly lighter skin tone. ype V skin can be unpredict-
u
tive complications include in ection, persistent erythema,
r
able and o ten hyperpigments.36 Oral contraceptives,
s
scarring, pigment alteration, and, in the case o phenol, estrogens, photosensitizing drugs, sunlight, and preg-
systemic toxicity. nancy within 6 months o a peel may exacerbate post-peel
Frequent postoperative visits are necessary to recognize hyperpigmentation. Combination therapy with a topical
the early onset o bacterial in ection. In ection may pres- retinoid, hydroquinone 4% to 6%, and a low-potency topi-
ent as delayed wound healing, ulcerations, or a buildup cal steroid can alleviate post-peel hyperpigmentation.37
o necrotic material with excessive scabbing, crusting, Deep peeling with phenol carries the risk o cardiac
purulent drainage, and odor. T e use o 0.25% acetic acid arrhythmia, nephrotoxicity, and hepatotoxicity. Cardiac
soaks to debride crust and remove residual necrotic debris arrhthymias are associated with treating 50% or more o
as well as the removal o the ointment with each soak the ace within 60 minutes. Anxiety and exercise increase
may deter bacterial growth. In ection should be treated ectopic beats while sedation and relaxation can decrease
empirically with coverage or both Staphylococcus and ectopic beats. In patients who were deliberately peeled
Pseudomona s until cultures and susceptibility testing are rapidly (30 minutes) tachycardia was noted rst ollowed
available to guide therapy. Early recognition and institu- by premature ventricular contractions, bigeminy, paroxys-
tion o appropriate antibiotics will prevent the spread o mal atrial tachycardia, and ventricular tachycardia. Severe
in ection and minimize scarring. cases can progress to atrial brillation. Diuresis allows
Herpes simplex virus reactivation most commonly metabolism and excretion o phenol and reduces arrhyth-
occurs on perioral skin and o ten mani ests itsel 7 to 10 mias. I an arrhythmia occurs the peel should be stopped
days a ter the procedure. Unusual and unexpected pain until a normal sinus rhythm is sustained or 15 minutes.
occurring 3 or 4 days postoperatively may herald the T e procedure may then be resumed with extension o the
onset o viral in ection. T e risk o scarring is high and peel intervals by an additional 15 minutes.38– 40
all patients must be treated prophylactic antiviral medica-
tions. A 14 day course o valcyclovir 500 to 1000 mg b.i.d.
to t.i.d. should be initiated 1 day prior to the procedure or
r ef er en c es
prophylaxis. I herpetic lesions appear, treatment should 1. Monheit GD, Chastain MA. Chemical peels. Facial Pla st Surg
be at a dose o 1000 mg t.i.d. I caught early, herpetic in ec- Clin North Am. 2001;9:239– 255, viii.
tions usually do not scar. 2. Eller JJ, Wol S. Skin peeling and scari cation. JAMA. 1941;
Persistent erythema is a rare syndrome in which the 116: 934– 938.
skin remains erythematous and/or pruritic beyond the 15 3. Ayres S 3rd. Dermal changes ollowing application o chemi-
cal cauterants to aging skin. Super cial chemosurgery. Arch
to 30 days that is normally expected or a medium-depth Dermatol. 1960;82:578– 585.
chemical peel or 60 to 90 days expected or a deep peel. In 4. Ayres S 3rd. Super cial chemosurgery in treating aging skin.
396 addition to in ectious etiologies, this condition can result Arch Dermatol. 1962;85:385– 393.
 5. Brown AM, Kaplan LM, Brown ME. Phenol-induced histo-
logical skin changes: hazards, technique, and uses. Br J Pla st
23. se Y, Ostad A, Lee HS, et al. A clinical and histologic
evaluation o two medium-depth peels. Glycolic acid versus
4
Surg. 1960;13:158– 169. Jessner’s trichloroacetic acid. Derma tol Surg. 1996;22:781–
6. Baker J. Chemical ace peeling and rhytidectomy. A com- 786.
bined approach or acial rejuvenation. Pla st Reconstr Surg 24. Monheit GD. Chemical peels. Skin T erapy Lett. 2004;9:6–11.
ransplant Bull. 1962;29:199– 207. 25. Lawrence N, Cox SE, Cockerell CJ, Freeman RG, Cruz PD Jr.
7. Stegman SJ. A comparative histologic study o the e ects o A comparison o the e cacy and sa ety o Jessner’s solution
three peeling agents and dermabrasion on normal and sun- and 35% trichloroacetic acid vs 5% f uorouracil in the treat-
damaged skin. Aesthetic Pla st Surg. 1982;6:123– 135. ment o widespread acial actinic keratoses. Arch Dermatol.
8. Van Scott EJ, Yu RJ. Control o keratinization with alpha- 1995;131:176– 181.
hydroxy acids and related compounds. I. opical treatment o 26. Witheiler DD, Lawrence N, Cox SE, Cruz C, Cockerell CJ,
ichthyotic disorders. Arch Dermatol. 1974;110:586– 590. Freemen RG. Long-term e cacy and sa ety o Jessner’s so-
9. Fitzpatrick B. T e validity and practicality o sun-reactive lution and 35% trichloroacetic acid vs 5% f uorouracil in the
skin types I through VI. Arch Dermatol. 1988;124:869–871. treatment o widespread acial actinic keratoses. Dermatol
10. Rubenstein R, Roenigk HH Jr, Stegman SJ, Hanke CW. Atypi- Surg. 1997;23:191– 196.
cal keloids a ter dermabrasion o patients taking isotretinoin. 27. Monheit GD. T e Jessner’s-trichloroacetic acid peel. An
J Am Acad Dermatol. 1986;15:280– 285. enhanced medium-depth chemical peel. Dermatol Clin.

C
11. Wol e SA. Chemical ace peeling ollowing therapeutic irra- 1995;13:277– 283.

h
diation. Pla st Reconstr Surg. 1982;69:859– 862. 28. Baker J, Gordon HL. Chemical ace peeling. In: Surgical

p
12. Glogau RG, Matarasso SL. Chemical ace peeling: patient and rejuvenation of the face. St. Louis, MO: Mosby; 1986.

t
peeling agent selection. Facial Pla st Surg. 1995;11:1– 8. 29. Hetter GP. An examination o the phenol-croton oil peel: part

r
3
13. Clark CP 3rd. O ce-based skin care and super cial peels: I. Dissecting the ormula. Pla st Reconstr Surg. 2000;105: 227–

2
the scienti c rationale. Pla st Reconstr Surg. 1999;104: 239; discussion 49– 51.
854–864; discussion 65– 66. 30. Beeson WH, McCollough EG. Chemical ace peeling without

:
:
14. Berg eld W, ung R, Vidimos A, Vellanki L, Remzi B, Stanton- taping. J Dermatol Surg Oncol. 1985;11:985– 990.

C
Hicks U. Improving the cosmetic appearance o photoaged 31. Alt H. Occluded Baker-Gordon chemical peel: review and

h
skin with glycolic acid. J Am Acad Dermatol. 1997; 36:1011– update. J Dermatol Surg Oncol. 1989;15:980– 993.

m
1013. 32. Maloney BP, McCollough EG. Deep-depth chemical peeling.

i
c
15. Garcia A, Fulton JE Jr. T e combination o glycolic acid and Facial Pla st Surg. 1995;11:30– 38.
hydroquinone or kojic acid or the treatment o melasma and 33. Brody HJ. Complications o chemical resur acing. Dermatol

P
related conditions. Dermatol Surg. 1996;22:443– 447. Clin. 2001;19:427– 438, vii-viii.
16. Van Scott EJ, Yu RJ. Hyperkeratinization, corneocyte cohe- 34. Alster . Laser scar revision: comparison study o 585-nm

s
sion, and alpha hydroxy acids. J Am Acad Dermatol. 1984; pulsed dye laser with and without intralesional corticoste-
11:867–879. roids. Dermatol Surg. 2003;29:25– 29.
17. Resnik SS. Chemical peeling with trichloroacetic acid. J Der- 35. Alster , Zaulyanov L. Laser scar revision: a review. Dermatol
matol Surg Oncol. 1984;10:549– 550. Surg. 2007;33:131– 140.
18. Stagnone JJ. Chemabrasion, a combined technique o chem- 36. Spira M, Gerow FJ, Hardy SB. Complications o chemical ace
ical-peeling and dermabrasion. J Dermatol Surg Oncol. 1977; peeling. Pla st Reconstr Surg. 1974;54:397– 403.
3:217– 219. 37. Kligman AM, Willis I. A new ormula or depigmenting hu-
19. Monheit GD. T e Jessner’s + CA peel: a medium-depth man skin. Arch Dermatol. 1975;111:40– 48.
chemical peel. J Dermatol Surg Oncol. 1989;15:945– 950. 38. ruppman ES, Ellenby JD. Major electrocardiographic
20. Monheit GD. Medium-depth chemical peels. Dermatol Clin. changes during chemical ace peeling. Pla st Reconstr Surg.
2001;19:413– 425, vii. 1979;63:44– 48.
21. Brody HJ. Variations and comparisons in medium-depth 39. Price NM. EKG changes in relationship to the chemical peel.
chemical peeling. J Dermatol Surg Oncol. 1989;15:953– 963. J Dermatol Surg Oncol. 1990;16:37– 42.
22. Coleman WP 3rd, Futrell JM. T e glycolic acid trichloroacetic 40. Gross BG. Cardiac arrhythmia during phenol ace peeling.
acid peel. J Dermatol Surg Oncol. 1994;20:76– 80. Pla st Reconstr Surg. 1984;73:590– 594.

397
 Photodynamic Therapy for
Ch a p t e r Nonmelanoma Skin Cancer and

33 Precursor Lesions
Katrine Togsverd-Bo & Merete Haedersdal

In t r o d u c t Io n Mec h a n Is Ms o f
ph o t o d yn a MIc t h er a py
Photodynamic therapy (PD ) is increasingly used in
both USA and Europe or the treatment o actinic kera- T e mechanism o PD involves the simultaneous pres-
tosis (AK) and selected cases o nonmelanoma skin can- ence o a photosensitizer, oxygen, and light. A photo-
cer (NMSC). Being a minimally invasive therapy, PD is sensitizer is a molecule that absorbs light o appropriate
especially suitable or the treatment o multiple lesions, wavelengths to initiate a photochemical reaction.6 When a
eld cancerization and lesions located in areas where photosensitizer absorbs light, an electron is trans erred to
optimal cosmetic outcome is essential.1,2 T e principle o a higher energy orbital and the photosensitizer enters the
PD involves the combination o a photosensitizer, oxy- excited singlet state (Fig. 33-1).7 T e excited singlet state
gen, and light to produce selective cytotoxic damage o is very unstable and thus, the photosensitizer emits excess
dysplastic cells. In dermatology, PD is used with a topi- energy as either f uorescence and/or heat, or undergoes
cally applied photosensitizer, which allows or speci c intersystem crossing to orm a more stable excited triplet
lesion targeting. state (Fig. 33-1).7 From the triplet state, PpIX can either (i)
opical PD was introduced in 1990 when Kennedy decay to the ground state, (ii) react directly with the sub-
and Pottiers applied 5-aminolevulinic acid (ALA), a pre- strate to orm ree radicals (type I reaction), or (iii) react
cursor o the endogenous photosensitizer, protoporphyrin directly with tissue oxygen to orm singlet oxygen (1O 2)
IX (PpIX), directly on skin tumors.3,4 T e use o a topically (type II reaction).8
applied photosensitizer was a major advantage compared T e main mechanism o action in PD is the type II
to the previously used photosensitizers, which required reaction, in which the excited PpIX reacts with molecu-
intravenous administration and produced long-lasting lar oxygen to orm 1O 2.7,9 1O 2 is highly unstable and reacts
phototoxicity.5 Since the introduction o PD with ALA with nearby molecules, including PpIX itsel , causing cel-
or its methylated ester, methyl aminolevulinate (MAL), lular damage and ultimately cell death.10 During type I and
intensive research has established PD in dermatology II reactions, PpIX itsel is degraded by a process known as
and the concept o PD is now substantially documented photobleaching, which is use ul or dosimetry o the PD
or the treatment o NMSC and precursor lesions. PD is response.11
per ormed with both ALA and MAL or AK lesions and T e biologic PD response involves direct cell death
besides, MAL-PD is approved in Europe or the treat- due to reaction with 1O 2, indirect tissue damage due to
ment o Bowen’s disease (BD, squamous cell carcinoma vasculature damage and shutdown, as well as inf amma-
[SCC] in situ), and super cial and small nodular basal tion and immune activation.6,12 Direct cell death is mainly
cell carcinomas (BCC).1,2 Furthermore, PD is adminis- mediated through apoptosis but also involves necro-
tered as o -label treatment or photoaged skin, acne, and sis and autophagous processes.10,12 T ese processes are
selected skin conditions o inf ammatory, in ectious, and accompanied by microvascular damage, which is consid-
neoplastic origin. ered an important contributor to tumor destruction.13 In

S 1 excite d P pIX Type 1 re a ction

T1 Ce llula r
da ma ge
e
n
c
y
o
n
i
g
e
t
r
p
c
e
r
s
n
o
e
E
s
r
Type 2 re a ction
o
b
A
u
l
F
Light 3
O 2 triple t
P pIX ground s ta te Oxyge n oxyge n

Figure 33-1 The photodynamic process.

addition, PD raises an in ammatory response, including
recruitment o antigen-presenting cells that may stimu- 1,2
P pIX a bs orption s pe ctrum
4
late the host immune response.14 T e immune response 1
is believed to play an important role in the long-term
ef cacy o PD in tumor treatment.12,15 0,8

u
0,6

a
ph o t o s en s It Iz In g a g en t s 0,4

0,2
opical PD in dermatology is currently licensed with two
PpIX prodrugs, ALA and its methylated ester, MAL. Both 0
0 100 200 300 400 500 600 700 800
are endogenously converted to PpIX by the heme biosyn- nm
thetic pathway and relatively selectively concentrated in

C
h
dysplastic tissue, which is possibly due to acilitated pen- Figure 33-2 The PpIX absorption spectrum in arbitrary

a
p
etration and increased PpIX metabolism in dysplastic tis- units (au). PpIX has absorption peaks around 405 to

t
e
430 nm (Soret band), 506 to 540 nm, 572 to 582 nm, and

r
sue.5,16,17 When ALA or MAL is exogenously applied, the

3
628 to 635 nm.

3
normal eedback mechanism is bypassed and PpIX accu-
mulates intracellularly in phototoxic concentrations.4

:
:
ALA is a small, hydrophilic molecule (molecular weight, (LPDLs) are widely used in PD or the treatment o espe-

P
MW, 168 Da) and a zwitterion (both positively and nega-

h
cially photodamaged skin, but also or acne and AK.29– 34

o
tively charged groups) at physiological pH.18 T ese charac-

t
Noncoherent light sources in the visible light spectrum

o
d
teristics make ALA unstable in aqueous ormulations and are now widely used or PD as they are inexpensive,

y
n
impair its penetration through lipophilic environments require little maintenance and may cover wide illumina-

a
m
such as the stratum corneum.19 o improve the bioavail- tion areas. A number o continuous, noncoherent light

i
c
ability o PpIX in dysplastic lesions, the more lipophilic sources with emission spectra in the visible spectrum

T
h
and stable MAL was introduced. MAL is slightly larger are available.35 T at is, blue light is available as a blue

e
r
than ALA (MW 182 Da) but penetrates and accumulates

a
uorescent lamp at 400 to 450 nm with emission peak at

p
more readily in lipophilic structures.20,21 MAL is selec-

y
417 nm (BLU-U, DUSA Pharmaceuticals, USA). Red light

o
tive with regard to PpIX accumulation in diseased skin is provided as narrowband LED light at 630 ± 3 nm (Akti-

r
N
and produces a higher lesion/normal tissue concentration lite, Galderma, France) or 633 ± 4 nm (Omnilux, Photo-

o
ratio than ALA.22,23 Recently, a nanoemulsion o ALA has

n
therapeutics, UK) and as broadband light sources at 560

m
been developed in order to improve ALA stability and to 710 nm (i.e., Waldmann, Waldmann Medizintechnic,

e
l
a
increase its skin sur ace penetration, thereby enhancing Germany; PhotoDyn, Hydrosun Medizintechnik; Pat-

n
o
PpIX tissue distribution.24 erson lamp, Paterson Institute, UK). Compared to the

m
a
broadband light sources, narrowband LED light produces

S
higher complete response rates and may also induce a

k
LIg h t s o u r c es f o r pd t

i
n
more pronounced PD response in the deeper skin lay-

C
ers.26,36 However, pain intensities during illumination

a
n
Ideally, light sources used or PD must have emission

c
are also signi cantly higher in narrowband compared to

e
spectra that match the PpIX absorption spectrum as well

r
broadband red light.36 Narrowband as well as broadband

a
as considerable skin penetration to photoactivate accu-

n
continuous light sources have shown to produce higher

d
mulated PpIX within the target lesions.6 Light penetration

P
degrees o PpIX photobleaching than pulsed light sources,

r
is in uenced by absorption o skin chromophores and by

e
including in deeper tissue layers, possibly due to oxygen

c
u
scattering o photons. Absorption and scattering e ects depletion during delivery o light.37,38

r
s
are more pronounced or shorter than longer visible wave-

o
r
lengths and thus, the penetration o light is deeper or

L
e
longer than shorter visible wavelengths.25 PpIX has a maxi- In d Ic a t Io n s a n d LIc en s es

s
i
o
mum absorption band in the blue light spectrum (Soret

n
s
band, 405–415 nm) and substantially weaker absorption In the USA, PD is approved or the treatment o super-
in the green (506– 540 nm), yellow (572– 582 nm), and cial and moderately thick (Olsen grade I and II), nonhy-
red (628– 635 nm) wave bands (Fig. 33-2). Although PpIX perkeratotic, nonhyperpigmented AK o the ace and scalp
absorption is substantially higher at 405 nm, blue light using ALA combined with blue light exposure and MAL
penetrates poorly into the dermis, whereas red light has a combined with red LED exposure.39 In USA and South
deep skin penetration and may drive PD reactions down America, ALA is currently marked as Levulan Kerastick
to 4 mm.26 Correspondingly, clinical studies have ound red 20% hydroalcoholic (Dusa Pharmaceuticals, Wilmington,
light to be superior or PD treatment o BD and BCC.2,27,28 MA, USA) and MAL is licensed as Metvixia cream
Clinically and experimentally, a wide range o light (Galderma International, Paris, France) containing 16.8%
sources have been used or PD . T ese include noncoher- MAL as hydrochloride. In Canada, Metvix 16.8% is
ent light sources with narrowband light-emitting diodes approved or thin or nonhyperkeratotic and nonpigmented
(LED); broadband light sources such as uorescent lamps, AK on the ace and scalp and or primary super cial BCC
metal halide and xenon arc lamps; as well as daylight and outside the central zone o the ace. In Europe, ALA was
coherent laser light. Furthermore, pulsed light sources such recently approved or grade I and II AK o the ace and
as intense pulsed light (IPL) and long-pulsed dye lasers scalp as a nanoemulsion gel with 7.8% ALA (Ameluz, 399
4 Bio rontera Bioscience GmbH, Leverkusen, Germany) and
or mild AK (grade I) as a sel -adhesive patch containing
8 mg ALA, 2 mg/cm 2 (Alacare, Spirig, Bern, Switzerland).
MAL-PD is approved in Europe, Australia, and New
Zealand or super cial, moderately thick AK (grade I– II),
or BD (except New Zealand), and or super cial BCC and
nonsclerotic, nonpigmented nodular BCC having a thick-
ness o up to 2 mm (except France).1,2 In Europe, Australia,
and New Zealand, only red LED light is approved or PD
with ALA or MAL.
ALA-PD with Levulan Kerastick is licensed or appli-
cation at 14 to 18 hours ollowed by blue light illumination
with a uorescent lamp (BLU-U, Dusa Pharmaceuticals,
Wilmington, MA, USA) at 400 to 450 nm in a dose o
10 J/cm 2, 10 mW/cm 2 irradiance, corresponding to an
S
e
illumination time o 1,000 seconds.40 PD with ALA
c
t
i
nanoemulsion, ALA patch and MAL is licensed using red
o
n
narrowband LED light at 630 ± 3 nm (Aktilite CL 128,
4
Galderma International, France), or 633 ± 4 nm (Omni-
:
:
lux, Phototherapeutics, UK) at 37 J/cm 2 and 68 mW/cm 2
irradiance, which corresponds to an illumination time o
A
e
approximately 9 minutes. ALA nanoemulsion and MAL
s
t
h
cream require an incubation time o 3 hours while ALA
e
t
patch must incubate on the skin lesion or 4 hours be ore
i
c
a
illumination. I narrowband light sources are not toler- Figure 33-3 Field-cancerized skin with actinic kerato-
n
d
ated due to intense pain during illumination, broadband ses be ore (top) and 3 months a ter MAL-PDT treatment
L
light sources at 570 to 650 nm, such as the Waldmann
a
(bottom).
s
e
1200 (Waldmann Medizintechnic, Germany) in a dose
r
P
o 170 J/cm 2 may be used; however clearance rates are
r
o
reported to be slightly lower (61%– 72% vs. 68%– 85% o was provided by broadband light sources and pulsed light
c
e
sources such as IPL and LPDL.1,30,41,42
d
AK lesions).36
u
In clinical studies, MAL-PD (MAL 3 hours, 570–
r
e
s
650 nm, 75 J/cm 2, 50– 250 mW/cm 2) has established ef -
a c t In Ic ker a t o s es cacy rates o 89% to 93% at 3 months a ter two treatments
given at 1 to 2 week intervals.43– 45 In a multicenter ran-
AKs are the most common premalignant lesion and char- domized study o thin and moderately thick AK, a nar-
acteristically, the lesions o ten appear in chronically sun- rowband red LED (630 ± 3 nm, 37 J/cm 2, 50 mW/cm 2)
damaged skin as a sign o eld cancerization. AK may was used to compare two MAL-PD treatments at 7 day
develop into SCCs, which have metastatic potential, espe- intervals versus a single treatment that was repeated at
cially in immunosuppressed patients. 3 months i required.46 T e study ound a single treatment
Since the introduction o ALA-PD in 1990, a large to be as e ective as two treatments, clearing 92% and
body o evidence has established PD with both ALA and 87% o lesions, respectively. T is led to a revision o the
MAL as an e ective treatment o AK and eld-cancerized EU license or MAL-PD , recommending an initial single
skin with superior cosmetic outcomes compared to con- treatment, repeated at 3 months i required.
ventional destructive therapies (Fig. 33-3).2 Studies have T e ef cacy o PD depends, similar to topical treat-
reported lesion response rates rom 71% to 96% at 1 to 3 ments or AK, on the thickness o the lesion. Using a sin-
months a ter PD o the ace and scalp while lower clear- gle PD treatment, studies have reported response rates
ance rates o 44% to 70% are reported or AKs located on o 75% to 93% or thin lesions; 64% to 83% or moder-
the trunk or extremities. ately thick lesions and 39% to 52% or thick lesions.5,6,16– 18
In clinical studies, ALA-PD has been applied in a Hence, two PD treatments at 1 to 2 week intervals are
variety o di erent protocols, whereas MAL-PD in most recommended or thick lesions.
studies is used according to the approved protocols. PD has previously been compared to other treat-
T e e ect o ALA-PD , applied according to the ments or AK, mainly cryotherapy but also 5- uoroura-
licensed protocol (ALA 14– 18 hours, 417 ± 5 nm, 10 J/cm 2, cil (5-FU) and imiquimod.46,48,50– 51 Studies comparing
10 mW/cm 2), was compared to placebo in a multicenter, PD and cryotherapy ound similar response rates rom
randomized controlled trial involving a total o 243 one or two treatments o PD compared to cryotherapy,
patients with multiple AK.40 At 8 weeks ollow-up, the AK while cosmetic outcomes were superior or PD with
response rate was 83% a ter one treatment, and retreat- 80% to 90% excellent results or PD vs. 51% or cryo-
ment o remaining lesions increased the response rate to therapy.45,47 PD has shown equivalent ef cacy com-
91% a ter 3 months (31% and 25% a ter placebo treatment). pared to 5-FU with lesion clearances o 79% and 80%
Similar clearance rates were ound in smaller clinical stud- respectively at 1 month and 73% and 70% at 6 months.
ies ollowing one or two treatments o ALA-PD although In smaller studies comparing PD and imiquimod, data
400 ALA incubation varied rom 1 to 6 hours and illumination have been somewhat ambiguous, since comparisons have
shown both PD and imiquimod to be superior or AK
treatment.48,59
4
Bo w en ’s d Is ea s e
PD is an e ective treatment or BD, clearing on aver-
age 80% to 93% o lesions.27,47,50 Immediate response rates
at 3 months range rom 88% to 100%, and responses at
12 months range rom 80% to 95%, which is signi -
cantly better than cryotherapy (67%) and similar to 5-FU
treatment (83%).47 At 2 years ollow-up, 68% o lesions

C
remained clear a ter PD , 60% a ter cryotherapy and 59%

h
a
a ter 5-FU, with cosmetically superior results o PD

p
t
compared to cryotherapy and 5-FU.4

e
r
While PD is e ective or BD, signi cantly lower

3
3
response rates are ound or invasive SCC.51 In view o
the metastatic potential o SCC, PD cannot be recom-

:
:
mended or treatment o invasive SCC.

P
h
o
t
o
Ba s a L c eLL c a r c In o Ma

d
y
n
a
m
BCCs are the most common cancers in the USA, Australia,

i
c
and Europe, and worldwide the incidence is increasing.

T
h
In Europe, Australia, and New Zealand, MAL-PD is

e
r
approved or primary, super cial BCC and low-risk nodu-

a
p
lar BCC. High risk tumors are not suitable or treatment

y
with PD . High risk tumors include those with (i) size

o
Figure 33-4 Basal cell carcinoma be ore (top) and

r
greater than 2 cm diameter; (ii) location in the central

N
6 months a ter two MAL-PDT treatment at 7 day interval

o
acial region (H-zone, especially around eyes, nose, lips,

n
(bottom).

m
and ears); (iii) clinically poorly de ned tumor margins;

e
l
(iv) pigmented BCC; (v) aggressive histologic subtype and

a
treatment or primary, low-risk nodular BCC.1,2,55 PD

n
perivascular or perineural invasion; (vi) recurrent tumors;

o
may be considered or nodular BCC in cases where sur-

m
and (vi) tumors in immunosuppressed patients.52 gical excision is relatively contraindicated or when other

a
S
Super cial BCCs are reported to respond well to PD actors, such as patient pre erence, comorbidities and/or

k
i
with clearance rates o approximately 85% at 12 months

n
cosmetic considerations result in a willingness to accept

C
a ter two treatments. At 5 years’ ollow-up, recurrences higher risk o recurrence. A recent European PD guide-

a
n
have been reported in 25%o cases, which is similar to cryo- line advises a minimum o 1 year ollow-up or patients

c
e
therapy (26%), but with PD resulting in signi cantly bet- receiving PD or nodular BCC.1

r
a
ter cosmetic outcomes than cryotherapy (excellent results

n
d
in 60% o PD patients vs. 16% o cryotherapy patients).53

P
f IeLd c a n c er Iz a t Io n a n d

r
In studies on nodular BCC, two MAL-PD treatments

e
c
s k In c a n c er pr e v en t Io n

u
at 1 to 2 week intervals achieved complete remission o

r
s
low-risk tumors in 82% to 91% o cases within 1 year post-

o
r
treatment. In these low-risk tumors, complete remission Field cancerization is characterized by multi ocal areas

L
e
was sustained in 78% to 86% o lesions at 3 to 5 years’ o clinical and subclinical premalignant and malignant

s
i
o
ollow-up, whereas PD treatment o high-risk BCC showed lesions that primarily appear in chronically sun-damaged

n
s
recurrence rates o 38% at 3 years’ ollow-up.1 skin.56,57 Field-directed PD is an attractive treatment
Long-term complete response o MAL-PD or pri- modality or eld cancerization, as it may be used or mul-
mary, low-risk BCC has been compared to surgical excision tiple lesions and large skin areas with excellent cosmetic
in a randomized controlled trial.54 reatment response at results. T e preventative potential o eld-directed PD
3 months showed 98% to 99% o surgically excised lesions or acial AKs in immunocompetent patients demonstrated
cleared a ter surgical excision, versus 92% o PD -treated a signi cant delay in development o new AKs up to 6
lesions, declining to 96% and 83% at 12 months’ ollow- months compared to control sites, highlighting its poten-
up.5 At 5 years posttreatment, surgical excision resulted in tial as a preventive measure.58 Recent studies have shown
higher sustained response rates o 96% compared to 76% that PD reduces the histological eatures o actinic dam-
o lesions a ter PD , whereas cosmetic outcomes avored age and expression o early oncogenic markers such as p53
PD , with good or excellent outcomes in 87% o cases a ter mutations in eld-cancerized skin.59,60 T ese ndings sup-
PD compared to 54% a ter surgery (Fig. 33-4). port the preventative e ect o PD in skin carcinogenesis.
In summary, there is increasing evidence that MAL- Patients receiving long-term immunosuppressive
PD is becoming established as an e ective treatment therapy such as organ transplant recipients (O Rs) are
modality or primary, super cial BCC and as a reasonable at particularly high risk o developing dysplastic eld 401
4 changes and multiple carcinomas. T ese patients require
multiple sessions o eld-directed therapies, requent
described the potential o PD to treat a variety o other
in ammatory diseases such as localized scleroderma, nec-
screening or malignancies and long-term ollow-up o robiosis lipoidica diabeticorum and perioral dermatitis, but
treated tumors.61 As in immunocompetent patients, eld- PD appears to have a limited role in treating psoriasis.73
directed PD in O R also prevents the development o In the treatment o in ectious diseases, ALA- and MAL-
new AK.58,62,63 In renal O R, one MAL-PD session sig- PD have shown to be a potential option or re ractory
ni cantly delayed the development o new AKs in an intra- viral warts, with clearance rates o 56% to 75% ollowing
patient randomized study (9.6 vs. 6.8 months or control two to six treatments.1,74 In genital warts, clearance rates
sites).63 In a multicenter study, repeated sessions o MAL- o 66% to 89% have been reported ollowing one to our
PD were initially more e ective than lesion-targeted ALA-PD treatments.1 In case reports o early stage, local-
cryotherapy or prevention o new AKs (65 vs. 103 AKs in ized cutaneous -cell lymphoma, ALA- and MAL-PD
control areas at 6 months).62 However, the superiority was success ully cleared plaque lesions, whereas solid tumors
lost by 27 months, suggesting that continued treatments responded less e ectively.75 Intraepithelial neoplasia o the
are required to maintain a sustained, protective e ect. vulva also responded to PD with complete histological
Repeated PD cycles (6– 8 treatments per year) showed a clearance o vulvar intraepithelial neoplasia (VIN) grade II
S
e
reduced incidence o new SCC in transplant recipients,64 to III in 57% to 73% o lesions at 1 year posttreatment.70,76
c
t
i
whereas a single PD treatment did not protect against However, studies have reported high recurrence rates o up
o
n
SCC development at 2 year ollow-up.65 to 50%, which calls or optimization o the protocols used.70
4
In summary, eld-directed PD is evolving as a suitable
:
:
therapeutic option or the prevention o AKs in O R and
immunocompetent patients having multiple dysplastic t r ea t Men t pr o c ed u r es
A
e
lesions. For these patients, eld-directed treatment is pre-
s
t
opical PD is a three-step process that involves lesion
h
erred over lesion-targeted therapy.
e
preparation, incubation with ALA or MAL, and light
t
i
c
exposure. An example o the most commonly used equip-
a
n
o f f -La BeL u s e ment is displayed in Figure 33-5.
d
L
a
s
e
PD is reported as o -label treatment or photoaged skin,
Les Io n pr epa r a t Io n
r
P
selected in ammatory and in ectious diseases and neo-
r
o
plastic diseases other than NMSC.
c
Care ul preparation o the treated lesion is essential to
e
PD is increasingly used or photoaged skin, o ten
d
optimize treatment outcome.77 Preparation depends on
u
in combination with ltered pulsed light sources and
r
e
the type o lesion and is per ormed in the clinic imme-
s
lasers.66 Multiple studies have demonstrated improve-
diately prior to treatment. Lesion marking may be use ul
ment o ne wrinkles, mottled hyperpigmentation, tactile
in the treatment o BD and BCC, since a margin o 5 mm
roughness and sallowness by addition o ALA or MAL
o normal skin surrounding the tumor should be treated
compared to light alone.67– 70 T ese results are supported
along with the lesion.78,79
by immunohistochemical analyses that revealed both
When treating AKs, all scale and crust should be
upregulation o collagen production and increased epi-
removed and the stratum corneum disrupted to acilitate
dermal proli eration.60 o minimize phototoxic reactions
suf cient depth o penetration o ALA and MAL. Gentle
a ter treatment, most studies have used short incuba-
tion periods (0.5– 1 hour) with ALA or MAL but several
protocols are currently being used or photodynamic
photorejuvenation.
During the past decade, PD has been extensively
studied as a treatment modality or in ammatory acne,
although without current existing consensus on optimal
protocols or photosensizers, incubation time, light source,
or dosimetry.71 However, the literature suggests that seba-
ceous glands are reduced a ter longer incubation periods
(3 hours) with a photosensitizing agent ollowed by red
light exposure rather than short incubation (10–30 min-
utes) and blue light exposure.71 T e mechanism o action
seems to involve an antibacterial e ect upon Proprionibac-
terium acnes, selective destruction o sebaceous glands and
possible immunologic changes in the acne lesions.71,72 PD
with di erent protocols and light sources has demonstrated
a 38% to 88% reduction in in ammatory lesions at 12 weeks
Figure 33-5 Equipment used or PDT treatment: dispos-
a ter 2 to 3 PD treatments, whereas no consistent reduc- able razor, ruler and pen, disposable gloves, disin ection
tion in nonin ammatory lesions was seen.23,32,71 However, swabs, local anaesthesia, needle and syringe, curette,
PD treatment o acne has been associated with intense swabs or application o MAL cream, MAL cream, adhesive
posttreatment in ammatory skin reactions, which at the dressing, nontransparent tape and bandage, cotton buds,
moment does not bolster support o PD as a rst-line and protective glasses or illumination. Forceps may be
402 therapy or acne. Case series and individual reports have used in tumor debulking when treating BCC.
 4

C
h
a
p
Figure 33-6 Field-cancerized skin immediately a ter

t
e
r
curettage o the entire treatment area. No bleeding or

3
3
oozing o the skin is present.

:
:
curettage or scraping with the edge o a scalpel blade is

P
h
care ully per ormed to avoid bleeding. In eld-directed

o
t
o
PD , curettage o the entire treatment area must be per-

d
y
ormed evenly (Fig. 33-6).

n
a
T e preparation o BCC requires a deeper scraping with

m
care ul removal o overlying epidermal keratin and deb-

i
c
T
ulking o the exposed tumor material. Local anesthesia

h
e
o the lesion may be required. T e intention is to remove

r
a
p
the central core o the tumor without per orming a ull

y
curettage o the lesion (Fig. 33-7). umor debulking is

o
r
usually per ormed immediately be ore PD , but may be

N
undertaken a ew days prior to treatment.79,80 Any bleed-

o
n
ing or oozing o the lesion must cease be ore application

m
e
o MAL in order to ensure cream penetration into the

l
a
n
lesion. Bleeding may be stopped by compression, whereas

o
m
hemostasis with diathermy, trichloroacetic acid, iron, or

a
aluminum chloride may a ect the outcome o PD due to

S
k
coagulation o blood in the treatment area.79,80

i
n
C
a
n
a ppLIc a t Io n o f

c
e
r
ph o t o s en s It Iz er

a
n
d
P
r
e
Following lesion preparation, ALA or MAL is applied Figure 33-7 Lesion preparation o nodular basal cell carci-

c
u
directly to the lesion site and the surrounding 5 mm o nor- noma be ore (above) and a ter tumor debulking (below).

r
s
mal skin. Incubation o the photosensitizing agent should

o
r
L
take place at room temperature as cold skin temperatures

e
■ Following incubation, the treatment area should be

s
may reduce the rate o PpIX ormation.17 High ambient

i
o
gently rinsed with water and dried be ore illumination.

n
temperature may on the other hand cause excessive sweat-

s
ing and thus dilute the drug concentration.79
T e application technique and incubation time depends a La pa t c h
on the photosensitizing agent and ormulation used.
■ Apply the patch and incubate or 4 hours.
a La f o r Mu La t ed In a ■ Following incubation, remove the patch and rinse the
treatment area with water.
LIq u Id s o Lu t Io n
■ Mix the ALA powder and alcohol solution o the a La n a n o eMu Ls Io n
aminolevulinic acid stick immediately (<2 hours) be ore
AK application. ■ Following lesion preparation, lesions must be wiped
■ Apply the prepared solution to uni ormly wet the sur ace with an ethanol or isopropyl alcoholol-soaked cotton
o the AK. Repeat when the initial application has dried. pad to degrease the skin. T e gel is then applied in a
■ Incubate or 14 to 18 hours without occlusion, avoiding 1 mm thick layer to the entire lesional area avoiding
bathing or washing o the lesion. application close to eyes, nostrils, mouth, and ears. 403
4 ■ Allow the gel to dry or approximately 10 minutes
be ore the treatment area is covered with occlusive a c u t e a n d s h o r t -t er M r ea c t Io n s
light-impermeable dressing. Incubate or 3 hours.
■ Following incubation, the occlusive dressing is Frequently observed reactions include pain during illu-
removed and the treatment area cleaned with saline mination and posttreatment in ammatory skin reactions.
and gauze. Pain during illumination can be a signi cant adverse
e ect, which may deter some patients rom receiving
continued treatments. Patients describe pain as a burn-
Ma L c r ea M ing, stinging sensation that peaks within the rst ew
minutes o illumination and continues throughout the
■ Apply MAL cream in a 1 mm thick layer to the entire entire illumination period. Pain intensities vary widely
lesion to be treated. between patients but the majority o patients report
■ reatment area must be covered with occlusive light- moderate-to-severe intensities (66% o patients).82 Fac-
impermeable dressing and incubated or 3 hours. tors associated with severe pain intensities include high
■ Following incubation, the occlusive dressing is removed amounts o accumulated PpIX at illumination, anatomical
S
e
and the treatment area cleaned with saline and gauze. regions such as scalp and ace, large treatment areas, red
c
t
narrowband LED light source and illumination with high
i
o
n
irradiances.82– 84 Pain issues are most typically managed by
ILLu MIn a t Io n
4
the use o cold water spray and pauses during illumina-
tion, which provide slight-to-moderate reductions o pain
:
:
Illumination with blue or red light is per ormed according intensities.81 For more e ective pain reduction, local anes-
A
to the ollowing: thesia and acial nerve blocks o orehead and scalp may
e
s
t
be used (pain intensities reduced rom 6.4 to 1.0 on visual
h
Adjust and x the distance rom lamp to patient
e
■
analogue scale).85 Continuous activation o PpIX with day-
t
i
according to manu acturer’s instructions.
c
light irradiation is signi cantly less pain ul and at the same
a
During illumination, patient and medical personnel
n
■
time as e ective as conventional PD with LED.86 T us,
d
should wear suitable protective glasses, whereas untreated
L
daylight-mediated PD may be an alternative treatment
a
surrounding skin needs no protection (Fig. 33-8). It is
s
modality or pain management.
e
advisable that illumination be per ormed under the sur-
r
Following PD , inf ammatory skin reactions such as
P
veillance o a health care pro essional in order to pause
r
o
erythema and edema occur in more than 60% o patients.78
c
or interrupt illumination i needed.
e
Reactions are usually o mild-to-moderate intensities and
d
■ A ter illumination, it is recommended that treated skin
u
typically last or 1 to 4 days. In severely photodamaged
r
be protected rom ambient light or 24 to 48 hours to
e
skin with high amounts o accumulated PpIX, in amma-
s
avoid additional local photosensitivity reactions.
tory skin reactions may be intense, including development
o crusts and sterile pustules (Fig. 33-9) whereas erosions
r ea c t Io n s a n d and bleeding are less requently observed. T ese reactions
usually resolve within 2 to 3 weeks but posttreatment ery-
a d v er s e ef f ec t s thema may persist or 1 to 2 months.78
Skin cultures to exclude in ections may be indicated,
Although generally well-tolerated, PD treatment is although uncommonly required (<1% o cases).78 During
associated with pain and phototoxic reactions such as healing, scaling and itching o the skin is common and
localized in ammation, erythema, edema, crusting, and application o a bland emollient may reduce discom ort.
scaling o the treated skin. Less requently, whealing urti- Whealing urticaria is an uncommon reaction, con-
caria, contact dermatitis, in ection, and hyperpigmenta- sidered due to exaggerated histamine release as part o
tion may occur.81 an immediate, short-lived urticarial response during

Figure 33-9 Moderate-to-severe in ammatory skin reac-

Figure 33-8 Illumination with narrowband red LED light tions with erythema, swelling, pustules, and crusts 3 days
404 (630 nm, Aktilite CL 128, Galderma International, France). ollowing f eld-directed PDT o AKs on the orehead.
 high recurrence rates o thick AKs and nodular BCC com-
pared to thin lesions is a urther disadvantage, particu-
4
larly when those recurrence rates are compared to those o
surgical excision. In order to improve PD in these areas,
research within recent years has ocused on (i) daylight-
mediated PD as a simpli ed, pain-reducing treatment
modality and (ii) ractional laser-assisted PD , which
increases ALA and MAL skin penetration, or intensi ed
treatment procedures.

d a yLIg h t -Med Ia t ed pd t

C
h
Daylight-mediated PD is based on continuous photoacti-

a
p
Figure 33-10 Whealing urticaria immediately a ter PDT vation o small amounts o PpIX during daylight exposure

t
e
rather than photobleaching large amounts o accumulated

r
illumination due to histamine release.

3
PpIX by lamp illumination. T e concept was developed by

3
Pro essor Hans Christian Wul , Copenhagen, Denmark,

:
illumination (Fig. 33-10).87 Urticaria occurs in approxi-

:
and the current body o evidence includes ve landmark
mately 1% o treated patients78 but has been reported

P
studies on AK carried out by Dr. Stine R. Wiegell rom

h
to occur in 3.8% o patients who received more than 7

o
2006 to 2012.90– 95 In daylight-mediated PD , sunscreen

t
PD treatments.87 As the reaction is mediated through

o
is applied be ore lesion preparation, which is ollowed by

d
H 1-receptors, prophylactic treatment with antihistamines

y
application o MAL cream without occlusion. Patients are

n
reduces itch and whealing and permits illumination to be

a
subsequently exposed to home-based ambient daylight or

m
continued.

i
2 hours, which provides an e ective light dose and makes

c
Contact dermatitis may occur rom MAL-PD and is

T
it unnecessary or patients to return to the clinic or light

h
e
most requently observed in patients exposed to repeated exposure (Fig. 33-11).91

r
a
PD treatments.78 MAL sensitization may be considered

p
Daylight comprises ultraviolet radiation as well as

y
in patients with prolonged dermatitis a ter PD treat- visible light and in rared light in a range rom 280 to

o
ment. T e diagnosis is con rmed by patch test with MAL

r
1000,000 nm, which covers PpIX absorption o blue and

N
cream a s is. T e risk o sensitization to MAL is estimated

o
red visible wavelengths.91 Daylight PD studies have

n
in 0.5% o patients but may occur in up to 3% in patients

m
been per ormed in Scandinavia and the PpIX e ective
having ve or more PD treatments.88 I sensitization to

e
l
a
MAL is induced, MAL-PD should be stopped and uture

n
o
treatments may instead be per ormed using ALA as the

m
a
photosensitizing agent.

S
k
i
n
C
Lo n g -t er M r ea c t Io n s

a
n
c
e
Long-term adverse reactions a ter PD include pigmen-

r
a
tary changes such as hyper- and hypopigmentation as well

n
d
as atrophic scarring. ransient hyperpigmentation has

P
r
been described in 5% to 6% o cases ollowing PD and

e
c
u
usually resolves within 3 to 6 months.54,78,81 T e increase

r
s
in pigmentation is considered due to increased activity

o
r
o melanocytes activated by PD and may be prevented

L
e
s
through adequate sun protection.89 In contrast, hypopig-

i
o
mentation due to phototoxic damage o melanocytes is

n
s
relatively uncommon ollowing PD .78 Atrophic or hyper-
trophic scarring is an in requent adverse e ect a ter PD
and is mainly observed ollowing skin in ections.78 How-
ever, atrophy may occur due to o local tumor destruction
and removal o tumor tissue as part o the debulking pro-
cedure. T us, PD in itsel carries a low risk o scarring
and, there ore, may be considered as a reasonable treat-
ment when cosmesis constitutes a major concern.

n ew per s pec t Iv es
T e main limitations o PD include pain during illumi-
nation and the resources required or patients and health Figure 33-11 Daylight-PDT treatment o AK on the chest
care personnel. Furthermore, reduced clearance rates and per ormed in the hospital garden. 405
4 light dose depends on latitude, weather conditions, and
time o year. In a recent study, measurements on e ec-
tive PpIX light dose ound that daylight PD may be per-
ormed until the middle o November in urin and all
year round in Israel.91
T e existing body o evidence on the ef cacy o daylight-
PD or multiple AKs on the ace and scalp consists o ve
randomized clinical trials. In the rst study, 30 patients
were treated in a split-site ashion with daylight-mediated
PD versus conventional PD with red LED light given in
a hospital setting.95 T e study ound that daylight-medi-
ated PD was as e ective as conventional PD (79% and
71% reduction o AK lesions at 3 month ollow-up) and
signi cantly less pain ul (mean maximal pain score o 2.0
vs. 6.7 on 10 point scale).5 In the second study, patients
S
e
were treated in a home-based setting with 8% and 16%
c
t
i
MAL application and subsequent daylight exposure
o
n
(77% cure o AKs at 3 months or 16% MAL and 80% or
4
8% MAL).94 Recently, two multicenter studies including a
:
:
large patient population (n = 120 patients with 2,768 thin,
moderately and thick AKs o the ace and scalp) substanti-
A
e
ated daylight-PD as a promising concept, especially or
s
t
h
patients with large eld-cancerized areas that can easily
e
t
be exposed to sunlight.92,93 Figure 33-12 Ablative ractional laser pattern be ore
i
c
MAL application or intensif ed PDT procedure in f eld-
a
n
cancerized skin o the scalp.
d
L
a
s
f r a c t Io n a L La s er -a s s Is t ed pd t
e
r
P
r ef er en c es
r
o
Ablative ractional resur acing (AFR) creates micro-
c
e
scopic vertical holes o ablated tissue that are surrounded
d
1. Morton CA, Szeimies RM, Sidoro A, Braathen LR. Euro-
u
by a thin layer o coagulated tissue.96 In an in vivo por- pean guidelines or topical photodynamic therapy part 1:
r
e
s
cine study these vertical channels acilitated the biodis- treatment delivery and current indications - actinic kerato-
tribution o topically applied MAL into deep skin layers ses, Bowen’s disease, basal cell carcinoma. J Eur Acad Der-
matol Venereol. 2012;27(5):536– 544.
and promoted an intensi ed PD response in the deep 2. Braathen LR, Szeimies RM, Basset-Seguin N, et al. Guide-
dermal compartment.97,98 At the mid-dermal level corre- lines on the use o photodynamic therapy or nonmelanoma
sponding to 1 mm skin depth, MAL-induced PpIX uo- skin cancer: an international consensus. International Soci-
rescence intensities were approximately 50 times higher ety or Photodynamic T erapy in Dermatology, 2005. J Am
in hair ollicle epithelium and dermal uorescence inten- Acad Dermatol. 2007;56(1):125– 143.
3. Kennedy JC, Pottier RH. Endogenous protoporphyrin IX, a
sities approximately 15 times higher as compared with clinically use ul photosensitizer or photodynamic therapy. J
non-AFR treated samples when AFR pretreatment was Photochem Photobiol B. 1992;14(4):275– 292.
per ormed. In a recent randomized study, the ef cacy 4. Kennedy JC, Pottier RH, Pross DC. Photodynamic ther-
and sa ety o AFR-assisted PD was compared to con- apy with endogenous protoporphyrin IX: basic principles
and present clinical experience. J Photochem Photobiol B.
ventional PD or AK treatment in eld-cancerized skin
1990;6(1– 2):143– 148.
(Fig. 33-12).99 T e study showed AFR pretreatment to 5. Kennedy JC, Marcus SL, Pottier RH. Photodynamic therapy
be signi cantly more e ective in the treatment o espe- (PD ) and photodiagnosis (PD) using endogenous photosen-
cially thick AKs compared to conventional PD , with sitization induced by 5-aminolevulinic acid (ALA): mecha-
87.5% vs. 58.8% o moderately and thick AKs cleared at nisms and clinical results. J Clin Laser Med Surg. 1996;14(5):
289–304.
3 months a ter treatment.101 AFR-pretreatment increased
6. Henderson BW, Dougherty J. How does photodynamic
the accumulated amount o PpIX prior to illumination therapy work? Photochem Photobiol. 1992;55(1):145– 157.
and acilitated an intensi ed PD response in terms o 7. Redmond RM. Photophysics and photochemistry in photo-
enhanced ef cacy as well as phototoxic reactions post- dynamic therapy. In: Hamblin MR, Mroz P, ed. Advances in
treatment. Initial clinical attempts have been made to Photodynamic T erapy. Ba sic, ranslational, and Clinical.
1st ed. Boston, MA: Artech House; 2008:41– 58.
investigate the easibility o ractional laser-assisted PD
8. Moan J, Juzeniene A. T e role o oxygen in photodynamic
or nodular BCC100 and this treatment modality is cur- therapy. In: Hamblin MR, Mroz P, ed. Advances in Photo-
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11. Nowis D, Golab J. Photodynamic therapy and oxidative
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namic T erapy Ba sic, ranslational and Clinical. 1st ed. 32. Haedersdal M, ogsverd-Bo K, Wiegell SR, Wul HC. Long-
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aminolevulinic-acid-derivative-induced porphyrin uo- Ioannides D. T e impact o di erent uence rates on pain

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i
22. Fritsch C, Homey B, Stahl W, Lehmann P, Ruzicka , Sies immunol Photomed. 2011;27(4):181– 185.

n
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H. Pre erential relative porphyrin enrichment in solar kera- 42. Morton CA, Brown SB, Collins S, et al. Guidelines or topi-

a
toses upon topical application o delta-aminolevulinic acid cal photodynamic therapy: report o a workshop o the Brit-

n
c
methylester. Photochem Photobiol. 1998;68(2):218– 221. ish Photodermatology Group. Br J Dermatol. 2002;146(4):

e
r
23. Wiegell SR, Wul HC. Photodynamic therapy o acne vul- 552– 567.

a
n
garis using 5-aminolevulinic acid versus methyl aminolevu- 43. Freeman M, Vinciullo C, Francis D, et al. A comparison o

d
linate. J Am Acad Dermatol. 2006;54(4):647– 651. photodynamic therapy using topical methyl aminolevu-

P
r
24. Szeimies RM, Radny P, Sebastian M, et al. Photodynamic therapy linate (Metvix) with single cycle cryotherapy in patients with

e
c
with BF-200 ALA or the treatment o actinic keratosis: results actinic keratosis: a prospective, randomized study. J Derma-

u
r
o a prospective, randomized, double-blind, placebo-con- tolog reat. 2003;14(2):99–106.

s
o
trolled phase III study. Br J Dermatol. 2010;163(2):386–394. 44. Pariser D, Loss R, Jarratt M, et al. opical methyl-aminolev-

r
L
25. Anderson RR. Laser- issue Interactions. In: Almound G, ulinate photodynamic therapy using red light-emitting

e
ed.Cutaneous La ser Surgery. T e art and science of selec- diode light or treatment o multiple actinic keratoses: a ran-

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tive photothermolysis. 2nd ed. St. Louis, Missouri: Mosby; domized, double-blind, placebo-controlled study. J Am Acad

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namic therapy. La sers Med Sci. 2004;19(3):139– 149. pared with cryotherapy or actinic keratosis: a prospective,
27. Morton CA, Whitehurst C, Moore JV, MacKie RM. Compar- randomized study. J Am Acad Dermatol. 2002;47(2):258–262.
ison o red and green light in the treatment o Bowen’s dis- 46. arstedt M, Rosdahl I, Berne B, Svanberg K, Wennberg AM.
ease by photodynamic therapy. Br J Dermatol. 2000;143(4): A randomized multicenter study to compare two treatment
767– 772. regimens o topical methyl aminolevulinate (Metvix)-PD
28. Valentine RM, Wood K, Brown C , Ibbotson SH, Moseley in actinic keratosis o the ace and scalp. Acta Derm Vene-
H. Monte Carlo simulations or optimal light delivery in reol. 2005;85(5):424– 428.
photodynamic therapy o non-melanoma skin cancer. Phys 47. Morton C, Horn M, Leman J, et al. Comparison o topical
Med Biol. 2012;57(20):6327– 6345. methyl aminolevulinate photodynamic therapy with cryo-
29. Alexiades-Armenakas M. Laser-mediated photodynamic therapy or Fluorouracil or treatment o squamous cell car-
therapy. Clin Dermatol. 2006;24(1):16–25. cinoma in situ: results o a multicenter randomized trial.
30. Alexiades-Armenakas MR, Geronemus RG. Laser-mediated Arch Dermatol. 2006;142(6):729–735.
photodynamic therapy o actinic keratoses. Arch Dermatol. 48. Hadley J, ristani-Firouzi P, Hull C, Florell S, Cotter M,
2003;139(10):1313– 1320. Hadley M. Results o an investigator-initiated single-blind
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imiquimod cream or the treatment o actinic keratoses.
67. Kohl E, orezan LA, Landthaler M, Szeimies RM. Aesthetic
e ects o topical photodynamic therapy. J Eur Acad Derma-
Dermatol Surg. 2012;38(5):722– 727. tol Venereol. 2010;24(11):1261– 1269.
49. Serra-Guillen C, Nagore E, Hueso L, et al. A randomized 68. Dover JS, Bhatia AC, Stewart B, Arndt KA. opical 5-
pilot comparative study o topical methyl aminolevulinate aminolevulinic acid combined with intense pulsed light in
photodynamic therapy versus imiquimod 5% versus sequen- the treatment o photoaging. Arch Dermatol. 2005;141(10):
tial application o both therapies in immunocompetent 1247– 1252.
patients with actinic keratosis: clinical and histologic out- 69. Gold MH, Bradshaw VL, Boring MM, Bridges M, Biron JA.
comes. J Am Acad Dermatol. 2012;66(4):e131– e137. Split- ace comparison o photodynamic therapy with 5-ami-
50. Morton CA, Whitehurst C, Moseley H, McColl JH, Moore nolevulinic acid and intense pulsed light versus intense
JV, MacKie RM. Comparison o photodynamic therapy with pulsed light alone or photodamage. Dermatol Surg. 2006;
cryotherapy in the treatment o Bowen’s disease. Br J Der- 32(6):795– 801.
matol. 1996;135(5):766– 771. 70. Hillemanns P, Wang X, Staehle S, Michels W, Dannecker
51. Calzavara-Pinton PG, Venturini M, Sala R, et al. Methyl- C. Evaluation o di erent treatment modalities or vulvar
aminolaevulinate-based photodynamic therapy o Bow- intraepithelial neoplasia (VIN): CO(2) laser vaporization,
en’s disease and squamous cell carcinoma. Br J Dermatol. photodynamic therapy, excision and vulvectomy. Gynecol
2008;159(1):137– 144. Oncol. 2006;100(2):271– 275.
S
52. Madan V, Lear J , Szeimies RM. Non-melanoma skin can- 71. Sakamoto FH, orezan L, Anderson RR. Photodynamic
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cer. Lancet. 2010;375(9715):673– 685. therapy or acne vulgaris: a critical review rom basics to
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53. Basset-Seguin N, Ibbotson SH, Emtestam L, et al. opi- clinical practice: part II. Understanding parameters or acne
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n
cal methyl aminolaevulinate photodynamic therapy versus treatment with photodynamic therapy. J Am Acad Dermatol.
4
cryotherapy or super cial basal cell carcinoma: a 5 year ran- 2010;63(2):195– 211.
domized trial. Eur J Dermatol. 2008;18(5):547– 553. 72. Sakamoto FH, Lopes JD, Anderson RR. Photodynamic ther-
:
:
54. Rhodes LE, de Rie MA, Lei sdottir R, et al. Five-year ollow- apy or acne vulgaris: a critical review rom basics to clinical
up o a randomized, prospective trial o topical methyl ami- practice: part I. Acne vulgaris: when and why consider photo-
A
e
nolevulinate photodynamic therapy vs surgery or nodular dynamic therapy? J Am Acad Dermatol. 2010;63(2):183–193.
s
t
basal cell carcinoma. Arch Dermatol. 2007;143(9):1131– 73. Morton CA, Szeimies RM, Sidoro A, Braathen LR. Euro-
h
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1136. pean guidelines or topical photodynamic therapy part 2:
t
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55. el er NR, Colver GB, Morton CA. Guidelines or the emerging indications - eld cancerization, photorejuvena-
a
management o basal cell carcinoma. Br J Dermatol. 2008; tion and in ammatory/in ective dermatoses. J Eur Acad
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159(1):35– 48. Dermatol Venereol. 2012;27(6):672– 679.
L
56. Slaughter DP, Southwick HW, Smejkal W. Field canceriza- 74. Stender IM, Na R, Fogh H, Gluud C, Wul HC. Photody-
a
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tion in oral strati ed squamous epithelium; clinical implica- namic therapy with 5-aminolaevulinic acid or placebo or
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r
tions o multicentric origin. Cancer. 1953;6(5):963– 968. recalcitrant oot and hand warts: randomised double-blind
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57. Young AR. Cumulative e ects o ultraviolet radiation on the trial. Lancet. 2000;355(9208):963– 966.
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skin: cancer and photoaging. Semin Dermatol. 1990;9(1): 75. Edstrom DW, Porwit A, Ros AM. Photodynamic therapy
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25– 31. with topical 5-aminolevulinic acid or mycosis ungoides:
u
58. Apalla Z, Sotiriou E, Chovarda E, Le aki I, Devliotou-Pan- clinical and histological response. Acta Derm Venereol.
r
e
agiotidou D, Ioannides D. Skin cancer: preventive photody- 2001;81(3):184– 188.
s
namic therapy in patients with ace and scalp cancerization. 76. Fehr MK, Hornung R, Schwarz VA, Simeon R, Haller U,
A randomized placebo-controlled study. Br J Dermatol. Wyss P. Photodynamic therapy o vulvar intraepithelial
2010;162(1):171– 175. neoplasia III using topically applied 5-aminolevulinic acid.
59. Bagazgoitia L, Cuevas SJ, Juarranz A, Jaen P. Photodynamic Gynecol Oncol. 2001;80(1):62– 66.
therapy reduces the histological eatures o actinic damage 77. Peng Q, Soler AM, Warloe , Nesland JM, Giercksky KE.
and the expression o early oncogenic markers. Br J Derma- Selective distribution o porphyrins in skin thick basal cell
tol. 2011;165(1):144– 151. carcinoma a ter topical application o methyl 5-aminolevu-
60. Szeimies RM, orezan L, Niwa A, et al. Clinical, histopatho- linate. J Photochem Photobiol B. 2001;62(3):140– 145.
logical and immunohistochemical assessment o human 78. FDA. Metvixia Label in ormation. 20-11-2012. Re ype:
skin eld cancerization be ore and a ter photodynamic ther- Pamphlet.
apy. Br J Dermatol. 2012;167(1):150– 159. 79. Christensen E, Warloe , Kroon S, et al. Guidelines or prac-
61. Zwald FO, Brown M. Skin cancer in solid organ transplant tical use o MAL-PD in non-melanoma skin cancer. J Eur
recipients: advances in therapy and management: part II. Acad Dermatol Venereol. 2010;24(5):505– 512.
Management o skin cancer in solid organ transplant recipi- 80. Morton CA. Methyl aminolevulinate (Metvix) photody-
ents. J Am Acad Dermatol. 2011;65(2):263–279. namic therapy - practical pearls. J Dermatolog reat. 2003;
62. Wennberg AM, Stenquist B, Stock eth E, et al. Photody- 14(suppl 3):23– 26.
namic therapy with methyl aminolevulinate or prevention 81. Ibbotson SH. Adverse e ects o topical photodynamic therapy.
o new skin lesions in transplant recipients: a randomized Photodermatol Photoimmunol Photomed. 2011;27(3):116–130.
study. ransplantation. 2008;86(3):423– 429. 82. Halldin CB, Gillstedt M, Paoli J, Wennberg AM, Gonzalez H.
63. Wul HC, Pavel S, Stender I, Bakker-Wensveen CA. opi- Predictors o pain associated with photodynamic therapy: a
cal photodynamic therapy or prevention o new skin retrospective study o 658 treatments. Acta Derm Venereol.
lesions in renal transplant recipients. Acta Derm Venereol. 2011;91(5):545– 551.
2006;86(1):25– 28. 83. Wiegell SR, Skiveren J, Philipsen PA, Wul HC. Pain dur-
64. Willey A, Mehta S, Lee PK. Reduction in the incidence o ing photodynamic therapy is associated with protoporphy-
squamous cell carcinoma in solid organ transplant recipi- rin IX uorescence and uence rate. Br J Dermatol. 2008;
ents treated with cyclic photodynamic therapy. Dermatol 158(4):727– 733.
Surg. 2010;36(5):652– 658. 84. Valentine RM, Ibbotson SH, Brown C , Wood K, Mose-
65. de Graa YG, Kennedy C, Wolterbeek R, Collen AF, Wil- ley H. A quantitative comparison o 5-aminolaevulinic
lemze R, Bouwes Bavinck JN. Photodynamic therapy does acid- and methyl aminolevulinate-induced uorescence,
not prevent cutaneous squamous-cell carcinoma in organ- photobleaching and pain during photodynamic therapy.
transplant recipients: results o a randomized-controlled Photochem Photobiol. 2011;87(1):242– 249.
trial. J Invest Dermatol. 2006;126(3):569– 574. 85. Halldin CB, Paoli J, Sandberg C, Gonzalez H, Wennberg
66. Kohl E, Karrer S. Photodynamic therapy or photorejuvena- AM. Nerve blocks enable adequate pain relie during topical
tion and non-oncologic indications: overview and update. G photodynamic therapy o eld cancerization on the orehead
Ital Dermatol Venereol. 2011;146(6):473– 485. and scalp. Br J Dermatol. 2009;160(4):795– 800.
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86. Wiegell SR, Wul HC, Szeimies RM, et al. Daylight photo-
dynamic therapy or actinic keratosis: an international con-
1(1/2) vs. 2(1/2) h in daylight-mediated photodynamic ther-
apy with methyl aminolaevulinate in patients with multiple
4
sensus: International Society or Photodynamic T erapy in thin actinic keratoses o the ace and scalp. Br J Dermatol.
Dermatology. J Eur Acad Dermatol Venereol. 2012;26(6): 2011;164(5):1083– 1090.
673– 679. 94. Wiegell SR, Haedersdal M, Eriksen P, Wul HC. Photody-
87. Kaae J, Philipsen PA, Haedersdal M, Wul HC. Immedi- namic therapy o actinic keratoses with 8% and 16% methyl
ate whealing urticaria in red light exposed areas during aminolaevulinate and home-based daylight exposure: a dou-
photodynamic therapy. Acta Derm Venereol. 2008;88(5): ble-blinded randomized clinical trial. Br J Dermatol. 2009;
480– 483. 160(6):1308– 1314.
88. Korshoj S, Solvsten H, Erlandsen M, Sommerlund M. Fre- 95. Wiegell SR, Haedersdal M, Philipsen PA, Eriksen P, Enk CD,
quency o sensitization to methyl aminolaevulinate a ter Wul HC. Continuous activation o PpIX by daylight is as
photodynamic therapy. Contact Dermatitis. 2009;60(6): e ective as and less pain ul than conventional photodynamic
320– 324. therapy or actinic keratoses; a randomized, controlled, sin-
89. Karrer S, Bosserho AK, Weiderer P, Landthaler M, Szeimies gle-blinded study. Br J Dermatol. 2008;158(4):740– 746.
RM. In uence o 5-aminolevulinic acid and red light on col- 96. Manstein D, Herron GS, Sink RK, anner H, Anderson RR.

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lagen metabolism o human dermal broblasts. J Invest Der- Fractional photothermolysis: a new concept or cutaneous

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matol. 2003;120(2):325– 331. remodeling using microscopic patterns o thermal injury.

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90. Wiegell SR, Heydenreich J, Fabricius S, Wul HC. Continu- La sers Surg Med. 2004;34(5):426– 438.

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ous ultra-low-intensity arti cial daylight is not as e ec- 97. Haedersdal M, Katsnelson J, Sakamoto FH, et al. Enhanced

3
3
tive as red LED light in photodynamic therapy o multiple uptake and photoactivation o topical methyl aminolevu-
actinic keratoses. Photodermatol Photoimmunol Photomed. linate a ter ractional CO 2 laser pretreatment. La sers Surg

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2011;27(6):280–285. Med. 2011;43(8):804– 813.
91. Wiegell SR, Wul HC, Szeimies RM, et al. Daylight photo- 98. Haedersdal M, Sakamoto FH, Farinelli WA, Doukas AG,

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dynamic therapy or actinic keratosis: an international con- am J, Anderson RR. Fractional CO(2) laser-assisted drug

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sensus: International Society or Photodynamic T erapy in delivery. La sers Surg Med. 2010;42(2):113– 122.

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d
Dermatology. J Eur Acad Dermatol Venereol. 2012;26(6): 99. ogsverd-Bo K, Haak CS, T aysen-Petersen D, Wul HC,

y
673– 679. Anderson RR, Haedesdal M. Intensi ed photodynamic ther-

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92. Wiegell SR, Fabricius S, Gniadecka M, et al. Daylight-medi- apy o actinic keratoses with ractional CO(2) laser: a ran-

m
ated photodynamic therapy o moderate to thick actinic domized clinical trial. Br J Dermatol. 2012;166(6):1262– 1269.

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keratoses o the ace and scalp: a randomized multicentre 100. Haedersdal M, ogsverd-Bo K, Paasch U. Case reports on

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study. Br J Dermatol. 2012;166(6):1327– 1332. the potential o ractional laser-assisted photodynamic ther-

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93. Wiegell SR, Fabricius S, Stender IM, et al. A randomized, apy or basal cell carcinomas. La sers Med Sci. 2012;27(5):

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multicentre study o directed daylight exposure times o 1091– 1093.

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409
 Ch a p t e r Noninvasive Skin Tightening

34 Technology
Andrew A. Nelson

Loose, sagging skin is an un ortunate but o ten inevitable

part o the aging process. T ese changes are particularly
Ba s ic s c ien c e o f c o l l a g en
troublesome on acial and neck skin where they result in
Aging results in damage to collagen, which mani ests
deep, static rhytides. raditionally, surgical procedures
itsel as ragmentation o the collagen bers and solar
incorporating skin removal and suspension sutures were
elastosis. T is occurs as a result o extrinsic damage such
utilized to remove the excess skin and reposition the
as sun exposure and smoking, as well as intrinsic e ects
remaining skin to recreate a younger acial structure and
including genetics. issue tightening technologies ocus
appearance. Most commonly these procedures consist o
on dermal heating to tighten existing, damaged collagen
a aceli t or neckli t, which are o ten per ormed together
and stimulate neocollagenesis. It is, there ore, important
to achieve better results. Due to the increasing epidemic
to have an understanding o the basic science o collagen.
o obesity, and the changes in skin tone and tightness ol-
Collagen is a triple helical structure, held together by
lowing weight loss, demand or skin tightening o non-
interstrand hydrogen bonds. As collagen is heated, these
acial skin has also increased dramatically in recent years.
bonds are broken down, allowing the lattice to unwind.
Although invasive surgical procedures remain the gold
When the lattice unwinds, the coils shorten and contract.
standard or large-scale skin tightening and removal, many
T e hydrogen bonds then re orm in this more compact,
patients are concerned about the downtime, healing, and
tightened con guration. ypically, this is seen histologi-
cost associated with these procedures. As a result, patients
cally as collagen bers with greater diameters and shorter
are increasingly turning to noninvasive procedures to
lengths.1 Controlled heating also stimulates the ormation
tighten their loose skin and minimize the aging process,
o new collagen (neocollagenesis), urther contributing
and cosmetic skin tightening has become a rapidly enlarg-
to the tissue tightening e ect. Collagen denaturation is
ing eld.
dependent on time and temperature2; higher tempera-
T ere are now multiple noninvasive treatment options
tures are associated with shorter treatment times, but may
to achieve skin tightening. T e most commonly uti-
result in increased patient discom ort and a higher risk o
lized technologies include laser, radio requency (RF),
thermal burns. Lower temperatures require longer expo-
and ultrasound. T ese noninvasive treatment options
sure times, but may be sa er. Although the overall goal
are most appropriate or those patients with mild-to-
o the technologies are similar, the exact mechanism o
moderate skin laxity. Patients with signi cant skin laxity,
action through which each technology achieves controlled
such as severe jowl ormation, are typically better candi-
heating o collagen di ers, and treatment exposure times
dates or surgical li ting procedures. Although there are
vary as well.3
signi cant di erences between these new, noninvasive
technologies, in general, their goal is to tighten existing
skin via controlled dermal heating to stimulate collagen
remodeling and neocollagenesis. T ere are advantages epid er ma l c o o l in g
and disadvantages to each technology, and as a result, no
single technology is best or all patients. Furthermore, it Noninvasive skin tightening technologies attempt ocused
is o ten di cult to predict who will bene t most rom heating o dermal collagen to remodel existing collagen
one procedure or another. T us, it is important to be and stimulate neocollagenesis. Although the technologies
amiliar with all o these technologies to be able to o er have advanced techniques to ocus the heat, there remains
each patient the treatment that best achieves their cos- some nonspeci c bulk heating o surrounding tissues.
metic goals. T is can be a signi cant challenge, as nonspeci c epider-
It is important to remember that many o the treat- mal heating can result in thermal burns, dyspigmentation,
ments we discuss in this chapter may not be speci cally and potential scarring. As a result, many o these tech-
FDA cleared or skin tightening; instead, they may be nologies incorporate epidermal cooling devices to reduce
approved or other uses, such as deep dermal heating or these risks. T ere are several di erent types o epidermal
cellulite improvement. Many o the treatments we dis- cooling devices, including dynamic (spray) cooling and
cuss in this chapter may, there ore, represent o -label contact cooling (Pelletier). When selecting a noninvasive
indications or these devices. In addition, we will not skin tightening device, providers must have a good under-
ocus on noninvasive at contouring technologies in this standing o the proper unctioning o that device’s cooling
chapter; these technologies are discussed elsewhere in mechanisms to o er sa e, e ective skin tightening or their
this book. patients.
Pa t ien t Sel ec t io n time associated with traditional ablative resur acing made
it a less desirable option or patients. In an e ort to reduce
4
the downtime associated with ully ablative lasers, raction-
Patient selection and education are critical or proper
ated nonablative and ablative technologies were developed.
implementation o noninvasive skin tightening devices.
T ese ractionated technologies treat only a portion o the
In general, noninvasive skin tightening devices work best
epidermal sur ace, known as microthermal zones. By only
in patients with mild-to-moderate skin laxity, requiring
treating a portion o the skin sur ace, typically 5% to 25%, it
either acial or non- acial skin tightening. Patients with
is possible to reduce the downtime and healing associated
signi cant excess skin, mani esting as severe jowls, naso-
with ablative laser resur acing. Fractionated ablative lasers
labial olds, deep rhytides, or excess body skin are not ideal
can be used to e ectively treat rhytides, sur ace irregu-
candidates. T ese patients may achieve some skin tight-
larities, melasma, and multiple other indications; however,
ening with noninvasive technologies, but are likely bet-
their e ect on skin tightening remains modest.7 Fraction-
ter treated with an invasive surgical procedure to achieve
ated ablative lasers are more ully discussed elsewhere in
more clinically signi cant skin tightening.
this book, and will not be discussed urther in this section.
Patients should also be educated about the likely out-
Nonablative in rared lasers (750 nm through 1 mm wave-

C
comes o noninvasive skin tightening. It is essential that

h
length) have become widely utilized or noninvasive skin

a
patients have realistic expectations. It is important to

p
tightening. T ese lasers target water in the dermis as their

t
e
note that improvement may be unpredictable. I a patient

r
major chromophore. T ere are several reasons or utilizing

3
expects a noninvasive skin tightening procedure to pro-

4
in rared wavelengths or skin tightening. First, the depth
duce an outcome similar to that o a surgical aceli t or
o laser penetration is directly related to its wavelength;

:
abdominoplasty, that patient will inevitably be disap-

:
the longer the wavelength o light, the deeper its penetra-
pointed. T ese patients should either not be treated, or the

N
tion. Second, longer wavelengths are less well absorbed by

o
physician should ensure that they are educated to be more

n
melanin; this means that these in rared wavelengths are not

i
realistic in their expectations. Patients should also be edu-

n
absorbed by epidermal melanin, reducing the risk o ther-

v
a
cated that with certain technologies a series o treatments

s
mal burns o the epidermis. T ird, with less absorption o

i
v
over an extended time period will likely be necessary to
light by epidermal melanin, the in rared lasers generate a

e
achieve a better outcome.

S
higher e ective f uence o energy at the level o the dermal

k
Patients with mild-to-moderate skin laxity and realistic

i
n
collagen – the target o tissue tightening. Finally, these in ra-

T
treatment expectations will achieve the greatest bene t

i
red lasers do not produce ablation (removal) o the epider-

g
rom noninvasive skin tightening. By selecting the proper

h
mis, thereby signi cantly reducing downtime and healing.

t
e
patients and educating them appropriately, physicians can

n
T e original in rared devices or skin tightening were

i
help these patients to achieve their treatment goals.

n
lasers with wavelengths in the mid-in rared range. One

g
T
o the early devices utilized a 1320 nm Nd:YAG laser to

e
c
target dermal water (Cool ouch, Cool ouch Corporation,

h
l a Ser Dev ic eS

n
Roseville, CA). In a clinical study, however, this device

o
l
o
resulted in minimal or mild reduction in wrinkles.8 Simi-

g
y
Laser (Light Ampli cation by Stimulated Emission o Radi- larly, a 1450 nm diode laser was developed or acne scar-
ation) devices were among the rst technologies to be FDA ring and dermal remodeling (SmoothBeam, Syneron Inc.,
cleared or skin tightening. Lasers produce monochromatic, Irvine, CA). Again, in a clinical study, mild-to-moderate
high intensity, coherent light. T e e ect o lasers on tissue improvement in acial rhytides was observed ollowing
is generally predicted by the theory o selective photother- a series o treatments, along with a possibly increased
molysis. According to selective photothermolysis, there are expression o collagen.9,10 T ese devices produced mod-
our main chromophores in the skin: water, melanin, oxy- est improvements in skin tone, texture, and in some
hemoglobin, and deoxyhemoglobin.4 T e central tenet o cases, skin tightening. More recently, broadband in rared
selective photothermolysis is that by utilizing a laser with a devices have been developed in an attempt to increase
wavelength selectively absorbed by the target chromophore, clinical e cacy. A broadband in rared lamp, emitting
with su cient energy to heat the target, and an appropri- wavelengths rom 1100 to 1800 nm, has been developed
ate pulse duration to contain the energy within the target, that produces dermal heating rom 1 to 2 mm in depth
the target can be speci cally heated while minimizing the ( itan, Cutera, Brisbane, CA). By incorporating e ec-
unintended spread o energy to surrounding tissue. In order tive pre and post cooling, a prolonged multisecond heat-
to heat collagen and e ectively remodel it, it is necessary to ing cycle can be utilized. With these improvements, the
target water within the dermis as the chromophore. T ere broadband in rared device may achieve e ective noninva-
are multiple wavelengths o light that can target water, and, sive skin tightening.
there ore, several wavelengths that should theoretically Erbium glass-based lasers have also been developed
stimulate collagen remodeling and neocollagenesis. to target dermal collagen. Fraxel re:store (Solta Medical
Initially, ully ablative lasers such as the carbon dioxide Inc., Hayward, CA) utilizes a 1550 nm erbium-doped ber
(CO 2) and erbium:yttrium-aluminum-garnet (Er:YAG) were to target dermal water; this device utilizes nonablative
studied or tissue tightening. Although these ablative lasers ractional photothermolysis to deliver the laser energy
were very e ective in reducing rhytides and sur ace changes, through thermally con ned microthermal zones. T ere
the results on skin tightening were more modest and may is another device utilizing a f ashlamp system with a spe-
have been related to wound contraction rather than colla- ci c codoped Yb-Er:phosphate glass material to gener-
gen remodeling.5,6 In addition, the several weeks o healing ate a 1540 nm wavelength (Lux1540 handpiece, Palomar
411
4 Medical echnologies Inc., Burlington, MA). T is device
also utilizes a ractionated delivery system to target the
o 50 patients, signi cant improvement in photodamaged
acial and non- acial skin (Fig. 34-2) was achieved, includ-
dermis. T ese erbium glass systems can be used to treat ing a reduction in rhytides.14 However, other authors have
ne lines, wrinkles, acne scars, and a myriad o other indi- noted that while super cial rhytides may improve with
cations. T ey may also have a modest e ect on skin tight- nonablative ractional erbium-doped ber lasers, moder-
ening through dermal heating. ate and deeper rhytides do not improve as signi cantly
as with previous ablative laser treatment options.15 As a
result, many physicians consider these nonablative rac-
c l in ic a l o u t c o mes tional laser treatment options to be better options or
super cial dyspigmentation, photodamage, and super -
In rared lasers or skin tightening (1100– 1800 nm) are cial rhytides. Although mild skin tightening may also be
best used in patients seeking mild-to-moderate improve- observed ollowing nonablative ractional erbium glass
ment in ne lines and skin tone as well as skin tightening. laser treatments, signi cant skin tightening is less likely
Patients seeking more signi cant improvements are better to be achieved. T us, these technologies may be a good
candidates or surgical interventions. O ten, the degree o option or patients seeking mild-to-moderate skin tight-
S
e
improvement is di cult to predict prior to treatment. ening with the simultaneous treatment o photodamage.
c
t
i
In a clinical trial o a broadband in rared device ( itan,
o
n
Cutera, Brisbane, CA), the greatest skin tightening was
4
noted over the malar region, the neck, and the body o pa t ien t ed u c a t io n a n d
:
:
the mandible; however, the average tightening in these
areas was 10%, 10%, and 12%, respectively.11 In another a d v er s e ev en t s
A
e
clinical study o skin laxity in Asian skin, 23% o patients
s
t
h
reported mild skin tightening, 15% reported moderate reatment protocols and algorithms have evolved over the
e
t
improvement, and 54% reported signi cant improvement years since these devices were developed. Initially, many
i
c
a
3 months ollowing a series o treatments.12 T is again o the devices utilized a single pass, single treatment pro-
n
d
emphasizes that while skin tightening can be achieved tocol with high energy levels. Un ortunately, the highest
L
with broadband in rared devices, these improvements are energy levels may increase the risk o discom ort, thermal
a
s
e
mild to moderate in most cases, and there can be a great burns, and scarring. More recent treatment algorithms
r
P
deal o variability in patient outcomes. utilize lower energy, multiple pass treatments. Many o
r
o
Erbium glass systems (Fraxel re:store, Solta Medical, the devices now require a series o two to our separate
c
e
treatments in order to achieve e cacy.
d
Hayward, CA) can also be used to achieve mild-to-moder-
u
ate skin tightening (Fig. 34-1). In a study o Asian patients Side e ects o in rared devices include mild erythema
r
e
s
with acne scarring, acial images o patients were analyzed and edema immediately ollowing the treatment, which
with computer so tware to indicate that, in addition to are typically transient. Although new protocols have
scar remodeling, skin tightening was achieved ollowing reduced the risk o serious adverse e ects, there is still the
a series o noninvasive erbium glass laser treatments.13 potential or thermal burns and scars, particularly i the
Erbium-doped ber lasers can also be used to improve cooling system on the technology is not unctioning prop-
photodamage, dyspigmentation, and rhytides. In a study erly during the treatment.

Figure 34-1 Clinical results showing skin tightening and a reduction in rhytides following two treatments with a 1550 nm
noninvasive device. (Reproduced from Beasley KL, Weiss RA. Nonablative fractional lasers. In: Goldman MP, Fitzpatrick RE, Ross
412 EV, Kilmer SL, Weiss RA, eds. Lasers and Energy Devices for the Skin. 2nd ed. Boca Raton, FL: CRC Press; 2013, with permission.)
 the current passes rom the handpiece through the
patient’s body and exits through the return electrode.
4
Monopolar devices in theory allow or greater depth o
penetration than bipolar and multipolar devices, but
may have an increased risk o unintended spread o the
current throughout the body. Bipolar RF devices, in con-
trast, utilize a handpiece that incorporates both the posi-
tive and negative poles to create a closed electrical circuit
with a xed distance between the positive and negative
electrodes. T e distance between the two electrodes
helps to determine the ultimate depth o penetration o
the RF energy, which is typically considered to be a depth
o penetration equal to one-hal o the distance between
the electrodes. Bipolar RF devices may not allow energy
to penetrate as deeply as monopolar devices, but may

C
h
be sa er due to the closed controlled electrical circuit.

a
p
Relatively new devices known as multipolar RF have also

t
e
r
been developed. T ese multipolar devices are best con-

3
4
sidered as a type o sequential bipolar device. T ey utilize
multiple bipolar electrodes, set at a variety o distances

:
:
apart. When the device discharges RF energy rom these

N
multiple bipolar electrode pairs, it e ectively heats the

o
n
dermis at di ering levels. T ese new multipolar devices

i
n
may potentially o er greater e cacy due to the multi-

v
a
s
ple treatment depths that can be achieved with a single

i
v
e
treatment.

S
In addition to the polarity o an RF device, the tech-

k
i
n
nologies can be divided based upon the manner in which

T
i
the energy is delivered. RF energy can be delivered via

g
Figure 34-2 Clinical improvement of photodamaged chest

h
a static, stamping motion with in which the RF hand-

t
following two treatments with a 1550 nm noninvasive

e
n
device. (Reproduced from Beasley KL, Weiss RA. Nonabla- piece is held in a single position while energy is deliv-

i
n
ered, and then the handpiece is moved be ore the next

g
tive fractional lasers. In: Goldman MP, Fitzpatrick RE, Ross EV,

T
Kilmer SL, Weiss RA, eds. Lasers and Energy Devices for the Skin. RF pulse is delivered. RF can also be delivered in a mov-

e
c
2nd ed. Boca Raton, FL: CRC Press; 2013, with permission.) ing, dynamic pattern where the handpiece is constantly

h
n
rotated or moved across the skin sur ace while the energy

o
l
o
is delivered. Dynamic devices may allow or larger areas

g
y
to be treated more e ciently, while static devices may
r a d io f r eq u en c y allow or the treatment o smaller more targeted areas.
Finally, RF energy can be ractionated, similar to rac-
Radio requency (RF) devices are chromophore indepen- tional lasers. As a result o all o these di erences, it is
dent, ocused heating sources. T ese devices utilize oscil- important or physicians to care ully research each indi-
lating current, which is passed through the tissue target. vidual technology prior to incorporating these devices
T e alternating f ow o electricity causes increased molec- into their practice.
ular vibration and riction, which in turn generates heat.16 T ere are many di erent RF devices available that
Di erent RF devices utilize di ering requencies, but typically all into one o three categories determined by
most devices or tissue tightening incorporate requencies the polarity o the device ( able 34-1). Further subdivi-
in the MHz range. T e requency o an RF device has an sions and variations o each o these categories also exist.
e ect on tissue penetration, with lower requency devices In addition to pure RF devices, RF can be combined with
typically o ering a greater depth o penetration and heat- other technologies such as lasers or intense pulsed light.
ing. As RF heating does not depend on a speci c molecule A ull description o each o these numerous combination
absorbing the energy, it does not ollow the principle o devices is beyond the scope o this review.
selective photothermolysis and is, there ore, chromophore
independent. T is property is bene cial in that RF is sa e
to use in all skin types, even skin types V and VI. c l in ic a l o u t c o mes
T ere are many di erent RF devices currently on the
market, and there are likely to be many more added in As a result o so many di erent RF technologies being
coming years. Rather than ocusing speci cally on each available, a comprehensive review o all clinical trials is
device, we will group the devices into a ew categories. not possible in this chapter. Rather, we will ocus on a
First, RF devices can be divided based upon their polar- ew speci c trials and RF technologies. Initial studies o
ity: monopolar, bipolar, and multipolar. Monopolar a static, monopolar RF device (T ermage, Solta Medical,
devices utilize a single positive pole incorporated into Hayward, CA) revealed mild-to-moderate improvements
the handpiece and a ground (return) electrode placed in periorbital wrinkling, cheek and neck skin laxity, naso-
somewhere on the patient’s body. In this con guration, labial olds, marionette lines, and jowls (Fig. 34-3).17– 19 413
4 TABLE 34-1
r io qu ncy d vic o s kin t igh ning, d ivi a cco ing o m ho o r f en gy d liv y

monopol r f d vic Bipol d vic mul ipol d vic

TruSculpt (Cutera, Brisbane, CA) Accent (has both unipolar and bipolar Venus Freeze (combines multipolar
handpieces) (Alma Lasers, Bu alo Grove, IL) RF with magnetic pulsed f elds)
(Venus Concept, Toronto, ON, Canada)
Thermage Com ort Pulse Technology ePrime (Syneron Inc., Irvine, CA) Apollo (tripolar RF) (Pollogen LTD,
(Solta Medical, Hayward, CA) Jerusalem, Israel)
Exilis (BTL Industries, Framingham, MA) VelaShape (Syneron Inc., Irvine, CA) EndyMed Pro (EndyMed Medical Ltd,
Caesarea, Israel)
Pelleve (Ellman International, Hicksville, NY) eMatrix (Syneron Inc., Irvine, CA) Reaction (Viora, Jersey City, NJ)
S
e
Forma (InMode Inc., Yokenam, Israel)
c
t
i
o
n
4
:
A novel dynamic moving monopolar RF device (Pelleve, built-in sensors including epidermal thermal, impedance,
:
Ellman International, Oceanside, NY) has also been shown and contact sensors has been observed to achieve e ective
A
e
to improve patients’ overall skin laxity, texture, wrinkles, skin tightening ollowing a series o treatments (Fig. 34-5).
s
t
h
and overall appearance by 30% to 50%, 1 year ollowing a T e built-in eedback sensors allow or prolonged, con-
e
series o treatments.20 Similarly, another dynamic mono-
t
trolled dermal heating while limiting the risk o overheat-
i
c
polar device with incorporated Pelletier cooling (Exilis, ing or burning the treatment area. A multipolar RF device
a
n
B L Industries, Framingham, MA) has been observed to (EndyMed PRO, EndyMed Medical, Caesarea, Israel) has
d
L
improve skin texture and skin tightening both or acial also been shown to result in skin tightening and improve
a
s
and non- acial indications (Fig. 34-4). the appearance o cellulite.22
e
r
P
Bipolar and multipolar RF devices have also been Although many o these devices appear to help patients
r
o
reported to result in improved patient appearance with achieve mild-to-moderate improvement in skin tighten-
c
e
increased skin tightening. A bipolar, multi requency, ing ollowing a series o noninvasive RF treatments, many
d
u
suction-assisted RF device (Reaction, Viora Inc., Jersey studies do not adequately quanti y the degree o improve-
r
e
s
City, NJ) resulted in improved thigh skin laxity appear- ment. Furthermore, head-to-head comparison studies
ance in 57% o patient-assessed outcomes and 78% o between these di erent RF devices are lacking. It is, there-
investigator-assessed subjects.21 In addition, a novel bipo- ore, dif cult to state with any certainty which device, i
lar RF device (Forma, InMode Inc., Yokenam, Israel) with any, is superior.

Figure 34-3 Clinical improvement with tightening o neck skin and improved band appearance 4 months ollowing a
series o monopolar RF treatments. (Photo used with permission o Dr. Suzanne Kilmer, Laser & Skin Surgery Center o
414 Northern Cali ornia, Sacramento, CA.)
 4

C
h
a
p
t
e
r
3
4
:
:
N
o
n
Figure 34-4 Clinical improvement showing skin tightening of the abdomen following series of three

i
n
v
dynamic monopolar RF treatments. (Reproduced from Garibyan L, Jalian HR, Avram MM,Weiss RA. Body

a
s
contouring: Noninvasive fat reduction. In: Goldman MP, Fitzpatrick RE, Ross EV, Kilmer SL, Weiss RA, eds.

i
v
e
Lasers and Energy Devices for the Skin. 2nd ed. Boca Raton, FL: CRC Press; 2013, with permission.)

S
k
i
n
T
i
g
h
t
e
n
i
n
g
T
e
c
h
n
o
l
o
g
y
Figure 34-5 Clinical improvement in skin tightening, skin texture and rhytide reduction following a
series of four nonablative bipolar radiofrequency treatments. (Photo used with permission of Dr. Andrew
Nelson, Nelson Dermatology, Saint Petersburg, FL.)

415
4 pa t ien t ed u c a t io n a n d Recently, micro ocused ultrasound (MIFU) technol-
ogy has been developed, which allows or the targeting o
a d v er s e ev en t s dermis, subcutaneous tissues and ascia, resulting in skin
tightening. T e Ulthera device (Ulthera Inc., Mesa, AZ) is
Patients should be educated regarding the extent o currently the only FDA-cleared MIFU device or skin tight-
improvement to be seen with RF skin tightening. In most ening. In contrast to previous technologies, MIFU has been
cases, mild-to-moderate improvement in rhytides along reported not only to heat collagen in the dermis, but also to
with some skin tightening will be observed. Most RF e ectively heat deeper structures including the super cial
devices typically require a series o 4 to 6 weekly treatments muscular aponeurotic system (SMAS), which connects
or greatest e cacy; patients must be able to commit to a muscles o acial expression to the dermis o the ace. T e
series o treatments. It is important to note that improve- SMAS is o ten tightened during surgical aceli ts in order
ment, i any, may be modest. Patients with signi cant, to provide longer-lasting results. T eoretically, heating and
deep rhytides are likely better candidates or a surgical remodeling the SMAS with a noninvasive device should
procedure. Following RF skin tightening, the skin typically result in a longer-lasting, more clinically apparent result.
appears erythematous and slightly edematous; this may However, to date, there are no de nitive data to support
S
e
this conclusion and urther studies are required.
c
last a ew hours. T e skin typically eels warm to touch
t
i
MIFU utilizes short pulse durations, with high re-
o
immediately a ter treatment, and patients may occasionally
n
note that the treated area eels hot. With many RF devices, quency transducers, to produce ocused beams o ultra-
4
patients can return to their normal activities the day a ter sound energy, resulting in small areas o coagulative
:
:
treatment. necrosis known as thermal injury zones ( IZs). T e depth
o the IZ is a unction o the requency o the ultrasound
A
Reports o thermal burns and scars with RF devices, par-
e
energy. Higher requencies penetrate less deeply and,
s
ticularly rst generation monopolar devices, exist. T ese
t
h
complications have been reported with newer devices as there ore, result in a more super cial IZ. Lower requen-
e
t
cies penetrate more deeply, resulting in a deeper IZ.
i
well.23 As a result RF devices have begun incorporating
c
a
temperature and skin impedance monitoring, allowing or MIFU devices utilize an initial low-energy imaging mode
n
d
real time eedback and control o dermal heating. T ese in order to visualize the intended target as well as deter-
L
a
modi cations make the treatment more com ortable while mine the depth o the target. T e device then uses one o
s
e
also limiting the risk o burns, scars, and electrical arcing. several transducers to treat the intended target. T e re-
r
P
T ere is concern regarding possible RF inter erence with quencies o the handpiece are xed at 7 MHz (3 and 4.5
r
o
mm ocal depth), 4 MHz (4.5 mm ocal depth), and 19
c
implanted cardiac pacemakers and de brillators, known
e
d
as electromagnetic inter erence (EMI); theoretically, bipo- MHz (1.5 mm ocal depth). T e transducers deliver energy
u
r
lar and multipolar RF devices may carry a lower risk as in straight-line patterns, with the IZs separated rom
e
s
they have a closed electrical circuit. Although in general, each other by 0.5 to 5 mm o untreated skin. T e device
current RF devices are sa e and e cacious treatment utilizes short pulse durations with low energy to limit the
options or skin tightening in patients o all skin types, RF size o the IZ, e ectively controlling the zone o heating
devices are probably not the ideal noninvasive skin tight- and limiting damage to surrounding tissue. As the energy
ening technology or patients with implanted cardiac is directed to the deep dermis and SMAS, rather than epi-
devices. dermis, super cial cooling may not be necessary. Also, due
to the ractionated nature o the treatment with normal
untreated skin between IZs, recovery may be aster.
u l t r a s o u n d d ev ic es
Ultrasound devices utilize mechanical compression waves c l in ic a l o u t c o mes
above the range o hearing to have their e ect on tissue.
As the acoustic waves pass through the tissue, they cause Initial studies, including those per ormed or FDA clear-
vibration o the molecules. T is vibration leads to riction ance or MIFU, analyzed the e ect o this technology on
between molecules, which in turn, generates heat in the eyebrow position. In a study o 36 patients, 86% were
tissue target. Most patients are amiliar with diagnostic observed to have clinically signi cant brow li t 90 days
ultrasound devices, which utilize low energy, non ocused a ter a single treatment with the 7 MHz, 4.5 mm trans-
energy; these devices allow or imaging o the tissue with- ducer; the mean eyebrow li t was 1.7 mm.24 Notably,
out directing energy at any one area long enough to gener- edema and erythema were common, with an average pain
ate su cient heating. More recently, ocused ultrasound score o 7/10 on a visual analog scale. MIFU has also been
devices have been developed, which speci cally ocus studied or its e ect on skin tightening on the lower ace
convergent ultrasound waves at a speci c target. High- and jowls. In a study o 10 patients with multiple passes
intensity ocused ultrasound (HIFU) devices were initially (initial pass with 4 MHz, 4.5 mm transducer, ollowed
used or medical treatments o deep structures, such as by the 7 MHz, 3 mm transducer), 25% o patients were
ultrasound lithotripsy o kidney stones or ultrasound abla- noted to have signi cant improvement in jowls as well as
tion o solid organ cancers. Such depth o treatment is not lower ace tightening, 50% o patients were observed to
seen in other dermatologic technologies. HIFU has also have moderate improvement, and 25% were noted to have
been adapted to allow or treatment o subcutaneous at mild improvement.25 MIFU has also been noted to result
(Liposonix, Solta Medical Inc., Hayward, CA), a technol- in mild-to-moderate skin tightening o the décolletage ol-
ogy which is discussed in more detail in the chapter on lowing a single treatment (Fig. 34-6).26 MIFU can also be
416 body contouring in this book. used or non- acial applications including in areas such as
 4

C
h
a
p
t
e
r
3
4
:
:
N
Figure 34-6 Clinical improvement with reduction of jowls and tightening of neck skin 3 months following a single micro-

o
focused ultrasound (MIFU) treatment. (Photo used with permission of Dr. Suzanne Kilmer, Laser & Skin Surgery Center of

n
i
n
Northern California, Sacramento, CA.)

v
a
s
i
v
e
S
the arms, knees, and medial thighs, to produce skin tight- ollowing the procedure. More signi cant side e ects

k
i
n
ening and li ting.27 including nodule ormation and motor nerve paresthesias

T
i
I multiple transducers are to be utilized, the patient’s have also been reported; these appear to be temporary, but

g
h
deeper tissue zones are usually treated rst, ollowed can last 2 to 6 weeks. Motor nerve paresthesias seem to

t
e
n
by treatment o more super cial tissue levels. In areas occur more commonly in “danger areas” where the motor

i
n
with relatively thin skin, the more super cial transduc- nerves are relatively super cial; the nerves at greatest risk

g
T
ers should be utilized. It is thought that by layering mul- appear to be the temporal branch o CNV (trigeminal

e
c
tiple di erent levels o treatment, greater clinical e cacy nerve) and the marginal mandibular branch o CNVII.27

h
n
can be achieved. However, as the technology is relatively

o
l
o
new, exact treatment protocols and parameters continue
c o n c l u s io n s

g
y
to evolve.
As noted earlier, in clinical studies, patients have
reported relatively high pain scores during the procedure. Noninvasive skin tightening is a rapidly expanding area o
As a result, topical anesthesia alone is not su cient or cosmetic rejuvenation, particularly as patients are increas-
many patients to tolerate the procedure, particularly with ingly eschewing invasive surgical procedures. Patients can
the lower requency, more deeply penetrating handpieces. sa ely and e ectively achieve collagen tightening, remod-
Multiple pain reduction techniques have been reported in eling, and contraction with noninvasive treatments. T ese
the literature to diminish the discom ort o MIFU devices, procedures typically result in mild-to-moderate skin
including nerve blocks and local anesthesia, nonsteroidal tightening, although at times improvement can be di -
anti-inf ammatory agents, oral anxiolytics, oral/intramus- cult to discern. Many patients with severe volume loss,
cular/intravenous narcotics, and conscious sedation. T eir jowling, and substantial excess skin may not be ideal can-
use depends upon the o ce acility and the physician’s didates or these noninvasive procedures. It is, there ore,
com ort level with these techniques. More recently, less extremely important to educate patients with severe lax
aggressive treatment regimens have been employed that skin and volume loss that a traditional aceli t, abdomi-
generate less pain. noplasty or other surgical intervention may be a better
option. As a result, patient selection is a critical compo-
nent in achieving satis action ollowing noninvasive skin
pa t ien t ed u c a t io n a n d tightening. Ideal candidates are typically patients with
mild-to-moderate skin laxity, no signi cant acial volume
a d v er s e ev en t s loss, and realistic outcome expectations.
In recent years, multiple new skin tightening technolo-
Patients should be advised that MIFU is most e ective in gies have evolved, initially consisting o in rared lasers and
patients with mild-to-moderate skin laxity. More severe more recently including RF devices and ocused ultra-
cases should be re erred or excisional procedures. sound technologies. All o these technologies similarly
Following MIFU treatment, patients typically notice target collagen or ocused heating, remodeling o existing
erythema and edema, which may last several days. Skin collagen and stimulation o neocollagenesis. As a result,
tenderness in the treatment area may last or several weeks multiple di erent options and devices are available to help 417
4 patients achieve their skin rejuvenation goals. Un ortu-
nately, to date, head-to-head studies comparing these di -
an in rared device with contact cooling in the treatment o
skin laxity in Asians. La sers Surg Med. 2008;40(2):146– 152.
13. Dainichi , Kawaguchi A, Ueda S, et al. Skin tightening e ect
erent technologies are lacking; as a result, it is di cult to
using ractional laser treatment: I. A randomized hal -side
state objectively which technology or device, i any, is most pilot study on aces o patients with acne. Dermatol Surg.
e cacious. It is there ore up to the individual provider to 2010;36(1):66– 70.
determine which technology best ts their practice as well 14. Wanner M, anzi EL, Alster S. Fractional photothermoly-
as the needs o their patients. With proper patient selec- sis: treatment o acial and non acial cutaneous photodam-
age with a 1550-nm erbium-doped ber laser. Dermatol Surg.
tion and education as to realistic expectations, patients
2007;33(1):23– 28.
can achieve satis actory skin tightening and rejuvenation 15. Geronemus RG. Fractional photothermolysis: current and
with any o these noninvasive technologies. uture applications. La sers Surg Med. 2006;38(3):169– 176.
16. Weiss RA. Noninvasive radio requency or skin tightening
and body contouring. Semin Cutan Med Surg. 2013;32(1):9–
r ef er en c es 17.
17. Fritz M, Counters J , Zelickson BD. Radio requency treat-
1. Zelickson BD, Kist D, Bernstein E, et al. Histological and ment or middle and lower ace laxity. Arch Facial Pla st Surg.
S
ultrastructural evaluation o the e ects o a radio requency- 2004;6(6):370– 373.
e
18. Alster S, anzi E. Improvement o neck and cheek laxity
c
based nonablative dermal remodeling device: a pilot study.
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i
with a nonablative radio requency device: a li ting experi-
o
Arch Dermatol. 2004;140(2):204–209.
n
2. Akeson WH. Application o the Arrhenius equation to rat tail ence. Dermatol Surg. 2004;30(4 Pt 1):503– 507.
4
tendon collagen. Nature. 1963;199:185– 186. 19. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer
3. Dierickx CC. T e role o deep heating or noninvasive skin S, Ruiz-Esparza J. Multicenter study o noninvasive radio re-
:
:
rejuvenation. La sers Surg Med. 2006;38(9):799– 807. quency or periorbital tissue tightening. La sers Surg Med.
2003;33(4):232– 242.
A
4. Anderson RR, Parrish JA. Selective photothermolysis: pre-
e
cise microsurgery by selective absorption o pulsed radiation. 20. aub AF, ucker RD, Palange A. Facial tightening with an
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t
advanced 4-MHz monopolar radio requency device. J Drugs
h
Science. 1983;220(4596):524– 527.
e
5. Koch RJ, Cheng E . Quanti cation o skin elasticity changes Dermatol. 2012;11(11):1288– 1294.
t
i
c
associated with pulsed carbon dioxide laser skin resur acing. 21. Kassim A , Goldberg DJ. Assessment o the sa ety and
a
e cacy o a bipolar multi- requency radio requency device in
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Arch Facial Pla st Surg. 1999;1(4):272–275.
d
6. Fitzpatrick RE, Rostan EF, Marchell N. Collagen tightening the treatment o skin laxity. J Cosmet La ser T er. 2013;15(2):
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114– 117.
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induced by carbon dioxide laser versus erbium: YAG laser.
s
22. Elman M, Harth Y. Novel multi-source phase-controlled
e
La sers Surg Med. 2000;27(5):395– 403.
r
7. Hunzeker CM, Weiss E , Geronemus RG. Fractionated CO2 radio requency technology or non-ablative and micro-
P
r
ablative treatment o wrinkles, lax skin and acne scars. La ser
o
laser resur acing: our experience with more than 2000 treat-
c
ments. Aesthet Surg J. 2009;29(4):317– 322. T er. 2011;20(2):139– 144.
e
d
8. Chan HH, Lam LK, Wong DS, Kono , rendell-Smith N. 23. Mayoral FA, Vega JM. Multiple acial burns with the new ther-
u
mage CP system. J Drugs Dermatol. 2011;10(11):1320– 1321.
r
Use o 1320 nm Nd:YAG laser or wrinkle reduction and the
e
24. Alam M, White LE, Martin N, Witherspoon J, Yoo S, West DP.
s
treatment o atrophic acne scarring in Asians. La sers Surg
Med. 2004;34(2):98– 103. Ultrasound tightening o acial and neck skin: a rater-blinded
9. anzi EL, Williams CM, Alster S. reatment o acial rhyt- prospective cohort study. J Am Acad Dermatol. 2010;62(2):
ides with a nonablative 1450-nm diode laser: a controlled 262– 269.
clinical and histologic study. Dermatol Surg. 2003;29(2):124– 25. Lee HS, Jang WS, Cha YJ, et al. Multiple pass ultrasound
128. tightening o skin laxity o the lower ace and neck. Dermatol
10. Nouri K, Zhang YP, Singer L, et al. E ect o the 1450 nm Surg. 2012;38(1):20– 27.
diode non-ablative laser on collagen expression in an arti - 26. Fabi SG, Massaki A, Eimpunth S, Eimpunth S, Pogoda J,
cial skin model. La sers Surg Med. 2005;37(1):97– 102. Goldman MP. Evaluation o micro ocused ultrasound with
11. Carniol PJ, Dzopa N, Fernandes N, Fernandes N, Carniol E , visualization or li ting, tightening, and wrinkle reduction o
Renzi AS. Facial skin tightening with an 1100– 1800 nm in ra- the décolletage. J Am Acad Dermatol. 2013;69(6):965– 971.
red device. J Cosmet La ser T er. 2008;10(2):67– 71. 27. Alster S, anzi EL. Noninvasive li ting o arm, thigh, and
12. Chan HH, Yu CS, Shek S, Yeung CK, Kono , Wei WI. A pro- knee skin with transcutaneous intense ocused ultrasound.
spective, split ace, single-blinded study looking at the use o Dermatol Surg. 2012;38(5):754– 759.

418
 Ch a p t e r Ablative and Fractional

35 Ablative Resurfacing
Arisa E. Ortiz, Mitchel P. Goldman, & Richard E. Fitzpatrick

In t r o d u c t Io n better clinical results than those seen with nonablative

technologies and approaches but does not achieve the
results seen with ully ablative resur acing. Signi cant
Laser resur acing began in the 1980s with ully ablative
clinical improvement, along with decreased downtime
(con uent) skin resur acing to address cosmetic concerns
and an enhanced sa ety pro le, has advanced the adoption
o aging skin. Chronologic aging contributes to deteriorat-
o ractional ablative lasers. T is chapter will review the
ing skin texture and tone. T is process is exacerbated by
indications, patient selection, perioperative management
years o ultraviolet light exposure leading to photodam-
and anesthesia, and complications or traditional ablative
age in the orm o lentigines, rhytides, texture irregularity,
and ractional ablative lasers.
and telangiectasia. raditional resur acing was rst per-
ormed with a 10,600 nm carbon dioxide (CO 2) laser and
later evolved with the 2940 nm erbium-doped yttrium alu-
minum garnet (Er:YAG) laser either as a short pulse a ter Abl At Iv e l As er s
CO 2 laser or alone as a long-pulsed Er:YAG laser.
CO 2 laser resur acing is based on the theory o selec- t ec h n o l o g y
tive photothermolysis.1,2 Brie y, selective photothermoly-
sis allows or the selective targeting o a chromophore raditional ablative resur acing began in the 1980s with the
by choosing a speci c wavelength and appropriate pulse 10,600 nm CO 2 laser. T e 10,600 nm wavelength is in the
duration or that chromophore. T e 10,600 nm wavelength ar-in rared electromagnetic spectrum. T e speci c chro-
speci cally targets water as the primary chromophore to mophore at this wavelength is water. T ere ore, CO 2 lasers
completely ablate the epidermis and the super cial dermis. are able to ablate the skin without regard or the presence
A uence o 5 J/cm 2 has been determined to be necessary o melanin or hemoglobin. In order to achieve success ul
to vaporize epidermal cells. T e delivered energy must ablation o the skin, without the risk o scarring, the extent
be within the thermal reaction time o the target, which o nonspeci c thermal damage should be limited to about
is less than 1 ms or epidermal cells. T e re-epithelialized 100 to 150 µm. T is may be achieved with a CO 2 laser u-
skin has a more youth ul appearance with improved tex- ence above the vaporization threshold o the skin (5 J/cm 2)
ture and tone. For decades, ully ablative CO 2 lasers were and a pulse duration shorter than the thermal relaxation
considered the gold standard in skin resur acing or rhyt- time o the skin (1 ms).10– 12 Fluences below the vaporiza-
ides, photodamage, and scars.3– 5 T e results seen with tion threshold will only achieve coagulation and longer
traditional resur acing are predictable and success ul, but pulse durations result in an increased risk o scarring.
coincide with a risk o scarring, dyspigmentation, and pro- T e advent o short-pulsed high-power CO 2 lasers and
longed downtime dependent on the extent o nonspeci c lower energy rapidly scanning continuous-wave CO 2 lasers
thermally damaged tissue remaining a ter tissue vaporiza- signi cantly reduced the risks seen with the previous gen-
tion. As a result, alternative approaches to circumvent the eration o continuous-wave CO 2 laser devices. T e short-
side-e ect pro le o traditional CO 2 and Er:YAG lasers pulsed, high-power CO 2 laser can deliver 500 mJ in 600 µs
were developed. to 1 ms, resulting in 5 J/cm 2.13 T is uence can be achieved
T e nonablative laser-resur acing devices that appeared with either a 3 mm spot or a computerized pattern genera-
on the market were initially met with great enthusiasm, tor that rapidly and precisely places several 2.25 mm spots
but quickly ell out o avor due to marginal clinical in di erent patterns. Rapidly scanning continuous-wave
improvement.6,7 Nonablative technology was signi cantly CO 2 lasers use optomechanical ash scanners connected
advanced in 2004 with the introduction o ractional pho- to conventional continuous-wave CO 2 lasers to ocus
tothermolysis.8 In ractional photothermolysis, the laser small-diameter beams that distribute the energy into a
beam is pixilated, delivering the energy to only a spe- train o pulses with a dwell time less than 1 ms, mimicking
ci c raction o the epidermal and dermal architecture. a truly pulsed laser. Few systems employ this technology
T e undamaged intervening areas o skin allow or more currently, as more technical expertise is required than with
rapid healing and an improved side-e ect pro le. T e rst shuttered pulse lasers, which raises sa ety concerns.
laser to employ this technology was a 1550 nm erbium- Further progression in ablative technology led to the
doped ber laser. Although ractional nonablative devices 2940 nm Er:YAG laser. T e 2940 nm wavelength is bet-
showed more improvement than traditional nonablative ter absorbed by water due to its closer approximation to
devices, the results were still less impressive compared to water’s peak absorption at 2935 nm. T is allows or more
ablative resur acing and required a series o treatments.9 precise ablation compared to the CO 2 laser. At the same
T is led to the development o ractional ablative devices. time, the increased absorption by water limits its depth
Fractional ablative resur acing produces signi cantly o penetration to only 1 to 3 µm per J/cm 2 and results
4 PAt Ien t s el ec t Io n
It is essential to thoroughly evaluate patients prior to ini-
tiation o treatment. Ideal patients have realistic expec-
tations o cosmetic outcomes and a clear understanding
o the amount o downtime required. Patients must also
understand the side e ects associated with traditional
con uent ull-sur ace ablation. Patients with Fitzpatrick
skin types I through III have the highest incidence o
hypopigmentation ollowing ull-sur ace and even rac-
tional ablation because they have the least active and least
dense concentrations o melanocytes. Although skin types
IV through VI may develop relative hypopigmentation,
they are at a much greater risk o signi cant postin am-
S
matory hyperpigmentation (PIH). raditional ablation is
e
c
t
Figure 35-1 A patient with deep static perioral rhytides not advised in darker-skinned patients unless the physi-
i
o
n
at baseline (top). Dramatic improvement o perioral lines cian is extremely well versed in lasers and wound healing.
4
a ter CO2 laser resur acing (bottom). (Photographs used A complete medical history is very important or the
with permission o Richard E. Fitzpatrick, MD.) selection o appropriate patients. Patients with a history
:
:
o keloids should be treated with caution, as laser resur-
A
acing may trigger keloid ormation. Recent or concur-
e
s
t
rent isotretinoin use during laser procedures is a relative
h
in more bleeding rom decreased thermal coagulation o
e
contraindication, as scarring has been reported rom laser
t
blood vessels when pulses less than 500 ms are used.
i
c
procedures, dermabrasion, and chemical peeling in asso-
a
Comparative studies between CO 2 lasers and short-
n
ciation with isotretinoin.16,17 Although collagen synthe-
d
pulsed (500 ms) Er:YAG lasers tend to avor the CO 2 laser
L
sis and wound healing has been shown to be una ected
a
or skin resur acing. However, the results are o ten very
s
by isotretinoin,18 it is still prudent to avoid elective laser
e
similar when the Er:YAG is pulsed in the 6 to 10 ms range
r
procedures a ter recent isotretinoin use. T e exact wash-
P
as these lasers can then produce an area o nonspeci c
r
o
thermal damage similar to that achieved with CO 2 abla- out time or isotretinoin has not been determined, but
c
e
6 months seems to be suf cient. Likewise, patients with
d
tion.14,15
u
dermatologic diseases that koebnerize, such as vitiligo or
r
e
psoriasis, should be discouraged rom elective procedures
s
In d Ic At Io n s that may worsen their condition.
Areas with ew adnexal structures, such as the neck,
T e primary indication or ablative laser resur acing is chest, and hands, should not be treated because o their
photoaging. T is includes static rhytides, texture irregular- greater risk o scarring. Areas that have been previously
ity, telangiectasia, and lentigines. Other indications include irradiated have the same risk o scarring due to the loss o
scarring, actinic cheilitis, actinic keratoses, seborrheic adnexal structures.
keratoses, benign epidermal lesions (verrucae, sebaceous
hyperplasia, epidermal nevi, and the like) and rhinophyma.
With the introduction o ractional ablation, con u- Per Io Per At Iv e MAn Ag eMen t An d
ent ull-sur ace ablation has allen out o avor due to its An es t h es IA
prolonged downtime and high-risk sa ety pro le. However,
there is still a role or traditional ablation when treating deep T is section will brie y describe the appropriate management
static periorbital and perioral rhytides (Fig. 35-1), as well o patients undergoing traditional ablation. A more exhaus-
as benign epidermal lesions and rhinophyma (Fig. 35-2), tive discussion will ollow in the ractional ablative section,
which are particularly dif cult to improve with ractional since there is great overlap between the two techniques.
devices. Precancerous lesions and super cial skin cancers Prophylaxis with antiviral agents and antibiotics is gen-
are also more e ectively treated with con uent ablation, erally recommended to prevent herpes simplex outbreaks
as ractional ablation theoretically should only treat a rac- and secondary bacterial in ections.19 Anti ungal and anti-
tion o the lesion. yeast medications may also be prescribed, but are not the
standard o care.20
Several options exist or anesthesia, including a com-
bination o topical agents, local in ltration, nerve blocks,
and systemic tranquilizing and analgesic agents. T e
CO 2 lasers tend to be more pain ul than the short-pulsed
Er:YAG lasers, whereas long-pulsed Er:YAG lasers are
associated with similar pain levels. T is is thought to be
Figure 35-2 A patient with moderate rhinophyma at rom greater tissue heating o type C pain bers.
baseline (le t). Result a ter traditional resur acing (right). Postoperative management o edema may include the
(Photographs used with permission o Richard E. Fitzpat- use o a short course o oral or intramuscular corticoste-
420 rick, MD.) roids, but we recommend against this practice in general as
it may increase the risk o postoperative in ection or sup-
pression o neocollagenesis. T e care o exudate and skin
Maximum ablation depths have been reported to extend
over 1.5 mm into the dermis at higher energies (70 mJ).25– 27
4
sloughing includes saline, deionized water, or diluted white Re-epithelialization occurs within 2 days, but collagen
vinegar soaks, cool compresses, head elevation, and the use remodeling persists 3 months post procedure consistent
o petrolatum ointment. Erythema may persist or several with the presence o heat shock protein (HSP) 47 ound
months. T ere ore, the need or sun avoidance and protec- on histology.25 Initially, neocollagenesis is con ned to the
tion should be emphasized to reduce the risk o PIH.21,22 healing columns o ablation, and then becomes general-
ized throughout the dermis approximately 1 month post
procedure.
c o MPl Ic At Io n s T ere are currently three commercially available
wavelengths that employ ractional ablative technology:
T e most notable complications o con uent laser abla- 2790 nm erbium-doped:ytrrium-scandium-gallium-garnet
tion are scarring and delayed-onset hypopigmentation. laser (Er:YSGG); 2940 nm Er:YAG; and 10,600 nm CO 2
Delayed-onset hypopigmentation presents 6 to 12 months laser. By adjusting laser parameters, the di erent wave-
a ter the procedure. It is estimated that over 50%o patients lengths may be able to produce essentially comparable

C
have this complication.23 However, we rarely see this com-

h
results. Several ractional ablative devices are available with

a
p
plication when using conservative settings and limiting various treatment hand pieces, depth o ablation and coag-

t
e
nonspeci c thermal damage. Hypopigmentation tends

r
ulation, spot size, and shape ( able 35-1). Hand pieces can

3
to occur rom deeper ablation, while super cial ablation

5
either deliver energy via a rolling or stamping mechanism.
generally results in hyperpigmentation. Scarring generally

:
:
occurs rom too much thermal necrosis/nonspeci c ther-
mal damage, excessively deep ablation, or wound in ection In d Ic At Io n s

A
b
that extends the depth o injury beyond that which was

l
a
t
intended. Some areas are particularly prone to scarring,

i
T e applications or ractionated devices are increasing

v
e
most notably areas o very thin skin such as the eyelids, rapidly. Although initial studies were directed toward

a
n
neck, and chest. T e neck is particularly at risk and should reversal o photoaging, ractionated lasers are currently

d
not be treated with con uent ull-sur ace resur acing, as

F
being used in many capacities.

r
a
even a single pass produced a 10% incidence o scarring in Fractional deep dermal ablation has been shown to

c
t
a small pilot study.24 Other complications including in ec-

i
improve dyspigmentation, telangiectasia, and rhytides.28

o
n
tion, acnei orm eruptions, and eczematous dermatitis are Speci cally, ractional ablative resur acing can signi -

a
l
generally sel -limited and resolve with proper care.

A
cantly improve lentigines, seborrheic keratoses, actinic

b
l
keratoses, telangiectasia, rhytides, textural irregularity, and

a
t
i
skin laxity to some degree (Figs. 35-3 and 35-4). Although
Fr Ac t Io n Al Abl At Iv e l As er s

v
e
ractional lasers can achieve results that approach those

R
e
o traditional resur acing, they are not able to sustain the

s
u
t ec h n o l o g y same level o improvement in wrinkle reduction. With

r
a
time, the improvement in rhytides seen with ractional

c
i
n
Fractional ablative technology has revolutionized the eld resur acing seems to retrogress.29 T e same appears to be

g
o laser resur acing due to its signi cantly improved sa ety true with reduction o dyschromia. However, it has been
pro le, reduced healing time, and e ective results. Frac- shown to be sa e to combine multiple lasers in the same
tional devices deliver columns o thermal injury, termed treatment session with ractional ablative lasers result-
microthermal zones (M Zs) (includes areas o ablation ing in more signi cant and longer lasting improvement.
and coagulation), while the surrounding skin remains Our approach is to treat vascular lesions rst with a vas-
untreated. Una ected ollicular units and their stem cells, cular speci c laser, such as the 595 nm pulsed dye laser
as well as broblasts, aid in the healing process. T is leads or an Intense Pulsed Light device. Next, discrete brown
to a decreased healing time and a lower incidence o spots (lentigines, seborrheic keratoses) are treated with
adverse outcomes. a Q-switched (QS) laser (alexandrite or ruby) and/or an
T e most signi cant variables that determine clinical Intense Pulsed Light device insuring 100% coverage o the
ef cacy and wound healing include the percentage o sur- epidermal sur ace. T en, the pulsed CO 2 laser is used to
ace area treated (density), the diameter o the M Zs, and treat upper and lower lip lines, ollowed by precise sculpt-
the depth o ablation. No studies to date have examined ing with a pulsed Er:YAG laser. Finally, the entire ace, and
the e ect o the ratio o ablation to coagulation within the at times the neck and chest, are treated with ractional
M Zs. For example, the volume o injury might be simi- CO 2. Alternatively, the Intense Pulsed Light device is uti-
lar, but i the volumes contain di erent ratios o ablation to lized to treat the neck and chest. T is treatment sequence
coagulation, wound healing and cosmetic outcomes may be is not provided to suggest that everyone can treat their
a ected. Greater proportions o ablation seem to improve patients as aggressively, but rather to demonstrate the
cosmetic outcome, while greater proportions o coagula- compatibility o sequential multilaser treatments with
tion prolong healing time i excessive, but may be important ractional laser delivery. In act, the greatest advantage o
in achieving tightening o treated skin. T e optimal ratio o ractional lasers is their lower risk o complications such as
ablation:coagulation has yet to be elucidated. It is impor- in ection and delayed long-term hypopigmentation com-
tant to note that some manu acturers include surrounding bined with aster healing times.30 T ere is also a decreased
coagulative necrosis in the density calculation, whereas risk o scarring, especially away rom the ace. Prior to
other manu acturers only account or the zone o ablation. ractional technology, con uent resur acing o the neck 421
4 TAbLE 35-1
cu n ly Availabl Abla iv r su fa ing vi s.

Manufa u / en gy Puls
d vi t yp /Wav l ng h o u pu du a i n c mm n s
Alma Lasers Fractional 200–2500 mJ/P Three tip options:
HarmonyXL plat orm Er:YAG Pixel/2940 nm 7 × 7 mm, 9 × 9 mm, 1 × 7 mm
Pixel 2940
Alma Lasers Fractional 70 W 50–1000 µs Three tip options:
HarmonyXL plat orm CO2/10,600 nm 7 × 7 mm, 9 × 9 mm, 1 × 7 mm
Pixel CO2
Alma Lasers Handpiece or CO2 30–100 W N/A Fits Coherent, Lumenis, and Sharplan CO2
HarmonyXL plat orm plat orms/10,600 nm lasers
S
e
Pixel omni t
c
t
i
o
Cutera Fractional 60–320 mJ/ 600 µs Deep a lation >1 mm. Real time
n
4
Xeo pearl ractional Er:YSGG/2,790 nm microspot cali ration
Cynosure Fractional
:
30 W 1–20 ms Varia le scanning patterns. Adjusta le
:
Smart skin CO2/10,600 nm power, depth o a lation, dwell time, spot
A
pitch, and scan shapes
e
s
t
h
DEKA Fractional CO2 150 W/250 W 200–2000 µs Adjusta le a lation and dwell time
e
t
SmartXide DOT scanner/10,600 nm Varia le scanning modes
i
c
a
Ellman CO2 ractional with Up to 105 mJ 2–7 ms Adjusta le scan density and pulse
n
d
Elluminé ractionalCO2 scanner and exi le duration
L
a
laser system er/10,600 nm
s
e
r
Focus Medical Fractional 50 W Up to 10 ms Pending FDA approval
P
r
NaturaLase CO2 CO2/10,600 nm
o
c
e
Hironic Co. Fractional 60 mJ Up to 5,000 µs Adjusta le scan size and eam size
d
u
MIXEL CO2/10,600 nm
r
e
s
ILOODACo. Fractional Up to 30 W 0.1–5 ms Fast scanning mode
Fraxis CO2/10,600 nm
LASERING Fractional 0.5–30 W 2.5–16 ms Varia le spot sizes with ocusing
MiXto SX CO2/10,600 nm handpieces
Lumenis Fractional 1–225 mJ <1 ms CoolScan handpiece
UltraPulse active FX CO2/10,600 nm
Lumenis Fractional 2.5–50 mJ <2 ms 120 µm spot size scanning handpiece
UltraPulse deep FX CO2/10,600 nm with penetration depth up to 2 mm
Lumenis Fractional 1–225 mJ <2 ms Com ination o active/deep Fx
UltraPulse total FX CO2/10,600 nm
Lumenis Fractional 2.5–150 mJ <2 ms Increased depth o a lation to treat
Ultrapulse SCAAR FX CO2/10,600 nm thicker scars
Lumenis Fractional 1–170 mJ <2 ms
AcuPulse multimode CO2/10,600 nm
Lutronic Fractional Up to 240 mJ Varia le Multiple tip sizes and shapes. Handpiece
eCO2 CO2/10,600 nm availa le or continuous wave
Palomar Fractional 2,940 nm 2–5.5 mJ/ 0.25–5 ms IPL plat orm with multiple handpieces or
Starlux 500 plat orm 0.1 mm dif erent applications
Lux 2940 ractional
Sandstone Medical Fractional scanner N/A N/A Fractional scanner with 150 mm ocusing
Technologies (adapts to most CO2 handpiece
Matrix LS 40 with lasers CO2)/10,600 nm
Ultra ne FS ractional
scanner
Sandstone Medical CO2 and Er:YAG/10,600 Up to 40 W Adjusta le to Fractional CO2 com ined with Er:YAG and
Technologies and 2,940 nm 100 ms ractionated Er ium
Cortex resur acing
422 work station
 TAbLE 35-1 (Continued )
4
Manufa ur r/ en rgy Puls
d vi t yp /wav l ng h o u pu d ura i n c mm n s
Sciton Er:YAG/2,940 nm Up to 400 J/cm 2 Varia le 20 × 20 mm scanner with 250 µm
Joule/ProFractional spot size
Solta Medical 1927 Thulium f er Up to 20 mJ/ N/A Intelligent Optical Tracking System IOTS ,
Fraxel DUAL laser/1927 nm MTZ adjusts to hand speed to provide uni orm
delivery o laser energy
Solta Medical Fractional CO2 5–70 mJ/MTZ N/A Integrated smoke evacuation system.
Fraxel Re:Pair laser/10,600 nm Also with IOTS

C
Syneron and Candela Fractional CO2/ 60 W 30–60 mJ Multiple patterns allow or simultaneous

h
a
CO2 RE 10,600 nm 60–90 mJ superf cial/deep treatment

p
50–80 mJ

t
e
r
60–70 mJ

3
5
1–10 mJ

:
:
A
l
and chest with CO 2 and Er:YAG lasers was a orbidden o skin scars (CROSS) technique. T e f rst study on rac-

a
t
i
territory, with the exception o very conservative, super- tional CO 2 laser resur acing o acne scars showed clini-

v
e
f cial treatment.31 cal improvement o scarring in 23 out o 25 patients a ter

a
n
Another key indication or ablative ractional resur acing 3 months.32 Subjects received one to three treatments

d
F
is the treatment o scars. Interestingly, ractional resur acing 1 month apart with treatment energies ranging rom 20

r
a
has exhibited the ability to improve both atrophic and hyper- to 100 mJ and total densities o 600 to 1600 M Z/cm 2.

c
t
i
trophic scars.26 Anecdotally, scarring seems to respond to No serious complications were noted. Patients had the

o
n
lower density (<35%) and higher depth (>500 µm) treatment added benef t o improvement in their overall appearance,

a
l
A
settings. No study to date has conf rmed this belie . including dyspigmentation and rhytides. Even patients
Acne scarring, in particular, presents a treatment chal- with darker skin types can be sa ely treated or scarring

l
a
t
lenge to the laser surgeon and causes great psychological with ractional ablative lasers given the decreased risk o

i
v
e
distress in the patient. Small box-car scars and rolling scars PIH compared to con uent ablation (Fig. 35-5).

R
e
tend to respond well to ablative ractional lasers. In gen- Surgical and traumatic scars have also shown promising

s
u
eral, rolling scars will predictably respond well i the scar results with ablative ractional technology (Fig. 35-6). Not

r
a
attens and disappears with stretching o the scar between only is there cosmetic improvement, but ractional abla-

c
i
n
the f ngers. Ice-pick scars, or scars that do not respond tive lasers have also produced unctional improvement in

g
well to laser treatment alone, may require additional pliability and increased range o motion.33 T e improve-
interventions such as subcision, punch excisions, f llers, ment in range o motion is almost instantaneous in certain
or the trichloroacetic acid ( CA) chemical reconstruction cases. T e mechanism by which this may occur is unclear,

Figure 35-3 Seventy three year old emale with severe Figure 35-4 A emale patient with severe dyspigmenta
photodamage, static rhytides, and acial laxity prior to tion and static rhytides at aseline left . Note almost com
treatment left . Four months a ter one ractional CO2 laser plete resolution o lentigines and signif cant improvement
treatment. Note improvement in lentigines, f ne lines and in rhytides, particularly in the perioral region, a ter rac
jowl laxity right . Photographs used with permission o tional CO2 laser treatment right . Photographs used with
Mitchel P. Goldman, MD. permission o Richard E. Fitzpatrick, MD. 423
4 o the pigment while also allowing transepidermal extru-
sion o pigment through ablated channels. In the case o
an allergic reaction to tattoo pigment, use o an ablative
CO 2 laser may be considered instead o QS and/or pico-
second lasers to prevent any systemic e ects rom release
o tattoo ink into the blood stream.34 T is technique may
prove to be an alternative paradigm or tattoo inks that are
dif cult to treat with currently available QS and picosec-
ond lasers.
When used in conjunction with QS and picosecond
lasers, the ractional ablative lasers provide another mech-
anism o pigment removal and are much less likely to
cause hypopigmentation, as they are not targeting mela-
nin and encourage melanocyte migration with wound
healing. Another advantage is that the ractional ablative
S
e
laser will treat any scarring associated with the QS laser.
c
t
i
T ere are numerous other promising applications or
o
n
ractional ablative lasers, such as treatment o syringo-
4
Figure 35-5 A male patient with skin type IV with severe
atrophic acne scarring prior to treatment (left). Signi cant mas,35 striae,36 rhinophyma,37 actinic cheilitis, regressed
:
:
improvement in acne scars with no evidence o postin- in antile hemangiomas, and repigmentation o delayed-
onset hypopigmentation ollowing con uent ablation.26
A
f ammatory hyperpigmentation (right). (Photographs used
e
with permission o Richard E. Fitzpatrick, MD.) Repigmentation may occur via the renewed stimulation
s
t
h
o melanocytes, but this has yet to be investigated. T e use
e
t
o ractional ablative lasers or the treatment o prema-
i
c
a
lignant and malignant lesions is limited by design as less
n
d
but appears to be due to the physical removal o a raction than 100% o the skin sur ace is treated. A more promising
L
o the scar tissue. Over time, the abnormal scar tissue is
a
approach to skin cancer therapy is the use o ractional
s
e
replaced by type III nascent collagen, which may also play ablative devices or enhanced drug delivery o medica-
r
P
a role in long-term improvement o unction and cosmesis. tions such as methyl 5-aminolevulinate (MAL) or 5-ami-
r
o
A newer indication or ractional ablation is tattoo nolevulinate (ALA) or photodynamic therapy.38 Drug
c
e
d
removal. raditionally, tattoo removal has been accom- delivery via ractional ablation is an exciting new arena
u
r
plished using QS and/or picosecond lasers. T e addition because essentially any drug can be applied. T e only
e
s
o ablative ractional lasers a ter treatment with QS lasers potential limitations would be solubility and the molecu-
may enhance tattoo removal by physically ablating some lar size o the drug.

Figure 35-6 A 7 year-old emale with traumatic acial scars prior to laser treatment (top le t). Progression o improvement
a ter two treatments with ractional CO2 laser. Signi cant improvement o scarring 1 year a ter initial accident (bottom
424 right). (Photographs used with permission o Mitchel P. Goldman, MD.)
 PAt Ien t s el ec t Io n
are administered during the same time rame as the antivi-
rals. We use minocycline because it almost always covers
4
Staphylococcus species, as well as normal ora – which are
Appropriate patient selection is key to a success ul resur- the two most common groups o bacteria isolated rom
acing procedure. Evaluation o patients considering rac- slow-healing wounds. Anti ungals, such as uconazole,
tional ablative procedures is very similar to those seeking may be given or prevention o secondary candidal or un-
ully ablative procedures. However, there is greater exi- gal in ections. However, this is more dependent on the
bility in skin types, ages, and body sites that may be treated patient’s history and is not the standard o care.
with ractional ablative lasers. Unlike traditional ablation, Pain is managed with a topical anesthetic agent, such
any skin phototype may be treated with ractional ablative as lidocaine or prilocaine cream, applied 1 hour prior to
lasers. Nevertheless, skin type V to VI should be treated the procedure. T is is not likely to be e ective as a single
with caution at low-density settings to decrease the risk o agent unless conservative, minimally aggressive treatment
pigmentary complications. parameters are chosen. Additional pain control can be
achieved with supraorbital, in raorbital, nasalis, and men-
Per Io Per At Iv e MAn Ag eMen t tal nerve blocks immediately prior to the procedure. Local

C
h
An d An es t h es IA in ltration may be necessary in the preauricular area, as

a
p
well as in other areas not covered by nerve blocks, which

t
e
r
Standard prophylaxis with antivirals and antibacteri- tend to be very pain ul even with the a orementioned

3
5
als prior to treatment with ractional lasers has not been techniques. Intramuscular nonsteroidal anti-in ammatory
shown to prevent complications.30 However, in certain medications or oral antianxiolytics may also be used. Intra-

:
:
high-risk patients, antiviral and antibiotic prophylaxis may venous sedation may help to provide an easier experience

A
be considered. An antiherpetic agent, such as valcyclovir, or both the laser surgeon and the patient. It is impera-

b
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is initiated on the day o procedure and continued or tive or patients receiving systemic medications that alter

a
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about a week. Prophylactic antibiotics are usually penicil- mental unction to be properly monitored and to have a

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lins, macrolides, or tetracyclines, such as minocycline, and method o transport prearranged. During the procedure,

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e
s
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a
c
i
n
g
Figure 35-7 Typical progression o healing seen in a patient a ter ractional CO2 laser resur acing. The patient at baseline
(top left), 1 day a ter procedure (top middle), 4 days a ter procedure (top right), 8 days a ter procedure (bottom left), 3
weeks a ter procedure (bottom middle), and 4 weeks a ter procedure (bottom right). Note that crusting has resolved by
day 4 and that erythema can easily be covered with makeup by 1 week. (Photographs used with permission o Mitchel P.
Goldman, MD.) 425
4 cold-air cooling can maximize com ort. Postoperative pain
is generally minor, reminiscent o a mild sunburn. T us,
treatment. It is imperative that the person per orming the
procedure be able to recognize and properly treat HSV
any increase in pain a ter the procedure should prompt an in ection in order to avoid delayed wound healing and
immediate in-of ce evaluation to rule out in ection. scarring. Patients with active HSV in ections on the day o
Postoperatively, patients should apply diluted vinegar procedure should not be treated to prevent dissemination.
soaks every ew hours ollowed by application o petro- Postoperative bacterial in ections with Staphylococcus,
latum ointment or oozing and crusting, which may last Pseudomona s, and Klebsiella have been reported.42 Any
up to 3 days (Fig. 35-7). Sun avoidance and protection is increase in pain, erythema, erosions or crusting is usually
imperative to minimize the risk o PIH. a sign o in ection.
Patients with darker skin types should be counseled that
they are at high risk or PIH (Fig. 35-9). T ese patients may
c o MPl Ic At Io n s bene t rom posttreatment with hydroquinone or other
bleaching agents. Pretreatment with bleaching agents has
T e primary advantage o ractional ablative resur ac- not been ound to be e ective in preventing hyperpigmen-
ing over ull ablation is an improved sa ety pro le. Most tation.43 However, the use o a high-potency topical steroid
S
e
signi cant is its lower risk o scarring and delayed-onset in an ointment ormulation with minimal preservatives
c
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hypopigmentation. T is lower risk o scarring also extends and/or stabilizers twice daily or 2 days prior to treatment
o
n
to non- acial areas, such as the neck, chest, back, and and 2 days post treatment may be bene cial in decreasing
4
extremities, which previously could not be treated with the incidence o PIH by shutting down the in ammatory
:
:
ully ablative lasers, although there have been a ew cases cascade. Sun avoidance and protection are imperative or
o scarring and ectropion reported in the literature.39– 41 several weeks be ore and a ter treatment.44
A
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Scarring rom ractional ablative lasers is almost always Other minor complications may include acne exacerba-
s
t
h
a result o improper technique or excessive energy and tion or milia ormation. Occlusive ointments may play a
e
t
density settings (Fig. 35-8). It is important to minimize signi cant role in the development o these lesions. T ese
i
c
a
bulk heating by allowing the skin suf cient time to cool medications should, there ore, be discontinued and replaced
n
d
between passes. T is is especially important when treat- with a lighter moisturizer a ter complete re-epithelialization
L
a
ing smaller anatomic areas. Ironically, the same laser that has occurred, usually the third or ourth day a ter resur ac-
s
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created the scar may later be used to treat the scar when ing. Others eel that thermal injury to the ollicular open-
r
P
proper settings are employed. ings and sebaceous gland ducts alters the maturation o the
r
o
In ections with cutaneous herpes simplex virus (HSV) epidermis, resulting in blockage o the gland openings and
c
e
d
are rare, and generally present within the rst week a ter subsequent milia ormation as well as acne ares.
u
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e
s
A

Figure 35-9 A. Postinf ammatory hyperpigmentation in

Figure 35-8 Scarring as a result o a ractional CO2 laser a patient with skin type IV a ter ractional CO2 laser resur-
426 treatment with excessive energy and density settings. acing.
 4

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B

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Figure 35-9 (Continued ) B. Progressive improvement in hyperpigmentation a ter several courses o bleaching agents

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and intense pulsed light treatments.

d
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c o n c l u s Io n remodeling using microscopic patterns o thermal injury.

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La sers Surg Med. 2004;34:426– 438.

o
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9. Fisher GJ, Varani J, Voorhees JJ. Looking older: broblast

a
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T e eld o nonsurgical resur acing has been trans ormed collapse and therapeutic implications. Arch Dermatol. 2008;

A
144:666– 672.

b
with the advent o ractional ablative technology. Despite

l
a
10. Kauvar AN, Waldor HA, Geronemus RG. A histopathologi-
results that all short o the results o con uent ablation,

t
i
cal comparison o “char- ree” carbon dioxide lasers. Derma-

v
ractional ablative technology has gained overwhelming

e
tol Surg. 1996;22:343– 348.

R
avor over ully ablative procedures due to its more avor- 11. Walsh J Jr, Flotte J, Anderson RR, Deutsch F. Pulsed CO 2

e
s
laser tissue ablation: e ect o tissue type and pulse duration

u
able side-e ect pro le, reduced recovery time, and overall

r
ef cacy. T ese qualities are inspiring the investigation o on thermal damage. La sers Surg Med. 1988;8:108– 118.

a
c
12. Green HA, Domankevitz Y, Nishioka NS. Pulsed carbon

i
novel applications or ractional ablation o the skin and

n
dioxide laser ablation o burned skin: in vitro and in vivo

g
perhaps other organs as well. analysis. La sers Surg Med. 1990;10:476– 484.
13. Yang CC, Chai CY. Animal study o skin resur acing using the
ultrapulse carbon dioxide laser. Ann Plast Surg. 1995;35:154–158.
14. Goldman MP, Manuskiatti W. Combined laser resur acing
r eFer en c es with the 950-microsec pulsed CO 2 + Er:YAG lasers. Derma-
tol Surg. 1999;25:160– 163.
1. Anderson RR, Parrish JA. Selective photothermolysis: pre- 15. Rostan EF, Fitzpatrick RE, Goldman MP. Laser resur acing
cise microsurgery by selective absorption o pulsed radiation. with a long pulse erbium:YAG laser compared to the 950 ms
Science. 1983;220:524– 527. pulsed CO(2) laser. La sers Surg Med. 2001;29:136–141.
2. Altshuler GB, Anderson RR, Manstein D, Zenzie HH, 16. Rubenstein R, Roenigk HH Jr, Stegman SJ, Hanke CW. Atypi-
Smirnov MZ. Extended theory o selective photothermolysis. cal keloids a ter dermabrasion o patients taking isotretinoin.
La sers Surg Med. 2001;29:416– 432. J Am Acad Dermatol. 1986;15:280–285.
3. Waldor HA, Kauvar AN, Geronemus RG. Skin resur acing o 17. Bernestein LJ, Geronemus RG. Keloid ormation with the
ne to deep rhytides using a char- ree carbon dioxide laser in 585-nm pulsed dye laser during isotretinoin treatment. Arch
47 patients. Dermatol Surg. 1995;21:940– 946. Dermatol. 1997;133:111– 112.
4. Fitzpatrick RE, Goldman MP, Satur NM, ope WD. Pulsed 18. Moy RL, Moy LS, Bennett RG, Zitelli JA, Uitto J. Systemic
carbon dioxide laser resur acing o photo-aged acial skin. isotretinoin: e ects on dermal wound healing in a rabbit ear
Arch Dermatol. 1996;132:395– 402. model in vivo. J Dermatol Surg Oncol. 1990;16:1142–1146.
5. Alster S, West B. Resur acing o atrophic acial acne scars 19. Manuskiatti W, Fitzpatrick RE, Goldman MP, Krejci-Papa N.
with a high-energy, pulsed carbon dioxide laser. Dermatol Prophylactic antibiotics in patients undergoing laser resur-
Surg. 1996;22:151– 154; discussion 54– 55. acing o the skin. J Am Acad Dermatol. 1999;40:77– 84.
6. Paithankar DY, Cli ord JM, Saleh BA, Ross EV, Hardaway 20. Conn H, Nanda VS. Prophylactic uconazole promotes reep-
CA, Barnette D. Subsur ace skin renewal by treatment with ithelialization in ull- ace carbon dioxide laser skin resur ac-
a 1450-nm laser in combination with dynamic cooling. ing. La sers Surg Med. 2000;26:201– 207.
J Biomed Opt. 2003;8:545– 551. 21. Goldman MP, Roberts L 3rd, Skover G, Lettieri J , Fitz-
7. Goldberg DJ. Non-ablative subsur ace remodeling: clini- patrick RE. Optimizing wound healing in the ace a ter laser
cal and histologic evaluation o a 1320-nm Nd:YAG laser. abrasion. J Am Acad Dermatol. 2002;46:399–407.
J Cutan La ser T er. 1999;1:153– 157. 22. Fitzpatrick RE, Williams B, Goldman MP. Preoperative anes-
8. Manstein D, Herron GS, Sink RK, anner H, Anderson RR. thesia and postoperative considerations in laser resur acing.
Fractional photothermolysis: a new concept or cutaneous Semin Cutan Med Surg. 1996;15:170– 176. 427
4 23. Dijkema SJ, van der Lei B. Long-term results o upper lips
treated or rhytides with carbon dioxide laser. Pla st Reconstr
35. Cho SB, Kim HJ, Noh S, Lee SJ, Kim YK, Lee JH. reatment o
syringoma using an ablative 10,600-nm carbon dioxide rac-
Surg. 2005;115:1731– 1735. tional laser: a prospective analysis o 35 patients. Dermatol
24. Fitzpatrick RE, Goldman MP, Sriprachya-Anunt S. Resur ac- Surg. 2011;37:433– 438.
ing o photodamaged skin on the neck with an UltraPulse((R)) 36. Lee SE, Kim JH, Lee SJ, et al. reatment o striae distensae
carbon dioxide laser. La sers Surg Med. 2001;28:145– 149. using an ablative 10600-nm carbon dioxide ractional laser:
25. Hantash BM, Bedi VP, Kapadia B, et al. In vivo histological a retrospective review o 27 participants. Dermatol Surg.
evaluation o a novel ablative ractional resur acing device. 2010;36:1683– 1690.
La sers Surg Med. 2007;39:96– 107. 37. Serowka KL, Saedi N, Dover JS, Zachary CB. Fractionated
26. Hunzeker CM, Weiss E , Geronemus RG. Fractionated CO 2 ablative carbon dioxide laser or the treatment o rhino-
laser resur acing: our experience with more than 2000 treat- phyma. La sers Surg Med. 2014;46(1):8– 12.
ments. Aesthet Surg J. 2009;29:317– 322. 38. Haedersdal M, Sakamoto FH, Farinelli WA, Doukas AG, am
27. Hantash BM, Bedi VP, Chan KF, Zachary CB. Ex vivo histo- J, Anderson RR. Fractional CO(2) laser-assisted drug deliv-
logical characterization o a novel ablative ractional resur- ery. La sers Surg Med. 2010;42:113– 122.
acing device. La sers Surg Med. 2007;39:87– 95. 39. Fi e DJ, Fitzpatrick RE, Zachary CB. Complications o rac-
28. Rahman Z, MacFalls H, Jiang K, et al. Fractional deep der- tional CO 2 laser resur acing: our cases. La sers Surg Med.
mal ablation induces tissue tightening. La sers Surg Med. 2009;41:179– 184.
S
2009;41:78–86. 40. Ross RB, Spencer J. Scarring and persistent erythema a ter
e
29. Ortiz AE, remaine AM, Zachary CB. Long-term ef cacy ractionated ablative CO 2 laser resur acing. J Drugs Derma-
c
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o a ractional resur acing device. La sers Surg Med. 2010;42 tol. 2008;7:1072– 1073.
o
n
:168– 170. 41. Avram MM, ope WD, Yu , Szachowicz E, Nelson JS.
4
30. Campbell M, Goldman MP. Adverse events o ractionated Hypertrophic scarring o the neck ollowing ablative rac-
carbon dioxide laser: review o 373 treatments. Dermatol tional carbon dioxide laser resur acing. La sers Surg Med.
:
:
Surg. 2010;36:1645– 1650. 2009;41:185– 188.
31. Fitzpatrick RE. CO 2 laser resur acing. Dermatol Clin. 2001;19: 42. Ortiz AE, ingey C, Yu YE, Ross EV. opical steroids impli-
A
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443– 451, viii. cated in postoperative in ection ollowing ablative laser
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32. Walgrave SE, Ortiz AE, MacFalls H , et al. Evaluation o a resur acing. La sers Surg Med. 2012;44:1– 3.
h
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novel ractional resur acing device or treatment o acne scar- 43. Sriprachya-anunt S, Marchell NL, Fitzpatrick RE, Goldman
t
i
c
ring. La sers Surg Med. 2009;41:122– 127. MP, Rostan EF. Facial resur acing in patients with Fitzpatrick
a
33. Waibel J, Beer K. Ablative ractional laser resur acing or the skin type IV. La sers Surg Med. 2002;30:86– 92.
n
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treatment o a third-degree burn. J Drugs Dermatol. 2009; 44. Chan HH, Manstein D, Yu CS, Shek S, Kono , Wei WI. T e
L
8:294– 297. prevalence and risk actors o post-in ammatory hyperpig-
a
s
34. Ibrahimi OA, Syed Z, Sakamoto FH, Avram MM, Ander- mentation a ter ractional resur acing in Asians. La sers Surg
e
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son RR. reatment o tattoo allergy with ablative ractional Med. 2007;39:381– 385.
P
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resur acing: a novel paradigm or tattoo removal. J Am Acad
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Dermatol. 2011;64:1111– 1114.
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 Ch a p t e r Nonablative Dermal

36 Remodeling
Yoon-Soo Cindy Bae & David J. Goldberg

Although promising in their potential, ablative approaches o the three devices, with e ective heating to the depth o
to rejuvenating photodamaged skin, including both CO 2 400 µm compared to a depth o approximately 300 µm
and Er:YAG laser technology, are sometimes accompanied achieved by the 1450 nm diode laser.1 In addition, the 1320
by untoward side e ects and complications. T e most nm wavelength is associated with signi cant scattering,
common o these is postoperative erythema, experienced resulting in deposition o energy outside the laser beam
by virtually all patients treated with ablative resur acing. and subsequent e ective dermal heating. Although low
Other potential risks induced by these dermal wounding throughout the mid-in rared spectrum, laser light absorp-
lasers consist o delayed healing, postoperative pigmen- tion by epidermal melanin is approximately 1.6 times lower
tary changes, and scarring, which may be seen not only at 1540 nm compared to 1320 nm.2 It has, there ore, been
in patients with lower Fitzpatrick skin types, but also in suggested that the ormer wavelength may be sa er to use in
patients with higher Fitzpatrick skin types. T ese risks, in darkly pigmented individuals.
addition to a prolonged recovery period a ter treatment, In one o the rst studies evaluating a nonablative
have prompted the development o nonablative and more approach to dermal remodeling, a 1064 nm Q-switched
recently, ractionated resur acing technologies. Nd:YAG laser was used in an attempt to improve rhyt-
T e clinical improvement noted a ter ablative laser ides.3 Eleven subjects (Fitzpatrick skin types I, II) with
therapy results rom dermal wounding, which stimu- Class I to II perioral or periorbital rhytides were treated
lates new collagen ormation and deposition in a parallel using a Q-switched Nd:YAG laser at 5.5 J/ cm 2 and a
con guration. echniques that induce a dermal wound 3 mm spot size. T e authors sought a nonspeci c clini-
without epidermal ablation should, there ore, theoretically cal endpoint o pinpoint bleeding. Subjects were treated
produce cosmetic improvement o dermal photodamage only once and were evaluated 7, 30, 60, and 90 days a ter
and scarring. T is idea led to the development o newer treatment or improvement o rhytides, healing, pig-
rejuvenating laser systems known as nonablative dermal mentary changes, and erythema. T ree patients (two
remodeling systems, which can be classi ed into three perioral/one periorbital) were thought to have improve-
main groups: mid-in rared lasers, visible lasers, and ment, with results comparable to those ollowing treat-
intense pulsed light (IPL) sources. T ese groups operate ment with ablative resur acing. Six patients (three
on the principles o selective photothermolysis, as they perioral/ three periorbital), were noted to have clinical
target either a discrete chromophore or dermal water. improvement, but their results were not comparable to
Despite having di erent targets, these lasers, whether those achieved with ablative laser systems (Figs. 36-1
directed at dermal microvasculature, pigment or tissue and 36-2). No clinical improvement was seen in two
water, produce similar histologic changes due to ther- patients (one perioral/one periorbital) and no pigmen-
mal injury. T ese changes in dermal collagen account or tary change or scarring was seen in any o the treated
the clinical improvement observed a ter treatment with subjects. At 1 month, 3 o 11 subjects showed persistent
these modalities. T e recent study and development o er ythema at the treated sites, which eventually resolved
radio requency (RF) devices and ractional laser delivery at 3 months.
systems has expanded the approach to using nonabla- O note, Q-switched Nd:YAG laser energy is not well
tive treatments or dermal remodeling. T is chapter will absorbed by tissue water and results in relatively deep
review what is currently known about these treatment penetration into the skin; it is nonselectively placed within
modalities. the dermis. T e previous study was, there ore, modi ed by
potentiating the Q-switched Nd:YAG laser using a topical
carbon-assisted solution (Fig. 36-3).4 T is modi cation was
In f r a r ed La s er s thought to localize the cellular damage to the tissue imme-
diately adjacent to the carbon, thereby minimally a ecting
T e water absorption coe cient is relatively low in the in ra- the nontargeted tissue and requiring less than 10% o the
red portion o the electromagnetic spectrum (>700 nm), typical energy output rom CO 2 laser treatment.
which allows or deeper laser tissue penetration. Mid-in ra- With this new approach, 242 solar anatomic sites on
red lasers typically used or photorejuvenation include the 61 human subjects underwent three 1064 nm Q-switched
1320 nm neodymium:yttrium–aluminum–garnet (Nd:YAG) Nd:YAG laser treatments. Parameters o treatment
laser, the 1450 nm diode laser, and the 1540 nm ytterbium– included a f uence o 2.5 J/cm 2, pulse duration o 6 to 20
erbium:phosphate glass, also known as the erbium:glass nanoseconds, and a spot size o 7 mm. T e treatment sites
(Er:glass) laser. Light produced by all three lasers is absorbed were evaluated at baseline, 4, 8, 14, 20, and 32 weeks or
by water, with the 1320 nm wavelength absorbed least. As a skin texture, skin elasticity, and rhytide reduction. All sites
result, optical penetration depth by this laser is the greatest were treated at a baseline visit, and later at 4 and 8 weeks. At
4

Figure 36-1 Periorbital rhytides be ore treatment with a Figure 36-2 Improvement in rhytides a ter treatment
S
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Q-switched Nd:YAG Laser. with a Q-switched Nd:YAG Laser.
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8 months, the investigators reported improvement in skin laser on one acial hal and a long-pulsed 1450 nm diode
:
texture and skin elasticity, as well as reduction in wrinkles laser on the contralateral acial hal . Using digital photogra-
:
compared to baseline (Figs. 36-4 and 36-5). T e majority phy and three-dimensional in vivo microtopography mea-
A
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o adverse events were limited to mild and brie erythema. surements, patients were evaluated at each treatment visit
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As a result o these earlier investigations, the rst spe- and at 1, 3, 6, and 12 months postoperatively. Histologic
h
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ci cally nonablative laser to be marketed solely to the evaluations o cutaneous biopsies obtained be ore treat-
t
i
c
physician community was a 1320 nm Nd:YAG in rared ment, immediately a ter the rst treatment, and at 1, 3, 6,
a
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laser. Nelson et al.5 per ormed a study using one or more and 12 months a ter the third treatment were per ormed.
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passes o the 1320 nm Nd:YAG laser on photoaged skin. In the majority o patients studied, mild-to-moderate clini-
a
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T e wave orm consisted o three 200 usec laser pulses at a cal improvement was observed a ter the series o three
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r
100 Hz repetition rate. Laser energy was delivered through treatments. Patient satis action scores and in vivo micro-
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a 5 mm spot with f uences up to 10 J/cm 2. A dynamic cryo- topography measurements paralleled the photographic
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gen cooling technique was applied immediately prior to and histopathologic changes seen. Side e ects o treat-
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laser treatment to produce selective subsur ace skin heat- ment were limited to mild transient erythema, edema,
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e
s
ing without epidermal damage. Immediately a ter treat- and hyperpigmentation. No scarring or adverse textural
ment, mild edema and erythema appeared in the treated changes resulted rom the use o either laser system. T e
skin. T ese side e ects resolved within 2 days and at authors concluded that the 1450 nm diode laser showed
2 months a ter treatment acial rhytides were noted to greater clinical scar response at the parameters studied
have improved. No persistent erythema or pigmentary (Figs. 36-8 and 36-9).7
changes were appreciated (Figs. 36-6 and 36-7). Dahan et al.8 investigated the use o an Erbium glass
T e e cacy o the 1320 nm Nd:YAG laser has been com- 1540 nm laser in 20 patients to increase dermal thickness
pared to that o the 1450 nm diode laser, an in rared laser and rmness. Skin thickness and mechanical properties
with lower peak powers, necessitating longer pulse dura- were measured be ore the rst treatment, 1 month a ter
tions to achieve optimal f uences.6 A study o 20 patients the third treatment, 1 month a ter the th treatment, and
(Fitzpatrick skin types I to V) with mild-to-moderate atro- 3 months a ter the th treatment. All patients reported an
phic acial acne scars randomly received three successive improvement in both skin tone and texture. Using ultra-
monthly treatments with a long-pulsed 1320 nm Nd:YAG sound imaging, dermal thickness o the neck and ore-
head increased and a dramatic increase in rmness o the
orehead skin was observed. No immediate or late adverse
e ects were noted throughout the treatment regimen.
T is study demonstrated that irradiation with a 1540 nm
Er:glass laser emitted in a pulsed mode and coupled with
an e cient contact cooling system increases dermal thick-
ness and rmness, leading to clinical improvement in neck
lines and orehead rhytides.
o address the potential postprocedural pigmentary
changes a ter various laser treatments in patients with
higher Fitzpatrick skin types, Badawi et al.9 published a
retrospective study analyzing nonablative scar treatments
in dark skin types using a submillisecond Nd:YAG 1064 nm
laser. T e theory behind using microsecond pulse dura-
tions stems rom the concept that this type o laser heating
more selectively targets the microvasculature in the papil-
Figure 36-3 Topical carbon surrounding hair ollicle used lary dermis and melanocytes within the epidermis, without
430 in carbon-assisted, low uence Q-switched Nd:YAG Laser. actually damaging larger dermal vessels or the epidermis.
 4

Figure 36-4 Periorbital rhytides be ore treatment with a

C
Figure 36-5 Improvement in rhytides a ter treatment with

h
carbon-assisted, low uence Q-switched Nd:YAG Laser. a carbon-assisted, low uence Q-switched Nd:YAG laser.

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3
In addition, bulk heating, using a 5 mm spot size and puls- known as the pulsed dye laser (PDL). Histopathologic

6
ing at 5 to 10 Hz, allows delivery o large amounts o energy examination o 585 nm PDL-treated scars revealed

:
in short pulses aster than the body can extract the heat. In improvement in dermal collagen. T ere was also an

:
nonselective heat conduction, no structures are speci cally increase in the number o regional mast cells in the treated

N
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targeted, thereby permitting patients with higher Fitzpat- scars. As mast cells elaborate a variety o cytokines, their

n
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rick skin types to be sa ely treated.9 presence ollowing irradiation and accompanying tissue

b
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In their retrospective review, 22 patients with Fitzpatrick revascularization may provide an explanation or thera-

a
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i
skin types III to VI were enrolled and treated or an average peutic improvement ollowing PDL treatment. Using this

v
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o six sessions at an average o 24.5 day intervals. o opti- concept, Zelickson et al.10 evaluated the use o PDL in

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mize laser results and allow greater light penetration into the treatment o rhytides. T e authors reported clinical

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the papillary dermis, the skin was treated with microderm- improvement in 75% to 90% o mild-to-moderate rhytides

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abrasion throughout the submillisecond 1064 nm Nd:YAG and 40% o moderate-to-severe rhytides; however, the

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e
laser treatment series (3 days minimum or microderm- study results were tempered by cosmetically unacceptable

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abrasion to laser treatment). T e authors did not administer purpura, which are commonly seen ollowing PDL treat-

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prophylaxis against postinf ammatory hyperpigmentation. ment (Figs. 36-10 and 36-11).

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Assessment o pre and post procedure photographs by two Although in the case o vascular lesions, the develop-

g
blinded dermatologists and one plastic surgeon indicated ment o purpura is associated with e ective treatment,
improvements in scarring, texture, and postinf ammatory anghetti et al.11 questioned the e cacy o low dose or
hyperpigmentation. No transient or permanent hyper- or subpurpuric f uences using a PDL to treat photodamage
hypopigmentation was observed.9 T e authors recognized (textural changes, rhytides). Prior studies demonstrated
the need or prospective trials and possible split ace trials that multipass, subpurpuric treatments increase the depth
to con rm treatment e cacy.9 o total tissue e ect while reducing the risk o purpura.12
anghetti et al. sought to investigate treatment methods
and parameters to address the most e ective approach,
Pu Ls ed d ye La s er splitting 20 o their patients into two groups: one group
receiving a series o our single-pass treatments at 2 week
Dermal remodeling has also been demonstrated using intervals and the other receiving a series o our double-
another nonablative approach targeting hemoglobin, pass treatments at similar intervals. Within each patient,

Figure 36-6 Patient be ore treatment with a 1320 nm Figure 36-7 Patient 6 months a ter 1320 nm Nd:YAG laser
Nd:YAG laser. treatment. 431
4

Figure 36-9 Improvement in rhytides a ter treatment

S
Figure 36-8 Periorbital rhytides be ore treatment with a
e
with a 1450 nm diode laser.
c
1450 nm diode laser.
t
i
o
n
4
one-hal o the ace was randomized to receive treatment treatment related purpura. Goldberg et al. enrolled 30 sub-
with either the 585 or 595 nm wavelength. All treatments jects (Fitzpatrick skin types I, II) with Class I to II perior-
:
:
were provided using a pulse duration o 0.5 ms with a bital, perioral, and orehead rhytides and administered one
A
10 mm handpiece. reatment f uences were maintained to our IPL treatments. Noncoherent IPL was delivered to
e
s
just below the individual’s subpurpuric threshold or each the skin using a 645 nm cuto lter, which led to emission
t
h
e
respective wavelength and ranged rom 3 to 4 J/cm 2. o light with wavelengths between 645 nm and 1100 nm.
t
i
c
T e Fitzpatrick skin type o each patient was not noted; Light was delivered through a bracketed cooling device, in
a
n
however, the authors reported no adverse events rom triple 7 ms pulses, with a 50 ms interpulse delay between
d
the study. Blinded observers rated an average overall the pulses. Delivered f uences were between 40 and 50 J/cm 2.
L
a
improvement o 1.2 (scale o 1– 4, our being exceptional T e authors evaluated the degree o improvement 6 months
s
e
r
improvement) in patients’ acial rhytides and reported no a ter the last treatment using the ollowing descriptive cat-
P
r
di erence between the 585 and 595 nm groups or even egories: (1) no improvement; (2) some improvement; (3)
o
c
between the single or double pass groups when comparing substantial improvement; and (4) total improvement.
e
d
photographs be ore treatment and 6 months a ter the last Six months a ter the nal treatment, ve subjects were
u
r
e
treatment. O note, the authors mention that the major- noted to have no improvement. Similarly, no subjects were
s
ity o observed improvement was related to a reduction noted to have total improvement. Some improvement was
in super cial dyspigmentation. T is study appears to sup- observed in 16 subjects, while nine subjects showed sub-
port the use o subpurpuric f uences to achieve improve- stantial improvement. All participants were evaluated or
ment o photodamage, although additional studies may be pigmentary changes, posttreatment blistering, erythema,
needed to con rm these ndings. and scarring. Blistering immediately a ter treatment
occurred in three o the 30 subjects. All 30 subjects had
posttreatment erythema. Six months a ter treatment, no
pigmentary changes, erythema, or scarring were noted. T e
In t en s e Pu Ls ed LIg h t authors concluded that IPL could improve some rhytides
(Figs. 36-12 and 36-13); however, the changes appeared to
IPL, which targets both melanin and hemoglobin, has his- be more subtle than those seen a ter ablative resur acing.14
tologically revealed neocollagenesis a ter treatment o rhy- T e principle behind tightening o the skin with IPL
tides.13 Compared to PDL, use o IPL has not demonstrated rests on the theory that heating collagen bers with

Figure 36-10 Periorbital rhytides be ore treatment with a Figure 36-11 Improvement in rhytides a ter treatment
432 pulsed dye laser. with a pulsed dye laser.
 4

C
Figure 36-13 Improvement in rhytides a ter treatment

h
Figure 36-12 Periorbital rhytides be ore treatment with

a
with an Intense Pulsed Light source.

p
an Intense Pulsed Light source.

t
e
r
3
6
high-intensity light energy leads to their contracture. T is r a d Io f r eq u en c y

:
:
may account or the textural changes described in skin

N
treated with IPL, which has been reported as a second- In order to increase penetration depth so as to stimulate

o
ary observation in several studies.15 Furthermore, thermal

n
collagen contracture and produce skin tightening, RF

a
b
stimulation o dermal broblasts by the higher wave- devices have been developed. T is technology uni ormly

l
a
lengths within the IPL spectrum has been shown to result delivers a volumetric heating e ect into the deep dermis,

t
i
v
in increased synthesis o extracellular matrix proteins, which is potentiated by the tissue’s resistance to current

e
D
leading to at least partial replacement o the lost dermal f ow. Jacobson et al.20 treated 24 patients with redundant

e
r
volume seen due to the intrinsic and extrinsic aging pro- nasolabial olds, marionette lines, and jowls with one

m
a
cess. Speci cally, wavelengths in the 1200 nm spectrum to three RF passes using 106 to 144 J with the T erma-

l
R
are absorbed by water in the dermis, triggering a cyto- cool system (T ermage; Hayward, CA). Seventeen o 24

e
m
kine reaction, which in turn, stimulates the ormation o patients demonstrated visible improvement 1 to 3 months

o
new collagen I, III, and elastin.16 Histological evaluation a ter treatment. For patients who received more than a

d
e
o the e ects o ve subsequent IPL treatments with 570 single treatment, it appeared that subsequent sessions

l
i
n
g
to 645 nm wavelengths showed epidermal thickening o urther improved acial skin laxity. Similarly, patients who
100 to 300 um, new rete ridge ormation, a decrease in received more than one pass with the device appeared to
proportion o degenerated elastic bers, and new der- bene t more than those who were treated with a single
mal collagen ormation.17 In addition to new collagen pass. Patients not only described a sensation o tighten-
ormation, improvement in age-related vascular and pig- ing in the treated areas but also noted visually observable
mented lesions has also been described ollowing IPL, as improvement. Using a three-dimensional imaging system,
these wavelengths target both hemoglobin and melanin, a signi cant decrease in rhytide depth was demonstrated
although this limits its use among patients with higher in two patients. However, subsequent studies ailed to
Fitzpatrick skin types.14,18 demonstrate statistically signi cant improvement.21
Studies comparing the e cacy o PDL to that o IPL o broaden the application o nonablative RF devices,
are limited although both modalities have been used or Ruiz-Esparza treated nine patients with laxity and rhyt-
skin rejuvenation. Kono et al. compared IPL to long- ides o the lower eyelids (Fitzpatrick skin types not noted).
pulsed pulsed dye laser (LPDL) in rejuvenating acial A single treatment using a single pass on two patients, two
skin. en patients with Fitzpatrick skin types III to IV passes in ve patients, and three passes in two patients was
were enrolled; hal o each patient’s ace was treated with per ormed and these patients were ollowed-up or 1 year.
IPL (six treatment sessions) and the other hal with LPDL T e authors noted improvement, with marked eyelid skin
or three treatment sessions. T e LPDL was used to treat contraction and correspondingly high patient satis action.
acial rhytides with f uences between 10 and 12 J/cm 2 and T e author speci cally treated anchoring points, or areas
a pulse duration o 20 ms, using a pulse stacking tech- distal to the target area, to prevent complications includ-
nique. T e parameters or use o IPL or wrinkles included ing scarring, ectropion, and pigmentary changes seen with
f uences between 27 and 40 J/cm 2 and a pulse duration ablative laser resur acing, blepharoplasty, or even chemi-
o 20 ms. Overall, the investigators ound no signi cant cal peels. T e author there ore recommended use o RF
di erence between IPL and LPDL in wrinkle reduction devices to noninvasively contract the lax skin o the orehead
although the degree o improvement ranged rom 26% to produce an eyebrow li t, as well as tightening the skin on
to 100% with both modalities. No scarring or pigmen- the cheeks, neck, and other areas to produce visible li ting.22
tary changes were seen with either device. T e authors Overall, the patients enrolled in these studies did not expe-
pointed out that LPDL was signi cantly more e ective rience any downtime or complications,23 urther supporting
than IPL in treating lentigines.19 T us, both modali- the application o RF technology to acial rhytides.
ties demonstrate promise in treating photodamaged Continued improvement in RF devices has led to a
acial skin. novel electrosurgical technology that uses substantially 433
4 lower energy. T is resur acing device uses a bipolar
multielectrode-tipped stylet and an electrically conduc-
re-epithelialization.30 Histological studies demonstrated
ull epidermal healing occurring within the rst 24 hours
tive medium, usually isotonic sodium chloride solution.24 a ter the procedure.30 T is rapid barrier restoration low-
Multielectrode RF resur acing is a low-heat process com- ered the risk o in ection, erythema, changes in pigmen-
pared with traditional electrosurgery; hence, the term tation, and other complications requently associated with
coblation (cold + ablation) has been coined. Using a con- ablative resur acing procedures.29 Although results were
ductive medium, the device applies low-energy RF, which ar superior to those seen with non ractionated nonabla-
causes a vapor layer o ionized particles, or plasma eld, tive technologies, multiple treatments, typically in the
to orm around the electrodes.24 T ese ionized particles range o ve to seven, were needed.
possess su cient energy to dissociate organic molecular T e e cacy o ractional nonablative photothermolysis
bonds within the tissue. Investigations using this device in the treatment o photodamaged acial skin was rst
on ex vivo human skin demonstrated no apparent epider- demonstrated in 2005.31 In this study 12 subjects with
mal ablation, but an increasing amount o residual thermal acial rhytides were treated with a rst generation laser
damage with increased pass number.25 A ter three passes using f uences o 6 to 20 J at 1 to 4 week intervals with den-
at 86, 108, and 139 V, the mean thickness o the layer o sities o 2000 to 3000 M Z/cm 2. Each participant received
S
e
thermal damage was 97, 80, and 80 µm, respectively.25 T e an average o our to ve treatments and was assessed or
c
t
i
similarity o this pattern o tissue damage to that associ- improvement in texture, dyschromia, and wrinkles on the
o
n
ated with short-pulsed CO 2 laser resur acing indicated ace, neck, and the chest. Signi cant improvement was
4
that this RF device should be e ective in cutaneous resur- seen in all clinical parameters, and was supported by his-
:
:
acing, with rapid postoperative wound healing. tological evidence o new collagen ormation. Side e ects
o apply this innovation to the treatment o rhytides, were minimal and limited to posttreatment erythema and
A
e
Grekin et al. prospectively enrolled 95 patients (Fitzpat- mild edema that resolved within a ew days.
s
t
h
rick skin types I to III) with periorbital (75 treatment sites) In a subsequent study, the long-term e cacy o ractional
e
t
and perioral (50 sites) photodamage. T e participants were nonablative photothermolysis in treating both acial and
i
c
a
treated with two to three passes at 125 or 139 V. Wrinkle non acial photodamage, rhytides, and dyspigmentation was
n
d
and cosmetic improvement were evaluated by an indepen- demonstrated.32 Fi ty patients (Fitzpatrick skin types I–III)
L
a
dent panel o ve evaluators. All evaluators discerned a underwent a series o three consecutive treatments (2000
s
e
positive mean improvement in wrinkling, both in perior- M Z/cm 2 at 8 mJ or acial areas; 1500–2000 M Z/cm 2 at
r
P
bital and perioral anatomic sites, using photographs taken 8 mJ or non acial areas, Fraxel 750 SR) spaced 3 to 4 weeks
r
o
at baseline and 6 months a ter treatment, with greater apart. wo blinded physicians assessed clinical improve-
c
e
d
improvement seen in patients with more severe wrinkling ment with a three-point quartile grading scale. T e investi-
u
r
at baseline. An increased number o passes and higher volt- gators reported a mean improvement o 2.23, 2.10, and 1.96
e
s
age settings had a positive impact on wrinkle improvement. at 3, 6, and 9 months a ter treatment, respectively. Simi-
ransient postinf ammatory hyperpigmentation occurred lar results were observed or non acial areas, with a mean
in 26% o periorbital and 4% o perioral sites. Hypertrophic improvement o 1.85, 1.81, and 1.70 at 3, 6, and 9 months
scarring occurred in 3.8% o treatment sites, with all but a ter treatment, respectively. An overall improvement o
one scar resolving by 6 months. Overall, healing was rapid, 51% to 75% was ound in 73% ( acial arm) and 55% (non-
pain was minimal, and erythema largely resolved within acial arm) o patients 9 months a ter treatment. Adverse
2 months. T e authors concluded that treatment with the e ects were limited and short-lived. T e authors concluded
bipolar RF device led to less severe postoperative morbid- that FP was a sa e and e ective treatment or acial and non-
ity than usually occurs with ablative approaches.26 acial photodamage, rhytides, and dyspigmentation with a
avorable recovery and side-e ect pro le.
Investigations comparing ractional ablative versus
f r a c t Io n a L Ph o t o t h er mo Lys Is ractional nonablative laser systems have been per ormed
retrospectively.33 Alajlan et al. reviewed patients with
In 2003 the innovative concept o ractional photother- acne scars and Fitzpatrick skin types III to V. A total o 82
molysis (FP) was reported 27 and was ollowed in 2004 with patients were recruited or the study, 45 o whom received
development o an original prototype FP device.28 With an average o ve sessions with the nonablative ractional
this modality, small columns o thermal injury known as laser (1550 nm) and 37 patients treated on average two
“microthermal zones” (M Zs) were produced by light times with the ablative ractional CO 2 laser. T e average
energy delivered in a pixilated ashion to the skin. T is f uence, density, and time a ter treatment or the nonab-
ractional emission o light di ered rom traditional abla- lative and ablative groups were 2.87 kJ and 125 mJ/cm 2,
tive resur acing, in which a uni orm patch o epidermal 17% and 30%, and 1 month and 2 months, respectively.
and dermal injury was delivered using a f at, non raction- T e authors noted that both treatment modalities were
ated beam. With these initial prototype devices, the deep e ective in treating acne scars in ethnic skin with good
epidermis and dermis became necrotic in the individual patient satis action rates and a high sa ety pro le. One o
M Zs, without being vaporized, and the stratum corneum the side e ects reported was postinf ammatory hyperpig-
remained histologically intact. Resur acing with these ini- mentation; the severity and rate o occurrence decreased
tial ractional devices was termed “nonablative” and could a ter initiating use o a topical bleaching ormulation with
be delivered using wavelengths only moderately absorbed hydroquinone 4% to 6% in combination with retinoic
by water (1410 nm, 1440 nm, 1540 nm, 1550 nm).29 Because acid, glycolic acid, or Kojic acid or 6 to 8 weeks, begin-
FP produces microscopic zones o thermal injury, the sur- ning 1 week a ter treatment with the laser. One interest-
434 rounding islands o normal tissue serve as a reservoir or ing nding mentioned in the study was improvement in
pore size a ter treatment with the nonablative ractional
laser. T e investigators concluded that there was signi -
manner using an array o multielectrode pins. Hruza
et al.34 delivered ractional RF treatment using di erent tips
4
cantly less downtime in patients treated with the nonab- at varying energies and coverage rates to the abdomen in
lative ractional laser and that patient satis action was individuals scheduled or abdominoplasty. Another group
comparable or the two approaches (71% or nonablative o subjects received three acial treatments scheduled at
ractional laser and 65% or ablative CO 2 ractional laser). 3 to 4 week intervals. Histological ndings immediately
Although the analysis suggested comparability o the two a ter treatment revealed well-demarcated zones o abla-
systems, the authors acknowledged that prospective tri- tion, coagulation, necrosis, and subnecrosis up to a depth
als are needed to more rigorously evaluate the di erences o 450 µm. Higher energy levels generated deeper tissue
in e cacy between the ablative and nonablative ractional e ects. Subjects undergoing acial treatment had minimal
lasers. In addition, it was noted that patients with more pain and no permanent side e ects or signi cant down-
severe cases o acne scarring were chosen or treatment time. Investigators’ assessments o improvement in acial
with the ablative CO 2 ractional laser.33 skin texture correlated with subjects’ evaluations and were
In 2009, Hruza et al.34 introduced the ractional RF greater than 40% in approximately hal o subjects. Eighty
device, the rst nonlaser, nonlight based device capable o percent o the subjects were satis ed with the results.

C
h
inducing ractional skin ablation, coagulation, and necro- Man and Goldberg aimed to evaluate the sa ety and e -

a
p
sis or skin rejuvenation. Brightman applied the term cacy o bipolar ractionated RF devices in improving skin

t
e
r
“sublative rejuvenation” to this technology, as it produces texture, ne lines, and wrinkles in patients with Fitzpat-

3
6
limited epidermal disruption with coagulative e ects con- rick skin types V and VI. Fi teen subjects each received
centrated in the mid to deep dermis. Compared to lasers, three treatments to the ull ace with a ractionated bipo-

:
:
RF energy produces higher volumetric heating through lar RF device (Syneron Inc., Irvine, USA) 30 days apart.

N
tissue impedance, which allows the di usion o heat to Patients were evaluated by the study investigator and a

o
n
deeper tissues.35 T is technology holds the greatest prom- blinded investigator at each treatment and 90 days a ter

a
b
ise or the ractional resur acing o patients with darker the last treatment or treatment sa ety and e cacy. T e

l
a
skin types.36 Since the epidermis is mostly spared, rac- authors reported a statistically signi cant improvement in

t
i
v
e
tional RF lowers the risk o scarring and postinf ammatory wrinkles, texture, and ne lines in most subjects. Adverse

D
hyperpigmentation in susceptible patients. events, speci cally postinf ammatory hyperpigmenta-

e
r
A recently introduced ractional RF device is the Matrix tion and hypopigmentation, were not seen in any o the

m
a
RF (Syneron Medical Ltd.). Matrix RF is the rst bipolar RF- patients, suggesting that the use o ractionated RF devices

l
R
based aesthetic device capable o delivering ablative tun- is a sa e and e ective method o skin rejuvenation or skin

e
m
able RF energy to the skin in a nonhomogeneous ractional types V and VI (Figs. 36-14 and 36-15).37

o
d
e
l
i
n
g
Figure 36-15 Improvement in f ne lines a ter treatment
Figure 36-14 Be ore treatment o f ne lines with a with ractionated bipolar radio requency device-–note
ractionated bipolar radio requency device. lack o pigmentary changes a ter treatment. 435
4 Nonablative approaches, including nonablative rac-
tionated systems, represent the newest approach to
13. Goldberg DJ. New collagen ormation a ter dermal remodel-
ing with an intense pulsed light source. J Cut La s T er. 2000;
2(2):59– 61.
improving photodamaged skin. T e degree o collagen
14. Goldberg DJ. Histologic changes a ter treatment with an
remodeling and the decrease in epidermal pigmentary intense pulsed light. J Cut La s T er. 2000;2:53– 56.
changes are not expected to be as great as those caused 15. Weiss RA, Weiss MA, Beasley KL. Rejuvenation o photo-
by other more destructive, ablative approaches or speci c aged skin: 5 years results with intense pulsed light o the ace,
pigmented lesion lasers. However, with the advent o rac- neck and chest. Dermatol Surg. 2002;28(12):1115– 1119.
16. Wong WR, Shyu WL, sai JW, Hsu KH, Pang JH. Intense
tionated nonablative laser systems, dermal remodeling
pulsed light e ects on the expression o extracellular matrix
comparable to that achieved using ablative lasers has been proteins and trans orming growth actor beta-1 in skin der-
achieved a ter multiple treatments. In addition, the advan- mal broblasts cultured within contracted collagen lattices.
tages o nonablative therapies over ablative laser resur ac- Dermatol Surg. 2009;35(5):816– 825
ing are numerous. Patients do not develop open wounds, 17. Hernandez-Perez E, Ibiett EV. Gross and microscopic nd-
ings in patients submitted to nonablative ull- ace resur ac-
which reduces their risks o in ection, dyspigmentation,
ing using intense pulsed light: a preliminary study. Dermatol
and scarring in addition to minimizing downtime.38 One Surg. 2002;28(8):651– 655.
o the other signi cant advances in nonablative FP is the
S
18. Bitter PJ. Noninvasive rejuvenation o photoaged skin using
e
ability to treat non acial areas, including the neck, chest, serial, ull- ace intense pulsed light treatments. Dermatol
c
t
i
back, and extremities, which are prone to developing Surg. 2000;26:835– 843.
o
n
19. Kono , Gro WF, Sakurai H, et al. Comparison study o
hypertrophic scarring i treated with traditional abla-
4
intense pulsed light versus a long-pulse pulsed dye laser in
tive or even ractionated ablative resur acing.39– 41 With the treatment o acial skin rejuvenation. Ann Pla st Surg.
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:
continued experience using ractionated RF technology, 2007;59(5):479– 483.
it is possible that the risk o treating patients with darker 20. Jacobson LG, Alexiades-Armenakas MR, Bernstein L,
A
e
skin types or ear o postprocedure pigmentary changes Geronemus RG. reatment o nasolabial olds and jowls
s
t
with a non-invasive radio requency device. Arch Dermatol.
h
may diminish signi cantly.36,37 In the uture, standardized
e
2003;139:1313–1320.
t
treatment regimens controlling or di erences in density
i
c
21. Hsu S, Kaminer MS. T e use o nonablative radio requency
a
and spot size could revolutionize the eld o laser therapy technology to tighten the lower ace and neck. Semin Cutan
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d
or the treatment o super cial photodamage as well as Med Surg. 2003;22:115– 123.
L
22. Ruiz-Esparza J, Gomez JB. Non-ablative radio requency tis-
a
deeper wrinkling in patients encompassing the ull range
s
sue tightening o acial skin: the medical ace li t: a report o
e
o Fitzpatrick skin types.
r
25 patients. La sers Surg Med Suppl. 2003;15:36.
P
r
23. Ruiz-Esparza J. Noninvasive lower eyelid blepharoplasty: a
o
c
new technique using nonablative radio requency on perior-
r ef er en c es
e
d
bital skin. Dermatol Surg. 2004;30(2 Pt 1):125– 129.
u
24. Olho er IH, Le ell DJ. What’s new in electrosurgery? Cobla-
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e
1. Hardaway CA, Ross EV, Barnette DJ, Paithankar DY. Non- tion: a new method or acial resur acing. Aesthet Dermatol
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ablative cutaneous remodeling with a 1.45 micron mid-in rared Cosmet Surg. 1999; 1:31–33.
diode laser: phase I. J Cosmet La ser T er. 2002;4:3– 8. 25. ope WD. Multi-electrode radio requency resur acing o ex
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evaluation o skin remodeling by using an Er:glass laser with 26. Grekin RC, ope WD, Yarborough JM Jr, et al. Electrosurgical
contact cooling. La ser Surg Med. 2000;27:1– 9. acial resur acing: a prospective multicenter study o e cacy
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switched Nd:YAG laser. Dermatol Surg. 1997;23:903– 907. 27. Huzaira M, Anderson RR, Sink K, Manstein D. Intradermal
4. Goldberg DJ, Metzler C. Skin resur acing utilizing a low f u- ocusing o near-in rared optical pulses: a new approach or
ence Nd:YAG laser cut laser ther. 1999;1:23–27. non-ablative laser therapy. Lasers Surg Med. 2003; 32(Suppl 15):
5. Nelson JS, Millner E, Dave D, et al. Clinical Study o non 17– 38.
ablative laser treatment o acial rhytides. La sers Surg Med. 28. Manstein D, Herron GS, Sink RK, anner H, Anderson RR.
1998;17(suppl 9):150. Fractional photothermolysis: a new concept or cutaneous
6. Sadick NS, Makino Y. Selective electro-thermolysis in aes- remodeling using microscopic patterns o thermal injury.
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7. anzi EL, Alster S. Comparison o a 1450-nm diode laser 29. Bogdan Allemann I, Kau man J. Fractional photothermolysis–
and a 1320-nm Nd:YAG laser in the treatment o atrophic an update. La sers Med Sci. 2010;25(1):137– 144.
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matol Surg. 2004;30(2 Pt 1):152– 157. responses to ractional photothermolysis. La sers Surg Med.
8. Dahan S, Lagarde JM, urlier V, Courrech L, Mordon S. 2006;38:142– 149.
reatment o neck lines and orehead rhytids with a nonab- 31. Rokhsar CK, Fitzpatrick RE. T e treatment o photodamage
lative 1540-nm Er:glass laser: a controlled clinical study and acial rhytides with ractional photothermolysis. La sers
combined with the measurement o the thickness and the in Surgery and Medicine. 2005;Suppl 17:32.
mechanical properties o the skin. Dermatol Surg. 2004;30: 32. Wanner M, anzi EL, Alster S. Fractional photothermoly-
872– 879. sis: treatment o acial and non acial cutaneous photodam-
9. Badawi A, ome MA, Atteya A, Sami N, Morsy IA. Retro- age with a 1550-nm erbium-doped ber laser. Dermatol Surg.
spective analysis o non ablative scar treatment in dark skin 2007;33(1):23– 28.
types using the sub millisecond Nd:YAG 1064 nm laser. 33. Alajlan A, Alsuwaidan S. Acne scars in ethnic skin treated
La sers Surg Med. 2011;43:130– 136. with both non-ablative ractional 1550 nm and ablative
10. Zelickson BD, Kilmer SL, Bernstein E, et.al. Pulsed dye laser ractional CO 2 lasers: comparative retrospective analysis with
or sun damaged skin. La sers Surg Med. 1999;25:229– 236. recommended guidelines. La sers Surg Med. 2001;43:787– 791.
11. anghetti EA, Sherr EA, Alvarado SL. Multipass treatment 34. Hruza G, aub AF, Collier SL, Mulholland SR. Skin rejuvena-
o photodamage using the pulse dye laser. Dermatol Surg. tion and wrinkle reduction using a ractional radio requency
2003;29(7):686–690; discussion 690– 691. system. J Drugs Dermatol. 2009;8(3):259– 265.
12. Bjerring P, Clement M, Heickendor L, Egevist H, Kiernan 35. Brightman L, Goldman MP, aub AF. Sublative rejuvenation:
M. Selective non-ablative wrinkle reduction by laser. J Cutan experience with a new ractional radio requency system or skin
La ser T er. 2000;2(1):9– 15. rejuvenation and repair. J Drugs Dermatol. 2009;8(11 Suppl):s9–13.
436
36. aub AF, Garretson CB. reatment o acne scars o skin
types II to V by sublative ractional bipolar radio requency
39. Ciocon DH, Rokhsar CK. Fractional resur acing o di -
cult to treat anatomical locations. In: Mckenna J, Clements
4
and bipolar radio requency combined with diode laser. J Clin S, eds. US Dermatology Review. London: ouch Brie ngs;
Aesthet Dermatol. 2011;4(10):18– 27. 2007.
37. Man J, Goldberg DJ. Sa ety and e cacy o ractional bipolar 40. Avram MM, ope WD, Yu , Szachowicz E, Nelson JS.
radio requency treatment in Fitzpatrick skin types V-VI. Hypertrophic scarring o the neck ollowing ablative rac-
J Cosmet La ser T er. 2012;14(4):179– 83. tional carbon dioxide laser resur acing. La sers Surg Med.
38. Ciocon DH, Rokhsar CK. “Laser treatment o pigmentation 2009;41(3):185– 188.
associated with photoaging”. In: Carniol PJ, Sadick NS, eds. 41. Fi e D, Fitzpatrick RE, Zachary CB. Complications o rac-
Clinical Procedures in La ser Skin Rejuvenation. Boca Raton, tional CO 2 laser resur acing: our cases. La sers Surg Med.
FL: In orma Press; 2007. 2009;41:179– 184.

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 Ch a p t e r

37 Fillers
Jason Emer & Heidi A. Wa dor

In t r o d u c t Io n sel injury with resultant complications. Most short-term

adverse e ects, such as pain, erythema, edema, and ecchy-
mosis, are considered to be expected injection-related com-
Much has been written about selection o lling agents
plications and are more rom the injection technique rather
and anatomic considerations or so t-tissue augmentation.
than the ller itsel .1,2 Although there are reports o serious
An increased understanding o the volumetric changes
complications such as skin necrosis, blindness, or stroke,
that occur with aging and their e ect on our perception
complications o so t-tissue lling generally can be avoided
o beauty has changed the way we use llers over the last
with proper technique and patient and material selection.3–5
decade. Rather than lling individual wrinkles, modern
Blunt-tipped cannulas have a long-standing history
so t-tissue augmentation ocuses on replenishing lost at
o use in the injection o autologous at ( at trans er)
pads, providing increased structural support and volume,
or volume restoration and have only become popular
and constructing acial contours. Injections may be done
or dermal llers over the past ew years ollowing their
by bolus to li t or by anning along vectors. In recent years,
introduction in Europe.6,7 T e large size and exibility o
the availability o new tools has introduced still more pos-
these cannulas makes them suitable or use with dermal
sibilities or variation in the injection procedure. Although
llers in the subcutaneous and supraperiosteal planes,
manu acturers may claim improved cosmetic results and
although smaller sizes (larger gauges) are available and
ewer complications, is it the product being injected, the tool
may be use ul or intradermal injections, which require
used to inject, the injection technique, the injector or a com-
greater precision in their placement.8,9 T e proposed
bination that is responsible? Herein, we describe injection
bene ts, as compared to sharp needle injection, include
techniques with and without the use o blunt-tipped micro-
the reduction in postinjection bleeding and ecchymo-
cannulas or acial contouring, and we outline when and
sis (atraumatic injection), a decrease in the number o
where their use can provide a less traumatic, reliable, and
injection entry points, decreased risk o inadvertent
versatile technical option or the treatment o acial aging.
intravascular injection, and less patient discom ort dur-
ing injection ( able 37-1).10 Additively, this equates to
a reduced risk o adverse events. Other potential ben-
o v er v Iew e ts include the increased ability or large volume or
pan acial volume restoration rom a single entry point,
Blunt-tipped microcannulas are sterile, disposable (single increased precision and sa ety in higher risk areas (i.e.,
use) surgical steel injection tips available in a range o gauges glabella, nasal dorsum, temple, orbital rim, and neck),
and lengths (Fig. 37-1). T ey may be used in places or situa- and better control o product placement in a single level
tions in which there is a signi cant risk o the cutting bevels plane. T is limits downtime and increases patient satis-
o the hypodermic needle causing tissue trauma and ves- action. Studies also suggest the potential or collagenesis

Figure 37-1 Microcannu a examp es. There are many types o microcannu as,
ut a have unt ends and dista port sites in common (see insets). This company
(DermaScu pt, CosmoFrance, Inc.) ma es hu s o various co ors to corre ate with the
microcannu a au e. Various en ths are avai a e, ut the most common y used in
dermato o y ran e rom 1 to 2.75 in.
 Ta bl e 37-1
Furthermore, a recent double-blind, randomized, con-
trolled clinical trial comparing the use o a proprietary
4
a v g di v g f 21 gauge, 30 mm metallic blunt-tipped cannula to a
Mi V s pn standard sharp needle (30 gauge, 13 mm) or nasolabial
old augmentation (n = 25) reported ewer side ef ects,
a v g di v g such as pain, edema, redness, and hematoma, with the
Needle Quick Sh rp new tool as compared to the standard needle.17 On evalu-
ation 3 days a ter injection, there was a bilateral decrease
Supp i d with Incr s d punctur sit s
in the Modi ed Fitzpatrick Wrinkle Scale (MFWS) indi-
product Risk o n urov scu r cating clinical improvement in both o the nasolabial
In xp nsiv injury in d ng r zon s olds.
Incr s d risk o Most recently, a study o 96 patients aged 30 to
ruising nd sw ing 76 years old desiring either acial, décolleté, or hand aug-
Microcannula b unt tipp d Tim consuming mentation were treated with an HA ller (Restylane or
Incr s d s ty R quir s sh rp n d Perlane; Juvederm, Allergan, Irvine, CA; Hydrelle, Ankia
in n urov scu r or initi punctur T erapeutics, Inc., Bed ord, MA) either with a microcan-
d ng r zon s ( ntry sit ) nula (DermaSculpt, CosmoFrance, Inc., Miami Beach, FL;
18, 22, 25, 27, or 30 gauge; 25, 38, 50, 70 mm) with a blunt-
F w r punctur Dif cu t to us in thick/
sit s s c ous skin or in tip and side port or hypodermic sharp needle (27 gauge,

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r s o pr vious tr um , 0.5 or 1.5 in). Overall clinical improvement was equivalent

p
surg ry, or sc rring with both implantation devices but pain, bruising, and

t
ecchymosis were reduced with the use o the blunt-tipped

r
D cr s d risk Mor xp nsiv

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microcannulas, leading to aster recovery times in these

7
o ruising nd
sw ing patients.18

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It should also be noted that while the approval o blunt-
Su cision ct R quir s incr s d
tipped microcannulas enables them to be used or uid

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m y promot t chnic ski or us

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n oco g n sis injection or aspiration, use with so t-tissue llers is con-

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sidered of -label by the United States Food and Drug
Administration (USFDA). T is caveat should be noted to
rom multiple back-and- orth subdermal passes o the the patient and included in the in ormed consent prior to
microcannula ( anning injection technique), even without injection. Each ller product is speci cally approved or
the addition o llers, via the mechanical stimulation o use with the sharp needle(s) that are packaged with it.
broblasts. 11,12 Increased treatment times (depending on Four brands o blunt-tipped microcannulas are currently
experience level) and added cost/procedural steps may approved by the USFDA as 510(k) Hypodermic Single
hinder naive injectors. Some ear overstatement o the Lumen Needle devices: DermaSculpt, SK (distributed
sa ety pro le o these cannulas and report that smaller by Merz Aesthetics, Inc., San Mateo, CA), Magic Needle
gauge (30 gauge) blunt-tipped cannulas, especially i (Needle Concept, France), and So tFil (So tFil-USA, Kery-
in exible, can puncture vessels, nerves, and the orbital los Corporation, Los Angeles, CA).
septum.13 Large-bore blunt cannulas have been reported
to cause middle cerebral artery in arction and vision loss,
at least in the at trans er literature, more so with high- In j ec t Io n Pa t t er n a n d
pressure bolus injections.14,15 Nonetheless, choosing the
smallest bore exible cannula (pre erably 22 gauge or
In j ec t Io n t ec h n Iq u es
larger), using constant movement (avoiding static injec-
tions), avoiding high injection pressures by depositing Gen er a l a PPr o a c h es
small aliquots o product, injecting into multiple planes
so as to avoid wide tunnels, evenly distributing product Appropriate injection technique can help ensure suc-
and preventing pooling, as well as understanding surgical cess ul outcome and limit the risk o contour irregu-
anatomy, can promote good aesthetic outcomes. larities or excessively super icial placement with
A study o 26 patients injected with a hyaluronic acid subsequent patient dissatis action. Serious compli-
ller (HA; Restylane, Q-Med, Sweden) using rein orced, cations rom administration are rare, but can occur,
rigid microcannulas (Pix’L, Esthetique, Ltd., Limassol, including vascular occlusion or embolism with result-
Cyprus) into the periorbital and eyebrow region demon- ing skin necrosis, blindness, or stroke. Many injection
strated high rates o patient satis action (85% reported sat- patterns are recognized such as anning, serial punc-
is ed or very satis ed) with ewer complications, including ture, cross-hatching, and linear threading; the choice o
irregularities, in ammatory reactions, and ecchymosis pattern is based on the location to be injected and the
(three cases o bruising, our cases o lymphatic stasis) as product utilized (Fig. 37-2).19
compared to published results.16 Patients were evaluated Recently, two novel techniques have been de ned that
immediately a ter injection, 10 to 25 days a terward, and of er alternative means o delivering the product.20,21
3 months post treatment. It was noted that product was T e tower technique involves injecting ller in a vertical
evenly distributed throughout the treatment areas and manner (at a 90 degree angle to the base o the injection
produced excellent aesthetic improvement with a low rate site) and while withdrawing the syringe, small deposits o
o hematoma or posttreatment edema. ller are placed between the tissue planes to help build 439
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Figure 37-2 Injection technique with sharp need e. be ore (left) and a ter (right) 3.0 cc o ca cium hydrox-
y apatite (Radiesse) mixed with 0.3 cc o 2% idocaine with 1:100,000 epinephrine to the mid ace (cross-
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hatchin and supraperiostea depot) as we as the marionette and mandi u ar an e (supraperiostea
A
depot and annin ). 0.8 cc o a hya uronic acid e er (Juvederm U tra) mixed with 0.1 cc o 2% idocaine
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with 1:100,000 epinephrine was used ( inear threadin ) on the ower cutaneous ip/chin or contourin
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and i tin . Notice, the naso a ia o d itse was not treated, ut a c ear improvement is noted.
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“towers” or “columns” in the tissue. T is limits lateraliza- Unlike needles, cannulas have blunt-tips/ends and ex-
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tion o ller and helps or li ting (vertical extension) as ible or rigid bodies that o er increased sa ety by decreas-
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it provides sel -support. T is technique has been recom- ing the chance or trauma to the surrounding so t tissue,
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mended in areas where no base is present, such as the nerves, or vessels. T is correlates with less pain, bruising,
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nasolabial olds, marionette lines, the upper and lower lip, and swelling post procedure. Decreased risk o ecchymo-
d
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and cheeks. T e vertical supraperiosteal depot technique sis is a major advantage especially in areas such as the
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uses a single, small depot o so t-tissue ller material nasojugal old, upper eyelid, prejowl sulcus, and perioral
placed on the bone or periosteum. T e orbital rim, zygo- regions in which bruising is commonplace (Fig. 37-3).
matic bone, mandible, bridge o the nose, and the entire Injectors may be able to per orm the an-like injection
orehead can utilize this technique. Finally, the “ ern” or technique without the increased risk o side e ects rom
“bridging” technique involves a combination o linear anning with hypodermic needles. T e degree o exibility
threading and serial puncture. T e needle is inserted per- (vs. rigidity) o the microcannulas can impact their clinical
pendicular to the old and advanced a ew millimeters behavior. Longer (38 mm or more) and smaller gauge (27
away rom the old. T is procedure is repeated along the or more) microcannulas tend to be more exible, while
extent o the old in multiple passes alternating between shorter (25 mm or less) and larger gauge (23 or less) are
the le t and right sides o the old. A sca old o material more rigid. Physical characteristics can a ect clinical out-
li ts and supports the wrinkle. T e “ ern” technique is come, and will in uence the passage o ller through tis-
particularly bene cial along the length o the nasolabial sue as well as injection patterns.
old or marionette lines.
T e proper use o these patterns can help the injec-
tor more uni ormly treat the desired areas with ewer a t l a s Gu Id e t o In j ec t Io n w It h
side e ects. Glogau et al. ound in a prospective, blinded, MIc r o c a n n u l a
controlled study o 283 patients randomized to mid ace
volume correction o the nasolabial olds and oral com- T e approach to using cannulas is to properly clean the
missures with HA lling agents (Restylane or Perlane) that skin with alcohol and/or chlorhexidine, evaluate the skin
local adverse events ollowing injection were related to areas to be treated, and decide on an entry point (Fig.
investigator technique and not to di erences in the intrin- 37-4A,B). Cannula injection is not completely atrau-
sic properties o the ller or needle size.22 T e elements matic, and the initial entry point requires anesthesia
ound to be associated with an increased risk o adverse and puncture with a needle larger than the cannula (typi-
events included injection techniques that increased the cally 21 or 23 gauge) to penetrate the skin just beyond the
likelihood o dissection in the subepidermal plane such as bevel be ore cannula insertion (Fig. 37-4C,D). I bruising
an-like projection, rapid injection, rapid ow rates, and does occur during the use o microcannulas, it is typi-
higher volumes. Interestingly, injection techniques that cally at the insertion site o the pilot needle or in areas o
increased epidermal damage or subcutaneous contact increased tissue resistance (i.e., dense beard area, brosis
such as serial puncture or deep depot injections had no rom previous surgery, or acne scarring) or ragile ves-
e ect on adverse events. T us, proper technique is essen- sels. A recent consensus statement reported the use o a
440 tial to success ul outcomes. 23 gauge sharp needle or 25 gauge microcannula and a
 4

Figure 37-3 Ecchymosis o the tear trou h (left) and ips (right) a ter injection o hya uronic acid e er
(Juvederm U tra) usin sharp need e (31 au e) injection. O note, oth patients were ta in aspirin.

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Figure 37-4 A, B. Usin the mid ace (chee /tear trou h) as an examp e, a mu titude o entry points can e used or microcan-
nu a insertion. Recontourin and vo umization can e achieved rom any o these sites. Optima entry sites (black arrows) a ow
or a ar e area o treatment. A ternative sites (red arrows) a ow or customized contourin and vo umizin with the a i ity to treat
near y areas such as the temp e or eye row or mid ace entry sites and naso a ia o ds, cutaneous ip, and marionette ines/
prejow or upper cutaneous ip/ ip corner entry sites. C. Anesthetic (2% idocaine with 1:100,000 epinephrine) is injected intrader-
ma y into the area chosen as an entry site. D. Sharp need e (23 au e) is punctured throu h the upper s in into the su cutaneous
tissue to create a porta o entry or the microcannu a. Care shou d e ta en to imit super cia vesse injury and o tain the correct
p ane or insertion. (continued ) 441
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Figure 37-4 (Continued ) E. The cannu a is inserted into the su cutaneous ayer (left) and mu tip e, ret-
ro rade inear threads are injected at vectors chosen to revo umize and recontour (right) the mid ace.
Note one entry point a ows or quic treatment o a ar e cosmetic area, with itt e, i any, pain. F. Pinch-
in o the s in ensures proper p acement o the microcannu a in the correct p ane, he ps imit the ris o
neurovascu ar injury, and a ows or easier p acement o er whi e threadin in vectors. It is important
to retract the microcannu a and redirect when switchin vectors so an appropriate new tunne can e
created without over appin er p anes.

26 gauge sharp needle or 27 gauge microcannula entry.10 37-4F). T e cannulas have a Luer-Lock tip and plastic hub
As the pilot needle is close in size to the microcannula, to accommodate the most commonly used ller syringes
some injectors pre er to “pinch” the skin around the nee- rom various companies (Fig. 37-1).
dle with the noninjecting/nondominant hand and have A major advantage o microcannulas is that with a
an assistant pull out the needle while their ocus stays on single or double puncture site an entire lip, nasolabial
the puncture site. T e authors nd that the use o a larger old, cheek, orehead, hand, mandible, or décolleté can
gauge pilot needle (21 or 23 gauge or 25 or 27 gauge be injected. A disadvantage is that anesthesia is typi-
microcannula entry) and using lidocaine with epineph- cally required at the desired insertion sites ( able 37-1).
rine to anesthetize and blanch the entry site so as to more Some have reported the use o topical anesthesia with a
easily see the resultant opening, allows the injector to lidocaine-based mixture locally or with a polyvinyl gel
remove the pilot needle without the help o an assistant, composed o tetracaine 5% and lidocaine 5% (Anesthetic
thereby reducing the risk o needle stick. I it is dif cult Peel-O Mask, compounded by ApothéCure, Dallas, X)
to locate the entry site a ter the initial puncture, rubbing over an entire area. Some time (about 30– 60 minutes)
o the area with the sterile, gloved ngers can produce later the cream/mask is removed and the area is cleansed,
slight bleeding. T e blunt-tipped, exible microcannula leaving it ready or injection. Injectable lidocaine with or
is then maneuvered through the newly created entrance without epinephrine (~0.05– 0.1 cc/site) can be injected
and positioned into the planned area o volume enhance- over the anticipated area or quicker treatment times.
ment (Fig. 37-4E). Li ting the skin to guide the cannula Niamtu reported the use o intraoral injections o lido-
442 through the plane and direction desired is help ul (Fig. caine with epinephrine or augmentation o the lips, peri-
ora , and naso abia o d areas.23 Nerve b ocks can be used
in an anxious patient or those with a ow pain to erance,
can be very e ective. Cross-hatching works by creating a
series o inear threads even y spaced in a progressive grid,
4
but are ike y unnecessary and can distort the anatomica simi ar to a sca o d that works to ensure a arge space is
site prior to injection, eading to unwanted c inica resu ts supported and ed. Severa eve s may be needed to he p
such as improper product p acement or overtreatment. and i t the area o treatment, especia y in the mid ace
T e authors have ound that uti izing injectab e anes- where there is no osseous backing o acia support. Fan-
thetic or the insertion site and ing agents containing ning is simi ar to inear threading except that the need e
or mixed with anesthetic e iminates the need or addi- is not comp ete y withdrawn and is advanced in a di er-
tiona topica or injectab e anesthetic. ent ocation (c ockwise or counterc ockwise) a owing or
the same injection site to be used to a particu ar area.
T is imits the number o skin punctures needed and may
Pea r l s o f In j ec t Io n t ec h n Iq u es decrease the risk o sur ace bruising and swe ing.24,25 How-
ever, the process o anning the need e horizonta y through
T e naso abia o ds, g abe a, phi tra co umns, ne peri- the skin increases the chance o encountering sma vesse s
ora and periocu ar rhytides, ips, orehead ines, and and, there ore, carries a risk o deeper bruising i using a
ora commissures do we with seria puncture or inear hypodermic sharp need e, and a ower risk i using b unt-
threading techniques. With seria puncture, mu tip e tipped microcannu as. A ternative y, use o the depot
sma depot injections are made a ong a wrink e or crease, method, where arger vo umes o ow viscosity product are
which a ows or accurate materia p acement. T e skin o injected and then massaged or mo ded to acia contours,

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the treatment area must be he d taut between the thumb

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imits both sur ace and deeper need e movement. Micro-

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and ore nger as the need e tip is guided horizonta y cannu as shou d not be used or seria puncture or micro-

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unti it just bare y penetrates the epidermis. Care must a iquot injection techniques (inc uding depot injections);

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be taken to ensure that each injection is o equa vo ume this shou d be reserved or use with sharp need es.

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and sequentia so the overa picture is that o a smooth,

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continuous ine that i ts or s out the o d. Steady,
continuous pressure on the syringe p unger produces a a r ea - a n d Pr o d u c t -s Pec If Ic

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f ow o materia into the dermis. Mo ding and massag- c o n s Id er a t Io n s

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ing can he p to ensure that gaps are ed in and so ten
minor irregu arities post treatment. O note, HAs shou d Physicians current y working with b unt-tipped micro-
be injected into the mid-to-deep dermis as to avoid the cannu as be ieve that there is a great bene t to using
ynda e ect (b ue disco oration due to super cia p ace- them, and that they achieve more pronounced vo ume
ment) and super cia umps and bumps. restoration with ewer entry points. Longer microcan-
Be otero (Merz Aesthetics, Inc., Franksvi e, WI), nu as a ow treatment o arge areas and easy re nement
recent y approved by the USFDA as a 1 mL pre ed g ass in acia contours as compared to onger need es, which
syringe containing 22.5 mg/mL o cross inked HA to be need more precision during injection and have increased
injected with 30 gauge, 0.5 in need es, can be imp anted into tissue resistance in the subderma p ane, as compared to
the upper dermis with a ower risk o the a orementioned cannu as tracking in the subcutis ( ab e 37-2).
side e ects due to its unique structure and abi ity to inte-
grate into the dermis. Po y-l - actic acid (PLLA; Scu ptra,
Sano -Aventis, Bridgewater, NJ) and ca cium hydroxy apa-
tite (CaHA; Merz Aesthetics, Inc., Franksvi e, WI) shou d TAbl E 37-2
be injected in the deep derma , subcutaneous, or periostea P i P u Mi
p anes and super cia p acement shou d be avoided.
Se ect the sma est num er o entry points to imit injection
Linear threading works we or the ips (a ong the “white
re ated side e ects
ro ”), naso abia o ds, atera zygoma, ang e o the mandi-
b e, and preauricu ar areas. T e correct technique invo ves Use sharp need e o arger gauge than chosen microcannu a
inserting the u ength o the need e into the midd e o size (e.g., 21 gauge need e or use o a 22 gauge microcannu a)
the wrink e or area to be enhanced and creating a tunne l onger engths (50 mm or more) or arge p acement areas
that wi be ed with the product by either an antero-
Short engths (38 mm or ess) or f ne tuning procedures or
grade (whi e need e is advanced) or retrograde injection
sma er treatment areas
(whi e need e is withdrawn). Both techniques are accept-
ab e and give exce ent cosmetic resu ts. Some may ee l arge gauges (18–25) or high viscosity f ers and arger f areas
that the anterograde method is sa er as it a ows the mate- Sma gauges (27–30) or ow viscosity f ers and superf cia
ria being injected to “push away” sma cutaneous vesse s p acement
and nerves and may decrease comp ications, most notab y
P acement o product shou d e in the deep su derma ,
bruising and swe ing. However, in areas that are high y
su cutaneous, or periostea p anes; avoid intraderma injection
vascu ar such as the g abe a or ip, a retrograde method
may be a better choice as it decreases the ike ihood o an Use a road, mu tidirectiona , anning technique or even
intra-arteria injection. T e potentia spaces in the vermi - distri ution o f er in arge areas
ion border (“white ro ”) and phi tra co umns a ow easy Not or superf cia injection o f ne rhytides or or
product f ow and p acement with antegrade injection. supraperiostea depot injections o product
For very arge areas such as the cheek, mid ace, and
Optima in neurovascu ar danger zones to essen risk o injury
marionette ines, the cross-hatching or anning technique 443
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Figure 37-5 Microcannu a injection or nec ines. Two percent idocaine with 1:100,000 epinephrine is
injected at a chosen entry site (top left) and sharp need e (23 au e) is used to create porta o entry (top
right). Microcannu a (27 au e, 50 mm) is inserted into the appropriate su cutaneous p ane (bottom
left) and hya uronic acid er (Juvederm U tra) di uted 1:1 with 2% idocaine is imp anted in retro rade
inear threads a on the wrin e crease. Note the tip o the cannu a (black arrow) upon u insertion
(bottom right). l on er cannu as en ths (50 mm or hi her) are use u in areas such as the nec where
ar e sur ace areas are required to e treated.

A recent consensus panel on the use o blunt-tipped a higher risk o puncturing nearby vessels or nerves. For
microcannulas suggested the greatest utility rom using hand augmentation, very long, exible cannulas (70 mm)
27 gauge, 1.25 in long sharp needles when injecting CaHA are needed to cover the area using only a ew entry points.
into the mid ace and the 22 gauge, 70 mm (2.75 in) blunt- Depending on the ller type, large-gauge (CaHA) or low-
tipped microcannulas or the 25 gauge, 1.5 in long sharp gauge (HAs) can be chosen.
needle or the use o PLLA. One o the panel members has In the periocular area including the tear trough and
been utilizing a 22 gauge blunt-tipped microcannulas with lateral eyebrow, many sizes and lengths o cannulas can
a length o 50 mm (2 in) or longer or all acial areas. None- be used depending on the area to be treated. T e lips and
theless, as described previously, the speci c characteristics perioral area (some argue) should never be injected with
and design o the cannula as well as the product chosen CaHa or PLLA as there is a high risk o nodule or lump/
are both needed to determine the best injection technique. bump ormation due to the high rate o muscle movement
For large areas o volume loss such as the cheeks, naso- and the potential or granuloma ormation and clumping
labial olds, temples, mandible, chest, and neck (décolleté), with these products. A small gauge (27 or 25) and long
longer cannulas (38 mm or more) will be required (Figs. length (38 or 50 mm) cannula is needed to cover the entire
37-5 and 37-6). Larger gauges should be used with CaHA, area through one entry site.
PLLA, or more viscous HAs (such as Perlane, Juvederm Overall, blunt-tipped microcannulas appear to be supe-
Ultra Plus, Juvederm Voluma, unless thinned out). In the rior to sharp needles or the injection o llers with regard
chest and neck (décolleté), temples or lips, a semirigid to sa ety, but they do not replace them. In act, needles
444 or ully rigid cannula may make injection easier, but has are still necessary or ne-tuning asymmetries, areas o
 4

Figure 37-6 be ore (left) and a ter (right) hya uronic acid er (Juvederm U tra) injection with micro-
cannu a (27 au e, 50 mm) or unwanted nec ines. Si ni cant improvement is noted with minima

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ruisin , swe in , or erythema. Pinpoint ruisin can e noted at areas o oca injection o anesthesia

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and need e puncture entry sites.

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under-treatment, the lip tubercles or philtral columns, may be all that are required or rejuvenation in this loca-

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or super cial placement including very small perioral or tion. Although all lling agents have been used, tradition-
periocular lines, crepe skin on the lateral mid ace/preau- ally CaHA and/or PLLA are the primary products chosen

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ricular, in the upper cheek/lower eyelid/tear trough, or or as they provide a substantial amount o volumization with

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depot injections, especially periosteal injections on the the need or less product and have longer-lasting results as
mandible, zygoma, temporal ossa, or lateral orbital rim. compared to HAs. However, the introduction o a new HA
Microcannulas can be a rst-line option or deep ller (Juvederm Voluma) in the United States with better li ting
injection to areas o di use volume loss, but combining
them with sharp needles to address super cial changes and
ocal volume loss can give an optimal balance o sa ety and
ef cacy with volume restoration plus contouring and shap-
ing. Microcannulas are the authors’ tool o choice or the
upper ace including the tear troughs, midcheek, temples,
eyebrow, and orehead, as well as whenever the plunger
on a syringe cannot be pulled back be ore injection. T us,
when using PLLA, a liquid solution, microcannulas are
not necessary because intravascular injection is more eas-
ily avoided (Fig. 37-7). On the other hand, the plunger on
a syringe o CaHA cannot be pulled backward, so use o
anning technique with a cannula provides an alternative
to supraperiosteal bolus injection to reduce complications.

MIc r o c a n n u l a In j ec t Io n
t ec h n Iq u es by l o c a t Io n
TEMPl ES. emporal li ting is o the greatest bene t to
individuals with signs o aging around the eyes and ore-
head. T is procedure li ts the eyebrows, reduces crow’s eet
lines, contours the outer area o the eye, so tens the hood-
ing o the outer eyelid, and rids the person o a skeletonized
appearance.26 T ose with temporal recession o ten report a
perceived increase in age, disease status (HIV), or drug use
(amphetamines). Some simply have had a recent pro ound
weight loss and eel less youth ul and upset over their sunken
appearance. T us, rejuvenation in this area can have a great Figure 37-7 Aspiration prior to injection is much easier
e ect both on a person’s sel -perception and the way in which with po y-l - actic acid as its consistency is f uid. b ood aspi-
others perceive them.27 rate indicates an intravascu ar ocation o the need e and
Depending on the degree o temporal recession and the si na s the practitioner to stop the procedure, remove the
length o cannula chosen, as ew as one to two entry points need e, and ho d pressure over the area. 445
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Figure 37-8 A. Eye row and temp e
s
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shapin and vo umizin can e per-
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ormed rom injection in vectors rom a
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o
sin e entry site. Microcannu a injection
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e
can sa e y e per ormed in hi h-ris areas
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such as the temp e where neurovascu ar
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und es are more super cia and suscep-
s
ti e to injury. B. A ternative entry sites
B
and vectors or eye row i tin /reshapin
and temp e vo umization.

capacity may change these recommendations. All llers in zygomatic arch midway between the hair line/helical rim
this location have proven clinically e ective and sa e.28– 31 and the lateral canthus/orbital rim, and along the superior
With any gauge (ranging rom 30 gauge or thinner HAs, hairline in a vector directly posterior to the lateral third o
to 27 gauge or CaHA, and 25 gauge or PLLA), 1 to 1.5 in the eyebrow (Fig. 37-8A,B).
sharp needle, vertically oriented depot injections are placed
in a periosteal location along the temporal ossa (sphenoid PERIORbITAl AND TEAR TROUg H. Rejuvena-
and temporal bones) until adequate augmentation is seen. tion o the periorbital area gives signi cant patient sat-
Some will use a single entry point midway between the lat- is action and optimal outcomes when per ormed prop-
eral canthus and the tragus just superior to the zygomatic erly.32,33 raditional injection with a sharp needle o ten
arch. Palpation o the temporal artery just anterior to the requires multiple injection points; due to the increased
tragus/helix above the temporomandibular joint ( MJ) will vascularity in this area, signi cant bruising and bleeding
prevent unanticipated puncturing o the artery or nearby can occur. Prolonged swelling (“ estooning”), visible pap-
vein. T is area is high risk as it houses the temporal nerve ules/product i injected super cially, and a yndall e ect
and vessels, so care should be taken to avoid medial and can also be seen i intradermal injections are not done
superior injections that put the needle in a compromising astidiously.34,35 HA llers are most commonly used, as
zone. For this reason, blunt-tipped microcannulas may be PLLA and CaHA have been avoided due to their potential
pre erred in this location to acilitate sa er injections, espe- or causing asymmetry and nodule ormation, although
cially in the more super cial planes. Deeper planes contain their use can be per ormed by an experienced injector
no anatomical structures that could in uence the develop- with proper dilution.36 A recent report demonstrated
ment o complications. Microcannula ( exible or semirigid) success ul treatment o unwanted, improperly injected
sizes ranging rom 22 to 25 gauge, 38 to 70 mm in length super cial CaHA with saline injections and erbium laser
are pre erred or vectoring or anning techniques. Serial in the in erior periorbital area/eyelid.37 With more com-
puncture or large-volume depot injections should be done monly used deeper injection techniques (subcutaneous
only with sharp needles along the periosteum. Entry points into at pads and supraperiosteal), side e ects are limited
or the blunt-tipped microcannula include superior and lat- and large volume restoration and contouring can be per-
446 eral to the lateral canthus along the orbital rim, along the ormed.38 O importance, visual loss/change due to orbital
in arction ollowing ller injection has been documented
in the literature, so meticulous injection technique and
as one or two entrance points can be used or complete
mid acial treatment.
4
a thorough knowledge o anatomy are required to mini- T e mid ace requires longer cannulas (50 mm or more)
mize the risk o catastrophic complications.39– 42 to cover the large areas o volume loss. T e 22 or 25 gauge
For use o cannulas in the tear trough, some pre er a sizes can be used or the most commonly used ller prod-
smaller diameter (27 or 30 gauge) and short (25 or 38 mm) ucts (HA, CaHA, PLLA). Once the larger areas o loss have
length in the deep (subcutaneous or supraperiosteal) been re lled and contoured, ocal areas o loss and the
planes rom an entry along the de ormity or on the mid- super cial drapery, re ecting a loss o elasticity rom aging,
cheek. However, the authors pre er approaching rom the can be addressed with sharp needle depot or small aliquot
lateral cheek with a 25 or 27 gauge, 38 to 50 mm (1.5–2 in) serial puncture techniques. HA ller super cially injected
cannula to reduce the risk o intravascular injection and with a short needle (32 gauge, 4 mm mesotherapy needle)
reduce needle sticks near the lower lid, where there is a in a microdroplet injection technique (0.02 ml injections,
higher chance o subsequent ecchymosis or lymphedema to whole cheek, about 25 injections) was recently reported
(Fig. 37-4A). On the upper eyelid and below the eyebrow, to target improvement in skin elasticity and provide excel-
better control can be obtained with shorter or semirigid lent changes in appearance.45 A an-like injection tech-
cannulas. Longer (38 or 50 mm) and larger (25 or 22 gauge) nique with linear threads perpendicular to the direction o
cannulas can be used in multiple acial areas and i used the smile lines in a super cial (subdermal) plane was used
in this area a single entry point placed in the superolateral with the exible blunt microcannula. T e overall picture
mid ace (along the zygoma, lateral and in erior to the lateral was that o a smoother skin sur ace and the disappearance

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canthus) gives access to both the lower eyelid and the lower o smile lines. For this technique, 27 to 30 gauge microcan-

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orehead above the eyebrow, as well as access to the mid ace nulas, 38 mm or more in length, can be used. Long-term

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and tear trough.10,18 In a recent case report, a single entry improvement rom this technique comes rom the pharma-

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point in erior to the lateral canthus along the patient’s tear cologic characteristics o the ller product itsel , as well as

7
trough de ormity with subsequent insertion o a 27 gauge, the mechanical stimulation (microtrauma) o the cannula

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42 mm blunt, rigid microcannula demonstrated excellent through the plane o injection, promoting collagenesis. An
clinical results without any patient discom ort or immedi- advantage o utilizing a cannula or the mid ace is the abil-

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ate bruising or swelling a ter 0.7 mL o an HA ller (into tear ity to treat the pyri orm aperture, an o ten neglected but

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trough) was placed.43 T e single entry point has the bene ts important area to improve, rom the same entry point and
o limiting pain, bruising, and swelling, but also provides without using a sharp needle (Fig. 37-9).
access to multiple acial sites at one time, thereby simpli y-
ing the injection technique. It is best to inject with a linear l IPS AND l OWER FACE. Flexible or rigid blunt-
technique in a retrograde (while withdrawing) ashion. It is tipped microcannulas can be extremely use ul in this area,
also recommended that the patient be injected in a seated as bruising and swelling are common complications rom
rather than reclining position in order to achieve accurate sharp needle injection. Niamtu8 was the rst to report the
ller placement and avoid overcorrection. use o a rigid, blunt 0.9 mm (20 gauge), 5 cm at injection
microcannula to inject the entire lip and nasolabial old
MIDDl E FACE – NASOl AbIAl FOl DS AND with one entry point or each location (Fig. 37-10). An 18-
CHEEkS. Mid ace rejuvenation has undergone dramatic gauge needle was used to make a puncture site at the site
changes in recent years in both injection techniques and o injection (lateral vermillion border/oral commissure and
perception.44 T is has led to a paradigm shi t in our thera- along the in erior aspect o the nasolabial old) and the
peutic approach. Rather than using llers to simply ll a line, microcannula was then inserted the entire length o the lip
with increased understanding o acial aging and changes or old and the ller injected in a retrograde, linear thread-
that occur with the subcutaneous at pads and cranio a- ing ashion. He concluded that there was less edema and
cial skeleton, we now account or the three-dimensional bruising and a aster patient recovery as compared to using
shape o the ace, allowing or the use o llers as li ting and hypodermic needles.
sculpting agents. issue repositioning and contouring can T e belly o the lip is an ideal location or use with micro-
be achieved by replacing atrophic and drooping at pads cannulas and the amount o ller can be tapered easily as
with injection along the periosteum at areas o recession. the cannula is retracted to give more product placement
With the use o cannulas, large areas can be lled, li ted, in the middle o the lip and less as it is withdrawn laterally
and recontoured through ew entrance points with almost (Fig. 37-11). T is gives a natural appearance rather than
no downtime. Vectoring the ller, along with injection a “sausage”-type lip, which has no contour or shape. T e
directly into the at pads, can li t the super cial skin drap- vermillion is more dif cult or cannula insertion although
ery and provide a more natural, youth ul appearance. small gauge (27 or less) microcannulas can be used.
Possible entry points or the mid ace include just supe- Length will vary depending on the area to be treated, but
rior and lateral to the oral commissure on the upper cuta- longer lengths (50 mm or more) should rarely be needed.
neous lip, giving easy access to the nasolabial olds, medial T e vermillion border, Cupid’s bow, philtral columns, and
cheeks and marionette lines; in the central cheek midway very ne perioral lines may require sharp needles or more
between a line drawn posteriorly rom the oral commis- precision when injecting.
sure and the superior helical rim (an alternative would be T e oral commissures can easily be treated with an
a lower entry point midway between a line drawn rom the entrance point directly lateral to the commissure, supero-
oral commissure and the tragus) providing ull access to lateral or in erolateral to the commissure, or a point supe-
the medial and lateral cheeks including the zygomatic arch rior to the prejowl sulcus. Areas where the microcannula
(Fig. 37-4A,B). Depending on the cannula length, as ew should not be introduced include at the insertion o the 447
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Figure 37-9 Cannu a entry site options to reach the pyri orm aperture (black arrows). The pyri orm ap-
erture is a heart- or pear-shaped openin in the s u that en ar es with a e, inf uencin the shape and
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hei ht o the nasa carti a inous structures and upper cutaneous ip. Addin support to this area with
A
so t-tissue er can have a si ni cant cosmetic inf uence on the shape o the upper cutaneous ip and
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nasa tip.
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depressor anguli oris (DAO) muscle and platysma muscle still be per ormed with sharp needles; CaHA or PLLA are
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on the mandibular angle. Various gauge diameters (22, 25, excellent products here. For the jawline itsel , the senior
l
or 27), 38 mm or more in length, will be best or all ller author does pre er the use o a 25 or 27 gauge, 5/8 to 1 in
a
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e
types. It is best to proceed with caution when using CaHA needle to provide a sharp margin, especially in those who
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or PLLA in the perioral areas as high movement due to have had prior surgeries.
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the orbicularis oris muscle can increase the risk or nod-
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ule and granuloma ormation. T e lips should never be HANDS. Prominent signs o aging can be seen in a
d
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directly injected with CaHA or PLLA, even i signi cantly person’s hands including increased vascularity, tendons,
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diluted. bony prominences, sun spots, and wrinkling o the skin
T e entire lower ace including the mandibular angle/ (skin turgor), all a consequence o a complex interaction
prejowl sulcus, chin, and lower cutaneous lip can all be between genetics and environmental exposure (derma-
accessed through an entrance point just superior and toheliosis). Many have reported success with the use o
medial to the insertion o the DAO onto the mandible llers (mainly HA, CaHA, at) in this area but proper
(Figs. 37-12 and 37-13). An additional site along the jaw- technique is needed or adequate results.46– 49 A single
line just in erior to the ear lobule (similar sites used in entrance point on the dorsum o the hand at the wrist
neck liposuction) can access the entire preauricular area or in the nger web between the middle (third) and ring
and mandibular angle. Longer microcannula lengths will ( ourth) ngers may be all that is needed. Alternatively,
be needed to access the entire length o the jaw (50 or two entrance points can be made with the rst between
70 mm). Depot injections along the periosteum should the index (second) and middle (third) ngers and the
second between the ring ( ourth) and little/pinky nger
( th). Entering rom the wrist and injecting proximal
to distal provides easier access to the ull sur ace o the
hand but positioning the patient may be more dif cult.
Pre erred microcannulas are 22 or 25 gauge and 38 mm.
Fulton reported the use o an 18 gauge, 70 mm microcan-
nula on the dorsum o the hand with excellent results 6
months a ter implantation o 2 mL o an HA ller.18 T us,
the ller length and size should be customized to the in-
dividual and the product chosen.
I CaHA is used, and many consider this the ller o
choice in this area due to its opacity, diluting 1:1 with
1% or 2% lidocaine lowers the viscosity o the ller and
acilitates its spread through the tissue a ter implanta-
tion. T e technique is not any di erent in this area than
in others, but due to thin skin and increased vascularity
Figure 37-10 Anesthesia o microcannu a entry site. l ip it is imperative to choose an entry site that is not directly
enhancement with microcannu a is throu h one entry site over a vein to prevent intravascular injection or increased
at the atera commissure. Opposin vectors can e used bleeding/bruising rom the procedure. T e entry point is
448 to contour and revo umize. pinched and a needle (larger than the microcannula size
 4

Figure 37-11 Microcannu a (22 au e, 50 mm) insertion into the ip is pain ess and easy due to unt dissection ( e t).
Upon u insertion, the tip o the cannu a (black arrow, midd e) can e noted at the media portion o upper ip e y.
Si ni cant eversion and ip u ness are noted (ri ht) a ter er materia (Resty ane) is injected as the cannu a is retracted.

chosen) is inserted to create a port site or the cannula. injections in this area. T e use o the anning injection tech-

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Without letting go, the needle is removed and the can- nique with a 25 gauge, 38 mm or larger, exible or semirigid

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nula inserted in a distal to proximal direction. T e an- microcannulas can be used in the vertical lines o this area.

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ning injection technique should be utilized when using HA llers are generally the products o choice in this area.

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microcannulas or optimal results. More ller may be CaHA is being used at dilutions o 2:1 or greater (mixed
required in this area or adequate revolumization as com- with 1% lidocaine plus 0.9% saline) in a similar manner

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pared to acial sites, especially i using an HA ller. Some to the technique in the hands with good results. Although

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like to have the patient clench their st while injecting, highly diluted PLLA is used, there is a risk o leaving

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as this can potentially help to prevent injecting distal to visible nodules in this thin-skinned area.

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the metacarpophalangeal (MCP) joints or proximal to the
wrist bones, which should both be avoided. However, this
may obscure the skin laxity and compress veins, giving a h IGh -r Is k c o n s Id er a t Io n s –
alse impression o adequate lling. A ter the injection is n eu r o va s c u l a r
complete, massaging with a petrolatum or glycerin-based
product and ice/cold packs should be used to ensure even As stated previously, the clinical bene ts o using blunt-
placement o the product and decrease pain, bruising, or tipped microcannulas include the near elimination o
swelling post procedure. traumatic injection and risk to vital neurovascular struc-
tures. Certain anatomical regions are more sensitive to
DéCOl l ETé. Use o microcannulas in the décolleté injury, either due to the nature o the skin at that location
region is a signi cant advantage as it can cover a wide area in (decreased thickness) or the structures that lie beneath
a short period o time with little or no discom ort or bruis- (vessels or nerves). T e major anatomic vessels o concern
ing. Both the skin wrinkles (crinkling o skin) and promi- when per orming so t-tissue augmentation o the ace
nent vascularity seen with aging can be treated with ller include: (1) supratrochlear artery, (2) superior and in e-
rior labial arteries, (3) angular artery, and (4) the parotid
duct.50 With the use o microcannulas o 27 gauge or larger,
the chance o intravascular injection is nearly impossible,
and vital structures will be pushed aside as the cannula
transverses through the tissues. A 30 gauge cannula, espe-
cially i rigid, may still have the potential to cause injury
and should be passed through tissue slowly with product
extruded at low orces. T e longer length o cannulas as
compared to sharp needles (typically 13 mm/0.5 in to
19 mm/0.75 in) intrinsically decreases extrusion orces
when injecting llers in this manner.
With the recent popularity o lling temple concavi-
ties as well as correcting nasal contour irregularities, the
super cial temporal artery as well as the dorsal nasal
artery are areas o concern and caution. T e periocular
area and tear trough, temple and lateral brow, and angle
Figure 37-12 Vectors or ower ace microcannu a injec- o the mandible, may be more dif cult to treat and chal-
tion, author’s pre erence. Mu tip e ocations can e chosen lenging to a novice injector. Strict adherence to proper
to access an area consistin o the ower cutaneous ip/ technique can help limit serious side e ects in these
chin, marionette ines, prejow /jaw ine, and preauricu ar locations, but minor side e ects may be unavoidable
re ion. and should be explained completely prior to treatment. 449
4
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Figure 37-13 Microcannu a (25 au e, 38 mm) injection o the ower ace invo ves reorientin in mu -
tip e vectors whi e in the su cutaneous p ane. Pinchin the s in he ps to ensure accurate p acement o
product and depth o the microcannu a.

For example, the periorbital area is surrounded by sev- into the vessel at this point can lead to nasal ala, nasal tip,
eral major vessels and nerves that can be injured dur- nasolabial old, and upper lip necrosis.52,53
ing careless injection or simple bad luck, and this type Clinicians should take every precaution to avoid vas-
o injury could potentially result in visual impairment or cular compromise. I possible, aspirating prior to injec-
blindness.40,50,51 Injections above the bony border o the tion in anatomic danger zones can be help ul but proves
orbit can result in septal damage and possibly injury to quite dif cult with viscous llers and may only be more
the globe that may be irreversible. reliable in circumstances such as using PLLA. Intravas-
T e supratrochlear artery is at particularly high risk o cular injection may lead to immediate blanching ollowed
injury rom injection in the glabellar region and/or superior by ischemia and necrosis (Fig. 37-14). When using local
medial bony orbit. T e super cial temporal artery is most anesthesia either separately or mixed into a lling agent, it
vulnerable in the preauricular, lateral zygoma, and tempo- is important to know whether the anesthetic contains epi-
ral locations. Vessel damage here can potentially lead to the nephrine so that the cause o blanching can be determined
devastating complication o unilateral scalp necrosis. quickly. T is is one reason that most clinicians pre er to
T e superior and in erior labial arteries are at risk o use lidocaine without epinephrine during tissue augmen-
injury with augmentation o the perioral area and lips, as tation, although the junior author believes the addition o
these arteries supply the upper lip including some o the epinephrine helps limit bruising.
nasal ala and the lower lip and superior part o the chin, Other structures can also be at risk. Like the artery, the
respectively. T e angular artery (continuation o the acial super cial temporal nerve is vulnerable in the preauricu-
artery) provides blood to the medial cheek, nasal ala, nasal lar, lateral zygoma, and temporal locations. T e temporal
sidewall, and dorsum o the nose. Care should be exercised branch o the acial nerve is at risk over the lateral brow
when injecting near the alar groove, as excessive compres- and the zygomatic branch o the acial nerve is at risk over
450 sion with large volumes o ller or rank injection directly the zygoma. Injury to the nerves in this location can lead
 injections. With any cosmetic procedure, the results are
dependent upon the knowledge and skill o the practitio-
4
ner and the sa ety and ef cacy o the employed technique.
echniques or the use o blunt-tipped, exible microcan-
nulas have been described here, although more controlled
studies with the use o microcannulas o various types are
needed to determine proper guidelines or use as com-
pared to traditional sharp hypodermic needles. For most
patients a combination o blunt-tipped microcannulas
and sharp needles will be needed or optimal volumiza-
tion and contouring as well as precise treatment o ne
rhytides and ocal areas o volume loss. T e proposed ben-
e ts, including decreased pain, bruising and swelling, as
well as the ability to treat large areas with ew puncture
sites, are very attractive. Ultimately, however, evidence-
based approaches are needed to determine the optimal
locations and uses or these relatively new injection tools.

r ef er en c es

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1. La aille P, Benedetto A. Fillers: contraindications, side e ects

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and precautions. J Cutan Aesthet Surg. 2010;3(1):16– 19.

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2. Andre P, Lowe NJ, Parc A, Clerici H, Zimmermann U. Ad-

7
verse reactions to dermal llers: a review o European experi-
ences. J Cosmet La ser T er. 2005;7(3– 4):171– 176.

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3. Scla ani AP, Fagien S. reatment o injectable so t tissue ller

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complications. Dermatol Surg. 2009;35:1672– 1680.

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4. Levy LL, Emer JJ. Complications o minimally invasive cos-

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s
metic procedures: prevention and management. J Cutan Aes-
thet Surg. 2012;5(2):121– 132.
5. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and
Figure 37-14 Impendin necrosis. A dus y, reticu ated treatment o dermal ller complications. Aesthet Surg J.
patch is noted on the mid ace quic y a ter sharp need e in- 2011;31(1):110– 121.
jection o a hya uronic acid e (Juvederm U tra) y the su- 6. Coleman SR. Facial augmentation with structural at gra ting.
praperiostea injection technique. No on -term seque ae Clin Pla st Surg. 2006;33(4):567– 577.
resu ted, ut the patient required treatment with hya uron- 7. Zeichner JA, Cohen JL. Use o blunt tipped cannulas or so t
tissue llers. J Drugs Dermatol. 2012;11(1):70– 72.
idase, nitro ycerin paste, aspirin, and warm compresses.
8. Niamtu J 3rd. Filler injection with micro-cannula instead o
needles. Dermatol Surg. 2009;35(12):2005– 2008.
9. Hertzog B, Andre P. T e exible needle, a sa e and easy new tech-
to the inability to move the eyebrow or close the upper nique to inject the ace. J Cosmet Dermatol. 2010;9(3):251–252.
eyelid on that side completely. Injections near the angle o 10. Sundaram H, Weinkle S, Pozner J, Dewandre L. Blunt-tipped
microcannulas or the injection o so t tissue llers: a consen-
the mandible put the marginal mandibular branch o the
sus panel assessment and recommendations. J Drugs Derma-
acial nerve at risk and injury to this nerve causes denerva- tol. 2012;11(8):s33– s39.
tion o the depressors o the lip/mouth, leading to chronic 11. Fisher GJ, Varani J, Voorhees JJ. Looking older: broblast col-
drooling or the inability to chew/eat correctly. Finally, the lapse and therapeutic implications. Arch Dermatol. 2008;144(5):
parotid duct (Stensen’s duct) enters the mouth at the level 666–672.
12. Harris AK, Stopak D, Wild P. Fibroblast traction as a mechanism
o the second molar and is vulnerable to trauma during
or collagen morphogenesis. Nature. 1981;290(5803):249–251.
mid ace and cheek augmentation, especially in patients 13. Dono rio LM. Blunt-tipped microcannulas– a personal per-
with a more signi cant degree o aging, extreme weight spective. J Drugs Dermatol. 2012;11(8):s41– s42.
loss, and HIV lipoatrophy. Decreased subcutaneous vol- 14. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP,
ume makes the duct more susceptible to injury. schopp H. Middle cerebral artery occlusion AND ocular at
embolism a ter autologous at injection in the ace. J Neurol.
o avoid complications when using microcannulas, in
1998;245(1):53– 54.
general a 27 gauge or larger diameter cannula should be 15. Feinendegen DL, Baumgartner RW, Vuadens P, et al. Autolo-
used in place o a 30 gauge sharp needle and a 25 gauge gous at injection or so t tissue augmentation in the ace: a
microcannula or larger diameter cannula should be used in sa e procedure? Aesthetic Pla st Surg. 1998;22(3):163– 167.
place o a 27 gauge sharp needle. Decreased extrusion orces 16. Berros P. Periorbital contour abnormalities: hollow eye ring
management with hyalurostructure. Orbit. 2010;29(2):119–125.
acilitate increased and even ow o ller product, decreas-
17. Hexsel D, Soire mann M, Porto MD, Siega C, Schilling-Souza
ing the potential or an inappropriately large ller bolus lead- J, Brum C. Double-blind, randomized, controlled clinical trial
ing to asymmetries, vascular compression, or overtreatment. to compare sa ety and ef cacy o a metallic cannula with that
o a standard needle or so t tissue augmentation o the naso-
labial olds. Dermatol Surg. 2012;38(2):207– 214.
c o n c l u s Io n 18. Fulton J, Caperton C, Weinkle S, Dewandre L. Filler injec-
tions with the blunt-tip microcannula. J Drugs Dermatol.
2012;11(9):1098– 1103.
Blunt-tipped microcannulas are a signi cant advantage 19. Vleggaar D, Forte R. Cosmetic injectable devices: a review o the
in our armamentarium o options or so t-tissue ller injection techniques. J Drugs Dermatol. 2006;5(10):951–956. 451
4 20. Van Eijk , Braun M. A novel method to inject hyaluronic
acid: the Fern Pattern echnique. J Drugs Dermatol. 2007;6(8)
37. Vrcek IM, Malou P, Gilliland GD. A novel solution or su-
per cially placed calcium hydroxylapatite (Radiesse) in the
:805– 808. in erior eyelid. Orbit. 2012;31(6):431– 432.
21. Sattler G. T e tower technique and vertical supraperiosteal 38. Vage MR, McMullan F, Burroughs JR, White GL Jr,
depot technique: novel vertical injection techniques or vol- McCann JD, Anderson RL. Calcium hydroxylapatite or
ume-ef cient subcutaneous tissue support and volumetric orbital volume augmentation. Arch Fa cial Pla st Surg. 9(6):
augmentation. J Drugs Dermatol. 2012;11(8):s45– s47. 439– 442.
22. Glogau RG, Kane MA. E ect o injection techniques on the 39. Roberts SA, Arthurs BP. Severe visual loss and orbital in arc-
rate o local adverse events in patients implanted with no- tion ollowing periorbital aesthetic poly-(L)-lactic acid (PLLA)
nanimal hyaluronic acid gel dermal llers. Dermatol Surg. injection. Ophthal Pla st Reconstr Surg. 2012;28(3):e68–e70.
2008;34:S105–S109. 40. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and
23. Niamtu J 3rd. Simple technique or lip and nasolabial old anes- ischemic oculomotor nerve palsy a ter vascular emboliza-
thesia or injectable llers. Dermatol Surg. 2005;31(10):1330– tion o injectable calcium hydroxylapatite ller. Ophthal Pla st
1332. Reconstr Surg. 2010;26(4):289– 291.
24. Rohrich RJ, Ghavami A, Crosby MA. T e role o hyaluronic acid 41. Lazzeri D, Agostini , Figus M, Nardi M, Pantaloni M, Lazzeri
llers (Restylane) in acial cosmetic surgery: review and techni- S. Blindness ollowing cosmetic injections o the ace. Pla st
cal considerations. Plast Reconstr Surg. 2007;120:41S–54S. Reconstr Surg. 2012;129(4):995– 1012.
S
25. Carruthers JD, Carruthers A. Facial sculpting and tissue aug- 42. Kim YJ, Kim SS, Song WK, Lee SY, Yoon JS. Ocular ischemia
e
mentation. Dermatol Surg. 2005;31:1604– 1612. with hypotony a ter injection o hyaluronic acid gel. Ophthal
c
t
i
26. Raspaldo H. emporal rejuvenation with llers: global acec- Pla st Reconstr Surg. 2011;27(6):e152– e155.
o
n
ulpture approach. Dermatol Surg. 2012;38(2):261– 265. 43. revidic P. T e Use o blunt-tipped cannulas or tear trough
4
27. aub AF, Sarno D, Gold M, Jacob C. E ect o multisyringe correction. J Drugs Dermatol. 2012;11:S38–S40.
hyaluronic acid acial rejuvenation on perceived age. Derma- 44. Greco M, Antunes MB, Yellin SA. Injectable llers or volume
:
:
tol Surg. 2010;36(3):322– 328. replacement in the aging ace. Facial Plast Surg. 28(1):8–20.
28. Ross JJ, Malhotra R. Orbito acial rejuvenation o temple hol- 45. Landau M. Hyaluronic acid “skinboosters” and use o blunt
A
e
lowing with Perlane injectable ller. Aesthet Surg J. 2010; injection microcannulas. J Drugs Dermatol. 2012;11(3):
s
t
30(3):428– 433. 41– 43.
h
e
29. Moradi A, Shirazi A, Perez V. A guide to temporal ossa aug- 46. Park H, Yeo KK, Seo SW, et al. Clinical experience with
t
i
c
mentation with small gel particle hyaluronic acid dermal complications o hand rejuvenation. J Pla st Reconstr Aesthet
a
ller. J Drugs Dermatol. 2011;10(6):673– 676. Surg. 2012;65(12):1627– 1631.
n
d
30. Lambros V. A technique or lling the temples with highly 47. Sadick NS, Anderson D, Werschler WP. Addressing volume
l
diluted hyaluronic acid: the “dilution solution”. Aesthet Surg J. loss in hand rejuvenation: a report o clinical experience.
a
s
2011;31(1):89– 94. J Cosmet La ser T er. 2008;10:237– 241.
e
r
31. Fitzgerald R, Vleggaar D. Facial volume restoration o the aging 48. Brandt FS, Cazzaniga A, Strangman N, Coleman J, Ax ord-
P
r
ace with poly-l-lactic acid. Dermatol T er. 2011;24(1):2–27. Gatley R. Long-term e ectiveness and sa ety o small gel par-
o
c
32. Succi IB, da Silva R , Oro no-Costa R. Rejuvenation o peri- ticle hyaluronic acid or hand rejuvenation. Dermatol Surg.
e
d
orbital area: treatment with an injectable nonanimal non- 2012;38:1128– 1135.
u
crosslinked glycerol added hyaluronic acid preparation. Der- 49. Butterwick KJ. Rejuvenation o the aging hand. Dermatol
r
e
matol Surg. 2012;38(2):192– 198. Clin. 2005;23:515– 527.
s
33. Rzany B, Cartier H, Kestermont P, et al. Correction o tear 50. Cohen JL, Brown MR. Anatomic considerations or so t tissue
troughs and periorbital lines with a range o customized hyal- augmentation o the ace. J Drugs Dermatol. 2009;8(1):
uronic acid llers. J Drugs Dermatol. 2012;11:s27– s34. 13– 16.
34. Dayan SH, Arkins JP, Somenek M. Restylane persisting in 51. Silva M , Curi AL. Blindness and total ophthalmoplegia a ter
lower eyelids or 5 years. J Cosmet Dermatol. 2012;11(3):237– aesthetic polymethylmethacrylate injection: case report. Arq
238. Neuropsiquiatr. 2004;62(3B):873– 874.
35. Nettar K, Maas C. Facial ller and neurotoxin complications. 52. Grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Bau-
Facial Pla st Surg. 2012;28(3):288– 293. mann L. T e risk o alar necrosis associated with dermal ller
36. Stewart DB, Morganroth GS, Mooney MA, Cohen J, Levin injection. Dermatol Surg. 2009;35:1635– 1640.
PS, Gladstone HB. Management o visible granulomas ollow- 53. Kassir R, Kolluru A, Kassir M. Extensive necrosis a ter injec-
ing periorbital injection o poly-L-lactic Acid. Ophthal Pla st tion o hyaluronic acid ller: case report and review o the
Reconstr Surg. 23(4):298– 301. literature. J Cosmet Dermatol. 2011;10(3):224– 231.

452
 Ch a p t e r

38 Injectables
Karen L. Connolly, David M. Ozog, & Joel L. Cohen

In t r o d u c t Io n AbobotulinumtoxinA is supplied in a lyophilized orm

along with human serum albumin and lactose. Onabotu-
linumtoxinA is supplied in a vacuum-dried orm contain-
Botulinum toxin (BoN ) has long been recognized as a
ing human albumin. IncobotulinumtoxinA is supplied in a
potent neurotoxin, which causes symmetric accid paral-
lyophilized orm with human albumin and sucrose.
ysis upon ingestion o ood contaminated with bacterial
spores. Clostridium botulinum, a spore- orming, gram-
positive, anaerobic bacterium, produces the toxin along Mec h An Is M o f Ac t Io n
with its associated proteins.1
T e use o BoN in medicine dates back to the 1970s, Following injection o BoN -A, the product di uses over
with its initial use in ophthalmology to treat strabismus the target muscles and is absorbed into presynaptic motor
via its paralyzing e ects on the extraocular muscles. T e nerve terminals. In order to enter the nerve, the toxin
rst cosmetic use o BoN in acial aesthetics occurred in molecule initially binds to SV2, a synaptic vesicle protein
the late 1980s.2 Use o BoN or acial rejuvenation now that anchors the heavy chain o the toxin complex through
ranks as the number one cosmetic treatment in the United receptor-mediated endocytosis. T e toxin complex then
States.3 T e only current FDA-approved cosmetic indica- enters the nerve, and once it is intra-neural, the heavy
tion or botulinum toxin type A (BoN -A) in the United chain and light chain separate. T e light chain then trav-
States is treatment o moderate-to-severe glabellar lines in els to the nerve terminus where it cleaves synaptosomal-
adults, with three di erent BoN -A agents: Ona- (Botox®. associated protein (SNAP-25), a protein responsible or
Allergan. Irvine, CA. USA), Abo- (Dysport®. Ipsen.), and exocytosis and release o acetylcholine in synaptic vesi-
Inco- (Xeomin®. Merz. Germany). However, the BoN -A cles.8,9 T e mechanism o action o botulinum toxin type B
agents are commonly used o -label or other aesthetic pur- (BoN -B) di ers slightly rom its type A counterpart; this
poses on the ace, neck, and sometimes the upper chest. serotype cleaves vesicle-associated membrane protein
In the United States, AbobotulinumtoxinA, Inco- (VAMP, also called synaptobrevin) instead o SNAP-25,
botulinumtoxinA, and OnabotulinumtoxinA are also but the result is similar in that it blocks the exocytic
approved by the FDA or the treatment o cervical dysto- release o Ach rom the nerve terminus.10 T e e ects
nia. OnabotulinumtoxinA is approved or the treatment o BoN -A at doses used or cosmetic treatment begin
o blepharospasm, strabismus, and severe primary axil- within 2 to 5 days, peak at about 4 weeks, and start to
lary hyperhidrosis that is inadequately managed by topical wane by 2 to 3 months. T ey typically resolve completely
agents. IncobotulinumtoxinA is also approved or treat- by 6 months.8
ment o blepharospasm.

AvAIl Abl e t o x In s Pr ePAr At Io n o f t h e

n eu r o Mo d u l At o r
Currently, seven serotypes o BoN s exist (A– G), all
resulting in temporary muscle paralysis. Only serotypes A fo r use
and B are currently commercially available.1 For the three
preparations o BoN -A licensed in the United States Each o the three BoN -A neuromodulator agents must
or cosmetic use, OnabotulinumtoxinA, Abobotulinum- be reconstituted or use. Reconstitution with unpreserved
toxinA, and IncobotulinumtoxinA, there is no standard 0.9% sodium chloride is recommended in each o the
equivalency ratio. Several clinical studies have attempted three products’ manu acturers’ package inserts. However,
to determine a ratio speci cally or OnabotulinumtoxinA recent literature has suggested that there is no change
and AbobotulinumtoxinA. A single unit o Onabotu- in OnabotulinumtoxinA’s ef cacy using saline preserved
linumtoxinA is approximately equivalent to 2 to 4 units o with benzyl alcohol, although decreased pain with injec-
AbobotulinumtoxinA but this estimation varies between tion has been noted.11 T ere are also a ew small studies
studies, physicians, countries, and by indication.4– 6 analyzing reconstitution with an anesthetic.12 Preserved
Although there are current investigations underway com- saline has by ar become the most common diluent or
paring the potency o IncobotulinumtoxinA and Ona- reconstitution in clinical practice.13 T e recommended
botulinumtoxinA, a recent study suggests close to a 1:1 manu acturers’ reconstitution volumes or Dysport, Xeo-
ratio between the products ( able 38-1).7 min, and Botox or treatment o glabellar lines are detailed
 s r u d c orP r s aL d n a ci t h ts A :: 4 n oi tc S

4
4
5
4
TAbLe 38-1
b li mt i P u d l pm i h u i s a

bo t o x c m i /
vi a l®/ dy p / dy p My l ®/ n t -201/
bo t o x vi a ® r l i ® c m i n bl ® xeo MIn P t ®
Company All rgan Inc. All rgan Inc. Ips n Inc./M dicis Inc. Ips n Inc./M dicis Solstic N urosci nc s M rz Pharmac uticals M ntor Corporation
Inc. Inc.
Typ Typ A Hall strain Typ A Hall strain Typ A Typ A Typ b Typ A Hall strain Typ A Hall strain
Approvals In ov r 75 countri s In ov r 16 countri s, In ov r 65 countri s; G rmany, oth r Som europ an G rmany, oth r europ an Non
worldwid , including including Unit d Stat s, not approv d in US or europ an countri s, US, Canada countri s, M xico,
US and Canada Canada, Italy, Franc Canada countri s Arg ntina
Activ botulinum toxin typ botulinum toxin typ A botulinum toxin typ botulinum toxin botulinum toxin typ b botulinum toxin typ A, botulinum toxin typ A,
su stanc A compl x (900 kD) compl x (900 kD) A compl x (900kD)a typ A compl x compl x (700 kD) r rom compl xing r rom compl xing
(mol cular (900kD)a prot ins (150 kD) prot ins (150 kD)
w ight)
Indications bl pharospasm; Gla llar lin s bl pharospasm; Gla llar lin s C rvical dystonia bl pharospasm; c rvical Phas 3 or gla llar
c rvical dystonia; c rvical dystonia dystonia; gla llar lin s lin s; Phas 1 or
gla llar lin s; spasmodic torticollis/
hyp rhidrosis c rvical dystonia
Mod o action SNAP 25 SNAP 25 SNAP 25 SNAP 25 VAMP SNAP 25 SNAP 25
b
Pharmac utical Powd r dissolv d in Powd r dissolv d in Powd r dissolv d in Powd r dissolv d Solution Powd r dissolv d in
orm solution or inj ction solution or inj ction solution or inj ction in solution or solution or inj ction
inj ction
b
Units/vial 100 50 500 300 or 500 2500; 5000; 10,000 50 or 100
b
Volum 10 mL maximum 1.25 mL or 2.5 mL 2.5 mL r comm nd d 5 mL maximum 0.5 mL; 1 mL; 2 mL 8 mL maximum
r comm nd d
R constitution 0.9% NaCl solution 0.9% NaCl solution 0.9% NaCl solution 0.9% NaCl solution Pr par d solution, 0.9% NaCl solution 0.9% NaCl solution
diluta l
b
Storag 2°–8°C or <–5°C 2°–8°C or <–5°C 2°–8°C 2°–8°C 2–8°C do not r z Up to 25°C

Summary o otulinum toxin products approv d or und r d v lopm nt or cosm tic indications.
a
Th ormulation contains compl x s o varia l siz tw n 500 and 900 kD.2
b
Data unavaila l or unconf rm d.
SNAP-25 (synaptosomal associat d prot in with th mol cular mass o 25 kD), an intrac llular prot in that is ss ntial or synaptic v sicl transmission; it has n id ntif d as th mol cular targ t o bTX A.; VAMP
(synaptobrevin), a prot in involv d in synaptic v sicl mov m nt that has n id ntif d as th mol cular targ t o bTX b.
Source: Adapt d with p rmission rom Carruth rs A, Carruth rs J. botulinum toxin products ov rvi w. Skin Therapy Lett. 2008;13(6):1–4.
 TAbLe 38-2
evaluating a patient or treatment using neuromodulators,
one must evaluate the extent o wrinkling caused by pho-
4
b i mt i r i i G i i todamage and distinguish this rom wrinkling caused by
repetitive movement o acial muscles. T is will help pre-
v m dict the extent o improvement the patient may expect rom
f 0.9% treatment and actors into their overall aesthetic plan. T e
u i s i m wrinkles caused by muscles o acial expression are arranged
(u i c i r i g perpendicular to the vectors o muscle contraction. T ese
P via ) (ml ) c a i can be temporary or persistent, and both orms can be
improved with treatment using BoN -A.17 Analysis o acial
Dysport 300 2.5 10 Units p r 0.08 mL
movement, as well as recognition o any pre-existing asym-
Dysport 300 1.5 10 Units p r 0.05 mL metry or ptosis, must be considered when deciding on the
botox 100 2.5 4 Units p r 0.1 mL placement and dose o toxin to be used. Photographs are
cosm tic particularly important be ore and a ter the initial treatment
session, as patients are o ten unaware o pre-existing base-

C
botox 50 1.25 4 Units p r 0.1 mL

h
line asymmetry and may later believe that this was caused

a
cosm tic

p
by the neuromodulator treatment itsel .

t
X omin 50 0.25–5 Vari s with dilution

r
Realistic expectations regarding the degree o improve-

3
8
X omin 100 0.5–8 Vari s with dilution ment expected and the eventual nancial cost to the
patient must be discussed in detail. Any o -label use o

:
:
toxin should be clearly disclosed and ideally should be part

I
n
in able 38-2. However, in clinical practice reconstitution o the consent orm as well.

j
Contraindications or cosmetic use o BoN -A

c
volumes can vary based on location and indication. Lower

t
a
volumes are o ten used in areas where di usion needs to include known hypersensitivity to any botulinum prod-

l
be minimized (such as perioral injections or orbicularis uct, current in ection at the proposed injection sites,

s
oris) while higher volumes are sometimes used to acili- and pre-existing neuromuscular junction disorders
tate spread o the medication when there are larger target (myasthenia gravis, amyotrophic lateral sclerosis, and
areas (such as or axillary hyperhidrosis). Lambert-Eaton Syndrome). Special precautions should
T e product insert or Botox recommends that once be taken when treating patients with pre-existing swal-
opened and reconstituted, the product should be stored at lowing or breathing dif culties, or who are taking high
2° to 8°C and used within 24 hours. T e vial is single-use systemic doses o aminoglycosides or other medica-
and it is not recommended that it be rozen once recon- tions inter ering with neuromuscular release, which
stituted. For Dysport, the product insert similarly rec- may potentiate the e ect o BoN -A. Interactions are
ommends the vial be single-use, stored at 2° to 8°C, used also possible with certain medications, including chlo-
within 4 to 6 hours and protected rom light. It also states roquine and hydroxychloroquine, which may antago-
the product should not be rozen once reconstituted. In nize the onset o BoN -A activity. Cyclosporine can
contrast, Xeomin may be stored in unopened vials at room also potentially cause neuromuscular blockade.9 Allergy
temperature at 20° to 25°C, re rigerated at 2° to 8°C, or in a to cow’s milk protein is an additional contraindication
reezer at −20° to −10°C, or up to 36 months. Once recon- to use o AbobotulinumtoxinA, which may contain trace
stituted, the Xeomin product insert states that the product amounts o this product.
should be used within 24 hours. AbobotulinumtoxinA, IncobotulinumtoxinA, and Ona-
Despite the manu acturer’s recommendation that a vial botulinumtoxinA are Pregnancy Category C, and thus are
be single-use, some studies suggest that a reconstituted not recommended or use during pregnancy. T e excre-
BoN -A vial can be used and re-accessed or up to 6 weeks tion o BoN -A or its metabolites in breast milk is pos-
when stored with re rigeration, without loss o ef cacy or sible, and their use is not recommended during lactation.
contamination.14 T e majority o providers use each vial or
more than one patient and sometimes store BoN -A or
greater than 1 week,11,13,15 while in a busy cosmetic practice
t ec h n Iq u es d Iv Id ed by
a bottle is o ten not in use or longer than a day or two. An At o MIc l o c At Io n
BoN -A is typically administered using a 30-gauge
13 mm (1/2 in) needle, but di erent syringes and needles
can be used. A 0.3 mL 30 gauge insulin syringe (product
Gl Abel l Ar c o MPl ex
number 3,28,438, manu actured by B-D Inc, Franklin
T e glabellar complex is the area most commonly treated
Lakes, NJ) to decrease injection pain has been advocated
with BoN -A, and again is the only aesthetic area that is
by Flynn et al.16
FDA-approved or injection o all three currently available
BoN -A products (Fig. 38-1). T e corrugator and procerus
PAt Ien t s el ec t Io n An d muscles contract to produce a urrowed brow, which may
give the impression o anger or sadness. T ese muscles are
Pr eo Per At Iv e c o n s u l t At Io n identi ed by asking the patient to rown or scowl. T ree
to ve intramuscular injection points are typically used in
Photodamage, loss o skin elasticity with aging, and repeated this area (one in the belly o the procerus, and one to two
muscular contractions all contribute to wrinkling. When injections along the corrugators). A single injection point 455
4

A B

Figure 38-1 Gla ellar lines (A) in a patient with maximal rown pretreatment and (B) attempting to rown a ter treatment
S
(23 units Ona otulinumtoxin). (Photos used with permission o Joel L. Cohen, MD.)
e
c
t
i
o
n
in each corrugator may sometimes be pre erred due to T is is more common with older patients, probably due to
4
concern that the agent will spread to the adjacent rontalis downward repositioning o the brow a ter the neuromod-
:
:
muscle in some circumstances due to a patient’s unique ulator agent relaxes the rontalis muscle. For this reason,
A
anatomy. When administering glabellar complex injec- injections have historically been located in the upper two-
e
s
tions, grasping the muscles during contraction, and then thirds o the orehead to allow or maintenance or elevation
t
h
asking the patient to relax, may allow or more precise tar- o brow position; in reality, however, this approach can lead
e
t
i
geting o the muscle belly. I possible, the needle should be to an odd or arti cial appearance when the patient does
c
a
placed intra ollicularly, as this has been shown to decrease elevate their brows, as only the most in erior portion o
n
d
pain on injection.18 o minimize the risk o eyelid ptosis, the rontalis is unctioning in this case. For this reason, the
L
a
some practitioners advocate that injections into the corru- authors recommend care ul patient selection and clear-
s
e
gators should be placed at least 1 cm superior to the supra- cut patient discussions. For many patients, we simply try
r
P
orbital rim at the central area o the eyebrow. Palpating to “so ten” the overall musculature to make it less promi-
r
o
c
with a nger along the bony orbital rim can o ten identi y nent and, there ore, less active in imprinting the skin with
e
d
this landmark.3,19 However, it is important to tailor treat- etched-in lines. Some patients want a total “knock-out”
u
r
ment to each patient, as too high an injection in patients o all orehead movement and we try to deter them, but
e
s
with signi cant lateral brow-lid redundancy can result in i they are young, lack signi cant dermatochalasis, and do
brow ptosis i the lateral corrugator injection spreads to not depend on their rontalis to raise their lateral brows,
the adjacent rontalis muscle (Fig. 38-2) ( able 38-3). we may be more apt to per orm this treatment (Fig. 38-4).
Horizontal orehead lines or urrows are created by Brow ptosis is a complication that is usually avoidable
repeated contraction o the underlying rontalis muscle with proper patient selection. Complete orehead paralysis
(Fig. 38-3). T e signi cant variation in patient anatomy should be discouraged in order to achieve a more natural
is re ected in the variety o techniques used to treat this aesthetic result, and lower starting doses are, there ore, pre -
location. In our opinion, success ul treatment o this area erable, although their duration o action may not be as great
is more challenging than treatment o either the glabellar as those o higher doses. T ese points should be conveyed
complex or crow’s eet. Some patients may decide later that to the patient prior to their rst treatment. Some patients
they do not like either the physical appearance o a “treated will decide to try BoN -A once to determine whether they
orehead” or the “ eeling” o the inability to raise their brow. like the look and eel o reduced or absent rontalis muscle
activity. T ese patients should be seen the week a ter injec-
tion to determine whether additional toxin may be needed
to balance any asymmetry in their appearance.
Multiple rontalis injection sites (sometimes eight or
more) are typically placed using a super cial intramus-
cular injection technique. When injections are placed too
medially, a quizzical eyebrow can result due to continued
activity o the untreated lateral rontalis bers. T is can be
corrected with additional BoN -A injected into the lateral
rontalis,3,20 which can carry a risk o lateral brow droop,
so it is essential to emphasize the need or lower dosages
on the orehead, particularly or patients who have not yet
had experience using this medication.

Figure 38-2 Medial row depression rom gla ellar treat-

ment with undesira le spread o boNT-A to the medial c r o w ’s f eet (o f f -l Abel In d Ic At Io n )
rontalis muscle. The lateral row shows an upward pull as
rontalis f ers in that area persist, resulting in an artif cial Wrinkles radiating outward rom the lateral canthus while
456 look. (Photo used with permission o Joel L. Cohen, MD.) smiling are commonly known as crow’s eet (Fig. 38-5). T e
TAbLe 38-3
4
d o ag G i i or bo i m to i I j io

t o a u i s ar i g d o
n m ro Po ia
I j io Poi bo o /x omi d y por A a omi l a mark c omp i a io

Ga ar c omp
3–5 20–30 50 Palpat th ony sup rior Ptosis, asymm try o th
or ital rim and stay 1 cm rows
a ov it

h orizo a f or a li

C
h
4–8 4–20 10–60 Upp r two thirds o th ey row ptosis, quizzical

a
p
or h ad y row shap with

t
inj ctions plac d too

r
3
c ntrally

8
c ro ’ f

:
:
I
n
1–5 p r sid 12–30 units 20–60 Stay 1–2 cm outsid th bruising, asymm tric smil

j
xt rnal or ital rim. Avoid with paralysis o zygomaticus

c
t
a
visi l lood v ss ls y major (inj ctions too d p

l
str tching und rlying skin or or in rior), ptosis (inj ctions

s
tt r visualization. too d p)

l a ra bro li a ey ro s api g
1 p r sid 12–16 20–40 Lat ral y row. Stay lat ral brow and y lid ptosis can
to th or ital rim occur i inj ction is too clos
to th or ital rim

b yli
1 p r sid 2–4 5–10 1 cm a ov th upp r lat ral bruising, lip drooping i
nostril th l vator la ii ala qu
nasi (LLAN) and l vator la ii
sup rioris ar targ t d, or
asymm tric smil du to
knockout o LLAN and thus
f att ning o NLF as w ll

n a a d roop
Singl inj ction at th 3–5 8–12 Just sup rior to th angl Upp r lip ptosis ( xc ss
as o th colum lla o th colum lla and upp r paralysis o d pr ssor s pti
cutan ous lip nasi). Pain.

lo r ey i w ri k
1–2 p r ach und r 2–4 2–5 Mid pupillary lin , 2 mm ey dryn ss with high r
y low th low r y lid dos s
margin

c i d imp i g
1 p r sid (2 total) 1–3 5–8 bony jawlin , clos to th Inj cting too high into th
or 1 midlin c nt r or icularis oris can caus
inj ction low r lip w akn ss and
drooling. Inj cting too
lat rally can caus slurr d
sp ch or asymm trical smil
i d pr ssor la ii in rioris
inj ct d.

(Continued )
457
4 TAbLe 38-3 (Continued )
d age G i e i e rb i mt i I je i

t a u i s ar i g d e
n m er P e ia
I je i P i b /xe mi dy p r A a mi l a mark c mp i a i

Peri ra w ri k e
1–2 p r upp r lip sid 6–10 10–20 V rmillion ord r no Ov rdosing: di culty
and 1 p r low r lip mor than 5 mm sup rior , sp aking, ating, drinking.
sid philtrum at l ast 1 mm Inj ction too clos to th
lat ral , mouth corn rs at mouth corn rs: mouth
l ast 1.5 cm m dial asymm try or drooping lip.
S
Inj ction >5 mm sup rior
c
to th v rmillion ord r can
t
i
o
caus lip ptosis, inv rsion, or
n
v rsion.
4
d r e o ra c mmi re
:
:
A
1–2 p r upp r lip sid 4–10 10–20 V rmillion ord r no Ov rdosing: di culty
s
and 1 p r low r lip mor than 5 mm sup rior , sp aking, ating, drinking.
t
h
sid philtrum at l ast 1 mm Inj ction too clos to th
t
i
c
lat ral , mouth corn rs at mouth corn rs: mouth
a
l ast 1.5 cm m dial asymm try or drooping lip.
n
d
Inj ction >5 mm sup rior
L
a
to th v rmillion ord r can
s
caus lip ptosis, inv rsion, or
r
P
v rsion.
r
o
c
G mmy s mi e
d
u
r
1 p r sid 2 total 5 10 Lat ral nasal ala Asymm tric smil , xc ssiv
s
l ngth ning o th upp r lip

P a y ma ba
Maximum o 10 points 10–34 5–10 maximum Inj ctions start just low th Dysphonia, dysphagia, n ck
p r sid 20 total dos 100 total jawlin and continu to th w akn ss xc ssiv dos s
mid and and too d p inj ction .
In cacy poor pati nt
s l ction .

Ma e er h yper r p y
1–3 points p r sid up 40–60 60 or Jaw lin or th sup rior Dysphonia, dysphagia, n ck
to 6 total Caucasians, 120 most inj ction. Continu to w akn ss xc ssiv dos s
or Asians th mid and. and inj cting too d p .
In cacy poor pati nt
s l ction .

Primary f a h yper i r i
1 p r cm 2 50–100 p r axilla 150–300 p r Minor’s starch iodin t st Transi nt w akn ss o
30–40 total inj ction axilla d lin at s af ct d ar a intrinsic hand muscl s,
points p r ar a int ns pain with improp r
an sth sia o th palm or
sol .
Comp nsatory hyp rhidrosis
in untr at d ar as.
Note: each ta l giv s only a rough guid lin or num r o inj ction points and starting dos s. ev ry pati nt’s uniqu anatomy must valu
at d individually and tr at d accordingly.

458
 4

A B

Figure 38-3 Horizontal forehead lines (A) at maximal eye row raise pre-treatment and (B) at maximal eye row raise
posttreatment (7 units of Incobotulinum toxin). Lower doses were used for a more “natural result,” to simply lessen the

C
muscular prominence of the frontalis. (Photos used with permission of Joel L. Cohen, MD.)

h
a
p
t
e
r
3
8
:
:
I
n
lateral f bers o the orbicularis oculi muscle are responsi- note, as inadvertent paralysis o these f bers can result in

j
e
ble or producing these lines. Signif cant patient variation an asymmetric smile. T is is avoided by injecting superf -

c
t
a
exists in this area21 and proper injection placement must be cially, as mentioned previously, as well as by making certain

l
determined on an individual basis. ypically, three injection that the lowest injection point is not placed too ar

e
s
points are used, but anywhere rom 1 to 5 injection points in eriorly.3,20,21
may be possible depending on individual patient character-
istics. Injections are generally placed 1 to 2 cm lateral to the
bony external orbital rim. T e needle is typically pointed l At er Al br o w l If t An d br o w
away rom the orbit and injections are superf cial, creating s h APIn G (o f f -l Abel In d Ic At Io n )
intradermal blebs. Superf cial placement in this area mini-
mizes bruising; stretching the skin can help the injector to Drooping lateral eyebrows or brow-lid redundant skin can
visualize superf cial veins so they can be avoided. Some create a tired or unhappy expression. T e “ideal” emale
individuals recruit f bers rom the zygomaticus minor eyebrow lies with the highest point o the arch above the
muscle in creating their crow’s eet, which is important to lateral canthus. Contraction o the lateral orbicularis oculi

A B

Figure 38-4 Horizontal forehead lines (A) in a su ject efore frontalis treatment upon lifting rows and
(B) in a su ject after treatment (32 units of A o otulinumtoxin) upon attempting to lift rows. Patient
desired a “frozen forehead” look despite eing cautioned and advised againast it—as this is the way she
has een treated with otulinum toxin at other facilities in the past. (Photos used with permission of Joel
L. Cohen, MD.)

459
4
S
e
c
t
i
o
n
4
:
:
A
e
s
t
h
A B
e
t
i
c
Figure 38-5 Crow’s eet (A) in a su ject pretreatment and (B) a ter treatment (A o otulinumtoxin 30
a
n
units) at maximum smile. (Photos used with permission o Karen L. Connolly, MD.)
d
L
a
s
e
r
P
r
o
c
e
d
bers depresses the lateral eyebrow, whereas the procerus sidewall into the belly o the musculature. Avoiding the
u
r
and corrugators are responsible or depression o the cen- laterally based levator labii alaeque nasi (LLAN) and
e
s
tral eyebrow. A lateral eyebrow li t can be achieved using levator labii superioris prevents lip ptosis, which can be
toxin to block depression o the lateral eyebrow tail.22,23 a potential complication.19,24 It is usually help ul to take a
One lateral injection point is usually used per side spe- lateral approach to the nasalis muscle and to inject in a
ci cally targeting the lateral orbicularis oculi at the eye- medial direction; this helps prevent unwanted di usion
brow tail, or simply the point at which a squinting patient to the laterally located lip elevators, which also contrib-
demonstrates maximal pull o the orbicularis oculi down- ute to the prominence o the nasolabial old.25 Not every
ward on the lateral brow. T e injector must ensure that patient’s anatomy allows or a success ul treatment result,
the injection point is at least 1 cm rom any trailing lateral and some patients, or unknown reasons, still maintain
bers o the in erior rontalis at the temporal usion line; airly prominent musculature o this area. As this area
otherwise the attempt at li t by targeting only the supe- lies in the same horizontal plane as the crow’s eet, this
rior lateral portion o the orbicularis oculi will be neutral- area is requently injected along with the lateral canthal
ized or o set by hitting the rontalis above it, which would rhytids.
drop the brow. Reported complications include eyelid and
brow ptosis. Injections should be super cial and intra-
muscular.3 Attempts at a lateral brow li t are not always
success ul, especially in patients who have excessive n As Al d r o o P
lid laxity; these patients would best be treated with a (o f f -l Abel In d Ic At Io n )
blepharoplasty .
T e depressor septi nasi muscles control the degree o
nasal tip drooping. reatment o this muscle group with
bu n n y l In es (o f f -l Abel In d Ic At Io n ) toxin can potentially raise the nasal tip, increasing its
distance rom the upper lip and giving the nose a more
“Bunny lines” radiate down the sides o the nose and occur youth ul and resher appearance; however, this treat-
due to contraction o the nasalis muscle on the proximal ment does not reliably create improvement. A single
nasal sidewall (Fig. 38-6). T ese lines are o ten treated deep injection just superior to the angle o the columella
along with the glabellar complex to prevent recruitment; and upper cutaneous lip is typically the point at which
contraction o the procerus muscle itsel can contribute BoN -A is placed. T e injection can be pain ul, so icing
to prominent “bunny lines” as well. One injection point the area be orehand will improve patient tolerance.
per side is placed super cially to minimize bruising; this Adverse e ects include upper lip ptosis with excessive
is usually placed high and medial on the proximal nasal dosages.19,26,27
460
 4

C
h
a
p
t
e
r
3
8
:
:
I
n
A B

j
e
c
t
a
b
l
e
s
C D

Figure 38-6 Patient (A, B) prior to treatment and (C, D) after treatment at maximum nose
wrinkle. (Onabotulinumtoxin 16 units to glabellar complex and 4 units to bunny lines).
(Photos used with permission of Karen L. Connolly, MD.)

in conjunction with crow’s feet injections, thereby pro-

Lo w er eyeLid w r in kLes ducing more noticeable effects. These injections are
(o f f -La beL in d ic a t io n ) superficial, should be done with the needle angled hori-
zontally and away from the globe and should create a
Lower eyelid wrinkles can be caused by activity of the bleb in the skin. Patients must not have dr y eyes or large
orbicularis oculi muscles and photodamage, and can eye bags, and must have a good snap test (demonstrat-
also be hereditar y, although a combination of all three ing that the lower eyelids snap back into place imme-
causes is quite common. Wrinkling caused by hyper- diately after pulling downward on the lower lid). This
activity of the inferior pre-tarsal orbicularis oculi can technique can also be used to achieve the effect of wid-
be treated using one injection point per side at the ening and rounding the eyes19,28 especially if they have
mid-pupillar y line, approximately 2 mm below the an almond shape. This procedure is best performed by
lower lid margin. This technique is usually performed experienced injectors.
461
4

A B

Figure 38-7 Perioral rhytides in (A) patient pretreatment upon contraction o the or icularis oris and (B) posttreatment
S
e
with boNT-A (6 units Onabotulinum toxin). (Photos used with permission o Joel L. Cohen, MD.)
c
t
i
o
n
4
:
:
A
c h In d IMPl In G d o w n t u r n ed o r Al c o MMIs s u r e
e
s
(o f f -l Abel In d Ic At Io n ) (o f f -l Abel In d Ic At Io n )
t
h
e
t
i
c
T e mentalis muscle is responsible or wrinkling and dim- Permanent downward angling o the lateral corners o
a
n
pling o the chin with animation, creating a peau d’orange the mouth conveys an unpleasant rowning appearance
d
L
appearance, as well as protrusion o the lower lip. Push- (Fig. 38-8). T e depressor anguli oris (DAO) muscle
a
s
ing the lower lip superiorly emphasizes this wrinkling. is responsible or this expression, in opposition to the
e
r
reatment with BoN can help smooth these depressions zygomaticus major and minor muscles, which elevate
P
r
o
(sometimes called “gol ball chin”) using one to two injec- the corners o the lips to smile. Injection o BoN -A into
c
e
tion points at the jaw line. Injections are deep and intra- the DAO can allow a so tening o the downward pull on
d
u
muscular. Injecting too high must be avoided, as lower the corners o the mouth by the zygomaticus muscles.
r
e
lip weakness and possibly drooling can occur i the orbi- A combination approach with toxin plus llers can ur-
s
cularis oris is targeted instead o the mentalis muscle.3,19 ther improve marionette lines or melomental olds in
Injections placed too laterally can a ect the depressor labii this area (Fig. 38-8). One deep intramuscular injection is
in erioris (DLI), causing an asymmetric smile, so it is very placed directly into the DAO, which is located along the
important to inject the mentalis medially or even midline mandibular line. Grasping the belly o the muscle dur-
when targeting wrinkles in this area. ing contraction helps to ensure proper placement.3,19 It
may also be help ul or the patient to contract the DAO
(by displaying their lower teeth); the muscle can then be
Per Io r Al w r In k l es (o f f -l Abel injected about 1 cm above the jawline. One should avoid
In d Ic At Io n , o n l y f o r the point on the posterior jawline at which the DAO and
ex Per Ien c ed In j ec t o r s ) DLI come together as a V, and the needle should be aimed
in a lateral direction to avoid unwanted di usion to the
Vertical perioral wrinkles give an appearance o aging and adjacent DLI.
are caused by movement o the orbicularis oris muscle,
which closes the mouth and purses the lips (Fig. 38-7).
Smoking, photoaging, playing a musical instrument, and
Gu MMy s MIl e (o f f -l Abel
whistling contribute to wrinkling in this area.29 wo to In d Ic At Io n , o n l y f o r
six very super cial injection points along the upper lip ex Per Ien c ed In j ec t o r s )
and two along the lower lip are placed at the vermillion
border. T e medial points should be placed at least 1 mm Gummy smile is characterized by excessive gingival
lateral to the philtrum, and the lateral points at least 1.5 exposure and is mainly caused by excessive movement
cm medial to the mouth corners. T e high unctional rom the levator labii superioris alaeque nasi. ypically,
importance o this area must be considered and use o greater than 2 to 3 mm o exposed gingiva is considered
the lowest e ective treatment dose is recommended. unaesthetic. When greater than 3 mm o exposed gin-
Potential adverse e ects include upper lip ptosis with giva posterior to the canines is seen, the zygomaticus
injections superior to the vermillion. Distortion o the muscles are usually involved as well. Most commonly,
Cupid’s bow can be avoided by injecting lateral to the a “gummy” smile is treated with one injection point
midline. O vertreatment with excessive doses can result on each side, at the site o convergence o the leva-
in speech impairment, dif culty eating and drinking, tor labii superioris alaeque nasi, zygomaticus minor,
and drooling. Injections in this area can also be quite and levator labii superioris, just lateral to the nasal
462 pain ul.3,19,29 ala.30– 33
 4

C
h
a
p
t
e
r
3
8
:
:
I
n
j
e
Figure 38-8 Downturned oral commissure treated y com ining boNT-A and a f ller agent, in this case Restylane, to

c
t
correct the appearance o a downturned smile. (Ona otulinumtoxin 3 units into each depressor anguli oris along with

a
Restylane 0.35 cc into each oral commissure). (Photos used with permission o Joel L. Cohen, MD. Reprinted with permis-

l
e
s
sion rom Cohen JL, Hirsch RJ. Challenge: correcting a downturned smile. The Dermatologist. 2006;14(2):52–53.)

Pl At ys MAl bAn d s MAs s e t er h yPer t r o Ph y

(o f f -l Abel In d Ic At Io n ) (o f f -l Abel In d Ic At Io n )
T e platysmal bands create prominent cord-like vertical Hypertrophy o the masseter muscles can create a square
bands as certain patients age, and can become promi- shaped ace and is common in Asian patients. In Cauca-
nent when speaking or smiling. Prominence o bands sian patients, bruxism is associated with masseter hyper-
is best assessed with the patient pronouncing the letter trophy, which can also be caused by regularly chewing
“E.” T e ideal patient or treatment o these bands has bulky bubblegum or grinding ice. T is hypertrophy can
retained elasticity o the neck skin and does not have be treated using a deep three point injection technique
excessive laxity or at in this area. T e patient should per side, thereby weakening the masseter muscles, which
also have prominent platysmal banding a t rest. T e dose can be palpated with the patient clenching the jaw. Injec-
and number o injection points var y widely in the lit- tions are placed between a line connecting the earlobe
erature. T e trend is toward lower toxin dosage in this and the corner o the mouth, and ending 1.5 cm above the
area, which results in excellent clinical improvement mandibular angle. Alternatively, the area can be treated
while minimizing complications and reducing costs. as a square with injections o the our corners and in the
Injections are placed by grasping the belly o the muscle middle o the square. Potential adverse e ects may occur
along a band and starting at the jawline, moving down with injections placed too close to the zygomaticus bone
ever y 1.5 to 3 cm or each successive injection. Dosing medially, which weaken the zygomaticus minor or major
is highly dependent on prominence o the patient’s mus- and cause a distorted smile, as well as weakened mastica-
culature. Our starting doses range rom 12 to 34 units tion i overdosing occurs. In Asian patients, higher doses
o Botox. Adverse e ects, including dysphagia, neck are typically used than in Caucasian patients, who tend to
weakness, and dysphonia are avoided by not exceed- have less hypertrophy. Clinical results are usually noted
ing maximum doses and using a horizontal superf cial in 2 to 4 weeks,19,36,37 but it o ten takes two treatment ses-
intramuscular injection technique, pulling the band sions about 3 months apart in our experience or more
away rom the underlying strap muscles.3,19 T ere is one noticeable improvement to be documented by standard-
report o a patient who received 60 units o Botox in the ized photos.
platysma and developed dysphagia, requiring a nasogas-
tric tube or 6 weeks.34
T e Ne ertiti li t, as described by Levy, involves injec- Pr IMAr y f o c Al h yPer h Id r o s Is
tion o BoN -A along the in erior border o the mandible
and the superior aspect o the most posterior platysmal Primary idiopathic ocal hyperhidrosis a ects the axil-
band, resulting in a tighter appearance o the jawline. Fi - lae, palms, and soles and has a signif cant social impact
teen to twenty units o Botox per side is the recommended on patients. T e sympathetic nervous system inner-
starting dose.35 vates eccrine sweat glands and stimulates sweating via 463
4 acetylcholine release. BoN has emerged as an e ective
treatment or severe or re ractory primary ocal hyper-
the area o injection, causing systemic symptoms o botu-
lism, although this seems to occur in therapeutic patients
hidrosis. Minor’s starch iodine test can be help ul to and not in cosmetic patients, as therapeutic patients are
delineate the initial treatment area, and is use ul in cases o ten treated with ve to ten times the typical overall cos-
requiring a “touch-up” to identi y the exact area or addi- metic dosages. Included in the warning are asthenia, gen-
tional treatment. T e a ected area is treated with a series eralized muscle weakness, diplopia, blurred vision, ptosis,
o intradermal BoN -A injections. reatment o axil- dysphagia, dysphonia, dysarthria, urinary incontinence,
lary hyperhidrosis is not all that pain ul and many times and breathing dif culties. Death rom breathing dif cul-
patients receive this treatment with only ice to the treat- ties has also been reported. No serious adverse event rom
ment area. On the palms and soles, most patients require distant spread o toxin has been reported with cosmetic
at least ice, while others may try a topical anesthetic; less use o BoN -A at the labeled dose. In the event o an over-
o ten nerve blocks o the palms or soles are per ormed due dose, an antitoxin is available rom the CDC. However, it
to signi cant pain with multiple injections in these sensi- is only e ective prior to onset o any clinically apparent
tive areas.38– 42 Sometimes multiple modalities such as ice, BoN e ects.
a compressed air device, and a vibratory massage device
S
e
can be use ul to decrease pain through the Gates Principle
c
t
i
o A erent Overstimulation.43,44 IMMu n o Gen Ic It y An d
o
n
t r eAt Men t f AIl u r e
4
:
:
Af t er c Ar e T e immunogenicity o the complexing proteins in BoN -
A
A ormulations has been a concern as well as develop-
e
s
ment o neutralizing and nonneutralizing antibodies.
t
Massage o the acial and neck treatment areas immedi-
h
e
ately a ter injection is not recommended by most experts, However, the actual incidence o antibody conversion is
t
i
c
although it may be used when treating hyperhidrosis to very low, estimated at 0.28% or glabellar lines and 0.46%
a
n
avoid displacement or excessive movement o the product. or axillary hyperhidrosis in patients treated with Ona-
d
botulinumtoxinA in a meta-analysis by Naumann et al.47
L
Contraction o the injected area or approximately 2 hours
a
O the 2240 subjects, only three became nonresponsive
s
a ter treatment is thought to increase product uptake.3
e
r
Applying pressure and ice immediately a ter injection in to OnabotulinumtoxinA, indicating that the majority o
P
r
antibodies ormed did not a ect the critical domain on
o
areas prone to bleeding and ecchymoses (e.g., crow’s eet)
c
the neurotoxin protein. A study by Lawrence and Moy48
e
can be help ul.
d
also ailed to show neutralizing antibody production in
u
r
e
1554 patients treated with 50 units o Abobotulinumtox-
s
inA at a variety o sites (although 0.32% o patients were
c o MPl Ic At Io n s seropositive or AbobotulinumtoxinA antibodies during
the study). T e package insert or IncobotulinumtoxinA
c o MMo n Ad v er s e ev en t s reports a 1.1% rate o conversion to neutralizing antibod-
ies in a group o 1080 subjects. However, the package
T e most common nonserious adverse events reported insert goes on to assert that the majority o patients who
since licensure o OnabotulinumtoxinA are lack o e ect developed neutralizing antibodies had been previously
(63%), injection site reaction (19%), ptosis (11%), muscle exposed to di erent botulinum neurotoxins. T e longest
weakness (5%), and headache (5%).45 T e common injec- e ective interval between treatments is, there ore, gener-
tion site-related adverse events reported in package inserts ally recommended.8
or all three licensed BoN -A products are similar and
include localized pain, in ection, in ammation, tender-
ness, swelling, erythema, bleeding, headache, respiratory MAl e PAt Ien t Po Pu l At Io n
in ection, injection site pain, nasopharyngitis, nausea,
blepharoptosis, and bruising. Male patients are expressing increased interest in pur-
Eyelid ptosis is uncommon with experienced injectors suing treatment with BoN -A. In most areas men can
but can certainly occur with BoN -A placement in the be treated with the same techniques as in women but
periorbital area including the glabellar complex. Alpha- with higher doses, due to increased muscle mass. he
adrenergic eye drops can be used in the treatment o glabella is a common area o treatment and the recom-
BoN -A– induced blepharoptosis through activation o mended starting dose o Botox is at least 25 units, and
Muller’s muscle in the upper eyelid.46 possibly as high as 35 to 40 units. echnique must be
adjusted according to individual patient anatomy, as
some male patients have a broader corrugator muscle,
s er Io u s Ad v er s e e v en t s necessitating more lateral injection points.49,50 Crow’s
eet are also common areas o treatment or male
Serious adverse events occur more commonly with the patients, requiring similar techniques with increased
use o BoN s or therapeutic as opposed to cosmetic use. doses. It has been our experience that many men do
A black box warning was added to the package inserts o better with lower doses in the orehead to simply so ten
Dysport, Botox, and Xeomin ollowing postmarketing the musculature, rather than attempting to completely
464 reports that BoN products may spread distantly rom paralyze the muscle.
c o n c l u s Io n 18. Lewis , Jacobsen G, Ozog D. Intra ollicular ori ce injec-
tion technique or botulinum toxin type A. Arch Dermatol.
4
2008;144(12):1657– 1658.
As the use o non-invasive cosmetic procedures rises 19. Ascher B, alarico S, Cassuto D, et al. International consensus
in prevalence, amiliarity with the various injectable recommendations on the aesthetic usage o botulinum toxin
type A (Speywood Unit)– Part II: Wrinkles on the middle and
toxins will continue to hold importance or the cos- lower ace, neck and chest. J Eur Acad Dermatol Venereol.
metic practitioner. he authors emphasize an indi- 2010;24(11):1285– 1295.
vidual approach to treatment with close evaluation o 20. Ascher B, alarico S, Cassuto D, et al. International consen-
each patient’s unique musculature and acial structure sus recommendations on the aesthetic usage o botulinum
or optimal outcomes. With experience and detailed toxin type A (Speywood Unit)– Part I: upper acial wrinkles.
J Eur Acad Dermatol Venereol. 2010;24(11):1278– 1284.
knowledge o acial anatomy, master y o these tech- 21. Kane MA. Classi cation o crow’s eet patterns among Cau-
niques can be achieved. casian women: the key to individualizing treatment. Pla st
Reconstr Surg. 2003;112(Suppl 5):33S– 39S.
22. Ahn MS, Catten M, Maas CS. emporal brow li t using botu-
linum toxin A. Pla st Reconstr Surg. 2000;105(3):1129– 1135;
r ef er en c es

C
discussion 1136– 1139.

h
23. Cohen JL, Dayan SH. Botulinum toxin type a in the treatment

a
p
1. Aoki KR. Pharmacology and immunology o botulinum neu- o dermatochalasis: an open-label, randomized, dose-com-

t
e
rotoxins. Int Ophthalmol Clin. 2005;45(3):25– 37. parison study. J Drugs Dermatol. 2006;5(7):596– 601.

r
2. Carruthers A. History o the clinical use o botulinum toxin A

3
24. Carruthers J, Carruthers A. Botulinum toxin A in the mid

8
and B. Clin Dermatol. 2003;21(6):469– 472. and lower ace and neck. Dermatol Clin. 2004;22(2):151– 158.
3. Carruthers J, Fagien S, Matarasso SL; Botox Consensus 25. Pessa JE, Brown F. Independent e ect o various acial

:
:
Group. Consensus recommendations on the use o botu- mimetic muscles on the nasolabial old. Aesthetic pla st Surg.
linum toxin type a in acial aesthetics. Pla st Reconstr Surg.

I
1992;16(2):167– 171.

n
j
2004;114(Suppl 6):1S– 22S. 26. Dayan SH, Kempiners JJ. reatment o the lower third o the

e
c
4. Karsai S, Raulin C. Current evidence on the unit equivalence nose and dynamic nasal tip ptosis with Botox. Pla st Reconstr

t
a
o di erent botulinum neurotoxin A ormulations and rec- Surg. 2005;115(6):1784– 1785.

l
ommendations or clinical practice in dermatology. Dermatol

e
27. Ghavami A, Janis JE, Guyuron B. Regarding the treatment

s
Surg. 2009;35(1):1– 8. o dynamic nasal tip ptosis with botulinum toxin A. Pla st
5. Wenzel R, Jones D, Borrego JA. Comparing two botulinum Reconstr Surg. 2006;118(1):263– 264.
toxin type A ormulations using manu acturers’ product 28. Flynn C, Carruthers JA, Carruthers JA, Clark RE 2nd. Botuli-
summaries. J Clin Pharm T er. 2007;32(4):387– 402. num A toxin (BO OX) in the lower eyelid: dose- nding study.
6. Klein AW, Carruthers A, Fagien S, Lowe NJ. Comparisons Dermatol Surg. 2003;29(9):943–950; discussion 950–951.
among botulinum toxins: an evidence-based review. Pla st 29. Cohen JL, Dayan SH, Cox SE, Yalamanchili R, ardie G. Ona-
Reconstr Surg. 2008;121(6):413e– 422e. botulinumtoxinA dose-ranging study or hyperdynamic peri-
7. Jandhyala R. Relative potency o incobotulinumtoxinA vs oral lines. Dermatologic Surg. 2012;38(9):1497– 1505.
onabotulinumtoxinA a meta-analysis o key evidence. J Drugs 30. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin:
Dermatol. 2012;11(6):731– 736. a new approach based on the gingival exposure area. J Am
8. Sattler G. Current and uture botulinum neurotoxin type A Acad Dermatol. 2010;63(6):1042– 1051.
preparations in aesthetics: a literature review. J Drugs Derma- 31. Mangano A. Current strategies in the treatment o gummy
tol. 2010;9(9):1065– 1071. smile using botulinum toxin type A. Pla st Reconstr Surg.
9. Huang W, Foster JA, Rogache sky AS. Pharmacology o 2012;129(6):1015e.
botulinum toxin. J Am Acad Dermatol. 2000;43(2 Pt 1): 32. Hwang WS, Hur MS, Hu KS, et al. Sur ace anatomy o the
249– 259. lip elevator muscles or the treatment o gummy smile using
10. Spencer JM. Botulinum toxin B: the new option in cosmetic botulinum toxin. Angle Orthod. 2009;79(1):70– 77.
injection. J Drugs Dermatol. 2002;1(1):17– 22. 33. Sucupira E, Abramovitz A. A simpli ed method or smile
11. Alam M, Dover JS, Arndt KA. Pain associated with injection enhancement: botulinum toxin injection or gummy smile.
o botulinum A exotoxin reconstituted using isotonic sodium Pla st Reconstr Surg. 2012;130(3):726– 728.
chloride with and without preservative: a double-blind, ran- 34. Carruthers J, Carruthers A. Practical cosmetic Botox tech-
domized controlled trial. Arch Dermatol. 2002;138(4):510–514. niques. J Cutan Med Surg. 1999;3(Suppl 4):S49–S52.
12. Vadoud-Seyedi J, Simonart . reatment o axillary hyperhi- 35. Levy PM. T e ’Ne ertiti li t’: a new technique or speci c
drosis with botulinum toxin type A reconstituted in lidocaine re-contouring o the jawline. J Cosmet La ser T er. 2007;
or in normal saline: a randomized, side-by-side, double-blind 9(4):249– 252.
study. Br J Dermatol. 2007;156(5):986–989. 36. Choe SW, Cho WI, Lee CK, Seo SJ. E ects o botulinum
13. Liu A, Carruthers A, Cohen JL, et al. Recommendations and toxin type A on contouring o the lower ace. Dermatol Surg.
current practices or the reconstitution and storage o botu- 2005;31(5):502– 507; discussion 507– 508.
linum toxin type A. J Am Acad Derma tol. 2012;67(3):373– 37. Kim NH, Chung JH, Park RH, Park JB. T e use o botuli-
378. num toxin type A in aesthetic mandibular contouring. Pla st
14. rindade De Almeida AR, Secco LC, Carruthers A. Handling Reconstr Surg. 2005;115(3):919– 930.
botulinum toxins: an updated literature review. Dermatol 38. Solish N, Bertucci V, Dansereau A, et al. A comprehensive
Surg. 2011;37(11):1553– 1565. approach to the recognition, diagnosis, and severity-based
15. Hexsel DM, De Almeida A , Rutowitsch M, et al. Multicenter, treatment o ocal hyperhidrosis: recommendations o the
double-blind study o the ef cacy o injections with botulinum Canadian Hyperhidrosis Advisory Committee. Dermatol
toxin type A reconstituted up to six consecutive weeks be ore Surg. 2007;33(8):908– 923.
application. Dermatol Surg. 2003;29(5):523–529; discussion 9. 39. Vergilis-Kalner IJ. Same-patient prospective comparison o
16. Flynn C, Carruthers A, Carruthers J. Surgical pearl: the Botox versus Dysport or the treatment o primary axillary
use o the Ultra-Fine II short needle 0.3-cc insulin syringe hyperhidrosis and review o literature. J Drugs Dermatol.
or botulinum toxin injections. J Am Acad Dermatol. 2011;10(9):1013– 1015.
2002;46(6):931–933. 40. Naumann M, Lowe NJ, Kumar CR, Hamm H; Hyperhi-
17. Hillebrand GG, Liang Z, Yan X, et al. New wrinkles on drosis Clinical Investigators Group. Botulinum toxin type
wrinkling: an 8-year longitudinal study on the progression a is a sa e and e ective treatment or axillary hyperhidro-
o expression lines into persistent wrinkles. Br J Dermatol. sis over 16 months: a prospective study. Arch Dermatol.
2010;162(6):1233– 1241. 2003;139(6):731– 736. 465
4 41. Hornberger J, Grimes K, Naumann M, et al; Multi-Specialty
Working Group on the Recognition, Diagnosis, and reat-
47. Naumann M, Carruthers A, Carruthers J, et al. Meta-analysis
o neutralizing antibody conversion with onabotulinumtox-
ment o Primary Focal Hyperhidrosis. Recognition, diagno- inA (BO OX(R)) across multiple indications. Mov Disord.
sis, and treatment o primary ocal hyperhidrosis. J Am Acad 2010;25(13):2211– 2218.
Dermatol. 2004;51(2):274– 286. 48. Lawrence I, Moy R. An evaluation o neutralizing antibody
42. Benohanian A. What stands in the way o treating palmar induction during treatment o glabellar lines with a new US
hyperhidrosis as e ectively as axillary hyperhidrosis with ormulation o botulinum neurotoxin type A. Aesthet Surg J.
botulinum toxin type A. Dermatol Online J. 2009;15(4):12. 2009;29(Suppl 6):S66–S71.
43. Cohen JL, Cohen G, Solish N, Murray CA. Diagnosis, impact, 49. Kane MA, Brandt F, Rohrich RJ, Narins RS, Monheit GD,
and management o ocal hyperhidrosis: treatment review Huber MB; Reloxin Investigational Group. Evaluation o
including botulinum toxin therapy. Facial Pla st Surg Clin variable-dose treatment with a new U.S. Botulinum oxin
North Am. 2007;15(1):17– 30, v– vi. ype A (Dysport) or correction o moderate to severe glabel-
44. Cohen JL, Solish N. reatment o hyperhidrosis with botulinum lar lines: results rom a phase III, randomized, double-blind,
toxin. Facial Plast Surg Clin North Am. 2003;11(4):493–502. placebo-controlled study. Pla st Reconstr Surg. 2009;124(5):
45. Cote R, Mohan AK, Polder JA, Walton MK, Braun MM. 1619– 1629.
Botulinum toxin type A injections: adverse events reported 50. Carruthers A, Carruthers J. Prospective, double-blind, ran-
to the US Food and Drug Administration in therapeutic and domized, parallel-group, dose-ranging study o botulinum
S
cosmetic cases. J Am Acad Dermatol. 2005;53(3):407– 415. toxin type A in men with glabellar rhytids. Dermatol Surg.
e
46. Karami M, aheri A, Mansoori P. reatment o botulinum 2005;31(10):1297– 1303.
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toxin-induced eyelid ptosis with anticholinesterases. Derma-
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tol Surg. 2007;33(11):1392–1394; discussion 1394– 1395.
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 Ch a p t e r

39 Non-Invasive Fat Removal

H. Ray Jalian

In t r o d u c t Io n various clinical situations support the cryo-sensitivity o

adipocytes.8– 11 With these historical observations in mind,
a series o pre-clinical experiments in swine demonstrated
Fat uels a 20 billion dollar industry in the United States.
loss o super cial at 3 months a ter a single application
One hundred eight million Americans are on a diet every
o cold without signi cant pigmentary alteration, textural
year.1 T e desire or weight loss and optimization o the
changes, or scarring.6,12
human physique is hardly a new trend. As health care
T e mechanism o action o cryolipolysis is hypoth-
and sanitation have improved, the waist circum erence o
esized to be through apoptosis o adipocytes. Alternative
Americans has increased. With better availability o ood
mechanisms include cold and vacuum induced reper u-
has come an increased incidence o overweight people.
sion injury and subsequent oxidative damage. Histology
T e progression o this trend ushered in the era o weight
specimens rom treatment areas demonstrate a delayed,
loss regimens and schemes. T is was apparent as early as
mixed in ammatory lobular panniculitis, peaking at 2 to
the late nineteenth century in William Banting’s “Letter
4 weeks a ter treatment. As the in ammatory in ltrate
on Corpulence, Addressed to the Public.”2 We are con-
subsides, variably sized adipocytes and widening o the
tinuously inundated with a glut o “too good to be true”
brous septa are observed concurrent with the clinical
schemes, and the public’s obsession with at loss has never
reduction in at.6
been greater.
Numerous randomized clinical trials support the
In the 1920s, a primitive orm o liposuction gained
modest, but appreciable, clinical e cacy o cryolipolysis
popularity in France but was largely abandoned a ter a
(Fig. 39-1). Initial clinical studies treated 32 subjects with
French model su ered gangrene in her leg ollowing the
ocal adiposity o the “love handles” demonstrating decrease
procedure in 1926. T e late 1960s saw the re-emergence
in adiposity by digital photography, blinded assessment and
o liposuction, which evolved into suction assisted lipo-
subject satis action. Ultrasonographic evaluation revealed
suction in the early 1980s, and shortly therea ter into
an average 22% reduction in at layer thickness in the treat-
tumescent liposuction, which enabled the procedure to
ment area.13 Subsequent studies have demonstrated similar
be per ormed in the o ce setting. Currently, liposuction
improvements by photographic as well as caliper measure-
is the top cosmetic surgical procedure per ormed in the
ments.14,15 More recently, Garibyan et al. conducted a ran-
United States.3 Despite its popularity, it is still an invasive
domized trial evaluating the clinical e cacy o cryolipolysis
surgical procedure and involves signi cant risks, includ-
using standardized three-dimensional photography. An
ing in ection, anesthesia complications, and even death.4,5
average volumetric reduction o 50 cc was observed at the
As a result, there is a signi cant desire or e ective, sa e
treatment site when compared to controls (personal com-
non-invasive modalities or body contouring.
munication, Lilit Garibyan, MD, PhD).
In the last 5 years, we have seen the introduction o
Currently, cryolipolysis is approved by the Food and
several device-based treatments or body contouring and
Drug Administration (FDA) or the treatment o ocal adi-
non-invasive at reduction. Some o these technologies,
posity o the “love handles” and the abdomen. T e cur-
such as cryolipolysis and lipid selective lasers, selectively
rent commercial device utilizes a variety o cup-shaped
target unique physical properties o adipocytes. Others,
vacuum applicators with two cooling panels (CoolSculpt-
such as ultrasound and radio requency (RF), selectively
ing, Zeltiq Aesthetics, Inc, Pleasanton, CA). A ter applica-
heat adipose tissue or disrupt cell membranes to produce
tion o a gel-saturated abric, the vacuum draws the tissue
their e ects. T is chapter will serve as an overview o the
inward to ll the applicator as well as acilitate cooling by
various approaches to non-invasive body contouring.
causing relative vasoconstriction. T ere is a pre-deter-
mined cooling intensity actor (CIF), a value representing
the rate o ef ux o heat rom the tissue, or a 60 minute
c r yo l Ipo l ys Is cycle. Following treatment, the applicator is removed and
the treatment area is manually massaged to homogenize
Manstein et al. 6 introduced the concept o cryolipolysis, the ice crystals.
the use o controlled cooling to selectively damage adipo- Following initial clearance by the FDA in 2010, there
cytes. T e discovery o cold sensitivity o adipocytes is not have been over 700,000 treatment cycles o cryolipolysis
a new observation, but rather was rst described in the per ormed. T e majority o side e ects are predictable and
1970s by Epstein. He described so-called “popsicle pannic- transient. Common and immediate side e ects include
ulitis” in three children who developed ocal lipoatrophy erythema localized to the treatment site. Ecchymosis is
o the cheek a ter prolonged exposure to a cold popsicle.7 not uncommon, particularly i the patient is on anticoagu-
Indeed, numerous reports o cold induced lipoatrophy in lants. Pain during the procedure is minimal, and decreases
4

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Figure 39-1 Cryolipolysis treatment o subject’s le t love handle. (A) Anterior and (B) posterior view prior to treatment.
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Three months ollowing a single cycle to treatment area, there is a noticeable decrease in size o the love handle on the
n
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(C) anterior and (D) posterior view. Only treatment o le t side was per ormed. Note no signif cant change in contralateral
L
(untreated) site. (Photos used with permission o Lilit Garibyan, MD, PhD, Wellman Center or Photomedicine.)
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urther once the anesthetic e ect o cooling takes e ect. the male demographic. T e onset o PAH is delayed sev-
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Alterations in cutaneous sensation were reported in the eral months ollowing treatment. o date, no cases o PAH
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initial clinical trials, with up to 96% o subjects expe- have resolved spontaneously and all have required either
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riencing temporarily decreased sensation. T is numb- lipoplasty or abdominoplasty to correct the de ect. T e
ness largely resolves by 1 week posttreatment, though it mechanism o action is largely unknown.20
can linger or up to 2 months.16 No permanent cases o
anesthesia have been reported. Posttreatment pain is lim-
ited, but rare cases o severe, intractable “shooting” and u lt r a so u n d
“jabbing” pain have been reported. T e incidence is
approximately one in 2000 and most commonly ollows Ultrasound can non-invasively target adipocytes through
treatment with the larger applicator.17 T ere is no signi - nonthermal and thermal mechanisms. Ultrasound is a
cant increase in serum lipids or elevated liver unction cyclic sound pressure wave with a requency above the
tests ollowing cryolipolysis.18 Cryolipolysis is relatively range o human hearing (>20 kHz). T ese waves pass
contraindicated in patients with cold sensitive dermato- through tissue, where they are scattered, re ected, or
ses, including cryoglobulinemia, cold urticaria, Raynaud’s absorbed. Depending on the requency o the incident
syndrome, or paroxysmal cold induced hemoglobinuria. ultrasound wave, various tissue interactions can occur.
With an increasing number o treatment cycles, rare side Low-intensity/low- requency ultrasound results in non-
e ects ollowing cryolipolysis have emerged. Subcutane- thermal cavitation in the adipose tissue. In this case, the
ous induration, described as generalized induration or dis- energy delivered has su cient negative pressure to disrupt
crete nodules (BB pellets to marbles) in the treatment area, the molecular adhesion o the adipocytes, thus creating
was reported in a small subset o subjects. T is side e ect “holes” within the tissue. High-intensity ocused ultra-
typically develops 2 weeks to 2 months post treatment, is sound (HIFU) delivers energy o su cient intensity to the
transient in nature, and is o ten best appreciated by palpa- adipose tissue to result in thermal ablation o adipocytes.
tion. T is phenomenon is sel -limited and resolves in 3 to 6
months without any intervention.19 Perhaps more concern-
ing is the report o paradoxical adipose hyperplasia (PAH), l o w -In t en s It y u l t r a s o u n d
which is delayed enlargement beyond baseline o the treat-
ment site. T e incidence o PAH is approximately one in Low-intensity, nonthermal ultrasound delivers concen-
20,000 treated patients, although as new cases continue to trated energy to a precise depth in the subcutaneous tis-
emerge it may prove to be a more common phenomenon. sue. T is mechanical energy is used to disrupt at cells
Various anatomic locations have been reported including without generating heat, thus sparing the neighboring
the anks, abdomen, and upper back. No single, uni ying structures such as skin, blood vessels, and nerves. T is
characteristic has been identi ed among a ected individu- approach relies on the di erential susceptibility o at cells
468 als at this time, although it seems to be more common in to mechanical stresses. A transducer utilizing an external
guidance system directs a ocused beam o energy into the
tissue. Pulses o low intensity ultrasound waves alter adi-
Side e ects rom HIFU occurred in approximately 10%
o subjects and included prolonged tenderness, edema,
4
pocyte cellular membranes, generating cavitations within ecchymoses, and hard lumps. All adverse events resolved
the tissue.21,22 within 1 to 3 months ollowing treatment. T e procedure
Low-intensity ultrasound is approved by the FDA or is more pain ul than nonthermal ultrasound, and some
circum erence reduction o the waist, hips, and thighs. study subjects did not tolerate the treatment. No increases
One o the initial studies to evaluate the e cacy o in serum lipids or transaminases were noted.
low-intensity ultrasound demonstrated a reduction in
circum erence measurements and at thickness, as mea-
sured by ultrasonography, 1 month a ter three monthly r a d Io Fr eq u en c y
treatments (UltraShape Ltd, el Aviv, Israel).22 A larger
study reported a mean reduction o approximately 2 cm RF has numerous applications in medicine, including RF
in treatment area circum erence and approximately 2.9 cardiac ablation.32 RF delivered at nonablative energy is
mm in at thickness up to 12 weeks a ter a single treat- used mainly to target dermal collagen in an attempt to
ment.23 Side e ects were minimal with subjects reporting tighten the skin. Quite simply, an RF current introduced

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mild pain, erythema, purpura, and rarely blister orma- into the tissue generates heat by trans er o energy rom

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tion. No treatment related elevations in serum lipids were the electric eld to charges in the tissue. RF can be deliv-

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reported. Despite initial excitement, these results were ered using monopolar, bipolar, and unipolar devices. In

3
9
not reproducible in a cohort o Asian subjects in a ollow- monopolar RF, a delivery electrode is placed over a tar-
up study.24 O note, none o the a orementioned studies get area and a return electrode is applied at a distant site.

:
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had any histologic assessment o adipose tissue. Further T is allows a current to be generated that passes through

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studies are needed to determine the e cacy and the exact the target tissue. In general, these monopolar devices

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mechanism o at loss. have greater depth o penetration and are more pain ul.

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Delivery o energy can be static (e.g., short cycle in pulses)

v
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or dynamic (e.g., long cycles with a continuously mov-

s
HIg H-In t en s It y Fo c u s ed

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ing handpiece). In bipolar RF devices both electrodes are

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u lt r a so u n d

F
incorporated into a single hand-piece. T e depth o heat-

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ing is determined by the distance between the electrodes.

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HIFU has been used or nearly hal a century or the non- Unipolar RF systems unction with one electrode and no

m
invasive treatment o tumors o various organs,25,26 but has grounding pad.

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only recently been evaluated as a method or the selec- RF devices can non-invasively heat large volumes o tis-

a
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tive destruction o adipose tissue. High-energy ultrasonic sue. By choosing the appropriate device and parameters o
waves are ocused into the subcutaneous tissue, quickly heat delivery, it is possible to selectively con ne heat to the
raising the temperature above 56°C, resulting in coagula- adipose tissue. Although the majority o studies using RF
tive necrosis o the adipocytes, and a subsequent reduc- investigate e cacy or skin tightening and cellulite, more
tion o the at layer. Histology rom pre-clinical and clinical recently introduced devices are designed speci cally or
studies demonstrates localized damage selective to the non-invasive body contouring. Large, peer-reviewed stud-
adipose tissue with sparing o the vasculature and nerve ies demonstrating the utility o these devices or this appli-
bers within the treatment area. Gross examination o cation are or the most part lacking. Nonetheless several
abdominoplasty specimens reveals well demarcated zones devices have gained clearance by the FDA. T ese devices
o necrosis limited to the treatment area. Microscopically, vary rom static, pulsed monopolar devices (T ermacool
adipocyte necrosis is evident as demonstrated by disrup- C, Solta Medical, Hayward, CA; rusculpt, Cutera, Bris-
tion o cell membranes immediately a ter treatment. wo bane, CA) to dynamic monopolar devices (Exilis, B L,
weeks ollowing treatment, lipid-laden macrophages are Prague, Czech Republic). Further studies are needed to
present within the treatment zone. Resorption o lipids evaluate the e cacy o these devices.
and healing are complete at approximately 14 weeks ol- T e mechanism o action is largely unknown, although
lowing a single treatment, corresponding to the observed one study demonstrated thermal injury to adipocytes 9
clinical decrease at that time point. Examination o organs days a ter treatment. Subsequent granulomatous in am-
rom distal organs in pre-clinical studies did not nd any mation coupled with oamy histiocytes was later observed
at emboli.27– 29 within the adipose tissue. In the limited data available,
T e second-generation HIFU device gained FDA clear- there has been no associated increase in circulating serum
ance in 2011 (Solta Medical, Hayward, CA). Initial evi- lipids ollowing treatment with an RF device.33
dence or e cacy and sa ety in humans was based on two
large case series o over 300 patients who had a single
HIFU treatment to the anterior abdomen and anks.27,30 l o w -l ev el l a s er t Her a py
Waist circum erence measurements taken 12 weeks post-
treatment showed an average decrease o approximately Low-level laser therapy (LLL ) is a relatively new area o
4.5 cm. Moreover, subject satis action was greater than photobiology based on the use o speci c wavelengths
70% 3 months ollowing treatment. A subsequent ran- o light to target cellular ultrastructure and alter cellular
domized control trial o 180 patients demonstrated a sta- unction. T is technology is widely being applied to vari-
tistically signi cant decrease in waist circum erence in ous applications in dermatology including treatment o
the treatment group when compared to the sham treated androgenetic alopecia and wound healing.34,35 T e enthu-
control at 12 weeks ollowing a single treatment.31 siasm regarding the use o LLL or targeting at is based 469
4 on the in vitro observation that transient pores can be
induced in adipocytes a ter exposure to a 635 nm laser.36
at, or desire global improvement are not ideal candidates.
Moreover, those wishing to achieve noticeable weight loss
T e ormation o the pore is hypothesized to allow or the or improvement in visceral at will have negligible results.
escape o lipid contents into the interstitial compartment T e nascent nature o this eld makes it di cult to com-
with subsequent clearance rom the body. Although ini- pare the various technologies to determine whether one
tially utilized as a combination treatment with liposuction, device is better than the other. Even with promising clini-
LLL alone is now used or at reduction. cal results it is always important to approach these emerg-
LLL or non-invasive body contouring was FDA ing technologies with a healthy dose o skepticism. Studies
cleared in 2010. Many o the commercial devices contain evaluating non-invasive body contouring are di cult to per-
multiple low-power laser diodes operating in the spec- orm. Circum erence measurements are inherently error-
trum o red light (635 nm). Multiple treatment sessions prone and susceptible to variation due to body positioning
are per ormed and o ten a nutritional supplement is con- and variation in investigator methodologies. T e same can
currently administered throughout the treatment course. be said regarding standardized photographs. Moreover
Although this approach appears to be quite sa e, there are some o these studies were not controlled or weight and
con icting studies to support its e cacy.37,38 In addition, thus can have variations based on weight changes. Finally,
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unlike many o the technologies described previously, no very ew have looked at actual at thickness by non-invasive
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histologic evidence o selective damage to adipocytes has means. Although some caliper measurements have been
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been published ollowing LLL . per ormed, these also are error-prone.42 Longevity o results
4
and long-term sa ety are still relatively unknown.
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Despite the limitations and modest e cacy, non-
In Fr a r ed l a s er s invasive body contouring is now a reality and, just as the
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average waistline o Americans is growing, the demand
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Selective photothermolysis involves the selection o a or this technology is rising. As the technology continues
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wavelength o light and pulse duration that su ciently to evolve, we are likely to see improved clinical e cacy,
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a
heat a speci c target without damage to the surround- which perhaps will one day rival the dramatic e ects o
n
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ing tissue.39 T is con nement o heat allows or the tar- liposuction.
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geting o individual chromophores without disruption
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o bystander tissue. Lipid-rich tissue has characteristic
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absorption within the in rared spectrum due to molecu- r eFer en c es
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lar vibrations o the carbon and hydrogen bonds. With
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this in mind, Anderson et al.40 characterized the absorp-
d
1. 100 Million Dieters, $20 Billion: T e Weight-Loss Indus-
u
tion spectrum o at, and identi ed relative absorption
r
try by the Numbers. 2012. http://abcnews.go.com/Health/
e
s
peaks at 1210 nm and 1720 nm where the absorption o 100-milliondieters-20-billion-weight-loss-industry/story?id
lipid is greater than that o water. A pilot human easibil- = 16297197. Accessed November 20, 2013.
2. Banting W. Letter on Corpulence, Addressed to the Public.
ity study investigated the use o a 1210 nm diode laser or 2nd ed. London: Harrison and sons; 1863:22.
the non-invasive destruction o at. Punch biopsy speci- 3. Statistics, Surveys & rends. American Society o Aesthetic
mens revealed damage to subcutaneous at character- and Plastic Surgeons. 2012. http://www.surgery.org/media/
ized by lipomembranous change.41 Although microscopic news-releases/celebrating-15-years-o -trustworthy-plastic-
samples demonstrated selective damage to the adipocytes, surgery-statistics. Accessed August 7, 2014.
4. Grazer FM, de Jong RH. Fatal outcomes rom liposuction:
there are no large-scale clinical trials to support the use census survey o cosmetic surgeons. Pla st Reconstr Surg.
o this methodology or non-invasive at reduction. Fur- 2000;105(1):436– 446; discussion 447– 448.
ther studies and optimization o treatment parameters are 5. Matarasso A, Swi t RW, Rankin M. Abdominoplasty and
needed to determine whether a 1210 nm wavelength laser abdominal contour surgery: a national plastic surgery survey.
may become a use ul tool or the non-invasive selective Pla st Reconstr Surg. 2006;117(6):1797– 1808.
6. Manstein D, Laubach H, Watanabe K, Farinelli W, Zurakowski
destruction o at. D, Anderson RR. Selective cryolysis: a novel method o non-
invasive at removal. La sers Surg Med. 2008;40(9):595– 604.
7. Epstein EH Jr, Oren ME. Popsicle panniculitis. N Engl J Med.
c o n c l u s Io n 1970;282(17):966– 967.
8. Beacham BE, Cooper PH, Buchanan CS, Weary PE. Eques-
Despite a historically tarnished track record, non-inva- trian cold panniculitis in women. Arch Dermatol. 1980;116
(9):1025– 1027.
sive at reduction is now a reality. T e last 5 years saw 9. Collins HA, Stahlman M, Scott HW Jr. T e occurrence o
the introduction o various non-invasive at technolo- subcutaneous at necrosis in an in ant ollowing induced
gies with novel approaches to target the adipose tissue. hypothermia used as an adjuvant in cardiac surgery. Ann
T ese devices, while not per ect, o er a predictable, sa e Surg. 1953;138(6):880– 885.
approach to body contouring. As with any procedure, 10. Rotman H. Cold panniculitis in children. Adiponecrosis E ri-
gore o Haxthausen. Arch Dermatol. 1966;94(6):720– 721.
patient selection is key. It is important to set realistic 11. Solomon LM, Beerman H. Cold panniculitis. Arch Dermatol.
expectations regarding clinical outcomes to avoid dis- 1963;88:897– 900.
satis action. Interested patients should be in ormed that 12. Zelickson B, Egbert BM, Preciado J, et al. Cryolipolysis or
these technologies do not approach the degree o e cacy noninvasive at cell destruction: initial results rom a pig
o liposuction. Ideal candidates are those that have ocal model. Dermatol Surg. 2009;35(10):1462– 1470.
13. Kaminer M, Weiss R, Newman J. Visible cosmetic improve-
adiposity that can be adequately targeted. Depending on ment with cryolipolysis: photographic evidence. In: Annual
the device chosen, multiple treatments may be necessary. Meeting of the American Society for Dermatologic Surgery.
470 T ose that want dramatic results, have large amounts o 2009: Phoenix, AZ.
14. Dierickx CC, Mazer JM, Sand M, Koenig S, Arigon V. Sa ety,
tolerance, and patient satis action with noninvasive cryoli-
subcutaneous adipose tissue or noninvasive body contour-
ing: sa ety studies in human volunteers. Aesthet Surg J. 2011;
4
polysis. Dermatol Surg. 2013;39(8):1209– 1216. 31(4):401– 410.
15. Shek SY, Chan NP, Chan HH. Non-invasive cryolipolysis or 29. Jewell ML, Desilets C, Smoller BR. Evaluation o a novel high-
body contouring in Chinese– a rst commercial experience. intensity ocused ultrasound device: preclinical studies in a
La sers Surg Med. 2012;44(2):125– 130. porcine model. Aesthet Surg J. 2011;31(4):429– 434.
16. Coleman SR, Sachdeva K, Egbert BM, Preciado J, Allison J. 30. Fatemi A, Kane MA. High-intensity ocused ultrasound
Clinical e cacy o noninvasive cryolipolysis and its e ects on e ectively reduces waist circum erence by ablating adipose
peripheral nerves. Aesthetic Pla st Surg. 2009;33(4):482– 488. tissue rom the abdomen and anks: a retrospective case
17. Dover J, Saedi N, Kaminer M, et al. Side e ects and risks asso- series. Aesthetic Pla st Surg. 2010;34(5):577– 582.
ciated with cryolipolysis. In: Annual Meeting of the American 31. Jewell ML, Baxter RA, Cox SE, et al. Randomized sham-con-
Society for Laser Medicine and Surgery. 2011. Grapevine, X. trolled trial to evaluate the sa ety and e ectiveness o a high-
18. Klein KB, Zelickson B, Riopelle JG, et al. Non-invasive intensity ocused ultrasound device or noninvasive body
cryolipolysis or subcutaneous at reduction does not a ect sculpting. Pla st Reconstr Surg. 2011;128(1):253– 262.
serum lipid levels or liver unction tests. La sers Surg Med. 32. Alster S, Lupton JR. Nonablative cutaneous remodeling
2009;41(10):785– 790. using radio requency devices. Clin Dermatol. 2007;25(5):
19. Jalian HR, Avram MM, Anderson RR. Rare side e ects o 487– 491.

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cryolipolysis. In: American Society for La ser Medicine and 33. Franco W, Kothare A, Ronan SJ, Grekin RC, McCalmont H.

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Surgery. 2013: Boston, MA. Hyperthermic injury to adipocyte cells by selective heating o

a
p
20. Jalian HR, Avram MM, Garibyan L, Mihm MC, Anderson subcutaneous at with a novel radio requency device: easi-

t
e
RR. Paradoxical adipose hyperplasia ollowing cryolipolysis. bility studies. La sers Surg Med. 2010;42(5):361– 370.

r
3
JAMA Dermatology. 2014;150(3):317– 319. 34. Avci P, Gupta A, Sadasivam M, et al. Low-level laser (light)

9
21. Jewell ML, Solish NJ, Desilets CS. Noninvasive body sculpt- therapy (LLL ) in skin: stimulating, healing, restoring. Semin
ing technologies with an emphasis on high-intensity ocused Cutan Med Surg. 2013;32(1):41– 52.

:
:
ultrasound. Aesthetic Pla st Surg. 2011;35(5):901– 912. 35. Avci P, Gupta GK, Clark J, Wikonkal N, Hamblin MR. Low-

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22. Moreno-Moraga J, Valero-Altés , Riquelme AM, Isarria- level laser (light) therapy (LLL ) or treatment o hair loss.

o
Marcosy MI, de la orre JR. Body contouring by non-inva- La sers Surg Med. 2014;46(2):144– 151.

n
-
sive transdermal ocused ultrasound. La sers Surg Med. 36. Neira R, Arroyave J, Ramirez H, et al. Fat lique action: e ect

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n
2007;39(4):315–323. o low-level laser energy on adipose tissue. Pla st Reconstr

v
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23. eitelbaum SA, Burns JL, Kubota J, et al. Noninvasive body Surg. 2002;110(3):912– 922; discussion 923– 925.

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i
v
contouring by ocused ultrasound: sa ety and e cacy o the 37. Elm CM, Wallander ID, Endrizzi B, Zelickson BD. E cacy

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Contour I device in a multicenter, controlled, clinical study. o a multiple diode laser system or body contouring. La sers

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Pla st Reconstr Surg. 2007;120(3):779– 789; discussion 790. Surg Med. 2011;43(2):114– 121.

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24. Shek S, Yeung CK, Kono , Chan HH, et al. T e use o 38. Jackson RF, Dedo DD, Roche GC, urok DI, Maloney RJ.

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ocused ultrasound or non-invasive body contouring in Low-level laser therapy as a non-invasive approach or body

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Asians. La sers Surg Med., 2009;41(10):751– 759. contouring: a randomized, controlled study. La sers Surg Med.

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a
25. Fruehau JH, Back W, Eiermann A, et al. High-intensity 2009;41(10):799– 809.

l
ocused ultrasound or the targeted destruction o uterine 39. Anderson RR, Parrish JA. Selective photothermolysis: pre-
tissues: experiences rom a pilot study using a mobile HIFU cise microsurgery by selective absorption o pulsed radiation.
unit. Arch Gynecol Obstet. 2008;277(2):143– 150. Science. 1983;220(4596):524– 527.
26. Yoshizawa S, Ikeda , Ito A, Ota R, akagi S, Matsumoto Y. 40. Anderson RR, Farinelli W, Laubach H, et al. Selective photo-
High intensity ocused ultrasound lithotripsy with cavitating thermolysis o lipid-rich tissues: a ree electron laser study.
microbubbles. Med Biol Eng Comput. 2009;47(8):851– 860. La sers Surg Med. 2006;38(10):913– 919.
27. Fatemi A. High-intensity ocused ultrasound e ectively 41. Wanner M, Avram M, Gagnon D, et al. E ects o non-inva-
reduces adipose tissue. Semin Cutan Med Surg. 2009;28(4): sive, 1210-nm laser exposure on adipose tissue: results o a
257– 262. human pilot study. La sers Surg Med. 2009;41(6):401– 407.
28. Gadsden E, Aguilar M , Smoller BR, Jewell ML. Evaluation o 42. Schmidt PK, Carter JE. Static and dynamic di erences among
a novel high-intensity ocused ultrasound device or ablating ve types o skin old calipers. Hum Biol. 1990;62(3):369– 388.

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 Ch a p t e r

40 Non-Invasive Body Contouring

Andrew A. Nelson & Mathew M. Avram

In t r o d u c t Io n their therapeutic goals. Depending on the patient’s weight

and individual body habitus, as well as their “problem
Mankind has long been obsessed with achieving the so- areas” and goals, some devices may be a better option than
called “per ect body”; in di ering times and di erent cir- others. As always, it is important to assess whether the
cumstances, the ideal body has evolved. Currently, in our patient has realistic goals as to the bene ts o a procedure
image-obsessed culture, many people possess a strong prior to any treatment.
desire to lose weight to achieve their per ect body. Un or- T e classic de nition or obesity is based on a patient’s
tunately, obesity is an epidemic in our culture and weight body mass index (BMI = person’s weight in kilograms
loss is a challenging goal or many. Although traditional divided by the square o their height in meters). T is is
dieting and exercise remain the best way to lose weight a quick and easy calculation or patients and physicians.
and maintain the weight loss, this may not work or all Obese patients are de ned as those patients having a
patients. Even patients who have achieved weight loss BMI>30. ypically, obese patients (BMI>30) are not good
may continue to have small “problem areas.” As a result, candidates or non-invasive body contouring and likely
patients are increasingly turning to their physicians, desir- would bene t more rom bariatric or other surgical inter-
ing new technologies to help achieve body contouring and ventions to help achieve meaning ul weight loss. T us,
the ideal physique. the simple BMI calculation may help to determine those
Historically, liposuction was the only means to patients who are not ideal candidates or non-invasive
achieve body contouring – other than diet and exer- body contouring. Un ortunately, the BMI is also an over-
cise. Although liposuction remains the gold standard, simpli cation, as it does not necessarily take into account
it is an invasive procedure with associated pain, bruis- the patient’s mixture o muscle and adipose tissue, or
ing, downtime, and rarely, more serious side e ects. their overall body type. Many patients who present or
Modern medicine has witnessed a dramatic move- non-invasive body sculpting may be in very good shape
ment toward minimal or no downtime procedures, as overall with a normal BMI, but eel plagued by only a ew
patients have become increasingly unwilling to toler- small problem areas, such as their thighs or anks. For
ate prolonged healing or recovery times. While many these patients, we, there ore, utilize measurements such as
topical agents have been reported to improve the thigh circum erence, waist circum erence, skin old thick-
appearance o cellulite, the improvements have typi- ness, visual assessment, and photographic comparisons
cally been limited or modest in clinical experience.1– 4 pre- and post-procedure; these assessments more typically
T e eld o body contouring has rapidly evolved in the re ect the patient’s ultimate clinical presentation and out-
last several years with the introduction o numerous new come.
technologies including lasers, RF devices, ultrasound It is also important to di erentiate between at and
devices, and cryolipolysis. Non-invasive at removal cellulite when assessing each patient.5 reatments or
procedures are now ar more commonly per ormed excess at and cellulite are largely distinct. Excess at and
than liposuction procedures. Non-invasive devices have obesity are due to an overabundance o structurally nor-
been reported to have multiple bene cial e ects includ- mal adipocytes. In contrast, cellulite is best considered
ing: improving the appearance o excess adipose tissue, as a structural phenomenon o subcutaneous adipose
reducing the overall volume o at, reducing waist and tissue present in nearly all postpubertal emales.6,7 How
thigh circum erence, improving the appearance o cellu- then does normal at become cellulite? T is remains an
lite, and skin tightening. Although these technologies are area o ongoing research, but it is thought that cellulite
relatively new, and their potential utility must ultimately may result rom hormonal changes. Cellulite is rare in
be determined by well-designed randomized scienti c prepubertal emales and males o any age, but is so com-
studies, the initial results and possibilities o some o mon in postpubertal emales that some researchers clas-
these technologies are promising. si y cellulite as a emale secondary sexual characteristic.
Estrogens are thought to stimulate lipogenesis while
inhibiting lipolysis, thereby contributing to cellulite
d e t er mIn In g t h e Pa t Ien t ’s ormation. Furthermore, it is believed that certain body
areas have less e ective lymphatic and vascular circula-
s t a t u s a n d t r ea t men t g o a l s tion, thereby contributing to the development o cellu-
lite in these “high-risk areas.” Ultrasound and magnetic
T e rst step in determining which therapeutic option is resonance imaging (MRI) studies have documented
the best is to assess each patient individually and discuss the signi cant structural alterations between normal
adipose tissue and abnormal cellulite structure.8,9 In
normal adipose tissue, the brous septae between the
r a d Io f r eq u en c y d ev Ic es
4
lobules o adipose tissue are arranged in an overlap- Radio requency (RF) devices pass sinusoidal, alternating
ping criss-cross pattern, creating greater tissue strength. current through tissue, thereby causing ionic ow and ulti-
Cellulite, on the other hand, has brous septae that are mately heat rom molecular riction. In essence, the tissue
arranged parallel to each other, and perpendicular to the itsel is the source o the heat, instead o the actual device. RF
skin sur ace. T is weaker structure allows or the ocal is, there ore, thought to create localized heat in the targeted
herniation o adipose tissue, which ultimately contrib- tissue mass, while limiting the collateral spread o energy,
utes to the classic undulating, lumpy, “cottage cheese” neuromuscular reactions, or electrolysis. Adipocytes have
appearance o cellulite. It remains unclear whether the high tissue resistance and relatively low heat trans er coef -
presence o excess adipose tissue increases the risk o cients; as a result, adipose tissue can be readily heated by RF
the development o cellulite. As a result o the di er- technologies and the heat will be relatively localized to the
ences between excess normal adipose tissue and struc- adipocytes. Recently, many RF devices have been advertised
turally abnormal cellulite, we believe that excess at to improve the appearance o at and cellulite.
and cellulite should be considered distinct entities and

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T e VelaSmooth and VelaShape (Syneron Medical Ltd,

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treated as such. Certain devices techniques that may be

a
Irvine, CA) devices combine physical manipulation simi-

p
e ective or treating cellulite may not treat excess adi-

t
lar to Endermologie (massage and suction), with bipolar

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pose tissue, and vice versa.10 RF energy and broadband in rared light (700– 2000 nm)

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Once the patient has been evaluated and their treat- to treat excess at and cellulite. It has been proposed that
ment goals discussed, the patient and the treating phy- these devices heat subcutaneous tissue and at, result-

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sician can begin to e ectively discuss the non-invasive ing in increased blood ow and lipolysis in the treatment

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body contouring options. Determining the best treatment areas, thereby improving the appearance o at and cel-

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option or each patient is dependent on clinical presenta- lulite. In a randomized clinical study by Nootheti et al.,

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tion, treatment goals, and most importantly, the patient’s patients were treated twice weekly or 6 weeks with either

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pre erences. the VelaSmooth device or another laser device or cellulite

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( riActive, Cynosure Inc, West ord, MA).13 Seventy- ve

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percent o patients were observed to have an improve-

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ment a ter comparing pre- and posttreatment photo-

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graphs, but the results were modest. Patients were also
n o n -In va s Iv e d ev Ic es

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observed to have a decrease in the upper and lower thigh

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circum erence, as well as an improvement in the appear-

u
Ph ys Ic a l t r ea t men t

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ance o cellulite (Figs. 40-1 and 40-2). However, no sta-

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o f f a t a n d c el l u l It e

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tistically signi cant di erences in the ef cacies o the two
devices were observed and no placebo group was included
Endermologie (LPG Systems, Valence, France) is an in the study. Bruising is a common side e ect ollowing
FDA-cleared device, which improves the appear- treatment with the VelaSmooth device, likely related to
ance o cellulite through massage and kneading o the the vacuum pressure and physical manipulation o the
a ected skin. T e device combines positive and nega- tissue rather than the RF technology itsel .
tive pressure created between two rollers to physi- Unipolar, volumetric RF devices with more di use,
cally manipulate the patient’s skin. T e technique is deep heating are also being studied or the treatment o
thought to stimulate blood and lymphatic ow, thereby at and cellulite. T irty patients were treated by Goldberg,
altering the architecture o the at and improving the et al. with a unipolar RF device (Accent, Alma Lasers US,
appearance o cellulite. It is less clear whether Ender- Bu alo Grove, IL) every other week or a total o six treat-
mologie has any e ect on reducing unwanted excess ment sessions; a decrease in mean leg circum erence o
adipose tissue. Modest clinical improvements in cellu- 2.45 cm was observed, although the study was limited due
lite have been documented in clinical studies. A study to a lack o placebo or untreated controls.14
by Gulec o 33 women who were treated with Ender- Recently, a novel RF device combining controlled RF heat-
mologie or 15 sessions demonstrated a statistically sig- ing and high-voltage ultrashort electrical pulses has been
ni cant improvement in the appearance o cellulite as developed to treat adipose tissue (BodyFX, InMode Inc,
assessed by a visual scale; however, ew o the patients Yokenam, Israel). T e BodyFX system utilizes a vacuum sys-
(5 o the 33) actually demonstrated clinical improve- tem and traditional RF heating to warm the tissue and adipo-
ment.11 A recent study by Collis et al.12 compared twice- cytes to the range o 43 to 45 degrees Celsius. T is heats the
weekly treatment with Endermologie to a combination triglyceride droplet within the adipocyte and begins thermal
treatment o aminophylline cream and Endermologie; adipocyte apoptosis. T e BodyFX device then delivers high-
the authors concluded that Endermologie is not an voltage RF pulsing, which electroporates the cell membrane,
e ective treatment or cellulite, although 10 out o basically poking a hole in the adipocyte membrane, leading
35 patients with Endermologie-treated legs reported to apoptosis o the adipocyte. T ese two mechanisms act
that their cellulite appearance improved clinically. In synergistically to achieve greater levels o adipocyte apop-
summary, Endermologie may result in modest improve- tosis and greater clinical improvement. In initial studies,
ments in the clinical appearance o at and cellulite; BodyFX has been shown to reduce circum erential measure-
however, it is likely that ongoing treatments would be ments o treated areas, reduce the thickness o subcutaneous
necessar y to maintain the improvement. at, induce direct adipocyte apoptosis, and simultaneously
473
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A B
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Figure 40-1 Clinical improvement in the appearance of the abdomen of a 60 year-old female before (A) and 3 months
:
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after (B) treatment with Velashape device. (Photos used with permission of Dr. Lori Brightman. Reprinted from, Wasserman
A
DI, Avram M, Nelson AA. Approach to cellulite and fat. In: Kim J, Lask G, Nelson A, eds. Comprehensive Aesthetic Rejuvena-
e
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tion: ARegional Approach.1st ed. New York, NY: Informa Healthcare; 2012:136–144.)
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tighten skin through neocollagenesis in the treatment area have been developed to treat adipocytes and the subcutis.
n
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(Fig. 40-3).15 T e BodyFX device represents another poten- T e Liposonix device (Solta Medical, Hayward, CA) was
L
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tial option or the treatment o excess at, as it combines the recently FDA cleared or non-invasive waist circum er-
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added bene t o tightening the treatment area through tra- ence reduction.
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P
ditional RF. A recent study by Jewell et al. o the Liposonix HIFU
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o
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T ese RF technologies represent sa e and ef cacious device (Solta Medical, Hayward, CA) reported improve-
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therapeutic options or patients, although urther clinical ment ollowing a single treatment session.16 One hun-
u
r
studies are necessary to establish their exact roles. dred and eighty patients were randomized to one o two
e
s
di erent doses o HIFU or to a sham treatment. welve
weeks ollowing the single treatment, the patients treated
u l t r a s o u n d d ev Ic es with the higher HIFU dose had achieved a statistically
signi cant improvement in waist circum erence com-
T e diagnostic utility o ultrasound devices has long been pared to the sham group (−2.44 cm vs. −1.43 cm). Patients
established; more recently, ocused ultrasound devices were observed to have “improved” or “much improved”

A B

Figure 40-2 Clinical improvement in the appearance of the arms of a 55 year-old female before (A) and 6 months after
(B) 5 treatments with the Velashape device (Radiofrequency level 3, infrared level 2, Vacuum level 1, treatment duration
7 minutes and 45 seconds). (Photos used with permission of Dr. Lori Brightman. Reprinted from, Wasserman DI, Avram M,
Nelson AA. Approach to cellulite and fat. In: Kim J, Lask G, Nelson A, eds. Comprehensive Aesthetic Rejuvenation: ARegional
474 Approach.1st ed. New York, NY: Informa Healthcare;2012:136–144.)
 4

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Figure 40-3 Clinical improvement showing a reduction of subcutaneous fat and tightening of skin in treatment area

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following a series of 6 BodyFX treatments. (Photo used with permission of InMode Inc., Yokenam, Israel.)

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outcomes as assessed by physicians, and patients were sat- or anks. welve weeks a ter the treatment, circum-

B
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is ed with their treatments (Fig. 40-4). Common adverse erence reductions o the abdomen (mean reduction

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events ollowing the treatment included pain, bruising, and 2.3 cm), thighs (mean reduction 1.8 cm), and anks

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edema. However, no signi cant laboratory abnormalities (mean reduction 1.6 cm) were observed. T e majority o

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were observed ollowing treatment, including lipid pro- the improvement in measured circum erence was noted

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les, markers o in ammation, coagulation, liver or renal to occur within the rst 2 weeks ollowing treatment.

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unction, hematologic assessments, or blood chemistry. Ultrasound technologies represent a new and evolving

g
Another novel ultrasound technology, the UltraShape area within the eld o non-invasive at treatment. Ultra-
device (Syneron Inc., Ir vine, CA) was recently FDA sound technologies can also be incorporated into invasive
cleared or non-invasive reduction o abdominal circum- liposuction procedures, known as ultrasound-assisted
erence via mechanical (not thermal) at cell destruction. liposuction (UAL). Although this is an e ective treatment
A prospective, nonrandomized, controlled trial o 164 method, it requires an invasive liposuction procedure.
patients was conducted by eitelbaum et al. to deter- More recently, novel non-invasive HIFU technologies
mine the ef cacy o the device.17 A total o 137 patients have been developed or improving the appearance o
underwent one HIFU treatment to the abdomen, thighs, at and cellulite. Although these devices require urther

Figure 40-4 Clinical improvement following a single treatment with a high-intensity focused ultrasound device. (Repro-
duced with permission of Solta Medical, Inc.; courtesy of Solta Medical Aesthetic Center. Reprinted from Garibyan L, Jalian
HR, Avram MM, Weiss RA. Body contouring: Non-invasive fat reduction. In: Goldman MP, Fitzpatrick RE, Ross EV, Kilmer SL,
Weiss RA, eds. Lasers and Energy Devices for the Skin. 2nd ed. Boca Raton, FL: CRC Press; 2013.) 475
4 clinical study to determine their long-term ef cacy and
sa ety pro le, they represent an exciting and promising
remodeling. Devices with wavelengths in the near in rared
region, as well as intense pulsed light (IPL) sources, all into
opportunity within this eld. this category. At the time o this writing, ew laser devices
are FDA cleared or the direct treatment o at and cellulite.
T e riActive device (Cynosure Inc, Bed ord, MA) com-
bines deep tissue massage and suction (similar to Ender-
l a s er s a n d l Ig h t s o u r c es mologie), with contact cooling and a low-intensity diode
laser (808 nm). T e riActive device is meant to improve
Multiple novel light sources and laser technologies have the appearance o cellulite by increasing lymphatic drain-
been developed as therapeutic options or at and cel- age, improving blood ow, and tightening the skin in
lulite. Historically, these laser devices were utilized as an treated areas. Patients typically are treated with the device
adjunct with liposuction, known as laser-assisted liposuc- twice weekly, with progressive improvement ollowing
tion (LAL). More recently, new non-invasive laser and light each treatment. In clinical studies, patients were noted to
source devices have been marketed or the treatment o at achieve objective reductions in hip and thigh circum erence
and cellulite. It is important to note that several devices as well as subjective improvements in the appearance o cel-
S
e
which are marketed to improve at and cellulite actually lulite, including a reduction in the appearance o skin dim-
c
t
i
do not a ect the adipocytes themselves, but rather, target pling, improvement in the overall contour o the limb, and
o
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the dermis in an attempt to stimulate collagen ormation/ improvement in overall skin texture (Fig. 40-5). riActive
4
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e
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A B

Figure 40-5 Clinical improvement in the appearance of abdominal cellulite and subcutaneous fat before (A) and
after (B) 20 treatments with the Triactive device. (Photos used with permission of Dr. Andrea Pelosi. Reprinted
476 from, Wasserman DI, Avram M, Nelson AA. Approach to cellulite and fat. In: Kim J, Lask G, Nelson A, eds. Comprehensive
Aesthetic Rejuvenation: A Regional Approach. 1st ed. New York, NY: Informa Healthcare; 2012:136–144.)
treatments were generally well tolerated, although approxi-
mately 20% o patients developed mild bruising.
mobilized via a temporary pore in the cell membrane
rom inside the cell to the interstitium, where the at is
4
he SmoothShapes device (Eleme Medical, Mer- ultimately absorbed into the lymphatic system. ypi-
rimack, NH), combines two di erent wavelengths o cally, Zerona treatments are per ormed every other day
laser with a physical massage system similar to Ender- or a total o six treatments, with each treatment lasting
mologie. he 915 nm diode wavelength is meant to approximately 40 minutes. T ere are other FDA-cleared
lique y at, while the 650 nm wavelength is meant to low-level laser therapies. Further study will determine
improve at membrane permeability, thereby allow- whether they constitute a signi cantly e ective treat-
ing the adipocytes to be mobilized to the interstitium. ment option or excess adipose tissue.
A treatment session consists o multiple passes with
the SmoothShapes device, and two to three treatment
sessions are per ormed each week or best results. In c r yo l IPo l ys Is
clinical studies by Lach and Kulick, the SmoothShapes
device results in reduction o the thickness o the sub- CoolSculpting (Zeltiq Aesthetics, Pleasanton, CA) is a
cutaneous at pad, as assessed by MRI (Fig. 40-6).18,19 novel FDA-cleared device or non-invasive at reduction.

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he device was well tolerated with no signi icant CoolSculpting utilizes cryolipolysis technology (con-

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associated adverse events. trolled cold exposure) to selectively cool at, thereby

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causing adipocyte apoptosis.20 T e treatment cycle lasts

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T e VelaSmooth and VelaShape (Syneron Medical Ltd,

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Irvine, CA) devices, as discussed previously, combine approximately 60 minutes, at the conclusion o which the
physical manipulation, bipolar RF energy, and broadband skin is cool, rm, and erythematous. Following the treat-

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:
in rared light (700– 2000 nm) to acilitate a multimodal- ment, the physician massages the area gently to break

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ity approach to at and cellulite treatment. T e ef cacy up any crystallized adipocytes. Over the next several

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o these devices was previously discussed in the section weeks to months, the adipocytes undergo apoptosis, are

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regarding RF. In the uture, more devices may approach mobilized and ultimately eliminated by the body. ypi-

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at and cellulite treatment through this multimodality cal treatment areas include the ank “love handles,” the

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approach in an e ort to achieve greater ef cacy. back “ at pads” and the abdomen “muf n top”. In a recent

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Recently, a low-level laser device (Zerona, Erchnia Inc, clinical study, a signi cant reduction in the thickness o

o
the at in the treatment area was observed ollowing a

d
McKinney, X) was FDA cleared or the non-invasive

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reduction in circum erence o hips, waist, and thighs. single CoolSculpting treatment (mean at pad thick-

C
o
Zerona is a low-level diode laser (615 nm), which pro- ness reduction o 22.4%, as measured on ultrasound).

n
t
O the 32 patients in the study, all had achieved a sig-

o
duces ve independent beams. T e center beam is

u
ni cant visible contour improvement ollowing a single

r
xed, while the our remaining beams can be individu-

i
n
ally adjusted allowing multiple body areas (abdomen, treatment.21,22 T e best results were seen in patients with

g
ank, thighs) to be treated simultaneously. T e exact localized, discrete at bulges. reatments are typically
mechanism o action has not been elucidated, though well tolerated, although patients may develop bruising
it has been claimed that low-level laser therapy stimu- as well as transient altered sensation, numbness or even
lates the at cell to emulsi y; the lique ed at is then pain in the treatment area. Although the treatment and

A B C D

Figure 40-6 Clinical improvement in thigh circumference and texture before (A, C) and after (B, D) 8 treatments with
the Smoothshapes device. (Photos used with permission of Dr. Khalil A. Khatri. Reprinted from, Wasserman DI, Avram M,
Nelson AA. Approach to cellulite and fat. In: Kim J, Lask G, Nelson A, eds. Comprehensive Aesthetic Rejuvenation: ARegional 477
Approach. 1st ed. New York, NY: Informa Healthcare; 2012:136–144.)
4 recovery rom treatment are typically quite com ortable,
signi cant pain can rarely be experienced in the area o
5. Avram MM. Cellulite: a review o its physiology and treatment.
J Cosmet La ser T er. 2004;6:181– 185.
6. Nurnberger F, Muller G. So-called cellulite:an invented disease.
treatment or 1 to 2 weeks.23 CoolSculpting represents
J Dermatol Surg Oncol. 1978;4:221– 229.
a sa e, novel and ef cacious, non-invasive treatment 7. Rossi AB, Vergnanini AL. Cellulite: a review. J Eur Acad
option or at. Dermatol Venereol. 2000;14:251– 262.
8. Mirrashed F, Sharp JC, Krause V, Morgan J, omanek B. Pilot
study o dermal and subcutaneous at structures by MRI in
c o n c l u s Io n s individuals who di er in gender, BMI, and cellulite grading.
Skin Res echnol. 2004;10:161– 168.
9. Querleux B, Cornillon C, Jolivet O, Bittoun J. Anatomy and
T e last ew years have witnessed pro ound changes in physiology o subcutaneous adipose tissue by in vivo magnetic
the eld o body contouring with the development o resonance imaging and spectroscopy: relationships with sex
sa e, e ective, non-invasive technologies. T ese non- and presence o cellulite. Skin Res echnol. 2002;8:118– 124.
10. Hexsel DM, Mazzuco R. Subcision: a treatment or cellulite.
invasive devices have been reported to have multiple Int J Dermatol. 2000;39:539– 544.
bene cial e ects including improving the appearance o 11. Güleç A . reatment o cellulite with LPG endermologie. Int
excess adipose tissue, reducing the overall volume o at,
S
J Dermatol. 2009;48:265– 270.
e
reducing waist and thigh circum erence, improving the 12. Collis N, Elliot LA, Sharpe C, Sharpe D . Cellulite treatment:
c
t
i
a myth or reality: a prospective randomized, controlled trial
o
appearance o cellulite, and skin tightening. Although
n
o two therapies, endermologie and aminophylline cream.
liposuction and surgical procedures remain the gold
4
Pla st Reconstr Surg. 1999;104(4):1110– 1114.
standard or patients seeking large volume at removal, 13. Nootheti PK, Magpantay A, Yosowitz G, Calderon S, Gold-
:
:
many patients pre er these novel non-invasive therapies man MP. A single center, randomized, comparative, prospec-
as simple, no downtime alternatives to improve the tive clinical study to determine the ef cacy o the Velasmooth
A
e
appearance o limited at and cellulite. For this reason, system versus the riactive system or the treatment o
s
t
cellulite. La sers Surg Med. 2006;38(10):908– 912.
h
non-invasive treatments now ar outnumber invasive
e
14. Goldberg DJ, Fazeli A, Berlin AL. Clinical, laboratory and
t
procedures.
i
c
MRI analysis o cellulite treatment with a unipolar radio re-
a
Physical manipulation devices, RF devices, ultrasound quency device. Dermatol Surg. 2008;34(2):204– 209.
n
d
devices, lasers, and cr yolipolysis have all been developed 15. Boisnic S, Divaris M, Nelson AA, Gharavi NM, Lask GP.
L
A clinical and biological evaluation o a novel, noninvasive
a
or the non-invasive treatment o at and cellulite. Each
s
radio requency device or the long-term reduction o adipose
e
technology has its own risks and bene ts. Ultimately,
r
tissue. La sers Surg Med. 2014;46(2):94– 103.
P
rather than there being one single best technology or
r
16. Jewell ML, Baxter RA, Cox SE, et al. Randomized sham-
o
all patients, it is likely that di erent technologies will
c
controlled trial to evaluate the sa ety and e ectiveness o a
e
d
have speci c patient types and situations or which they high-intensity ocused ultrasound device or noninvasive
u
body sculpting. Pla st Reconstr Surg. 2011;128(1):253– 262.
r
are best suited. As a result, it is important or physicians
e
17. eitelbaum SA, Burns JL, Kubota J, et al. Noninvasive body
s
to assess each patient individually, discuss their current contouring by ocused ultrasound: sa ety and ef cacy o the
state and ultimate treatment goals, and choose a device Contour I device in a multicenter, controlled, clinical study.
accordingly. Ultimately, determining the best treatment Pla st Reconstr Surg. 2007;120(3):779– 789.
option or each patient is dependent on clinical pre- 18. Kulick MI. Evaluation o a noninvasive, dual-wavelength
sentation, treatment goals, and most importantly, the laser-suction and massage device or the regional treatment
o cellulite. Pla st Reconstr Surg. 2010;125(6):1788– 1796.
patient’s pre erences. Some devices are better studied 19. Lach R. Reduction o subcutaneous at and improvement
and more e ective than others. Following these prin- in cellulite appearance by dual-wavelength, low-level laser
ciples, it is possible or patients to undergo sa e, e ec- energy combined with vacuum and massage. J Cosmet La ser
tive, non-invasive treatments to treat unwanted at and T er. 2008;10(4):202– 209.
cellulite. 20. Manstein D, Laubach H, Watanabe K, Farinelli W, Zura-
kowski D, Anderson RR. Selective cryolysis: a novel method
o non-invasive at removal. La sers Surg Med. 2008;40(9):
595– 604.
r ef er en c es 21. Dover J, Burns J, Coleman S, et al. A prospective clinical
study o noninvasive cryolypolysis or subcutaneous at layer
1. Hamilton EC, Greenway FL, Bray GA. Regional at loss reduction—Interim report o available subject data. Presented
rom the thigh in women using 2% aminophylline. Obes Res. at the Annual Meeting o the American Society or Laser
1993;1: 95S. Medicine and Surgery. April 2009, National Harbor, MD.
2. Kligman AM, Pagnoni A, Stoudemayer . opical retinol 22. Rosales-Berber IA, Diliz-Perez E. Controlled cooling o sub-
improves cellulite. J Dermatolog reat. 1999;10:119– 125. cutaneous at or body reshaping. Presented at the 15th World
3. Pierard-Franchiemont C, Pierand GE, Henry F, Vroome V, Congress o the International Con ederation or Plastic,
Cauwenbergh G. A randomized, placebo controlled trial o Reconstructive and Aesthetic Surgery. 2009, New Delhi, India.
topical retinal in the treatment o cellulite. Am J Clin Derma- 23. Klein KB, Zelickson B, Riopelle JG, et al. Non-invasive cryoli-
tol. 2000;1369– 1374. polysis or subcutaneous at reduction does not a ect serum
4. Rotunda AM, Avram MM, Avram AS. Cellulite: Is there a role lipid levels or liver unction tests. Lasers Surg Med. 2009;41(10):
or injectables? J Cosmet La ser T er. 2005;7:147– 154. 785–790.

478
 Ch a p t e r

41 Liposuction
Danie P. Friedmann, Kimber y J. B tterwick, & Arisa E. Ortiz

In t r o d u c t Io n Pa t Ien t s el ec t Io n
T e popularity o liposuction has increased dramatically c o n s u l t a t Io n
over the past two decades, with liposuction constituting
10% o all ambulatory cosmetic procedures per ormed in Patients presenting or a liposuction consultation o ten
the United States between 1995 and 2010.1 T is interest, have preconceived notions about the procedure, having
particularly among dermatologists and non-core cosmetic heard both positive and negative reports rom riends or
practitioners, has grown in large part due to Klein’s intro- via the internet. Although the advent o social media now
duction o the tumescent technique, allowing this pro- connects individuals en masse, this may only potentiate
cedure to be per ormed com ortably and less invasively the spread o biased and unreliable in ormation.12 Poten-
under local anesthesia with minimal postoperative down- tial patients need to be properly in ormed and educated
time, unparalleled patient sa ety, and improved aesthetic regarding tumescent liposuction, including the risks, ben-
results.2,3 e ts, alternatives, and a realistic appraisal o the postopera-
tive course and expected results. T e physician utilizes the
consultation visit to determine whether the patient is men-
In d Ic a t Io n s tally and physically healthy, has no contraindications to
surgery, and has atty deposits that are amenable to treat-
Diet- or exercise-resistant subcutaneous at in virtu- ment. Once both the patient and the physician have ade-
ally any area o the body can now be treated sa ely and quate in ormation, the decision to proceed can be made.
e ectively with tumescent liposuction, rom excessively
ull jowls to thick ankles. Potential non-cosmetic indica- Pa t Ien t s el ec t Io n a n d
tions or liposuction, such as breast reduction in women c o n t r a In d Ic a t Io n s
and the treatment o gynecomastia in men, are listed in
able 41-1.4– 11 T e ideal patient is in excellent health, is not overweight,
and has atty deposits out o proportion to overall body
shape, with otherwise normal skin tone and elasticity.
T ese atty deposit areas are primarily genetic in origin,
gender speci c, and resistant to diet and exercise. T e ideal
TABl E 41-1 patient also has reasonable and realistic expectations. T e
n c m i I i i f ideal patient age range is 30 to 55 years old, as this group
t m l ip i is generally mature enough to undergo this procedure and
more likely to be ree o underlying illnesses, with less risk
I i i e mp o excessive skin laxity or other complicating actors.
Given that the majority o patients vary rom this
l ipoma So itary
ideal in some manner, the consultation and preoperative
Angio ipoma
examination enable the physician to screen and choose
Fami ia m tip e ipomatosis
patients who are suitable or the procedure. T e actual
Adiposis do orosa (Derc m’s disease)
age o a prospective patient, or instance, is not as impor-
l oca ized B a o h mp d e to C shing’s syndrome tant as their overall mental and physical health. T e
ipodystrophy Ins in ind ced ipohypertrophy authors have sa ely per ormed tumescent liposuction
HAART associated ipodystrophy on patients rom 18 to 85 years old. T e extent o the
Endocrine Axi ary hyperhidrosis or bromhidrosis
procedure will also determine the ability o a particular
Macromastia
patient to tolerate it. Patients with mild, controlled medi-
Gynecomastia or pse dogynecomastia
cal conditions such as diabetes or hypertension or elderly
individuals in otherwise good health can, there ore, sa ely
Reconstr ctive/ F ap ndermining or de atting undergo a limited procedure under appropriate operative
S rgica Hematoma evac ation conditions.
Post s rgica ymphedema It is important that the patient’s weight be stable or
Adapted with permission rom Co eman WP, F ynn TC. l ipos ction. several months prior to surgery. Patients with patterns o
In: Bo gnia Jl , Jorizzo Jl , Rapini RP, eds. Dermatology, 2nd ed. Spain: progressive or cyclical weight gain will most likely gain
Mosby; 2008:2346. Copyright E sevier. weight a ter surgery and have suboptimal results. Patients
4 TABl E 41-2
ollowing the procedure and need to have someone moni-
tor them or the rst 24 hours. It is help ul to have a relative
M i c i i i or close riend educated in postoperative care as well at the
t m l ip i time o the visit. A detailed history and physical examina-
tion is also per ormed and preoperative laboratory stud-
c i i i
ies, prescriptions, photographs, and in ormed consents are
Morbid obesity obtained.
Pregnancy
Severe cardiovasc ar or rena disease Med Ic a l /s u r g Ic a l HIs t o r y
Severe coag ation disorder
A detailed medical and surgical history is obtained to con-
Active hepatitis or chronic iver ai re rm that there are no contraindications to surgery. I there
Major imm nos ppression is a signi cant underlying medical condition, the patient’s
primary care physician is later contacted or medical
S
e
Active cancer
clearance.
c
t
i
History o ma ignant hyperthermia Ruling out patients with active liver disease is impera-
o
n
tive as adequate hepatic unction is essential or lidocaine
4
Rep b ished with permission o Tay or &Francis Gro p l l C, rom B t
terwick KJ. l ipos ction: cons tation and preoperative considerations. metabolism.17,18 Patients who are positive or hepatitis C
:
:
In: Narins RS, ed. Safe Liposuction and Fat Transfer. New York, NY: Marce or HIV but are otherwise healthy must nevertheless be
approached with caution due to potentially compromised
A
Dekker, Inc; 2003:43. Permission conveyed thro gh Copyright C earance
e
Center, Inc. immune and liver unction. HIV-positive patients may also
s
t
h
exhibit unpredictable metabolism o lidocaine, indepen-
e
t
who have lost large amounts o at in a short span will dent o antiviral therapy.19 Patients who have undergone
i
c
a
have very loose skin and are poor candidates or surgery. chemotherapy may have an altered ability to metabolize
n
d
Although most patients are within 10 to 25 pounds o their lidocaine even with normal liver unction tests, as reported
l
ideal weight, some may be more than 20% heavier. Yet the in one case o lidocaine toxicity that occurred up to 2 years
a
s
e
majority o these patients have localized, disproportionate post treatment.20 Immunocompromised patients are also
r
P
atty deposits that would bene t rom the procedure. Oth- poor candidates or liposuction due to their increased risk
r
o
ers may have a moderate degree o cellulite that will not o in ection and delayed wound healing.
c
e
improve with treatment along with signi cant underlying
d
Risk actors or thromboembolism should be identi ed.
atty deposits that may be dramatically recontoured. It is
r
T ese include a prior history o thrombophlebitis, throm-
e
s
important to note that patients lose little weight with the bophilia or thromboembolism, high-dose estrogen ther-
procedure; however, the body- at percentage is generally apy, obesity, varicose veins, immobilization, and positive
lower a ter liposuction and the basal metabolic rate (i.e., smoking history.21 All allergies to medications, surgical
calories burned at rest) may increase.13 T e importance o materials, and postoperative dressings need to be noted.
weight maintenance postoperatively must be emphasized A surgical history is help ul to screen or poor wound
to patients to achieve optimal long-term results. healing, a tendency or keloidal or hypertrophic scarring,
Prospective patients who are generally excluded rom in ectious complications, and bleeding diatheses. Patients
liposuction include those with medical contraindications who have undergone recent abdominal surgery should
( able 41-2), excessively loose skin, unrealistic expectations wait 6 months or longer be ore undergoing liposuction in
– seeking per ection, immediate results, and/or substantial that area. Multiple abdominal surgeries may compromise
weight loss – and/or who are emotionally or psychologi- results due to muscle laxity or adherent scarring. Multiple
cally unstable.14,15 Certain personality traits and disorders, pregnancies may also signal weak abdominal musculature
including per ectionism, eating disorders, and body dys- and the need or alternative procedures.
morphic disorder, have been suggested to correlate with
dissatis ed cosmetic surgery patients.16 Although exces-
sively loose skin is typically a contraindication to treatment, PHys Ic a l ex a MIn a t Io n
older individuals who have poor skin tone but are more
concerned about their shape in clothing than skin laxity NECK. When evaluating or photographing the head and
may end up being happy patients. neck, the ideal pro le should be viewed with the head held
in the Frank urt horizontal plane, in which a horizontal line
can be drawn through the highest point o the ear canal
Pr eo Per a t Iv e c o n s Id er a t Io n s meatus and the lowest point o the orbital rim.22 A 90° to
135° cervicomental angle, ormed by the horizontal plane
I the initial consultation is success ul and the patient has o the submentum and the vertical plane o the neck, and
decided to undergo tumescent liposuction, a preoperative a de ned in erior mandibular border are key anatomic ea-
visit is scheduled with a trained nurse practitioner or reg- tures o a youth ul neck that can become blunted with age
istered nurse to prepare or the day o surgery. T e recom- and weight gain.23 Grasping the submental at and tucking
mended procedure is reviewed verbally, as are the detailed, it up under the chin to “remove” it rom view can illustrate a
written preoperative and postoperative instructions and postoperative result to patients. It is important to note that
the in ormed consent orms. In particular, patients need lax, photoaged neck skin may look more wrinkled postop-
480 to be reminded that they cannot drive themselves home eratively, and the patient should be advised appropriately.
POSTERIOR ARMS. T e arms should be examined in should include an assessment or excess skin laxity, which
4
the anatomic position as well as abducted perpendicularly can worsen postoperatively. Excess underlying muscula-
rom the body with thumbs up. Ideal patients have moder- ture within the thigh and buttock may also limit results.
ate amounts o excess at localized to the posterior and lat- Although areas o cellulite should be noted, patients must
eral aspects o the arms with mild-to-minimal skin laxity. be in ormed that it may not improve with treatment.
However, postoperative skin retraction can still produce
excellent results in patients with large, hanging at deposits MEDIAl THIGH AND KNEE. T e thigh should be
and/or signi cant skin laxity as long as a su cient amount examined or overall shape with the patient standing. T e
o super cial at remains to ensure skin smoothness.24 T e ideal medial thigh has a slight proximal ullness, 2 to 8 cm
biceps area should be avoided in the majority o patients, posterior and in erior rom the perineal– thigh crease, and
given its thin overlying skin. tapers to a thin mid-thigh and knee. As the thin, inelastic
skin o the medial thigh leads to notoriously poor postop-
ABDOMEN, WAIST, AND Fl ANKS. T e abdomen erative skin retraction, preexisting wrinkling and sagging
should be examined as a whole with the patient standing in should be ruled out, as it may worsen postliposuction.28,29

C
anatomic position. Patients with prominent lower abdomi- Subcutaneous at o the knee is primarily localized

h
over the medial condyles o the tibia and emur and ide-

a
nal protrusion due to muscle diastasis, marked skin laxity,

p
t
and/or visceral at are likely poor candidates or liposuc- ally ought to be relatively f at, with minimal associated at

e
r
tion.25 Men with taut, protuberant abdomens due to visceral in the patellar, in rapatellar, and lateral knee at pads. T e

4
1
at may still have ample subcutaneous tissue. Having the suprapatellar at pad is a bro atty region that can become
patient lie supine with back and hips slightly f exed may ac- ptotic and wrinkled due to age, gravity, and the weight o

:
:
centuate these deposits.26 T e presence or absence o a peri- the overlying anterior thigh.30

l
i
umbilical or ventral hernia should always be documented as

p
o
its presence may increase the risk o peritoneal per oration. Med Ic a t Io n s

s
c
T e male f anks lie just above the hips, extending

t
i
o
between the iliac rim and the in erior costal margin, over- A care ul history o medication use is essential and includes

n
lying the lateral oblique muscles (Fig. 41-1A). On the other prescription, over-the-counter, and herbal remedies. Par-
hand, in emale patients the anatomic area equivalent or ticular attention is given to medications that a ect clotting
slightly superior to the male f ank is the waist. T e emale and should be avoided be ore or immediately ollowing sur-
f anks lie in rascapularly, between the waist and the bra line gery. Medications or supplements containing aspirin, non-
(Fig. 41-1B). steroidal anti-inf ammatory agents, vitamin E, ever ew, or
the our G’s – ginkgo, ginseng, garlic, and ginger – are com-
HIPS, Ou TER THIGHS, AND Bu TTOCKS. T e monly discontinued 2 weeks prior to surgery to minimize
patient should be examined in a standing position. A gy- intraoperative bleeding and bruising.31 Long-term antico-
necoid pattern o at distribution predisposes women to agulation with war arin or subcutaneous heparin is also a
commonly accumulate at in all three o these areas. Full- contraindication or surgery and should not be discontin-
ness at the iliac crest o the hip and subtrochanteric area ued or elective procedures. o reduce cardiac stimulation,
o the outer thigh, with an intervening lateral gluteo emo- thyroid replacement therapy and pseudoephedrine are
ral depression, produce this “violin de ormity”; downward stopped 3 days, and appetite suppressants gradually dis-
and outward pressure rom the buttock also augments continued 2 weeks, prior to surgery. Ca eine, alcohol, and
lateral thigh protrusion.27 Examination o the outer thighs tobacco products are also best avoided periprocedurally.

A B

Fig ure 41-1 A. Ma e anks marked by an e ipse. B. Fema e hip (recta ngle), waist (ellipse), and ank
(polygon). Note that the ema e waist is approximate y e iva ent to the ma e ank in anatomic
position. 481
4 TABl E 41-3
M i i P i a ff i li i M im

c yP1a 2 I hi i c yP3a 4 I hi i
Competitive Antidepressants (TCAs), Atypica Antipsychotics Antidepressants (TCAs and SSRIs), Atypica
S bstrates Proprano o , Verapami Antipsychotics, Benzodiazepines
War arin Proprano o , CCBs, Statins, Amiodarone
Some Chemotherape tic and Hormona Dr gs War arin, C opidogre
(tamoxi en, estradio ) Chemotherape tic & Hormona Dr gs
Protease Inhibitors, Nevirapine
Macro ide Antibiotics (not azithromycin)
Azo e Anti nga s
Strong Inhibitors F oro ino ones (cipro oxacin) Protease Inhibitors (indinavir, ritonavir)
S
e
F voxamine C arithromycin
c
t
i
CCBs (Verapami ) Ch oramphenico
o
n
Herbs/Herba Teas Itraconazo e, Ketoconazo e
4
Moderate Inhibitors Erythromycin, F conazo e
:
:
CCBs (di tiazem, verapami )
A
e
Weak Inhibitors Ca eine F oxetine
s
t
Cimetidine Cimetidine
h
e
t
u nspecif ed Inhibitors
i
Amiodarone Amiodarone
c
a
Inter eron Cipro oxacin
n
d
Isoniazid Isoniazid
l
a
F voxamine
s
e
r
TCAs, tricyc ic antidepressants; SSRIs, serotonin specif c receptor inhibitors; CCBs, ca ci m channe b ockers.
P
r
o
c
e
d
Given that lidocaine is rapidly and almost exclusively to surgery to minimize bruising.37 For anxious patients,
r
e
s
eliminated by hepatic cytochrome P450 3A4 (CYP3A4) lorazepam 1 mg PO is prescribed or the night be ore and/
and 1A2 (CYP1A2), attention must be given to medica- or the morning o the procedure.
tions that inhibit or are competitively metabolized by
these enzymatic pathways, as they may inter ere with
lidocaine metabolism and lead to elevations in lidocaine
l a bo r a t o r y s t u d Ies
blood levels.32,33 Although early in vitro studies impli-
Preoperative laboratory studies or most liposuction pro-
cated CYP3A4 as the main enzyme in lidocaine metabo-
cedures include a complete blood cell count with di eren-
lism, recent clinical studies have con rmed that CYP1A2
tial and platelet count, chemistry panel, prothrombin and
is most likely principally responsible or the metabolic
partial thromboplastin times, serum pregnancy test, and
breakdown o lidocaine in subjects with normal liver unc-
serologies or hepatitis B and C and HIV.38 An electrocar-
tion.17 Antidepressants, anti ungals, antivirals, and antibi-
diogram is also ordered or patients over the age o 60. T e
otics are common culprits as substrates and inhibitors o
surgeon reviews the results, pre erably 2 weeks prior to
both enzymes ( able 41-3). oxic levels o lidocaine due to
surgery, and any abnormalities are addressed.
such drug interactions have been reported.34 Patients are
instructed to discontinue potentially problematic medi-
cations 2 weeks prior to surgery a ter checking with their PHo t o g r a PHs
prescribing physician. However, some patients may need
to taper their medications over a longer period o time. For Digital, standardized preoperative photographs (with
patients discontinuing antidepressants, lorazepam (1 mg separate in ormed consent) are obtained, and every
PO qHS) may be prescribed or 1 week prior to surgery attempt is made to achieve consistent distance and back-
to mitigate any di culties in tolerating the interruption in ground. T e use o 45 degree strobe lighting ensures so t,
therapy. Patients unable to interrupt therapy with drugs natural-looking light and minimizes shadowing. Patients
that may inter ere with lidocaine metabolism can still be usually wear surgical underwear or bathing suits or the
treated, albeit with lidocaine doses reduced by at least 30% photographs. Baseline measurements may be obtained
to 40%.35 More than one treatment session may, there ore, at this time, including weight, percentage o body at,
be necessary.36 and circum erential measurements. Given that patients
Preoperative prescriptions are started the day be ore rarely have an accurate recollection o their preoperative
surgery. Seven days o ce adroxil or cephalexin 500 mg PO anatomy, such as congenital irregularities or asymmetry,
b.i.d. (minocycline 100 mg PO q.d. i penicillin-allergic) pretreatment photos are crucial. Postoperative photos are
are typically prescribed. Phytonadione (Vitamin K) 5 mg not taken until 3 to 6 months ollowing treatment to docu-
482 PO b.i.d. or arnica is also recommended or 10 days prior ment nal results.
 ous tissue away rom underlying structures, allowing or
the sa e treatment o areas such as the neck.41
4
Prior to tumescent anesthesia, liposuction was per-
ormed with either a “dry” or “wet” technique. Dry tech-
nique liposuction required general anesthesia and utilized
no preoperative f uid in ltration, o ten leading to exces-
sive bleeding and the need or intraoperative or postop-
erative intravenous (IV) f uids or blood trans usions. T e
prolonged recovery time and potential or dis guring
irregularities o the overlying skin also marred this pro-
cedure.44 Wet and superwet techniques added the use o a
vasoconstrictive solution o epinephrine. Although super-
wet liposuction is still widely used, it requires pro ound
narcotic-induced anesthesia and has the potential or
excessive bleeding and f uid overload secondary to intra-

C
h
operative IV f uids.45

a
p
An unsubstantiated ear o lidocaine doses in excess o

t
e
r
7 mg/kg combined with a lack o understanding regarding

4
1
Figure 41-2 Preoperative topographica markings o the lidocaine pharmacokinetics within subcutaneous tissues
abdomen and anterior waist. contributed to the popularity o such procedures and the

:
:
shunning o tumescent technique liposuction by nonder-

l
matologic surgeons during its nascency.44 Clinical studies

i
p
Ma r kIn g a n d Pr ePa r a t Io n

o
have nevertheless con rmed that tumescent lidocaine dos-

s
ages up to 45 mg/kg are exceedingly sa e, with dosages up

c
t
to 55 mg/kg likely being sa e in the majority o patients,

i
Marking is per ormed immediately pre-procedure as a

o
n
blueprint or surgery. A blue or black elt-tip permanent regardless o the speed o in ltration.2,46,47 Lidocaine dos-
marker is used to topographically mark the area/s under- ages in this range demonstrate peak plasma levels at 12
going liposuction with the surgeon seated and the patient to 14 hours post-in ltration, well below the threshold or
standing erect in anatomic position (Fig. 41-2). Bulges systemic toxicity (Fig. 41-3).48 Despite overwhelming evi-
requiring more aggressive treatment, areas to be avoided, dence to the contrary, the opinion that tumescent anesthe-
preexisting depressions, and side-to-side asymmetry can sia is unsa e or unnecessary – or that tumescent anesthesia
all be easily demarcated with this method. Once com- should be disregarded entirely – still endures outside o
pleted, the patient is trans erred to the procedure room the dermatologic community.49– 51
and the area/s to be treated is/are thoroughly cleansed
with a chlorhexidine wash. FORMu l ATION. A guideline or lidocaine and epi-
nephrine concentrations in tumescent anesthetic prepara-
tions, based on the authors’ pre erences and experience, is
Per Io Per a t Iv e t ec Hn Iq u es presented in able 41-4. Nevertheless, more brous areas,
a n d Ma n a g eMen t such as the upper abdomen, breast, back, and periumbili-
cal region, may require greater concentrations o lidocaine

t u Mes c en t a n es t Hes Ia
BACKGROu ND, PHARMACOKINETICS, AND
SAFETY. umescent liposuction is a technique based TABl E 41-4
upon the direct in ltration o large volumes o dilute li- t m a h i F m i
docaine with epinephrine in bu ered physiologic saline,
allowing or pro ound local anesthesia and hemostasis o I i 0.05% 0.1%
skin and subcutaneous tissues without the need or general
0.9% Norma sa ine 1l 1l
anesthesia.39 Percutaneous in ltration o local anesthetic
solution into subcutaneous tissue causes f uid spread and 1% l idocaine 500 mg (50 ml ) 1000 mg (100 ml )
hydrodissection (known as bulk f ow) throughout the hydroch oride
interstitial connective tissue compartment that envelops 1:1000 Epinephrine 0.65 mg (0.65 ml ) 0.65 mg (0.65 ml )
adipocytes.40 Although lidocaine is lipophilic and some (f na concentration
portion o the in ltrated volume may be sequestered by at o 1:1,500,000)
cells directly, adipocyte swelling is not noted in tumesced
8.4% Sodi m 10 mE (10 ml ) 10 mE (10 ml )
areas.41 T e interstitial reservoir o lidocaine and its com-
bicarbonate
pressive e ects on subcutaneous capillaries, combined
with the vasoconstriction produced by epinephrine and Optional: 10 mg (1 ml ) 10 mg (1 ml )
the inherent relative avascularity o adipose tissue, slow Triamcino one
the systemic absorption o lidocaine and lead to complete, acetonide
prolonged anesthesia and hemostasis without third spac- Note: Ingredients other than norma sa ine isted in mg or mE (ml )
ing.42,43 umescence also hydraulically elevates subcutane- needed to create 0.05% and 0.1% so tion concentrations. 483
4 layers, impeding optimal tumescent anesthesia.41 Once tis-
sues are brief y – albeit su ciently – anesthetized with a
25 G needle, a 20 G needle (or blunt-tipped larger cannula
in non- brous areas) can be used. Pretreating in ltration
sites with intradermal blebs o anesthetic solution (30 G
needle, 5 mL syringe) can also increase patient com ort .I
in ltration is per ormed correctly, these intradermal injec-
tions may be the most pain ul part o the entire procedure.
Most patients pre er to have some preprocedure anxio-
lytic and are typically given lorazepam 1 mg PO (with or
without clonidine 0.1 mg PO) prior to the surgery. Patient
com ort during in ltration is also directly related to the
rate o tumescent in usion with variable-rate peristaltic
pumps. Faster in ltration rates require premedication with
IV analgesics (midazolam 1 to 3 mg, entanyl 25 to 50 µg).
S
e
Nevertheless, the convenience o rapid tumescent in ltra-
c
t
i
tion must be weighed against the inherent risks o intraop-
o
n
erative systemic narcotics and potentially uneven aesthetic
4
results due to irregular tumescence.41 Waiting 20 to
:
:
60 minutes a ter in ltration to allow or complete detumes-
cence makes target at easier to grasp and ensures maximal
A
e
hemostasis, which enhances the com ort o the practitioner.
s
t
h
e
t
i
c
MIc r o c a n n u l a s a n d
a
n
l IPo r a s PIr a t Io n
d
l
a
s
e
Pro ound vasoconstriction produced by tumescent anes-
r
P
thesia allows surgeons to use microcannulas with an inner
r
o
Figure 41-3 P asma idocaine eve s and associated tox diameter ≤2.2 mm. T e decreased pain, greater ease o
c
e
icity. The potentia or idocaine toxicity is c inica y sig subcutaneous penetration, and more uni ormly smooth
d
nif cant at p asma idocaine concentrations >6 µg/ml . results associated with microcannulas greatly outweigh
r
e
Adapted with permission rom B tterwick KJ, Go dman
s
any bene ts that might arise rom using larger cannulas.55
MP, Sriprachya An nt S. l idocaine eve s d ring the f rst However, small volumes o aspirate at per stroke and the
two ho rs o inf tration o di te anesthetic so tion or
need or a greater number o cannula entry sites are rela-
t mescent ipos ction: rapid vers s s ow de ivery. Derma-
tol Surg. 1999;25(9):681–685. tive disadvantages o microcannulas compared to their
larger counterparts.
Microcannula entry sites may be either 2 mm incisions
and epinephrine to achieve complete anesthesia and hemo- via an 11 blade or 1.0, 1.5, or 2 mm openings made via a
stasis.52 Moreover, areas o greater skin laxity may require biopsy punch. T e latter (known as adits) may allow or
greater volumes o f uid, such as the upper inner thigh.30 less cannula-induced riction during treatment and bet-
T e appropriate volume o tumescent anesthetic is the ter postoperative drainage than linear incisions.56 wo-
minimal volume that will produce complete local anesthe- millimeter diameter adits are best placed in the in erior
sia and hemostasis, albeit not necessarily complete tumes- portion o a treated area to maximize drainage. T e number
cence (swelling or rmness) o tissue.41 o entry sites is dependent on a number o actors, typi-
A number o actors associated with tumescent solution cally increasing with larger and/or more brous areas and
can increase patient tolerance pre- and postprocedure. smaller microcannula diameters.44 Entry sites should ide-
T e addition o sodium bicarbonate (10 mEq/L) to anes- ally be placed in natural skin olds, i possible, to minimize
thetic solution eliminates the burning and stinging associ- their postoperative appearance. Avoiding entry sites that
ated with the acidic pH o commercially available lidocaine are too small will also decrease cutaneous riction and
solutions.44 Warming o anesthetic solution prior to in l- trauma rom microcannula movement.
tration dramatically increases tolerability with no signi - Liposuction is typically started with smaller (16 or
cant hemodynamic e ects.53,54 riamcinolone (10 mg/L), a 14 G) microcannulas. As they produce less discom ort
highly lipophilic corticosteroid, may be added to decrease than larger (12 or 10 G) microcannulas, a surgeon utilizes
inf ammation and tenderness postoperatively. them initially to ensure that target areas are properly anes-
thetized. T e creation o small tunnels within the subcuta-
TECHNIq u E. A 25 G spinal needle is used to start neous layer, especially in more brous areas, also increases
in ltration in the deepest planes o a targeted subcutane- the ease and e ciency o larger microcannulas.
ous compartment, ollowed by in usion o partially anes- When attached to an active, negative-pressure vacuum
thetized, more super cial layers o at. In ltrating with a canister, a moving microcannula will rasp away small
super cial-to-deep approach produces early induration ragments o at that are then immediately aspirated via
o super cial layers, making in usion o deeper at more suction, making lipoaspiration a more appropriate term
484 technically di cult, and obscures the deep subcutaneous than liposuction.56 While the dominant hand moves the
 4

A B

Figure 41-4 A. Operative position or t mescent ipos ction o the neck. Three o the f ve entry sites are denoted with

C
h
circ es. The typica anning pattern o treatment is shown with arrows. B. Foam tape app ied with traction immediate y

a
p
post treatment: two shorter pieces at the mid ine and a third, arger piece across the entire area he p decrease centra

t
e
poo ing. Tape is removed 24 to 48 ho rs post proced re.

r
4
1
:
:
microcannula in a anning motion with long, smooth at should also be le t to prevent irregularities at the skin

l
strokes, the non-dominant hand helps raise grasp and raise sur ace.22

i
p
a subunit o skin and subcutaneous tissue. T is allows or Unlike other areas o the neck and lower ace, the cen-

o
s
more e cient targeting o deep at and enhances sa ety by tral to lateral submentum (submental crease to superior

c
t
elevating the tissues away rom underlying structures. An edge o the thyroid cartilage) can be treated aggressively.

i
o
n
even pinch test and topographic smoothness throughout Jawline accentuation is achieved by directing the cannula
the treatment area signi y the end o treatment. Recent 3 to 4 cm below the mandibular ramus. Deep at near the
guidelines rom the American Society or Dermatologic ramus should be avoided to minimize the risk o marginal
Surgery recommend removal o no more than 4 L o supra- mandibular nerve injury. I necessary, treatment o the
natant at in a single session, whereas prior guidelines rom jowls and lower cheeks should be per ormed very conser-
the society and the American Academy o Dermatology vatively with eathering (tunneling without suction) o the
advised limiting total aspirate volumes to 5 L.14,57 A national borders.22
survey published in 2004 reported single-session mean
total aspirate and supranatant at volumes o 1740 mL and POSTERIOR ARMS. Liposuction o 75% o the bra-
1160 mL, respectively.57 chial circum erence, sparing the thinner, more brous at
deposits o the anterior arm, leads to optimal outcomes
in the majority o patients.59 Suctioning is per ormed with
t ec Hn Iq u e a n d c o n s Id er a t Io n s the patient in a lateral decubitus position with their arm
by a n a t o MIc l o c a t Io n either at their side ( or posterior/lateral compartment) or
raised with their hand behind their head ( or medial com-
T e goal o tumescent liposuction is the three-dimensional partment). Long strokes with small microcannulas (14 or
contouring o subcutaneous adipose tissue at a given body 16 G) directed relatively parallel to the long axis o the arm
site with optimal sa ety and enhanced cosmesis, although via incisions or 1.5 mm adits at the proximal or distal por-
not necessarily a per ect result. T e ollowing are site-spe- tions o the arm maximize cosmetic results (Fig. 41-6).60
ci c clinical techniques, pearls, and caveats or commonly T e authors have also ound that treating the posterior
treated areas. and anterior axillary wings concurrently urther increases
patient satis action.
NECK AND JOWl S. Once in ltration has been com-
pleted, patients may eel some anxiety due to the swelling ABDOMEN AND Fl ANKS. T e upper and lower
and tautness o the area and must be reassured that this abdomen are accessed via three suprapubic and two peri-
is normal and will loosen within minutes o starting the umbilical crease entry sites. wo-millimeter adit sites in
procedure. ypical volumes o in ltrated solution are 400 the suprapubic abdomen may provide the best postopera-
to 500 mL. tive drainage. wo additional incisions o the lateral abdo-
Standard neck liposuction utilizes ve small entry sites: men at the level o the umbilicus allow access to the up-
submental crease, two lateral submental, and two in erior per and lower abdomen or cross-tunneling, as well as the
to the angle o the mandible (Fig. 41-4A).58 Although it waist and f anks. Microcannula entry sites are also created
may be tempting to per orm the entire procedure through over the spine or the latter. Incisions or adits above the
one site, crisscrossing and anning via multiple sites leads level o the umbilicus and on the back should be limited
to the most thorough and smooth result with a minimal in number due to potential post-inf ammatory hyperpig-
risk o depression. T e use o small microcannulas (16 G mentation.
then 14 G) prevents super cial skin irregularities, and may T e relatively inelastic skin and brous at o the upper
maximize skin retraction by preserving subcutaneous con- abdomen mandates conservative treatment with a criss-
nective tissue strands (Fig. 41-5). A thin, 3 to 5 mm layer o crossing radial pattern o microcannula movement to 485
4
S
e
c
t
i
o
n
4
:
:
A
e
s
t
h
e
t
i
c
a
Figure 41-5 T mescent ipos ction o the neck. Preoperative (left) and 3 months postoperative (right).
n
d
A tota o 40 ml o at removed in a sing e session.
l
a
s
e
r
P
r
o
ensure smooth results.26 Force ul microcannula thrusts HIPS, Ou TER THIGHS, AND Bu TTOCKS. With
c
e
directed at the costal margin may lead to rib bruising or
d
the patient in the lateral decubitus position, treatment o
penetration o the diaphragm or pleural space. Attention the hip is per ormed via three entry sites (superior, in e-
r
e
s
should be given to the periumbilical area, to avoid leaving rior, and posterior mid-lateral). Microcannula movement
behind a “donut” o at. Initial tunneling o highly brous in this area is primarily in a vertical plane. T e posterior
subcutaneous tissue o the f anks (and waist in women) incision site is also used to eather into the waist and ante-
with a small microcannula (16 or 14 G) dramatically riorly toward the abdomen.27,61
increases the ease o ensuing treatment with larger (12 or T e ideal outer thigh position is in modi ed lateral decu-
10 G) microcannulas. Figures 41-7 and 41-8 demonstrate bitus with a midline wedge cushion, abducting and inter-
typical results in male and emale patients. nally rotating the extremity to best approximate standing.

A B

Figure 41-6 T mescent ipos ction o the posterior arm. Preoperative (A) and
severa months postoperative (B) with signif cant red ction in adiposity and associ
486 ated axity.
 4

C
h
A B

a
p
t
e
Figure 41-7 T mescent ipos ction o the ma e abdomen and anks. Preoperative (A) and 6 months

r
4
postoperative (B).

1
:
:
T is position also limits oversuctioning by rotating away to avoid signi cantly suctioning this area. Buttock contrac-

l
the greater trochanter. Entry sites are placed superiorly, tion emphasizes this area. Liposuction o the “banana old,”

i
p
o
in eriorly, and in the in ragluteal crease. T e latter can be a convexity rom the in erior gluteal crease to the posterior

s
used to blend the outer and posterior thigh together (Fig. thigh that houses the ligament o Luschka, is best avoided or

c
t
i
41-9). Circum erential treatment o thigh at should never treated super cially only in a horizontal plane.27,62 Injury to

o
n
be per ormed in a single session due to the potential or this in ragluteal ligament may cause buttock drooping and
compartment syndrome and persistent lymphedema. herniation o at into the posterior thigh.
Compared to the other two sites, the buttock is treated
ar less commonly. T e area is treated with the patient prone MEDIAl THIGH AND KNEE. Liposuction o the
and a pillow placed under the pelvis, with 1 to 3 microcan- proximal medial thigh, mid-thigh, and medial knee is rst
nula entry sites placed in ragluteally. T e lateral gluteal (tro- per ormed separately in each area then blended togeth-
chanteric) depression must be clearly marked preoperatively er. All three regions are per ormed in a lateral decubitus

A B C

Figure 41-8 (A) Pre and (B) 2 weeks and (C) 5 months o owing t mescent ipos ction o the ema e abdomen, waist,
and anks. 487
4
S
e
c
t
i
o
n
4
:
:
A
e
s
t
A B
h
e
t
i
Figure 41-9 (A) Pre and (B) severa months o owing t mescent ipos ction o the atera
c
a
thighs.
n
d
l
a
s
e
r
P
position with the contralateral extremity f exed high onto liposuction (LAL), has been purported to improve aes-
r
o
a oam cushion. thetic results and postoperative recovery compared to
c
e
d
Proximal medial thigh at is unique in its so t, non- liposuction alone. Yet the prospective bene ts achieved
brous nature, which makes the at easily extracted and
r
with LAL must be weighed against device costs and the
e
s
de ects quick to develop. Placing an incision site at the risk o cutaneous thermal injury.
distal aspect o the proximal medial thigh bulge or in the Although selective photothermal e ects may play a
mid-thigh can result in depressions and should be avoided. role in LAL devices (ranging rom 920 to 1440 nm), heat-
Hidden entry sites are placed posteriorly, one near the generated sequelae most likely account or its potential
mid-in ragluteal crease and one placed 2 to 3 cm in erior clinical capabilities. Collagen thermocoagulation and
and anterior to the rst, allowing cross-tunneling. Suc- subsequent neocollagenesis within the reticular dermis
tioning should be conservative in the lowermost border may enhance skin retraction.63 Laser-induced blood
o the proximal medial thigh to avoid excessive resection. vessel thrombosis and lymphatic channel closure may
unneling without suction is per ormed distally into the reduce postoperative ecchymosis and edema.64 Greater
thicker, more brous mid-thigh at. An incision site in the at emulsi cation rom adipocyte cellular membrane
mid-anterior thigh 1 to 2 cm in erior to the inguinal crease degradation (adipolysis) may decrease the extent o
can also target the anterior portion o the medial thigh. mechanical damage produced by microcannulas (accel-
Aggressive suctioning o the medial knee success ully erating postoperative recovery) and improve the treat-
tapers the distal thigh. Suction is primarily per ormed ment o brous at.65– 67
through one posterior incision site placed distal to (not Despite all o these possible advantages, studies com-
within) the popliteal crease. A second incision site 2 to paring LAL to liposuction alone using the tumescent
3 cm superior to the medial popliteal crease is use ul or technique have shown mixed results. A randomized,
conservative cross-tunneling, as well as or mid-thigh double-blind study comparing 1064 nm LAL to liposuc-
access. Fat pads in erior and medial to the patella are also tion alone in 220 split body areas demonstrated signi -
treated aggressively. However, aggressive suctioning o cantly less postoperative pain with LAL ( p < 0.0001), but
the suprapatellar at pad should be avoided, as inherently no di erences in ecchymosis, edema, skin retraction, or
poor skin retraction and ptosis o the anterior thigh may overall cosmetic outcome.68 A randomized, nonblinded
cause sagging and creasing o the knee.30 unneling with- study o posterior arms treated with 1064 nm LAL versus
out suction blends the knee to the mid-thigh and cal . liposuction alone also ound no signi cant di erences in
T e mid-thigh is then treated conservatively with long, at reduction or skin retraction.69 Nevertheless, other
smooth vertical strokes using preexisting entry sites. nonblinded studies have shown greater – albeit mod-
est – improvements in postoperative arm circum erence
l a s er -a s s Is t ed l IPo s u c t Io n and abdominal skin tightening with LAL.70,71 More com-
parative studies are needed to solidi y whether LAL has
T e addition o Nd:YAG or diode laser lipolysis to stan- any true advantage over standard tumescent liposuc-
488 dard liposuction techniques, known as laser-assisted tion.72
 u lt r a so u n d - a n d
Hypertonic anesthetic solution remaining in subcuta-
neous tissue ollowing tumescent liposuction (up to 80%
4
r a d Io Fr eq u en c y-a s s Is t ed o volume in ltrated) is unable to be resorbed due to wide-
l IPo s u c t Io n spread surgical disruption o lymphatic capillaries.80 I le t
undrained, the hyperosmotic interstitial environment
Ultrasound-assisted liposuction (UAL) utilizes inter- incites the di usion o f uid out o the intravascular space,
nal pulsed or continuous ultrasound energy to produce across the osmotic gradient, leading to longstanding lym-
adipocyte ragmentation and at emulsi cation prior to phatic edema. Postoperative compression encourages
suction.73 A multicenter, randomized, subject-blinded drainage via open microcannula entry sites, minimizing
study comparing superwet UAL to standard liposuction post-liposuction edema.81
revealed only minor improvements in skin retraction and Bimodal compression, as advocated by dermatologist
surgical hemostasis with UAL and no signi cant di er- and tumescent liposuction pioneer Je rey Klein, involves
ences in satis action or postoperative induration, edema, two sequential degrees o compression in the postop-
or ecchymosis.74 Subjects also reported greater postop- erative period.82 A high degree o uni orm compression is
erative pain, burning, numbness, and swelling with UAL.75 used until 24 hours a ter drainage has ceased (i.e., a total

C
h
T e anecdotal nature o UAL bene ts must be cautiously o 2 to 4 days), at which time only a mild degree o com-

a
p
weighed against its lack o high-quality clinical data and pression (e.g., Spandex®garment) is needed.83 Prolonged

t
e
r
ostensibly greater risk o burns, necrosis, and seromas.76 high-grade compression instead collapses lymphatic

4
1
Radio requency-assisted liposuction (RFAL) has also capillaries, blocking drainage o residual subcutaneous
been asserted to improve skin tightening and at reduc- f uid and worsening edema postoperatively.82 Mild con-

:
:
tion. A suction cannula with an electrode tip delivers tinued compression o ers patients physical com ort and

l
monopolar RF energy, while an external electrode ref ects maintains interstitial f uid hydrostatic pressures just high

i
p
o
absorbed heat back into the dermis.77 However, no stud- enough to slow transudate ormation.82 Nevertheless, once

s
ies have compared RFAL with standard liposuction tech- drainage has stopped, continued external compression is

c
t
not essential and has no signi cant bearing on the ultimate

i
niques.78,79

o
n
cosmetic result.
Certain areas o the body have speci c compression
Po s t o Per a t Iv e c a r e requirements, given their location or greater potential
or adverse events. Patients undergoing liposuction o
the submental area should be advised that ocal areas o
umescent liposuction has an uncomplicated postopera-
induration, representative o localized interstitial edema,
tive course with relatively low maintenance compared to
always develop as an expected, temporary condition that
non-tumescent liposuction under systemic anesthesia or
resolve over a period o 4 to 8 weeks. A compressive chin-
other cosmetic surgical procedures.
strap is worn 24 hours a day during the drainage phase,
then may be used 2 to 4 hours a day or another 3 weeks.22
IMMed Ia t e Po s t o Per a t Iv e Per Io d Breasts have an increased risk o bleeding, ecchymosis,
and hematoma ormation in the immediate postopera-
Once tumescent liposuction is complete, the area is tive phase and require an exceptionally high degree o
cleansed and absorbent pads or sanitary napkins are compression. Very high ( rst 12 to 18 hours), high (until
applied over the microcannula entrance sites to collect 24 hours a ter drainage ceases), and mild compression
drainage, held in place with tape or tubular elastic netting. can be achieved with a single, adjustable breast garment.82
T e treated area is then secured with a circum erential Circum erential thighs or calves and ankles have a greater
compression garment. Following tumescent liposuction o risk or excessive or prolonged edema. T e combination
the neck, oam tape may be applied (Fig. 41-4B) to mini- o a compression stocking (15 to 20 mm Hg), ankle-length
mize bruising and pooling o f uid and ree-f oating adi- support garment, and leg elevation during the rst 3 days
pocytes in the submental area. As tumesced areas remain postoperatively will minimize edema ormation. wenty
at least partially anesthetized up to 18 to 24 hours post to thirty or 30 to 40 mm Hg stockings, depending on the
procedure, this prolonged anesthetic e ect minimizes the amount o edema, are then used 24 hours a day or 1 week
need or potent oral analgesics.50 ollowed daily or 4 to 8 weeks.30

Su RGICAl SITES. T e vast majority o patients tol-

s Ho r t -t er M erate the postoperative period exceedingly well. Surgical
Po s t o Per a t Iv e Per Io d site tenderness and mild edema are common short-term
complaints. Over-the-counter oral analgesics or rarely a
COMPRESSION. Compression garments serve a short course o low-dose narcotics are su cient to con-
number o important unctions during the postopera- trol symptoms. Although nonthermal ultrasound, pulsed
tive period including decreasing edema and ecchymosis, short-wave diathermy, and magnetic eld therapy have all
mitigating discom ort, and accelerating patients’ return to been studied post-liposuction, none lead to signi cant and
normal activities. Patients o ten maintain that the com- reliable improvement in discom ort, edema, and bruis-
pression garment splints or supports the area that has ing.84– 86 Ecchymosis, however, is generally mild, given the
been treated, making it less pain ul than when it is not in vasoconstrictive e ects o tumescent anesthesia and post-
use. Open drainage and proper compression also virtually treatment compression. I it develops, it is dependent in
eliminate the risk o postoperative seromas.80 nature and migrates in eriorly; or example, purpura rom 489
4 tumescent liposuction o the neck tends to dri t below the
collar line.
ouch-ups are per ormed no earlier than 6 months – and
ideally beyond 1 year – ollowing the original treatment
Adit or incision sites should be le t open or optimal session, allowing or maximum so t-tissue remodeling
drainage o residual anesthetic solution, preventing the be ore evaluating nal results. Obvious irregularities are
occurrence o post-liposuction edema. Drainage usually o ten easily corrected by removing residual pockets o adi-
ceases within 24 to 72 hours postoperatively with uni orm, pose tissue (Fig. 41-10). Incorrect endpoint assessment by
high-grade compression. As they are actively healing sec- the physician due to excess skin laxity or patient position-
ond intention wounds, erythema and mild ecchymosis ing, as well as patient hypersensitivity to parts or all o the
surrounding the cutaneous openings are expected. Moist procedure leading to incomplete at removal, can all con-
occlusive wound care without scab ormation and proper tribute to postoperative irregularity requiring touch-up
sun protection will lead to a nearly imperceptible scar at 1 treatment.91 However, touch-ups or patient complaints
year post treatment. Although adit sites may lead to bet- that are not clinically appreciable by the physician or
ter postoperative drainage, the use o 2 mm incisions in his/her sta should be avoided. Avoiding excessive at
darker skin types may minimize postinf ammatory hyper- resection urther minimizes the incidence o patient dis-
pigmentation. satis action.
S
e
A retrospective review o 954 tumescent liposuc-
c
t
i
tion surgeries (1613 areas treated) by Butterwick et al.91
o
l o n g -t er M Po s t o Per a t Iv e Per Io d
n
reported a rate o 12.3% touch-up procedures (9% rate per
4
area). T e most common areas or touch-up, the neck and
Setting appropriate patient expectations prior to per orm-
:
:
abdomen, were also the most common areas to be treated.
ing tumescent liposuction ensures that the majority o T e brous areas o the back, chest, and ankles, however,
A
e
patients will be pleased with the subjective results. Pre- had the highest touch-up rate. Males and emales had
s
t
and postoperative digital photographs in a side-by-side
h
an equal incidence o touch-ups, with greater than 80%
e
ormat help illustrate the positive aesthetic changes and
t
having the procedure 6 months or longer ollowing their
i
c
the importance o a healthy li estyle. Weight should be
a
original surgery and 47% demonstrating a gain in weight
n
measured at each ollow-up visit, since it is not uncom-
d
during that time. More than one-third o those patients
l
mon or unsatis ed patients to have gained weight in the
a
elected to have a second liposuction procedure, indicating
s
postoperative period. Although liposuctioned areas will
e
overall satis action.
r
resist weight gain, atty deposits may subsequently accu-
P
r
o
mulate in other areas o the body, such as the breasts,
c
c o MPl Ic a t Io n s
e
abdomen, or viscera.87– 89 A survey per ormed by Rohrich
d
et al.90 ound that 73% o patients who gained weight or
r
e
82% o those who did not gain weight post treatment were Large-scale studies have con rmed that liposuction per-
s
satis ed with results. However, only 29% o those who ormed solely with tumescent anesthesia using a clean
gained weight rated their appearance as good or excellent, surgical technique has remarkably ew complications
compared to 79% o those who did not gain weight. and no associated deaths ( able 41-5). T e morbidity and

A B

Figure 41-10 Resid a adiposity o e t proxima media thigh rom prior t mescent ipos ction, be ore
490 (A) and 2 months a ter (B) to ch p.
 TABl E 41-5
4
l ip i s f s i

F i r
s a h i n m fc (p 100,000)
Newman and Do sky, 198492 SA 5,458 0
Bernstein and Hanke, 198893 29% SA, 71% oca anesthesia a 9,478 0
Teimo rian and Rogers, 199194 SA 75,591 2.6
Di er d, 199195 57% SA 43% oca anesthesia a 3,511 0
Hanke et a , 199596 Tl A 15,336 0
ASPRS Task Force on l ipos ction, 199797 SA 24,295 20.6

C
h
Jackson and Do sky, 199998 SA 200,000 2.4

a
p
Grazer and de Jong, 200099

t
SA 496,245 19.1

e
r
4
H ghes, 2001100 SA 94,159 2.1

1
Ho sman et a , 2002101 91% Tl A, neg igib e SA 66,570 0

:
:
Hanke et a , 200457 Tl A 668 0

l
i
p
Habbema, 2009102 Tl A 3,240 0

o
s
Boeni, 2011103 Tl A 4,380 0

c
t
i
o
Chia and Theodoro , 2012104 Tl A 1,000 0

n
Tl A, t mescent oca anesthesia (inc ding minima conscio s sedation); SA, systemic anesthesia (inc ding genera anesthesia or intraveno s
narcotics).
a
The oca anesthesia described here may a so inc de a component o intraveno s sedation with narcotics.

rare – albeit concerning – mortality seen with liposuction extremely rare, given the highly dilute nature (1:1,000,000)
under general anesthesia is not simply a actor o the anes- o epinephrine.80 A review o 10 year mandatory ambula-
thesia itsel , but is also directly related to the protracted tory surgery adverse event reports in Florida by Starling
or excessive procedures (“megaliposuction”) or multiple et al. also ound no serious complications rom tumescent
concomitant procedures in a single session that it acili- liposuction; liposuction under general anesthesia, how-
tates.105 Although there have been numerous reports o ever, accounted or 32% o all cosmetic procedure-related
mortality related to “tumescent liposuction,” it is impor- deaths.112
tant to note that these cases did not represent true tumes- T e combination o excessive liposuction, iatrogenic
cent technique. All included the use o general or deep IV hemodilution secondary to excessive intraoperative IV
sedation and o ten additional, excessive intraoperative IV f uids, closure o microcannula insertion sites, and exces-
f uids or multiple concomitant procedures.106– 111 With true sive external compression can also lead to a state o mas-
tumescent techniques as per ormed by dermatologic sur- sive, progressive, osmotically mediated subcutaneous
geons, it is not surprising that the incidence o intraopera- edema known as ampli ed liposuction edema (ALE).81
tive (visceral per oration, f uid overload) or postoperative Extreme cases o ALE can result in acute renal ailure and
(embolic) adverse events should be virtually eliminated atal pulmonary and central nervous system edema.
since patients are alert and awake during the procedure
and can resume normal activities almost immediately.
A national survey o tumescent liposuction by derma- c o n c l u s Io n
tologic surgeons revealed minimal morbidity and no li e
threatening complications, blood trans usions, or hospi- Liposuction has evolved signi cantly in the past three
talizations in 15,336 patients with 44,014 separate body decades. Once a procedure raught with intraoperative
areas.96 T e most requent complications were scrotal or and postoperative morbidity, the tumescent technique
labial edema and ecchymosis (0.39%), mild localized in ec- now allows liposuction to be per ormed purely as an out-
tions (0.34%), cutaneous irregularities such as dimpling or patient procedure on awake patients with rare adverse
retraction (0.26%), ocal subcutaneous induration (0.20%), events. Despite all o the new “bigger and better” tech-
hematoma/seroma (0.17%), reactions to medications or nologies that have entered the marketplace to enhance
tape (0.12%), and post-liposuction edema (0.10%). Cuta- the speed and results o treatment, the secret to success-
neous ulceration/necrosis, persistent postoperative pain ul liposuction remains unchanged: proper patient selec-
or ecchymosis, and excessive postoperative somnolence or tion, patience, meticulous technique, an aesthetic eye, and
nausea all occurred rarely. Intraoperative tachycardia was excellent surgical sta . 491
4 r eFer en c es
24. Lillis PJ. Liposuction o the arms. Dermatol Clin. 1999;17:
783– 797.
25. Narins RS. Abdomen: hourglass abdomen, f anks, and modi-
1. Ahn CS, Davis SA, Dabade S, Willi ord PM, Feldman SR. ed abdominoplasty. In: Narins RS, ed. Safe Liposuction and
Cosmetic procedures per ormed in the United States: a Fat ransfer. New York, NY: Marcel Dekker, Inc; 2003:95–120.
16-year analysis. Dermatol Surg. 2013;39:1351– 1359. 26. Klein JA. Abdomen. In: Klein JA, ed. umescent echnique:
2. Klein JA. umescent technique or regional anesthesia per- umescent Anesthesia and Microcannular Liposuction. St.
mits lidocaine doses o 35 mg/kg or liposuction. J Dermatol Louis, Mosby, Inc; 2000:297– 324.
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3. ierney EP, Kouba DJ, Hanke CW. Sa ety o tumescent and RS, ed. Safe Liposuction and Fat ransfer. New York, NY:
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emales. Aesthetic Pla st Surg. 2011;35:402– 407. Surg. 1996;22:973– 976.
5. Boni R. umescent power liposuction in the treatment o the 30. Butterwick KJ. Liposuction o the medial thigh, knee, cal ,
enlarged male breast. Dermatology (Ba sel). 2006;213:140– and ankle. In: Narins RS, ed. Safe Liposuction and Fat rans-
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143. fer. New York, NY: Marcel Dekker, Inc; 2003:149– 182.
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4
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:
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with liposuction. Dermatol Surg. 2001;27:497– 500. In: Klein JA, ed. umescent echnique: umescent Anesthesia
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505–511. liposuction. A case report o probable drug interactions.
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28:971– 978. ing a atality during tumescent liposuction. Forensic Sci Int.
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cent local anesthesia in 3,240 consecutive cases. Dermatol 110. Rao RB, Ely SF, Ho man RS. Deaths related to liposuction.
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thesia in a series o 4,380 patients. Dermatology. 2011;222: Steinau HU. Major and lethal complications o liposuction:
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278– 281. a review o 72 cases in Germany between 1998 and 2002.
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795– 802. o Alabama data reveal. Dermatol Surg. 2012;38(2):171–177.
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 Ch a p t e r Hair Transplantation for

42 Men and Women

Nicole E. Rogers & Marc R. Avram

In t r o d u c t Io n once daily and is approved or use in en only. I works by

blocking he enzy e 5-alpha reduc ase ype II, which con-
ver s es os erone o dihydro es os erone (DH ). DH
Be ween 40% and 50% o en and wo en su er ro ale
has been shown o have a inia urizing e ec on hair ol-
and e ale pa ern hair loss. Over i e, hair loss can have
licles and is believed o be one ac or con ribu ing o he
a pro ound i pac on sense o sel -i age, sel -awareness,
develop en o ale pa ern hair loss. Wi h ongoing use
and sel -con dence. Hair provides an i por an ra e o
o nas eride, en can expec o have con inued increases
he ace, and i also serves as a eans o sel -expression.
in bo h hair coun s and hair hickness or up o 2 years
Individuals ay cu , color, and s yle heir hair however
be ore his e ec reaches a pla eau.1,2
hey choose. T e involun ary loss o his abili y can be
Rogaine®(ac ive ingredien inoxidil) is FDA approved or
ex re ely dis ressing. When i a ec s young people in
hair loss in bo h en (5% oa and solu ion) and wo en (2%
heir eens and wen ies, i can be especially devas a ing.
solu ion). Recen evidence has shown ha wo en can use he
As hair res ora ion surgeons, we have he unique abili y
5% once daily a bed i e wi h he sa e e ec s as seen using
o help recrea e our pa ien s’ sense o sel -i age and con-
2% wice daily.3 I s exac echanis o ac ion is unknown bu
dence. However he resul s o early hair ransplan a ion
i is believed o work hrough a co bina ion o local vasodi-
were no always cos e ically accep able. Hair ransplan a-
la ion, he opening o po assiu channels, and possibly by
ion or any s ill carries he s ig a o oversized “pluggy”
down-regula ing in a a ion.4 Even a er surgery, inoxidil
gra s and hairlines placed oo low or unna urally. I is
plays a po en ially valuable role in speeding up he grow h o
i pera ive or novice surgeons o learn he conserva ive
ransplan ed ollicles and s opping ur her loss.5
s eps necessary or op i al, na ural resul s. I is especially
Low-level ligh herapy (LLL ) has also shown pro ise
i por an o learn hese s eps so ha we as prac i ioners
as a edical rea en or hair loss. Several devices exis on
o his pro ession do no repea his ory.
he arke using 655 n “red ligh ” o shine direc ly on he
Hair na urally grows in groupings o one o our hairs
hair ollicle. T e Hair ax Laserco b received FDA 510(k)
per ollicular uni (FU) (Fig. 42-1). By separa ing he FUs
clearance as a edical device or he rea en o andro-
ro one ano her and allowing he hairs o re ain as hey
gene ic alopecia in en in 2007. Addi ional clearance or
do in na ure, hey can be reloca ed o areas o hinning
e ales was ob ained in 2011. Pa ien s are ins ruc ed o use
wi h na ural and unde ec able resul s.
he device o co b hrough he scalp hree i es weekly or
15 inu es each i e. So ar he da a is li i ed bu pro is-
Med Ic a t Io n s Fo r Ha Ir Lo s s ing and ur her independen s udies will soon be available.6

Presen ly, here are only wo FDA-approved edica- Ha Ir Lo s s c o n s u Lt a t Io n

ions or hair loss ha co e in a varie y o or ula ions
(Fig. 42-2). Propecia®is a 1 g nas eride pill ha is aken
During he consul a ion, i is i por an rs o gain an
unders anding o how long he pa ien has been su ering

Figure 42-1 Hair ollicles naturally grow in groupings o Figure 42-2 FDA approved medications or hair loss
one, two, three, and our hairs. include Propecia and Rogaine.
4

I II II A
S
e
c
t
i
o
III III Ve rtex III A
n
4
:
:
A
e
s
t
h
e
t
i
c
a
n
d
IV V IV A
L
a
s
e
r
P
r
o
c
e
d
u
r
e
s
VI VII VA
Figure 42-3 The Norwood system is used to classi y male pattern hair loss.

ro hair loss. I he i e ra e is as brie as 6 on hs, dis ribu ion o hair loss (Fig. 42-3). In young pa ien s, i
hey ay have a shor - er condi ion called elogen can be dif cul o predic how heir hair loss will evolve
e uviu , which can be due o childbir h, general anes- over he succeeding 20 o 50 years. Fa ily his ory can
hesia, ajor physiologic s ress, changes in edica ions, be help ul bu no al oge her predic ive. ransplan ing
hyroid dis urbances, or o her labora ory abnor ali ies. only he ron al 0.5 c o he hairline or ver ex in young
We encourage pa ien s o bring any previous labora ory en (early 20s) ay leave he wi h unna ural-appearing
resul s wi h he or re er he o heir in ernis or endo- resul s years la er. In hese cases, s ar ing wi h edica-
crinologis i ur her es ing is necessary. ions or hair loss ay be he bes op ion.
For he vas ajori y o pa ien s seeking hair ransplan a- For wo en, we use he Ludwig sys e o classi y hair loss
ion, heir hair loss has been long-s anding and hey under- (Fig. 42-4). Fe ale pa ern hair loss does no usually resul
s and ha here is a gene ic co ponen o heir condi ion. in a recession o he hairline bu ra her a loss o densi y in
T ey ay have a bro her, sis er, paren , or uncle wi h severe
hair loss. I is i por an o unders and wha rea en s hey
have already ried (bo h prescrip ion and over- he-coun er
supple en s) and ask whe her hese have i proved heir
hair loss. We encourage pa ien s o con inue heir edica-
ions even i hey proceed wi h hair ransplan a ion because
i will help o s abilize heir ongoing loss.
Nex , i is i por an o assess he age o he pa ien
and heir degree o hair loss. We discuss wi h pa ien s he
ac ha androgene ic alopecia is an ongoing condi ion
which can progress even a er hair ransplan a ion (hence Type I Type II Type III
he role o edica ions in preserving exis ing hairs). For Figure 42-4 The Ludwig system is used to classi y emale
496 en, we use he Norwood sys e o classi y he exis ing pattern hair loss.
 TAbLE 42-1
4
Li fF a d i H i
t l c l i
Age o patient
Degree o hair loss
Duration o hair loss
Past treatments: Medications? Supplements?
Expectations: Reasona le? Any history o bDD?
General Health: Smoker? Cardiovascular risk actors?
Physical Examination: Cali er/color o donor hair

C
h
a
p
t
A co ple e lis o ac ors o consider in he hair rans-

e
r
plan consul a ion is shown in able 42-1.

4
2
:
:
Figure 42-5 Magnif ed examination o the occipital scalp
d a y o F s u r g er y

H
a
prior to hair surgery helps assess donor density.

i
r
Pa ien s o en arrive or heir surgery sligh ly anxious

T
r
a
and wi h so e apprehension abou wha is abou o ake

n
s
place. I is help ul o provide as uch wri en a erial

p
he ron al one-hal o wo- hirds o he scalp. Wo en co -

l
a
as possible abou wha o expec be ore he procedure

n
plain o a “see hrough” e ec and eel sel -conscious ha

t
and a er i is co ple e. Pa ien s are given a ple i e

a
o hers are looking a heir scalp ra her han heir eyes. Gen-

t
i
o review he packe and ask any nal ques ions be ore

o
erally, here are no risks o ransplan ing wo en bu heir

n
signing he consen or . T e surgical plan is reviewed,
resul s will be bes i hey have good donor hair densi y. I

o
and baseline pho ographs can be aken and should docu-

r
he hair on he occipi al scalp is jus as hin as i is elsewhere,

M
en several di eren views o he pa ien i possible.

e
surgery ay no provide signi can cos e ic bene .

n
A er all consen s are signed pa ien s are given a ild
T e physical exa ina ion involves assessing he exis -

a
n
seda ive such as diazepa o relax. T eir blood pressure
ing dis ribu ion o he hair loss as well as he donor hair a

d
is checked and i i is wi hin nor al li i s he pa ien

W
he back o he scalp. I is i por an o exa ine he en ire

o
is escor ed o he surgical sui e o change in o a gown.

m
scalp o ake sure ha ano her condi ion is no causing
Pa ien s are encouraged o wear a bu on down shir so

e
he pa ien ’s hair loss. I here is ever any doub as o he

n
ha a he end o he day hey do no need o pull heir
e iology o a pa ien ’s hair loss, a scalp biopsy should be
shir over heir bandage.
per or ed. T icker hairs will o er be er coverage han
T e donor area is arked on he occipi al scalp by pin-
hairs o ne, hin caliber. Der oscopy can be help ul o
ning he hair up wi h a piece o ape and hairclips. I he
assess whe her pa ien s have ollicle inia uriza ion in he
hair is long enough (approxi a ely 1– 3 c ) i will cover
donor region as well. Generally, pa ien s wi h good caliber
he donor scar. T e area is hen ri ed using a razor and
and suf cien hair densi y (60– 100 FUs/c 2) ake excel-
he pa ien is placed in a prone posi ion. Specialized pil-
len candida es or hair ransplan a ion (Fig. 42-5).
lows are available o allow he pa ien o res co or ably
Realis ic expec a ions are vi al o he success o he pro-
while prone. So e surgeons ay o er headphones wi h
cedure. Pa ien s us unders and how ongoing hair loss
usic or dis rac ion. We generally alk o our pa ien s
will i pac he perceived densi y o a hair ransplan over
and keep an easy conversa ion going hroughou he har-
i e (Ne densi y = hair ollicles ransplan ed − ongoing
ves and hrough he res o he day.
hair loss). Pa ien s should unders and be ore he procedure
he areas in which heir ransplan ed hair will appear na u-
ral 1 year and 10 years a er he procedure. ransplan ing a n es t Hes Ia a n d
on he ron al hal o he scalp in bo h en and wo en
will have he grea es cos e ic i pac and is he cos- d o n o r Ha r v es t In g
e ically sa es area in which o ransplan or long- er
resul s. ransplan ing hairs o he ver ex o he scalp will In he early days o hair ransplan a ion, donor ollicles
have he leas cos e ic i pac and has he grea es risk o were harves ed ro he occipi al scalp using 4 o 6
developing an unna ural appearance over i e, as exis ing punch rephines. When he hair was oved o areas
hair is los . Pa ien s wi h body dys orphic disorder (BDD) o hinning, i con inued o grow in oversized group-
should be iden i ed early because hey ay never be happy ings o 10 o15 hairs. Since hen, newer echniques have
wi h surgical resul s. I a pa ien ’s goal is o achieve grea er evolved, including bo h radi ional s rip excision and
rela ive coverage o heir scalp wi h a single procedure, and ollicular uni ex rac ion (FUE). T ese echniques o er
hey unders and ha co ple e coverage ay ake wo or ore na ural resul s and less no iceable scarring in he
ore procedures, hen a good ou co e can be expec ed. donor region. 497
4

Figure 42-6 Local anesthesia using 0.5%, 1%, and 2% Figure 42-8 Harvesting o donor tissue rom the occipital
S
e
lidocaine as well as 0.25% upivicane. scalp.
c
t
i
o
n
4
s t r Ip exc Is Io n S ar ing a one end, he s rip should be li ed and gen ly
separa ed ro he underlying scalp issue by working
:
:
T e gold s andard or harves ing has radi ionally been he slowly across he scalp (Figs. 42-9 and 42-10). T e edges
A
s rip excision, in which a long narrow s rip is aken ro should be apered and when re oved, he s rip should be
e
s
placed in saline un il gra separa ion begins.
t
he occipi al scalp, below he op level o he ears. o avoid
h
e
he crea ion o a wide scar, he s rip should be no ore T e donor si e can be closed wi h ei her s aples or su ures
t
i
c
han 1 o 1.5 c wide. So e surgeons have had success (Fig. 42-11). A varie y o absorbable and nonabsorbable
a
n
wi h wider s rips bu cau ion should be used. Excess en- su ures can be used. T e au hors use bo h s aples (MA) and
d
running 3-0 or 4-0 polyglac in 910 su ures (NR). Under-
L
sion on he donor scalp can resul in very wide scars, or
a
ining is generally no required and i is up o he surgeon
s
worse, co ple e skin necrosis.
e
r
Various co bina ions o local anes hesia can be used o whe her o use local elec rocau ery or he os asis. S aples
P
r
and su ures us re ain in place or 7 o 10 days, while dis-
o
nu b he donor area (Fig. 42-6), including 0.5%, 1%, and
c
solving su ures are a good op ion or ou -o - own pa ien s
e
2% lidocaine solu ions wi h 1:1,00,000 epinephrine. We
d
who canno re urn or su ure re oval. Many advoca e he use
u
s ar wi h a bu ered 2% lidocaine wi h epinephrine solu-
r
e
ion along he in erior aspec o he donor s rip, where he o a richophy ic closure echnique o ini ize he appear-
s
occipi al nerve origina es. Bupivicane 0.25% is hen added ance o he scar. T is is per or ed by re oving a narrow,
around he periphery o he donor s rip o allow or longer- super cial ledge o epider is ro one or bo h wound edges
er anes hesia o he surrounding area a er s rip harves so ha when he hairs grow back, hey will grow hrough he
(Fig. 42-7). Finally, saline is injec ed in o he donor area o scar and help ca ou age i s appearance.
provide u escence in he subcu is. T is allows or r -
ing o he skin and helps o eleva e he ollicles above any
nerves and blood vessels below. Fo LLIc u La r u n It ex t r a c t Io n (Fu e)
Nex a single- or double-bladed scalpel wi h a #10 blade
is used o re ove he donor s rip (Fig. 42-8). Care should In he las 5 years, here has been a rend oward “no scar”
be aken o angle he blade in he caudal direc ion so ha i surgery, propelled bo h by pa ien desires and arke
alls be ween exis ing hairs and does no ransec any ol- orces. T is or o donor harves involves he re oval o
licles. So e surgeons reco end jus scoring he epider- individual FUs one a a i e using s all (0.6–1 ) an-
is and using ension o dissec he der is and subcu is. ual or o orized punch devices. A larger donor area us

Figure 42-7 Injection o local anesthesia into the donor Figure 42-9 Removal o donor strip using sterile tech
498 area prior to surgery. nique.
 4

Figure 42-10 Su cutaneous at remains a ter donor strip

C
h
has een harvested.

a
p
t
e
r
4
2
be used and closely shaved o allow or harves ing o indi-
vidual ollicles. Mos doc ors use loupes or so e or o

:
:
agni ca ion o correc ly iden i y he angle o he ollicle as

H
i exi s he scalp. Local anes hesia can be used and no clo-

a
i
r
sure is necessary or he pinpoin scars le behind. Pa ien s

T
r
si ply keep he area clean and covered wi h a pe rola u

a
n
based or an ibio ic oin en while he si es are healing.

s
p
l
T ere are cer ain cavea s o his echnique. Firs , here

a
n
can be considerably higher ollicle ransec ion ra es seen

t
a
t
wi h FUE, especially during he early phase o i ple en a-

i
o
n
ion. I he angle is no correc , or excess ension is placed

o
on he ollicle, i ay be cu in hal or lose i s inves ing is-

r
M
sue. Ei her condi ion will de er subsequen grow h. I is also
Figure 42-12 Patient is com orta ly reclined during gra t

e
considerably ore i e-consu ing, as i provides jus one-

n
placement.

a
hird o hal he nor al nu ber o gra s wi hin he sa e

n
d
opera ive i e. T is can ul i a ely ake his echnique

W
ore expensive or he pa ien s who choose i . Finally,

o
also provide oral diazepa bu encourage hose pa ien s

m
pa ien s ay be le wi h reduced donor densi y in he even

e
who ake i no o drive a er he procedure is over. In cer-

n
ha hey desire a radi ional s rip excision o be per or ed
ain pa ien s wi h above-average anxie y, i ay be help-
la er. i e will ell how his echnique co pares wi h radi-
ul o prescribe a s ronger anxioly ic edica ion and allow
ional s rip excision.
he o ake i be ore hey co e in (wi h consen s signed
be orehand) or o arrange or an anes hesiologis o be
er g o n o MIc s a n d presen or he procedure i he opera ing roo is accred-
i ed or seda ion and oni oring.
pa t Ien t c o MFo r t Pa ien s are encouraged o le us know when hey need
o s re ch or use he ba hroo . Depending on he ex en
Local anes hesia is generally suf cien o achieve good o he procedure i ay be necessary o break or lunch in
he os asis and axi al co or or os pa ien s. We he iddle o he day. A elevision is ins alled in he oper-
a ing roo and pa ien s are invi ed o bring any ovies or
DVDs hey would like o wa ch. Frequen ly hey jus enjoy
alking and lis ening o usic (Fig. 42-12). I is i pera ive
o ain ain a relaxed bu pro essional a osphere.

Ha Ir LIn e d es Ig n
T e loca ion and orien a ion o he hairline are bo h
ex re ely i por an or he crea ion o na ural resul s. T e
area ha is ransplan ed us look cos e ically appropri-
a e bo h in he presen as well as 20 o 50 years a er he
procedure has been per or ed. For wo en, whose hair-
lines generally s ay in ac , his is less o an issue. However
in en, hairlines ha are placed oo low, wi h FUs ha are
Figure 42-11 Donor scalp immediately ollowing closure. orien ed radially or oo perpendicular o he scalp (as in a 499
4 picke ence) look unna ural and can lead o even worse
sel -es ee or a ec ed pa ien s.
In en, he ron al hairline should begin no less han
approxi a ely 9 c above he glabella. Many surgeons
crea e a 1 o 2 c deep zone o reduced densi y along he
ron al hairline, using hairs ha are ner in caliber wi h
only one hair per FU. Behind his hairline, larger FUs can
be placed. I is i pera ive ha he na ural e poral reces-
sions be preserved, since he appearance o a rounded
hairline can be qui e e inizing in a an. Under cer ain
circu s ances, en can bene ro hair res ora ion o
he e ples as well.
Many en reques res ora ion o heir balding ver-
ex. T e abili y o ll in he ver ex depends largely upon
heir age, degree o hinning, and a oun o donor hair.
S
e
Generally en in heir 50s and 60s ay be ransplan ed
c
t
i
because heir pa ern o hinning is ore well-es ablished
o
n
and less likely o advance rapidly. T e ver ex should no
4
be ransplan ed in en aged 20 o 45 years whose u ure
:
:
is less cer ain. I hey have only a s all hairless area, and
i is ransplan ed bu expands la er, hey will be le wi h
A
e
a large, unna ural looking island o hair. As physicians we
s
t
h
us educa e pa ien s abou hese possible scenarios and
e
t
resis he e p a ion o give in o pa ien s’ (o en isin-
i
c
a
or ed) desires or hairline design.
n
d
L
a
g r a Ft c r ea t Io n
s
e
r
P
r
o
A er he donor s rip is re oved, i is cleaned and soaked
c
e
in saline be ore being separa ed in o individual FUs. o
d
u
separa e he uni s, he donor s rip is rs placed leng h- Figure 42-13 Strip is f rst slivered into thin slices o tissue
r
e
1 ollicular unit wide.
s
wise on a hard sur ace such as a ongue depressor or a
speci cally designed plas ic cu ing board (Fig. 42-13).
Individual s rips are hen slivered perpendicularly ro
he s rip, each con aining 10 o 25 FUs depending on he
wid h o he s rip (Fig. 42-14). As hese s rips are crea ed,
r ec IpIen t s It e c r ea t Io n
o her e bers o he ea begin separa ing each sliver
in o individual FUs o one o our hairs each, care ully pre- While he gra s are being crea ed, he surgeon anes-
serving he con or a ion in which hey na urally exis . he izes he area o be ransplan ed and crea es recipi-
As he ollicles are separa ed, hey are placed in a pe ri en si es or he gra s. O en a 1% or 2% lidocaine ring
dish wi h saline solu ion and a nons ick pad lining he bo - block, injec ed care ully across he orehead, is suf cien
o o he dish (Fig. 42-15). I is essen ial ha he ollicles o reduce he sensa ion o subsequen lidocaine injec ions
s ay ois during his s ep and hroughou he procedure. pos eriorly. O her doc ors per or local nerve blocks by
I hey dry ou or beco e desicca ed hey will no survive injec ing he edial aspec o he eyebrows, ro which
he ransplan a ion process. One us also be cau ious
no o place gra s ha have beco e desicca ed bu , when
placed back in saline, appear viable.
Much o wha ueled he surge oward ore na ural
resul s was he in roduc ion o s ereo icroscopic dissec-
ion o FU gra s. In 1994, Dr. B. L. Li er published a
land ark paper describing his echnique o gra crea ion
using icroscopes wi h 10× agni ca ion.7 Since hen,
any surgeons have begun using agni ca ion o assis
in he separa ion and crea ion o FU gra s (Fig. 42-16).
O hers use eyewear such as loupes or drugs ore glasses o
agni y he hairs during dissec ion.
As he echnicians crea e he gra s hey record he nu -
bers o gra s crea ed. So e ea s keep rack o how any
o each one-, wo-, hree-, and our-hair FU hey crea e in
order o know he o al nu ber o hairs ransplan ed in a
single procedure. O hers go by he o al nu ber o gra s
500 regardless o how any o each size FU is crea ed. Figure 42-14 Single sliver in cross section.
 4

Figure 42-15 Slivers are kept chilled during gra t dissec

C
h
tion process.

a
p
t
e
r
4
2
he supraorbi al and supra rochlear nerves exi heir
ora ina. T e skin should be nu bed very super cially;

:
:
o en a 0.5% lidocaine concen ra ion is suf cien . Regard-

H
less, he nu bed area us be rein orced every 30 o 45

a
i
r
inu es o ain ain anes hesia and o keep he pa ien

T
r
co or able. Layering wi h bupivicaine can also help

a
n
reduce he requency o injec ions needed.

s
p
l
Various ools are available or aking recipien si es. Per-

a
n
haps he os inexpensive and readily available ools are

t
a
t
si ple 18, 19, and 20 gauge needles. T ese correspond o

i
Figure 42-17 Microscopic examination o gra t sites prior

o
n
to gra t placement.

o
r
M
e
wid hs o 1.25, 1.1, and 0.9 . O her co ercially avail-

n
able ools are Minde blades and SP blades. T e la er can be

a
n
d
oun ed on adjus able handles o con rol he dep h o he

W
blade as i en ers he scalp. O her surgeons use chisel blades

o
m
ha are cus o ade or co ercially available. Personal

e
pre erence and ergono ics see o be he os i por an

n
ac ors in choosing wha ype o ool o use.
As he gra si es are crea ed, he ins ru en handle
should be angled orward, abou 30 o 45 degrees up ro
he skin in ron o he si e. I is especially i por an ha
his be done along he ron al hairline where i is os vis-
ible. So e have argued ha his angle canno be oo s eep.
T e si es should be crea ed in a rando ashion, placing
sli s in and a ong he exis ing ollicles (Fig. 42-17). Near
he e poral recessions, he hair spli s i s direc ion o ori-
en a ion. Medially, he hairs should here ore be angled
cen rally and oward he idline. La erally hey should be
angled la erally and oward he chin. Again he narrower
he angle is when he hairs e erge ro he scalp, he
ore na ural he resul s will appear (Fig. 42-18).
I si es are ade on he ver ex o he scalp, hey should
ollow he direc ion o exis ing hairs, which ay be a
C-shaped whorl or a double S-shaped whorl. Again he
hairs should be very acu ely angled as hey are rans-
plan ed. O herwise, hey will have an unna ural appear-
ance i hey exi oo perpendicularly ro he scalp.
As he gra si es are ade, he o al nu ber is coun ed
in order o know whe her ha nu ber corresponds wi h
he nu ber o gra s crea ed. So e bleeding can occur bu
is no usually ore han can be handled wi h ligh pres-
Figure 42-16 Microscopes can increase the ease and vis sure. T e recipien area is repea edly sprayed and cleaned
i ility o gra t separation. wi h saline as he procedure progresses. 501
4 pro ec he donor area as well as he newly placed gra s.
Pa ien s are ins ruc ed o leave he bandage on overnigh
and re ove i in he orning. I given a seda ive, hey are
no allowed o drive ho e a er he procedure.
T a nigh , pa ien s are encouraged o avoid exer ing
he selves. T ey ay use he co pu er, read, or relax
wi h a ovie. Pain edica ion is prescribed. T e day
a er surgery pa ien s ay gen ly pour war wa er over
heir scalp, bu hey are ins ruc ed o wai 3 days be ore
sha pooing. T ey can re urn o ull physical ac ivi ies
a er 1 week. T is includes running, biking, swi ing,
or weigh -li ing.
A possible resul o hair ransplan a ion can be swelling
o he orehead a er surgery. T is can occur as he anes-
Figure 42-18 Patient immediately a ter placement o one hesia works i s way down he ace due o gravi y. wo
S
e
to our hair ollicular unit gra ts. s eps can be aken o preven his. Firs , one can include
c
t
i
an an i-in a a ory prepara ion such as ria cinolone
o
n
in he local anes he ic solu ion. T e second is o si ply
4
prescribe an oral an i-in a a ory edica ion such as
g r a Ft pLa c eMen t
:
:
prednisone o be aken or 3 o 5 days a er surgery. Bo h
echniques work well and any physicians use bo h wi h
A
e
A nu ber o di eren specialized orceps are used o al os no pa ien s repor ing pos opera ive ede a.
s
t
h
place he gra s. T ey are narrow enough a he ips ha
e
t
hey can be inser ed sligh ly in o he gra si e, along wi h
i
Fu t u r e t r en d s
c
a
he gra , and hen be released o leave he gra in place.
n
d
Wooden co on- ipped applica ors are also used o hold
L
he gra in place while i is again gen ly inser ed he res o Recen ly, robo ic devices have been in roduced or he
a
s
e
he way in o he gra si e. Each gra should be picked up purpose o hair ransplan a ion. T e AR AS® sys e
r
P
jus above he base o he ollicle wi h care ul a en ion no received FDA 510(k) clearance in April 2011 as an au o-
r
o
o crush he bulb or he bulge area above i . A wo-handed a ed or o FUE. A co pu erized robo calcula es
c
e
echnique is usually necessary o “shi y” he gra s in he dis ance o he scalp and he angle o he exi ing
d
u
place, and pa ience is a vir ue or hose s ar ing ou . donor hairs. I hen re oves a 0.8 o 1.0 wide cylin-
r
e
s
Depending on he size and area being ransplan ed, i ay der o issue surrounding he hair as is done by he an-
be possible or one, wo, or even hree echnicians o place ual FUE echnique described earlier. T e advan ages are
he gra s a once. Pa ien s wi h eleva ed blood pressures ay less a igue and eye s rain or he physician, bu hese
have ore “popping,” a process which occurs when he hairs, ay be ou weighed by he cos and space required. I
once ransplan ed, co e back ou o heir si es. Pa ience, is unclear whe her robo ic devices can o er lower ran-
good ligh ing and ergono ics are all essen ial o reduce eye sec ion ra es han are seen wi h anual FUE. Fur her
s rain and uscle a igue. echnicians are also encouraged o research and re ne en s o he device will help answer
ake breaks as needed. hese ques ions.
T e NeoGra ® device is ano her ool or FUE, al hough
i does no have FDA device approval. Ra her han using a
po s t o per a t Iv e c a r e robo , i i ple en s a suc ion device o help re ove he
FUs once hey are anually scored by he doc or. Physi-
A he co ple ion o surgery, long-ac ing bupivicaine can cians new o hair surgery should unders and ha he
be injec ed again in o he donor area o rein orce anes- Neogra t m is a ool or ( ollicular uni ) donor harves ing.
hesia during he evening hours. An ibio ic oin en is Surgical skills are s ill required o design he hairline and
applied o he donor area, and el a dressings ay or ay ar ully place he ollicles back in he scalp. Again, i e will
no be applied o he ron al recipien areas. Con or ing ell whe her he cos o his achine is balanced ou by i s
gauze bandages ay be used o wrap he en ire scalp o bene o he surgeon. Such produc s ay be ore help ul
in arke ing prac ices han in expedi ing or i proving he
surgical procedure.
Perhaps he os long-awai ed advance en in hair
TAbLE 42-2 ransplan a ion is he abili y o clone hairs. Presen ly we
F lli l u i e i are li i ed by he a oun o pa ien donor hair avail-
able. I one day we can ake a s all punch biopsy ro
a di he scalp and hen replica e 1000 or 10,000 FUs ro i ,
he eld o hair ransplan a ion will change dra a ically.
No linear scar Potential or higher rate o Far ore pa ien s will beco e candida es or he proce-
Potentially easier transection o ollicles during harvest dure and he donor harves and gra crea ion process
donor site healing More time consuming will no longer be necessary. Many priva e co panies are
Lower yield per harvest a e p ing o develop his echnique bu i s ill appears
May need to shave large donor area
502 o be years away.
c o n c Lu s Io n 2. Kau an KD, Finas eride Male Pa ern Hair Loss S udy Group.
Long- er (5-year) ul ina ional experience wi h nas eride 1
4
g in he rea en o en wi h androgene ic alopecia. Eur J
Modern hair ransplan a ion echniques o er resul s ha Dermatol. 2002;12:38– 49.
are na ural and unde ec able. T e separa ion o hairs in o 3. Pey avi UB, Hill ann K, Die z E, Can eld D, Garcia Bar els
N. A rando ized, single-blind rial o 5% inoxidil oa once
individual FUs was he lynchpin oward aking his pro- daily versus 2% inoxidil solu ion wice daily in he rea en
cedure cos e ically success ul or pa ien s in bo h he o androgene ic alopecia in wo en. J Am Acad Dermatol.
long and shor run. Physician knowledge and experience 2011;65:1126– 1134.
is s ill essen ial in planning and execu ing an excellen 4. Messenger AG, Rundegren J. Minoxidil: echanis s o ac ion
hair ransplan resul . I will be exci ing o see ore ools on hair grow h. Br J Dermatol. 2004;150:186– 194.
5. Avra MR, Cole JP, Gandel an M, e al. T e po en ial role
and devices develop wi hin his eld. T e os i por an o inoxidil in he hair ransplan a ion se ing. J Derm Surg.
innova ions will be hose ha can increase hair ollicle 2002;28:894– 900.
survival, reduce he a oun o donor hair needed, and 6. Leavi M, Charles G, Hey an E, Michaels D. HairMax Laser-
i prove he pa ien ’s co or and experience during he co b laser pho o herapy device in he rea en o ale an-
procedure. drogene ic alopecia: a rando ized doubleblind, sha -device-

C
con rolled, ul icen re rial. Clin Drug Invest. 2009;29:283–

h
292.

a
p
7. Li er BL. Ellip ical donor s ereoscopically assis ed icro-
r eFer en c es

t
e
gra ing as an approach o ur her re ne en in hair rans-

r
4
plan a ion. J Dermatol Surg Oncol. 1994;20:789– 793.

2
1. Price VH, Mene ee E, Sanchez M, Ruane P, Kau an KD.
Changes in hair weigh and hair coun in en wi h androge-

:
:
ne ic alopecia a er rea en wi h nas eride, 1 g daily. J Am
Acad Dermatol. 2002;46:517– 543.

H
a
i
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r
a
n
s
p
l
a
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a
t
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o
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e
n
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n
d
W
o
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e
n
503
 Ch a p t e r Special Considerations for

43 Hair Restoration Surgery

Marc R. Avram & M na Singh

In t r o d u c t Io n In It Ia l eva l u a t Io n
Hair transplantation has been per ormed since the 1960s Overall, hair transplantation into areas o scarring alope-
or the treatment o androgenetic alopecia. T e technique cia can be more challenging as the patient not only needs
o ollicular unit transplantation (FU ) provides consist- a suitable donor area, but the in ammatory stage o the
ently natural appearing cosmetic outcomes or patients scarring alopecia must also be inactive. It is, there ore,
with this condition, and the majority o patients who seek important that patients with scarring alopecias second-
consultation or hair restoration are seeking treatment ary to in ammatory scalp dermatoses be treated medi-
or thinning hair as a result o emale or male pattern hair cally be ore considering surgery. Some patients respond
loss. However, there is a subset o patients who require to medical therapy within months, others over years. For
special consideration or hair restoration. In this chapter, some patients, reactivation o the in ammatory stage may
we describe hair restoration surgery or scarring alopecia occur post transplant and lead to loss o the transplanted
and corrective hair surgery. hairs. Patients with primary scarring alopecia seeking hair
T e general public o ten perceives androgenetic alo- transplant surgery should be aware o the impact that
pecia as a normal variant o aging, but hair loss due to reactivation o in ammation would have on transplanted
scarring alopecia is o ten more cosmetically dis guring. hair, as well as the need or regular ollow-up with their
Moreover, patients who seek corrective hair surgery typi- dermatologist ollowing surgery. In addition, scalp brosis
cally do so because their previous surgery appears unnat- and diminished blood supply may lead to decreased gra t
ural and they eel as though they must do something to survival, as well as limited cosmetic improvement. For
correct their unnatural appearing, “pluggy” transplants. these reasons, when a patient seeks consultation or hair
T ese patients need special consideration not only restoration, it is o utmost importance to have an accurate
because they may be more troubled or devastated by the diagnosis or the cause o the alopecia and or patients to
cosmetic appearance o the involved bald areas, but also understand the challenges associated with transplanting
because they will need special considerations regarding hair in the setting o their scalp disease.
the techniques to be used or their corrective surgery to Importantly, patients may seek out consultation or
be success ul. what is believed to be androgenetic alopecia; however,
they may in act have a scarring alopecia that is mimicking
androgenetic alopecia (Fig. 43-1). Because transplanting
Ha Ir r es t o r a t Io n s u r g er y into scarring alopecia takes special consideration, it is crit-
ical that the surgeon not miss these diagnoses, as surgical
Fo r c Ic a t r Ic Ia l (s c a r r In g ) outcomes may be suboptimal and lead to poor cosmetic
results and patient dissatis action.
a l o pec Ia Making a proper diagnosis o cicatricial alopecia entails
per orming a detailed history and scalp examination.3
T e term “cicatricial alopecia” will be used interchange- ( ables 43-1 and 43-2). Help ul clues in diagnosing cica-
ably with scarring alopecia in this section. Cicatricial or tricial alopecia include shiny atrophic skin with loss o
scarring denotes that the ollicular epithelium has been ollicular openings, as well as signs o in ammation, such
replaced with brous connective tissue. Hair surgeons as peri ollicular erythema, hyperkeratosis, crust, dyschro-
o ten use the term more broadly than dermatologists, mia, pustules, and tu ting or “doll hairs.”3 A hair pull test
with any cicatricial alopecia generally being de ned as may also be per ormed. I oozing, bleeding, or crusting is
any orm o in ammation or trauma that leads to a scar- present, tissue culture may be warranted. Additionally,
ring process. T is can, there ore, include scarring hair loss a scalp biopsy is strongly recommended, i there is any
rom cosmetic surgery, burns, or radiation. Cicatricial doubt regarding the etiology o a patient’s hair loss.4
alopecia can be divided into primary and secondary cica-
tricial alopecias.1 In primary cicatricial alopecia, the hair
ollicle is the target o the in ammation and disease activ- HIs t o pa t Ho l o g Ic ex a mIn a t Io n
ity.2 In secondary cicatricial alopecia, the hair ollicle just
happens to be present in the area o disease activity, as A biopsy can be use ul not only to determine the diagno-
in radiation dermatitis or burns. In this chapter, the vari- sis, but also to evaluate the potential or regrowth. I the
ous types o cicatricial alopecia will be discussed, as well alopecia is end-stage and has become permanent, histo-
as special considerations or transplanting patients with pathologic examination will reveal scar and peri ollicular
scarring alopecia. brosis with minimal lymphohistiocytic in ammation.4 It
 4

C
h
a
p
t
r
4
3
A B

:
:
Figure 43-1 Hair transp ant consu ts or ma patt rn hair oss. A. On c os insp ction, pati nt had p ri o icu ar ryth

S
p
ma, sca , and shiny, atrophic sca p skin. Biopsy was consist nt with ich n p anopi aris. B. Di us thinning with incr as d
c ntra part width and pr s rvation o ronta hair in . Pati nt comp ain d o t nd rn ss o sca p and on c os r insp ction,

c
i
a
th r was a oss o o icu ar ostia and atrophic sca p skin, consist nt with c ntra c ntri uga cicatricia a op cia (CCCA).

C
o
n
s
i
is also important to consider where to biopsy, how many T e various in ammatory alopecias present with erythema,

d
r
biopsies to per orm, and how the tissue is processed. T e peri ollicular papules, scale and pustules, and sometimes

a
t
best diagnostic yield is produced when obtaining two with bogginess. Ongoing in ammation leads to peri ol-

i
o
n
biopsies or vertical and horizontal sectioning. I direct licular brosis and eventual quiescence o the in amma-

s
immuno uorescence (DIF) is warranted, the vertical tion. Permanent loss o the hair ollicle is thought to result

o
r
section can be bisected using a no. 15 blade. One piece rom ongoing damage to the isthmus o the ollicle, which

H
a
will be placed in ormalin or Hematoxylin– Eosin (H&E) destroys the stem cells and sebaceous glands.5 T ese in am-

i
r
R
staining and the second piece will be placed in specialized matory alopecias at end-stage appear as scarring alopecias,

s
media or DIF. DIF is typically per ormed when either presenting with shiny, atrophic patches o hair loss with loss

t
o
lichen planopilaris (LPP) or lupus erythematosus (LE) is o the ollicular ostia.

r
a
t
suspected.

i
o
n
c l a s s IFIc a t Io n o F t He pr Ima r y

S
u
pr Ima r y c Ic a t r Ic Ia l

r
c Ic a t r Ic Ia l a l o pec Ia s

g
r
(s c a r r In g ) a l o pec Ia

y
T e North American Hair Research Society proposed a
working classi cation or primary cicatricial alopecias
Primary cicatricial alopecias are areas o permanent, scar- based on the type o peri ollicular in ammation present:
ring hair loss due to an in ammatory disorder o the scalp. lymphocytic, neutrophilic, or mixed ( able 43-3).6 We will
T e etiology o this group o alopecias is largely unknown. discuss the more commonly seen types in brie that
ollows and ocus more on the technical considerations
or hair transplantation in these entities.
TABl e 43-1
s Q i e i i Hi f
s i a i
Is th hair oss gradua or sudd n? TABl e 43-2
o s e i i , h p i sh
Is th hair oss sh dding or nonsh dding? B e f th ch
Is th r th pr s nc o high v r or syst mic dis as ?
Is th hair oss oca iz d or di us ?
Is th r a r c nt str ssor or m dication xposur ?
Is th r ryth ma, p ri o icu ar papu s, sca s, or oozing?
Is th r th pr s nc o harsh ch mica s on hair such as
Is th r o icu ar p ugging?
r ax rs or dy s?
Is th r cutan ous invo v m nt?
Is th r th pr s nc o itching, burning, t nd rn ss, or oozing?
Is th r a oss o o icu ar ostia?
Is th r a history o traumatic hairsty ing practic s such as
tight braids, w av s, or cur rs? Ar th r do hairs pr s nt?
505
4 TABl e 43-3
can be a clue to the diagnosis. Histopathologic exami-
nation demonstrates hyperkeratosis, ollicular plugging,
p c ifi i f p i ci i i basement membrane thickening, vacuolar inter ace
a i change at the dermoepidermal (DE) junction, pigment
incontinence, dermal mucin deposition, and super cial
l h i n hi i mi and deep peri ollicular and perivascular lymphocytic
Chronic cutan ous Fo icu itis Acn k oida is in ammation. DIF can demonstrate continuous granu-
upus ryth matosus d ca vans lar deposition at the DE junction with IgG, IgM, IgA,
and C3. Individuals with discoid LE who have systemic
l ich n p anopi aris Diss cting Acn n crotica
involvement should not be considered as candidates or
c u itis
hair transplantation.7
Fronta brosing erosiv pustu ar
a op cia d rmatosis
Ps udop ad o Brocq l Ic Hen pl a n o pIl a r Is
S
C ntra c ntri uga
c
LPP is another common cause o cicatricial alopecia. It is a
t
cicatricia a op cia
i
o
common mimicker o androgenetic alopecia as its activity
n
A op cia mucinosa may be subclinical. LPP is more commonly seen in emales
4
and Caucasians with scattered patches o partial hair loss,
:
:
peri ollicular papules, erythema, and scale. It is commonly
A
associated with pruritus, burning, and tenderness.8
pr ed o mIn a n t l y l ympHo c y t Ic
s
Frontal ibrosing alopecia is thought to be a variant o
t
h
LPP, typically occurring in postmenopausal women with a
per IFo l l Ic u l a r In FIl t r a t es
t
i
band o alopecia along the rontotemporal scalp, vari-
c
a
ably associated with peri ollicular papules and eyebrow
n
d
l u pu s er y t Hema t o s u s involvement (Fig. 43-3).9 Graham– Little– Piccardi–
l
a
Lassueur syndrome, another variant o LPP, demonstrates
s
Chronic cutaneous LE can lead to discoid plaques on LPP on the scalp, keratosis pilaris on the extremities,
r
P
the scalp and scarring alopecia in its late stages. When and noncicatricial alopecia in the axilla and groin.10
r
o
c
active, it can present with atrophic, er ythematous, Histopathologic evaluation o LPP and its variants
d
hyper- or hypopigmented plaques with ollicular plugging shows lichenoid inter ace dermatitis with dyskeratotic
u
r
(Fig. 43-2). Lesions o LE seen in the external ear canal keratinocytes at the upper portions o the ollicles. At
s
A B

Figure 43-2 A. Discoid upus ryth matosus with typica hyp r/hypopigm nt d p aqu s with scarring a op cia. B.
Bright y ryth matous p aqu s on sca p, pr vious y mistak n or s borrh ic d rmatitis, which on c os insp ction d m
onstrat d ar y scarring a op cia. Histopatho ogy and dir ct immunof uor sc nc con rm d th diagnosis o cutan ous
506 upus ryth matosus.
 4

A B

C
h
Figure 43-3 A. C assic pr s ntation o ronta brosing a op cia with r c ssion o th ronta hair in and y brow oss.

a
p
B. A rican Am rican woman origina y diagnos d with traction a op cia. How v r, on c os r insp ction, sh had symm t

t
r
ric ronta hair in r c ssion with skin atrophy, p ri o icu ar papu s, and y brow oss. Th diagnosis o ronta brosing

4
a op cia was con rm d with biopsy.

3
:
:
S
p
late stages, peri ollicular ibrosis, scar, and polytrichia and traumatic hairstyling practices such as tight braids,

c
i
may be present. DIF o LPP lesions shows grouped weaves, and use o “hot combs.” Histologic examination

a
C
globular IgM immuno luorescence and shaggy ibrin demonstrates lymphohistiocytic in ammation at the upper

o
n
deposition adjacent to the ollicular epithelium.11 portions o the ollicle with variable loss o the sebaceous

s
i
glands, concentric lamellar broplasia and premature des-

d
quamation o the inner root sheath. In late stages, peri ol-

r
a
c en t r a l c en t r IFu g a l c Ic a t r Ic Ia l

t
licular brosis and polytrichia may be present.12

i
o
a l o pec Ia

n
s
o
t r a c t Io n a l o pec Ia

r
Central centri ugal cicatricial alopecia (CCCA) is a progres-

H
a
sive, expanding, symmetric scarring hair loss on the crown

i
r
o the scalp, most commonly seen in A rican American

R
raction alopecia is a “biphasic alopecia” in that in its early
women (Fig. 43-4). Because o the symmetric, progressive

s
stages this entity is considered nonscarring; however, with

t
o
nature o the hair loss, it can o ten be mistaken or andro- chronic involvement the hair loss can become permanent.

r
a
t
genetic alopecia during a hair transplant consultation. On raction alopecia is caused by chronic pulling and tension

i
o
n
scalp examination, the involved area may appear shiny and on the hair because o prolonged tight hairstyling prac-

S
atrophic, and tiny “doll hairs” may be present. CCCA has tices, such as tight braids, ponytails, weaves, extensions,

u
r
g
been variably associated with the use o chemical relaxers curlers, or dreadlocks. It is most commonly seen in A rican

r
y
A B

Figure 43-4 A and B. Two pati nts d monstrating traction a op cia o th rontot mpora hair in and CCCA, which can
o t n co xist. 507
4 TABl e 43-4 po s t s u r g Ic a l a l o pec Ia
e fs ci i i a i
Cosmetic surgeries, such as a ace or brow li t, or excision
s ci i i a i on the scalp can leave visible scars. In addition, hairlines
may be altered and/or pulled posteriorly (Fig. 43-5). Hair
Trauma In ction Postinf ammatory N op astic transplantation can provide cosmetically pleasing correc-
Pr ssur Tin a Sarcoid Basa c
tion o these postsurgical alopecias with restoration o
induc d capitis carcinoma hair in the temporal and preauricular regions and/or plac-
ing hair into the scar itsel .15
Postsurgica Morph a Squamous c
scars carcinoma
Burns Gra t v rsus host A op cia pr es s u r e-In d u c ed
dis as n op astica
(po s t o per a t Iv e) a l o pec Ia
Radiation
S
c
Pressure-induced alopecia can occur in individuals a ter
t
i
o
long periods o pressure on the scalp during general anes-
n
American women. I the hair styling practice is discon-
4
thesia or in chronically ill individuals with persistent pres-
tinued and treatment is sought early on, hair regrowth is sure on one area o the scalp. It is thought to be due to
:
:
possible. However, chronic traction on the hair will lead pressure-induced ischemia.16 Histology can show throm-
A
to permanent loss in that area. Clinically, patchy areas o bosis and dermal and subcutaneous perivascular in am-
s
nonscarring alopecia are seen most commonly around mation in the early stages and epidermal and perieccrine
t
h
the hairline with no associated evidence o peri ollicular necrosis i severe, with an increased number o telogen
t
i
papules or scale (Fig. 43-4).13 Histopathologic ndings can
c
hairs.
a
mimic trichotillomania in its early stages. End-stage trac-
n
d
tion alopecia shows a marked reduction in terminal hairs
l
t In ea c a pIt Is
a
with columns o connective tissues replacing the ollicular
s
epithelium.14
r
P
r
o
inea capitis is a dermatophyte in ection o the hair sha t.
c
s ec o n d a r y c Ic a t r Ic Ia l Common causes include richophyton tonsurans and
d
u
Microsporum canis. It is more commonly seen in A ri-
r
a l o pec Ia s can American children or their caregivers. Examination
s
reveals annular, scaly, crusted patches o alopecia with
As stated earlier, with secondary cicatricial alopecias, the variable occipital lymphadenitis. I in ection persists
hair ollicle is not the in ammatory target, but is simply in chronically, the a ected individual may develop perma-
the same area as disease activity or trauma ( able 43-4). nent hair loss in the area (Fig. 43-6). T e diagnosis can be

A B

Figure 43-5 A. Imm diat postop rativ photograph o transp ant into pr auricu ar ar a a t r a ac i t with th hair in
508 pu d post rior y. B. R storation o th pr auricu ar hair in and camouf ag d scar.
 4

C
h
a
p
t
r
4
3
A B

:
:
Figure 43-6 A. A 14 y ar o d gir with patchy scarring a op cia in th v rt x sca p du to tin a capitis. B. Mod st cov rag

S
a t r on s ssion o 150 1 to 3 o icu ar unit gra ts into th scarr d ar as.

p
c
i
a
C
o
n
s
con rmed with a ungal culture. KOH preparation o an per orming a biopsy postoperatively to evaluate or dis-

i
d
involved hair ollicle can reveal ectothrix (hyphal elements ease activity.

r
a
adjacent to the hair sha t) or endothrix (hyphal elements Areas o scarring alopecia o ten have decreased blood

t
i
o
present within the hair sha t).17 supply and thickened brotic tissue. For this reason, there

n
s
is typically decreased gra t survival. T ere ore, scalp thick-

o
r
ness and available blood supply should be determined pre-

H
t ec Hn Ic a l c o n s Id er a t Io n s operatively to the greatest degree possible.9

a
i
r
R
Fo r Ha Ir t r a n s pl a n t a t Io n In

s
t
c Ic a t r Ic Ia l a l o pec Ia

o
TABl e 43-5

r
a
t
i
d iff B w p f i H i

o
n
T e same general principles apply in scarring alopecias t i i p i Wi h s i

S
a i v n i a i .

u
when per orming hair transplantation as when tranplant-

r
g
ing nonscarred scalp. T is includes the instrumentation,

r
anesthesia, gra t creation, and postoperative care.18 T e s i n i

y
major di erences when transplanting into scarring alo- a i a i
pecia lie in candidate selection, managing patient expec-
Number of Consid r t st ar a, On to two s ssions
tations, donor harvesting, recipient site creation, and
Sessions th n two to our
the number o surgeries per ormed ( able 43-5).15 Spe-
s ssions
cial consideration needs to be taken when determining
whether the individual is a proper candidate, as candidate Donor Area Mor unpr dictab Mor pr dictab
selection is one o the most important aspects o hair res- sa donor ar a
toration surgery. When a patient seeks consultation or Recipient Dis as must b May hav ongoing
hair transplantation, it is important to per orm a detailed Area inactiv or at ast dis as activity
history as well as a scalp examination. T e history and 1–2 y ars
scalp examination should be used to determine the type Transp ant with Can transp ant at
o alopecia the patient has, as well as details o the tech- ow r d nsiti s du high r d nsiti s
nical components o the surgery, such as donor supply to a t r d vascu ar
and the caliber and density o hair. ransplants should supp y and brotic
only be per ormed into primary cicatricial alopecias i tissu
the involved areas have been inactive or 1 to 2 years;
Outcomes D cr as d gra t Most gra ts surviv
the disease should be quiescent, without anticipation o surviva and grow
urther disease progression.19 T is decreases the chance
o the transplantation causing a disease are and prevents l ss cov rag can b Mor cov rag can
the transplanted hairs rom being targeted by the immune achi v d with ach b achi v d with
system. I the transplanted hairs do not grow as expected surg ry gr at r cosm tic
satis action
or have signs o in ammation, it is important to consider 509
4

B
S
A
c
t
Figure 43-7 A. l arg scarring d ct on t ronta sca p s condary to craniotomy and radiation. B. With ad quat cos
i
o
n
m tic cov rag a t r on s ssion with 640 1 to 4 o ic unit gra ts. Not th vari d growth and gra t surviva within th
4
scar tissu . Th pati nt was unab to und rgo a s cond s ssion.
:
:
A
s
t
t He eFFec t o F va s c u l a r s u ppl y
h
Because hypertrophic scars tend to be thicker, the surgeon
t
may want to consider making deeper incisions to reach
i
c
o n Ha Ir t r a n s pl a n t a t Io n the blood supply. Atrophic scars may have a poor blood
a
n
supply and incisions may need to be per ormed more
d
l
Vascular supply can be a major limitation o transplanta- super cially in these areas, leading to poor gra t survival.
a
s
tion into scar tissue. Scar tissue tends to have a decreased Incisions within atrophic scars should be made at a more
r
P
blood supply compared to normal tissue. T is di erence acute angle to compensate or the lack o subcutaneous
r
o
can lead to poor gra t survival (Fig. 43-7). Dense packing tissue to support the transplanted hair ollicle.15
c
o transplanted hairs is not advisable in scar tissue because
d
u
o poor blood supply. A test transplant to assess growth o
r
d o n o r a r ea
s
transplanted hair in patients with a compromised vascu-
lar supply may be help ul (Fig. 43-8). Some recommend
applying 2% to 5% minoxidil topically 1 week preopera- When surgically treating androgenetic alopecia, the
tively or pentoxyphylline 400 mg 2 weeks preoperatively optimal donor region is the midoccipital scalp.18 T is is
in order to increase blood supply to the area.19 considered the sa e zone in anticipation that the hair
will continue to thin to a greater degree over the rest o
the scalp, as androgenetic alopecia is a progressive pro-
s c a l p t HIc k n es s a n d FIBr o s Is cess. Placement o the donor site in the occipital region
minimizes the risk o a visible donor scar in the uture.
Scars can be hypertrophic or atrophic; there ore, their With scarring alopecia, however, the horizontal zone in
thickness and texture can vary a great deal. Scar tissue the occiput rom which hair would typically be harvested
can be tough and tacked down or inelastic and riable. may have been a ected by disease activity. T ere ore, it

A B

Figure 43-8 A. A rican Am rican woman with di us scarring a op cia du to CCCA. examp o xt nsion o scarring
510 a op cia into occipita donor ar a. B. Diminish d d nsity in donor ar a du to invo v m nt o scarring a op cia.
is important to individually assess each patient to deter-
mine where adequate ollicular units may be available and TABl e 43-6
4
whether the patient has adequate donor hair to produce a F c i Wh d i i d
desirable cosmetic outcome. H i m h
As with hair transplantation or the treatment o andro-
genetic alopecia, evaluation o the caliber o hair as well s i Fu e
as donor density should be per ormed. T e caliber o the Duration of Short r tim to l ong r harv sting
hair may become even more important when transplanting Surgery harv st tim
into scarring alopecia. ransplanting at higher densities l ong r tim to l ss tim to trim
into the scarred skin is inadvisable due to reduced blood trim gra ts gra ts
supply19; there ore, with lower densities, larger-caliber hairs Sam tim or Sam tim or
will achieve greater coverage than lower-caliber ne hairs. p anting gra ts p anting gra ts
Donor density is a major determinant o the success o Number of Typica y mor l ss gra ts
transplantation into scarring alopecia, and may be even Grafts gra ts can b harv st d, may
more limiting than in individuals a ected by androgenetic

C
harv st d in n d mor than

h
alopecia alone. Certain scarring alopecias, such as CCCA, d n d sa on s ssion

a
p
can lead to di use hair loss involving even the occiput, rom harv sting zon Robotic FUe may

t
r
which the gra ts would normally be harvested (Fig. 43-8). yi d c os to qua

4
3
Because o disease activity in the occipital region, donor o an ips
hair density may be limited and surgery may not be pos- Overall Cosmetic Sam Sam

:
:
sible. Density is determined by the number o ollicular Outcome

S
units per square centimeter as opposed to the number o

p
Considerations B caus o Can choos ar as
hairs per square centimeter. Most surgeons generally aim

c
for Scarring unpr dictab o high r d nsity

i
a
to achieve at least 20 to 40 ollicular units per square cen-
Alopecia donor ar a, and ar as not

C
timeter; however, with cicatricial alopecia, ewer units may

o
may hav mor invo v d with

n
be acceptable because the density o the transplanted hair is

s
variab d nsity in a op cia or

i
d
generally decreased. in ar ar a harv sting

r
a
t
Scar Visib in ar scar No visib in ar

i
o
d o n o r Ha r v es t In g

n
scar, may s

s
hypopigm nt d

o
r
dots or risk moth

H
Similar to per orming hair transplantation or androge- at n ook with

a
netic alopecia, there are two methods o donor harvesting:

i
r
ov r harv sting

R
(1) strip excision and (2) ollicular unit extraction (FUE).18

s
When determining which method is pre erred, a number

t
o
r
o actors should be considered ( able 43-6). Patient pre -

a
ring alopecia (10– 20 cm 2) versus male or emale pattern

t
i
erence can also dictate which method to choose.

o
hair loss (20– 30 cm 2). T e patient is counseled that two

n
T e advantage o strip excision is that the surgeon can

S
to our sessions may need to be per ormed every 9 to 12

u
harvest more ollicular units more quickly with lower

r
months at a minimum, and that with each session higher

g
transection rates. However, there is a visible scar present i a densities can be achieved.

r
y
patient wears his/her hair short. Strip excision is, there ore, It is important to set expectations or hair transplanta-
recommended or individuals who wear their hair longer tion patients with scarring alopecia. T ey must be aware
in the back, those who require more ollicular units to be that gra t survival is decreased, that they may not achieve
harvested, and those who have contraindications to FUE ull coverage o the alopecic area, that the hairs may grow
or where FUE would be technically more dif cult, such as in kinky at rst and then straighten with additional hair
in individuals with very curly hair. cycles, and that two to our surgical sessions may be nec-
FUE is recommended or patients with scarring alo- essary. T ose who accept the limitations o the procedure
pecia in whom a linear scar in the occiput would be vis- are generally satis ed with any cosmetic improvement;
ible, who have a limited donor area or require a decreased there ore, all patients with end-stage cicatricial alopecia
number o ollicular units, or those individuals who tend should be o ered hair restoration surgery as an option
to heal with wider, thickened scars. or treatment o their cosmetically dis guring condition
(Figs. 43-10 and 43-11).
o t Her c o n s Id er a t Io n s
s u mma r y c o n s Id er a t Io n s
A small test area can be per ormed in patients in whom
growth o transplanted ollicles is uncertain due to scar- Fo r c Ic a t r Ic Ia l a l o pec Ia
ring (Fig. 43-9). A 1 to 2 square centimeter area can be
transplanted initially. A ter 9 to 12 months, depending on 1. I caused by in ammatory alopecia, disease should
the assessment o gra t survival in the test area, a larger be inactive without progression and inactive on
session can be per ormed.19 biopsy or 1 to 2 years.
Due to reduced blood supply we suggest using ewer 2. Consider starting with a test area with decreased
recipient sites per centimeter squared in patients with scar- density. 511
4
S
c
t
i
o
n
4
A B
:
:
Figure 43-9 A. Di us scarring a op cia du to CCCA. D monstrating two 1 cm 2 t st ar as with 15 gra ts p r squar c n
A
tim t r and 25 gra ts p r squar c ntim t r. B. Imm diat y a t r transp antation into t st ar as.
s
t
h
t
i
c
a
n
3. Per orm smaller, less dense sessions every 9 to gra ts were dissected into large ollicular groupings o
d
l
12 months. 10 to 25 hairs per gra t (Fig. 43-12). Incisions were then
a
s
4. Consider minoxidil to improve blood ow. made into the alopecic areas with punch incisions and
r
P
5. Consider making incisions at acute angle. the large gra ts were inserted into these areas. T is led to
r
o
very unnatural appearing, “pluggy” hair transplants that
c
were not only un attering cosmetically, but patients who
d
u
c o r r ec t Iv e Ha Ir received these procedures were also easily recognizable
r
s
to the general public. In addition, natural appearing hair-
r es t o r a t Io n s u r g er y line design was less emphasized during this time period
and led to very straight, unnatural appearing hairlines.
From the 1960s until the 1990s, hair transplantation was Because o its unnatural, cosmetically un attering results,
per ormed using 3 to 4 mm punch biopsies and later strip hair restoration surgery as a whole endured a time period
excisions to harvest hair rom the donor areas. T e donor o negative public opinion.

A B

Figure 43-10 A. Scarring a op cia ov r t t mpora sca p. B. Improv d cov rag a t r hair transp anta
512 tion o 500 1 to 3 o icu ar unit gra ts.
 4

C
h
a
A B

p
t
r
Figure 43-11 A. Traction a op cia. B. Imm diat postop rativ p ac m nt o gra ts r storing th ronta hair in .

4
3
:
:
S
p
Some patients may be angry, depressed, or even dev- bination o so tening the hairline and adding density to

c
i
a
astated by the results o their previous surgery, so it is the a ected areas, surgical removal o the larger, “pluggy”

C
important to develop trust and aim to truly understand gra ts, and/or partially thinning the larger gra ts, using

o
n
their concerns and goals with respect to corrective sur- selective FUE or laser hair removal.22

s
i
d
gery. T eir goal may be to simply achieve a “normal”

r
appearance. T at is a realistic goal. It may take multiple

a
t
c o n s u l t a t Io n

i
sessions to achieve the ultimate cosmetic outcome but

o
n
improvement is possible.

s
o
Overall, corrective hair surgery should aim to conceal
r ea s o n s Fo r c o n s u l t a t Io n

r
H
aws rom previous surgeries by adding hair strategically,

a
to remove gra ts that cannot be naturally concealed, and

i
r
Previous methods o hair transplantation led to vari-

R
to urther treat worsening areas o balding.20– 24
ous complications, including unnatural hairline design,

s
Many hair transplant surgeons are now seeing patients

t
o
a “pluggy” appearance, scalp irregularities, or improper

r
rom previous generations who are seeking out consulta-

a
t
angling o transplanted hair (Figs. 43-13 and 43-14 and

i
tion or corrective surgery to create a more natural appear-

o
able 43-7).23

n
ing, less recognizable hair transplant. Fortunately, there

S
u
are now many options or correction o these patients’

r
g
previous hair transplant surgeries. T is can include a com-
u n n a t u r a l Ha Ir l In e d es Ig n

r
y
A transplant may have been per ormed with a low or
unnatural hairline design. T ese designs may have been
too straight, and lack irregularity or single ollicle gra ts.

TABl e 43-7
c c i i f p i
H i s i l i c i f
c i s

c r f c i s
Unnatura hair in d sign
“P uggy” app aranc
Sca p irr gu ariti s
A B
Improp r ang s
Figure 43-12 A. Fo icu ar unit gra t. B. 3 to 4 mm punch/
Poor anticipation or ongoing hair oss
p ug with mu tip o icu ar units. 513
4
S
c
t
i
o
A B
n
4
:
:
A
s
t
h
t
i
c
a
n
d
l
a
s
r
P
r
o
Figure 43-13 A. Norwood VI ma patt rn
c
hair oss with signi cant scarring a op cia
d
u
and unnatura , too straight ronta hair in
r
s condary to f ap hair r storation. B. Sam
s
C
pati nt a t r shaving. C. Scars rom f ap.

pl u g g y a ppea r a n c e In a d eQu a t e a n t Ic Ipa t Io n o F

o n g o In g Ha Ir l o s s
Larger, 10 to 25 ollicular unit gra ting produced a “corn
row” or pluggy appearance along the gra ted scalp. Large
Even with use o smaller, 1 to 4 ollicular unit gra ts and
gaps between the gra ts may also be present.
natural hairline design, i the gra ts were placed in areas
without consideration o uture, ongoing hair loss, the cos-
metic outcome several years a ter the transplant can appear
s c a l p Ir r eg u l a r It Ies quite unnatural. T is is most requently seen when the
gra ts are placed too low on the rontal hairline, when
As previously mentioned, older techniques or site cre- the temples are lled in, and when gra ts are placed on the
ation entailed multiple punch excisions. T is o ten led vertex scalp (Fig. 43-16).
to textural changes on the scalp including peri ollicular As with all hair restoration surgery, consultation or
scarring, cobblestoning, and hypo/ hyperpigmentation hair corrective surgery should include determination o
(Fig. 43-15). the patient’s goals and desires, setting realistic expecta-
tions, and identi ying any possible limitations. Each surgi-
cal plan should be detailed and reviewed with the patient
based on their individual goals and their overall scalp
Impr o per a n g l es examination.
Consultation or hair corrective surgery may include
T e previous transplant may have been per ormed with a correction or alteration o one or more possible complica-
natural appearing hairline design; however, the transplant tions. T ere ore, a combination o approaches may need
may not appear natural due to improper angling o the to be per ormed in order to provide the most natural
514 hairs at the time o implantation. appearing, cosmetically improved result. In addition, the
 4

C
h
a
p
t
r
4
3
:
:
S
p
c
i
a
C
A C

o
n
s
i
d
r
a
t
i
o
n
s
o
r
H
a
i
r
R
s
t
o
r
a
t
i
o
n
B D

S
u
r
g
Figure 43-14 A. D monstrating unnatura app aring, too straight, p uggy ronta hair in . B. l at ra

r
vi w. C. Sam pati nt 5 y ars at r with ongoing hair oss d monstrating p uggy v rt x sca p with ring

y
o a op cia. D. Six y ars at r with continu d thin cov rag in donor ar a, hypopigm nt d scars rom
xcis d p ugs ar now visib .

transplant surgeon should assess donor availability rom

either newly harvested or already transplanted areas rom
which plugs will be removed. Ongoing hair loss or balding
can also a ect outcomes and selection o donor area, and
must be taken into consideration.

pa t Ien t s el ec t Io n
T e most appropriate patient or hair corrective surgery is
one with realistic expectations as to what can be achieved,
with stable hair loss, who ideally is aged 40 years or older.
Patients with unrealistic expectations or those with mini-
mal donor hair availability should be excluded. I the
Figure 43-15 D monstrating too r gu ar, unnatura ap patient is not a candidate or hair restoration, cosmetic
p aring, p uggy ronta hair in and sca p with atrophic, camou ages, such as hairpieces or tattooing, may be dis-
pitt d scars. cussed. 515
4 TABl e 43-8
s i F c i H i
r i s
FUT to so t n, incr as d nsity, and cr at mor natura
app aring hair
Surgica r mova with punch biopsy or iptica xcision o
xisting p ugs +/− diss ction into sma r o icu ar units and
r ocation
l as r hair r mova o xisting p ugs
Strat gic thinning or d bu king o p ugs
Combination o a o th abov
Source: R produc d with p rmission rom Avram MR. Corr ctiv hair
S
transp antation. In: Avram MR, Rog rs Ne, ds. Hair Transplantation.
c
N w York, NY: Cambridg Univ rsity Pr ss, 2010. © Cambridg Uni
t
i
o
v rsity Pr ss 2010.
n
4
:
want to get rid o the plugs, especially on the crown or
:
vertex scalp. T is can be achieved either with elliptical
A
or punch excision or with laser hair removal. Otherwise,
s
t
plugs may be selectively excised or debulked using FUE
h
or punch excision and relocated with a combination o an
t
i
c
FU procedure to ll in the gaps, add density, and pro-
a
n
duce a more natural appearance. An additional FU pro-
d
l
cedure would be again limited by donor supply and the
a
s
potential or uture ongoing hair loss.
r
P
r
o
c
u s In g a c o mBIn a t Io n o F
d
Figure 43-16 D monstrating unnatura app aring, p uggy
u
Fu t a n d d Is s ec t Io n a n d
r
gra ts in th v rt x with ongoing hair oss aving ring o
s
a op cia surrounding gra ts. r el o c a t Io n o F l a r g er
r emo v ed pl u g s
c o n s u l t a t Io n a s s es s men t Excised gra ts can be dissected under magni cation into
smaller 1 to 4 ollicular units per gra t. Depending on
T e caliber, density, wave pattern, and color o the donor donor supply in the occipital region, an additional FU
hair are important to assess. In addition, assessing pos- can be per ormed using strip excision or FUE depending
sible ongoing hair loss is pertinent as well. T e patient can on patient pre erence and the possibility o a visible scar.
expect improved cosmetic outcomes based on increased T ese additional gra ts can be used to strategically ll in
density and coverage, as well as a more natural appearing larger areas o balding scalp, as well as add density, so ten,
hairline, covering the bald scalp. and recreate a more natural looking hairline (Fig. 43-17).

g en er a l a ppr o a c H t o c o r r ec t Iv e s u r g er y o F t He
c o r r ec t Iv e Ha Ir s u r g er y v er t ex s c a l p
In many instances, the hairline may have been created I corrective surgery is needed to provide a more natural
with a design that was too “regular,” such as with straight appearing vertex scalp, the rontal scalp is also likely to
lines, or it may have been placed too low ( able 43-8). o need revision. T ere ore, because o limited donor avail-
correct this problem, an elliptical excision may be per- ability, the vertex scalp may need special consideration.
ormed to remove those gra ts and relocate them on the T e exception occurs when the rontal scalp has been
scalp in a so ter, more natural distribution, with 1 to 4 ol- designed well, but ongoing hair loss was not anticipated
licular units per gra t.24 on the vertex scalp, leading to a ring o alopecia surround-
I the hairline is unnatural and designed with widely ing the transplanted hair on the vertex.
spaced, larger plugs, punch excision may be per ormed to T e vertex scalp may be the area that is most amena-
relocate these gra ts to other areas on the scalp, once again ble to complete removal o gra ts with either laser hair
to create a more natural, denser appearing hairline. removal or surgical removal to create a natural appearance
o make large plugs less recognizable, a combination o (Fig. 43-18). Because there is a limited supply o donor
516 methods may need to be pursued. T e patient may simply hairs, the surgeon may be required to restore density to
 the rontal scalp more than the vertex scalp to optimize
4
the outcome o the corrective procedure.

t ec Hn Ic a l c o n s Id er a t Io n s
Fo l l Ic u l a r u n It t r a n s pl a n t a t Io n
One treatment option or corrective hair restoration is to
per orm an additional hair transplant surgery using stan-
A dard techniques and ll in the a ected area with more natu-
ral appearing 1 to 4 hair ollicular units. T is approach can
be used to so ten and mask an unnatural appearing hairline,
increase density overall and create a more natural look.

C
h
a
p
x

t
x x x x x
x x x x x
x
c a mo u Fl a g In g “pl u g s ”

r
x x x x
x x x x

4
x x
x

3
x
x x
x x x xx x x x x
x x x x x o correct poor hairline design, the surgeon can choose

:
:
either to construct a more natural hair line anterior to
the previous one, to ll in the gaps created by the plugs,

S
p
or a combination o the two. T e new hairline appears

c
i
more natural with single hair ollicular units and with-

a
out lowering the hairline more than necessary. Adding

C
B

o
smaller ollicular unit gra ts to the larger, pluggier gra ts

n
s
i
is advisable because o the appearance o increased den-

d
sity (Figs. 43-19 and 43-20). I the donor supply is insu -

r
a
t
cient to ll in spaces or gaps, strategically removing the

i
o
n
larger plugs and simply relocating them along the hair-

s
line is advised.

o
r
H
a
i
r
r emo va l o F t r a n s pl a n t ed Ha Ir

R
s
t
o
T is is typically the rst step with any corrective hair sur-

r
a
t
gery. However, there are many ways to go about removing

i
o
C

n
the hair. First, it is important to discuss the choices with

S
the patient as well as the goals he/she wishes to achieve

u
r
Figure 43-17 A. l arg , p uggy, unnatura app aring

g
with corrective surgery. T e physician can decide with the
gra ts. B and C. Adding sma r o icu ar unit gra ts to

r
patient which gra ts to remove in order to achieve a more

y
so t n th cosm tic app aranc .
natural appearance. In general, it is best to remove the
pluggier gra ts at the hairline to so ten its appearance and
have it look more natural. It is important to be strategic
about which gra ts to remove; all gra ts do not necessarily
need to be removed to achieve a more natural appearing
hairline.

A B

Figure 43-18 A. D monstrating ack o anticipation o ongoing hair oss on v rt x sca p with ring o a op cia surrounding
gra ts. B. Mu tip 3 mm punch biopsi s to xcis pr vious gra ts, aving natura app aring ba ding v rt x sca p. 517
4

A B

Figure 43-19 A. D monstrating p uggy, unnatura app aring ronta hair in . B. So t ning o ronta hair in a t r gra t
r mova with punch xcision and r imp antation o gra ts a t r diss cting into sma r 1 to 4 o icu ar unit gra ts.
S
c
t
i
o
n
Gra t removal can be per ormed with a punch tool or peri ollicular hypo/hyperpigmentation. However, o ten
4
with elliptical excision. I the goal is to completely remove these smaller diameter punch tools may be smaller than
:
the gra t, the punch should be large enough to t the the diameter o the gra t and it may, there ore, make sense
:
entire gra t. I the goal is to simply debulk the gra t, a to thin the gra t instead o completely removing it. ypi-
A
smaller punch diameter may be selected. With both tech- cally, the larger gra ts will need to be removed with larger,
s
t
h
niques, care should be taken not to transect the ollicles. >2 mm, diameter punch tools. T ese de ects are closed
t
T e risk o this can be reduced by increasing punch diam- with epidermal 4-0 nylon sutures. Larger gra ts may leave
i
c
a
eter, angling in the direction o ollicle growth, and using unpredictable scarring and/or a cobblestoning e ect.
n
d
saline tumescence to increase tissue turgor. T e holes that T ere is also a risk o postoperative erythema. In addi-
l
remain should be closed with 4-0 nylon suture. tion, there are visible sutures present in the postoperative
a
s
I the patient chooses to use the excised hairs to retrans- period, which are removed in 5 to 7 days. I the diameter
r
P
plant in a more natural ashion, the larger gra ts can be o the punch is less than 2 mm, these wounds may be le t
r
o
strategically excised. FUE with a 0.75 to 1 mm punch tool to heal by secondary intention. Excising multiple gra ts in
c
can be utilized as these smaller diameter punch tools are close proximity may reduce scalp laxity and make closure
d
u
less likely to leave a visible scar and are less likely to leave dif cult. T is complication can potentially be eliminated
r
s
A B

Figure 43-20 A. D monstrating v ry unnatura app aring,

too straight, p uggy ronta hair in and sca p with poor an
ticipation o ongoing hair oss and d p t d donor supp y.
Th pati nt masks th outcom o his pr vious transp ant with
a hair pi c . B. Sam pati nt a t r FUT, s ctiv arg r gra t
r mova with punch xcision and subs qu nt addition o 1000
1 to 4 o ic unit gra ts to th ronta hair in and sca p in
b tw n th p uggy gra ts. C. A t r s cond FUT, adding 350
additiona 1 to 4 o ic unit gra ts to ronta sca p and r in
C
orcing th hair in . Pati nt was v ry satis d and no ong r
518 n d d his hair pi c .
 designed hair transplantations. During consultation,
understanding the patient’s goals, developing realistic
4
expectations, and constructing a plan that all parties are
com ortable with is essential. Depending on the patient’s
goals, a combination o strategic excision o gra ts with
relocation to the rontal scalp and additional FU is likely
to be required to achieve an optimal result.

r eFer en c es
1. Somani N, Berg eld WF. Cicatricial alopecia: classi cation
and histopathology. Dermatol T er. 2008;21:221– 247.
2. Ross EK, an E, Shapiro J. Update on primary cicatricial alo-
pecias. J Am Acad Dermatol. 2005;53:1– 37.
3. Rongioletti F, Christana K. Cicatricial (scarring) alopecias:

C
h
an overview o pathogenesis, classi cation, diagnosis, and

a
trreatment. Am J Clin Dermatol. 2012;13(4);247– 260.

p
t
Figure 43-21 D monstrating as r hair r mova o p ugs. 4. Sperling LC, Cowper SE. T e histopathology o primary cica-

r
tricial alopecia. Semin Cutan Med Surg. 2006;25:41– 50.

4
3
5. McElwee KJ. Etiology o cicatriciai alopecias: a basic science
point o view. Dermatol T er. 2008;21:212– 220.

:
:
6. Olson EA, Berg eld WF, Costerelis G, et al. Summary o
North American Hair Research Society (NAHRS)-sponsored

S
by per orming an elliptical excision o more closely spaced

p
Workshop on Cicatricial Alopecia, Duke University Medical
gra ts. Elliptical excision may be an important tool or cos-

c
Center. J Am Acad Dermatol. 2003;48:103– 110.

i
a
metically less important areas, and is less laborious than 7. Hordinsky M. Cicatricial Alopecia: discoid lupus erythemato-

C
punching out individual gra ts. Elliptical excisions may be sus. Dermatol T er. 2008;21:245–248.

o
n
closed in two layers with 4-0 vicryl interrupted vertical 8. Kang H, Alzolibani AA, Otberg N, Shapiro J. Lichen plano-

s
pilaris. Dermatol T er. 2008;21:249– 256.

i
d
mattress sutures and then 4-0 nylon or 3-0 polypropylene 9. an K , Messenger AG. Frontal brosing alopecia: clinical

r
interrupted super cial sutures.

a
presentations and prognosis. Br J Dermatol. 2009;160:75– 79.

t
i
A ter the gra ts have been strategically excised, i the

o
10. Viglizzo G, Verrini AM, Rongioletti F. Familial Lassueur-Gra-

n
patient chooses, the hairs can be dissected into smaller ham-Little-Piccardi syndrome. Dermatology. 2004;208:142–144.

s
11. Mehregan DA, Van Hale HM, Muller SA. Lichen planopilaris:

o
one to our ollicle groupings and retransplanted as men-

r
clinical and pathologic study o orty- ve patients. J Am Acad

H
tioned previously to create a more natural look and add Dermatol. 1992;27:935– 942.

a
i
increased density. Otherwise, the patient’s look will be

r
12. Whiting DA, Olson EA. Central centri ugal cicatricial alope-

R
restored to its pretransplantation appearance. cia. Dermatol T er. 2008;21:268– 278.

s
I the patient wants to permanently remove the hairs, 13. Callender VD, McMichael AJ, Cohen GF. Medical and surgi-

t
o
cal therapies or alopecias in black women. Dermatol T er.

r
one easy method without carrying the risk o additional

a
t
2004;17(2):164– 176.

i
scarring is to per orm laser hair removal to the a ected

o
14. Borovicka JH, T omas L, Prince C, Mehregan DR. Scarring

n
areas (Fig. 43-21). Permanent laser hair removal typically alopecia: clinical and pathologic study o 54 A rican-Ameri-

S
u
takes ve to seven sessions and only works on pigmented can women. Int J Dermatol. 2009;48(8):840–845.

r
g
hairs. T e major disadvantage is that those hairs are per- 15. Unger W, Unger R, Wesley C. T e surgical treatment o cica-

r
tricial alopecia. Dermtalogic T er. 2008;21(4):295– 311.

y
manently lost and cannot be retransplanted elsewhere
16. Wiles JC, Hansen RC. Postoperative (pressure) alopecia. J Am
on the scalp. However, laser hair removal is noninvasive Acad Dermatol. 1985;12:195– 198.
and has a decreased risk o scar, cobblestoning, or pig- 17. Alvarez MS, Silverberg NB. inea Capitis. Cutis. 2006;78(3):
mentary change. T ere is no recovery time and, in addi- 189– 196.
tion, because laser hair removal reduces the number o 18. Avram MR, Rogers NE. Hair ransplantation. New York, NY:
hair ollicles by 50% to 80%, it can reduce larger gra ts to Cambridge University Press; 2010.
19. Rose P , Shapiro R. ransplanting into scar tissue and areas o
smaller ollicular units. cicatricial alopecia. In: Shapiro R, Unger W, eds. Hair rans-
Depending on the patient’s ultimate goals and donor plantation. New York, NY: Marcel Dekker; 2004:606– 610.
and recipient site qualities, a combination o adding addi- 20. Bernstein RM, Rassman WR, Rashid N, Shiell RC. T e art o
tional 1 to 4 ollicular unit gra ts, FUE o the pluggy gra ts, repair in surgical hair restoration– part II: the tactics o repair.
and laser hair removal o the larger gra ts may need to Dermatol Surg. 2002;28(10):873– 893.
21. Bernstein RM, Rassman WR, Rashid N, Shiell RC. T e art o
be per ormed in order to achieve the best, most natural repair in surgical hair restoration part I: basic repair strategies.
appearing outcome. Dermatol Surg. 2002;28(9):783– 794.
22. Avram MR. Corrective hair transplantation. In: Avram MR,
Rogers NE, eds. Hair ransplantation. New York, NY: Cambridge
c o n c l u s Io n University Press, 2010.
23. Unger WP. Recipient area hair direction and angle during
transplanting. Dermatol Surg. 2004;30(6):829– 836.
Corrective hair restoration surgery is typically per ormed 24. Knudsen RG. T e donor area. Facial Plast Surg Clin North
in individuals who have undergone outdated or poorly Am. 2004;12(2):233– 240.

519
 Ch a p t e r

44 Sclerotherapy
Kar n L. B asl y & Rob rt A. W iss

In t r o d u c t Io n that urther testing with ultrasound may be needed would

include: leg pain and/or swelling; bulging veins, a prominent
reticular vein network, history o varicose vein surgery, or a
Utilized in ancient Greece to alleviate pain ul leg varicosi-
strong amily history o varicose veins coupled with promi-
ties, sclerotherapy, the therapeutic injection o sclerosant
nent telangiectasias in the areas supplied by the greater or
into veins, has been success ully practiced or thousands
small saphenous vein. All large sources o ref ux must be
o years. Sclerotherapy is the treatment o choice or telan-
detected and eliminated be ore any treatment o spider
giectasias and reticular veins o the legs. T e technique has
veins is undertaken. Failure to do so will cause a high rate o
undergone signi cant advancements in the development
treatment ailure and complications, including telangiectatic
o oamed solutions to improve its e cacy and side-e ect
matting, hyperpigmentation, and early recurrence.7
pro le. It provides a rapid, e ective, and sa e treatment
alternative that is particularly attractive or patients with
extensive networks o small abnormal veins. t el a n g Iec t a s Ia r o m r e t Ic u l a r
T e appearance o telangiectatic vessels may be so dis- VeIn s
turbing to patients that they curtail their activities and
modi y their li estyles to avoid situations in which their elangiectasia can develop due to ref ux rom reticular
legs are visible. T ey may avoid the pool and the beach, as veins, thin-walled blue super cial venules that are part
well as wearing shorts or skirts. Besides causing cosmetic o an extensive network o subcuticular veins, otherwise
embarrassment, spider veins can also produce symptoms o re erred to as the lateral subdermic venous system (LSVS).
pain, burning, and atigue. T ese symptoms may be wors- T is lateral network typically does not have direct con-
ened by prolonged standing or sitting and can be relieved nections to the saphenous system. Although it is com-
by wearing support hose or by elevation o the legs.1 Vein monly being per ormed at vein treatment centers around
size alone does not predict the presence o symptoms. the United States, endovenous saphenous vein ablation
Vessels causing symptoms may be smaller than 1 mm in rarely has an e ect on the appearance o telangiectasias
diameter.2 Sclerotherapy not only o ers remarkably good associated with the LSVS. Small per orating veins may be
cosmetic results, but has also been reported to yield an 85% present, particularly in the cal , which connect to the deep
reduction in symptoms.3 Many di erent techniques have venous system. Reticular veins associated with telangiec-
been used in the treatment o small veins, but certain basic tasias are commonly called “ eeder” veins and can be visu-
principles are universal and will be outlined later.4–8 ally identi ed by the “arrowhead sign” (Fig. 44-1). With

c l a s s I Ic a t Io n a n d a n a t o my
TABLe 44-1
o diagnose and treat telangiectasias in a logical way, a 9
c ii i Vi
classi cation scheme is help ul ( able 44-1). A discussion
o the classi cation o leg veins includes telangiectasias Typ I T langi ctasia (spid r v ins)—0.1–1 mm
(tiny red vessels <1 mm), venulectasias (small dark red diam t r, usually r d
IA—t langi ctatic matting (r d n twork)
or purple veins 1– 2 mm), and associated reticular veins
(light blue vessels 2– 4 mm). For the purposes o discus- Typ II V nul ctasia—1–2 mm diam t r, violac ous
sion o sclerotherapy o spider veins (types I– III), it will be IIA—v nul ctatic matting (violac ous n twork)
assumed that the major primary varicose veins o types IV Typ III R ticular varicositi s ( d r v ins) 2–4 mm
and V have already been eliminated or are absent. diam t r, cyanotic blu to blu gr n
Typ IV Varicositi s (s condary saph nous branch or
t el a n g Iec t a s Ia r o m a x Ia l p r orator r lat d) 3–8 mm, blu to blu gr n
r e lux or colorl ss i d p r
Typ V Saph nous varicositi s (truncal or axial
elangiectatic webs may be the result o axial ref ux due to varicositi s including main saph nous trunks
junctional or large per orator incompetence.7 It is crucial to and rst g n ration branch varicositi s) 5 mm
realize that axial ref ux does not always result in large visible or gr at r—blu to blu gr n, colorl ss i
varicosities. A detailed history and physical examination are d p r, may b palpabl and not visibl
there ore essential to identi y patients who require urther R produc d with p rmission rom W iss RA, W iss MA. Scl roth rapy.
noninvasive diagnostic evaluation prior to treatment. Com- In: Wh land RG, d. Cutaneous Surgery. Philad lphia: WB Saund rs,
mon actors that would alert physicians to the possibility 1994. Copyright els vi r.
 patients should be in good health. Contraindications to
sclerotherapy include pregnancy, inability to ambulate or
4
comply with postsclerotherapy compression, clotting dis-
orders, general poor health, or active immunode ciency.

ed u c a t Io n a n d c o n s en t
Once a diagnosis is made and the patient is judged to be
a candidate or sclerotherapy, it is necessary to obtain
in ormed consent. Possible complications such as hyper-
pigmentation, matting, and ulceration are discussed. T e
necessity or multiple treatment sessions is emphasized
and the need or maintenance therapy is highlighted. I
the treatment plan will include sclerosants that are used

C
o -label or are not FDA approved, this act must be clearly

h
a
communicated. I the patient understands the plan, risks,

p
Figure 44-1 Arrowh ad sign.

t
bene ts, and alternatives, the consent orm is signed.

r
4
4
care ul Doppler technique, ree ref ux with augmentation pHo t o g r a pHs

:
:
can be heard through these reticular veins, and ultrahigh-

S
resolution duplex ultrasound may be used to map the path

c
It is impossible to overemphasize the importance o pho-

l
o transmission o venous hypertension rom small reticu- tographs. As treatment progresses, patients invariably

r
o
lar veins into telangiectasias.10,11

t
orget the original appearance o the treated areas. Pre-

h
treatment photographs are absolutely essential to help the

r
a
p
Is o l a t ed a r bo r Iz In g Webs physician evaluate treatment progress and to allow the

y
patient to recognize improvement.
Ref ux through ailed valves is the source o nearly all tel-
angiectatic webs associated with reticular veins. When
diagnostic tests ail to identi y a large vessel or a reticular pr e t r ea t men t In s t r u c t Io n s
network as a source o ref ux, localized small-vein valve
ailure is usually the culprit. Flow within even the smallest Patients are told to wear shorts and not to use moisturiz-
o venules is normally regulated by valves12 and localized ers or shave their legs on the day o treatment. Shaving the
valve ailure can produce arborizing networks o dilated leg may cause erythematous streaks, making it di cult to
cutaneous venules that are direct tributaries o underlying visualize patterns o reticular and telangiectatic veins. Use
larger veins.13 Arborization occurs through a recruitment o moisturizers causes poor adhesion o the tape used to
phenomenon in which high pressure causes dilatation o secure compression ollowing injections, but more impor-
a venule, ailure o its valves, and transmission o the high tantly causes slower evaporation o the alcohol used to
pressure across the ailed valves into an adjacent vein. prep the leg. Patients are encouraged to eat at least a small
Angiogenesis may also play a role in ormation o telan- meal be orehand to minimize vasovagal reactions.
giectasias. reatment o an arborizing system must be
directed at the entire system, because i the point source t es t In j ec t Io n s
o ref ux is not ablated, the web will rapidly recur.
est injections, which were standard practice with use
s t eps pr Io r t o t r ea t men t o the sclerosant sodium tetradecyl sul ate (S S), are
now optional i using the sclerosant polidocanol (POL).
T e package insert or S S (Sotradecol®) recommends
HIs t o r y a n d pHys Ic a l a test site injection to assess or allergic reactions. T e
ex a mIn a t Io n package insert or POL (Asclera®) does not require a test
site injection. I utilizing S S as the sclerosant or i the
No matter how small and how localized the telangiecta- patient is nervous, the rst treatment session may be lim-
sias, every patient must initially be evaluated by a detailed ited to a small number o sites to observe or any allergic
history and physical examination, with noninvasive diag- reactions. It also serves to amiliarize the patient with
nostic vascular tests per ormed as needed. Even when the the treatment and treating physician, clinic surround-
physical examination is normal, historical actors may ings, and the sensation o the ne needle. More extensive
suggest that urther testing is necessary. Previous venous treatment can usually be undertaken on the second visit,
surgery is an indication or more extensive evaluation, as is as the patient is typically more relaxed. T e e ectiveness
a amily history o large varicose veins, since such patients o the concentration and class o the sclerosing agent
are likely to have early axial ref ux even when present- used during the test injections can also be evaluated at
ing with telangiectasias alone.14– 16 T e patient’s leg veins the ollowing visit.
should be evaluated with a 360 degree view while stand- When the patient returns in 2 to 6 weeks, the test site
ing and supine to assess or bulging veins. Sclerotherapy or limited treatment area is compared with pretreatment 521
4 photographs. Any side e ects such as matting and pig-
mentation can be explained. Reasonable time intervals or TABLe 44-3
clearance o treated vessels can be rein orced. At each ses- s c i t i i
sion, all sites treated are noted in anatomic diagrams in
the chart. mi i m i
ef iv r
c i c i s

s c l er o s a n t s el ec t Io n 0.1% 0.2% Sodium

t trad cyl sul at
(Sotrad col)
As sclerosing solution f ows away rom the point o injec- liquid
tion, it is diluted by blood and becomes less potent. T is
problem has been alleviated with the advance o using 72% Unchang d Glyc rin
oamed sclerosants. T e oamed sclerosants displace the dilut d with
blood inside the vein, which maximizes contact with and 1% lidocain
S
(1:100,000) in a
subsequent damage to the endothelial sur ace. Foamed
c
2:1 solution
t
i
solutions are, there ore, stronger then liquid solutions, and
o
n
a smaller sclerosant concentration is required or the same 0.25% 0.5% Polidocanol
4
therapeutic e ect. Decreased concentration logically (Ascl ra) liquid
:
leads to decreased potential side e ects, such as inf amma-
:
11.7% 23.4% Hyp rtonic
tion, hyperpigmentation, necrosis, and systemic toxicity.
A
salin
able 44-2 shows suggested volumes and concentrations
s
t
Not r comm nd d Not r comm nd d Any oam d
h
o sclerosants or treating small reticular veins. able 44-3
solution
t
shows suggested volumes and concentrations o scle-
i
c
a
rosants or treating telangiectasias.
n
d
T e volume injected should be only as much as is nec-
L
essary to f ush the visible segment o vein that is being
a
s
treated to be clear o blood. Usually no more than 0.5 cc o eq u Ipmen t
r
P
sclerosing solution per injection site is necessary, although
r
o
some larger or longer reticular veins may require up to Cotton balls soaked with 70% isopropyl alcohol
c
■

1 cc o solution. In many cases, spasm may be observed Protective gloves

d
■
u
a ter injection o sclerosant. When this occurs, it is a 3 cc disposable syringes
r
■
s
desirable endpoint. T e most commonly used sclerosing ■ 30 gauge ½ in disposable transparent hub needles
solutions include S S, POL, 72% glycerin compound, and ■ Cotton balls or oam pads or compression
hypertonic saline. In our practice, we have abandoned the ■ Hypoallergenic tape (synthetic silk or paper)
use o hypertonic saline due to pain, the risk o necrosis ■ 2% nitroglycerin paste ( or prolonged blanching or
and the inability to treat larger numbers o vessels in one extravasation)
session. ■ Sclerosing solutions (sequestered rom other inject-
ables in the clinic and labeled)
■ Magni ying loupes or lenses (2– 5×)
■ Sterile connector or oam production
TABLe 44-2
T e brand o syringe to be used or sclerotherapy is a
s c i s r i
Vi personal choice. It is worth the e ort to try a variety o
syringes, as there is a marked di erence in plunger ric-
r m i tion between di erent kinds o syringes and between
s i r syringes rom di erent manu acturers. When any deter-
c i c i gent type o sclerosant is utilized, it is recommended to
(%) (%) s use latex- ree syringes. In high enough concentrations
(≥ 0.5%), S S or POL will dissolve the rubber rom the
0.2 0.5 Sodium plunger, thereby releasing rubber and rubber products
t trad cyl sul at into solution (data on le, Wyeth– Ayerst Laboratories).
(Sotrad col) T ere is a relatively high and increasing incidence o
liquid latex allergy in the general population.17 T eoretically,
0.5 1.0 Polidocanol the risk o a severe allergic reaction may be increased
(Ascl ra) liquid with latex-containing syringes. We have not yet seen
allergic reactions to S S in more than 400,000 injections
0.1 0.2 Sodium
t trad cyl sul at
we have per ormed since switching to latex- ree syringes
(Sotrad col) in 1994. Since POL was approved in the United States
oam we have not encountered any allergic reactions with the
use o latex- ree syringes or POL injections. In a recent
0.25 0.5 Polidocanol comparison study, no reaction to either POL or S S was
(Ascl ra) oam
522 observed.18
 pa t Ien t pr epa r a t Io n Ha n d po s It Io n
4
T e patient is placed in a recumbent position that allows T e syringe is held in the dominant hand, which rests on the
convenient access to the leg veins to be treated. I avail- patient’s leg, and the needle is advanced at a shallow angle
able, a motorized table with height adjustment will acili- through the skin and into the reticular vein. When the phy-
tate easy access to all regions o the leg. T e areas to be sician eels the typical “pop-through” sensation o piercing
treated may be cleansed with cotton balls saturated with the vein, the plunger is gently pulled back until blood return
70% isopropyl alcohol, temporarily allowing better visu- is seen in the transparent plastic hub (Fig. 44-2). T e pull
alization o the vessels by increasing light transmission back is important or solutions that could potentially cause
through ref ective scale on the epidermal sur ace. Glyc- skin necrosis. ypically one injects up to 0.5 cc o sclerosant
erin can also be used, which does not cause an evaporative and then massages the solution toward any associated tel-
cooling e ect. When alcohol is used, it needs to evaporate angiectasias. When injecting oam, enough oam is injected
completely or be wiped o to minimize pain o the needle to visually ll the targeted reticular vein. Injection should
pushing alcohol into the skin. Use o double-polarized be stopped immediately i any signs o leakage occur or i a

C
lighting (Syris v600, Syris Scienti c, Gray, ME) has also bleb or bruising is noted.

h
a
proven to be help ul. T e neck and back position o the

p
t
treating physician must be optimal to avoid injury to the

r
c a n n u l a t Io n o t He Ves s el

4
physician over the long term. Indirect lighting is best, as

4
harsh halogen surgical lights bleach out reticular veins and

:
:
some telangiectasias. A 3 cc syringe with a 30 gauge needle is used, which is

S
bent to an angle o 10 to 30 degrees to acilitate cannula-

c
l
tion (rather than trans xion) o the vein. A 1 cc syringe
t ec Hn Iq u e

r
o
generates too much pressure and will most likely rupture

t
h
the vein, so it should not be utilized. T e cannulation o

r
In j ec t Io n o r e t Ic u l a r VeIn s

a
a reticular vein can be quite di cult at times because

p
y
reticular veins can go into spasm, and may virtually dis-
T e same basic principle o treatment rom the largest appear during an attempt at cannulation. Use o alcohol
to the smallest varicosities holds true no matter the size or cleansing may cause evaporative cooling, which may
o the vessels being treated. Sclerotherapy o small veins lead to reticular vein spasm. When this occurs, another
begins with injection o the eeding reticular veins, then injection site must be sought. During the injection o scle-
venulectases, then telangiectatic webs or networks, and rosant, extravasation will result rom the slightest move-
nally the smallest and most isolated telangiectasias. ment o the injecting hand, and can also occur when the

A B

Figure 44-2 R ticular v in inj ction. A. Th n dl , b nt

to an angl o 10 to 30 d gr s to acilitat cannulation. B.
Th plung r is pull d back g ntly until blood r turn is s n
in th transpar nt plastic hub. C. Up to 0.5 cc o scl rosant
C is inj ct d at on sit and massag d into any small r asso
ciat d v ss ls. 523
4 vessel goes into spasm and pulls away rom the cannulat-
ing needle. Until the physician gains experience with retic-
Once the needle tip is seen in the lumen o the ves-
sel, a tiny bolus o air (<0.05 cc) may be injected to help
ular veins, cautious injection with the gentlest sclerosants demonstrate that the needle is within the vein. Some phle-
should be the rule, to avoid tissue necrosis and ulceration. bologists recommend an “air block” technique in which a
larger bolus o air is used to clear the arborizing vessels o
blood be ore the sclerosing solution is in used.22
In j ec t Io n o s c l er o s a n t s
When injecting a reticular vein, the sclerosing solution is In j ec t Io n o s c l er o s a n t s
sometimes seen f owing into the telangiectasias. When this
happens, the telangiectasias o ten do not need to be injected Because solutions are not readily diluted in telangiecta-
directly. Similarly, sclerosing solution injected into a telangi- sias, the initial treatment o telangiectatic webs begins
ectasia may be seen f owing into the eeder vein, but reticular with the minimal e ective concentration o sclerosant.23
veins usually still need to be injected directly, as it is di cult At the next visit, the same concentration is used i scle-
to deliver an e ective volume and concentration o scle- rosis was e ective and a higher concentration is used i
S
rosant to the reticular vein indirectly. Until the reticular vein sclerosis was ine ective. T e injection o telangiectasias
c
t
i
is per ormed very slowly, with minimal pressure on the
o
has been adequately treated, telangiectasias will be resistant
n
to treatment and will demonstrate early recurrence. For this syringe (Fig. 44-3). A ew drops o sclerosant are su cient
4
reason, some pre er to treat reticular veins rst, to wait and to ll the vein and maintain contact with the vessel wall
:
:
assess the results o treatment a ter a ew weeks, and to treat or 10 to 15 seconds. T e amount in used is approximately
remaining telangiectasias at a later time.19–21 Others pre er to 0.1 to 0.2 cc per site, which is o ten su cient to produce
A
treat the entire ref uxing system at one time, although treat- blanching in a radius o 2 cm rom the site o injection.
s
t
h
ing reticular veins rst theoretically minimizes pigmenta- Rapid f ushing o the vessels with larger volumes o scle-
t
tion and matting in telangiectatic webs.6,21 rosant or with higher pressures leads to problems with
i
c
a
extravasation, tissue necrosis, and ulceration, as well as an
n
d
increased incidence o telangiectatic matting and hyper-
In j ec t Io n o t el a n g Iec t a s Ia s
L
pigmentation.24
a
s
o minimize skin necrosis, especially with hypertonic
r
Injection o telangiectasias is per ormed a ter all sites o
P
saline, extravasation must be avoided. I there is resistance
r
o
ref ux, larger varicosities, and eeding vessels have been to the f ow o sclerosant, or i a “bleb” begins to orm at
c
injected. T e smaller the vein, the lower the initial volume
d
the injection site, the injection must be stopped imme-
u
and concentration o sclerosant needed or e ective treat-
r
diately. Extravasation o low concentrations o POL does
s
ment. Foamed sclerosant is too strong to inject in most not cause tissue necrosis, but signi cant extravasation o
telangiectasias, especially those less than 1 mm in diam- higher concentration (>0.1%) S S or o hypertonic saline
eter, and may cause a higher incidence o matting and will cause necrosis and ulceration. A randomized study
pigmentation. in animals ound the incidence o ulceration to be greater
when attempts were made to dilute the extravasated scle-
rosant by the injection o normal saline into the area.25
Ha n d po s It Io n Vigorous massage o any blebs is recommended to mini-
mize the chance o necrosis.
A syringe o sclerosant is prepared with a 30 gauge needle
that has been bent to an angle o 10 to 30 degrees with
the bevel up. T e needle is placed f at on the skin so that c o mpr es s Io n
the needle is parallel to the skin sur ace. Most practitioners
pre er to inject with the needle pointing away rom the Compression will speed vessel clearance and reduce stain-
clinician. In this case, the syringe is held like a cigarette ing rom any vessel that protrudes above the sur ace o the
between the index and middle ngers, and the thumb is skin.26– 28 A ter treatment o telangiectasias, compression
used to control the plunger. is provided by ready-to-wear gradient compression hose
(15– 20 mm Hg) placed over cotton balls that are secured
with tape at the sites o injection. I larger reticular veins
c a n n u l a t Io n o t He Ves s el (>3 mm) are treated at the same session, Class I 20 to 30
mm Hg compression is used ( able 44-4). Some authori-
T e technique requires a gentle, precise touch, but with ties recommend that continuous compression be applied
practice the beveled tip o the 30 gauge (0.3 mm diameter) or as long as the patient will tolerate it (usually 1– 7 days).
needle may be used to cannulate vessels as small as 0.1 mm. However, in our practice, we ask the patient to wear the
T e bevel o the needle usually can be seen within the compression hose daily or 2 weeks, except when bathing
lumen o the telangiectasias with use o 1.75× to 5× magni- and sleeping. T ere is ongoing debate about compression
cation. Needles smaller than 30 gauge or longer than ½ in while sleeping. We believe that external compression while
are di cult to use because they tend to veer o course when recumbent is not necessary as venous pressure is zero.
advanced through the skin. Depending on the patient’s skin Patients are encouraged to walk, and the only restrictions
type, needles can become dull rather quickly, and should on activity are those that result in sustained orce ul mus-
be replaced whenever resistance to skin puncture is noted. cular contraction and venous pressure elevation, such as
524 T is typically occurs within 3 to 10 punctures. heavy weightli ting.
 4

A B

C
h
a
p
t
r
4
4
:
:
S
Figure 44-3 T langi ctatic w b inj ction. A. A 30 gaug

c
l
n dl (b nt to an angl o 10–30 d gr s, b v l up) is

r
o
plac d at on th skin so that th n dl is parall l to th

t
h
skin sur ac . B. Th rmly support d n dl pi rc s th top

r
a
o th tiny v in suf ci ntly to allow in usion o solution with

p
minimal pr ssur on th plung r. C. Th amount slowly

y
C
in us d is approximat ly 0.1 cc to 0.2 cc p r sit , l ading to
visibl blanching o th conn ct d t langi ctasias.

o treatments needed depends on the extent o the prob-

t r ea t men t In t er Va l s lem and the extent o the areas treated at each session.
Some patients are highly responsive to treatment, and can
Physician and patient pre erences play a large role in be treated with weak sclerosants in only a ew sessions.
determining treatment intervals. New areas may be Others are highly resistant, and may require more sessions
treated at any time, but retreatment o the same areas and stronger sclerosants.
should be de erred or several weeks because some tel- A ter the initial series o treatments, a “rest” period o 4
angiectasias will ultimately clear even a ter exhibiting to 6 months will allow time or pigmentation and matting
no response within the rst 2 weeks.29 Patients o ten are to clear, and or any remaining reticular veins to establish
anxious to speed their course o treatment, but allowing a “new” routes o ref ux or drainage. Approximately 80%
longer time between treatment sessions may minimize the o patients will clear to their satis action during the rst
number o sessions needed. Some physicians recommend course o treatment. Any remaining telangiectatic webs or
waiting as long as 4 to 8 weeks between treatments, while new telangiectasias are then reassessed to determine the
others may see their patients at weekly intervals. It is not best approach or another round o treatment.
uncommon or there to be small, rm areas o hyperpig-
mentation along the track o reticular veins and protuber-
ant telangiectasias. On ollow-up sessions, these areas are po o r r es po n s e t o t r ea t men t
typically “nicked” with an 18 gauge needle to release the
dark, liquid blood trapped in the developing brosis. T is When patients have had a poor response to the initial
allows aster resolution o the pigmentation. T e number series o treatments, the original diagnosis must always be
called into question. Failed treatment o ten means that a
hidden source o ref ux was overlooked. Evaluation with
TABLe 44-4 handheld Doppler or pre erably color-f ow duplex ultra-
sound is indicated to elucidate the patterns and sources
g i i c i
o ref ux that have led to a treatment ailure. Unsuspected
T langi ctasias only—OTC 15–20 mm Hg sources o ref ux can include truncal varices, incompetent
per orating veins, and unrecognized reticular vessels.
T langi ctasias and r ticular v ins—20–30 mm Hg
I no untreated source o ref ux can be identi ed, the
R ticular and small varicos v ins—20–30 mm Hg patient must be care ully questioned about proper com-
Truncal varicos v ins—30–40 mm Hg pliance with compression. Many patients abandon com-
pression immediately a ter sclerotherapy, and this can
All compr ssion or 2–3 wks, most critical in th rst 3 days
lead to treatment ailures. T e concentration and volume 525
4 o sclerosant used should also be reexamined. It is not
uncommon to nd that the concentrations selected were
10. Weiss RA, Weiss MA. Doppler ultrasound ndings in reticu-
lar veins o the thigh subdermic lateral venous system and
implications or sclerotherapy. J Dermatol Surg Oncol. 1993;
ine ective or the size and type o vessel being treated. I
19(10):947– 951.
no explanation or the treatment ailure is ound, the con- 11. Somjen GM, Ziegenbein R, Johnston AH, Royle JP. Anatomi-
centration o sclerosant may be increased or another class cal examination o leg telangiectases with duplex scanning. J
o sclerosants may be used.30 Some women taking high Dermatol Surg Oncol. 1993;19(10):940– 945.
doses o estrogen and progesterone may rarely improve 12. Braverman IM, Keh-Yen A. Ultrastructure o the human der-
mal microcirculation. IV. Valve-containing collecting veins at
the results o sclerotherapy by temporarily suspending
the dermal-subcutaneous junction. J Invest Dermatol. 1983;
hormonal supplementation.31– 33 81(5):438– 442.
13. deFaria JL, Moraes IN. Histopathology o telangiectasias asso-
ciated with varicose veins. Dermatologica. 1963;127:321– 329.
CONCLUSION 14. T ibault P, Bray A, Wlodarczyk J, Lewis W. Cosmetic leg
veins: evaluation using duplex venous imaging. J Dermatol
Surg Oncol. 1990;16:612– 618.
When based upon a correct diagnosis and an appropriate 15. Komsuoglu B, Goldeli O, Kulan K, Cetinarslan B, Komsuoglu
treatment plan, sclerotherapy is a highly e ective method
S
SS. Prevalence and risk actors o varicose veins in an elderly
o treatment or telangiectasias. Formulating an e ective population. Gerontology.1994;40(1):25– 31.
c
t
i
treatment plan requires a detailed knowledge o venous 16. Schultz-Ehrenburg U, Weindor N, Matthes U, Hirche H. New
o
n
anatomy, a thorough understanding o the principles and epidemiological ndings with regard to initial stages o vari-
4
cose veins (Bochum study I-III). In: Raymond-Martimbeau P,
patterns o ref ux, and an intimate amiliarity with a range Prescott R, Zummo M, eds. Phlebologie ‘92. Paris, FR: John
:
:
o volumes and concentrations o sclerosing solutions. Libbey Eurotext; 1992:234– 236.
T e results obtained depend greatly on the experience o 17. Cheng L, Lee D. Review o latex allergy. J Am Board Fam Pract.
A
the clinician, but with care and attention to detail, clearing 1999;12(4):285– 292.
s
t
18. Rabe E, Schliephake D, Otto J, Breu FX, Pannier F. Sclerother-
h
rates o 90% can be achieved in most patients.
apy o telangiectases and reticular veins: a double-blind, ran-
t
Patient satis action is enhanced through education and
i
c
domized, comparative clinical trial o polidocanol, sodium tet-
a
in ormed consent, photographic documentation, and a radecyl sulphate and isotonic saline (EASI study). Phlebology.
n
d
measured approach to treatment. When the basic princi- 2010;25(3):124– 131.
L
ples o diagnosis and treatment are ollowed meticulously, 19. Guex JJ. [T e treatment o microvarices, varicosities and tel-
a
s
a success ul outcome is highly likely. It is important to angiectasis in 1992]. Phlebologie. 1992;45:401– 404; discussion
r
405– 407.
P
educate the patient that telangiectasias may be a li elong
r
20. Guex JJ. Indications or the sclerosing agent polidocanol
o
problem. Development o new veins within a ew months
c
(aetoxisclerol dexo, aethoxisklerol kreussler). J Dermatol Surg
d
to years a ter success ul treatment does not constitute Oncol. 1993;19:959– 961.
u
21. Guex JJ. Microsclerotherapy. Semin Dermatol. 1993;12:129–
r
treatment ailure; rather, it demonstrates the chronicity o
134.
s
venous insu ciency. It also demonstrates an active wound
22. Bodian EL. Sclerotherapy: a personal appraisal. J Dermatol
healing response in which new capillaries and small ves- Surg Oncol. 1989;15:156– 161.
sels are generated in seemingly limitless capacity. 23. Sadick NS. Sclerotherapy o varicose and telangiectatic leg
veins. Minimal sclerosant concentration o hypertonic saline
and its relationship to vessel diameter. J Dermatol Surg Oncol.
r e er en c es 1991;17:65– 70.
24. Ouvry PA, Davy A. T e sclerotherapy o telangiectasia.
1. Blättler W, Kreis N, Lun B, Winiger J, Amsler F. Leg symp- Phlebol. 1982;35:349– 359.
toms o healthy people and their treatment with compression 25. Zimmet SE. T e prevention o cutaneous necrosis ollowing
hosiery. Phlebology. 2008;23(5):214– 221. extravasation o hypertonic saline and sodium tetradecyl sul-
2. Weiss RA, Heagle CR, Raymond-Martimbeau P. T e Bulle- ate. J Dermatol Surg Oncol. 1993;19:641– 646.
tin o the North American Society o Phlebology. Insurance 26. Fegan WG. Continuing uninterrupted compression technique
Advisory Committee Report. J Dermatol Surg Oncol. 1992; o injecting varicose veins. Proc R Soc Med. 1960;53:837– 840.
18:609– 616. 27. Goldman MP, Beaudoing D, Marley W, Lopez L, Butie A.
3. Weiss RA, Weiss MA. Resolution o pain associated with Compression in the treatment o leg telangiectasia: a prelimi-
varicose and telangiectatic leg veins a ter compression sclero- nary report. J Dermatol Surg Oncol. 1990;16:322– 325.
therapy. J Dermatol Surg Oncol. 1990;16:333– 336. 28. Weiss RA, Sadick NS, Goldman MP, Weiss MA. Post-sclero-
4. Beasley KL, Weiss RA. Leg Rejuvenation. In: Hirsh RJ, ed. therapy compression: controlled comparative study o dura-
Aesthetic Rejuvenation A Regional Approach. New York, NY: tion o compression and its e ects on clinical outcome. Der-
McGraw-Hill;2009:173– 189. matol Surg. 1999;25(2):105– 108.
5. Goldman MP, Bennett RG. reatment o telangiectasia: a 29. Goldman MP. My sclerotherapy technique or telangiectasia and
review. J Am Acad Dermatol. 1987;17:167– 182. reticular veins. Dermatol Surg. 2010;36(Suppl 2):1040–1045.
6. Weiss RA, Weiss MA. T erapy o telangiectasia and varicose 30. Sadick NS. Hyperosmolar versus detergent sclerosing agents
veins and their complications. In: Baran R, Maibach H, eds. in sclerotherapy.E ect on distal vessel obliteration. J Derma-
Textbook of Cosmetic Dermatology. London: Martin Dunitz tol Surg Oncol. 1994;20(5):313– 316.
L D; 2004:375– 384. 31. Weiss RA, Weiss MA. Incidence o side e ects in the treat-
7. Weiss RA, Weiss MA. Pain ul telangiectasias: diagnosis and ment o telangiectasias by compression sclerotherapy: hyper-
treatment. In: Bergan JJ, Weiss RA, Goldman MP, eds. Varicose tonic saline vs. polidocanol. J Dermatol Surg Oncol. 1990;16:
Veins and Telangiectasias: Diagnosis and Treatment. 2nd ed. 800– 804.
St. Louis, MO: Quality Medical; 1999:389– 406. 32. Sadick NS, Niedt GW. A study o estrogen and progesterone
8. Goldman MP, Bergan JJ,Guex JJ. Sclerotherapy,treatment ofvar- receptors in spider telangiectasias o the lower extremities.
icose and telangiectatic legveins. 4th ed. New York, NY: Elsevier J Dermatol Surg Oncol. 1990;16:620– 623.
Health Sciences; 2006. 33. Davis L , Du y DM. Determination o incidence and risk ac-
9. Weiss RA, Weiss MA. Sclerotherapy. In: Wheeland RG, ed. tors or postsclerotherapy telangiectatic matting o the lower
Cutaneous Surgery. Philadelphia, PA: W.B. Saunders Co; 1994: extremity:a retrospective analysis. JDermatol SurgOncol. 1990;
526 951– 981. 16:327– 330.
 Ch a p t e r Minimally Invasive Treatment of

45 Varicose Veins
Karen L. Beasley & Robert A. Weiss

In t r o d u c t Io n substantially equivalent procedures to RF ablation. T e rst

laser FDA cleared by substantial equivalence to RF was the
810 nm diode laser, which was cleared or marketing in 2000.
T e development o minimally invasive methods to heat,
T e advances in endovenous ablation have revolutionized
denature, and shrink varicose veins has been a major
in-o ce varicose vein treatment or physicians and patients.
achievement in the eld o phlebology and medicine.
RF energy, like a laser with a water absorption predominant
Minimally invasive endovenous occlusion techniques
wavelength, heats and contracts the collagen within the vein
using radio requency (RF) or laser are now the standard o
wall causing contraction o the varicose vein. Endovenous
care in the United States. When saphenous venous system
laser treatment o varicose veins can be divided into two
re ux is present, it must be addressed prior to the treat-
categories: hemoglobin absorption predominant and water
ment o visible associated varicosities, reticular veins or
absorption predominant. T e water absorption predomi-
telangiectasias. Without elimination o re ux, the patient
nant wavelengths are primarily above 1100 nm, in which
will be doomed to recurrence o the varicosities and
hemoglobin is no longer a chromophore (Fig. 45-1).
smaller vessels below the level o saphenous vein re ux.
Previously, the only treatment option or these patients
with varicose veins rom saphenous insu ciency was sur- Ven ef It ™Pr o c ed u r e
gical ligation and stripping o the vessels under general
anesthesia. T is procedure resulted in signi cant postop- (c o VId Ien , Sa n Jo Se, c a )
erative down time with surgical scars, swelling, bruising,
and pain. T e expense o a hospital stay and missed work, t a r g e t ed en d o Ven o u S t h er a Py
along with an unacceptable rate o recurrence, has greatly
decreased the popularity o this procedure. RF energy is delivered through a specially designed
RF ablation started the minimally invasive varicose vein endovenous electrode to accomplish controlled resistive
trend with its approval in March 1999 by the US FDA as heating o the vessel wall. T is causes vein shrinkage or
the VNUS Closure™procedure, now known as the Vene t™ occlusion by contraction o venous wall collagen to elimi-
procedure. Subsequently, endovenous ablation techniques nate saphenous venous re ux. Although the concept o
utilizing lasers were led as US FDA 510(k) applications as endovenous elimination o re ux is not new, previous

Light a bs orption in tis s ue

G
G
G
G
G
G
A
A
A
A
A
A
Y
Y
Y
Y
Y
Y
.
.
.
.
D
x
m
.
.
d
o
r
r
e
N
N
H
E
E
T
l
A
0
0
0
4
0
10
5
8
4
2
10
6
5
0
7
9
3
0
7
1
1
2
2
2
2
1µm
10µm
100µm
1mm
10mm
810nm 1320nm
100mm Me la nin
He moglobin
1m
Wa te r
10m
100m
0.1 0.2 0.3 0.4 0.5 1 2 3 4 5 10
Wave le ngth
1320nm is a bs orbe d uniformly in wa te r, with little or no e ffe ct be me la nin a nd he moglobin
Figure 45-1 Absorption curves o light through in rared wavelengths. There is virtually no absorption
by hemoglobin beyond 1100 nm. Water is the target o 1320 nm.
4 approaches have relied on electrocoagulation o blood.
T is resulted in thrombus occluding the venous struc-
ohmic) heating o a narrow rim (<1 mm) o tissue that
was in direct contact with an electrode. T is method was
tures, with the potential or recanalization o throm- much more di cult to per orm as electrodes were suscep-
bus being very high. T e concept o application o RF tible to coagulum, which would cut of the RF due to high
directly to tissue, rather than blood, has been ef ectively resistance or impedance. T e present system completely
applied or ablation o abnormal conduction pathways or bypasses this problem. emperature, not ohmic resis-
arrhythmias.1 T is concept was conceived and adapted tance, is the limiting actor or the eedback loop.
or the treatment o varicose veins as well. T e potential It was thought that the optimal target temperature or
sa ety o this technique was supported by the act that in vein closure was 70° to 90°C since tissue heated above
animal studies there was no evidence o thrombus exten- 100°C begins to boil, but we now understand that this not
sion, while the zone o thermal damage had been limited the case.2 All o the endovenous techniques heat the ves-
to no more than 2 mm beyond the targeted vessel. A high sel at 120°C or beyond. A 7 cm long metal core at the tip
acute success rate o 92% was ollowed by long-term vessel o the catheter is heated to 120oF and allowed to transmit
occlusion in the animal model. heat to the treated vessel or 20 seconds, which shrinks
veins 7 cm at a time to allow or very ast ablation. T e
S
e
ClosureFast™catheter and machine are shown in Figure
c
o r Ig In a l Vn u S c l o Su r e
t
i
45-3. T is catheter cannot treat segments shorter than
o
n
t ec h n o l o g y™Ver Su S Ven ef It 7 cm, with a rigid structure that also limits the treatment
4
c l o Su r ef a St ™ o more serpentine saphenous veins, but a new 3 cm metal
:
:
core has been developed to treat shorter segments. T e
Present ClosureFast™technology utilizes a method or RF device requires close, stable contact between the active
A
e
vein heating that evolved rom the original version (Fig. electrode and the vessel wall and requires tumescent anes-
s
t
h
45-2). In the current model, RF energy is directed toward thesia to allow contact o the vein wall with the metal coil.
e
t
By controlling temperatures, boiling, vaporization, and
i
vein walls. T e vein walls then shrink rom the resultant
c
a
denaturing o the vein wall protein. T e previous mecha- carbonization o the tissues are avoided.3 With the previ-
n
d
nism by which RF current heated tissue was resistive (or ous generation RF system, as shrinkage and compaction
L
a
o tissue occurred, there was a decrease in impedance that
s
e
decreased heat generation,4 but this is no longer the case
r
P
as only the temperature o the catheter’s metal tip is moni-
r
o
tored. Over 10 years o clinical experience suggest that the
c
e
d
RF endovenous ablation procedures are highly ef ective
u
r
at occluding saphenous veins and abolishing re ux. Stud-
e
s
ies o Closure Fast™, introduced in 2007, indicate that it
is even more e cacious than the previous generation RF
model.5

Ca the te r Ca the te r in RF e ne rgy Ca the te r Ve in is

r eSu l t S o f r a d Io f r eq u en c y
ins e rte d in
re fluxing
pos ition,
e le ctrode s
initia te d,
ve in wa ll
s lowly
withdrawn,
phys ica lly
na rrowe d
en d o Ven o u S a bl a t Io n
ve in de ploye d contra cts clos ing ve in
A For clinical symptoms, the RF endovenous occlusion
procedure rapidly reduces patient pain, atigue and ach-
ing correlating with a reduction in CEAP clinical class
or symptoms and clinical severity o disease ( able
45-1). When patients have had surgical stripping on the
opposite leg, the degree o pain, tenderness, and bruis-
ing have been ar greater on the leg treated by stripping.
Skin burns occurred prior to the tumescent anesthe-
sia technique in 2.5%, but this has not been seen since
1998. Other side ef ects virtually eliminated by tumescent
anesthesia included clinical phlebitis at 6 weeks in 5.7%,
and temporary quarter-sized areas o paresthesia in 18%,
with most o these occurring immediately above the knee
and resolving within 6 months to a year. Endovenous RF
B occlusion has replaced traditional surgery, which con-
sisted o ligation and stripping o similar size saphenous
Figure 45-2 Comparison o original design o RF catheter
versus the new ClosureFast™design. A. Electrodes contact veins. Most importantly or patients, side ef ects o DV
the vein wall. B. A wire coil heats up using RF energy, which and nerve injury are ar lower with RF when used with
then secondarily heats vein wall by direct contact as the tumescent anesthesia compared to traditional ligation
catheter is pulled back. (Used with permission o Covidien, and stripping. Endovenous ablation using the Closure-
San Jose, CA. Vene t is a trademark o a Covidien company. Fast™catheter has been reported to maintain occlusion
528 © 2013 Covidien.) o 97.4% o treated vessels at 1 year 6 and 92% o treated
 4

C
h
a
p
t
e
r
4
5
:
:
M
i
n
i
m
A B

a
l
l
y
Figure 45-3 A. The ClosureFast™catheter. B. The Vene t™radio requency machine. (Used with permission o Covidien,

I
n
v
San Jose, CA. Vene t is a trademark o a Covidien company. © 2013 Covidien.)

a
s
i
v
e
T
r
e
a
vessels at 5 years.7 A clinical example is shown in Figure

t
m
45-4. T is is a more avorable outcome or varicose veins

e
n
TABLE 45-1 than traditional surgery, which has been reported to have

t
o
long-term e cacy rates much lower than 90%.8 Patients
c ea P c ss d s ip i wi fi i s

V
remain symptom ree and patent GSVs are not visible

a
e v srf o si

r
i
under Duplex ultrasound. Clinical results observed at

c
o
6 months are indicative o the long-term results, so that

s
c ea P

e
i the GSV is ablated at 6 months, it is likely to remain

V
c i i c ss d s ip i

e
ablated at 10 years.

i
n
s
0 Asymptomatic T e superior epigastric vein that continues to empty
superiorly into the common emoral vein is a critical
1 Telangiectasia
structure to preserve and endovenous techniques are now
2 Varicose veins per ormed so as to preserve this vein. Energy is applied
3 Edema starting at 2 cm below the sapheno emoral junction below
the superior epigastric tributary. We have always believed
4 Skin changes
that a high margin o sa ety is maintained by maintain-
5 Healed venous ing ow through this tributary. Among the many reasons,
ulcer the most important are that the high ow rate through the
6 Venous ulcer epigastric vein into the common emoral vein appears to
diminish the possibility o extension o any thrombus (in
Mean CEAP Class the unlikely event that this would occur) rom the GSV,
c s as well as the act that normal venous drainage rom the
lower abdomen is allowed to continue. In our experience,
S
thrombus has never been observed in over 1000 cases
P p i P 6 Wk 6m
o endovenous ablation, although it has been reported
Pre Tx CEAP 2.0 0.5 0.5 by others.8,9
class = 2
Pre Tx CEAP
class = 3
3.0 0.5 0.3 l a Ser S WIt h h emo g l o bIn
Pre Tx CEAP 4.0 2.3 1.4
Pr ed o mIn a n t a bSo r Pt Io n
class = 4
Endovenous laser treatment with these wavelengths is
Total 2.4 0.8 0.6
designed to produce endothelial and vein wall shrinkage 529
4
S
e
c
t
i
o
n
4
:
:
A
e
s
t
h
e
t
i
c
a
n
d
L
a
s
e
r
Figure 45-4 Clinical improvement a ter RF endovenous ablation. Pretreatment varicosities are prominent and 6 weeks
P
r
o
postprocedure varicosities are undetectable.
c
e
d
u
r
e
s
by nonspeci c heating o the vessel, o ten by a superheated the vein. T e overall long-term e cacy o hemoglobin-
coagulum at the ber tip or by the heating o hemoglobin targeting lasers is less than that o water-absorbing lasers.
within red blood cells to create steam bubbles.10 T e target
or lasers with 810, 940, 980, and 1064 nm wavelengths
is the intravascular red blood cell. Without the presence Su mma r y o f en d o Ven o u S
o blood in the vein, such as in an experimental situation l a Ser S WIt h h emo g l o bIn
in which the vein is lled with saline, laser-induced vessel
wall injury is con ned to a small site o direct laser impact. Pr ed o mIn a n t a bSo r Pt Io n
By contrast, blood- lled veins exhibit thermal damage in
more remote areas, including the vein wall opposite to the Wavelengths o 810, 940, and 980 nm endovenous lasers
laser impact. Steam bubbles are generated in hemolytic have short-term e cacy ranging rom 90% occlusion during
blood by all our lasers, while no bubbles can be produced the rst year o ollow-up to 70% a ter 2 years.13–17 Un ortu-
in normal saline or plasma.10 T ere ore the success o nately, many patients experience signi cant degrees o post-
these lasers is highly dependent on correct placement o operative ecchymosis and discom ort.17– 23 (Fig. 45-5)
tumescent local anesthesia to have a thin layer o blood Saphenous nerve injury, skin burns, and deep venous
surrounding the laser ber while having enough anesthe- thromboses have occurred due to the high temperatures
sia present to protect the surrounding nerves and muscles o blood heating at these wavelengths (Fig. 45-6), although
rom injury. T is can be di cult to achieve and results in the overall sa ety and e cacy record is better with these
unpredictable pain and recurrence. laser endovenous ablations than with ligation and strip-
Direct thermal ef ects on the vein wall without the pres- ping.22 O all the wavelengths, 810 nm has the lowest
ence o blood may lead to small spots o wall injury with long-term improvement at 70%.23 Ideally, or a hemoglo-
resulting pain and early recanalization o the treated vein.11 bin-absorbed wavelength to work most e caciously, it is
Less consistent clinical results are seen than with RF abla- best to have a well-de ned layer o hemoglobin between
tion or with 1320 nm endovenous laser (see lasers with the ber and the vein wall. Varicose veins are saccular,
water predominant absorption). Considerable site varia- however, and irregular pockets o hemoglobin are re-
tion in success rates and postoperative pain or these types quently encountered, leading to sharp rises in temperature
o lasers has been reported.12,13 T is is understandable and vein per orations when using hemoglobin-absorbing
given that these lasers are dependent on so many dif erent wavelengths. When using tumescent anesthesia with a
actors, including the amount o blood in the lumen, the hemoglobin-targeting wavelength, it can be very di cult
rate o pullback, pulsed versus continuous laser output, to gauge the correct amount o uid to compress the vein
530 and the amount o tumescent anesthesia placed around since some hemoglobin is necessary or the mechanism o
 l a Ser S WIt h Wa t er
4
Pr ed o mIn a n t a bSo r Pt Io n
c o o l t o u c h en d o Ven o u S c t eV™
1320 n m (c o o l t o u c h , In c .,
r o Se VIl l e, c a )
A variation o the endovenous laser with a wavelength o
1320 nm (Cool ouch C EV™Endovenous reatment) was
developed in 2003 by dermatologic surgeons, Robert A.
Weiss and Mitchel P. Goldman, in an attempt to circum-
vent the problems associated with the wavelengths that
absorb hemoglobin. issue water within the vein wall is

C
h
the speci c target o the 1320 nm laser, and the presence

a
p
or absence o red blood cells within the vessels is, there-

t
e
ore, unimportant. For a more controlled release o laser

r
4
energy, the laser is coupled with an automatic pullback

5
device that can pull back the laser ber at the rate o

:
:
0.5 or 1 mm/sec (Fig. 45-7). T e penetration o the 1320

M
nm wavelength is unique in that it ef ectively heats and

i
n
contracts the vein with ar less heat generation and ewer

i
m
risks than with the hemoglobin-absorbing wavelengths.

a
l
T e 1320 nm wavelength was explored or use in endo-

l
y
I
venous ablation and clinical trials per ormed resulting in

n
v
FDA clearance in September 2004 or treatment o the

a
s
i
greater saphenous vein. By August 2005, su cient data

v
e
had been accumulated that the FDA approved the 1320

T
r
e
nm device or obliteration o re ux in the small saphenous

a
t
vein as well. Based on our experience, there is reduced

m
Figure 45-5 One day post endovenous 810 nm diode

e
laser ablation demonstrates bruising. pain reported with the 1320 nm versus the hemoglobin-

n
t
absorbing wavelengths due to in requent vein per ora-

o
tions and more uni orm heating. T is is likely due to the

V
a
action. I too much tumescence is used, there can be char- 1320 nm device targeting water in the vein wall combined

r
i
c
ring o the inner wall o the vein without heating o the with a de ned pullback speed or uni orm distribution

o
s
outer vein wall, with resulting inter- and postoperative o energy. Although patients may rarely experience mild

e
V
pain and ailure to close the vein. With all o these potential pain a ter 1320 nm, this is related to heat dissipated into

e
i
n
obstacles to ideal treatment conditions or the hemoglo-

s
bin-absorbing laser wavelengths, it makes ar more sense
to use a predominantly water-absorbing wavelength to
treat incompetent varicose veins by endovenous laser.
umescent anesthesia can then be employed using the pre-
erred method o complete compression o the vein with
exsanguination leading to uni orm results and reduced
side ef ects.

Figure 45-6 A. Skin burns caused by di usion o heat Figure 45-7 CTEV CoolTouch Trio laser with automatic
rom 810 nm diode endovenous laser seen at 4 days post pullback mechanism. (Used with permission o CoolTouch
procedure. Inc., Roseville, CA.) 531
4 the surrounding tissue rather than vein per orations. T is
side ef ect can be virtually eliminated by the correct use o
tumescent anesthesia. Our incidence o pain ollowing
1320 nm is less than 1% and the vast majority o patients
return to work within 24 hours o the procedure. Side
ef ects are also kept to a minimum by using the mini-
mal ef ective energy to shrink the vein. Energy treatment
ranges rom 5 to 8 W, with most veins requiring 7 to 8 W
o energy. In our own unpublished observations, we have
ound that during emission o 5 W o 1320 nm energy
through a 600 µ ber moving at 1 mm/sec in a 2 mm thick
vein wall, the highest temperature recorded on the exte-
rior o the vein wall is 48°C. ypically, steam bubbles are
observed on Duplex ultrasound during the procedure. In a
saphenous vein, or ef ective sealing and shrinkage, higher
S
e
energies must sometimes be utilized. Proebstle et al.20 dem-
c
t
i
onstrated a statistically reduced rate o postoperative pain
o
n
accompanied by a higher initial success rate using 1320 nm
4
versus 940 nm. With the 1320 nm group, treatment-related
:
:
pain and the need or analgesics were signi cantly reduced A B
(p<0.005) in comparison with treatment-related pain (81%)
A
e
and the need or analgesics (67%) or the 940 nm laser
s
Figure 45-8 Clinical results with 1320 nm endovenous
t
h
group. Ecchymosis was also signi cantly reduced (p<0.05) laser. A. Be ore treatment, varicosities are noted. B. 6 weeks
e
t
using the 1320 nm wavelength. It has recently been shown
i
post treatment demonstrates signi cant improvement in
c
a
that microsecond-pulsed wave lasers with high peak power varicosities.
n
d
densities may be the best choice to minimize so t throm-
L
a
bus ormation during endovenous ablation treatments and
s
e
reduce side ef ects and complications.21
r
P
T e 1320 nm C EV system is a microsecond-pulsed o patients will determine the ef ectiveness o these newly
r
o
system. Our own experience has shown reduced side reported wavelengths employed or endovenous ablation.
c
e
d
ef ects, with a reduction in pain and bruising o 80%,
u
r
when switching rom 810 nm endovenous to 1320 nm
ImPo r t a n c e o f t u meSc en t
e
s
endovenous ablation. Having treated over 1000 greater
saphenous veins with 1320 nm, with ollow-up as long a n eSt h eSIa f o r en d o Ven o u S
as 10 years, our incidence o mild pain lasting less than t ec h n Iq u eS
24 hours is 5%. No signi cant pain inter ering with walk-
ing has been observed with the 1320 nm laser although it It is critical or all the endovenous techniques that tumes-
has been observed in up to 50% o patients who under- cent local anesthesia be employed. General anesthesia
went 810 nm laser treatment in our clinic. No deep venous should not be utilized or the endovenous ablation tech-
thrombosis has been observed. A clinical example o vari- niques as patient immobility a ter the procedure increases
cose veins resulting rom re ux at the sapheno emoral the risk o deep-vein thrombosis. umescent anesthesia is
junction pre- and post-treatment with a 1320 nm laser is the technique or local anesthesia delivery that maximizes
shown in Figure 45-8. sa ety by using pharmacokinetic principles to achieve
extensive regional anesthesia o skin and subcutaneous tis-
sue. Initially described or liposuction, the subcutaneous
mISc el l a n eo u S en d o Ven o u S in ltration o a large volume o very dilute lidocaine and
Wa Vel en g t h S epinephrine causes the at tissue to become swollen and
rm, or tumescent. T e primary advantage o tumescent
Other laser wavelengths are currently being explored anesthesia is that it permits procedures to be per ormed
or endovenous laser obliteration o varicose veins. For on patients without subjecting them to the inherent risks
example, a 1470 nm diode was studied in the treatment o general anesthesia and blood loss.
o 134 saphenous veins. It showed high rates o occlusion When applied to endovenous techniques, the ratio-
at 1 year but patients also had a 7.6% rate o paresthesias nale or use o tumescent anesthesia is dif erent rom its
at 1 year.24 An additional study concluded that closure o rationale or use in liposuction. T e uid compresses the
the varicose veins was possible with a marked reduction in vein, allowing contact with the laser ber or RF cath-
energy, postoperative pain, and ecchymosis with the 1470 eter. Furthermore it provides anesthesia and provides
nm as compared to the 980 nm wavelength.25 T e 980 nm a heat sink or the rise in vein temperature to protect
wavelength was also compared with another new laser surrounding tissue. T is application o tumescent anes-
with a 1500 nm wavelength in an animal model. T is study thesia to endovenous ablation was considered unique
ound that use o the 1500 nm laser correlated with a more enough to be issued the ollowing patents: US 6258084
homogeneous vein wall destruction and less perivenous B1 Method or Applying Energy to Biological issue
tissue destruction, which could possibly lead to less Including the Use o umescent issue Compression
532 postoperative pain.26 Further studies on a larger number and US 6752803 B2 Method and Apparatus or Applying
 the GSV or SSV or where the vein becomes too small to
cannulate with a standard introducer set. For the major-
4
ity o patients in our series this is at a point just above or
below the knee along the course o the GSV or just below
the mid-cal with treatment o the SSV.
Be ore proceeding, the patient’s eet are wrapped in thick
socks to minimize vasoconstriction, a heating pad is placed
under the thigh or around the oot and a small amount o
2% nitroglycerin paste may be rubbed onto the intended
entry point to minimize vasoconstriction during the ini-
tial cannulation process. T e patient is then prepped and
draped, a ter which 0.2 cc o 1% lidocaine with or without
epinephrine is injected at the ultrasound premarked site.
It is important that the patient experience no pain during
cannulation as the awareness or perception o pain will

C
Figure 45-9 SUPT anesthesia seen in a longitudinal view.

h
cause an immediate and rapid contraction o the saphe-

a
Dark, non ultrasound ref ective space is the tumescent

p
f uid “space,” which is created by instillation o 0.1% lido nous vein. T is makes cannulation almost impossible until

t
e
r
caine. The ber is in the center o the vein as indicated. the vein is no longer in spasm, which can take 30 minutes.

4
5
In order to place the sheath, a guidewire must be rst
inserted through the initial needle puncture. T e guidewire

:
:
is passed approximately 5 cm into the GSV. T e sheath is

M
Energy to Biological issue Including the Use o umes- then threaded along the guidewire, piercing the skin a ter

i
n
cent issue Compression. a stab incision with a number 11 blade. Its progress is ol-

i
m
A urther re nement o tumescent anesthesia or endo- lowed by Duplex ultrasound until it is seen rmly placed

a
l
l
venous techniques is its application under Duplex visual- within the lumen o the GSV. A ter establishing the intra-

y
I
ization. T is allows the operator to instill the tumescent

n
luminal placement o the sheath, the guidewire is care ully

v
anesthesia uid directly around the vein between the

a
withdrawn. Once the sealed sheath is placed into the vein,

s
i
super cial and deep ascia, essentially isolating the vein

v
the Closure™catheter is then advanced. Others pre er ini-

e
rom surrounding structures such as nerves and arteries.

T
tializing entry via a venous cutdown or pulling o the vein

r
e
T is has been named the SUP technique, which stands or close to the sur ace with an ambulatory phlebectomy hook.

a
t
Sub ascial Ultrasound—Guided Perivenous Tumescent

m
With the old design o the VNUS Closure™catheter,

e
anesthesia (Fig. 45-9). Since the application o this method diluted heparin solution or normal saline was required to

n
t
in our practice, there have been virtually no incidences o slowly drip through a central lumen but the new Closure-

o
paresthesias and the incidence o postoperative pain is vir- Fast™design eliminates this concern. Passage o the RF

V
a
tually zero. T is anesthesia is administered using the Klein catheter is monitored by duplex ultrasound. Once the RF

r
i
c
tumescent pump and a tumescent mixture o 0.1% lido-

o
catheter is in place, tumescent anesthesia is injected under

s
e
caine with 1:1,000,000 epinephrine. T e Klein pump makes ultrasound guidance primarily between the super cial

V
the application o tumescent anesthesia ar simpler than

e
ascia, the cannulated GSV and the deep ascia (so-called

i
n
with the use o syringes. Since typical volumes range rom SUP technique or Sub ascial Ultrasound—Guided Peri-

s
300 to 700 cc or the entire length o treated GSV, a pump venous Tumescent anesthesia). T is is or the purpose o
is highly recommended. A recent report details the use o a providing a heat sink, causing the vein to compress around
syringe but we recommended against this as it slows down the catheter and to provide a painless experience or the
the procedure.27 umescent anesthesia placement is even patient. Duplex monitoring o the anesthesia injection is
more critical to reduce side ef ects rom small saphenous not only recommended but is essential to insure that the
vein endovenous ablation. A sa e total dose o lidocaine is tumescent uid is injected into the perivenous space and
achieved using the tumescent method. that the ascial planes are pushed away rom the vein.
T e nal check o the position o the catheter is made
with Duplex ultrasound. T e tip o the metal core o the
c l In Ic a l t ec h n Iq u e 7 cm long energy delivery tip is care ully placed 2 cm
below the base o the terminal valve cusps. T e readout
o temperature prior to initiation o heating to 120°C
t a r g e t ed en d o Ven o u S t h er a Py should be substantially lower than body temperature due
Ven ef It ™Pr o c ed u r e to the sub ascial tumescent anesthesia. I the temperature
(r a d Io f r eq u en c y) readout rom the thermocouple is higher than 28°C, then
insu cient tumescent uid has been injected. We pre er
Patients with re ux in the great or small saphenous vein to see a baseline temperature a ter tumescent in ltration
are candidates. We have treated veins as large as 2.5 cm o 25° to 26°C. I a body temperature o 37°C is measured
when standing but which are compressed by tumes- at baseline, some aspect o setup is critically wrong and
cent anesthesia when the procedure is per ormed. Using the procedure should not continue.
Duplex ultrasound, the procedure begins with marking T e RF is then applied; the physician monitors the
the vein to be treated on the skin. An appropriate entry temperature and impedance. Within 10 to 15 seconds the
point that is easily percutaneously cannulated is selected. target temperature o 120°C should be reached. I this does
T is is usually just below where re ux is no longer seen in not occur, the catheter has most likely been mistakenly 533
4 advanced too ar into the common emoral vein and the
placement o the catheter needs to be care ully reas-
sessed. A ter target temperature is achieved, the catheter
is moved 7 cm down using the markings on the catheter
as a guide and the second application o energy occurs. It
is important to prevent application o energy to the skin
by making sure that markings on the catheter or the nal
7 cm o application are care ully observed. At the conclu-
sion, duplex ultrasound o the SFJ should reveal no ow
except within the super cial epigastric vein emptying into
the common emoral vein. T e GSV should be more echo-
genic with thicker appearing walls. Postoperative instruc-
tions are the same as those given a ter endovenous laser
ablation and are discussed later.
Figure 45-10 The SaphFire™laser ber has a rounded tip
S
e
that requires no sheath during CTEV treatment since
c
t
en d o Ven o u S l a Ser a bl a t Io n there is minimal danger o puncturing the wall o a vein
i
o
n
while advancing the beroptic. (Used with permission o
4
As previously discussed in the RF ablation technique sec- CoolTouch Inc., Roseville, CA.)
:
tion, the leg to be treated should remain warm as veins
:
tend to contract to conserve heat when skin temperature
A
e
decreases. We o ten place a heating pad set on low around
s
tumescent anesthesia is complete and the tip o the ber
t
h
the oot and patients are encouraged to bring warm socks.
e
con rmed at 2 cm below the SFJ, the laser is red or 2
t
I the vein remains too small to cannulate when the patient
i
c
to 3 seconds to visualize sealing o the targeted vein on
a
is supine, we apply gravitation pressure by tilting into Duplex. T e laser is then stopped or a moment while the
n
d
reverse rendelenburg position. A small amount o topi- pullback device is turned on. Once the laser ber starts to
L
cal 2% nitrogen paste may be rubbed into the skin where
a
pull back, the laser is immediately switched on. T e prog-
s
e
percutaneous access will be initiated.
r
ress can be monitored by Duplex or visually by the aiming
P
T e patient’s leg undergoes sterile preparation and a
r
beam reaching the skin sur ace rom within the vein. As
o
small catheter is threaded percutaneously into the incom-
c
the ber approaches the entry site, the laser is stopped.
e
petent vein. In the older technique, a sheath is placed
d
Patients can return to work the next day, discom ort is
u
along the entire length o the vein to be treated up to the
r
e
minimal and the rate o success ul long-term vein closure
s
sapheno emoral or saphenopopliteal junction. In the newer is 99% at 8 years. Side ef ects such as deep-vein throm-
technique, this step is omitted by using specially developed bus and nerve damage are extremely rare. We have never
blunt-tipped bers that do not require a protective sheath. seen deep-vein thrombosis in our clinic, although it has
umescent anesthesia is then injected along the vein and been reported elsewhere.28 Please re er to postoperative
injected sub ascially to separate and dissect the targeted instructions in Figure 45-11.
vein. Once tumescent anesthesia is achieved and totally sur-
rounds the targeted vein, the C EV™600 µm laser ber is
inserted. A helium neon aiming beam that is continuously
illuminated when the laser is on ensures that the laser ber
is in the super cial venous system and can be used to moni- Ve no us Pro c e dure Po s to pe rative Ins truc tio ns
tor automatic pullback visually. T e sheath acts to protect
1. Ke e p compre s s ion hos e on until be dtime. Le ave
the vein rom per oration during the insertion o a sharp- compre s s ion ba nda ge on until the morning. If toe s turn
tipped optical ber. However, the sheath must be com- blue or fe e l numb, loos e n the ba nda ge. If symptoms
pe rs is t, ca ll the doctor imme dia te ly.
pletely removed rom the vein prior to application o laser
energy at 1320 nm. T is is per ormed so that the automatic 2. You ca n re s ume norma l a ctivitie s today (wa lking is
e ncoura ge d).
pullback device may retract the ber unimpeded. Secondly,
i the laser ber retracts within the sheath, thermal destruc- 3. You ca n re s ume exe rcis ing in 3 days (no we ights
with the le gs for 1 we e k).
tion o the sheath occurs with no energy transmission to
the vein wall. With the addition o a rounded or protected 4. You ca n s howe r tomorrow but no hot ba ths for 1 we e k.

tip, such as the SaphFire™tip, no sheath is required as there 5. We a r your compre s s ion hos e for the next 3 days,
is minimal danger o puncturing the wall o a vein while from firs t thing in the morning until la s t thing a t night.

advancing the beroptic (Fig. 45-10). 6. S che dule your next follow-up in 6 we e ks.
Correct placement o the laser ber at least 2 cm dis-
7. Bruis ing, numbne s s, loca l swe lling, a nd te nde rne s s a re
tal to the sapheno emoral junction or 3 cm distal to the norma l a fte r s urge ry, but ple a s e fe ll fre e to ca ll the office
saphenopopliteal junction is con rmed with ultrasound. if you have a ny que s tions. To he lp re lieve symptoms,
400-mg ibuprofe n may be ta ke n in the morning a nd
umescent anesthesia is critical to compress the vein. eve ning with food for 1–2 we e ks.
Under ultrasound guidance and with an automatic pull-
8. Doctor’s e me rge ncy phone numbe r is .
back system, the laser seals the varicose vein rom the
inside out. Pullback is set or 0.5 mm/sec or the rst 2 to
3 cm o the GSV and then 1 mm/sec or the remainder o
534 the treatment. T e laser is set or 7 to 8 W at 50 Hz. Once Figure 45-11 Venous procedure postoperative instructions.
 c o mPa r ISo n o f r f t o en d o Ven o u S
5. Proebstle M, Alm J, Gockeritz O, et al; European
Closure Fast Clinical Study Group. T ree-year European ol-
4
l a Ser a bl a t Io n low-up o endovenous radio requency-powered segmental
thermal ablation o the great saphenous vein with or with-
out treatment o cal varicosities. J Va sc Surg. 2011;54(1):
Our experience is that postoperative pain is greatly reduced 146– 152.
with the ClosureFast™system compared with most laser 6. Dietzek A, wo-Year Follow-Up Data From A Prospective,
systems that utilize wavelengths targeting hemoglobin. Multicenter Study O T e E cacy O T e ClosureFAS
T ese include wavelengths o 810, 940, 980, and 1064 nm, Catheter, 35th Annual Vein Symposium. November 19, 2008.
New York.
but not 1320 and 1470 nm, which target water. Several
7. Proebstle . ClosureFast Long- erm European Multi-Center
recent reports o patient experiences kept via a diary indi- Study in patients with Chronic Venous Insu ciency (CVI).
cate less postoperative discom ort with the ClosureFast™ American College o Phlebology 26th Annual Congress. No-
system compared with the 980 nm wavelength.29,30 In this vember 15, 2012 Heidelberg, Germany.
report, 81 patients returned a home diary (RF ablation = 8. Hach-Wunderle V, Hach W. Invasive therapeutic options
in truncal varicosity o the great saphenous vein. Va sa.
45, 980 nm laser = 36). Patients receiving RF reported less
2006;35(3):157– 166.
postoperative pain than those receiving 980 nm at 3 and

C
9. Komenaka IK, Nguyen E . Is there an increased risk or

h
10 days. Most signi cantly those receiving RF via Closure- DV with the VNUS closure procedure? J Va sc Surg. 2002;

a
p
Fast™returned to work earlier than those receiving 980 nm 36(6):1311.

t
e
endovenous ablation (median 5 vs. 9 days).29 Clinical out- 10. Proebstle M, Sandho er M, Kargl A, et al. T ermal damage

r
4
o the inner vein wall during endovenous laser treatment: key
comes were similar at 6 weeks.30

5
role o energy absorption by intravascular blood. Dermatol
When RF is compared to water targeting 1320 nm Surg. 2002;28(7):596– 600.

:
:
(C EV) endovenous laser, postoperative pain is virtually 11. Weiss RA. Comparison o endovenous radio requency ver-

M
nonexistent and most patients return back to work by the sus 810 nm diode laser occlusion o large veins in an animal

i
model. Dermatol Surg. 2002;28(1):56– 61.

n
next day. Although these data are not yet published, this

i
m
12. de Medeiros CA, Luccas GC. Comparison o endovenous
is our clinical experience, which we have utilized or hun-

a
treatment with an 810 nm laser versus conventional stripping

l
dreds o patients since 2004. Clinical outcomes are excel-

l
y
o the great saphenous vein in patients with primary varicose

I
lent with both RF and 1320 nm with success ul saphenous

n
veins. Dermatol Surg. 2005;31(12):1685– 1694.

v
occlusion in 90% o original RF, 97.4% ClosureFast™ , and 13. Navarro L, Min RJ, Bone C. Endovenous laser: a new mini-

a
s
mally invasive method o treatment or varicose veins– pre-

i
99% o 1320 nm treated GSVs.

v
e
liminary observations using an 810 nm diode laser. Dermatol

T
Surg. 2001;27(2):117– 122.

r
e
c o n c l u SIo n

a
14. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous

t
m
laser treatment o the incompetent greater saphenous vein.

e
J Va sc Interv Radiol. 2001;12(10):1167– 1171.

n
t
Endovenous ablation techniques have become the gold stan- 15. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment

o
dard or the treatment o saphenous re ux. T ese methods o saphenous vein re ux: long-term results. J Va sc Interv Ra-

V
diol. 2003;14(8):991– 996.

a
are well proven to of er a less invasive alternative to ligation

r
16. Bush RG. Regarding “Endovenous treatment o the greater

i
c
and stripping. Endoluminal targeting o water rather than

o
saphenous vein with a 940-nm diode laser: thrombolytic oc-

s
hemoglobin is recommended or decreasing patient dis-

e
clusion a ter endoluminal thermal damage by laser-generated

V
com ort as well as obtaining the best possible long-term out- steam bubbles”. J Va sc Surg. 2003;37(1):242.

e
i
17. Desmyttere J, Grard C, Wassmer B, Mordon S. Endovenous

n
comes. Our clinical experience with endovenous techniques

s
980-nm laser treatment o saphenous veins in a series o 500
in thousands o patients shows a high degree o success patients. J Va sc Surg. 2007;46(6):1242– 1247.
with minimal side ef ects using RF and 1320 nm laser. Most 18. Proebstle M, Lehr HA, Kargl A, et al. Endovenous treat-
patients return to work the next day. umescent anesthesia is ment o the greater saphenous vein with a 940-nm diode la-
critical to the sa ety and e cacy o endovenous techniques. ser: thrombotic occlusion a ter endoluminal thermal damage
Endovenous RF and laser ablation side ef ects and downtime by laser-generated steam bubbles. J Va sc Surg. 2002;35(4):
729– 736.
are reduced with proper wavelength selection or targeting 19. Shari MA, Soong CV, Lau LL, Corvan R, Lee B, Hannon RJ.
water. Excellent long-term results are achieved with success Endovenous laser treatment or long saphenous vein incom-
rate o nonsurgical elimination o saphenous veins in over petence. Br J Surg. 2006;93(7):831– 835.
98% o patients when proper technique and wavelengths are 20. Proebstle M, Moehler , Gül D, Herdemann S. Endove-
utilized. nous treatment o the great saphenous vein using a 1320 nm
Nd:YAG laser causes ewer side ef ects than using a 940 nm
diode laser. Dermatol Surg. 2005;31(12):1678– 1683.
r ef er en c e 21. Hennings , Hennings D, Lindsay C. T rombus ormation
using endovenous lasers: an in vitro experiment. Phlebology.
1. Olgin JE, Kalman JM, Chin M, et al. Electrophysiological e - 2013;29(3):1– 8.
ects o long, linear atrial lesions placed under intracardiac 22. Chang CJ, Chua JJ. Endovenous laser photocoagulation
ultrasound guidance. Circulation. 1997;96(8):2715–2721. (EVLP) or varicose veins. La sers Surg Med. 2002;31(4):
2. Haines DE. T e biophysics o radio requency catheter abla- 257– 262.
tion in the heart: the importance o temperature monitoring. 23. Weiss R, Weiss M, Beasley K. Sclerotharapy and Vein
Pacing Clin Electrophysiol. 1993;16(3 Pt 2):586– 591. Treatment. 2nd ed. New York, NY: McGraw Hill; 2011.
3. Haines DE, Verow AF. Observations on electrode-tissue in- Chapter 21;p.165.
ter ace temperature and ef ect on electrical impedance during 24. Pannier F, Rabe E, Maurins U. First results with a new 1470-
radio requency ablation o ventricular myocardium. Circula- nm diode laser or endovenous ablation o incompetent
tion. 1990;82(3):1034– 1038. saphenous veins. Phlebology. 2009;24(1):26– 30.
4. Lavergne , Sebag C, Ollitrault J, et al. [Radio requency ab- 25. Almeida J, Mackay E, Javier J, Mauriello J, Raines J. Saphenous
lation: physical bases and principles]. Arch Mal Coeur Vaiss. laser ablation at 1470 nm targets the vein wall, not blood.
1996;89 Spec No 1:57– 63. Va sc Endova scular Surg. 2009;43(5):467– 472. 535
4 26. Vuylsteke M, Van DJ, Roelens J, De B , Mordon S. Endove-
nous laser treatment: a morphological study in an animal
29. Shepherd AC, Gohel MS, Lim CS, Hamish M, Davies AH. Pain
ollowing 980-nm endovenous laser ablation and segmental
model. Phlebology. 2009;24(4):166– 175. radio requency ablation or varicose veins: a prospective ob-
27. Lapid O. Syringe-Delivered tumescent anesthesia made easi- servational study. Va sc Endova scular Surg. 2010;44(3):212–
er. Aesthetic Pla st Surg. 2011;35(4):601– 602. 216.
28. Knipp BS, Blackburn SA, Bloom JR, et al.; Michigan Ve- 30. Shepherd AC, Gohel MS, Brown LC, Metcal e MJ, Hamish M,
nous Study Group. Endovenous laser ablation: venous Davies AH. Randomized clinical trial o VNUS ClosureFAS
outcomes and thrombotic complications are independent radio requency ablation versus laser or varicose veins. Br J
o the presence o deep venous insu ciency. J Va sc Surg. Surg. 2010;97(6):810– 818.
2008;48(6):1538– 1545.
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:
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 Phototherapy and Photodynamic
Ch a p t e r Therapy for the Treatment

46 of Acne Vulgaris
Michael H. Gold

In t r o d u c t Io n use o photosensitizers with lasers and light sources, we

have incredible “tools” at our disposal to help almost every
patient who su ers rom acne vulgaris.
Acne vulgaris, by all accounts, is the most common skin
concern seen regularly by dermatologists in their clinical
practices. By some estimates, patient visits or treating Et Io l o g y a n d Pa t h o g En Es Is
acne vulgaris and dealing with its associated sequelae make
up roughly one-third o all visits to dermatology o ces in o f a c n E Vu l g a r Is
the United States.1 T is is a very high percentage, and or
this reason alone, we, as dermatologists, need to stay at the Acne vulgaris is considered a multi actorial skin condition
ore ront o new therapeutic options and ideas, to oster with both genetic and hormonal inf uences playing a role
new medical approaches or our patients when appropri- in the origin o this disease and its progression over time.
ate, and to o er alternative orms o therapy to best manage Most patients with acne have a strong amily history o
those su ering rom acne vulgaris. T ese “other” orms o acne vulgaris in their parents or close relatives. Hormonal
therapy may involve non-medical therapy or our patients, inf uences are also strongly involved in the pathogenesis o
including the use o lasers and light sources, and may at acne. T e ormation o sebum in the pilosebaceous glands
times involve use o photosensitizers that sensitize the begins at or shortly be ore puberty, which leads to over-
pilosebaceous glands to an appropriate laser or light source. production o sebum in the ollicular unit. T is overpro-
Why care about treating acne vulgaris, especially in a duction leads to the ormation o what is typically called
procedural manner, when there are many other proce- the ollicular “plug,” one o the earliest events in the orma-
dures that make patients look and eel younger and more tion o the acne vulgaris skin lesion.
beauti ul? Why care about a skin condition that occurs In addition to genetics and hormonal inf uences, envi-
predominantly in children and in young adults? And why ronmental concerns, on occasion, also play a role in the
care about a skin disease that, more and more, is being development o acne vulgaris.3 We all have had patients
cared or by our primary care colleagues so we can con- who note that stress is causing their breakouts or that eat-
centrate on the more glamorous cosmetic concerns? ing this ood or drinking that so t drink causes their acne
Acne vulgaris a ects almost all individuals at some to f are. Although there is much more study to be done,
point in their li etime, with reports noting that as many most dermatologists believe that the environment can
as 94% o all emales in the United States will su er rom inf uence the course o acne, but it is not a direct reason
acne vulgaris.2 T e percentage in men is slightly lower or our patients to develop it, especially without the other
than that in women but is still signi cant. It is important actors already in place. Readers are encouraged to seek
or dermatologists to be at the ore ront o new therapies out other re erences to learn more about how hormones
and modalities to enhance those therapeutic options. As and environmental actors can inf uence the course o acne
a point o re erence, it can be noted that 20 years ago, the vulgaris, which will not be covered urther in this chapter.
dermatologist was the usual rst point o contact care or Acne vulgaris is a disorder o the pilosebaceous unit.
those su ering with acne vulgaris. Over the past 20 years, Detailed descriptions are available elsewhere on the cur-
many acne patients have rst been treated by non-derma- rent understanding o this process. When the produc-
tologists, whether the pediatrician or amily physician or tion o sebum increases, this causes the ollicular unit to
the younger group o patients, or by a host o other physi- become dilated, which is then ollowed by obstruction o
cians in the older patient population, including the amily the sebaceous glands, resulting in the rst phase o the
physician, the internist, and the gynecologist, among oth- acne lesion, known as the comedone. T is non-inf amma-
ers. More recently, a variety o over-the-counter skin care tory acne lesion takes the orm o the open comedone, or
and acne products have emerged as “wonder” products, whitehead, or the closed comedone, the blackhead. With
which have become rst-line therapy or patients who obstruction o the sebaceous gland, there is proli era-
attempt to avoid a medical visit to their dermatologist. tion and production o bacterial species within the gland
Dermatologists need to embrace the care o those su - itsel . T e most common bacterium in the sebaceous
ering rom and with acne vulgaris. We need to be at the gland associated with acne vulgaris is known as Propiono-
ore ront o treating and counseling those with this skin bacterium acnes. With the proli eration o P. acnes comes
concern and realize that the number o patients who will an associated inf ammatory response within the gland,
be helped by our skills is remarkable. With many o the resulting in acne lesions, commonly known as papules,
newer therapeutic modalities now available, including the pustules, and cysts. It is during this crucial phase that
4 many cytokines and inf ammatory mediators, which are
the means by which some o our new therapeutic modali-
many dose orms and extended release ormulations have
become available. As dermatologists, we must know the
ties bene t our patients, come into play.4 di erences between the various brand and generic equiva-
lents and determine whether the generic ormulations are
appropriate or whether should we utilize brand name phar-
MEd Ic a l t h Er a Py maceuticals. Dermatologists also sometimes use systemic
sul onamides, which are use ul in cases when other sys-
f o r a c n E Vu l g a r Is temic agents are not e ective. Oral contraceptives and anti-
androgenic medications are also used by many in treating
Despite the hype or lasers and light sources in dermatol- what is sometimes described as hormonal acne in the young
ogy, the gold standard or the treatment o acne vulgaris adult emale patient. Again, the reader is encouraged to
remains medical therapy. T ere are a variety o medical learn more about these medicines, their clinical indications,
therapies that have proven worthwhile in the treatment and their supporting evidence, outside o this chapter.5,6
o acne. Guidelines o care regarding how these medicines T e treatment o severe inf ammatory acne vulgaris
should be used assure the most appropriate outcomes or changed dramatically with the discovery and availability o
S
e
our patients su ering rom non-inf ammatory acne vul- oral isotretinoin. Isotretinoin is indicated or the treatment
c
t
i
garis and inf ammatory acne vulgaris.5,6 T e aim o this sec- o recalcitrant cystic acne vulgaris. Many patients and or
o
n
tion is to give an overview o the most common therapeutic that matter, many dermatologists, have ound this drug to be
4
modalities. Lasers and light therapies and photodynamic a wonder drug in the treatment o acne vulgaris and again,
:
therapy (PD ) also have their places and their roles in the
:
dermatologists are ortunate to have this drug at the ready
treatment armamentarium and will be explained shortly. when needed. One must remember that isotretinoin use is
A
e
opical therapy has been a mainstay or the treatment o currently under the auspices o the iPledge program and that
s
t
h
acne vulgaris or many years and numerous therapies exist, all patients and physicians prescribing isotretinoin utilize
e
t
which, when used appropriately, can truly be o bene t to this program to assure that patients are being properly mon-
i
c
a
our patients. Most o the current guidelines or the treat- itored throughout their course o treatment. Most patients
n
d
ment o acne recommend that all patients utilize a topical require isotretinoin in doses o 1 mg/kg/day and continue
L
retinoid in their regimens. opical retinoids are known to
a
therapy or 20 weeks, with monitoring done every 4 weeks.
s
e
reverse ollicular keratinization and improve comedones. Isotretinoin may be teratogenic in women who become
r
P
T ey come as stand-alone products or as combination pregnant while on the drug and has an associated poten-
r
o
products, either with the addition o benzoyl peroxide or tial or psychiatric e ects in a small percentage o patients,
c
e
a topical antibiotic. All o these newer combination prod-
d
necessitating the need or strict and accurate monitoring.3
u
ucts have shown superiority compared to a topical retinoid
r
T e use o systemic medicines or those su ering rom
e
s
alone in clinical trials, supporting their increased use in inf ammatory acne is crucial when needed. Un ortunately,
dermatology. opical antibiotics and benzoyl peroxides still several recent developments and reports have made the
have their place in the treatment o acne vulgaris as well, use o these medications to be considered somewhat sus-
although benzoyl peroxides have recently gone over the pect. T is includes reports o systemic antibiotic resis-
counter and are not being promoted as they once were. A tance to the P. acnes lesions, with some noting antibiotic
topical dapsone has also been recently introduced. Dapsone resistance as high as 60% to current medical regimens.7,8
is known as an oral anti-inf ammatory agent but this has Other interesting reports that are important to mention
been shown to be the case topically as well. Clinical trials with include one linking an increase in breast cancer to long-
topical dapsone have shown that emale acne vulgaris term antibiotic use9 and another linking long-term anti-
patients actually respond better than their male counter- biotic use to an increased risk o pulmonary in ections in
parts, so this therapy has gained widespread use among some individuals.10 T e restrictions and mandates o the
dermatologists or treating emale acne vulgaris su erers.3 iPledge system, designed to reduce the risks rom the use
One o the more interesting acets o topical therapy o isotretinoin, are also associated with more paperwork
recently has been the vehicle in which newer medicines than some o ces are willing to accept.
and combination medicines are being placed. We are Once again, medical therapy remains the gold standard
nding that the vehicles elicit their own e ects in many or the treatment o both non-inf ammatory and inf am-
instances; these enhanced vehicles may themselves play a matory acne vulgaris. Dermatologists are ortunate to have
uture role in topical therapy. Several new research initia- medicines that are tried and true or their patients, as well
tives are looking at some o these more unique vehicles to as newer combination compounds that have synergistic
understand their uture potential in dermatology. e ects to combat acne vulgaris. Pharmaceutical companies
Systemic therapy also is commonly used, especially when are also working diligently on new ormulations and com-
we have patients presenting with inf ammatory acne or pounds that will aid our patients even more in the uture.
mixed non-inf ammatory and inf ammatory acne lesions. However, not every patient responds to the thera-
Once again, guidelines o care exist, which the reader is pies just described. Some are interested in other thera-
encouraged to read to urther enhance their understand- peutic modalities. Others may not want to endure the
ing o the rationale or proper use o these therapies.5,6 Sys- mandatory waiting period that can exist or the iPledge
temic agents utilized early on to treat acne vulgaris were program—especially those who are not on a contracep-
oral erythromycin and tetracycline. T ese medicines are tive medicine. One o the options that has become more
rarely used today and have been replaced by oral minocy- and more popular in the past several years is the use o
cline and doxycycline, the most commonly prescribed sys- lasers and light sources in the treatment o acne. T e
538 temic agents used or acne vulgaris. In order to di erentiate remainder o this chapter will deal with the use o lasers,
themselves rom one another and rom generic equivalents, light therapy, and PD in the treatment o acne vulgaris.
l a s Er s a n d l Ig h t s o u r c Es and red light sources, green light lasers, yellow light lasers,
and the intense pulsed light source, commonly known as
4
f o r t h E t r Ea t MEn t o f the IPL. T ese lasers and light sources work through what
is known as an endogenous PD response.
In f l a MMa t o r y a c n E Vu l g a r Is Propionobacterium acnes demonstrates a PD response
that naturally occurs in the skin. During its growth cycle, P.
When using lasers and light therapy or the treatment o acnes produces porphyrins, predominantly protoporphy-
inf ammatory acne, we need to consider the varied mecha- rin IX (PpIX) and coproporphyrin III. T ese porphyrins
nisms o action used by these medical devices to make have an absorption spectrum o light that is demonstrated
lesions improve. One mechanism o action is by selective in Figure 46-1 or PpIX. Coproporphyrin III has a similar
destruction o the P. acnes bacterium itsel . T is process absorption spectrum. From the graph, we can see that the
occurs rom light that penetrates into the sebaceous gland major peak or PpIX is in the blue range o light at 415 nm,
and causes selective destruction o bacteria and their asso-

C
and this peak is commonly re erred to as the Soret band o

h
ciated gland. T e second mechanism that has been com-

a
absorption. A second major absorption peak is also seen at

p
monly used in the past is destruction o the sebaceous

t
about 630 nm, corresponding to red light. Both blue and

e
gland through a thermal reaction using light or laser energy

r
red light sources have been used routinely over the past

4
6
that targets water as a chromophore. A third mechanism o 10 years to treat inf ammatory acne vulgaris and will be
action is partial destruction o the sebaceous gland, which

:
reviewed later. One should appreciate, however, rom the

:
is the mechanism most commonly described with PD , as absorption spectrum, that other, smaller peaks also exist,

P
will be discussed later.4

h
explaining why other lasers and light sources can be use ul

o
t
or the treatment o acne vulgaris. T ese include, as noted

o
t
h
earlier, the green light lasers at 532 nm, the yellow light
l a s Er s a n d l Ig h t

e
r
lasers at 585 to 595 nm, and the IPL, which emits energies

a
p
s o u r c Es t h a t d Es t r o y via f ashlamps and a series o “cut-o ” lters in the range

y
a
typically between 400 to 1200 nm. Based on the lters

n
Pr o Pio n o ba c t er iu m a c n es

d
being used, light below the “cut-o ” lter will be blocked.3

P
h
Blue light therapy or the treatment o inf ammatory

o
t
Several light sources and lasers may be used or the selec- acne vulgaris has been reviewed extensively in the medi-

o
d
tive destruction o P. acnes. T ese include both the blue cal literature.11– 17 T ere have been three major blue light

y
n
a
m
i
c
T
h
e
r
a
p
y
f
o
r
t
h
e
T
r
e
a
t
m
e
n
t
o
f
A
c
n
e
V
u
l
g
a
r
i
s
Figure 46-1 Absorption spectrum of PpIX. (Used with permission from Michael H. Gold, M.D.) 539
4 Gold reported on 40 individuals treated with the
ClearLight system or mild-to-moderate in amma-
tory acne vulgaris.13 T e patients in this clinical trial also
received blue light therapy twice weekly or 4 weeks and
were ollowed-up 1 and 3 months a ter their nal treat-
ment. A 43% reduction in acne lesions was noted in this
trial. Adverse events, similar to the previous work, were
not seen and lesions continued to improve in many patients
during the ollow-up period. When comparing the clinical
trials o both Gold and Shalita, Gold’s data included both
“responders” and “nonresponders,” something that was
not done in Shalita’s clinical trial. It has been noted that
upwards o 20% o individuals treated with the blue light
system are nonresponders. Adding them into the total per-
centage o clearance would certainly have brought the two
S
e
clinical trials closer together in terms o the percentage
c
t
i
clearance. From these clinical trials, the sa ety and e cacy
o
n
o this blue light system was con rmed and it became one
4
o the most popular light-based acne treatment systems in
:
:
the United States in the 2000s.
For a variety o reasons, the ClearLight, high-intensity,
A
e
blue light system is currently not available commercially,
s
t
h
and its replacement device, known commercially as the
e
t
IClear, is also no longer available. Many still utilize these
i
c
a
Figure 46-2 ClearLight acne clearing device. (Used with light sources in their clinical practices, and they have made
n
d
permission from Michael H. Gold, M.D.) a major dif erence or many patients suf ering rom in am-
L
matory acne who either had not been adequately controlled
a
s
e
with medical therapy or who were looking or a aster path
r
P
systems available or the treatment o in ammatory acne to lesion clearance. Clinical examples o the use o the
r
o
in the United States. T e reader should be aware that other ClearLight system are shown in Figures 46-3 and 46-4.
c
e
blue light systems have since come and gone throughout
d
Several other clinical trials regarding blue light are
u
the years and although they may be comparable to what is
r
worth reviewing or the sake o completeness, and several
e
s
described later, each system is unique and should be stud- other blue light sources are also worthy o mention or the
ied on its own. treatment o in ammatory acne vulgaris. Papageorgiou et
T e rst FDA-approved, blue light source was a high- al.14 used a mixed blue and red light system (415 nm and
intensity, narrow-band blue light source with an absorption 660 nm) in one patient group, a blue light in another treat-
peak at 417 nm. Commercially this machine was known ment group, and white light in a third group. T ey were
as the ClearLight Acne Photoclearing System (CureLight, able to demonstrate that the combination o blue and red
Yokneam, Israel) (Fig. 46-2). Its FDA clearance was or the light decreased in ammatory acne lesions by 76% com-
treatment o mild-to-moderate in ammatory acne vul- pared to 58% clearance in the blue light treatment group,
garis, and its use, sa ety, and e cacy are well documented and both were more ef ective than treatment with white
in the literature.12,13 T e recommended use or this device light alone, which showed only a 25% clearance. Mef ert et
was to treat patients two times per week or up to 4 weeks al.15 used a high-energy, broad-spectrum, blue light source
or appropriate in ammatory acne vulgaris lesion control. that combined both blue light and ultraviolet A (UVA)
Many patients ound relie alone, or in combination with light, and noted marked improvement in patients with
medical therapy, with this system. In the “real” world, it pustular acne a ter 10 treatments.
was, at times, di cult or patients to come into the o ce T e second blue light source available in the United
or this treatment on a twice per week basis. For this reason, States or the treatment o acne vulgaris is still currently
many patients would utilize this device only once per week, available and is known commercially as the BLU-U (DUSA
and would routinely receive blue light therapy or upwards Pharmaceuticals, Wilmington, MA). T is is a low-inten-
o 15 to 20 minutes per session. sity, blue light source that has also shown its sa ety and
T e literature supporting the development o the e cacy in treating individuals with in ammatory acne.
ClearLight is as ollows. Kawada et al.,11 in 2002, reported Goldman et al.16 rst reported on its ef ectiveness in acne
that by using a blue light source or in ammatory acne vul- vulgaris in a series o 12 patients. In their study, they were
garis twice weekly or 5 weeks, lesions could be reduced, able to document a 40% reduction in papular lesions, a
on average, by 64%. Shalita et al.,12 in a multicenter clinical 65% reduction in pustular lesions, and a 62% reduction in
trial or the ClearLight system, reported an 80% signi cant comedonal acne. O note, this was one o the rst major
improvement rate in treating 35 individuals with mild-to- publications that noted an improvement not only in the
moderate in ammatory acne twice weekly or 4 weeks. in ammatory component o acne vulgaris with blue light
O note was that ollowing therapy, urther acne improve- but also in the non-in ammatory lesions. T e improve-
ment was noted in many o the patients who entered into ments described were seen as early as 2 weeks o therapy,
this study. Adverse events were not seen and all skin types similar to what had been reported with the high-intensity
540 were success ully treated. blue light systems. Gold et al.17 ollowed up on the previous
 4

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h
a
p
t
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r
4
6
:
:
Figure 46-3 Patient before treatment with the ClearLight. Figure 46-4 Patient after treatment with the ClearLight.

P
(Used with permission from Michael H. Gold, M.D.) (Used with permission from Michael H. Gold, M.D.)

h
o
t
o
t
or this claim.18 Clinical examples utilizing the BLU-U or

h
report and did a comparison clinical trial o topical 1%

e
r
clindamycin solution versus blue light therapy in patients inf ammatory acne vulgaris are shown in Figures 46-6 and

a
p
with mild to moderate inf ammatory acne vulgaris. T ey 46-7. Patients utilize this system in a ashion similar to that

y
a
demonstrated that blue light therapy was more e ective o the high-intensity, blue light system—once or two times

n
d
than topical clindamycin in reducing inf ammatory acne per week or 4 to 6 weeks is the norm, with patients receiv-

P
h
vulgaris lesions. T e BLU-U device available commercially ing 15 to 20 minutes o blue light therapy per treatment.

o
is shown in Figure 46-5. A recent clinical evaluation look- A third blue light source developed or the treatment

t
o
d
ing at blue light therapy with the BLU-U and its e ect on on inf ammatory acne vulgaris is called the OmniLux Blue

y
n
acne vulgaris with or without a topical photosensitizer Phototherapeutics System (OmniLux, Manchester, UK).

a
m
demonstrated that blue light alone was statistically sig- Clinical studies have also shown its e ectiveness in treating

i
c
ni cant in improving severe inf ammatory acne vulgaris, inf ammatory acne vulgaris. It used LED blue light arrays

T
h
leading to a supplemental FDA ling, which was granted with a peak irradiance o 410 to 420 nm and has shown

e
r
lesion reductions o up to 74% in clinical trials.19

a
p
y
It should be noted that there are a variety o home-use

f
o
blue light sources available or patients. T e home-use blue

r
t
light devices will not be discussed here; there are other

h
e
reviews that are readily available. Many patients nd these

T
r
devices use ul and are using them on a regular basis.20

e
a
t
Clinical studies with red light alone are not widely avail-

m
e
able in the medical literature,21,22 but a variety o red light

n
t
sources are also available commercially, which can be

o
f
utilized or the treatment o inf ammatory acne vulgaris.

A
c
T e use o red light devices, however, is quite widespread,

n
e
especially in association with the methyl orm o ami-

V
u
nolevulinic acid (ALA), which will be discussed later in this

l
g
chapter. Zane et al.21 per ormed a split- ace randomized

a
r
i
red light trial in 28 patients on a home-use red light source

s
device. Statistical improvement was noted with acne vul-
garis lesions improving more on the treated side versus
the non-treated side. Red light, because o its longer wave-
length as compared to blue light, penetrates more deeply
than blue light, including within the ollicular unit, and
thus may have bene ts beyond those o blue light alone.
Blue light has been shown, through clinical studies, to
be virtually painless or patients receiving treatment; red
light, however, can be pain ul, which may limit its overall
use or patients with acne vulgaris. Greater study o this
phenomenon needs to be per ormed.23
Green and yellow light lasers also have been reported
to improve inf ammatory acne vulgaris.24– 26 Bowes et al.24
Figure 46-5 BLU-U device. (Used with permission from treated 11 patients with mild-to-moderate inf ammatory
DUSA Pharmaceuticals, Inc.) acne in a split- ace, prospective, randomized clinical trial 541
4

Figure 46-6 Patient before treatment with the BLU-U for Figure 46-7 Patient after treatment with the BLU-U for
acne. (Used with permission from Michael H. Gold, M.D.) acne. (Used with permission from Michael H. Gold, M.D.)
S
e
c
t
i
with a 532 nm laser system. Four treatments were given, IPL device used light and heat energy, known as “LHE tech-
o
n
at monthly intervals, and there was a 1 month ollow-up nology,” to trigger destruction o the P. acnes bacteria. Elman
4
visit. Lesion counts decreased by 35.9% on the treated side et al.27 treated 19 patients with twice weekly therapy or
:
:
versus 11.8% on the controlled, non-treated side. Sebum 4 weeks and demonstrated that 85% o the individuals had a
measurements were also made and were shown to have greater than 50%improvement in their in ammatory acne. In
A
e
decreased by 28.1% on the treated side versus 6.4% on the another study, Dierickx et al. reported on the use o the LuxV
s
t
h
control side. K P laser systems are used regularly in many handpiece (Palomar Medical echnologies, Burlington, MA)
e
t
clinics or the treatment o telangiectasias, but can also be IPL system known at the time as the EsteLux. Newer models
i
c
a
used or the treatment o in ammatory acne vulgaris. have included the MediLux and the StarLux systems. Four-
n
d
Yellow light pulsed dye lasers (PDLs) can also e ectively teen patients with mild-to-moderate in ammatory acne vul-
L
treat in ammatory acne vulgaris. PDLs were developed to garis each received f ve treatments, given every 2 to 4 weeks.
a
s
e
treat vascular lesions, predominantly port-wine stains and wo to three passes were per ormed in each treatment with
r
P
hemangiomas. Since their introduction into the market, a an average uence o 10 J/cm 2. Six months a ter the last treat-
r
o
variety o cutaneous disorders have been shown to be treat- ment, 73%improvement was noted in the in ammatory acne
c
e
able with PDLs, including hypertrophic scars, keloids, and lesions and 72% in the non-in ammatory lesions.
d
u
recalcitrant verrucous lesions. Several PDLs are currently O note is the recent development o IPL systems with
r
e
s
available on the US market and the reader can f nd out an associated vacuum apparatus that are now popular in
more about them in other sections o this textbook. Seaton
et al.25 evaluated 41 individuals with in ammatory acne
treated with a low- uence PDL. In this double-blind, ran-
domized clinical trial 31 patients received PDL treatments
and 10 patients received sham treatments. One treatment
was given to all patients. Acne severity decreased rom
3.8 to 1.9 in the PDL group versus 3.6 to 3.5 in the sham
treatment group (using a modif ed Leeds grading system).
T e second clinical trial, by Orringer et al.,26 did not con-
f rm these results and, in act, ound no improvement with
this particular low- uence device. As noted, there are
several PDLs available. When utilized with appropriate
settings, these devices can be used to treat in ammatory
acne. More research, however, is required be ore def nitive
answers can be given with respect to the e ectiveness o
these devices in treating in ammatory acne vulgaris.
IPLs also have been studied or the treatment o acne.27,28
T ere are a myriad o systems available and the reader must
decide which system works best or them and whether to
use these devices or the treatment o in ammatory acne.
T ese devices were f rst developed or the treatment o leg
veins, then hair removal, and then pigment. In 2000, IPL
became known as the therapy o choice or photorejuvena-
tion.29 In photorejuvenation, IPLs can e ectively treat the
vascular components and pigment associated with aging
and have an e ect on the collagen and elastic tissues that
improves the texture and tone o the skin. T e f rst clini-
cal use o IPL in the treatment o in ammatory acne vul-
garis used a low-powered device known as the Clear ouch Figure 46-8 Isolaz®. (Reproduced with permission of Solta
542 (Radiancy Inc., Orangeburg, NY) or the SkinStation. T is Medical, Inc.; courtesy of Solta Medical Aesthetic Center.)
 treatment. T e median time or improvement was 5 days,
with some patients noting improvement in as little as 2
4
days. Lesion counts or papules decreased 50% to 60%, or
pustules 70% to 80%, and or comedones 40% to 50%. T ere
were no adverse events noted. Shamban et al.31 carried out
a retrospective evaluation o 56 individuals and showed a
50% reduction a ter the rst treatment, which increased to
90% a ter our treatments. In a study published in 2008,32
Gold et al. treated 11 individuals with the Isolaz at 3 week
intervals or our treatments. T e patients were ollowed or
3 months a ter their last treatment. T e study ound that a
78% reduction (p = 0.0137) was achieved in inf ammatory

C
acne lesions and a 57.8% reduction (p = 0.0383) in non-

h
a
inf ammatory acne lesions. Pain was minimal and was most

p
t
Figure 46-9 Acleara. (Used with permission of likely associated with the vacuum itsel . Side e ects were

e
r
Cynosure, Inc.) not seen. Patients treated with the Isolaz are shown in Fig-

4
6
ures 46-11 and 46-12. A second-generation device, known

:
as the Acleara, is also now available (Palomar Medical); this

:
treating both inf ammatory and non-inf ammatory acne device has a cooling system built or added sa ety.

P
h
lesions, or which they now have FDA clearance. wo

o
t
such devices are currently on the market. T e rst device,

o
l a s Er s t h a t d Es t r o y

t
shown in Figure 46-8, is known as the Isolaz (Solta Medical,

h
e
Hayward, CA) and the second device is called the Acleara

r
s Eba c Eo u s g l a n d s

a
p
(Palomar Medical, Boston, MA), shown in Figure 46-9.

y
a
Several clinical trials have shown their e ectiveness in the

n
T e second group o lasers that has been used in treating

d
treatment o acne.30– 32 T eir mechanism is quite interest-

P
ing—by using the vacuum, one can essentially clean out acne vulgaris consists o lasers that destroy the sebaceous

h
o
the acne pore and its accompanying sebum. T e light then glands themselves. T ese include the near-in rared lasers

t
o
and possibly the radio requency (RF) devices. Although all

d
selectively destroys the P. acnes in the sebaceous gland,

y
seem to have been e ective in the treatment o acne vul-

n
thus generating both inf ammatory and non-inf ammatory

a
garis, it is not clear how many o these devices are still in

m
acne improvement. T is mechanism o action is shown

i
use or the treatment o acne. Pain with treatment was sig-

c
schematically in Figure 46-10.

T
ni cant and or that reason alone, many clinicians stopped

h
In the rst report on the use o this device, Munavalli

e
using these therapies. However, the literature does sup-

r
and Weiss reported their experience in 10 patients treated

a
p
with the Isolaz. Patients received our treatments at one- port their e ectiveness.33– 39

y
f
T e near-in rared lasers used to treat acne vulgaris include

o
week intervals and were given two to our passes with the

r
the 1064 nm lasers, the 1319 nm Sciton Pro le (Sciton,

t
device per session. reatment sessions lasted no more than

h
Palo Alto, CA), the 1320 nm Cool ouch C 3 (Cool ouch

e
15 minutes and no topical anesthesia was given. T e

T
Inc., Roseville, CA), the 1450 nm SmoothBeam (Candela,

r
patients were ollowed or 1 month a ter their last

e
a
t
m
e
n
P hotopne uma tic te chnology:

t
The Me cha nis m

o
f
A
c
n
e
V
u
l
g
a
r
i
s
• Ha ndpie ce is pla ce d on • Ta rge ts e leva te d clos e r • Light a pplie d to • Ta rge ts a re s a fe ly a nd
tre a tme nt a re a to s kin’s s urfa ce tre a tme nt a re a pa inle s s ly de s troye d

• Blood conce ntra tion

re duce d

• Me la nin conce ntra tion

re duce d

Figure 46-10 Mechanism of action of PPX. (Used with permission from Michael H. Gold, M.D.) 543
4

Figure 46-12 Patient after treatment with the Isolaz.

S
Figure 46-11 Patient before treatment with the Isolaz.
e
(Used with permission from Michael H. Gold, M.D.)
c
(Used with permission from Michael H. Gold, M.D.)
t
i
o
n
4
Wayland, MA), and the 1540 nm erbium glass Aramis inf ammatory acne. Indocyanine green is not readily avail-
:
:
(WaveLight-Quantel, Clermont-Ferrant, France). able so this photosensitizer is not commonly used in clini-
A
O all the laser systems noted earlier, the Smooth- cal practice. T e 1540 nm laser has been used by Kassir et
e
s
Beam has the most literature supporting its e ectiveness al.38 in treating patients with inf ammatory acne vulgaris.
t
h
in destroying sebaceous glands and or the treatment o T ey evaluated 20 patients, treating with this device every
e
t
i
inf ammatory acne. Paithankar et al.33 reported their expe- 2 weeks or our sessions, and noted a 70% improvement
c
a
rience with this device and its associated patented dynamic over 3 months. No adverse e ects were reported. Ruiz-
n
d
cooling device (Fig. 46-13) in treating 27 individuals with Esparza et al.39 reported an observation using a monopolar
L
a
inf ammatory acne vulgaris on the back. Four treatments RF device in the treatment o inf ammatory acne vulgaris.
s
e
were given at 3 week intervals and the patients were ol- In 22 patients, excellent responses were noted in 82%, mod-
r
P
lowed or 6 months a ter their last treatment. A 98% reduc- erate responses in 9%, and no response in 9%. Further work
r
o
c
tion in inf ammatory acne lesions was demonstrated a ter is needed to see what urther potential RF devices may have
e
d
the our treatment sessions and at 6 months, all but one o or the treatment o inf ammatory acne.
u
r
the patients demonstrated 100% lesion clearance. Friedman
e
s
et al.34 evaluated 19 patients with acial acne vulgaris and
noted a 37% reduction in acne lesions a ter one treatment, a Ph o t o d yn a MIc t h Er a Py In t h E
58% reduction a ter two treatments, and an 83% reduction
a ter three treatments. ransient erythema and edema were
t r Ea t MEn t o f a c n E Vu l g a r Is
seen; topical anesthesia was needed to reduce discom ort
rom the therapy. Newer protocols and a new handpiece PD with either 5-aminolevulinic acid (ALA) or methyl
were introduced to reduce the pain component,35 but most aminolevulinate (MAL) applied topically has shown e -
clinics have stopped treating patients with this device at the cacy in the treatment o acne vulgaris in small, investigator-
time o this writing. initiated clinical trials. Although neither photosensitizing
Other clinical studies have evaluated the use o photo- agent is FDA-cleared or the treatment o acne by PD ,
sensitizers and laser systems in treating inf ammatory acne both—ALA as Levulan®Kerastick®(DUSA Pharmaceuticals,
vulgaris. uchin et al.36 and Lloyd et al.37 used indocya- Wilmington, MA) and MAL cream as Metvix™(PhotoCure
nine green and a diode laser to destroy sebaceous glands. ASA, Norway, Galderma, Lausanne, Switzerland)—are
Both o these studies showed a positive e ect in treating cleared by the US FDA or the photodynamic treatment o
nonhyperkeratotic actinic keratoses (AK) o the ace and
scalp. At the time o this writing, MAL is no longer avail-
able in the US market, although it is used in many coun-
tries or the treatment o non-melanoma skin cancers,
having shown sa ety and e cacy or this indication.40,41
Indocyanine green and methylene blue are two other non-
commercially available photosensitizers that have been
studied or acne treatment with PD but are not commer-
cially available at this time. T is section will ocus on ALA
and MAL or the treatment o acne vulgaris.
ALA is FDA-approved or the treatment o nonhyper-
keratotic AKs o the ace and scalp utilizing a blue light
source or 16 minutes and 40 seconds. ALA, once in the
skin, acts as a prodrug, is converted to its active metabo-
lite, PpIX, and accumulates in speci c cells within the
Figure 46-13 Levulan Kerastick. (Used with permission skin, mainly actinically damaged cells, nonmelanoma skin
544 from DUSA Pharmaceuticals, Inc.) cancer cells, and the pilosebaceous unit itsel . T e only
 his experience treating inf ammatory acne vulgaris and
sebaceous gland hyperplasia. He utilized a 1 hour ALA
4
incubation with either an IPL source or blue light or drug
activation. T e report noted “relative” clearing o the acne
vulgaris lesions a ter two to our once weekly ALA-PD
treatments. Patients noted the therapy to be pain ree and
no PD e ects were seen.
Gold 13 then reported his experience using a 30 to
60 minute ALA drug incubation and a high-intensity blue
light source to evaluate moderate to severe inf ammatory
acne vulgaris lesions in 10 individuals. T e study used
once-weekly ALA-blue light treatments and patients were

C
evaluated at 1 and 3 months ollowing their nal therapies.

h
a
Response rates o 60% were ound. T e treatments were

p
t
well tolerated and no adverse events were observed in any

e
r
o the treated patients.

4
6
Figure 46-14 Galderma—Metvix Package (Used with per- Goldman et al.45 then treated 22 patients with moderate-

:
mission from Galderma.) to-severe inf ammatory acne vulgaris using a blue light

:
with and without ALA. T ey ound a greater response

P
h
rate in those treated with ALA-PD and blue light in

o
t
product available in the United States is known as the comparison to those treated with blue light alone. No

o
t
Levulan Kerastick (DUSA Pharmaceuticals, Wilmington,

h
adverse events were seen in this patient population. aub46

e
r
MA), shown in Figure 46-13. MAL, available in Europe reported her experience with short-contact, ull- ace ther-

a
p
(Galderma), is shown in Figure 46-14. apy utilizing blue light sources (ClearLight or BLU-U) or

y
a
Hongcharu et al.42 reported the rst clinical trial utilizing IPL with RF (Aurora®, Syneron, Yokneam, Israel) in 18

n
d
ALA-PD in the treatment o inf ammatory acne vulgaris. individuals. T e patients received two to our treatments

P
T eir group evaluated 22 patients with inf ammatory acne

h
over a 4 to 8 week time period. Improvement was noted 4

o
treated with ALA and a 550 to 570 nm broadband light

t
months ollowing the last treatment; this included 11 o

o
d
source. T e ALA used in this clinical trial was incubated 18 patients showing 50% improvement and ve patients

y
n
on the skin or 3 hours prior to light exposure. Signi cant showing greater than 75% improvement in their lesions.

a
m
clearance o the acne lesions was evident a ter our weekly Gold et al.47 reported their experience with short-con-

i
c
treatments. T e patients experienced downtime prior to tact, ull- ace therapy utilizing ALA and an IPL device

T
h
healing, known commonly today as the “PD e ect,” as has (Harmony, Alma Lasers, Bu alo Grove, IL). Patients

e
r
been previously described by this author. T e PD e ect

a
received once weekly ALA-IPL treatments or up to our

p
in this trial consisted o an acnei orm olliculitis, post-

y
treatments and were ollowed or up to 3 months a ter

f
o
inf ammatory hyperpigmentation, super cial peeling, and their nal treatment. A 72% reduction in acne lesions was

r
t
crusting, which lasted upwards o a week post-therapy. T e seen. No PD e ects were observed.

h
e
mechanism o action or the improvement seen was docu- T ere have been at least two split- ace IPL treatments

T
r
e
mented through skin biopsies and immunof uorescence with ALA-PD reported in the literature or the treatment

a
t
staining to be via destruction o the P. acnes bacteria as well o inf ammatory acne vulgaris. Santos et al.48 reported their

m
e
as partial destruction o the sebaceous glands. experience with ALA-PD in moderate-to-severe inf am-

n
t
Many others have reported their clinical experiences with matory acne utilizing ALA-PD and the Quantum IPL

o
f
ALA-PD . Itoh et al.43 rst utilized a 635 nm pulsed excimer device (Lumenis, Santa Clara, CA). T irteen patients were

A
c
dye laser as well as a 4 hour ALA drug incubation in a single treated with short-contact, ull- ace therapy. In this split-

n
e
patient with intractable acne vulgaris on the ace. Follow- ace analysis, 10 o 13 patients showed a marked response

V
u
ing the therapy, the treated area remained disease ree or 8 on the ALA-IPL treated side versus the IPL side alone

l
g
months. T e authors did report a PD e ect, mani ested by a ter a single treatment. A second split- ace clinical trial,

a
r
i
erythema, edema, and crusting immediately a ter the ther- per ormed by Rojanamatin et al.49 con rmed the results

s
apy. In a subsequent study, Itoh et al.44 reported experiences previously described. T eir group evaluated 14 patients in
with 13 patients utilizing ALA-PD and a 600 to 700 nm a split- ace ashion with the same kind o IPL described
halogen light source. All o the patients in this trial showed by Santos et al.48 T ey ound that ALA-IPL treatment was
improvement in their acne and they were able to demon- superior to treatment with the IPL alone.
strate that the ormation o new lesions was reduced at 1, 3, Lasers have also been reported to be e ective in treating
and 7 months ollowing therapy. A PD e ect was seen and inf ammatory acne vulgaris with ALA-PD . Alexiades-
some recurrence was noted during the ollowing 6 months. Armenakas50 reported her experience with the long pulsed
Further investigations utilizing ALA or the treatment dye (PDL) laser utilizing ALA in patients with inf amma-
o inf ammatory acne vulgaris soon appeared in the medi- tory acne. She utilized a drug incubation time period that
cal literature. As was the case with AKs and ALA-PD , averaged 45 minutes and reported that with an average
these investigators utilized a short-contact, ull- ace thera- o three PDL sessions, she cleared all o the 14 patients
peutic approach in their clinical trials, an o -label use o treated. Miller and Van Camp 51 reported on the success-
the approved FDA indications. Goldman 16 was the rst ul use o ALA and the K P laser in patients with inf am-
o these investigators to look at short-contact, ull- ace matory acne vulgaris. Examples o patients treated with
ALA-PD therapy or acne vulgaris when he reported ALA-PD are shown in Figures 46-15 and 46-16. 545
4 moderate-to-severe acne vulgaris in a randomized, con-
trolled clinical trial utilizing MAL-PD . Each o the patients
in this trial was given two treatments 2 weeks apart utiliz-
ing MAL and a red light source. welve weeks a ter the last
treatment they ound a 68% reduction in inf ammatory
acne lesion counts, with no changes noted in the control
group. All patients experienced a “PD e ect” consisting o
severe erythema, pustular eruptions, and ex oliation o the
skin, which lasted up to a week a ter therapy. Moderate to
severe pain was also noted during the treatments. A second
clinical trial by Hor elt et al.53 evaluated 30 patients with
moderate-to-severe inf ammatory acne lesions using MAL
Figure 46-15 Patient before treatment with ALA-PDT. and a red light source. T is was a split- ace analysis, with a
(Used with permission from Michael H. Gold, M.D.) 3 hour drug incubation under occlusion, exposure to red
light, and two treatments given at 2 week intervals. welve
S
e
weeks a ter the last treatment, there was a statistical reduc-
c
A large multicenter controlled FDA clinical trial in the
t
i
tion in acne lesions o 54% versus 20% in the control group.
o
United States evaluated the use o ALA in the treatment o
n
Pain and a “PD e ect” were once again seen. Further clin-
4
moderate-to-severe inf ammatory acne. T e trial studied
ical trials are underway in Europe to urther evaluate the
the e ectiveness o blue light versus blue light plus ALA
:
:
role o the methyl ester o ALA in the treatment o mod-
to determine the e ect o adding ALA to the already FDA-
erate-to-severe inf ammatory acne vulgaris and whether
A
approved blue light source. Un ortunately, the study did
e
varying protocols (such as drug incubation times) can lead
s
not show clinical signi cance18 and thus the US acne vul-
t
h
to more acceptable results, especially in relation to PD
e
garis program or ALA-PD was halted.
t
e ects. It seems that with shorter contact, non-occlusion
i
c
Many in the United States still eel that the use o ALA-
a
MAL to acne vulgaris lesions and shorter light doses with
n
PD is warranted or moderate-to-severe acne vulgaris,
d
the red light source, a more tolerable approach or patients
despite the ailings o the FDA clinical trial. Many clini-
L
a
will be achieved. It should be noted that others are eval-
cians are utilizing ALA in their acne vulgaris treatment
s
e
uating longer drug incubations and longer light times to
r
armamentarium. T ere is no set “algorithm” that exists,
P
“blast” the acne vulgaris lesions—this approach may have
r
so clinicians will need to determine how best to use ALA-
o
e cacy, but we still need to be aware o the potential mor-
c
PD in their practices. In our clinical practice, which tries
e
d
bidity associated with this approach.
to keep patient com ort at the ore ront and downtime to
u
r
e
a minimum, we normally incubate the ALA or 15 to 30
s
minutes at the rst visit and give blue light or 10 min-
utes. We treat our patients every 2 weeks and increase the c o MPa r Is o n o f a l a -Pd t
drug incubation by 15 minutes at each subsequent visit as a n d Ma l -Pd t
well as increasing the light treatment by 2 to 3 minutes per
session, as tolerated. We have ound that treatments are Several reports have appeared in the medical literature try-
well tolerated and our patients do not have any signi cant ing to determine whether ALA-PD is more e ective than
downtime, which is important or students and younger MAL-PD and vice-versa, as well as looking at pain associ-
patients who have to go to school or to work and cannot ated with each o the therapies.54,55 In these evaluations, MAL
a ord the downtime that occurs with longer drug incuba- was studied utilizing the recommended lesion preparations
tions and longer light periods. and drug incubation under occlusion. ALA used in these
In Europe, MAL-PD has been studied in several clini- evaluations used the recommended FDA protocols but with
cal trials or the treatment o inf ammatory acne. Wiegell compounded ALA, rather than the standard FDA-approved
and Wul 52 were the rst to evaluate 21 patients with product, and was not used in the manner currently con-
sidered to be the “standard o care,” which is short contact,
ull- ace therapy. Pain was associated with the treatments
per ormed in this manner. An editorial by this author23
pointed out that there has not been a comparison o the stan-
dard US and European methods or PD and that, or the
most part, ALA-PD in this country has been per ormed
with minimal downtime and usually with no PD e ects.

c o n c l u s Io n
Lasers and light sources as well as ALA-PD can be e ec-
tive therapies or inf ammatory acne vulgaris. Dermatolo-
gists are at the ore ront o the treatment o this disease and
must remain the leaders in this eld. We are also the leaders
Figure 46-16 Patient after treatment with ALA-PDT. (Used in the use o lasers and light sources in skin disease. opical
546 with permission from Michael H. Gold, M.D.) and systemic medications remain the rst line o treatment
 or our acne patients, but many lasers and light sources,
as well as ALA-PD , have also been shown to be sa e and
23. Gold MH. 5-Aminolevulinic acid photodynamic therapy versus
methyl aminolevulinate photodynamic therapy or inf amma-
4
tory acne vulgaris. J Am Acad Dermatol. 2008;58(2):S60–S62.
e ective or the treatment o acne vulgaris. When appro-
24. Bowes LE, Manstein D, Anderson RR. E ect o 532 nm K P
priate, these devices should be utilized or our patients laser on exposure on acne and sebaceous glands. La sers Med
with inf ammatory acne a ter treatment with topical and Sci. 2003;18:S6–S7.
systemic medications, both to help minimize the extent o 25. Seaton ED, Charakida A, Mouser PE, Grace I, Clement RM, Chu
their lesions as well as the sequelae o their disease. AC. Pulsed dye laser treatment or inf ammatory acne vulgaris:
a randomized controlled trial. Lancet. 2003;362:1347–1352.
26. Orringer JS, Kang S, Hamilton , et al. reatment o acne vul-
r Ef Er En c Es garis with a pulsed dye laser: a randomized controlled trial.
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1. Leyden JJ. T erapy or acne vulgaris. N Engl J Med. 1997; 27. Elman M, Lask G. T e role o pulsed light and heat energy
336:1156– 1162. (LHE) in acne clearance. J Cosmet La ser T er. 2004;6:91– 95.
2. Leyden JJ. Oral isotretinoin. How can we treat di cult acne 28. Dierickx CC. reatment o acne vulgaris with a variable- l-

C
h
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a
29. Bitter PH. Noninvasive rejuvenation o photodamaged skin

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3. Gold MH. Acne and PD : New techniques with lasers and

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using serial, ull- ace intense pulsed light treatments. Derma-

e
light sources. La sers Med Sci. 2007;22:67– 72.

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4. Gold MH. Phototherapy or acne: What is the best approach? tol Surg. 2000;26:835– 843.

4
6
Expert Rev Dermatol. 2010;5(2):159– 172. 30. Munavalli GS, Weiss RA. Rapid acne regression using photo-
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n
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d
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P
ment o inf ammatory acne vulgaris with a 1450 nm diode

h
9. Velicer CM, Heckbert SR, Lampe JW et al. Antibiotic use in

o
relation to the risk o breast cancer. JAMA. 2004;291:827–835. laser: A pilot study. Dermatol Surg. 2004;30:147– 151.

t
o
10. Ellis CN, Krach KJ. Uses and complications o isotretinoin 35. Friedman PM, Marquez D, Kunishige J. Evaluation o large

d
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therapy. J Am Acad Dermatol. 2001;45:S150–S157. spot 1450 nm diode laser or the treatment o acial acne vul-

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a
11. Kawada A, Aragane Y, Kameyama H, Sangen Y, ezuka . garis. La sers Surg Med. 2008;40(S20):32.

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12. Shalita AR, Harth Y, Elman M. Acne photoclearing using 37. Lloyd JR, Mirkov M. Selective photothermolysis o the seba-

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13. Gold MH. T e utilization o ALA-PD and a new photo- 38. Kassir M, Newton D, Maris M, Euwer R, Servell P. Er: glass

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clearing device or the treatment o severe inf ammatory acne (1.54 nm) laser or the treatment o acial acne vulgaris. La sers

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vulgaris—Results o an initial clinical trial. J La sers Surg Med. Surg Med. 2004;34(S16):S65.

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39. Ruiz-Esparza J, Gomez JB. Nonablative radio requency or

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2003; 15(Suppl):46.

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14. Papageorgiou P, Katsambas A, Chu A. Phototherapy with active acne vulgaris: the use o deep dermal heat in the treat-

t
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o acne with visible light; decreased irradiation time by ical evidence or its expanded use. Expert Rev Med Devices.

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1990;176:597– 560. 41. Gold MH. Novel treatment options or severe inf ammatory

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16. Goldman MP, Atkin D, Kincad S. PD /ALA in the treatment acne vulgaris. Expert Rev Dermatol. 2006;1(1):13– 23.

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u
o actinic damage; real world experience. J La sers Surg Med. 42. Hongcharu W, aylor CR, Chang Y, Aghassi D, Sutham-

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2002;14(Suppl):24. jariya K, Anderson RR. opical ALA-photodynamic ther-

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17. Gold MH, Goldman MP. A multi-center investigatory study apy or the treatment o acne vulgaris. J Invest Dermatol.

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o the treatment o mild to moderate inf ammatory acne 2000;115(2):183– 192.
vulgaris with visible blue light in comparison to topical 1% 43. Itoh Y, Ninomiya Y, ajima S, Ishibashi A. Photodynamic
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18. http://www.clinicaltrials.gov/ct2/show/results/NC 0070643 44. Itoh Y, Ninomiya Y, ajima S, Ishibashi A. Photodynamic
3?term=DUSA+Pharmaceuticals&rank=1 therapy o acne vulgaris with topical delta aminolevulinic
19. Dierickx CC, Capezzera R, Pedretti A, et al. Lasers, light, and acid and incoherent light in Japanese patients. Br J Dermatol.
radio requency or treatment o acne. Med La ser Appl. 2004; 2001;144:575– 579.
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20. Gold MH. Blue light or the treatment o acne vulgaris. linic acid and 417 NM photodynamic therapy in the treat-
Prime. 2013;1(3):19– 25. ment o moderate to severe acne vulgaris. J Drugs Dermatol.
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Pinton P. Non-invasive diagnostic evaluation o photothera- 46. aub AF. Photodynamic therapy or the treatment o acne: a
peutic e ects o red light phototherapy o acne vulgaris. Pho- pilot study. J Drugs Dermatol. 2004;3: S10–S14.
todermatol Photoimmunol Photomed. 2008;24(5):244– 248. 47. Gold MH. T e use o a novel intense pulsed light and heat
22. Na JI, Suh DH. Red light phototherapy alone is e ective or source and ALA-PD in the treatment o moderate to severe
acne vulgaris: randomized, single-blinded clinical trial. Der- inf ammatory acne vulgaris. J Drugs Dermatol. 2004;3(6):
matol Surg. 2007;33(10):1228– 1233. S14–S18. 547
4 48. Santos AV, Belo VG, Santos G. E ectiveness o photody-
namic therapy with topical 5-Aminolevulinic acid and
52. Wiegell SR, Wul HC. Photodynamic therapy o acne vulgaris
using methyl aminolaevulinate: a blinded, randomized con-
intense pulsed light versus intense pulsed light along in the trolled trial. Br J Dermatol. 2006;154:969– 976.
treatment o acne vulgaris: comparative study. Dermatol 53. Hor elt C, Funk J, Frohm-Nilsson M, Wiegleb Edstrom D,
Surg. 2005;31(8 Pt 1):910– 915. Wennberg AM. opical methyl aminolaevuninate photody-
49. Rojanamatin J, Choawawanich P. reatment o inf ammatory namic therapy or treatment o acial acne vulgaris: results o
acial acne vulgaris with intense pulsed light (IPL) and short a randomized controlled study. Br J Dermatol. 2006;155:608–
contact o topical 5-aminolevulinc acid (ALA): a pilot study. 613.
Dermatol Surg. 2006;32:991– 997. 54. Wiegell SR, Wul HC. Photodynamic therapy o acne vulgaris
50. Alexiades-Armenakas MR. Long pulsed dye laser-mediated using 5-aminolevulinic acid versus methyl aminolevulinate. J
photodynamic therapy combined with topical therapy or Am Acad Dermatol. 2006;54(4):647– 651.
mild-to-severe comedonal, inf ammatory and cystic acne. J 55. Kasche A, Luderschmidt S, Ring J, Hein R. Photodynamic
Drugs Dermatol. 2006;5:45– 55. therapy induces less pain in patients treated with methyl
51. Miller A, Van Camp A. “ reatment o cane vulgaris with pho- aminolevulinate compared to aminolevulinic acid. J Drugs
todynamic therapy: the use o aminolevulinic acid and green Dermatol. 2006;5(4):353– 356.
light”. Cosm Derm. 2006;19(10): 624– 627.
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 Ch a p t e r

47 Acne Scarring
Sn ha Amin

Cl in iCa l Ov er v iew pathophysio ogy o various types o acne scars may

be simi ar, the treatment options var y or each type, so
it is worth c assi ying acne scarring rom a c inica per-
Acne vu garis a ects a most 80% o the popu ation at some
spective.
point in i e and eads to scarring in up to 95% o patients
with acne.1,2 Many patients su er ong-term psycho ogi-
ca and socia e ects rom the comp ications o acne.3 T e Cl a s s if iCa t iOn : t ype
preva ence o acne scarring in the genera popu ation has
been estimated to be 1% but is much higher in the der- a n d s ev er it y
mato ogy c inic popu ation.4 Even though the treatment o
acne scarring has great y improved in the ast decade with Acne scars are either depressed (atrophic) or e evated
respect to sa ety and e cacy, many patients are unaware (hypertrophic). T ere are three c inica subtypes o atro-
o their options regarding potentia therapies. T e pro i - phic acne scars: icepick, boxcar, and ro ing (Fig. 47-1). T e
eration o devices and techniques or improving acne scar- elevated type acne scars can be hypertrophic or ke oida .
ring present a cha enge or the c inician who must o ten Macu ar acne scars may a so have associated vascu ar and
app y severa treatments or an individua patient with pigment changes even i the skin texture is unchanged.
mu tip e types o acne scars. Fina y, it is important to note severity and distribution in
Most patients with acne report that prevention o acne se ecting the appropriate treatment moda ity ( ab e 47-1).
scarring is one o the main reasons or seeking pro es- In the dermato ogy c inic, the most common orm o
siona dermato ogic care, especia y in severe cases. How- acne scarring is the atrophic type, with most patients exhib-
ever, many patients speci ca y seek out the dermato ogist iting eatures o two or more subtypes. T e most common
or dermato ogic surgeon to address acne scarring ong subtype o atrophic acne scar is the crateri orm or boxcar
a ter the active esions have subsided. On y in the ast ew type (Fig. 47-2). T is esion o ten presents as a c uster o
decades has improvement o acne scarring become a sig- scars on the temp es or cheeks. Individua esions are 3
ni cant practice area or dermato ogists with the deve op- to 4 mm in diameter and about 0.5 mm deep. Eventua y
ment o new moda ities such as asers, surgica devices,
chemica pee s, and ers.
Most patients with acne scarring have imited areas o
invo vement on the temp es or cheeks. Some have more TAbl e 47-1
widespread invo vement on the ace, chest, and back. C c C c o o ac sc
T ere is no corre ation between the Fitzpatrick skin a oc sk C
type and gender with acne scar severity.5 A though most
Major typ s o acn scarring
acne scarring is atrophic, there are severa subtypes and
Atrophic or d pr ss d scars
c inica variations. In addition, whi e the under ying
Ic pick scars
boxcar scars
Ro ing scars
e vat d or protruding scars
Hyp rtrophic scars
K oida scars
Ice pick Boxca r Rolling Macu ar chang s +/- scarring
Punch excis ion Punch e leva tion Fille rs Vascu arity and ryth ma
Postin ammatory pigm nt chang s
-- La s e r re s urfa cing La s e r re s urfa cing S v rity
De rma bra s ion De rma bra s ion -- D pth
Sup r cia ( pid rma )
-- -- S ubcis ion Mod rat (papi ary d rmis)
P inpoint TCA Che mica l pe e ls -- D p (d p d rmis)
Distri ution
Figure 47-1 Thr typ s o atrophic acn scars. Appro l oca iz d
priat th rapy s ction d p nds on th typ o scars G n ra iz d
pr s nt.
4 Discoid upus scars tend to coa esce with centra areas o
vio aceous pigment and are usua y much arger. Sma pox
scars tend to be deeper, more even y distributed on the
ace and are o ten the ro ing type o scars (Fig. 47-4). Scar-
ring rom se -traumatization tends to have irregu ar pat-
terns o distribution as we as very we -de ned borders
(Fig. 47-5). Scarring induced by herpes simp ex and vari-
ce a viruses o ten appear in c usters and arrays and has
a punched-out border. So itary ke oida or hypertrophic
acne scars on the torso in the appropriate c inica context
may be di erentiated rom dermato brosarcoma protu-
berans with a punch biopsy.

pa t h Oph ys iOl Og y
S
c
t
T e pathogenesis o the initia inf ammatory acne esion
i
o
n
has been studied in detai .5,7 However, the pathogenesis o
4
acne scarring is ess we understood.4 T e initia o icu ar
inf ammatory process around a comedone eads to o ic-
:
:
u ar rupture, peri o icu ar abscess ormation, and even-
A
tua y wound hea ing. T e cascade o events invo ved in
s
t
wound hea ing that ead to acne scarring are comp ex and
h
invo ve inf ammation, granu ation tissue ormation, and
t
i
c
matrix remode ing. Matrix remode ing during the na
a
n
stages o wound hea ing may invo ve brosis, atrophy,
d
l
pigment, and vascu ar changes.8 Atrophic or hypertro-
a
s
phic brosis may be temporary or permanent. Occasion-
r
a y, acne scars are e evated or thickened, especia y on
P
r
o
the chest, shou ders, and back. A though not con rmed
c
in contro ed studies, traumatization, superin ection
d
u
Figure 47-2 Activ in ammatory acn with ic pick and by staphy ococcus or proprionibacterium, ong-stand-
r
oxcar typ scars in a pati nt with Fitzpatrick typ 4 skin. ing duration, or arge size o acne cysts can predispose
s
patients to severe acne scarring. T e type o initia esion
does not seem to determine the c inica type or eve o
a ter 3 to 12 months, acne scars assume a s ight y hypopig- acne scarring.2 Ce -mediated immunity, which is geneti-
mented or more o ten a norma skin tone. Most patients ca y inf uenced, may determine the severity eve o acne
exhibit mu tip e subtypes o acne scar (Fig. 47-3). scarring.9
T e cosmetic impact o an acne scar is dependent on T e ro e o ora medications in preventing or possib y
the depth o the scar as we as the ang e o the border or exacerbating acne scarring has been debated. Given the
wa at the edge o the scar (Fig. 47-4). A vertica wa with
a deeper base wi create a more pronounced shadow and,
there ore, have a greater cosmetic impact. Ro ing scars
are ess prob ematic cosmetica y because o edges that TAbl e 47-2
minimize shadow ormation. T e ang e o incident ight
C c s g s
wi a so have a signi cant impact on the appearance o
the scar in photographs; overhead spot- ighting tends to Grade I: Macu ar chang s on y with ryth ma,
exacerbate the appearance o acne scars, whereas ambi- hyp rpigm ntation, or hypopigm ntation. Pati nts may
ent natura ight tends to minimize scar severity. T e ang e p rc iv this to s v r d spit having minima t xtur
and qua ity o ighting is especia y important to note chang s in th skin.
when photographing acne scars or c inica or research Grade II: Mi d atrophic or hyp rtrophic chang s not o vious
purposes. A use u c inica grading system is described in at conv rsationa distanc . S ight t xtura chang s with
ab e 47-2.4,6 associat d co ag n disorganization. Pati nts not ack o
“glowing skin.” easi y cov r d with mak up or cosm tic
products.
d if f er en t ia l d ia g n Os is Grade III: Mod rat atrophic or hyp rtrophic chang s asi y
visi at conv rsationa distanc . Not asi y cov r d up with
A though the c inica diagnosis o acne scars is usua y mak up. Dist nsi or att n d with manua traction.
obvious, severa skin conditions produce scarring that can
Grade IV: S v r atrophic or hyp rtrophic chang s that ar
mimic oca ized or even genera ized acne scarring. Vari-
non dist nsi or do not improv y str tching th skin.
ce a scars in so itary and genera ized orms can mimic
D p ic pick or oxcar typ scars o vious in any ighting.
acne scarring. A so itary varice a scar is o ten better
550 de ned at the edges with near y vertica wa s (Fig. 47-3). Source: Data rom Goodman 28 and Fa rocini4
 4

C
h
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r
4
7
:
:
A
c
n
S
c
a
r
r
i
n
g
A B

Figure 47-3 A. east Asian pati nts with Fitzpatrick typ

3 skin xhi iting oxcar and ro ing scars on th t mp s,
C
ch ks, and n ck. B. So itary varic a scar with sid ight
ing on th t. C. Am i nt ight on th right.

551
4 Boxca r type s ca r Incide nt light

Be fore

S ha dow

Incide nt light

Afte r

S ha dow
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P
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d
u
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s
A B

Figure 47-4 boxcar typ scar. boxcar typ acn scars app ar dark caus o shadows cr at d y incid nt ight. D rm
a rasion or any oth r pid rma r sur acing so t ns th sharp dg s o pid rma scars. A t r d rma rasion, th shadow
ngth d cr as s v n i th d pth o th scar r mains th sam . A. Sma pox scars on th upp r ip and nos with hyp r
pigm ntation and atrophy. B. Not th s v r atrophy within individua sions.

ong history o ora antibiotics in treating active acne vu - paper– ike change can occasiona y be noted within
garis, it is un ike y that these medications exacerbate acne arger acne scars. T e u timate shape o the acne scar may
scarring. Severa studies have ana yzed acne scarring as depend on other actors as we as the under ying genetic
a c inica endpoint; they support the use o ora antibiot- predisposition o the patient. Why certain patients are
ics to prevent the occurrence o acne scarring and do not more prone to acne scarring than others is unc ear. T e
show any increased scarring.10 T e ro e o ora retinoids orientation and types o co agen bers invo ved in the
is ess certain in exacerbation o acne scarring; there ore, brosis may p ay a centra ro e in determining the shape
concomitant use o ora steroids is o ten recommended to o the acne scar. For examp e, horizonta bers o co agen
decrease the inf ammation that is o ten seen during ini- type 4 are o ten seen in hypertrophic scars whereas verti-
tiation o ora retinoid therapy.5 Whether either o these ca and horizonta co agen bers o types 1 and 3 are o ten
medications u timate y reduces the eve o acne scarring seen in ke oids.12,13 Variations in co agen distribution as
o ten depends on ear y initiation o therapy. De ayed initi- we as matrix enzymes and hea ing responses, which are
ation o treatment was strong y corre ated with increased ike y to be genetica y determined, may predispose acne
severity o scarring.10,11 patients to scarring.
T e pathophysio ogy o acne scarring has a so been Acne vu garis may a so ead to changes in epiderma
studied on a histo ogic eve and is characterized by and derma pigmentation without pa pab e skin sur ace
brosis in the dermis.11 T is derma neo-co agenesis changes. T is co or change may or may not be associ-
resu ts in a depression in the over ying epidermis, which ated with scarring or brosis. Because patients o ten
552 is more o ten atrophic and rare y sc erotic. A parchment associate co or change with scarring, the management
 o patients are visiting their dermato ogist or cosmetic
improvement o these skin changes. reatment se ec-
4
tion shou d take into consideration important actors
isted in ab e 47-3. A brie discussion o each actor
o ows.

1. Current acne invo vement and ike ihood o uture

f ares wi determine the timing and se ection
o acne scar therapy. During active acne f ares,
medica therapies inc uding ora and topica
retinoids as we as strategies to decrease the
severity o acne shou d be emp oyed. Patients
shou d be advised to avoid excoriating their esions
and maintain an aggressive medica regimen to
decrease acne scarring. reatment moda ities such

C
h
as non-ab ative asers and chemica pee s may be

a
p
initiated to treat active inf ammatory or comedona

t
acne as we as acne scarring.

r
4
2. T e distribution, ocation, and severity o acne

7
scarring wi strong y inf uence therapeutic

:
:
se ection. Surgica treatments that are sa e on
acia skin are o ten contraindicated on the chest

A
c
n
or shou ders due to risk o ke oid ormation. T e
advent o ractiona aser treatments has a owed

S
c
or sa er resur acing on non- acia ocations o acne

a
r
r
scars. So itary esions o ten respond we to sca pe -

i
n
g
based treatments, whereas wide y distributed
esions wi respond we to aser-based treatments.
3. Perhaps the most important actor in treatment
se ection is the type o acne scar present. Figure
Figure 47-5 Coa scing oxcar typ scars on th t 47-1 describes the three main types o acne scars
ang o th mouth in a pati nt with HSV xac r at d y and a so ists the typica treatments or each type
xcoriations. o acne scar. Icepick scars respond we to oca
surgica treatments. Since most icepick scars
o postinf ammatory pigment changes a ter reso ution o invo ve deep brosis, 2 mm punch excision is an
acne vu garis is an important aspect o treating acne scar- idea treatment, especia y when o owed with
ring. Postinf ammatory hyperpigmentation consisting o a series o non-ab ative ractiona resur acing
red-brown to vio aceous macu es is o ten noted, especia y treatments; pinpoint trich oracetic acid ( CA)
in darker skinned patients, and can persist or 12 months.14 is a so very e ective or these esions. Deep
Iso ated erythema usua y reso ves sooner un ess hyper- icepick scars do not respond to dermabrasion
vascu arity within acne scars is present. or non-ab ative aser resur acing. Ab ative aser
resur acing, i done at the appropriate settings,
can resu t in partia improvement. Because o
t r ea t men t pl a n n in g their epiderma invo vement, boxcar scars respond
to mu tip e moda ities. Super cia boxcar scars
Given the pro i eration o treatment moda ities or acne respond to mechanica and aser resur acing.
scarring in the past ew decades, an increasing number Mu tip e chemica pee s and dermabrasion can a so
correct these most y epiderma de ects. Deeper
boxcar scars respond very we to punch excision
TAbl e 47-3 or narrow scars and punch e evation or wider
f co t s c o scars. T e idea approach or boxcar scars may
1. Curr nt acn invo v m nt and ik ihood o utur ar s
invo ve initia surgery or oca esions o owed
2. Distri ution, ocation, s v rity o acn scarring by mu tip e ractiona resur acing sessions or
3. Typ o acn scarring, i. ., d rma vs. pid rma , ic pick vs. genera ized pigment and textura improvements.
oxcar Subcision is the idea treatment or ro ing
4. Dif r ntiating scar rom pigm nt and vascu ar chang s scars because o the associated derma brosis.
5. M dication history, sp cia y ora and topica r tinoids Subcision o owed by er therapy has become a
6. Psycho ogica and socia history, i. ., comp ianc , picking standard approach or deep ro ing scars. Surgica
7. G nd r, i. ., pr s nc o ard hair, us o mak up, tc. approaches that invo ve cutting into the epidermis
8. R c nt surgica , as r, or u travio t ight xposur are not indicated or ro ing scars since the skin
9. Fitzpatrick skin typ , i. ., postproc dur pigm nt chang s sur ace appears norma in this subtype o acne
10. K oid and surgica scar history scars. Non-ab ative aser and ight treatments
11. Pati nt xp ctations, i. ., r su ts, pain, h a ing p riod
such as the 1064 nm Nd:YAG aser are o ten 553
4 prescribed or ro ing scars; however, the cosmetic
improvement is usua y very subt e.
initiating new treatments. Patients shou d be
instructed not to tan or at east 1 month prior to
4. Di erentiating permanent scarring invo ving most surgica or aser treatments— onger or those
brosis (either atrophic or hypertrophic) rom patients with darker skin types who retain their
other ong- asting comp ications o acne such tans or a onger period o time. Postoperative sun
as hyperpigmentation is important in treatment avoidance and sunscreen app ication shou d be
se ection. Many patients use the term “acne scars” inc uded in any instruction sheet.
to describe the presence o postinf ammatory 9. As with any other dermato ogic treatment, acne scar
hyperpigmentation and/or erythema even i there patients with Fitzpatrick skin types 3 or greater shou d
is no brosis. reatment o postinf ammatory be treated on y by experienced operators. Subcision
pigmentation di ers rom treatment o true acne or er therapies carry itt e risk o pigmentation
scars. Many patients have both, so a detai ed changes and shou d be strong y avored in dark-
discussion about risks and expectations is very skinned patients. T e potentia or postoperative
important as we as an exp anation o brotic versus pigment changes with ractiona aser treatments can
pigmentary changes. Any treatment or patients be ow with appropriate treatment parameters and
S
with type 4 skin or higher shou d not be initiated comp iant patients, whereas surgica or conventiona
c
t
i
without an experienced dermato ogist present. Many ab ative treatments in dark-skinned individua s o ten
o
n
patients have mu tip e types o acne scars in various eave pigment a terations. Care u pretreatment and
4
anatomic ocations and there ore require mu tip e posttreatment regimens with topica hydroquinone,
:
:
moda ities to achieve an optima cosmetic outcome. ora or topica steroids, and possib y retinoids have
5. Most dermato ogists recommend abstaining rom been suggested or these patients with dark skin
A
any aser or surgica treatments or a period o 6 to undergoing cosmetic procedures.17
s
t
h
12 a ter ora isotretinoin therapy to avoid excessive 10. A patients shou d be in ormed o the risk or
t
or abnorma scarring. Concurrent ora isotretinoin ke oids with surgica therapy. It is unc ear whether
i
c
a
is strong y associated with de ayed wound hea ing acne scar patients are actua y at higher risk or
n
d
and hypertrophic scarring.15 Anecdota evidence ke oid deve opment.18
l
a
suggests that such a ong waiting period may be 11. As with any cosmetic treatment, the patient’s
s
unnecessary.16 Patients shou d be advised to avoid expectations about the eve o improvement, the
r
P
app ication o any topica retinoid products or duration o hea ing periods, and risk o comp ications
r
o
simi ar y irritating agents such as g yco ic acids shou d be discussed. T e operating physician must
c
d
or at east 2 weeks prior to and o owing any skin e icit speci c understanding o these issues with the
u
r
procedure. acne scar patient be ore se ecting any therapies.
s
6. T e patient’s psychosocia assessment wi strong y
impact therapy se ection. Comp iance eve inc uding Preoperative and postoperative p anning are essentia
tendency toward picking shou d be thorough y to the success o any cosmetic treatment. Every cosmetic
eva uated in the acne scar patient. E ements o body patient shou d comp ete a detai ed and speci c procedure
dysmorphic syndromes and obsessive-compu sive consent orm high ighting the individua procedure as we
disorders are o ten noted in acne scar patients who as the speci c risks associated with the procedure. Preoper-
have anxiety, habitua picking, or an exaggerated sense ative and postoperative operative photography are crucia in
o their scar severity. Because acne scar improvement treating the cosmetic patient. Because acne scar severity can
o ten invo ves ong-term therapies, a high-qua ity vary with the ang e o incident ight, standardized and pro-
doctor– patient communication strategy wi essiona photography by the dermato ogist is strong y sug-
aci itate c inica outcomes. Asking about upcoming gested. Use o a camera f ash, position o the patient re ative
socia events wi aci itate therapeutic p anning. to the camera, camera exposure settings, ambient co ors,
Comp iance with physician directives is essentia room ighting, and ocation in the examination room can a
or more invasive therapies. Avoidance o over- a ect the appearance o acne scars on digita photography.
the-counter anticoagu ants and retinoids shou d be
strong y advised. Preoperative treatment with antivira t r ea t men t s
and antibiotic therapy may be necessary when using
ab ative moda ities such as aser resur acing or deep
On the basis o the c inica c assi cation o acne scarring,
chemica pee s. Postoperative care instructions,
there are severa approaches to the cosmetic improvement
which may inc ude pressure dressings, antibiotics,
o acne scars. Speci ca y, these esions can be treated by
and occ usive ointments, shou d be reviewed with
the o owing approaches, which are exp ained in more
the patient and caregivers. T e operating physician
detai in the next section:
shou d assess the ike ihood o comp iance with sun
avoidance and sunb ock app ication. ■ Surgica y excising or recountouring the esions (punch
7. Patient gender wi impact the speci c therapies excision, subcision)
chosen. Some women may not mind using cover- ■ Resur acing the epidermis ( asers and dermabrasion)
up or persistent erythema a ter resur acing ■ Changing the esion co or (vascu ar asers and medica
treatments. Hair sty ing may be used to cover therapy)
sutures or dressing materia . ■ Increasing the esion vo ume ( ers and at)
8. Patients shou d be given at east a month to hea ■ Decreasing the esion vo ume (steroid injections)
554 rom previous aser or surgica therapies be ore ■ Re axing the surrounding skin (botu inum toxins)
 s u r g iCa l t r ea t men t s S ca r
4
Given that some physicians think that predisposition to
acne scarring can be seen more o ten in patients who
su er hypertrophic scarring a ter sca pe surgery, any
surgica approach must eva uated care u y or the acne
scar patient. However, a retrospective study showed no Incis ion point
corre ation between a previous history o non-acne scar-
ring and subsequent deve opment o acne scarring.2 Over
the ast decade, ractiona aser resur acing has overtaken
sca pe -based approaches to treating acne scarring. How-
ever, surgica treatments such as subcision and punch
excision remain simp e and e ective treatments or cer-
tain types o scarring. Moreover, these therapies can be

C
combined in a sequentia manner with aser therapy. Once

h
a
the therapy has been se ected, app ication o appropri- Figure 47-6 Su cision t chniqu with Nokor n d .

p
t
ate anesthetic techniques is essentia or patient com ort.

r
4
Most o the surgica moda ities can be per ormed with

7
injectab e anesthetic, whereas the aser treatments can

:
be per ormed with topica anesthetics.19,20 Extensive sub-

:
Sca pe excision inc udes conventiona e iptica exci-
cision or conventiona resur acing or dermabrasion may sion as we as punch biopsy– type excision. Deep inear

A
c
require tumescent or regiona anesthesia and, in some scars or round scars that have coa esced are good candi-

n
cases, genera anesthesia.21 dates or conventiona excision. Meticu ous suturing tech-

S
c
Subcision is indicated or depressed or atrophic- nique combined with postsurgica aser treatments with

a
r
type acne scars that have a ro ing sur ace. Icepick- and

r
ractiona resur acing or pu sed dye asers can achieve sig-

i
n
boxcar-type acne scars, which have a we -demarcated or

g
ni cant cosmetic improvement (Fig. 47-7).
vertica wa at the edges, shou d not be treated with sub- Sma icepick scars that are ess than 1 mm in diameter
cision. A simp e test o the potentia uti ity o subcision may be excised with a 2 mm punch biopsy too , which
invo ves stretching the skin with the thumb and index n- creates a very sma surgica de ect and a near y scar- ess
ger around the scars. I the scars improve, then subcision outcome. T is simp e yet e ective technique can be per-
may be he p u . I the scar persists during the maneuver, ormed on mu tip e esions during a sing e visit (Fig. 47-8).
then the epiderma change in the scar negates the uti ity Increased e cacy is seen when punch excisions are o -
o subcutaneous subcision. T e term itse is derived by owed short y therea ter by a series o non-ab ative rac-
shortening the phrase subcutaneous incisionless surgery.22 tiona resur acing treatments.
Various instruments inc uding 20 gauge need es, Nokor Boxcar-type acne scars that are approximate y 3 mm in
need es, mini-Beaver b ades, and iris need es have been diameter can be excised using a 3 to 4 mm punch too . Ori-
used to cut the vertica bers that tether the epidermis to enting the na de ect a ong the skin o ds is very impor-
the deep dermis and subcutaneous tissue. A ter oca or tant or arger scars. T ese arger scars can a so be treated
even tumescent anesthesia, the need e is inserted into the with punch e evation and punch gra ting. In either case,
skin a ew mi imeters adjacent to the scar perpendicu ar meticu ous suturing with 6-0 ny on is suggested. Derma
to the skin sur ace. T e need e is then ang ed near y par- suturing with 5-0 vicry may be necessary i the surgica
a e to the skin and inserted urther and swept back and de ect is greater than 2.5 mm. It is important to orient the
orth to cut the subcutaneous tissue under the scars. T e punch excision a ong the re axed skin tension ines. Spe-
subcision need e can a so be introduced under the skin ci ca y, the skin is stretched perpendicu ar to the re axed
a ter an initia puncture with an 18 gauge need e. Once skin tension ines with the thumb and index nger in order
the subcision device is in p ace, anning and stabbing tech- to achieve an e iptica surgica de ect with a round punch
niques are app ied to re ease the dermis rom the subcu- too (Fig. 47-9).
taneous tethers and occasiona y the deep dermis (Fig. A re ated technique, punch e evation, is used or cir-
47-6). T e area being treated shou d be rm y stretched cu ar boxcar type or crateri orm acne scars greater than
by the non-dominant hand o the operator, and tenting 4 mm in diameter (Fig. 47-10). In this technique, a punch
the skin away rom the patient with the tip o the need e too exact y the same diameter as the base o the crater
may aci itate the severing o subcutaneous bands. Bruis- is inserted into the skin to the subcutis. T e partia y
ing may occur despite rm pressure or at east 10 min- attached p ug o tissue is e evated s ight y above the eve
utes. No a ter care is necessary. Injection o brin oam o the surrounding skin. T is p ug o skin is xed into
or vo umizing ers can be per ormed a ter the subcision p ace with Steri-Strips, cyanoacry ate adhesive, or sutur-
taking care not to over-correct the de ect.23 Steroid injec- ing with 6.0 ny on. Super cia skin resur acing is usua y
tions are occasiona y necessary or hypertrophic scarring required or residua epiderma scarring. Punch gra ting
a ter subcision. Fo owing subcision, vertica y oriented is a simi ar technique with the exception that donor skin
brotic bands are re eased and c ot ormation and bro- or the centra p ug is acquired rom a distance site rather
sis ead to recontouring o the scarred skin. Formation o than the base o the scar. Skin co or, thickness, and texture
additiona scar tissue in the dermis and subcutis may a so matching are di cu t with punch gra ting and a so require
e evate the scar.24 postsurgica resur acing or optima cosmetic appearance. 555
4
S
c
t
i
o
n
4
:
:
A B
A
Figure 47-7 D p atrophic acn scar tr at d with surgica xcision. A. Pr surgica photograph shows
s
t
d pth o scar with sid ighting. B. Fo owing conv ntiona xcision, surgica scars can tr at d with
h
pu s dy as r or ractiona r sur acing or urth r cosm tic improv m nt.
t
i
c
a
n
d
l
a
s
r
P
r
o
c
d
u
r
s
A B

C D

Figure 47-8 A. Punch xcision o a sma di at d por or ic pick scar. B. Mo i izing th skin wi h p
556 d n th r ax d skin t nsion in s (RSTl ). C. and D. Str tching th skin p rp ndicu ar y to th RSTl wi
cr at an ova surgica incision with a round punch d vic .
 4

E F

C
h
a
p
t
r
4
7
:
:
A
c
n
S
c
a
r
r
i
n
g
G H

Figure 47-8 (Continued) E. Not th ova surgica d ct

that is para to th RSTl . F. G. H. Suturing with 6.0 ny on
I p rp ndicu ar y to th RSTl wi achi v h mostasis and a
surgica scar that is para to th RSTl . I. Fina r su t.

Dermabrasion with various instruments inc uding ster- T e shadow created by a boxcar-type scars wi be great y
i e sandpaper, circu ar knives, rasps, wire brushes, and reduced i the border o the scar is rounded or so tened
circu ar sanding dri s have been described over the ast (Fig. 47-4). Ro ing scars may improve s ight y with derm-
100 years. One o the ear iest insights into this cosmetic abrasion techniques but deep icepick scars shou d not be
technique invo ved the precise regu ation o the depth o treated aggressive y with this technique. As with any sur-
injury by the operating surgeon.25 I the reticu ar dermis gica or aser procedure, patient se ection shou d take into
was not injured during the mechanica abrasion o the account pigmentation, potentia or urther scarring, and
epidermis, there was imited or no scarring a ter re- other actors isted in ab e 47-3. Hypopigmentation is a
epithe ia ization. T e correct c inica endpoint can be major comp ication with dermabrasion and may be wors-
achieved by ooking or pinpoint b eeding, which imp ies ened with cryoanesthesia used prior to dermabrading
that the papi ary dermis has been abraded. Acne scars that the skin.26 umescent anesthesia may decrease the risk o
have sharp epiderma borders respond we to dermabrasion. hypopigmentation.27 557
4

Figure 47-9 Prior to th ins rtion o a punch into th

skin, str tching th skin p rp ndicu ar to th r ax d skin
t nsion in s wi cr at a surgica d ct that is iptica .
Th avoidanc o standing con s and ori ntation para
to skin t nsion in s wi r su t in a mor cosm tica y
acc pta scar.
S
c
Microdermabrasion shou d be di erentiated rom con-
t
i
o
ventiona dermabrasion. Microdermabrasion invo ves the
n
4
app ication o a vacuum tip with high-pressure a uminum
oxide or si ica crysta s to the skin. On y the epidermis is
:
:
abraded with this technique resu ting in temporary ery-
A
thema o the skin. T e depth o abrasion is dependent on
s
the vacuum pressure as we as the concentration and type
t
h
o crysta s app ied. With mu tip e sessions o microderm-
t
i
c
abrasion, histo ogic studies have revea ed s ight brosis in
a
n
the upper dermis as we as a signi cant y smoother epi-
d
dermis.28 A skin types can undergo this procedure with-
l
a
out signi cant or permanent postinf ammatory pigment
s
r
changes.
P
r
Microneed ing is a simp e and possib y e ective treat-
o
c
ment or many types o acne scarring. A sma observa-
d
tiona study showed signi cant improvement without
u
r
resu tant hyperpigmentation in 32 patients with ro ing
s
acne scars treated with two sessions o microneed ing.29
A samp e device is shown in Figure 47-11. In a re ated Figure 47-11 Micron d ing d vic . (D rmaro r, l l C,
technique, sma areas o scarring can be treated with a Thousand Oaks, CA.)

30 gauge need e that is repeated y stabbed to a depth o

2 to 3 mm. In either technique, derma punctures trigger
co agen ormation, edema, brosis, b eeding, and u ti-
mate y co agen remode ing. Microneed ing, un ike rac-
tiona or conventiona aser resur acing, does not create
any therma injury and there ore may have ess e cacy but
a so ewer side e ects. T e risk or injury to the opera-
tor with some o the more aggressive devices may be high;
reusing the ro ers is not advised.

f il l er t r ea t men t s
Fi er therapy or acne scarring is appropriate or ro ing
or depressed scars but not icepick or boxcar-type scars.
Various materia s have been emp oyed or improving
depressed scars inc uding auto ogous at, co agen, hya -
uronic acid, ca cium hydroxyapatite ge , si icone, and
po y-l - actic acid.12 Combining subcision techniques
with er therapy resu ts in an optima c inica appear-
ance. Se ection o the right er or an individua patient
invo ves eva uation o the acne scars as we the patient’s
Figure 47-10 Punch vation. Punch too must th risk to erance. Patients who are new to the dermato ogist
sam diam t r as th inn r crat r o a oxcar typ scar shou d not receive permanent ers without extensive
558 wh n p r orming punch vation. operator experience. Super cia or thin esions shou d
be treated with hya uronic ge products, whereas deeper
esions that require a thicker or more viscous product can
A typica treatment course invo ves month y sessions o
50% to 70% g yco ic acid. In addition to causing epider-
4
be treated with ca cium hydroxy apatite ge s.30 Po y-l - mo ysis in the stratum corneum and dispersing basa ayer
actic acid ge is indicated or ro ing acne scars a ter subci- me anin, g yco ic acids have a so been shown to increase
sion and not recommended or super cia scars. Injection hya uronic acid and co agen production in the dermis.35
into the papi ary dermis may create visib e persistent pap- T is treatment is contraindicated in patients with an
u es in a ew months a ter injection o po y-l - actic acid, active skin dermatitis, hypersensitivity, or pregnancy.
which can be treated with simp e excision.31 Severa other compounds are a so used or chemi-
A simp e maneuver to assess the appropriateness o er ca pee s in patients with active acne vu garis as we as
therapy or acne scars invo ves stretching the scarred skin acne scarring. Jessner’s so ution is composed o sa icy ic
with the thumb and ore nger. I the scar improves, then acid, actic acid, and resorcino . T e components o this
the area is an appropriate site or er therapy. T e same pee act synergistica y to disrupt the stratum corneum
maneuver can be used to assess or appropriateness o sub- and enhance absorption into the epidermis. o erabi ity
cision. Combining subcision and er therapy can be more is simi ar to other super cia a pha hydroxy pee s. T irty
e ective than the use o either a one.32 T e mechanism o percent sa icy ic acid is a beta hydroxy acid pee that has

C
h
cosmetic improvement depends on the speci c er uti- been used e ective y in darker skin types without comp i-

a
p
ized. For examp e, auto ogous at trans er invo ves not on y cations.36 Sa icy ism, characterized by tinnitus, abdomina

t
r
vo ume rep acement with mature adipocytes but a so sub- pain, and dizziness, can be avoided by use o this agent on

4
7
sequent brosis associated with dead adipocytes and pos- a imited skin sur ace area. CA causes immediate epider-
sib y stem ce trans er and stimu ation. 33 aking care not to ma protein denaturation, which is mani ested as rosting

:
:
inject into acia vesse s is crucia . Vascu ar occ usion can o the skin. A super cia derma pee can be per ormed

A
ead to u ceration and scar. Additiona detai s regarding with 10% CA; concentrations higher than 35% can cause

c
n
ers and injection techniques are described e sewhere in derma injury and there ore possib e scarring. T e use o

S
this textbook. CA or acne scar treatment shou d be avoided in patients

c
a
with Fitzpatrick skin type 4 and higher due to the risk o

r
r
i
hyperpigmentation and hypopigmentation.37

n
Ch emiCa l peel t r ea t men t s

g
A variant o CA chemica pee ing was speci ca y
deve oped to address icepick-type acne scars. Pinpoint
Chemica pee ing invo ves the app ication o a caustic sub- app ication o 50% to 100% trich oroacetic acid with a
stance to the skin, which destroys the epidermis and part sharp too such as the broken end o a cotton-tipped
o the dermis in order to stimu ate epiderma and derma app icator direct y into the center o the icepick scar
regeneration. Chemica pee s have been uti ized or a vari- can essentia y c ose the epiderma de ect.38 Carving the
ety o acne scars in a Fitzpatrick skin types. T e most wooden end o the app icator stick with a surgica b ade
common agents used inc ude pheno ic, trich oroacetic, to approximate the shape o the icepick scar has been sug-
sa icy ic, and g yco ic acids. T e particu ar agent uti ized gested to improve c inica resu ts. Care shou d be taken
as we as its concentration determines the e ective depth to avoid app ication to the surrounding norma skin by
o treatment. Deeper pee s such as pheno ic acids when preapp ication o petro atum. Due to the risk o hyperpig-
used in darker skin types o ten resu t in medium- to ong- mentation and depigmentation, CA treatments shou d
term hyperpigmentation.34 T e same approaches used be avoided in patients with dark skin. No anesthesia is
to minimize postinf ammatory hyperpigmentation with required or oca and imited treatment. T is procedure
aser treatments can be app ied to chemica pee s such as can be repeated month y to achieve optima resu ts.
pretreatment hydroquinone and posttreatment sun avoid-
ance. Repeat sessions on a month y basis with mi d-to-
moderate depth chemica pee s can a so avoid pigmentary l a s er t r ea t men t s
a teration whi e achieving signi cant improvement.
G yco ic acid treatments are probab y the most com- Over the ast ew decades, many types o asers and energy
mon y used and best-to erated a pha-hydroxy acid pee s. devices have been introduced to treat acne scarring ( ab e
T e duration o app ication and the concentration o g y- 47-4). Initia y, conventiona ab ative asers such as car-
co ic acid pee determine the depth o epiderma damage. bon dioxide and erbium:YAG asers were used or genera

TAbl e 47-4
l d c o ac sc

d c i c o f c o
A ativ as rs Car on dioxid R sur acing Avai a
er:YAG R sur acing Avai a
Non a ativ Pu s d dy as r eryth ma r duction N/A
l eD Photomodu ation N/A
In rar d as rs (i. ., 1320 nm) Th rma f cts N/A
er:YAG (i. ., 1550/1927 nm) Non a ativ r sur acing Avai a
Mix d Radio r qu ncy R sur acing, co ag n r mod ing Avai a
559
4 Epide rmis stimu ate co agen and myo brob ast remode ing. In gen-
era , icepick and deep acne scars have demonstrated poor
De rmis
responses to conventiona aser resur acing. In order
to ensure an optima cosmetic outcome, the who e ace
Conve ntiona l Fra ctiona l
shou d be treated when using conventiona aser resur ac-
Ae ria l view of
ing or acne scarring.
re s urfa ce d s kin
Er:YAG asers can be used a one or in combination with
Figure 47-12 Conv ntiona and ractiona a ation o carbon dioxide asers to treated depressed scars. Er:YAG
th skin. asers produce ess therma injury to surrounding tissue
than carbon dioxide asers despite more avid absorption
by water in the vaporized tissue. Mu tip e passes are per-
resur acing o the skin.39 Non-ab ative asers such as the ormed unti pinpoint b eeding is noted.41 As is the case
1320 nm in rared asers were ater introduced to improve with a conventiona aser resur acing treatments, there is
skin texture without actua y disrupting the epidermis.40 a signi cant risk o edema, pruritus, transient and persis-
T e overa c inica e ect o non-ab ative asers in ong- tent erythema, hypopigmentation, hypertrophic scarring,
S
term studies was subt e as best.23 In the ast decade, a and superin ection with bacteria and herpes virus. Care u
c
t
i
new c ass o asers described as pixe ated, scanning, or patient se ection is required to avoid these comp ications.
o
n
ractiona has been deve oped (Fig. 47-12). Essentia y, a Most patients with Fitzpatrick skin types 4 or greater
4
wider aser beam is sp it or ractionated into many sma er shou d not be treated with conventiona resur acing with-
:
:
beams; the resu tant spot size or the ractionated beam is out extensive operator experience. Detai ed instruction
sma enough that scar ess hea ing occurs whi e achieving on ab ative aser resur acing is discussed e sewhere in this
A
signi cant depth o penetration into the dermis. A terna- text.
s
t
h
tive y, a aser with a very narrow spot size can be scanned Fractionated or pixe ated asers are avai ab e in ab a-
t
across the skin in a contro ed manner to achieve the same tive, non-ab ative, and radio requency moda ities or
i
c
a
resu t. In between the pu ses is norma undamaged skin, acne scarring. T e advantages o these asers stem rom
n
d
which promotes quick re-epithei ization. T e immediate the spot size o the individua aser beam. T e area o
l
c inica resu t o ractionated ab ative resur acing with a therma damage and/or ab ation in both ab ative and
a
s
scanning carbon dioxide aser is shown in Figure 47-13. non-ab ative ractiona devices is approximate y 100 to
r
P
More recent y, radio requency devices have uti ized the 350 µm. Between these individua areas o therma dam-
r
o
princip es o ractiona resur acing to achieve remode ing age is norma skin. Both the regeneration o adjacent
c
d
with minima tissue damage. More detai ed descriptions epidermis and dermis as we as the trans-epiderma
u
o these moda ities are ound e sewhere in this text.
r
extrusion o necrotic dermis promote ast hea ing, which
s
Conventiona ab ative treatments inc ude carbon diox- is essentia y ree o noticeab e scar even though the
ide (10,600 nm) and Er:YAG (2940 nm) asers. T ese asers depth o penetration o the necrosis is up to 1500 µm.42
have been proven to be e ective in treating a types o T e ractionated devices eave most o the skin intact ;
moderate-to-severe acne scarring. T e in rared aser the sma areas o therma damage s ough o as f aky skin
energy is absorbed by water and vaporizes tissue to a pre- or a ew days a ter the treatment. With ractiona resur-
cise depth dependent on the f uence, dwe time, and the acing, there are usua y ewer areas o pinpoint b eed-
number o passes. T e super cia epidermis and dermis ing than are usua y seen with conventiona resur acing.
are vaporized whi e skin appendages are e t intact. T e T ere ore, the hea ing time is signi cant y acce erated
regenerated epidermis is smoother and more even y pig- to just 5 to 7 days. Improvement was noted in 90% o
mented a ter the skin hea s. T erma e ects in the dermis patients without subsequent dyspigmentation or scar-
ring in a arge prospective study o atrophic acne scar
patients treated with a ractiona aser.43 However, ab a-
tive ractiona devices have been reported to produce
hypertrophic scarring—particu ar y at higher f uences
and when treating o the ace.
Conventiona resur acing asers shou d genera y not
be used on non- acia acne scars. T e use o conventiona
carbon dioxide and erbium asers can resu t in depigmen-
tation and hypertrophic scarring on the neck and chest.
Even on the ace, the incidence o a porce ain- ike appear-
ance a ter carbon dioxide resur acing is so high that many
dermato ogists imit the use o conventiona carbon diox-
ide asers to patients with Fitzpatrick skin types 1 and 2.
However, the ractionated c ass o resur acing asers has
a owed dermato ogists to treat non- acia esions sa e y
and e ective y.44 Deeper resur acing invo ving high f u-
Figure 47-13 A pati nt with ic pick scars imm diat y ences, high aser dwe times, and high density o indi-
a t r ractiona car on dioxid a ativ as r tr atm nt. vidua ab ation zones (pitch or coverage) must sti be
Not th individua ar as o a ation with whit rosting avoided on non- acia sites. Additiona y, it is possib e that
ar approximat y 350 µm in diam t r with norma skin ractionated asers, inc uding the thu ium aser (1927 nm,
560 in tw n. designed more or the treatment o pigmentation than
acne scars) wi arge y rep ace conventiona carbon diox-
ide resur acing.
COn Cl u s iOn
4
Non-ab ative tissue remode ing may a so be under-
T e pro i eration o treatments or acne scarring has given
taken without epiderma disruption with asers that
patients options or what was once a permanent cosmetic
target water as a chromophore.45 Mid-in rared asers
prob em. T e dermato ogist now has numerous therapeutic
such as the 1320 nm Nd:YAG and the 1415 nm diode
options to draw rom; however, a thorough understanding
aser target derma water to create therma injury and
o the pathophysio ogy and c assi cation o acne scarring
stimu ate co agen remode ing. Repeated treatments are
is required in order to proper y match patients with appro-
required and c inica e cacy is high y variab e.46 Since
priate therapy. Aggressive management to prevent acne
these asers are not pigment-speci c, they are sa e or
scarring shou d a ways be combined with regimens to treat
use in a skin types and especia y use u or ro ing scars.
acne scarring to optimize e ectiveness and cosmesis.
With appropriate caution, pigment-speci c asers such
as the 595 nm pu sed dye aser, the 1064 nm Nd:YAG
aser, and the 755 nm a exandrite aser have a so been
used or non-ab ative derma remode ing with variab e r ef er en Ces

C
h
and most y short-term resu ts.

a
p
A signi cant component o acne scarring invo ves ery- 1. Ghodsi SZ, Orawa H, Zoubou is CC. Preva ence, severity, and

t
severity risk actors o acne in high schoo pupi s: A commu-

r
thema and hypertrophic scars. K P and pu sed dye asers

4
nity-based study. J Invest Dermatol. 2009;129(9):2136– 2141.

7
are common y used to reduce both o these prob ems 2. Layton AM, Henderson CA, Cun i e WJ. A c inica eva ua-
without epiderma disruption. Most common y used is tion o acne scarring and its incidence. Clin Exp Dermatol.

:
:
the 595 nm pu sed dye aser that targets hemog obin as a 1994;19:303– 308.

A
chromophore. Macu ar erythema and te angiectasias are 3. Capitanio B, Sinagra JL, Bordignon V, Cordia i Fei P, Picardo

c
n
easi y treated with this moda ity. Ke oida or hypertrophic M, Zoubou is CC. Underestimated c inica eatures o post-
ado escent acne. J Am Acad Dermatol. 2010;63(5):782– 788.

S
acne scars a so respond but require many treatment ses-

c
4. Fabbrocini G, Annunziata MC, D’Arco V, et a . Acne scars:

a
sions. Purpura is a common short-term side e ect; b is-

r
Pathogenesis, c assi cation and treatment. Dermatol Res

r
i
tering and depigmentation can occur, especia y in high y

n
Pract. 2010;2010:893080. doi: 10.1155/2010/893080.

g
pigmented patients. 5. Rivera AE. Acne scarring: A review and current treatment
Because the pigment deposition in acne scarring is derma moda ities. J Am Acad Dermatol. 2008;59(4):659– 676.
6. Goodman GJ, Baron JA. Post acne scarring: A qua itative
as we as epiderma , u tra-short-pu sed asers used or so ar g oba scarring grading system. Dermatol Surg. 2006;32:1458–
entigines or tattoos shou d genera y not be used on acne 1466.
scars. Medica treatments are more ike y to bene t patients 7. Goodman GJ. Post-acne scarring: A short review o its patho-
with hyperpigmentation associated with acne scars. physio ogy. Australa s J Dermatol. 2001;42(2):84– 90.
An a ternative to carbon dioxide or erbium aser resur- 8. Sato , Kurihara H, Akimoto N, Noguchi N, Sasatsu M,
Ito A. Augmentation o gene expression and production o
acing is p asma skin resur acing.43 High-energy ionized promatrix meta oproteinase 2 by Propionibacterium acnes-
nitrogen is used to heat and vaporize the epidermis and derived actors in hamster sebocytes and derma brob asts:
super cia dermis. Because nitrogen is an inert gas, very a possib e mechanism or acne scarring. Biol Pharm Bull.
itt e oxidation occurs, resu ting in ess carbonization or 2011;34(2):295–299.
charring. Since there is no open wound ormation, there 9. Ho and DB, Jeremy AH, Roberts SG, Seukeran DC, Layton
AM, Cun i e WJ. Inf ammation in acne scarring: A compari-
is a quicker hea ing and ess risk or in ection and scar- son o the responses in esions rom patients prone and not
ring. T ere is very itt e pub ished research regarding this prone to scar. Br J Dermatol. 2004;150(1):72– 81.
moda ity; however, p asma skin resur acing may be equiv- 10. Layton AM. Optima management o acne to prevent scar-
a ent to non-ab ative aser sur acing.47 ring and psycho ogica seque ae. Am J Clin Dermatol. 2001;
2(3):135– 141.
11. Sha ita A. T e integra ro e o topica and ora retinoids in
the ear y treatment o acne. J Eur Acad Dermatol Venereol.
med iCa l t r ea t men t s 2001;15:43– 49. doi: 10.1046/j.0926– 9959.2001.00012.x
12. A am M, Hsu S, Dover JS, Wrone DA, Arndt KA. Nonab a-
For grade 1 acne scarring, which inc udes macu ar tive aser and ight treatments: Histo ogy and tissue e ects—
and mi d contour changes, medica treatments are A review. La sers Surg Med. 2003;33:30– 39.
o ten adequate therapies. Patients with severe scar- 13. sao SS, Dover JS, Arndt KA, et a . Scar management. In:
Kaminer MS, Dover JS, Arndt KA, et a ., eds. Atlas of Cosmetic
ring shou d be advised o the potentia bene it rom Surgery. Phi ade phia, PA: W.B. Saunders Company; 2002.
simp e and e ective medica treatments. Mu tip e topi- 14. Shah S, A ster S. Laser treatment o dark skin: An update.
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hydroquinone, aze aic acid, adapa ene, and hydroxy management o dermabrasion. J Am Acad Dermatol. 1986;15
(4):888– 889.
acids. Sunscreen shou d be recommended or patients 16. Kings ey M, Graber E, Soo Y, Bae-Harboe C. reatment o
who deve op hyperpigmentation a ong with acne scar- acne scarring with ab ative ractionated aser resur acing
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into areas o dynamic rhytides such as the periora and 17. West B, A ster S. E ect o pretreatment on the incidence
o hyperpigmentation o owing cutaneous CO2 aser resur-
periorbita areas o ten appear accentuated with musc e acing. Dermatol Surg. 1999;25(1):15– 17.
activity. Botu inum toxin injections can temporar- 18. Fi e D. Practica eva uation and management o atrophic acne
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re axing the surrounding skin. matol. 2011;4(8):50– 57. 561
4 19. Amin SP, Go dberg DJ. opica anesthetics or cosmetic and
aser dermato ogy. J Drugs Dermatol. 2005;4(4):455– 461.
35. Bernstein EF, Lee J, Brown DB, Yu R, Van Scott E. G yco ic acid
treatment increases type I co agen mRNA and hya uronic acid
20. Sobanko JF, Mi er CJ, A ster S. opica anesthetics or der- content o human skin. Dermatol Surg. 2001;27(5):429– 433.
mato ogic procedures: A Review. Dermatol Surg. 2012;38: 36. Grimes PE. T e sa ety and e cacy o sa icy ic acid chemica
709– 721. pee s in darker racia -ethnic groups. Dermatol Surg. 1999;25(1):
21. Harahap M, Abadir A, eds. Anesthesia and Analgesia in Der- 18–22.
matologic Surgery. New York: In orma Hea th Care; 2008. 37. A -Waiz MM, A -Sharqi AI.Medium-depth chemica pee s
22. Orentreich DS, Orentreich N. Subcutaneous incision ess in the treatment o acne scars in dark-skinned individ- ua s.
(subcision) surgery or the correction o depressed scars and Dermatol Surg. 2002;28(5):383– 387.
wrink es. Dermatol Surg. 1995;21(6):543– 549. 38. Lee JB, Chung WG, Kwahck H, Lee KH. Foca treatment o
23. Gott ieb SK. So t tissue augmentation. T e search or acne scars with trich oroacetic acid: Chemica reconstruction
imp antation materia s and techniques. Clin Dermatol. 1987; o skin scars method. Dermatol Surg. 2002;28:1017– 1021.
5(4):128– 134. 39. A ster S, West B. Resur acing o atrophic acia acne scars
24. Koranda FC. reatment and moda ities in acia acne scars. In: with a high-energy, pu sed carbon dioxide aser. Dermatol
Ho t , Jr., (ed.) Facial scars. Saint Louis: Mosby; 1989:278–289. Surg. 1996;22(2):151– 154; discussion 154– 155.
25. Kromayer E. Cosmetic reatment of Skin Complaints. Lon- 40. Rogache sky AS, Hussain M, Go dberg DJ. Atrophic and
don: Ox ord University Press; 1930. a mixed pattern o acne scars improved with a 1320-nm
S
26. Harmon CB, Mandy SH. Dermabrasion. In: Nouri K, Lea - Nd:YAG aser. Dermatol Surg. 2003;29(9):904– 908.
Khouri S, eds. echniques in Dermatologic Surgery. New York: 41. Kye YC. Resur acing o pitted acia scars with a pu sed
c
t
i
Mosby; 2003:163– 169. Er:YAG aser. Dermatol Surg. 1997;23(10):880– 883.
o
n
27. Goodman GJ. Dermabrasion using tumescent anaesthesia. J 42. Hantash BM, Bedi VP, Sudireddy V, Struck SK, Herron G,
4
Dermatol Surg Oncol. 1994;20:802– 807. Chan K. Laser-induced transepiderma e imination o der-
28. Freedman BM, Rueda-Pedraza E, Ear ey RV. C inica and his- ma content by ractiona photothermo ysis. J Biomed Opt.
:
:
to ogic changes determine optima treatment regimens or 2006;11(4):041115.
microdermabrasion. J Dermatolog reat. 2002;13(4):193– 200. 43. A ster S, Konda S. P asma skin resur acing or regeneration
A
29. Fabbrocini G, Farde a N, Mon reco a A, Proietti I, Innocenzi o neck, chest, and hands: Investigation o a nove device.
s
t
D. Acne scarring treatment using skin need ing. Clin Exp Dermatol Surg. 2007;33(11):1315– 1321.
h
Dermatol. 2009;34(8):874– 879. 44. ierney EP, Hanke CW. Ab ative ractionated CO2, aser
t
i
c
30. Go dberg DJ, Amin S, Hussain M. Acne scar correction using resur acing or the neck: Prospective study and review o the
a
ca cium hydroxy apatite in a carrier-based ge . J Cosmet La ser iterature. J Drugs Dermatol. 2009;8:723– 731.
n
d
T er. 2006;8(3):134– 136. 45. anzi EL, A ster S. Comparison o a 1450-nm diode aser
l
31. Burgess CM, Quiroga RM. Assessment o the sa ety and e - and a 1320-nm Nd:YAG aser in the treatment o atrophic
a
s
cacy o po y-L- actic acid or the treatment o HIV-associated acia scars: A prospective c inica and histo ogic study. Der-
r
acia ipoatrophy. J Am Acad Dermatol. 2005;52(2):233– 239. matol Surg. 2004;30:152– 157.
P
r
32. Goodman GJ. reatment o acne scarring. Int J Dermatol. 46. Bhatia AC, Dover JS, Arndt KA, Stewart B, A am M. Patient
o
c
2011;50(10):1179– 1194. satis action and reported ong-term therapeutic e cacy asso-
d
33. Shi man MA, ed. Autologous Fat ransfer: Art, Science, and ciated with 1,320 nm Nd:YAG aser treatment o acne scar-
u
Clinical Practice. Ber in; Heide berg: © Springer-Ver ag; 2010. ring and photoaging. Dermatol Surg. 2006;32:346– 352.
r
34. Park JH, Choi YD, Kim SW, Kim YC, Park SW. E ectiveness 47. Kono , Gro WF, Sakurai H, Yamaki , Soejima K,
s
o modi ed pheno pee (Exoderm) on acia wrink es, acne Nozaki M. reatment o traumatic scars using p asma skin
scars and other skin prob ems o Asian patients. J Dermatol. regeneration (PSR) system. La sers Surg Med. 2009;41:128–
2007;34:17–24. 130.

562
 Ch a p t e r

48 Management of Dyschromias
Clair Mari R y s Ha ito & Molly Wann r

Dyschro i is bro d ter used or disorders o ig ent - It inhibits the enzy e tyrosin se nd revents the conver-
tion. T ree co on ig ent ry issues re e s , ostin- sion o l -3,4 dihydroxy heny nine to e nin, e ding
tory hy er ig ent tion (PIH), nd der tohe iosis. to tered e noso e roduction nd incre sed e no-
A re ch r cterized by incre sed e nin de osition in the so e destruction.1,12 In co bin tion with sun rotection,
skin, though the thogenesis o e ch incre se is distinct. this edic tion c n i rove the e ider co onent
T e tre t ent o dyschro i is cco ished with to ic o e s . Hydroquinone 4% y be used twice d y
ther ies, che ic ee s, nd sers. Der tohe iosis is the on regu r b sis or short eriods o ti e. T e reco -
ost e si y tre t b e o the or s o dyschro i . Me s ended tre t ent ti e v ries nd r nges ro 8 weeks to
nd PIH re r ore ch enging. T is ch ter wi review 6 onths, de ending on the hydroquinone or u tion.13
the tre t ent o tions or e ch o these disorders. A though gener y we to er ted, hydroquinone c n
be ssoci ted with dverse e ects. It c n c use redness
nd irrit tion, nd s resu t, once d i y use is o ten rec-
Mel a s Ma o ended initi y. T e edic tion h s been re orted
to c use eye d ge nd shou d be used c utious y ne r
Me s is hy er ig ent tion o the ce, usu y seen in the eye. Cont ct der titis h s so been re orted.15
14

wo en with Fitz trick skin ty es III to IV nd ty ic y T ere is risk o exogenous ochronosis or b ue-b ck
distributed on the centr ce, r, or ndibu r re s. skin cu es c used by oc inhibition o ho ogentisic
T is chronic disorder occurs in 50% o regn nt wo en cid oxid se by hydroquinone. Exogenous ochronosis is
nd 10% o en.1 T e rev ence h s been re orted to be co on y seen with ro onged use, usu y within 6 to
40% in Southe st Asi nd to r nge ro s ow s 8% to s 60 onths in concentr tions s ow s 1% to 2%.16 T is
high s 80% ong L tin e es.2,3 side e ect is re orted to be co on in South A ric ,
Me s is c used by incre sed e nin ig ent de o- where high concentr tions o hydroquinone were v i -
sition in the skin triggered by u tr vio et ight, visib e ight, b e nd used or ong-ter eriods.16 Occu tion vit-
nd hor ones such s in regn ncy, or contr ce tion, i igo in hotogr hic deve o ers h nd ing hydroquinone
nd hor one re ce ent ther y.1,4 T yroid disorders, h s been re orted.17,18
genetic redis osition, nd ntiseizure nd hototoxic In 2006, the FDA r ised questions bout the s ety o
edic tions re other risk ctors th t y ect e s .1 hydroquinone19 due to concerns bout side e ects nd
E ider b rrier dys unction y so y ro e.5 otenti c rcinogenicity.20 In bor tory rodent stud-
T e ig ent tion in e s is due to en rged e no- ies, hydroquinone given syste ic y c used bone r-
cytes, incre sed e noso es, incre sed e nin content in row toxicity nd benign ren deno s. At this ti e,
ker tinocytes, nd e nin de osition in e no h ges.5,6 there is in dequ te evidence to su ort c rcinogenicity
r dition y, e s h s been c ssi ed s e ider , in hu ns.12 In Euro e, hydroquinone h s been b nned
der , or ixed ty e2,7; however, con oc icrosco y h s ro cos etic roducts nd is on y v i b e by re-
de onstr ted th t ost e s is ixed, with e ider scri tion. T e US FDA is considering si i r ro ch.12
hy er ig ent tion ying the ri ry ro e.5,8 Der ig- Hydroquinone is rescribed both one nd in co bin -
ent tion contributes ess to the c inic ni est tions; tion with other edic tions. One o the rst co bin tion
however the der brob sts y be invo ved in sign - cre s w s the K ig n–Wi is or u , which cont ins
ing thw ys th t e d to e s .5 Wood’s ight ex in - hydroquinone 5%, tretinoin 0.1%, nd dex eth sone
tion, historic y used to distinguish e ider nd der 0.1%.12 T e ddition o tretinoin enh nces hydroquinone’s
e s , h s not been ound to be c inic y ccur te.6,9,10 ightening e ect by reventing its oxid tion nd i rov-
T er ies or e s inc ude to ic ightening ing its e ider enetr tion. Corticosteroids, on the
cre s, che ic ee s, nd sers. Even or tre t ents other h nd, reduce irrit tion ro the two ingredients
h ve been tried, though the uti ity o this ro ch nd decre se ce u r et bo is , which inhibits e nin
needs to be urther e ucid ted.11 re t ent c n be ch - synthesis.12 An FDA- roved tri e co bin tion cre
enging nd is o ten ch r cterized by recurrence. Long- or e s is co osed o hydroquinone 4%, tretinoin
ter re ission c n be dif cu t to chieve. 0.05%, nd uocino one cetonide 0.01%. T is co bi-
n tion cre yie ded c e r nce o e s in 35% o
tients co red to 5% o tients who used hydroqui-
To pic a l Tr ea TMen Ts none 4% one.21
ri e co bin tion cre is indic ted or the short
Lightening agents. Hydroquinone (1,4 dihydroxybenzene) ter tre t ent o e s , nd shou d be used or no
is the ost co on y used ightening gent or e s . ore th n 8 weeks due to the risk o exogenous ochronosis
4 nd steroid-induced skin tro hy.22 However, review o
inter ittent or continuous use o tri e co bin tion ther- c h eMic a l peel s
y or onger dur tions o u to ye r de onstr ted
re tive y s e ro e with on y two c ses o i d tro hy.23 Whi e to ic roducts one c n be e ective, i rove-
In nother study, no st tistic y signi c nt histo tho- ent o e s y be enh nced with su er ci or
ogic signs o e ider or der tro hy were seen ter ediu de th che ic ee s. Che ic ee s re ove
6 onths o use o tri e co bin tion cre s.24 e nin nd c n incre se enetr tion o ightening gents.
Other ightening gents inc ude to ic retinoids, T e de th o ee nd concentr tion o ee ing gents re
ze ic cid, kojic cid, g yco ic cid (GA), scorbic cid, individu ized ccording to the tient’s history nd skin
e gic cid, rbutin, rucino , o igo e tides, icorice ty e. P tient consider tions re isted in b e 48-1. Skin
extr ct, equino , nd soy.1,12,25 Mequino nd soy, how- hototy e wi i ct ee choice. In ighter skin ty es,
ever, h ve been in y studied or ig ent tion in entigi- ore ggressive ee s c n be used. In d rker skin ty es, it
nes. Mequino h s been used e ective y or e s in is reco ended to st rt c utious y with su er ci ee s.
c se series o ve tients26 nd no tri s in e s h ve Gener y, ee s re contr indic ted or tients who
been done using soy. re regn nt or nursing, who h ve t ken isotretinoin
S
Retinoids, rticu r y tretinoin 0.05% nd d ene within 6 onths or h ve ctive her es si ex in ection.
c
t
For those who h d her es si ex in the st, ro hy c-
i
0.1%, h ve roduced decre se in the Me s Are nd
o
n
Severity Index (MASI) score by 37% nd 41%, res ec- tic ntivir s re given. Other ctors to consider inc ude
4
tive y ter 14 weeks o use.27 Aze ic cid 20% h s so connective tissue disorders or the resence o syste ic
dise se th t i cts he ing.41 S oking wi i ct he -
:
:
shown to be s e ective s hydroquinone 4% in 24 week
doub e-b ind tri or e s .28 Si i r y, study co - ing ter ee s s we .
A
ring kojic cid + GA re r tion with hydroquinone + Concurrent tre t ents wi ter ee resu ts. Sun
s
t
void nce nd use o sunscreen or the onth rior to
h
GA ound i rove ent o e s in both re r tions
ee is key rt o the tre t ent. retinoin he s enh nce
t
with no st tistic di erence between the two.29 In s it-
i
c
enetr tion nd ee intensity, nd retre t ent 2 to
a
ce r ndo ized study co ring scorbic cid 5% cre
n
4 weeks rior to ee y be he u . Discontinu tion
d
nd hydroquinone 4% cre , subjective i rove ent w s
L
ound to be 62% nd 93%, res ective y.30 o tretinoin 1 week rior wi essen the intensity o the
a
s
E gic cid 1%, rbutin 1%, nd the nt extr ct e gic subsequent ee nd incre se the s ety rgin, nd is
r
reco ended with ediu de th ee s. Hydroquinone
P
cid were co red in r ndo ized, ros ective, o en
r
o
be study. A three showed signi c nt decre se in decre ses PIH nd is use u djunct in d rker hototy es
c
t higher risk or hy er ig ent tion. St rting hydroqui-
d
ex eter ig ent density o e s with no signi -
u
none 1 to 4 weeks rior to ee ing nd continuing ost ee
r
c nt di erence ong the grou s.31 Rucino 0.3% h s so
wi be he u in ost tients with e s , but rticu-
s
shown signi c nt i rove ent o e s in r ndo -
ized, doub e-b ind cebo contro ed study.32 O igo- r y those with d rker skin.
e tides nd to ic iquiritin ( icorice) h ve so shown A ter ee s, strict sun rotection is required or t e st
c inic i rove ent o e s co red to vehic e 1 onth. P tients shou d be dvised to use gent e c e ns-
cre in s it- ce studies.33,34 ers nd skin c re roducts nd to void e ectro ysis nd
M inten nce ther y is o ten needed s the risk o w xing or the week o owing the ee .42 Hydroquinone
recurrence is high, rticu r y in sunny c i tes. Light- y be rest rted s soon s sever d ys ter the ee ,
ening gents c n be used once or twice week nd de ending on ee intensity. P tients shou d not tte t
incre sed to d i y when necess ry.7,35 A tern tive y, d i y
use o nonhydroquinone to ic such s tretinoin, ze- TAbLe 48-1
ic cid, kojic cid, or GA y be so used or in- p t tc d t p t
ten nce regi en. c m t p d
Photoprotection. Me s is sti u ted by u tr vio et
nd visib e ight nd s such, sun rotection is i ort nt. Skin phototyp
T e use o h ts, rotective c othing, nd sunscreen with Pr gnancy
high UVA nd UVB sun rotection ctor is critic rt
Nursing
o tre t ent. Without sun rotection, ost ther ies wi
be rgin y e ective. Isotr tinoin us
it niu dioxide nd zinc oxide re o ten reco - HSV history
ended in the tre t ent o e s 36 bec use they c n
rotect g inst visib e ight. However, these sunscreens Curr nt topical tr atm nts
e r white on the skin nd icronized versions do not R c nt las r or surg ry
o er the s e rotection.37,38 M ny sunscreen or u -
Hyp rtrophic scar history
tions h ve the dis dv nt ge o o ering ow UVA1 rotec-
tion nd visib e ight rotection 38,39 king the use o Conn ctiv tissu disord r
h t the ore i ort nt. Iron oxide, s n tern tive, Syst mic dis as
is shown to decre se visib e ight enetr tion.38 So e or-
u tions co bine hydroquinone with sunscreen. A Smoking
doub e-b ind study showed th t hydroquinone 4% co - Sun xposur /tan
bined with bro d-s ectru sunscreen c e red e s in
History o Vitiligo
564 96% o tients co red to hydroquinone one. 40
to ee their skin ter the rocedure nd shou d be
instructed to ex ect th t inten nce ee rotoco y
tion to GA ee in s it- ce tre t ent o e s , co -
ori eter n ysis showed n ver ge ightening o 2.93
4
43
be necess ry. Post ee tients c n ex ect s ight dryness nd 3.14 ight re ect nce (l v ue), res ective y, with no
with very su er ci ee s, or redness, sc ing nd even signi c nt di erence between the two.53
crusting sting 1 to 2 weeks with dee er ee s. Less requent y used or e s is SA, ker to ytic
Superf cial peels. T e ost co on y used ee s re bet -hydroxy cid. Co red with GA, SA is i o hi ic
su er ci . Su er ci ee s ect rt or o the e ider- nd re oves the interce u r i ids. T is resu ts in tten-
is nd cce er te e ider turnover.44 Pee s ci it te ing o residu e ider ce s nd ci it tes regener tion
ore uni or e ider structure nd ore even y dis- o the e ider is nd the i ry der is.54 In study co -
tributed e nin. Su er ci ee s inc ude h nd bet ring SA 30% with Jessner’s so ution, both so utions ro-
hydroxy cids, ino ruit ee s, Jessner’s ee , nd ow duced signi c nt reduction in e s nd MASI scores
concentr tions o trich oro cetic cid ( CA) (10%– 30%). (p < 0.0001) with no signi c nt di erence between the
GA is the ost studied che ic ee used or e s . two.55 However, in s it- ce study using our seri ee s
GA ee s cce er te the turnover o the e ider is by o SA 20% to 30% + hydroquinone 4% twice d y on one
decre sing the dhesion o corneocytes t the ower eve s side o the ce nd hydroquinone 4% one on the other

C
h
o the str tu corneu .45 GA so reduces e nin or- h o the ce twice d y, reduction in ig ent tion using

a
p
tion in e nocytes through inhibition o tyrosin se.46 n rrowb nd re ect nce s ectro hoto etry showed no sig-

t
r
Seri GA ee s re er or ed every 4 to 6 weeks with ni c nt di erence.56 Hence, SA ee s see ed to o er ini-

4
8
incre sing concentr tions s to er ted by the tient. T e dv nt ge co red with to ic tre t ent one.
ty ic st rting oint r nges ro 20% to 35% with 2 to Medium depth peels. Mediu de th ee s tre t the

:
:
3 inute ic tion. T e de th o the ee de ends on e ider is nd rt o the i ry der is, nd y be

M
the concentr tion nd ength o ti e it is e t on the skin use u to i rove der e s . So utions used to

a
n
be ore it is neutr ized with bic rbon te. One study ound chieve ediu de th ee re CA 35% to 50%, Jess-

a
g
c inic i rove ent o e s with GA 52.3% ied ner’s so ution + CA 35%, GA 70% + CA 35%, nd GA

m
43
or 3 inutes, but not t ower concentr tions. 70%.51 Skin desqu tion nd ree ithe i iz tion y t ke
GA ee s y enh nce the enetr tion o de ig ent- u to 7 to 10 d ys. P tients shou d be dvised th t they wi

n
t
ing gents or e s . Seri GA ee s co bined with h ve t e st week o downti e. Gent e skin c re with

o
odi ed K ig n’s cre (hydroquinone 4% + tretinoin void nce o sun nd ke-u is required. T ese ee s re

D
y
0.05% + hydrocortisone 1%) were co red to GA ee s ore unco ort b e th n su er ci ones, nd re edi-

s
c
h
one, nd showed decre ses in MASI score o 79.9% nd c tion is used or so e tients.41

r
o
63.1%, res ective y, ter 21 weeks.47 For d rker-skinned individu s with Fitz trick hoto-

m
T ere re ny other su er ci che ic ee s th t c n ty es IV-VI, ediu de th u ce ee s re not dvised

i
a
s
be used or e s th t y h ve si i r e ects to GA ee s due to the risk o PIH. However, ediu de th oc ee s
ccording to so e studies. retinoin 1% ee ing h s been o CA 30% to 50% or ight to d rk brown e s nd
shown to be co r b e to GA 70% ee ing in r ndo ized, oc ee s o CA 10% to 20% or eriocu r e s
doub e-b ind c inic tri invo ving 63 tients with bi ter h ve been ev u ted in 20 d rk-skinned tients.57 A ter
e s tre ted with our sessions done biweek y.48 e n o 3.2 ee sessions done 1 to 2 onths rt, 55%
A ino ruit cids (AFAs) re c rboxy ted ino cids. o tients h d good c inic res onse, with no signi c nt
A study th t co red seri GA ee s (20%– 70%) with co ic tions. Since requent su er ci ee s y induce
AFA ee s (20%– 60%) done every 2 weeks or 6 onths in hy er ig ent tion in so e d rk-skinned tients,58 oc
s it- ce tri showed no signi c nt di erence between ediu de th CA ee s y be nother o tion or these
the two in tre ting e s . In this study, AFA ee s were tients with reduced nu ber o c utious y used s ee
ess irrit ting nd better to er ted.49 sessions.
CA, nother co on y used ee or e s , is
deriv tive o cetic cid. CA c uses e ider rotein
den tur tion nd necrosis c using subsequent ree ithe i- l a s er s
iz tion ro e ider end ges. Histo ogic ndings
ter series o CA ee s showed n c nthotic e ider is L sers re not considered to be rst- ine tre t ent or
with rked decre se in the ount o e nin within e s , since there is rge degree o v ri bi ity in
the e ider ce s, s we s n incre se in the ount res onse. A tients shou d be counse ed bout the high
o co gen.50 risk o recurrence nd rti res onse. T ere re u ti e
Protein den tur tion is res onsib e or the skin rosting sers nd ight tre t ents th t h ve been tried or e s
observed ter one to two co ts o CA. T e intensity o inc uding the Q-switched ruby, ex ndrite nd Nd:YAG
the ee is re ted to concentr tion. Low CA concentr - sers, intense u sed ight (IPL), r ction ser, u sed dye
tions (10%– 30%) roduce su er ci ee .51 In study ser, Er:YAG, nd c rbon dioxide ser, with v rying ev-
co ring seri che ic ee s o GA (20%–35%) nd e s o success.12,59 T ere is ini evidence th t b tive
CA (10%– 20%) ied every 2 weeks or 12 weeks, the resur cing sers shou d be used or e s .12,60– 62
reductions to MASI scores were 79% nd 73%, res ective y, In nning or ser rocedure, thorough history
with no signi c nt di erence between the two.52 o edic conditions nd edic tions shou d be docu-
Jessner’s ee , co bin tion o ctic cid 14%, s icy ic ented. L sers re contr indic ted or tients who h ve
cid (SA) 14%, nd resorcino 14% in n coho b se, h s used isotretinoin in the revious 6 onths, h ve ctive
so been ound to i rove e s . Like CA, it resu ts her es si ex in ection or h ve viti igo.63 Antivir ro-
in rosting o the skin. In study co ring Jessner’s so u- hy xis c n be considered de ending on the ty e o ser 565
4 to be used, nd r ction ser is such n indic tion. Other
tient consider tions re ser de endent. Q-switched
Low uence Q-switched Nd:YAG ser in co bin -
tion with icroder br sion, hydroquinone, tretinoin,
sers re contr indic ted in tients with history o go d nd l - scorbic cid yie ded i rove ent in e s in
injections, or ex e. Strict sun void nce nd use o 27 subjects in n observ tion study.75 T e ck o PIH or
bro d-s ectru sunscreens is i ort nt or every tient hy o ig ent tion in this study w s ttributed to the use
with every ser. T e use o ightening gents be ore nd o very ow uences, the tre t ent interv , nd i ited
ter rocedure shou d be discussed with the tient, nu ber o tre t ents. A though this study ev u ted sub-
es eci y i they re rone to PIH. jects with re r ctory e s who i ed to ic tre t-
Fractional resur acing. Fr ction sers cre te is nds ents, it is unc e r how uch o the i rove ent c n
o d ge surrounded by nor skin.64 W ve engths o be ttributed to the ser or icroder br sion us
r ction sers inc ude 1540 n , 1550 n , 1927 n , to ic regi en. More d t is needed to u y e ucid te the
2790 n , 2940 n , or 10,600 n . Fr ction sers h ve dditive v ue o the Q-switched Nd:YAG.
65– 67
been shown to i rove e s , but recurrence h s Intense pulsed light (IPL). IPL is non ser ight source
been re orted with ong-ter o ow-u .68 th t e its w ve engths between 515 n nd 1200 n . As
T e 1550 n r ction ser is FDA c e red or tre t- with ser tre t ents, IPL c n i rove e s , but c r-
S
ent o e s nd h s been re orted to i rove this ries risk o PIH nd recurrence. In study o 89 tients
c
t
i
condition.65,66 A consensus er described e s s the with rec citr nt e s who underwent our tre t ents
o
n
63
ost dif cu t to tre t o the FDA-c e red indic tions. His- o IPL, the e n MASI decre sed ro 15.2 to 5.2 nd ter
4
to ogic nd u tr structur n ysis o e s be ore nd 3 onths to 4.5.84 Side e ects inc uded ede , erythe ,
:
:
ter our tre t ents with the 1550 n r ction ser con- icrocrusting, nd PIH in three tients. A study o hydro-
r ed decre se in the nu ber o e ider e nocytes quinone nd sunscreen with nd without IPL ound ore
A
nd ewer en rged e nocytes on e ectron icrosco y.67 i rove ent in the IPL r with decre se in e nin
s
t
h
However, r ndo ized study co ring the 1550 n r c- index o 39.8% versus 11.6% ter 16 weeks.85 At 6 onths
t
tion ser to tri e co bin tion hydroquinone cre osttre t ent, the IPL tre ted side showed so e recur-
i
c
a
ound both od ities to be e ective with no signi c nt rence with decre sed e nin index o 24.5%.
n
d
di erence between the two. Six onths osttre t ent, Vascular lasers. T e r tion e or the use o v scu-
L
a
recurrence o e s occurred in h o the subjects in r sers or ig ent ry conditions is two o d. First,
s
69
both grou s. Si i r y, r ction hotother o ysis nd u sed dye sers c n t rget e nin i used in conjunc-
r
P
CA 15% ee s h ve been shown to h ve co r b e r tes tion with co ression. Co ression re oves the ore
r
o
70
o i rove ent nd recurrence. A study o r ction high y bsorbed t rget (he og obin) nd ows ig en-
c
d
ser in Asi n skin re orted di inishing ef c cy over ti e t tion to be tre ted. Second, there y be connection
u
r
s we s PIH in so e subjects.71 P r doxic worsening o between tered v scu ture nd e s .86,87 In s ,
s
e s with di use hy er ig ent tion over the entire r ndo ized contro ed study, the u sed dye ser with
ce h s been re orted ter r ction ser tre t ent.69 co ression w s used in co bin tion with ri-Lu ®
T e 1927 n nd 10,600 n w ve engths h ve been cre versus ri-Lu ® one.59 T ere w s st tistic y
ev u ted or e s . T ese w ve engths h ve higher signi c nt reduction in the MASI score with the co bi-
bsor tion coef cient or w ter, con erring gre ter bi ity n tion tre t ent; however, PIH w s noted in so e sub-
to t rget ig ent in the e ider is. Signi c nt i rove- jects. In nother s study o 578 nd 511 n sers,
ent in MASI h s been shown ter 1 onth osttre t- st tistic y signi c nt reduction in MASI w s seen.72
ent using the 1927 n ser in sever studies.72– 74 In one
study, the 1927 n ser e icited 51% reduction in MASI
th t decre sed to 34% reduction 6 onths ter three to s u MMa r y
our tre t ents.74 Fr ction b tive ser t 10,600 n
h s so been shown to i rove e s with ower Me s is ch enging condition to tre t, nd every
recurrence r te i used in co bin tion with K ig n’s tient shou d be counse ed to ex ect recurrence. First ine
cre .75 Fr ction b tive ser h s been necdot y shou d be the use o to ic ther ies nd sun void nce. In
re orted to h ve higher incidence o recurrence nd PIH tre t ent resist nt tients, che ic ee s nd sers c n
th n non b tive r ction sers.76 be considered. Mu ti e studies su ort the use o g yco ic
Q-switched lasers. T e 1064, 755, nd 694 n ee s, though other ee or u tions h ve shown ef c cy
Q-switched sers h ve been studied or e s . T ese s we . Whi e ow uence Q-switched Nd:YAG in co bi-
sers tre t ig ent ry conditions by t rgeting e - n tion with icroder br sion nd hydroquinone h s
noso es. T e Q-switched Nd:YAG ser in rticu r shown recent ro ise, c ution shou d be exercised with the
c n t rget e noso es we into the der is. E ectron use o ny ser, since o the c rry risk with this dif cu t
icrosco y h s reve ed decre se in e nocyte vo - to tre t condition.
u e, ewer dendritic e nocytes, nd decre se in st ge
IV e noso es ter Q-switched Nd:YAG ser.77
T ere is itt e evidence or tre ting e s with po s Tin f l a MMa To r y
the Q-switched 694 nd 755 n sers, nd these sers h yper pig Men Ta Tio n
h ve resu ted in worsening o the condition.60,78,79 T e
Q-switched Nd:YAG ser h s been re orted to i rove PIH is nother skin disorder co on ong Fitz trick
e s , but h s resu ted in both hy er ig ent tion nd skin ty es III to VI, nd e rs s brown cu es or
unct te hy o ig ent tion in u ti e studies, even t tches in re s o revious skin irrit tion. PIH is c used
566 ow uences nd es eci y ter u ti e tre t ents.80– 83 by in tory edi tors th t sti u te e nocyte
synthesis nd tr ns er o ig ent to surrounding ker tino-
cytes. In ddition, in tion c n e d to bre kdown o the
g s bubb es roduced by c vit tion nd ru ture o e -
noso es.101– 103 A r ndo ized study o Q-switched ser
4
b s yer o the e ider is, re e sing e nin into the der- (ruby ser nd requency doub ed ND:YAG ser) tre t-
is. T is e nin is engu ed by der e no h ges nd ents or entigines ound th t s ight whitening roduced
e ds to urther disco or tion nd PIH t the site o injury.88 ess PIH co red with co ete whitening in Asi n
In tory rocesses th t y induce PIH inc ude tients.104 T e use o high-density r ction ser tre t-
in ection, in tory skin conditions or in so e c ses, ents h s higher risk o PIH co red with ow-density
94
tre t ent o skin disorders. Cut neous injuries, u- tre t ents. Coo ing o the skin, es eci y in s n -
osqu ous disorders, ergic re ctions, nd cne re to ic re s, is i ort nt s we to he decre se bu k
co on c uses o PIH. One study esti ted th t 65.3% tissue he ting nd revent PIH.
o A ric n A eric ns, 52.7% o His nics, nd 47.4% o
Asi ns h ve cne-induced PIH.89 T e occurrence o PIH
ter cos etic nd ser rocedures is not unco on, To pic a l Tr ea TMen Ts
with n incidence v rying ro 3.8% to 92% de ending on
the ty e o tre t ent.90 Lightening agents. o ic hydroquinone 2% to 4% is

C
h
T e n ge ent o PIH gener y invo ves e r y nd co on y used to tre t PIH nd c n be co bined with

a
p
e ective tre t ent o the under ying skin condition to tretinoin or α-hydroxy cids to incre se enetr tion nd

t
r
reduce urther in tion. A ic tion o to ic ight- ef c cy. C re shou d be ied when s re ding ightening

4
8
ening gents y be used to decre se e nin nd chieve gents over re s with ig ent tion bec use nor skin
uni or skin co or. Resur cing rocedures such s che - c n be “b e ched,” c using side e ect c ed “hydroqui-

:
:
ic ee s or sers y be dded to h sten skin nor iz - none h o.”105 However, or tients with ny PIH c-

M
tion. u es in who s ot tre t ent is not e sib e, hydroquinone

a
ied over the entire ected re .106

n
y be

a
g
In so e tients with irrit nt or ergic der titis to
pr e v en Tio n o f pih

m
hydroquinone, urther in tion nd PIH y occur.
esting s re such s on the u er inner r or

n
t
PIH c n be revented by e r y tre t ent o the in - sever d ys is dvis b e. A tern tive ightening gents

o
tory skin condition nd reducing the risk o irrit tion such s equino , ze ic cid, kojic cid, rbutin, soy, nd

D
y
ro to ic edic tions nd rocedures. Irrit tion ro ni cin ide c n be ied.

s
c
cne edic tions nd subsequent cne-induced PIH y

h
Retinoids h ve so de onstr ted ightening o PIH by

r
o
be ini ized by using to ic tre t ents with the ow- incre sing e ider turnover.107 In r ndo ized cebo

m
est e ective concentr tion, drug co bin tions with ois- contro ed tri , tretinoin 0.1% used or 40 weeks showed

i
a
s
turizing vehic es nd use o oisturizers concurrent y ightening o PIH esions by 40% co red to 18% in the
91
with edic tions. Avoid nce o ech nic irrit tion, cebo grou . E ider e nin content so decre sed
inc uding scr tching, rubbing, or icking, shou d so be by 23% in the tretinoin grou co red to 3% in the
e h sized to revent hy er ig ent tion.92 108
cebo grou . Likewise, t z rotene 0.1% cre nd
L ser rocedures nd che ic ee s c n e d to PIH, s d ene 0.1% ge h ve shown signi c nt i rove ent
we s sun ex osure ter tre t ent.93 T e risk o PIH c n o cne-induced PIH in tients with d rk skin ter 12 to
be reduced by voiding these rocedures in tients who 18 weeks o once d i y ic tion.109,110
h ve t n, nd dvising strict sun rotection with the use Photoprotection. Sun ex osure c n ex cerb te or
o sunscreen nd h ts or one onth rior to nd ter the c use PIH ter cos etic tre t ents. Use o bro d-s ec-
tre t ent.94 M tching rocedure to skin hototy e is so tru sunscreen is i ort nt to revent the worsening o
critic . For ex e, the risk o PIH ter r ction b - PIH through UV-induced e nogenesis. Photo rotec-
tive ser h s been re orted to be 92% in tients with skin tion be ore nd ter der to ogic rocedures such s
ty e IV co red with 23% in tients with skin ty es I ser is critic to reduce the risk o ig ent tion.
to III.95,96
T e use o hydroquinone rior to ser tre t ent h s
been dvoc ted s e ns to decre se PIH risk; however, c h eMic a l peel s
hydroquinone c n c use irrit tion nd y contribute to
PIH in so e c ses.97 o ic steroids y so decre se Adjunctive che ic ee s c n be done or PIH esions not
the risk o PIH i used ter ser tre t ents, but shou d res onding to to ic cre s. Pee s c n be ied to
be used s ring y to void steroid-induced side e ects.98 oc ized ig ented tch or over gener ized re with
In ddition, PIH is reduced by exercising c ution when sc ttered ig ented cu es. However, c re shou d be
se ecting tre t ent r eters in d rk-skinned individu- t ken in se ecting the ro ri te che ic ee to void
s. Aggressive che ic ee s or sers th t re high y irrit tion, which c n worsen PIH. Pre ee nd ost ee
se ective or e ider e nin re riskier. instructions inc ude strict d i y use o bro d-s ectru
L sers c n c use PIH. T ose th t he t the e ider is sunscreens nd void nce o sun ex osure to revent
ess intense y nd ow ti e or e ider coo ing re ddition ostin tory esions.
re erred to ini ize th t risk. Long- u sed sers h ve Superf cial peels. Su er ci ee s re gener y we
ower risk o PIH co red with Q-switched sers.99,100 to er ted by skin ty es. A series o ee s y be ben-
T e choice o ser end oint y in uence the risk s e ci or those tients, inc uding d rk-skinned tients,
we . T e end oint o Q-switched sers is whitening o who h ve ostin tory ig ent ry ch nges. How-
the skin in the re o tre t ent nd corres onds to the ever, che ic ee s shou d be used c utious y so s not 567
4

A B
S
c
t
Figure 48-1 b or (A) and a t r (B) s v n tr atm nts o ractional phototh rmolysis (1550 nm) or acn scarring and
i
o
postinf ammatory hyp rpigm ntation.
n
4
:
:
to worsen PIH, es eci y in d rk-skinned tients. For o the tre t ent o cne-induced PIH, the use o to ic
A
tients with cne-induced PIH, che ic ee s c n ct tre t ents (tri e co bin tion cre , ze ic cid with
s
both s co edo ytic nd ightening gents. steroid nd hydroquinone 4%– 6%), sers (595 n ong-
t
h
Bet hydroxy cid ee s, such s SA 20% to 30% nd its u sed dye ser nd/or 1064 n QS ND:YAG) or co bi-
t
i
deriv tive i ohydroxy cid (LHA) 5% to 10%, induce ker - n tion o three showed signi c nt g ob i rove ent
c
a
to ysis by disru ting interce u r ink ges between e ider- in PIH (50%, 55.6%, nd 70.6%, res ective y) with no sig-
n
d
ce s.42 Bet hydroxy ee s re i o hi ic nd, there ore, ni c nt di erence between the grou s.114
L
a
re rticu r y use u in tre ting cne-induced PIH. In As c se series re orted i rove ent in PIH with
s
study o 24 Asi n subjects with cne-induced PIH, SA ee s the 1064 n Q-switched Nd:YAG t ow uence.115 T e
r
P
done biweek y or 3 onths showed n incre se in ighten- Q-switched Nd:YAG w s so shown to be e ective in the
r
o
c
ing o esions, though it w s not st tistic y signi c nt.111 tre t ent o cne-induced PIH in Asi n tients in one
d
In nother study, SA 20% co bined with nde ic cid ros ective study. Subjects given ve week y 1064 n QS
u
r
10% ee showed st tistic y signi c nt i rove ent ND:YAG ser tre t ents with conco it nt benzoy er-
s
in PIH co red with GA 35% ee s done biweek y or oxide twice d i y were co red to subjects tre ted with
6 onths (59.8% nd 46.3%, res ective y).112 week y co edone extr ction nd intr esion injection
GA ee s y so be used s djuncts in tre ting PIH. rocedures in ddition to benzoy eroxide twice d i y.
Given th t che ic ee s c n so induce PIH, it is dvis- A ter 1 nd 3 onths, b inded ev u tor ssess ents
b e to st rt tre t ent with ow GA concentr tion, r- showed i rove ent in PIH in the ser grou nd itt e
ticu r y in skin o co or tients. In study o 16 A ric n to no i rove ent in PIH in the non ser grou .116
A eric n subjects with ci PIH, GA ee s (50%– 68%) Fr ction resur cing h s so been re orted to i rove
with to ic regi en o 2% hydroquinone + 10% GA nd PIH (see Fig. 48-1). In one c se re ort, PIH w s reduced
0.05% tretinoin were co red to to ic regi en use by 50% to 75% ter ve sessions o r ction 1550 n
one. T e ee grou showed th t the ddition o six GA erbiu -do ed ser over 2 onth eriod.117 In nother
ee s done every 3 weeks reduced hy er ig ent tion ore re ort using the s e device, PIH i roved by 95% ter
r id y th n to ic s one, though there w s no st tisti- three sessions.118
c y signi c nt di erence between the two grou s.113
CA 10% to 30% nd Jessner’s ee y so be e ec-
tive y used s ight sur ce ee s but ck studies su ort- s u MMa r y
ing tre t ent or PIH.
Medium depth peel. Mediu de th ee s y c use Prevention o PIH by choosing the tre t ent th t best
urther PIH, es eci y in tients with d rk skin. Mediu tches skin hototy e is i ort nt. T e choice o
ee s re usu y done s sing e tre t ent, c using tre t ent shou d not ex cerb te in tion or ig-
redness or sever d ys nd signi c nt desqu tion. ent tion. o ic tre t ent c n i rove PIH, nd in
Mediu de th ee s y be use u or cne-induced PIH nonres onders, ee s nd sers c n be considered.
with ssoci ted der ig ent tion or de ressed sc rs.
However, bec use o the risk o hy er ig ent tion, strict
sun void nce, d i y sunscreen, nd otenti y hydroqui- Der Ma To h el io s is
none re dvised.
Der tohe iosis is ter used to describe u tr vio et
ight-induced ch nges or “ hoto ging.” It is induced by
l a s er s chronic u tr vio et ight ex osure, s o osed to intrinsic
ging, which is due to genetic ctors.119 Ch r cteristics c n
Studies nd c se re orts h ve shown v ri b e success in inc ude uneven ig ent tion, e stosis, wrink es, erythe ,
568 using di erent sers or PIH. In retros ective n ysis te ngiect si , ctinic ker tosis, nd textur ch nges.
 T e dyschro i o der tohe iosis in rt is c used by
so r entigines. So r entigines, or iver s ots, re we -
induces skin ig ent tion by direct y nd indirect y
in uencing e nocytes nd ker tinocytes. Chronic
4
de rc ted cu es in sun-ex osed re s th t v ry in size u tr vio et ight h s been ssoci ted with so r entigines,
ro ew i i eters to ore th n centi eter, nd v ry ig ented ctinic ker toses, nd hy o ig ented s ots.125
in co or ro ye ow nd ight brown to d rk brown.120 In skin-gr ted ouse ode s, u tr vio et B h s so been
T ey h ve been shown to be strong y ssoci ted with ge shown to sti u te ker tinocyte roduction o inter eu-
nd cu u tive nd inter ittent sun ex osure. In study kin-1 h , which e ds to incre sed ig ent roduction
o risk ctors in C uc si n wo en, so r entigines were nd so r entigo or tion.126
ssoci ted with d rker skin co or, t nning c city, his- Sun rotection through the use o bro d-s ectru sun-
tory o reck es, sun ex osure beh vior, nd current int ke screens o t e st SPF 30, sun void nce between 10 a m
o or contr ce tive or rogesterone tre t ents.121 nd 2 pm nd use o rotective we r such s ong-s eeved
Histo ogic y, so r entigines h ve n incre sed nu - shirts nd wide-bri ed h ts re i ort nt to revent
ber o e nocytes with two e ider tterns: (1) t- hotod ge nd int in tre t ent resu ts.
tened e ider is with b s e nosis nd (2) e ider Retinoids. Retinoids h ve been roven histo ogic y
hy er si with budding rete ridges co osed o dee y nd c inic y to i rove ging skin. o ic retinoids

C
h
ig ented b s oid ce s.122 Re ect nce con oc icros- inc ude retino , retin dehyde, tretinoin, isotretinoin,

a
p
co y studies o so r entigines show th t their edges res- t z rotene, nd d ene. A ong these, tretinoin is the

t
r
ent with ore ctive e nocytes, which roduce ore ost studied, nd the histo ogic ch nges ssoci ted with

4
8
e nin nd h ve horizont y s re ding dendrites. T is it re e ider hy er si , co ction o the str tu
nding y ex in the centr ightening observed when corneu , thickening o the gr nu r yer, reduced e -

:
:
using b e ching gents nd the occurrence o PIH t the nocytic hy ertro hy, incre sed co gen or tion, nd

M
edges o so r entigines ter ser ther y.123 nor iz tion o the e r nce o e stic tissue.127 Long-

a
n
In ddition to so r entigines, the resence o sebor- ter use o tretinoin y reduce e ider nd e -

a
g
rheic ker toses dds to the uneven ig ent tion in ho- nocyte ty i , decre se eriv scu r in tion, nd

m
128,129
to ged skin. Seborrheic ker toses re benign ye ow- or incre se e ider ucin.
brown-r ised u es th t e r “stuck on.” U tr vio et retinoin-induced e ider desqu tion nd tyrosi-

n
t
ight contributes to the growth o these ker toses. In n se inhibition i rove dyschro i .130,131 I rove ent o

o
s it- ce study o 148 truck drivers, so r entigines, seb- hotod ged skin nd ightening o so r entigines h ve

D
y
orrheic ker toses, nd ctinic ker toses were ound to been re orted with the use o tretinoin in u ti e stud-

s
c
h
be incre sed on the ore sun-ex osed “driver’s side” o ies (see Fig. 48-2).130– 138 In 24 onth r ndo ized -

r
o
the ce.124 cebo contro ed tri , signi c nt i rove ent in rhytides

m
T e tre t ent o dyschro i is centr to the tre t- nd entigines in the tretinoin 0.05% grou w s seen by

i
a
s
ent o der tohe iosis. However, the tre t ent y the ourth onth nd sust ined throughout the 24 onth
so i rove te ngiect si s, wrink es, nd texture. o i- study.139 Loc irrit tion, sc ing, nd erythe c n i it
c ther y, che ic ee ing, nd ser y be done to the use o to ic tretinoin, nd s resu t, s eci ized
i rove o the e tures o der tohe iosis nd re r- e o ient or u tions h ve been deve o ed.
ticu r y he u or the dyschro ic co onent. Other retinoids studied or the tre t ent o so r en-
tigines re d ene nd t z rotene. In study on the
tre t ent o ctinic ker tosis nd so r entigines using
To pic a l Tr ea TMen Ts d ene, tients (75% o who h d so r entigines)
were r ndo ized to receive d ene 0.1% or 0.3% or
Photoprotection. As with the n ge ent o other vehic e ge once d i y or onth then twice d i y or u
dyschro i s, hoto rotection is critic rt o the to 9 onths. A ter 9 onths, d ene 0.1% nd 0.3%
tre t ent rogr or der tohe iosis. U tr vio et ight showed signi c nt ightening o esions in 57% nd 59%

A B

Figure 48-2 b or (A) and a t r (B) 16 w ks o tr tinoin cr am 0.05% at night. 569

4 o tients, res ective y nd n i rove ent in wrink es
b sed on hotogr h ev u tions.140 z rotene 0.1% ge
be required or r ised growths.153 For rge r ised esions
curett ge y be he u , or these esions y require sev-
h s so been shown to yie d so e i rove ent in ne er sessions o cryother y.
wrink ing, ott ed ig ent tion, entigines, nd other
signs o hotod ge ter 24 weeks in two rge u ti-
center tri s.141,142 c h eMic a l peel s
Lightening agents. Hydroquinone h s been wide y
used or the tre t ent o sun-induced hy er ig ent tion. Che ic ee s i rove der tohe iosis by both
In tre t ent study o ore r so r entigines, hydro- decre sing wrink es nd ightening ig ent tion. Ch r-
quinone 2% with cyc odextrin, n bsor tion enh ncer cteristic histo ogic nd u tr structur e tures o the
ied twice d i y or 2 onths, reduced e nin, thereby skin ter ee ing inc ude decre sed e ider intr cy-
decre sing the size o the entigines.143 In nother study, to s ic v cuo es, decre sed so r e stosis, incre sed
hydroquinone 5% co bined with v rying concentr tions ctiv ted brob sts, nd org nized r e rr ys o co -
o tretinoin (0.1% on the ce, 0.2% on the trunk, nd 0.4% gen.154,155
on the extre ities) w s used in Asi n tients with hy er- T e ty e nd de th o ee de ends on the histo ogic
S
ig ent tion disorders, inc uding 90 with so r entigines. de th o the c inic ch nges o der tohe iosis tre ted.
c
t
i
A ter 2 onths o twice d i y ic tion, ightening o E ider ig ent tion, ne wrink ing, nd rough tex-
o
n
esions w s observed in 82.2% o tients b sed on n r- ture c n be n ged by su er ci ee s. So r entigines,
4
rowb nd re ect nce s ectro hoto etry.144 ch r cterized by ig ented b s ce s, wi be tre ted
:
ore e ective y when using ediu de th ee s re ching
:
Another we -studied ightening gent or so r entigi-
nes is equino or 4-hydroxy niso e co bined with treti- the i ry der is, whi e dee wrink es c n be tre ted
A
noin. Mequino is heno ic gent th t is be ieved to ct with dee er ee s re ching the reticu r der is.51
s
t
h
s co etitive inhibitor o tyrosin se.12 In two r ndo - Superf cial peels. GA 50% ee s, done week y or 4
t
ized, contro ed, doub e-b ind u ticenter c inic studies weeks, h ve been shown to i rove texture, decre se
i
c
ne wrink es nd ctinic ker toses nd s ight y ighten
a
invo ving 1175 subjects, equino 2%/tretinoin 0.01%
n
d
w s co red with its ctive co onents nd vehic e or so r entigines in r ndo ized doub e-b ind contro ed
L
tri .156 Sing e or u ti e onth y SA 30% ee s h ve so
a
the tre t ent o so r entigines. A ter 24 weeks o twice
s
d iy ic tion, higher ro ortion o subjects in the been re orted to de ig ented s ots, decre se sur ce
r
P
equino 2%/tretinoin 0.01% grou h d t e st oder te roughness nd reduce ne ines.157 SA deriv tive LHA 5%
r
o
i rove ent on both the ore r nd ce (52.6% nd to 10% nd GA 20% to 50% ee s were co red in r n-
c
do ized, sing e-b inded, s it- ce study. A ter 12 weeks
d
56.3%) co red to equino 2% one (24% nd 33%),
u
o biweek y ee sessions, both LHA nd GA ee s de -
r
tretinoin 0.01% one (35% nd 43%), nd vehic e (17%
s
nd 19%). Bene t w s int ined osttre t ent in both onstr ted signi c nt reduction o ne ines (41% nd 30%
tri s ter 4 nd 24 onths. As with hydroquinone nd o subjects, res ective y) nd hy er ig ent tion (46% nd
tretinoin, equino c n resu t in oc irrit tion.145 34% o subjects, res ective y) with no signi c nt di er-
Mequino 2%/tretinoin 0.01% h s been co red with ence between the two.158
hydroquinone 3% in r ndo ized, doub e-b ind study.146 Medium depth peels. Mediu de th ee s re ching
A gre ter ro ortion o tients in the equino 2%/ the i ry der is tre t dyschro i in der tohe iosis
tretinoin 0.01% grou showed signi c nt i rove ent e ective y, es eci y in tients with ight skin. CA ee s
in ore r entigines co red to the hydroquinone 3% 35% to 50% c n be used one nd CA 35% c n be used in
grou b sed on the hysici n’s g ob ssess ent (60% vs. co bin tion with Jessner’s so ution or GA 70%.
38%). More tients in the equino 2%/tretinoin 0.01% CA ee s y be used s u ce ee or oc y
grou so h d i rove ent in ci entigines, but this s oc ized s ot ee or t rget re s. CA 40% h s
nding w s not st tistic y signi c nt. been shown to oder te y i rove so r entigines nd
skin texture, but not wrink es in one study on hoto ged
skin.159 Foc use o CA 50% to 65% h s so been studied
c r yo Th er a py or the tre t ent o so r entigines nd h s shown to be
e ective in 42 o 49 tients with d rk skin.57
Liquid nitrogen c n be used to tre t entigines nd sebor- Co bin tion ee s y ow dee er enetr tion o
rheic ker toses. Me nocytes nd ker tinocytes re sus- CA 35% without roducing severe co ic tions. Jess-
ce tib e to co d injury t −4° to −7°C nd −20° to −30°C, ner’s so ution or GA 70% ee ing is done rst o owed by
res ective y.147 Side e ects inc ude redness, swe ing, ic tion o CA 35%.
crusting, ede , bu or tion, hy er ig ent tion, nd Sever studies h ve shown th t co bin tion o GA
hy o ig ent tion, which c n be er nent.130 70% + CA 35% to 40% success u y ighten irregu r ig-
Cryother y h s been co red to che ic ee ing. ent tion nd so r entigines in non ci hoto ged
In ightening so r entigines, sever studies h ve shown skin.150,160 In s it- ce study, GA 70% + CA 35% nd
cryother y to be su erior to CA 30% to 35%,148,149 but Jessner’s + CA 35% were co red in hoto ged skin.
not to ediu de th ee with CA 35% + GA 70%.150 Both ee s equ y ightened entigines. However ore
Cryother y w s ound to be su erior to e r y gener - org nized e stic bers nd wider i ry der is were
tion sers,151 but in erior to newer techno ogies such s observed using GA + CA suggesting dee er enetr -
Q-switched sers.152 tion. Jessner’s + CA ee , on the other h nd, showed
Si i r to entigines, seborrheic ker tosis esions gen- ro onged erythe in so e tients, nd histo ogic y
570 er y res ond to cryother y. Longer reeze ti es y gre ter in tory res onse.161
 l a s er s
tients deve o ed erythe nd our tients deve o ed
hy er ig ent tion ter Q-switched ruby ser.97
4
Intense pulsed light (IPL). IPL sources re nons eci c
L sers nd ight sources e ective y tre t der tohe iosis, nd c n t rget the dyschro ic co onent o der tohe-
nd v riety o tre t ent o tions exist. So e sers c n iosis s we s the te ngiect si s. Cuto ters re ro-
t rget s eci c co onent o der tohe iosis such s vided with so e IPL devices to ow s ight y ore s eci c
entigines, whi e others y i rove ore th n one co - t rgeting o entigines. Si i r to ong- u sed sers, tre t-
162
onent. Q-switched ruby, ex ndrite, nd Nd:YAG s ent o entigines resu ts in esion d rkening ter sever
we s ong- u sed dye sers nd ex ndrite sers c n inutes s we s erythe nd swe ing in the tre t-
tre t entigines vi t rgeting o the chro o hore e nin. 169
ent. During the week ter tre t ent, nd s e ider-
IPL, r ction hotother o ysis, nd b tive sers such turnover occurs, tients shou d ex ect the entigines
s CO 2 erbiu sers wi tre t dyschro i in ore non- to s ow y reso ve. y ic y, sever tre t ents re needed.
s eci c nner. An o en study er or ed on tients with ci entigi-
Q-switched lasers. Q-switched ruby ser, Q-switched nes tre ted with IPL three to ve ti es showed th t 40% o
Nd:YAG ser, nd Q-switched ex ndrite sers re e - tients h d ore th n 50% c e r nce nd 16% o tients

C
nin-s eci c sers nd h ve been shown to i rove en-

h
h d ore th n 75%c e r nce o esions.170 P tients with s

a
tigines.101,163– 165 QS ruby ser h s been shown to i rove

p
so r entigines res onded we to IPL, but tients with rge

t
so r entigines in 91 tients ter one to two sessions by

r
or co bin tion o s nd rge esions showed oor

4
t e st 75%.163 A retros ective study o the QS ex ndrite

8
res onse. So r entigines o the h nds h ve so been shown
ser ound th t t e st 50% o entigines c e red in h o to i rove with IPL ter ve tre t ents in n o en study.

:
the subjects ter t e st three tre t ents.164 QS Nd:YAG

:
A ong the 31 tients, 62% h d ore th n 50% i rove-
(532 n ) h s so been shown to e ective y c e r 60% o

M
ent nd 23% h d ore th n 75% i rove ent.171

a
so r entigines tre ted by t e st 75% in study invo ving

n
Fractional resur acing. Fr ction hotother o ysis

a
37 tients ter sing e tre t ent.165

g
tre ts der tohe iosis nd dyschro i vi nons eci c
I edi te y ter ser ex osure, whitening o e ider

m
icrosco ic co u ns o injury in the e ider is nd der-
ig ented esions is seen.166 T is whitening reso ves sever is. T ese zones o d ge cont in e nin nd degen-

n
inutes ter ex osure. Redness nd swe ing re ex ected,

t
er ted der teri , nd re extruded through the

o
nd over the course o the next sever d ys, d rkening o e ider is. E ider nd der re ir occurs in the

D
the re wi occur. A ter 1 to 2 weeks, there is desqu -

y
re s o d ge.172 T e bene t o r ction hotother-

s
c
tion o the crusted re , nd in so e c ses i d redness

h
o ysis is th t sever co onents o der tohe iosis c n

r
re ins, which dissi tes over ti e. P tients shou d be

o
be i roved, inc uding entigines, texture, rhytides, nd

m
w rned bout the risks o hy er ig ent tion nd hy o ig- te ngiect si . Mu ti e di erent w ve engths re used in

i
a
ent tion, nd dvised to void sun ex osure to ini ize

s
r ction devices, which c n resu t either in ther d -
these risks. Sc rring nd b isters re r re side e ects. ge or b tion in the zones o injury.
Long-pulsed lasers. T e ong- u sed dye ser nd ex- Fr ction resur cing using the 1550 n erbiu -do ed
ndrite 755 n ser c n be used to tre t ig ented esions. ber ser h s been studied in 50 tients with oder-
Long- u sed sers ty ic y require ore tre t ents to te hotod ge, rhytides, nd dys ig ent tion. T ree
c e r entigines co red with Q-switched sers, but onth y ser tre t ents were done on ci nd non -
re ssoci ted with ower risk o PIH in studies o Asi n ci skin nd c inic i rove ent b sed on hotogr hs
skin.97,99 Sever inutes ter ser ex osure, there wi be w s gr ded by two b inded ssessors using qu rti e scoring
d rkening o the entigo. As with the Q-switched sers, sc es. C inic i rove ent by t e st 51% to 75% w s
redness, swe ing, hy er ig ent tion, hy o ig ent tion, seen in 73% nd 55% o tients with ci nd non ci
sc rring, nd b isters re otenti side e ects. tre ted skin, res ective y ter 9 onths.173 Non b tive
A study o ong- u sed ex ndrite ser i roved so r r ction 1540 n ser h s so been studied or tre t ent
entigines ter one tre t ent in 16 tients by t e st o hotod ged skin nd ctinic ker toses in 17 tients.
50%.167 A s it- ce study co ring Q-switched nd T ree onths osttre t ent there w s 51% to 75% c ini-
ong- u sed ex ndrite sers or the tre t ent o reck es c i rove ent in 12 tients nd >75% i rove ent in
nd so r entigines showed no st tistic y signi c nt di - three tients ter two to three tre t ents.174
erence between the two in i roving ig ent tion. PIH, In gener , u ti e tre t ents re needed to i rove
however, occurred ore requent y in the Q-switched der tohe iosis. P tients shou d ex ect redness nd
tre t ent (22%) th n in the ong- u sed tre t ent (6%). swe ing ter tre t ent or sever d ys nd y notice
P tients so re orted ore severe in, erythe , nd s d rk dots in the re o tre t ent. P tients y
ede during the Q-switched ex ndrite tre t ent.168 ex erience t n- ike e r nce th t reso ves over 1 to
Long- u sed dye ser with co ression h s so been 2 weeks o owing tre t ent.
co red with Q-switched ruby ser in study o 18 T e 1927 n r ction thu iu ber ser h s so
J nese tients with so r entigines. T e ddition o been ev u ted or the tre t ent o non ci hotod -
g ss co ression e i in tes he og obin bsor tion, ge. we ve tre t ent re s in nine tients who under-
thus owing the tre t ent o ig ent tion. T e degree went three onth y ser rocedures were ev u ted.
o c e r nce w s 83.3% or ong- u sed dye ser nd 70.3% C inic i rove ent w s gr ded by b inded ssessor
or Q-switched ruby ser. Co ic tions were subst n- on sc e o 0 to 4 one onth ro the st tre t ent.
ti y decre sed or the ong- u sed dye ser. On y our Me n i rove ent in hotod ge w s 3.25 nd e n
tients deve o ed erythe nd none deve o ed hy er- i rove ent in entigines w s 3.3 re resenting 51% to
ig ent tion ter ong- u sed dye tre t ent, whi e 75% i rove ent (see Fig. 48-3).175 571
4
S
c
t
i
o
n
4
:
:
A B
A
s
Figure 48-3 b or (A) and a t r (B) on tr atm nt ractional phototh rmolysis 1927 nm and on tr atm nt Q switch d
t
h
ru y las r.
t
i
c
a
n
dyschro i .151,181– 184 Ab tive sers c n e d to subst nti
d
T e 1927 n ser y be b e to t rget dyschro i
L
with ewer tre t ents, but h s ore downti e co red i rove ent in rhytides s we s der tohe iosis. Resur-
a
s
to non b tive od ities. It c n so be used to tre t cing the skin with CO 2 ser ob iter tes the e ider is
r
P
ctinic ker toses nd cu r seborrheic ker toses.176,177 nd rti y b tes the u er i ry der is. Ab tive
r
o
P tients shou d ex ect redness, swe ing, nd d rken- resur cing ro otes e ider nd der re ode ing
c
ing o entigines o owed by e ider ee ing th t sts with or tion o co gen nd e stin.181 A though exce -
d
u
roxi te y 1 week nd redness th t c n st roxi- ent cos etic outco es c n be chieved with the b tive
r
s
te y 1 onth. During he ing, tients re dvised to sers, these devices re o er tor nd technique de en-
y in etro tu or nother b nd oisturizer two dent with gre ter risks nd downti e or the tient. T e
to three ti es er d y. risks or ost rocedure co ic tions such s erythe ,
Fr ction b tive sers such s the CO 2, erbiu , nd in ection, PIH, hy o ig ent tion, nd sc rring re higher
YSGG sers h ve shown ef c cy in tre ting hotod - with the CO 2 ser co red with the r ction devices.175
ged skin. T e b tive r ction sers re rticu r y
suited or tre t ent o rhytides, but c n tre t s ects
o der tohe iosis inc uding dyschro i . T e 2790 n s u MMa r y
Er:YSGG ser h s been ev u ted or tre t ent o ho-
tod ge nd wrink es in 11 subjects.178 Most subjects Der tohe iosis is res onsive to ost tre t ent od i-
showed i rove ent in tone/texture (93%), dyschro i ties. A though to ic edic tions c n work, ser tre t-
(82%), nd wrink es (54%) ter two ci tre t ents. ents nd ee s rovide ore subst nti resu ts. T e
Ab tive Er:YAG ser (2940 n ) h s so been studied in choice o too de ends on the tient nd his or her re-
28 tients with i d to oder te ctinic d ge. wo erred b nce between e se o recovery nd s eed o
onths ter the st tre t ent, subjects h d i rove- i rove ent.
ent.179 In ros ective sing e-b inded study o the r c-
tion b tive CO 2 ser, 45 tients received two to three
ser tre t ents. Me n i rove ent w s 48.5% or skin c o n c l u s io n
texture, 50.3% or skin xity, 53.9% or dyschro i , nd
52.4% or over cos etic outco e.180 Disorders o dyschro i re co on. Che ic ee s,
Fr ction b tive sers h ve the ost downti e o the sers, nd to ic tre t ents re e ective or dychro-
r ction devices. In gener , tients shou d ntici te i . However, e ch subty e is tre ted so ewh t di -
1 to 2 tre t ents, nd shou d ex ect redness, swe ing, erent y, nd rognosis is etio ogy de endent. o ic
nd oozing ter tre t ent. He ing c n be ug ented tre t ents c n be used or e s , PIH, nd der to-
through the use o coo so ks. Every 3 to 4 hours, tients he iosis, nd re o ten rst ine in these disorders, r-
re dvised to y w ter-so ked g uze to the ce o - ticu r y or e s nd PIH. Che ic ee s re he u
owed by ic tion o etro tu . T e jority o the in dyschro i , with g yco ic ee s better studied or
he ing rocess is cco ished in week, but redness e s nd SA ee s or cne-induced PIH. Der to-
nd in so e c ses swe ing c n st onth. he iosis is high y res onsive to ser tre t ent, but y
Ablative lasers. CO 2 sers o owed by erbiu sers not be s e ective in PIH nd e s . In ddition to the
572 were so e o the rst devices used or the tre t ent o etio ogy o the dyschro i , choice o tre t ent wi be
in uenced by the tient’s skin ty e, with ore ggres-
sive tre t ents used ore c utious y in d rker skin ty es.
21. Cest ri , Adj dj L, Hux M, Shi izu MR, Rives VP. Cost-
e ectiveness o xed co bin tion o hydroquinone/
4
tretinoin/ uocino one cre co red with hydroqui-
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Loc iz tion o e nin ig ent tion in the skin with 157. K ig n D, K ig n AM. S icy ic cid ee s or the tre t-
r
Wood’s . Br J of Dermatol. 1977;96:245– 248. ent o hoto ging. Dermatol Surg. 1998;24(3):325– 328.
s
138. Gi chrest B. re t ent o hotod ge with to ic treti- 158. Ores jo C, Y tsk yer M, H nsenne I. C inic to er nce nd
noin: n overview. J Am Acad Dermatol. 1997;36:S27–S36. ef c cy o c ry oy s icy ic cid ee co red to g yco ic
139. K ng S, Berg e d W, Gott ieb AB, et . Long-ter ef c cy cid ee in subjects with ne ines/wrink es nd hy er ig-
nd s ety o tretinoin e o ient cre 0.05% in the tre t- ented skin. J Cosmet Dermatol. 2008;7(4):259– 262.
ent o hotod ged ci skin: two-ye r,r ndo ized, 159. Hu hreys R, Werth V, Dzubow L, K ig n A. re t ent
cebo-contro ed tri . Am J Clin Dermatol. 2005;6(4):245– o hotod ged skin with trich oro cetic cid nd to ic
253. tretinoin. J Am Acad Dermatol. 1996;34(4):638– 644.
140. K ng S, Go d rb M , Weiss JS, et . Assess ent o d - 160. Cook KK, Cook WR Jr. Che ic ee o non ci skin using
ene ge or the tre t ent o ctinic ker toses nd en- g yco ic cid ge ug ented with CA nd neutr ized b sed
tigines: r ndo ized tri . J Am Acad Dermatol. 2003; on visu st ging. Dermatol Surg. 2000;26(11):994– 999.
49(1):83– 90. 161. se Y, Ost d A, Lee HS, et . A c inic nd histo ogic
141. K ng S, Krueger GG, nghetti EA, et . z rotene ev u tion o two ediu -de th ee s. G yco ic cid ver-
Cre in Photod ge Study Grou . A u ticenter, sus Jessner’s trich oro cetic cid. Dermatol Surg. 1996;
r ndo ized,doub e-b ind tri o t z rotene 0.1% cre 22(9):781– 786.
in the tre t ent o hotod ge. J Am Acad Dermatol. 162. Po der KD, L nd u JM, Vergi is-K ner IJ, Go dberg LH,
2005;52(2):268–274. Fried n PM, Bruce S. L ser er dic tion o ig ented
142. Phi i s J, Gott ieb AB, Leyden JJ, et ; z rotene esions: review. Dermatol Surg. 2011;37(5):572– 595.
Cre Photod ge C inic Study Grou . Ef c cy o 163. S dighh A, S tee S, Muh ghegh-Z hed G. Ef c cy nd
0.1% t z rotene cre or the tre t ent o hotod ge: dverse e ects o Q-switched ruby ser on so r entigines:
12- onth u ticenter, r ndo ized tri . Arch Dermatol. ros ective study o 91 tients with Fitz trick skin ty e
2002;138(11):1486– 1493. II, III, nd IV. Dermatol Surg. 2008;34(11):1465– 1468.
143. Petit L, Piér rd GE. An ytic qu nti c tion o so r entigi- 164. K g i S, As hin A, W t n be R, et . re t ent o 153
nes ightening by 2% hydroquinone-cyc odextrin or u - J nese tients with Q-switched ex ndrite ser. La sers
tion. J Eur Acad Dermatol Venereol. 2003;17(5):546– 549. Med Sci. 2007;22(3):159– 163.
144. Yoshi ur K, H rii K, Aoy , Ig . Ex erience with 165. Ki er SL, Whee nd RG, Go dberg DJ, Anderson RR.
strong b e ching tre t ent or skin hy er ig ent tion in re t ent o e ider ig ented esions with the re-
Orient s. Pla st Reconstr Surg. 2000;105(3):1097– 1108. quency-doub ed Q-switched Nd:YAG ser. A contro ed,
145. F eischer AB Jr, Schw rtze EH, Co by SI, A t n DJ. T e sing e-i ct, dose-res onse, u ticenter tri . Arch Der-
co bin tion o 2% 4-hydroxy niso e (Mequino ) nd 0.01% matol. 1994;130(12):1515– 1519.
tretinoin is e ective in i roving the e r nce o so r 166. W t n be S. B sics o ser ic tion to der to ogy. Arch
entigines nd re ted hy er ig ented esions in two dou- Dermatol Res. 2008;300(1):S21–S30.
b e-b ind u ticenter c inic studies. J Am Acad Derma- 167. r e i JP, Kw n JM, Meeh n KJ, et . Use o ong- u se
tol.42(3):459– 467. ex ndrite ser in the tre t ent o su er ci ig ented
146. J rr tt M. Mequino 2%/tretinoin 0.01% so ution: n e ec- esions. Dermatol Surg. 33(12):1477– 1482.
tive nd s e tern tive to hydroquinone 3% in the tre t- 168. Ho SG, Yeung CK, Ch n NP, Shek SY, Ch n HH. A co -
576 ent o so r entigines. Cutis. 2004;74(5):319– 322. rison o Q-switched nd ong- u sed ex ndrite ser or
 the tre t ent o reck es nd entigines in orient
La sers Surg Med. 2011;43(2):108– 113.
tients. 177. Po der KD, Mith ni A, H rrison A, Bruce S. re t ent o
cu r seborrheic ker toses using nove 1927-n r c-
4
169. Go dberg DJ. Current trends in intense u sed ight. J Clin tion thu iu ber ser. Dermatol Surg. 2012;38(7 Pt
Aesthet Dermatol. 2012;5(6):45– 53. 1):1025–1031.
170. K w d A, Shir ishi H, As i M, et . C inic i rove ent 178. W gr ve SE, Kist DA, Noy ner- ur ey A, Ze ickson BD.
o so r entigines nd e he ides with n intense u sed ight Mini y b tive resur cing with the con uent 2790 n
source. Dermatol Surg. 2002;28(6):504– 508. erbiu :YSGG ser: i ot study on s ety nd ef c cy.
171. S s y H, K w d A, W d , Hir o A, Oiso N. C inic La sers Surg Med. 44(2):103– 111.
e ectiveness o intense u sed ight ther y or so r entigi- 179. L idoth M, Y gi Odo ME, Odo LM. Nove use o
nes o the h nds. Dermatol T er. 2011;24(6):584– 586. erbiu :YAG (2940-n ) ser or r ction b tive hoto-
172. ierney EP, Koub DJ, H nke CW. Review o r ction ho- ther o ysis in the tre t ent o hotod ged ci skin:
tother o ysis: tre t ent indic tions nd ef c cy. Dermatol i ot study. Dermatol Surg. 2008;34(8):1048– 1053.
Surg. 2009;35(10):1445– 1461. 180. ierney EP, H nke CW. Fr ction ted c rbon dioxide ser
173. W nner M, nzi EL, A ster S. Fr ction hotother o y- tre t ent o hoto ging: ros ective study in 45 tients nd
sis: tre t ent o ci nd non ci cut neous hotod - review o the iter ture. Dermatol Surg. 2011;37(9):1279–1290.
ge with 1550-n erbiu -do ed ber ser. Dermatol Surg. 181. A ster S. Cut neous resur cing with CO2 nd erbiu :
2007;33(1):23– 28. YAG sers: reo er tive, intr o er tive, nd osto er tive

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174. L idoth M, Ad tto M, H ch i S. re t ent o ctinic consider tions. Pla st Reconstr Surg. 1999;103(2):619– 632.

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ker toses nd hotod ge with non-cont ct r ction 182. A ster S. C inic nd histo ogic ev u tion o six

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1540-n ser qu si- b tion: n ex vivo nd c inic ev u - erbiu :YAG sers or cut neous resur cing. La sers Surg

t
tion. La sers Med Sci. 2012;28(2):537– 542. Med. 24:87– 92.

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175. Po der KD, H rrison A, Eub nks LE, Bruce S. 1927-n 183. A ster S, Lu ton JR. Erbiu :YAG cut neous ser resur c-

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r ction thu iu ber ser or the tre t ent o non ci ho- ing. Dermatol Clin. 2001;19(3):453– 466.
tod ge: i ot study. Dermatol Surg. 2011;37(3):342–348. 184. So o no B, H nt sh MB, Fincher EF, Wu P, G dstone HB.

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176. Weiss E , Br uer JA, Ano ik R, et . 1927-n r ction T e erbiu icro ee : ros ective, r ndo ized tri o

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resur cing o ci ctinic ker toses: ro ising new ther- the e ects o two uence settings on ci hoto ging. J

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eutic o tion. J Am Acad Dermatol.68(1):98– 102. Drugs Dermatol. 10(2):179– 185.

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 Ch a p t e r

49
Laser and Light Treatment of
Pigmented Lesions
Mussa at Hussai , Suza L. Kilm , & Oma A. Ib ahimi

In t r o d u c t Io n Currently, six wavelengths o QSL are available,

which include the Q-switched ruby laser (694 nm), the
Q-switched alexandrite laser (755 nm), the Q-switched
One o the earliest applications o lasers in medicine was
Nd:YAG laser (1064 nm), the Q-switched requency-
Leon Goldman’s use o the ruby laser to treat pigmented
doubled (FD) Nd:YAG laser (532 nm), and the Q-switched
lesions in 1963. At that time, the ability o a normal-mode
Nd:YAG laser with dye handpieces (585 and 650 nm).
ruby laser with a 0.5 ms pulse duration was noted to selec-
Many QSLs are also capable o operating in a microsecond
tively destroy pigmented structures in the skin.1 Although
mode, which can be used to target melanosomes.
seemingly ironic in hindsight, the eld o laser dermatol-
ogy then shi ted to the use o continuous wave modali-
ties such as the carbon dioxide laser (10,600 nm) and the Lo n g -Pu Ls ed La s er s
argon laser (418 nm), which were used in a non-selective
ashion to treat pigmented lesions. Needless to say, the Although long-pulsed (LP) lasers (pulsed dye laser [PDL]
results were o ten unpredictable, with complications such at 585– 595 nm, LP ruby at 694 nm, LP alexandrite at 755
as scarring and dyspigmentation. nm, LP Nd:YAG at 1064 nm, and LP diode at 800 nm)
A new era in the laser treatment o pigmented lesions have pulse durations that are in the millisecond domain,
arrived when R. Rox Anderson and John Parrish o Mas- they are capable o targeting melanosomes in clinical
sachusetts General Hospital described the theory o practice because melanosomes have a tendency to clus-
selective photothermolysis,2 which provided laser sur- ter together, particularly in Caucasians and Asians. T us,
geons with a plat orm on which to per orm the selective the overall size o the clustered melanosomes may enable
treatment o pigmented lesions. More recently, ractional con ned spatial damage with a millisecond laser pulse.
photothermolysis has been introduced to non-selectively reatment with LP lasers may be done in combination
improve the appearance o certain types o undesirable with diascopy to remove competing chromophores such
pigment,3– 7 but this time without the risks and downsides as hemoglobin.
o the continuous wave lasers.

In t en s e Pu Ls ed LIg h t s ys t ems
La s er s a n d IPL s o u r c es
Intense pulsed light (IPL) systems are high-intensity
u s ed t o t r ea t Ben Ig n pulsed sources that emit polychromatic light in a broad
PIg men t ed Les Io n s wavelength spectrum o 515 to 1200 nm. he wave-
length determines not only the absorption behavior but
also the penetration depth o the light. With the aid o
Q-s w It c h ed La s er s di erent cut-o ilters (515– 755 nm), the wavelength
spectrum can be optimized to ilter out light that does
Melanosomes have a size range o roughly 0.5 to 1.0 µm,
not correspond to the type and depth o the target
which translates into a thermal relaxation time in the
structures.9,10 Similarly, the wavelength spectrum can
nanosecond to microsecond range. Clinically these struc-
be adapted to suit the patient’s skin type, thereby mini-
tures can be targeted through the use o Q-switched lasers
mizing adverse e ects in those with darker skin types.9
(QSLs). QSLs store large amounts o energy in the opti-
he pulse duration o IPL systems is in the millisecond
cal cavity through the use o an optical shutter. When the
domain.
laser is red, it releases high-powered pulses o extremely
short duration, in the nanosecond range,8 resulting in a
photomechanical tissue reaction. QSLs are the current Fr a c t Io n a L Ph o t o t h er mo Lys Is
modality o choice in the treatment o pigmented lesions.
While most lesions can be signi cantly improved, com- Fractional photothermolysis is the treatment o the skin
plete clearance may be di cult to achieve and there is no with an array o laser beams that create vertical columns
guarantee that the skin will appear normal a ter treatment. o thermal damage or tissue ablation 3 (see Chapters 35 and
In addition, the operator’s ability, clinical knowledge, and 36). It has been observed that melanin may also be elimi-
training in the laser device are major actors a ecting the nated in the microscopic epidermal necrotic debris that is
outcome o treatment. ormed with ractional photothermolysis.4
t yPes o F PIg men t ed Les Io n s super cial location o epidermal pigmented lesions, depth
o penetration is not a signi cant issue. T ese lesions are
4
amenable to treatment with pulse durations ranging rom
Pr o Per Les Io n c La s s IFIc a t Io n nanoseconds to milliseconds. Ablative and non-ablative
ractional photothermolysis lasers are also capable o treat-
Prior to any laser treatment, proper evaluation o the pig- ing epidermal pigmented lesions, although use o this tech-
mented lesion must be per ormed. It is the opinion o the nology would be more appropriate in the context o a di use
authors that every lesion, but especially one that is new epidermal pigmentary aberration.
or changing, should be evaluated by a dermatologist prior
to treatment. Because o the increasing prevalence o L i i . Lentigines are small, sharply demarcated,
melanoma, there are numerous ethical and medicolegal round- to oval-shaped, light- to dark-brown macules.
implications that must be considered when per orming T ey can be rom a ew millimeters to a ew centimeters
laser treatment on pigmented lesions.11 Lesion classi ca- in diameter and ound on any area o the body including
tion will assist the laser surgeon in determining a treat- mucous membranes. Senile lentigines are acquired lesions
ment approach to each individual pigmented lesion. In resulting rom sun exposure. T ey are ound on sun-ex-

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particular, understanding the depth o the target pigment posed areas, such as the back o the hands, ace, and neck.

a
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distribution, epidermal, dermal, or a combination o both, T e number o lesions increases with age. Histologically,

t
is essential to selecting a treatment regimen. the basal cell layer o ten shows an increase in the num-

4
9
ber o melanocytes in the epidermis with increased lev-
LASer Tr eATMen T Of ePId er MAL PIg - els o melanin.12 Lentigo simplex can o ten be ound on

:
:
Men Ted LeSIOn S. Epidermal pigmented lesions can younger patients without a predilection or sun exposure

L
be approached with multiple laser modalities due to their and is histologically similar to a senile lentigo. Lentigines

a
s
super cial location. T e 532 nm (FD Nd:YAG) and 694 nm can also be a component o various cutaneous syndromes,

a
(ruby) wavelengths are the pre erred wavelengths or epi- such as lentiginosis pro usa, Peutz– Jeghers syndrome,
dermal lesions, ollowed by the 755 nm (alexandrite) and, Moynahan syndrome, and Leopard syndrome.

L
the least e ective, the 1064 nm wavelength (Nd:YAG). T e Nanosecond QSLs (Fig. 49-1), LP lasers, and IPL

i
h
shorter wavelengths are particularly attractive because they devices have demonstrated e cacy in the clearance o

t
T
have relatively greater melanin absorption and, given the lentigines.13– 21 T e desired treatment endpoint with QSLs

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A B

Figure 49-1 A. L ti i s o th o sum o th ha . B. App a a c ollowi two t atm ts with a QS

al xa it las .
579
4 would be to use a f uence that produces brisk whitening
without epidermolysis. LP lasers and IPL devices have a
s b i K .Seborrheic keratosis (SK)
is a benign epidermal proli eration o keratinocytes with
much more subtle clinical endpoint that includes lesion a normal or slightly increased number o melanocytes,
graying or darkening. increased melanization o keratinocytes, and a thickened
hyperkeratotic epidermis. T ese lesions range rom tan to
ep li F kl . Ephelides orreckles are 1
black in color. T ere are several histopathologic variants
to 3 mm tan-brown macules, which are present in sun-
but the acanthotic type is the most common one. Derma-
exposed areas and not on mucous membranes. T ey
tosis papulosa nigra is an entity that is clinically and his-
not only darken but almost always recur on exposure to
tologically similar to SK and occurs on the ace in patients
ultraviolet (UV) rays. Histologically, the number o me-
with darker skin types.
lanocytes is unchanged rom that o neighboring skin,
Lasers reported to treat SKs success ully include QSLs
although the melanosomes are typically larger.22 Axillary
(Fig. 49-2), LP lasers and UltraPulse CO 2 laser, ractional
reckling, the only type o ephelide that appears on non–
erbium-doped ber laser, ractional CO 2 laser, and the
sun-exposed skin, is seen in von Recklinghausen’s disease
1927 nm thulium ber laser.33– 38 Multiple treatment ses-
(neuro bromatosis).
S
sions may be needed or thicker lesions. It is important
T e treatment algorithm and desired endpoints or
c
to note laser therapy has not been shown to be any more
t
treatment o ephelides are analogous to those or lentigi-
i
o
e ective than treatment with non-laser destructive meth-
nes.17,18 Recurrence is high without strict UV protection
ods (cryotherapy and electrodesiccation).20,21 or these
4
ollowing treatment. Postlaser treatment, sun exposure
lesions
and tanning booths should be avoided or at least 6 weeks
:
:
and sunblocks should be used extensively.
A
LASer Tr eATMen T Of ePId er MAL/
c é Li m l .
s
Ca é-au-lait macules d er MAL PIg Men Ted LeSIOn S
t
h
(CALMs) are well-circumscribed, light- to dark-brown,
t
B k ’ n v . Becker’s nevus is an organoid ham-
i
c
hypermelanotic f at lesions which may be 1 to 20 cm in
a
diameter. CALMs may be ound in the normal population artoma, i.e., a developmental anomaly consisting o ab-
as an isolated nding or may be part o various syndromes, normalities in pigmentation, hair ollicles, and smooth
L
a
especially when multiple, such as von Recklinghausen’s muscle. T e lesion is predominantly f at but can have a
s
disease, or neuro bromatosis, Mar an syndrome, and papular verrucous sur ace. Becker’s nevus usually arises in
P
McCune– Albright syndrome.11 T ere are no malignant males around the age o 15 years. It is usually a light to me-
o
c
tendencies in CALM.12,23 Histologically, hypermelanosis dium brown patch that may be 2 to 30 cm in diameter. In-
is present within the epidermis. Giant melanosomes are creased hair growth ollows the onset o pigmentation and
u
present only in patients with neuro bromatosis, in both is localized to the area o the patch. Histologically, there is
s
basal melanocytes and keratinocytes. hyperpigmentation in the basal layer with variable acan-
Although CALMs are thin epidermal lesions that are thosis and hyperkeratosis. Although there is an increased
in theory amenable to treatment with pigment-speci c number o melanocytes, no nevus cells are ound.39,40
lasers, in clinical practice they are notoriously di cult to When treating a Becker’s nevus, one should consider
treat. Multiple treatments over a period o months or even both o its components, i.e., the hair and the pigmented
years may be required. Lesions may remain clear or up patch. est spots are recommended be ore treatment
to a year with spontaneous or UV-induced recurrences in is commenced. For hair removal, longer-pulsed lasers
more than 50% o cases. QSLs have been reported to have should be considered.41 reatment with Q-switched or
some success at improving CALMs.24,25 T e authors have millisecond lasers or IPLs have variable success, whether
also used the LP alexandrite laser with good success with used alone or in combination. High recurrence rates and
the hypothesis that the longer pulse width allows or col- hyperpigmentation have been reported, probably due to
lateral thermal damage to non– pigment-containing mela- the pathophysiology o this entity.42,43 We have ound in
nocytes. our experience that the LP alexandrite lasers can be used
or the simultaneous treatment o both the hair and pig-
n v s pil . Nevus spilus is a lesion characterized ment components (Fig. 49-3). Fractional photothermolysis
by darkly pigmented macules or papules within a eld has been reported to non-selectively improve the undesir-
that corresponds clinically to a CALM. T ese lesions able pigment component, but long-term study data rom a
are mostly present on the trunk or lower extremities.26 larger number o patients are needed.5
T ere are reports o melanoma arising within the nevi o
the nevus spilus, but in general, it is not considered to m l . Melasma is an acquired disorder o hyper-
be a precursor o malignant melanoma.27– 29 When treat- pigmentation, usually symmetric, that occurs most o ten
ing these lesions, care ul clinical assessment is impor- on the ace. Melasma has a genetic predisposition, with
tant and any suspicious changes should be evaluated by over 50% having a amily history,44– 48 and can be exacer-
biopsy.29 bated by sun exposure, hormonal f uctuations, and other
Pigment-speci c QSLs have been success ully used to less de ned actors. Melasma appears to be more common
treat the nevus spilus.30,31 Many studies have reported in emales, people with constitutive brown skin color, and
good responses to IPL treatments as well.32 We have also those who have greater sun exposure. Additionally, pa-
ound LP lasers to be bene cial in improving the appear- tients with endocrine disorders or cancers, nutritional
ance o these lesions, particularly the more darkly pig- disorders, and hepatic diseases may also present with
mented speckled areas. melasma.
580
 4

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A B

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Figure 49-2 A. S bo h ic k atosis p io to t atm t. B. f ollowi o t atm t with a QS al xa

s
i
o
it las . C. A clust o s bo h ic k atos s. D. f ollowi th t atm ts with a 532 m KTP las .

s
A B

Figure 49-3 A. B ck ’s vus B. f ollowi th t atm ts with a LP al xa it las , imp ov m t i both th hyp
t ichosis a th pi m t po tio is ot .

581
4 Clinically three patterns are recognized on the basis o
their distribution:
deposition o either melanin or hemosiderin or both. His-
tologically, PIH can have both epidermal and dermal com-
ponents.
i. A centro acial pattern
reatment o PIH with QSLs and IPL devices is mostly
ii. A mandibular pattern
unsatis actory with little improvement, or even the possi-
iii. A malar pattern
bility o exacerbation o the PIH. Strict sun avoidance and
topical bleaching creams should considered rst-line ther-
T ere are three histologic types that are recognized:
apies. Epidermal PIH has been reported to respond better
i. Epidermal (70%) than dermal PIH.59 Be ore commencing laser treatment,
ii. Dermal (10%– 15%) test spots are recommended.
iii. Mixed—occurring in both epidermis and dermis
(20%)
n v l i n vi
Histologically, in the epidermal type, melanin deposi- Acquired Nevomelanocytic Nevi. Acquired nevomela-
tion occurs in all layers o the epidermis. In the dermal nocytic nevi begin to appear in early childhood and can
S
type, melanin-laden macrophages are present in a perivas- mani est throughout li e.65 T ey are mostly asymptomatic,
c
t
acquired pigmented lesions, usually <1 cm in size, and can
i
cular distribution in both super cial and deep dermis. Sub-
o
types o melasma are best identi ed by examination under present as macules, papules, or nodules.
4
a Wood’s lamp. Epidermal melasma exhibits enhancement T ey are subdivided into junctional, compound, and
intradermal nevi based on the location o melanocytic
:
:
o color contrast when examined with a Wood’s lamp,
while no enhancement o color contrast is observed in nevus cells. Nevi o ten have a natural course o evolution
A
patients with dermal melasma.49 starting as junctional nevi, and maturing to compound
s
t
nevi and ultimately intradermal nevi. T e exact actors
h
QSLs, LP lasers, and IPL sources have been evalu-
inf uencing the natural history o acquired nevomelano-
t
ated in the treatment o melasma.50– 58 In our experience,
i
c
cytic nevi are not ully known, although sun exposure
a
melasma is a challenging condition to treat with lasers.
Strict sun precaution and inhibitors o pigmentation (such is likely a actor in the induction o nevi in exposed
L
areas.66– 69
a
as hydroquinone) must be part o any treatment regimen.
s
In addition, we nd the recurrence rate and appearance Laser treatment o nevi should be undertaken with
caution. All nevi should be evaluated by a dermatologist
P
o postinf ammatory hyperpigmentation (PIH) to be high
o
with laser therapy.43,59– 63 A recent study using a low-f uence prior to treatment to ensure that there is a low level o
c
QS Nd:YAG laser in combination with microdermabra- suspicion or atypia or malignancy. Nevi can be treated
u
sion has been reported to result in >75% improvement in with both QSL and LP laser that are melanin-speci c.
In our experience, smaller and thinner nevi respond
s
22 o 27 patients.64
Fractional lasers (Fig. 49-4) have also been approved by better to QSLs. All three QSL systems (QS ruby, alex-
the Food and Drug Administration (FDA) or the treat- andrite, and Nd:YAG lasers) are e ective with minimal
ment o melasma, and success ul treatment has been side e ects, although recurrence rates are high. LP lasers
reported.6 However, despite low treatment parameters have been shown to more e ciently eradicate these
and well-spaced treatment intervals, PIH occurs in 50% nevi, but hypertrophic scarring can occur.70 Skin cool-
o treated patients. ing may be turned o to increase e cacy but carries the
risk o excessive thermal damage to the epidermis. Abla-
P i f h p pi i . Any tive resur acing with an Er:YAG laser has been reported
cutaneous condition associated with inf ammation or in- in a small cohort to result in cosmetically satis actory
jury to the skin may result in PIH, characterized by the results.71

A B

Figure 49-4 A. M lasma. T st spots with QSL a LP las i ot yi l imp ov m t, whil o ablativ actio al su
aci t st spots w ou to b h lp ul. B. App a a c ollowi th o ablativ actio al su aci t atm ts
582 with low siti s.
Congenital Nevomelanocytic Nevi (CMN). By de ni-
tion, CMN appear at birth, but they may arise during
promising results.81 Ablative lasers such as the CO 2 and
Er:YAG lasers have been used alone or in combination
4
in ancy. T ey are mostly light or dark brown in color with QSLs. Arguing against any role or lasers in promot-
and are classi ed by size. Small CMN are <1.5 cm, ing malignant degeneration, a long-term histologic study
medium CMN are between 1.5 to 20 cm, and large/ o patients with congenital nevi treated with normal
giant CMN are >20 cm in size.72,73 It has been mode ruby laser ailed to show any malignant changes
reported that congenital melanocytic nevi, in par- a ter 8 years.82
ticular large/giant CMN, demonstrate an increased
potential or the development o melanoma,74– 77 but LASer Tr eATMen T Of d er MAL PIg Men Ted
pooled data suggest that the risk or malignant trans- LeSIOn S
ormation is signi cantly lower at ~2.5% or large/
garment-sized congenital nevi.78 Interestingly, nearly hal n v o n v I . Nevus o
o patients with a large/ garment-sized CMN have psy- Ota is a congenital dermal pigmented lesion. Although
chological or social di culties.79 Arguments have been most commonly unilateral, a rare bilateral variant orm
made both or and against treatment o CMN. Laser irra- known as Hori’s nevus can also occur.83 It is a conf uent

C
h
diation o CMN continues to be controversial, as oppo- mixture o blue and brown hyperpigmented patches on

a
p
nents o laser treatment argue that it can theoretically the skin and mucous membranes and is innervated by

t
induce a neoplastic change in the cellular behavior o the the ophthalmic or maxillary divisions o the trigeminal

4
9
lesion. However, no direct correlation has been made ner ve. T e conjunctiva, sclera, external auditor y canal,
linking laser treatment and malignant trans ormation tympanic membrane, oral and nasal mucosa, and hard

:
:
o CMN. Proponents o laser treatment o CMN argue palate may also be involved. Occasionally, there are pap-

L
that laser treatment can reduce the burden o nevome- ular, or even nodular portions in the pigmented patch.83

a
s
lanocytes, thereby reducing the risk o melanoma trans- T e blue hue o the lesion results rom the presence o
ectopic melanocytes in the deep dermis, which produce

a
ormation, while also improving the appearance o these
lesions and lessening their psychosocial burden. a yndall e ect. Histologically, dermal melanocytes are

L
A variety o lasers have been used to treat CMN. QSLs scattered in the upper and deep reticular dermis.84,85

i
h
have been popular or treatment because their nanosec- Rare cases o melanoma arising in the nevus o Ota have

t
T
ond pulse durations closely match the thermal relax- been reported,86 but these lesions are generally consid-
ered benign.

a
ation time o melanosomes. Responses range rom poor

t
m
to excellent. Multiple treatments are needed, and it has Clinically and histologically, the nevus o Ito is quite
been noted in one study80 that a ter a single initial laser similar to the nevus o Ota, except that it occurs in the

t
areas innervated by the supraclavicular and cutaneous

o
treatment o CMN, repopulation o the initially depleted

P
layers usually occurs within 3 to 6 months. While QSL brachii lateralis nerves, i.e., the scapular, supraclavicular,

i
treatments may improve the cosmetic appearance, they or deltoid areas.

m
are unlikely to remove all the nevus cell nests, in par- Pigment-speci c QSLs have excellent clearance rates

t
ticular the non-pigmented nests in the deeper dermis. in the treatment o these lesions. Q-switched ruby,
LP lasers have also been used to treat CMN due to their Q-switched alexandrite (Fig. 49-6), and Q-switched

L
potential to better target nests o melanocytes. Like Nd:YAG lasers have been used and tend to be the best

s
i
o
QSLs, results have been too variable to draw de nitive able to treat these conditions.87– 89 Laser treatments in

s
conclusions. Combination treatment (Fig. 49-5) with patients with the nevus o Ota or Ito can be sa ely initi-
both QSLs and LP lasers has also been reported with ated at any age, but children usually respond better and

A B

Figure 49-5 A. Co ital vus o th i ht thi h o a you woma . B. App a a c o l sio ollowi o t atm t
o combi atio LP a QS al xa it las s to i ht hal o l sio . 583
4

A B
S
c
t
Figure 49-6 A. n vus o Ota. B. App a a c ollowi six t atm ts with a QS al xa it las .
i
o
4
:
:
A
need ewer treatment sessions.90 Response is usually
Pa t Ien t s eLec t Io n a n d
s
gradual and patients may require our to six treatment
t
h
sessions. Periorbital lesions may require more treat- t r ea t men t a PPr o a c h
t
i
ments,91 and ocular shields must be used to minimize
c
a
the risk o damage to retinal melanin. reatment with In It Ia L Pa t Ien t c o n s u Lt a t Io n
non-ablative ractional photothermolysis has also been
L
a
reported to success ully clear these lesions.7 However,
s
T e initial patient consultation/evaluation is important,
larger studies are needed to establish these results. Post-
both or patients, who must leave with realistic expecta-
P
treatment, strict sun protection, and the use o bleaching
o
tions o treatment e cacy and downtime, and also or
c
agents can help minimize the risk o pigmentary com-
physicians, to identi y those patients at risk o complica-
plications.
u
tions. Written in ormed consent, including a discussion
o possible risks and adverse events, should be obtained
s
n v h i. Nevus o Hori is also termed acquired prior to any treatment. Patients should understand that
bilateral nevus o Ota-like macules. Clinically, it is char- multiple treatments may be required, depending on the
acterized by speckled or conf uent blue-brown or slate type o lesion being treated, and that complete clear-
gray macules in the malar, temple, or orehead regions. ance cannot be guaranteed. Usually, there is a 4 to 6 week
Unlike the nevus o Ota, these lesions are acquired, bi- interval between treatments.
lateral, and without scleral or mucosal involvement. His- A ocused medical history including recent sun expo-
tologically, melanocytes are largely present in the upper sure, pregnancy, breast- eeding, intake o photosensitizing
dermis.92 Although promising results in the treatment medications, photosensitive diseases, and genetic condi-
o Hori’s nevus with pigment-speci c QSLs (Q-switched tions,9 in ormation regarding wound healing and scarring
ruby, Q-switched alexandrite, and Q-switched Nd:YAG) tendencies and history o in ectious diseases is important.
have been reported, complete clearance rates are slightly Patients with a history o herpes simplex virus require
lower than those or the nevus o Ota, and lesions may antiviral prophylaxis10 i laser treatment is occurring in
require more treatment sessions.93 A higher rate o PIH the vicinity o the mouth. Patients who have received gold
is also observed ollowing laser treatments compared to salts or diseases such as rheumatoid arthritis should be
the nevus o Ota.94 approached with caution, as laser-induced chrysiasis a ter
treatment with QSL has been reported in individuals with
Bl n v . Blue nevi are acquired, solitary, well-cir- a history o gold salt use.95,96
cumscribed papules or nodules. T ey are mostly asymp- Laser treatment in individuals who have taken isotreti-
tomatic and benign and arise spontaneously, usually in noin therapy in the previous 6 months is controversial
children and young adults. T ese nevi result rom ectopic because there have been reports o keloid ormation in
proli eration o melanin-producing melanocytes within these individuals a ter laser treatment,97 although there is
the dermis, and their dark color results rom the yndall increasing evidence that these individuals may not have a
light scattering e ect o the overlying tissues. higher incidence o scarring.98 T e importance o avoiding
T e deep dermal melanocytes o blue nevi respond tanning prior to any laser treatments should be empha-
well to the pigment-speci c QSL (Q-switched ruby, sized, as it elevates the risk or temporary and permanent
Q-switched alexandrite, and Q-switched Nd:YAG) treat- dyspigmentation.
ments, as long as the lesion does not extend into deep sub- Expected sequelae o therapy, such as blistering, pur-
cutaneous tissue. pura, or crusting, as well as potential side e ects, such
as in ection, prolonged erythema, hypopigmentation,
584
hyperpigmentation, atrophy, scarring, hypertrophic scar-
ring, or keloid ormation, should be discussed prior to
r eFer en c es
4
treatment. 1. Goldman L, Igelman JM, Rich eld DF. Impact o the laser on
Photographic documentation should also be obtained nevi and melanomas. Arch Dermatol. 1964;90:71– 75.
prior to treatment. Additionally, inspection and docu- 2. Anderson RR, Parrish JA. Selective photothermolysis: pre-
mentation o pre-existing pigment disturbances, textural cise microsurgery by selective absorption o pulsed irradia-
changes, or scarring may be bene cial when evaluating tion. Science. 1983;220:524– 527.
3. Lauback HJ, annous Z, Anderson RR, Monstein D. Skin
patients or treatment. responses to ractional photothermolysis. La ser Surg. 2006;
36:142– 149.
4. Hantash BM, Bedi VP, Sudireddy V, Struck SK, Herron GS,
Pr o c ed u r e Chan KF. Laser-induced transepidermal elimination o der-
mal contents by ractional photothermolysis. J Biomed Opt.
Prior to treatment, basic laser sa ety measures should 2006;27:1104– 1115.
5. Glaich AS, Goldberg LH, Dai , Kunishige JH, Friedman
be observed in the procedure room. Every person in the PM. Fractionated resur acing: a new therapeutic modality
room should wear protective eyeglasses with the proper or Becker’s nevus. Arch Dermatol. 2007;143:1488– 1490.

C
h
optical density, including the patient. T e treatment site 6. Kroon MW, Wind BS, Beck JF, et al. Non-ablative 1550-nm

a
p
should be ree o any make-up, lotions, or creams. opi- ractional laser therapy versus triple topical therapy or the

t
cal or intralesional anesthesia may be necessary to thwart treatment o melasma: a randomized, controlled pilot study.

4
J Am Acad Dermatol. 2011;64:516– 523.
procedural pain. opical anesthetic creams are o ten

9
7. Kouba DJ, Fincher EF, Moy RL. Nevus o Ota success ully
applied under occlusion or 30 to 60 minutes be ore laser treated by ractional photothermolysis using a raction-

:
:
irradiation. ated 1440 nm Nd:YAG laser. Arch Derma tol. 2008;144:

L
It is always advisable to per orm a test spot. An imme- 156– 158.

a
8. Duke D, Byers R, Sober AJ, Anderson RR, Greevelink JM.

s
diate ash-white color 99 is the desired treatment endpoint
reatment o benign and atypical nevi with the normal-
with a QSL or most pigmented lesions. Some pinpoint

a
mode ruby laser and the Q-switched ruby laser. Arch Der-
bleeding may also be observed, which is acceptable. Subtle matol. 1999;135:290– 296.

L
darkening o the lesion is the desired endpoint with a LP 9. Raulin C, Greeve B, ed. La sers and IPL-technologie in der

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Dermatologie und Asthetschen Medizin. 1st ed. New York,

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or IPL device.

t
NY: Schattaur Stuttgart; 2001.

T
Skin tissues and blood can splatter and be aerosolized
10. Goldman MP. reatment o benign vascular lesions with the
during treatment, particularly with QSL. T is is likely

a
PhotoDerm VL, high intensity pulsed light source. Adv Der-

t
m
because o the photomechanical e ect o QSLs result- matol. 1998;13:503–521.
ing in rapid heating o the chromophore and generation 11. Stankiewicz K, Chuang G, Avram M. Lentigines, laser, and

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o shock waves. T e use o protective shields or mucosal melanoma: a case series and discussion. La sers Surg Med.

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sur aces is recommended, particularly in situations where 2012;44(2):112– 116.

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JG, Flotte J. Comparative studies o emtosecond to micro-

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15. Goldberg DJ. Laser treatment o pigmented lesions. Derma-
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1987;258:3146–3154. groups. La ser Surg Med. 2003;32:391– 395.

9
75. Illig L, Weidner F, Hundeiker M, et al. Congenital nevi <10 cm 91. Chan HH, Lam LK, Wong DS, et al. Nevus o Ota: a new
as precursor to melanoma: 52 cases, a review, and a new classi cation based on the response to laser treatment. La ser

:
:
conception. Arch Dermatol. 1985;121:1274–1281. Surg Med. 2001;28:267– 272.

L
76. Rhodes AR, Sober AJ, Day CL, et al. T e malignant poten- 92. Lam AY, Wong DS, Lam LK, Ho WS, Chan HH. A retrospec-

a
s
tial o small congenital nevocellular nevi: an estimate o tive study on the e cacy and complications o Q-switched
association based on a histologic study o 234 primary alexandrite laser in the treatment o acquired bilateral nevus

a
cutaneous melanomas. J Am Acad Dermatol. 1982;6: o Ota-like macules. Dermatol Surg. 2001;27:937– 942.
230– 241. 93. Polnikorn N, anrattanakorn S, Goldberg DJ. reatment o

L
77. Rhodes AR, Melski JW. Small congenital nevocellular nevi Hori’s nevus with the Q-switched Nd: YAG laser. Dermatol

i
h
and the risk o cutaneous melanoma. J Pediatr. 1982;100: Surg. 2000;26:477– 480.

t
219– 224. 94. Lee B, Kim YC, Kang WH, Lee ES. Comparison o charac-

T
78. Krengel S, Hauschild A, Scha er . Melanoma risk in con- teristics o acquired bilateral nevus o Ota-like macules and

a
genital melanocytic naevi: a systematic review. Br J Derma- nevus o Ota, according to therapeutic outcome. J Korean

t
m
tol. 2006;155:1– 8. Med Sci. 2004;19:554– 559.
79. Pers M. Naevuspigmentosusgiganticus: indikationer or 95. Vergas G, Chan K, T omsen S, Welch A. Use o osmotically

t
operative behandling. Ungeskrift Laeger. 1963;125:63. active agents to alter optical properties o tissues: e ects on

o
80. Greevelink JM, van Leeuwen RL, Anderson RR, Byers HR. the detected f uorescence signal measured through skin.

P
i
Clinical and histological responses o congenital melano- La sers Surg Med. 2001;29(3):213– 220.

m
cytic nevi a ter single treatment with QSL. Arch Dermatol. 96. McNicholas R, Fox M, Gowda A, Fox MA, uya S, Bell B,
1997;133:349– 352. Motamedi M. emporary dermal scatter reduction quanti-

t
81. Kono , Erçöçen AR, Nozaki M. reatment o congeni- tative assessment and implications or improved laser tattoo
tal melanocytic nevi using the combined (normal-mode removal. La sers Surg Med. 2005;36(4):289– 296.

L
plus Q-switched) ruby laser in Asians: clinical response 97. Kobayashi H, ogashi K. C o tattoos removed with laser

s
in relation to histological type. Ann Pla st Surg. 2005;54: therapy. Am J Roentgenol. 2000;174:1468– 1469.

i
o
494– 501. 98. Baumler W, Eibler E , Hohenleuter U, Sens B, Sauer

s
82. Imayama S, Ueda S. Long and short-term histological obser- J, Landthaler M. Q-switced laser and tattoo pigments: rst
vations o congenital nevi, treated with the normal-mode results o the chemical and photophysical analysis o 41
ruby laser. Arch Dermatol. 1999;135:1211– 1218. compounds. La sers Surg Med. 2000;26:13– 21.
83. urnbull JR, Assa Ch, Zouboulis C, ebbe B. Bilateral nevus 99. aylor CR, Gange RW, Dover JS, et al. reatment o tat-
o Ota: a rare mani estation in a Caucasian. J Eur Acad Der- toos by Q-switched ruby laser. A dose response study. Arch
matol Venereol. 2004;18:353– 355. Dermatol. 1990;126:893– 899.

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 Sect ion
A h cP b
5
ch a pt er

50 Tattoos
Mussarrat Hussain, Suzann L. Kilm r, & Omar A. I rahimi

His t o r y how to minister t ttoo were pu lishe s e rly s 6th

entury, in ook entitle “Me i e Artis Prin ipes,” writ-
ten y the Greek Physi i n Aetius.7 ttoos n e l ssi e
Hum ns h ve m rke their o ies with t ttoos or millen-
s e or tive, osmeti , me i l, tr um ti , n i trogeni .
ni . T ese esigns h ve lw ys een person l n un -
tione s mulets, st tus sym ols, e l r tions o love, . DECORATIVE TATTOOS: De or tive t ttoos
signs o religious elie s, n ornment. O ten their uses re most ommon n re urther su ivi e into
exten e eyon the e or tive n were utilize s pro ession l n m teur. Pro ession l t ttoos re
orm o ther py or even punishment.1 typi lly pl e more eeply in the ermis y the
“Otzi the I em n,” is overe on the It li n-Austri n vi r ting nee le o t ttoo m hine, long with
or er in 1991, e me the e rliest known ex mple in gre ter ensity o pigment. Pro ession l t ttoo
terms o t ttoos on the tu l o y; he w s r on- te pigments re mostly yes use in hemi l in ustry,
t roun 5,200 ye rs ol . His o y w s oun to h r or whi h in orpor te i erent kin s o org ni n
57 t ttooe ots n sm ll rosses on his lower spine, inorg ni pigments. Inorg ni pigments m y
right knee, n nkle joints, likely suggestive o his t t- e ompose o mium, hromium, mer ury,
toos hol ing ther peuti signi n e.2 An ient Egypti n iron, tit nium, luminum, sili , opper, romine,
women h t ttoos on their o ies n lim s n were sul ur, r on, n m gnesium.8 T e num er o
present on sever l em le mummies ting k to c 2000 org ni m teri ls use is even more impressive,
bc . Numerous gurines epi ting t ttooing on their o - with most l ssi e s either zo or non- zo, or
ies h ve lso een is overe rom up to c 4000 to 3500 poly y li ompoun s.9 One stu y10 h s shown
bc , m ny with t ttoos on their thighs.3 Cru e nee les n photo e omposition o two wi ely use zo-
pigmente owls use in e rly t ttooing h ve lso een ont ining t ttoo pigments into known r inogeni
oun in Egypt, Fr n e, Sp in, n Portug l.3,4 n ytotoxi pro u ts.
In the l te 1800, the invention o the ele tri t ttooing Am teur t ttoos re o ten homem e r on-ri h
m hine revolutionize the rt o t ttooing.1 T is v n e mixtures th t re o ten mixe with hippe utomo ile
rought t ttooing into the m instre m ulture in m ny p ints or other in ustri l sour es to oost the olor.
ountries. In the Unite St tes, it is estim te th t up to Both pro ession l n m teur t ttoo pigments re
one-qu rter o young to mi le- ge ults h ve t le st ompose o non-homogeneous gr nules size s well
one t ttoo.5,6 However, espite the popul rity o t ttooing o unknown purity n omposition.
in the Unite St tes, it is still poorly regul te . . COSMETIC TATTOOS: Cosmeti t ttoos h ve
e ome in re singly popul r in re ent ye rs. T ey re
pplie or v riety o re sons, in lu ing to improve
or re te the ppe r n e o norm l n tomi l
t yPes o f t At t o o s stru tures or to isguise s rs. Some osmeti t ttoos
re rel te to me i l on itions, su h s t ttoos th t
ttoos result rom the exogenous eposition o mi ron- mimi n reol in re st re onstru tion ollowing
size ink or other pigment- ont ining p rti les into the m ste tomy, where s others re use to thi ken the
ermis, eli er tely or s result o tr um . Instru tion on ppe r n e o thinning eye rows, eyel shes, or the lip
5 vermilion. T e olors th t re use most requently
re rown, pink, re , n ull or nge.11
Histori lly, ll metho s use in t ttoo remov l involve
some element o estru tion (tr um tizing) o the super -
. TRAUMATIC TATTOOS: r um ti t ttoos n i l ermis. T e est results were o t ine in p tients with
o ur ollowing i erent types o injury th t re h prolonge / el ye woun he ling n n in re se in m-
the epi erm l rrier o the skin, su h s r sions, m tory response, whi h eli its n exu tive ph se, n pro-
vulsions, n l er tions. T ese pigments e ome motes n umul tion o m roph ges in the injure re
tr ppe in the ermis ter re-epitheli liz tion o the with their in re se ph go yti tivity. T ese responses
woun n result in t ttoos. promote the loss o ition l pigment in post-oper tive
r um ti t ttoo p rti les v ry in size rom very ph se o he ling.20,21
ne mi ros opi p rti les to l rge m sses o gr vel, M ny te hniques h ve een trie to hieve the go l o
r on, ro t r, sph lt, n irt rom motor su ess ul t ttoo remov l, in lu ing hemi l, me h ni-
vehi le i ents, gr phite rom pen ils, surgi l l n therm l tre tment, in r re o gul tion, surgi l
pens, or gl ss. Am lg m t ttoos re tr um ti in ex ision, n l ser tre tment. Even to y, with the evel-
origin n typi lly ollow impl nt tion o met l opment o n nose on n pi ose on pulse l sers, the
p rti les into the or l mu os uring ent l quest or omplete t ttoo remov l rem ins un ul lle .
S
pro e ures. On o sion, explosion o p rti ul te
c
t
i
m tter su h s gun pow er, reworks, or petroleum
o
n
pro u ts n rive oreign o ies into the skin n CHemiCAl t r eAt men t
5
result in tr um ti t ttoos.
o f t At t o o s
:
:
. MEDICAL TATTOOS: ttoos m y lso e re te
or me i l purposes. In r i tion ther py, t ttoos
A
re o ten pl e to esign te r i tion port. In i . SALABRASION: S l r sion is the pro ess o
s
t
h
ink is ommonly use in most ses. r ing the skin ollowe y the ppli tion o s lts
t
e. IATROGENIC TATTOOS: I trogeni t ttoos m y n w s rst es ri e y the Greek physi i n Aetius
i
c
in 543 a .d .19 S l r sion h s een re ently stu ie y
P
result rom impl nt tion o pigmente p rti les into
r
o
woun uring surgery or nother me i l pro e ure, num er o rese r h groups.19,22– 24 A ter equ te
l
su h s with the use o Monsel’s solution.12 lo l nesthesi , rot ry motor with elt wheel
m
is lightly pplie to remove the super i l l yer o
s
the skin. Moist sponges ippe in norm l t le s lt
t At t o o Bio l o g y re then ru e lightly with even pressure over the
tre tment re or tot l o 10 to 11 minutes or the
rst tre tment. T e sen e o the super i l skin
ttoo p rti les resi e t v rious epths in the skin, r ng-
l yer llows the s lt to penetr te into the ermis. T e
ing rom 1.1 to 2.9 mm in epth, rom the gr nul r l yer
skin ppe rs right re olor ter 5 to 6 minutes.
o the epi ermis to the reti ul r ermis. Pro ession l t t-
A ter the pro e ure, ressing m y e pplie th t
toos ten to resi e more eeply in the ermis, where s
lso ont ins s lts, whi h stimul tes ition l ell
m teur t ttoos re more super i l. In ol er t ttoos, ll
injury th t n result in even more t ttoo pigment
pigment gr nules re intr ellul r n re oun within
eing remove , or the woun is overe with
lysosomes o mononu le r ells, su h s ro l sts n
ry, sterile ressing n the p tient is pl e on
m roph ges. T e istri ution o su h ells is typi lly
nti ioti s until the woun is he le . T e ressing is
periv s ul r or peri nex l.13
h nge ily n woun he ling usu lly o urs on
T e size o pigment gr nules n v ry rom 10 to
21st y. Repe t tre tments n e per orme 2 to
100 µm 14 n is riti l to the t ttoo’s ppe r n e, n lso
3 months l ter. Dis v nt ges o s l r sion in lu e
orrel tes with the e se o su sequent remov l. L rger
the signi nt risk o hypertrophi s rring or keloi
gr nules provi e more visi le olor n gre ter longevity,
orm tion, n overtre tment m y result in loss o
where s sm ller gr nules provi e gre ter homogeneity in
pigment n ull-thi kness skin loss.25
the t ttoo’s ppe r n e, ut re more prone to migr tion.15
. CAUSTIC CHEMICALS: C usti hemi ls h ve
een use or t ttoo remov l or enturies.26 A
st n r eep hemi l peel solution, su h s phenol,
His t o r y o f t At t o o r emo vAl use to e p inte on the t ttoo with Q-tips. For
t ttoos on the extremities, gentler peel solution
Reg r less o the initi l motiv tion or quiring t t- woul e use . Following 24 to 48 hours, 2%
toos, the esire to remove them is pro ly s ol s their queous genti n violet solution woul e p inte on
existen e. Although re sons or t ttoo quisition v ry the woun n then overe with g uze. T e ressings
etween popul tions, the motiv tion or t ttoo remov l were h nge ily until epitheli liz tion o urre .
ppe rs quite simil r.16,17 P tient surveys h ve shown th t T is metho w s ene i l or very super i l t ttoos,
these e or tive t ttoos re sometimes o t ine impul- ut w s if ult pro e ure to toler te. Pro ession l
sively.3 T e re sons st te or t ttoo remov l in one stu y18 t ttoos i not respon well n hyper- n
in lu e : enh n ement o sel -esteem (70%), so i l re sons hypopigment tion o urre requently.25
(35%), mily pressure (19%), improving employment . TANNIC ACID: T e use o t nni i intro u e
prospe ts (18%), n h nge o p rtner (6%). into the skin with re ipro ting nee les w s
T e e rliest o ument tion o t ttoo remov l w s y pu lishe y S utt.27 A ter t nni i ppli tion,
590 the Greek physi i n Aetius in 543 AD.19 ry, sterile ressing is pplie . An es h r orms
 in ew ys n sloughs o in out 7 to 10 ys.
Following this, the woun is llowe to epitheli lize.
s u r g iCAl exCis io n
5
Goo results h ve een reporte with low in i en e
Surgi l ex ision h s lso een use to remove t ttoos.
o s rring ut hyperpigment tion h s een o serve .
Prior to the evelopment o pulse l sers (see elow),
ex ision w s the tre tment o hoi e or sm ll, surgi lly
meCHAn iCAl t r eAt men t s men le t ttoos. T is tre tment h s the v nt ge o
imme i te remov l without the nee or multiple p tient
Me h ni l irrit tion s tre tment or t ttoo remov l h s visits, typi lly t r lower ost th n l ser t ttoo remov l.
lso een n ol reme y, n n e per orme either y L rger t ttoos require more omplex or multiple st ge
over-t ttooing or with erm r sion. A num er o stu ies surgeries th t hel the potenti l to e is guring. Surgi-
suggest th t the key to me h ni l tre tment is prolonge l remov l o t ttoos n e one either y ull thi kness
he ling n in re sing the in mm tory response.25,28 ex ision or split-thi kness ex ision with over-gr ting or
split-thi kness t ngenti l ex ision te hniques.25
. DERMABRASION: Derm r sion uses wire Although surgi l ex ision n remove t ttoo in sin-

C
rush or i mon r ise to r e the skin n gle tre tment with the possi ility o le ving line r s r,

h
a
the t ttoo pigments within it. Derm r sion n s rring n e quite signi nt or t ttoo remov l in om-

p
t
lso e one in om in tion with ryother py to plete. ttoos requiring multiple pro e ures t ke pl e

r
5
re te rigi skin sur e to r e. Following over m ny months in st ge remov l pro ess.37– 39

0
erm r sion, the woun n e o te with 2% Ex ision n gr ting o ten give poor osmeti results

:
queous genti n violet n overe with l yer o e use the p tient re eives two lemishe re s. T e

:
A pti g uze ollowe y ompression ressing gr te re wrinkles n ontr ts, where s its or er

T
a
o sterile p s n g uze wr p. T e ressings re

t
usu lly orms hypertrophi s r, n the onor site m y

t
o
h nge ily n rep inte with genti n violet. e visi le s well. Furthermore, the skin gr t requently

o
s
Derm r sion or the remov l o t ttoos is usu lly oes not over ll o the eep pigment.
ministere in single tre tment or sometimes in
series o tre tments in n ttempt to e re se the
s rring th t m y o ur rom single more ggressive l As er t r eAt men t
tre tment. Even with multiple, less ggressive sessions
o erm r sion, there is virtu lly lw ys some f o r t At t o o r emo vAl
s rring, loss o norm l skin pigment, n resi u l
t ttoo. When use on non- i l skin, the risk o On the sis o Einstein’s qu ntum theory o light,
s rring rom erm r sion is signi nt. A ition lly, M im n 40 evelope the rst oper ting l ser in 1960.
this pro e ure erosolizes loo n tissue p rti les, Explor tion o possi le me i l ppli tions o this evi e
whi h n e h z r to the tre ting physi i n n imme i tely ollowe , n in 1963, Leon Gol m n n his
other st in the tre tment room.21,23,24,29,30 olle gues41 reporte the ility o l ser light to sele tively
estroy t rgets in the skin. T ey note highly sele tive
injury o pigmente stru tures shortly there ter. Gol m n
t Her mAl t r eAt men t s lso reporte the use o norm l-mo e ru y l ser with
0.5 ms pulse ur tion n 5 J energy s the rst l ser to
f o r t At t o o r emo vAl tre t t ttoos.42
L ter in the 1960s n 1970s, num er o ontinuous-
Virtu lly ny sour e o he t h s een use t one point w ve l sers su h s the r on ioxi e l ser (10,600 nm
or nother to remove t ttoos. P tients h ve use re, hot w velength), the rgon-ion (Ar-ion) l ser (488 n
o ls, he te met l o je ts, ig rettes n ig rs, n 514 nm w velengths), n the N :YAG l ser (1064 nm
other sour es o he t to remove t ttoos y estroying w velength) were evelope . T ese l sers oul v porize
the super i l l yer o the skin with resulting in mm - n o gul te tissue with gre ter pre ision th n ele trosur-
tion n result nt t ttoo remov l. T ese therm l meth- gi l tools n were in orpor te into surgi l n erm -
o s o t ttoo remov l inevit ly lmost lw ys le ve tologi pr ti es s v poriz tion n o gul tion evi es.
s r.28 T e use o these ontinuous-w ve l sers uring the
1970s n e rly 1980s resulte in lini lly signi nt new
. Electrodesiccation and electrocautery with low
erm tologi l ser tre tment te hniques, in lu ing their
w tt ge settings use to remove t ttoos y m ging
non-sele tive use or t ttoo remov l. In hin sight, it is not
the super i l skin h ve resulte in unpre i t le
surprising th t these evi es usu lly le t s r, ut the
ene ts n s rring in goo num er o p tients.
s rs they le t were pre er le in m ny ses to the s rs
. Infrared coagulation w s evelope to remove
le t y ex ision l surgery or erm r sion.
v riety o skin lesions y therm lly o gul ting the
skin. It h s lso een use or t ttoo remov l.31– 34 . CARBON DIOXIDE LASER: C r on ioxi e
. Liquid nitrogen: On the opposite en o the (CO 2) l sers emit energy t 10,600 nm in the in r re
therm l spe trum, liqui nitrogen (−196°C), h s region. T e prim ry hromophore or CO 2 l ser is
een use to estroy num er o super i l skin w ter, whi h un ergoes inst nt neous v poriz tion
lesions in lu ing t ttoos, in non-spe i m nner, on exposure to l ser energy. In 1978, the rst reports
with lower risk o s rring.35,36 Cryother py, reg r ing the su ess ul remov l o t ttoos using
however, n use trophy n hypopigment tion.25 ontinuous-w ve CO 2 l ser were pu lishe .43,44 591
5 It ppe rs th t the CO 2 l ser removes t ttoo
pigments y me ns o therm l tissue o gul tive
e e ts, with the l ser surgeon relying on visu l
ee k to on ne the epth o tissue ne rosis to
the pre ise level o t ttoo pigments. V ri tion o the
pigment epth in i erent t ttoos orrespon s to
therm l woun s o v rying epths, the eepest o
whi h n o ten use signi nt in mm tion,
prolonge he ling, n the evelopment o
hypertrophi s rs.45 No spe i e e ts on t ttoo ink
p rti les were seen.46
Although t ttoo remov l y CO 2 l ser w s
skill ully evelope over the ye rs n l ter
om ine with topi l genti n violet n topi l
50% ure p ste ressings, with improve results47,
S
A B
resi u l t ttoo pigment n signi nt in i en e
c
t
i
o trophi n hypertrophi s rring were still seen.
o
Figure 50-1 A. Tattoo pr las r tr atm nt. B. Th ap
n
. ARGON LASER: T e rgon l ser emits lue or propriat clinical ndpoint o whit ning or las r tattoo
5
green ontinuous l ser e m t 488 n 514 nm r moval is s n.
:
:
w velengths n v porizes tissue y non-sele tive
he ting. Although l k t ttoos sele tively sor
A
Photome h ni l e e ts rely on the gener tion o pl sm ,
green light, the ontinuous-w ve elivery o the
s
pro ess lle opti l re k own, ollowe y sho k w ve
t
h
e m results in ulk he ting to the surroun ing skin gener tion, vit tion, n i the re tion o urs ne r soli
t
n results in s rring.45,48
i
oun ry, jet orm tion.51 T e en result is the esire lini-
c
P
l en point o tissue whitening over the t ttoo (Fig. 50-1).
r
o
t Heo r y o f s el eCt iv e
l
m
PHo t o t Her mo l ys is meCHAn is m o f t At t o o
s
l ig Ht en in g /t At t o o
Although ex itement w s initi lly gener te y the e rly
use o ontinuous-w ve l sers or t ttoo remov l, ulti- el imin At io n
m tely these l sers prove to e too estru tive with
high in i en e o s rring. T e pro ess o t ttoo lightening or in some ses t ttoo
In 1983, An erson n P rrish o H rv r Me i l le r n e ter tre tment with Q-swit he l sers is not
S hool’s Dep rtment o Derm tology pu lishe their yet ully un erstoo . In sense, l ser t ttoo remov l is
l n m rk rti le es ri ing the prin iple o sele tive pho- tu lly misnomer s it ppe rs th t the t ttoo ink is not
tothermolysis,49 whi h revolutionize ut neous l ser sur- ompletely remove rom the o y.52 Furthermore, om-
gery. T e theory eleg ntly expl ine th t t rgets in the skin plete lini l le r n e nnot lw ys e hieve .
su h s hemoglo in, mel nin, n w ter were hromo- Possi le me h nisms or t ttoo lightening m y in lu e:
phores th t h e ne light sorption spe trum. Sele -
. Re istri ution o ink p rti les to the lymph ti system.
tive m ge o t rget oul e hieve y hoosing
. Extern l tr ns erm l elimin tion.
l ser w velength th t w s m xim lly sor e y the hro-
. Alter tion o the opti l properties o the t ttoo to
mophore o whi h the t rget onsiste . T e m ge oul
m ke it less visi ly pp rent.
e on ne to th t t rget y limiting the pulse ur tion
to less th n the therm l rel x tion time o the ut neous Clini lly n histologi lly, the rst o these ppe rs to
hromophore. T e therm l rel x tion time is the time th t e the omin nt me h nism.
it t kes or the t rget tissue to lose 50% o its in i ent he t
without on u ting he t to the surroun ing tissue. In this
w y, sele tive non-s rring surgery oul e per orme on t yPes o f l As er s Cu r r en t l y
t rgete tissue without m ge to surroun ing stru tures. u s ed f o r t At t o o r emo vAl
PHo t o r eACt io n s in v o l v ed in ttoo pigment p rti les v ry rom less th n 10 to 100 nm in
i meter.14 T ese very sm ll stru tures (p rti les) require
l As er t At t o o t r eAt men t very r pi he ting, n the l ser pulse ur tion must e
shorter (n nose on or pi ose on r nge) th n the ther-
T e me h nism o l ser t ttoo remov l h s een n lyze m l rel x tion time o the t rget pigment p rti les to
n stu ie extensively. sele tively estroy them. Clini lly, this is omplishe
Clini lly this is omplishe through the use o through the use o Q-swit he l sers. ttoo remov l
Q-swit he l sers. Q-swit he l sers store l rge mounts y Q-swit he l sers is the urrent gol st n r or
o energy in their opti l vity through the use o n opti- unw nte t ttoos.53,54 However, omplete le r n e is
l shutter. When the l ser is re , it rele ses high-pow- not lw ys possi le n there is no gu r ntee th t the
592 ere pulses o extremely short ur tion, in the n nose on skin will ppe r norm l ter tre tment. Clini l ef y
r nge,50 resulting in photome h ni l tissue re tion. epen s on the type o t ttoo, the epth n ensity o the
 TAbLe 50-1
5
P b A e

A e P b r a /r a
Dark ning Pur ch mical trans ormation or las r induc d r duction o m tallic compounds such as rric oxid and
titanium oxid
All rgy M rcuric sul d is consid r d to th most common caus , which may trigg r an imm diat or d lay d,
localiz d or syst mic all rgic r action
Chrysiasis Q switch d las r can induc structural alt ration o th gold d posits, l ading to lu gray discoloration
within th tr at d ar a
Hypopigm ntation Partially a wav l ngth d p nd nt ph nom non. Incr as d m lanin a sorption with short r wav l ngth
Hyp rpigm ntation Mostly r lat d to pati nts’skin typ . Dark r skin typ s ar mor pron , no matt r which wav l ngth is us d

C
h
a
Scarring R tattooing, high d nsity o pigm nt, strong a sorption o n rgy. High r f u nc s produc int ns h at,

p
causing damag to th surrounding d rmis

t
r
5
T xtural chang s Mostly transi nt. Th s chang s hav n not d with xc ssiv f u nc s, r tattooing, or multipl

0
tr atm nts

:
:
Pin point l ding High r f u nc s

T
a
blist ring High r f u nc s, dark r skin typ s

t
t
o
In ction Inad quat post tr atm nt car

o
s
Itching early sign o all rgy or can part o h aling proc ss

pigments inje te in the ermis, n the hemi l n ture pigment remov l in 11, n minim l remov l in
o the pigments use .53,55,56 In ition, the oper tor’s 2. O the pro ession l t ttoos th t were tre te ,
ility, lini l knowle ge, n equ te tr ining in l ser 2 hieve omplete remov l, ne rly omplete
evi e re tors th t ontri ute to the out ome.57 remov l w s hieve in 5, 18 h signi nt
L ser t ttoo remov l urrently requires sever l sessions, remov l, minim l remov l w s seen in 25, n little
usu lly t 4 to 6 week interv ls. Be use m ny t ttoos re remov l in 12. Pro ession l t ttoos th t h yellow,
multi olore , they o ten ne essit te tre tment with mul- re , or green pigments e less th n the l k
tiple l ser evi es or evi e th t h s multiple w velength t ttoos. No s rring w s reporte in ny o the
output ( le 50-1). tre te p tients.
Currently, six w velengths o Q-swit he l sers or t ttoo A ition l lini l stu ies60 on rme these
remov l re v il le: the Q-swit he ru y l ser t 694 nm pioneering lini l stu ies, showing su st nti l
w velength, the Q-swit he lex n rite l ser t 755 nm lightening n le ring o the m teur n
w velength, the Q-swit he N :YAG l ser t 1064 nm improvement in the pro ession l t ttoos tre te with
w velength, the Q-swit he requen y- ou le N :YAG Q-swit he ru y l sers.
l ser t 532 nm w velength, the Q-swit he ye l ser t Q-swit he ru y l sers re quite e e tive t
585 nm w velength, n the Q-swit he N :YAG l ser t removing l k n rk- lue t ttoo pigments.
650 nm w velength. T ese l sers re m e y v riety o However, An erson et l. h ve shown th t these
ommer i l entities. l sers lso e e tively remove not only l k
pigment ut lso lue n green pigments.61
. Q SWITCHED RUBY 694 nm LASER: Presently, . Q SWITCHED Nd:YAG 1064 nm LASER: T e
the Q-swit he ru y l ser rem ins one o the Q-swit he N :YAG l ser w s evelope in 1989,
most use ul l sers in the tre tment o m teur, n is soli -st te, high- uen e l ser ont ining
pro ession l, tr um ti , n me i l t ttoos. ryst l ro o yttrium- luminum-g rnet ope with
A stu y y ylor et l.58 reporte remov l 1% to 3% neo ymium ions. T e 1064 nm w velength
o m teur n pro ession l t ttoos using the o light is invisi le to the hum n eye. T e l ser
Q-swit he ru y l ser, emonstr ting su st nti l emission n e ou le in requen y y pl ing
lightening or omplete remov l in 78% o m teur pot ssium-tit nyl-phosph te (K P) ryst l insi e
t ttoos ut only 23% o pro ession l t ttoos. the l ser vity n o using the e m through the
O 57 t ttoos tre te in this stu y, only one ryst l, pro u ing green light t 532 nm.
evelope s rring. In ition, m ny Q-swit he N :YAG l sers o er
S hei ner et l.59 pu lishe stu y in whi h h n pie es th t ont in ye-impregn te polymer
Q-swit he ru y l ser w s use to tre t 163 t ttoos, th t onverts 532 nm w velength light to 585 nm
in lu ing 101 m teur n 62 pro ession l t ttoos. or 650 nm light, thus en ling the v riety o t ttoo
On ver ge, three tre tments were ministere olors th t we o ten see in to y’s multi olore
to e h t ttoo. In this stu y too, m teur t ttoos t ttoos to e t rgete ( le 50-2).62
respon e well with omplete remov l in 4 ses, Kilmer et l.63 pu lishe their n ings ter tre ting 593
n lmost omplete remov l in 84, with signi nt 39 t ttoos using the Q-swit he N :YAG l ser with
5 TAbLe 50-2
62
op a Ab p Ba P C

da kB la
black/Dark lu QS ru y (694 nm), QS al xandrit (755 nm), QS Nd:YAG (1064 nm)
Gr n QS ru y (694 nm), QS al xandrit (755 nm)
Purpl /Orang /R d/Y llow/Light Fr qu ncy dou l d QS Nd:YAG (532 nm)
rown/Tan

uen es r nging rom 6 to 12 J/ m 2. In their stu y, omp nies m ke l ser evi es with i enti l w velengths
gre ter th n 75% remov l o l k pigment w s th t m y i er in spot size, pulse ur tion, n uen e
S
omplishe in 77% o p tients, n 90% le r n e r nges, omp r tive stu ies re if ult to per orm n
c
w s note in 28% o p tients ter our tre tments. interpret.
t
i
o
Colors other th n l k were remove less e e tively Zeli kson et l.,67 using n nim l mo el, stu ie the
n
5
in the stu y. lini l, histop thologi , n ultr stru tur l e e ts o
Greevelink n An erson 64 showe th t the the three types o Q-swit he l sers (Q-swit he ru y,
:
:
Q-swit he N :YAG l ser with uen es o 6 J/ Q-swit he lex n rite, n Q-swit he N :YAG).
A
m 2 w s s e e tive s the Q-swit he ru y l ser A or ing to the stu y, re - rown, rk- rown, n
s
in removing l k t ttoo ink. It w s sso i te with or nge pigments respon e est to the N :YAG l ser,
t
h
less listering n p in, ewer textur l h nges, n where s the Q-swit he lex n rite l ser w s most
t
i
c
no hypopigment tion. Although lue- l k pigment e e tive or removing lue n green pigments, n the
P
respon e well, green n re pigment tion i not Q-swit he ru y l ser w s more e e tive or removing
r
o
show signi nt response to the Q-swit he ND:YAG. purple n violet pigments. T e 532 nm w velength o
l
Jones et l.65 reporte on the tre tment o 15 t ttoos the requen y- ou le , Q-swit he N :YAG l ser w s
m
s
with the Q-swit he N :YAG l ser in p tients with onsi ere est or removing re pigment. All o these
Fitzp tri k skin type VI. More th n h l the t ttoos l sers were oun to e rel tively equiv lent or removing
tre te in this stu y were r te s eing 75% to 95% l k t ttoo pigment.
improve ter 3 to 4 tre tments. Slight skin lightening
w s note in only two p tients in this stu y, n no
s rring or textur l h nges were reporte . l As er t At t o o t r eAt men t
. Q SWITCHED ALEXANDRITE 755 nm
LASER: In 1993, the Q-swit he lex n rite l ser
. INITIAL PATIENT CONSULTATION: T e initi l
w s intro u e or the tre tment o t ttoos. T e
p tient onsult tion/ev lu tion is import nt or oth
lex n rite ryst l emits energy t w velength
the physi i n n p tient. T e p tient shoul le ve
o 755 nm, whi h is in the visi le to ne r-in r re
the onsult tion with re listi expe t tions, min ul
spe trum. T is w velength is longer th n th t o the
o possi le verse out omes ( le 50-2), re listi
Q-swit he ru y l ser n signi ntly shorter th n
expe t tion o the r nge in num er o tre tments
th t o the N :YAG l ser t 1064 nm.
require , n w reness o the limit tions o tre tment,
In stu y pu lishe y Fitzp tri k et l.,66 25
s well s the tre tment ost. T e onsult tion llows
p tients with oth m teur n pro ession l t ttoos
the physi i n to i enti y those p tients who h ve
were tre te with Q-swit he lex n rite l ser
unre listi expe t tions, who will e non- ompli nt
n reporte 95% remov l o t ttoo pigment in
or who m y e t risk or n verse event.
n ver ge o 8.9 tre tment sessions. empor ry
Un ortun tely, while t ttoos re r more
hypopigment tion w s note in 50% o p tients, n
if ult to remove th n they re to quire, there
12% note tr nsient textur l h nges. T e Q-swit he
is ommon mis on eption th t l sers n e sily
lex n rite l ser h s een shown to e etter th n
remove t ttoos, whi h is riven in p rt y the
the Q-swit he ru y n Q-swit he N :YAG l sers
me i , vertisements, wish ul thinking n the
in the remov l o green t ttoos.67 Un ortun tely, like
proli er tion o me i l sp s n l ser t ttoo remov l
the 694 nm w velength o Q-swit he ru y l ser, the
shops with untr ine n unin orme pr titioners.
Q-swit he Alex n rite l ser’s 755 nm w velength
Following the onsult tion, the p tient shoul
is well sor e y mel nin, whi h results in
un erst n th t multiple tre tments will e require
hypopigment tion ollowing tre tment.68
n th t omplete le r n e nnot e gu r ntee .
O ten it t kes 6 to 15 tre tments or even more to
Co mPAr is o n Bet w een t He remove the t ttoo epen ing on the t ttoo olor(s),
ge, lo tion, p tient’s skin type, n me h nism
t Hr ee Q-s w it CHed l As er s o pl ement (Fig. 50-2). re tments re usu lly
per orme t 4 to 6 week interv ls, so p tients re
Comp r tive stu ies67,68 or the e e tiveness o these looking t ommitment o 6 months to 1 to 2 ye rs
594 l sers h ve een pu lishe . However, e use m ny or more to omplete tre tment. P tients shoul lso e
 5

C
h
a
p
t
r
5
0
:
:
T
a
t
A B

t
o
o
s
Figure 50-2 App aranc o a r pr s ntativ tattoo ov r its
tr atm nt cours . A multicolor d tattoo o an Am rican f ag
consisting o r d, lu , lack, and y llow is shown. A. Tattoo
app aranc pr tr atm nt. B. Tattoo app aranc a t r v
tr atm nts showing signi cant ading. C. Tattoo app ar
anc ollowing 10 tr atm nts with signi cant ut not com
C
pl t ading.

vise th t i they think they will e uns tis e with tre tment in in ivi u ls who h ve t ken isotretinoin
only p rti l remov l o their t ttoo, they shoul not ther py in the previous 6 months is ontroversi l
pursue tre tment. e use there h ve een reports o keloi orm tion
A o use me i l history in lu ing me i tion in these p tients ter l ser tre tment,71 lthough
history, in orm tion reg r ing woun he ling there is in re sing evi en e th t these in ivi u ls
n s rring ten en ies n history o in e tious m y not h ve higher in i en e o s rring.72 In
ise ses is import nt. Import ntly, p tients ition, the import n e o voi ing ex essive sun
who h ve re eive gol s lts or ise ses su h exposure oth e ore n ter tre tment shoul
s rheum toi rthritis, shoul e ppro he e emph size , s this r ises the likelihoo o
with ution, s l ser-in u e hrysi sis h s een yspigment tion, whi h h s the potenti l to e
reporte in in ivi u ls with history o gol s lt perm nent (Fig. 50-3).
use ter tre tment with Q-swit he l sers.69,70 Written in orm tion reg r ing the pro e ure
Chrysi sis is h r teristi lue- l k is olor tion is use ul n shoul e given to the p tient pre-
o the skin th t is very if ult to tre t. L ser oper tively. Photogr phi o ument tion n 595
5
S
c
t
i
o
n
5
:
:
A
s
t
h
t
i
c
P
A B
r
o
l
m
s
C D

Figure 50-3 exampl s o dyspigm ntation with las r tattoo r moval. A. Pr las r tr atm nt. B. Post las r hyp rpigm n
tation ollowing tr atm nt with a QS Nd:YAG 1064 nm las r. C. Pr las r tr atm nt. D. Post las r hypopigm ntation ol
lowing tr atm nt with a QS Nd:YAG 1064 nm las r.

written in orme onsent shoul e o t ine prior pro e ure room shoul we r prote tive eye-gl sses
to the tre tment. Inspe tion n o ument tion o th t re spe i or the l ser w velength eing use .
pre-existing pigment istur n es, prior t ttoos, T e p tient shoul e provi e with prote tive eye-
textur l h nges, or s rring is import nt. we r or intr o ul r shiel s, i nee e .
O serv tion o v rious olors in the t ttoo/ T e tre tment site shoul e kept ry ter proper
t ttoos is import nt not only to pl n tre tment ut le nsing to remove ny m ke-up, lotions, or re ms.
lso to nti ip te the possi ility o ink rkening on opi l or intr lesion l nesthesi m y e ne ess ry
exposure to Q-swit he l ser irr i tion or t ttoos to minimize the sh rp nee le-like pri king sens tion
ont ining iron or tit nium ioxi e p rti les elt with Q-swit he l sers. T e most ommonly
(Fig. 50-4). Furthermore, t ttoos pl e over prior use topi l nestheti ompoun s re EMLA
existing t ttoos shoul e tre te t lower uen es re m (Astr Ph rm euti ls, West orough, MA),
in or er to voi higher potenti l or s r ue to eute ti mixture o li o ine 2.5% n prilo ine
the un n e o t ttoo ink p rti les. 2.5%, within n oil-in-w ter emulsion, El -M x
. TREATMENT PEARLS: Be ore ommen ing (Fern le L or tories, Fern le, MI), li o ine-
tre tment, s ety proto ols shoul e ross- ont ining liposom l re m, n LMX-5 (Fern le
596 he ke in the pro e ure room. Every person in the L or tories, Fern le, MI) 5% li o ine re m.73,74
 5

A B

Figure 50-4 A. R d lip lin r tattoo pr las r tr atm nt. B. Ink dark ning o th upp r v rmilion ord r post las r

C
h
tr atm nt

a
p
t
r
5
T e topi l nestheti re ms re o ten pplie t most pinpoint lee ing. Whitening o the tissue is ue

0
un er o lusion or 30 to 60 minutes e ore l ser to the orm tion o g s s w ter is v porize y he ting.

:
:
irr i tion. For intr lesion l nesthesi , lo l issue loss or ex essive lee ing is not require to o t in

T
in ltr tion o 1% to 2% li o ine with or without s tis tory response. I they o ur, pigment tion

a
t
epinephrine is gener lly use . istur n es or textur l h nges m y result.

t
o
o
Remov l o i erent olors within t ttoos n T e gre ter the mount o t ttoo ink present, the

s
theoreti lly e omplishe when l sers re use more impressive the lini l response n the less
in or n e with the sorption spe tr o their energy require to hieve proper tissue response
pigments. T is, however, is ompli te in lini l uring ther py.
pr ti e. . POST-TREATMENT: Appropri te post-tre tment
E h o the v il le Q-swit he l sers h s its woun re is riti l to optimize goo osmeti
ene ts n etermining the ppropri te l ser or results. A ter ompletion o l ser tre tment,
given p tient epen s upon the type n olor o non-sti k ressing ( el , Ken ll Me i l
t ttoo ( le 50-1) n the p tient’s Fitzp tri k skin Devi e Co., M ns el , MA) with n o lusive
type. T e longer w velength o Q-swit he N :YAG ointment th t oes not ont in nti ioti s, su h
l ser (1064 nm) inter ts less with epi erm l s Aqu phor ointment (Beiers or In ., Wilton,
mel nin n is pre er le or use in rker skin– type C ), is re ommen e . In the sen e o Aqu phor
in ivi u ls. It is lw ys pru ent to per orm test ointment, simple hy r te petrol tum n e use .
spot, p rti ul rly i the t ttoo to e remove is on O ten l rge listers n o ur, espe i lly when the
the e or nother osmeti lly sensitive re or t ttoo is tre te with the rel tively short w velength
when t ttoo pigment is suspe te o ont ining ru y l ser or higher uen es. P tients shoul
erri oxi e or tit nium ioxi e. An imme i te sh- voi re king the listers, i possi le. I they re
white olor t the site o imp t will resolve in 20 un om ort le, they shoul e l n e in the of e
minutes.58 T is shoul e onsi ere tre tment with sterile or le n te hnique. T e p tient shoul
en point known s “tissue whitening” (Fig. 50-1). I expe t the re to evelop rusting n s ing
it is not o serve , it is likely th t the l ser exposure th t will l st or 7 to 10 ys ter tre tment.
uen e is not suf ient or th t n ine e tive Free pigments will e intr ellul r g in t
w velength w s use . Some pinpoint lee ing pproxim tely 4 weeks ter tre tment, so su sequent
m y lso e o serve , whi h is ept le. Be ore tre tments shoul e s he ule t 4 to 6 week
ompleting the tre tment, the test spot shoul e interv ls56 to m ximize the remov l o t ttoo ink
re ully o serve or n imme i te p r oxi l p rti les y m roph ges.75 P tients shoul voi
rkening re tion. sun exposure uring the tre tment perio n or
issue n loo n spl tter n e erosolize t le st month e ore n ter tre tment (longer
uring t ttoo remov l, n thus prote tive g r or higher Fitzp tri k skin types), to minimize post-
overing the eyes n mu os l sur es o the l ser in mm tory hyperpigment tion.
surgeon n st is re ommen e .61 issue spl tter
o urs e use o r pi he ting o the skin sur e
n gener tion o sho k w ves ue to very short l As er t r eAt men t o f
pulses n high pe k powers elivere y Q-swit he
l sers. t r Au mAt iC t At t o o s
T e uen es hosen epen on the l ser use n
re lso se on the physi i n oper tor’s lini l re tment o tr um ti t ttoos is essenti lly simil r to
o serv tion uring the initi l l ser pulses or the test th t o m teur n pro ession l t ttoos. Most o ten, t t-
spot. issue o serv tion uring Q-swit he l ser toos ont ining r on n gr phite h ve een shown to
imp t shows imme i te whitening o the tissue, with respon well to tre tment with Q-swit he l sers.76– 78 597
5 I t ttoo p rti les re very l rge, the ultr short pulses o
Q-swit he l sers m y not e le to tre t them e e -
it nium ioxi e is nother potenti l o en er,
wi ely use to enh n e the rilli n e o green,
tively. In this situ tion, n l tive l ser m y e n option lue, yellow, lesh- olore , n purple t ttoos.86,87
to remove l rge em e e p rti les.79,80 A ition lly, In untre te t ttoos, tit nium is in iO 2 orm,
i the origin o the tr um ti t ttoo is un le r, iopsy whi h is right white in olor. High-intensity
shoul e onsi ere . l ser irr i tion results in the re u tion o i4+
I tr um ti t ttoos re the result o explosive i ents, to i3+, whi h is responsi le or its lue olor.88,89
tre tments shoul e ppro he with ution, e use A stu y90 h s shown th t the l ser-in u e
r gments o gunpow er or rework m y ignite upon h nges in tit nium ioxi e n errous oxi e
exposure to n nose on l ser pulses, potenti lly resulting re w velength n pulse ur tion epen ent.
in explosions.81,82 Investig tors o the stu y were un le to in u e
r um ti t ttoos typi lly respon more qui kly ink rkening in t ttoos with pulse ur tions
n ompletely to l ser t ttoo remov l th n pro ession l gre ter th n 1 ms.
t ttoos. L ser-tre tment o rkene t ttoo pigment
must e ppro he with extreme ution. T is
S
gener lly ut not lw ys n e remove with
c
t r eAt men t o f med iCAl
t
i
su essive tre tments.67
o
n
t At t o o s It is, there ore, highly vis le to per orm
5
test spot when ye within t ttoo is suspe te
:
:
Me i l t ttooing is ommonly use y r i tion on olo- o ont ining erri oxi e or tit nium ioxi e,
espe i lly when tre ting perm nent m ke-up.
A
gists to lo lize re s o tre tment. In i ink is ommonly
. POST-LASER TREATMENT ALLERGIC
s
use in most inst n es, whi h n e su ess ully tre te
t
h
y ny o the v il le Q-swit he l sers.60 T ey respon REACTIONS TO TATTOO PIGMENT AND
t
TRANSIENT IMMUNOREACTIVITY: Met l
i
c
qui kly n ompletely to l ser t ttoo remov l. Prior to
P
remov l, ommuni tion with the p tient’s r i tion s lts use in t ttoo pigments n use llergi ,
r
o
on ologist is re ommen e . gr nulom tous, li henoi , photo llergi , n pruriti
l
re tions. Re ink ont ining mer uri sul e
m
( inn r) is the most ommon use o llergi
s
t r eAt men t o f t At t o o re tions. However, these re tions re lso well-
o umente to mium sul e, hromium sul te,
Al l er g ies n o lt m ng nese present in i erent t ttoos.91
It m y e e use o the ntigeni properties o
re tment o llergi t ttoo re tions is h llenging. re n yellow t ttoo pigments th t they re noti e
Simple surgi l ex ision n e the tre tment o hoi e more y the immune system n o ten e more
or sm ll llergi re tions. One stu y83 oun th t re- qui kly th n other t ttoo pigments in p tients who
quen y- ou le , Q-swit he N :YAG l ser (532 nm) is o not experien e n llergi re tion.28
e e tive in p tients with llergi re tions, p rti ul rly to A ition lly, some p tients m y experien e
the re pigment. Import ntly, llergi pre utions shoul tr nsient immunore tivity ollowing l ser t ttoo
e implemente prior to ny Q-swit he l ser tre tment remov l tre tment.92 Symptoms m y in lu e
in or er to voi systemi llergi re tion. lymph enop thy, whi h m y e mist ken or
T e uthors h ve re ently es ri e the tre tment o ellulitis y those un w re o this phenomenon.93– 98
t ttoo llergy su ess ully tre te with l tive r tion l . PIGMENTARY CHANGES: Despite Q-swit he
resur ing.84 l sers’ ility to t rget t ttoo ink pre isely, epi erm l
mel nin pigment is o ten ompeting hromophore
Co mPl iCAt io n s As s o CiAt ed uring l ser tre tment. As result, some tr nsient
or perm nent pigment ry h nges, either
w it H l As er t At t o o t r eAt men t s hypopigment tion or hyperpopigment tion, re not
un ommon (Fig. 50-3). T ese h nges re p rti lly
. PIGMENT DARk ENING: Following tre tment w velength- epen ent phenomenon. Q-swit he
with Q-swit he l sers, pigment rkening n ru y l ser t 694 nm w velength; requen y- ou le ,
o ur in ert in t ttoos, prim rily osmeti Q-swit he N :YAG l ser t 532 nm w velength; n
t ttoos. (Fig. 50-4). he me h nism is not Q-swit he lex n rite l ser t 755 nm w velength
ompletely un erstoo , ut l ser-in u e re strongly sor e y mel nin n , there ore,
re u tion o met lli ompoun s use in r on use injury to pigmente ells in lu ing mel no ytes.
yes m y result in imme i te or progressive Perm nent hypopigment tion n e seen with
rkening. ttoos ont ining erri oxi e, repetitive tre tment sessions, p rti ul rly t higher
rown-re ingre ient wi ely use in re , pink, uen es. O ten, mu h o the hypopigment tion
n lesh- olore t ttoos, h ve een repute to improves over perio o 1 to 2 ye rs.
result in l k is olor tion upon tre tment Q-swit he l ser-in u e tr nsient
with Q-swit he l sers. he me h nism is hyperpigment tion h s een reporte in up to 15%
thought to involve the re u tion o erri oxi e o ses, n is more ommon in rker-skinne or
to errous oxi e, whi h is jet l k in olor.85 sunt nne in ivi u ls.
598
 5

C
h
a
p
t
r
5
0
A B

:
:
T
Figure 50-5 A. Tattoo prior to las r tr atm nt. B. Patchy hyp rtrophic scar ormation post las r tr atm nt

a
t
t
o
o
Hyperpigment tion n e use y eposition orti osteroi s m y e help ul to voi ex essive

s
o either mel nin or hemosi erin. s r t hing n su sequently minimize lo l tr um .67,104
Anim l stu ies99,100 in Q-swit he l ser– in u e
epi erm l hyperpigment tion h ve suggeste
th t mel no yte stimul tion le ing to tr nsiently PeAr l s
in re se mel nin orm tion o urs.
. TEXTURAL CHANGES: extur l h nges or . P tients un ergoing l ser ther py or t ttoo remov l
s rring re not ommon ter tre tment with shoul not h ve t n t the time o tre tment. I
Q-swit he l sers (Fig. 50-5). T e in i en e o ny signi nt t n is present, tre tment shoul e
s rring is less th n 0.5% .101 Mi ros opi lly, postpone , sin e these p tients will h ve mu h
the sen e o isruption or ne rosis o oll gen higher risk o post-oper tive hyperpigment tion
suggests th t v uol tion uses reversi le oll gen e use o stimul tion o their mel no ytes. A
e orm tion without signi ntly ltering its erm l le hing re m m y e pres ri e to h sten the
r hite ture. resolution o the sunt n.
However, tr nsient textur l h nges su h s ne . Q-swit he l sers re the urrent tre tment o hoi e
ig rette p per-like wrinkling, mil erythem or or ll types o t ttoos. T e use o ontinuous or long-
w xy, shiny sur e, s well s hypertrophi n pulse l sers or intense pulse light (IPL) systems is
trophi s rring h ve een note , when ex essive ontr in i te s pulse ur tion in millise on s or
uen es re use . T e use o ex essive uen es use longer is sso i te with high risk o s rring.105
the epi ermis to sor gre ter mount o energy, . T e lowest uen es require to invoke the tissue
whi h m y result in listering, skin sloughing, n whitening response shoul e use . Although higher
higher likelihoo o s rring. uen es m y le r t ttoos more e e tively,62 they
S rring or textur l h nges m y lso e m y lso e sso i te with higher in i en e o
sso i te with the origin l pl ement o t ttoos, verse events.
very strong sorption o l ser energy y high- . P tients with rker skin types h ve higher risk
ensity pigments in “ ou le t ttoos,” or with the o pigment ry lter tion n possi le s rring. For
he ling response seen ter multiple tre tments.75,102 these p tients, longer w velength l sers, su h s the
o re u e the risk o textur l h nges or s rring, Q-swit he N :YAG l ser (1064 nm), m y e more
re s th t re known to e prone to hypertrophi ppropri te e use o their e re se inter eren e
s rs, su h s the hest, ne k, upper k, rms, n with mel nin.106
nkles, shoul e tre te with lower uen es. e. Sele tion o proper spot size or e m i meter is
L rger l ser h n pie e spot sizes ten to import nt. It is etter to use the l rgest spot size th t
minimize epi erm l m ge, penetr te more eeply eli its lini lly relev nt tissue whitening response.
into the ermis, n re sso i te with ewer L rger spot size results in e re se peripher l
textur l h nges.103 s tter; su sequently higher per ent ge o energy
e. PRURITUS: wenty- ve per ent o Q-swit he is elivere to the t rget.
l ser tre te p tients ompl in o pruritus. It is . In re sing the l ser uen e y re u ing the spot size
signi nt uring the he ling ph se n usu lly is mist ke n shoul e voi e , s it results in
resolves within 2 to 3 ys o its onset. opi l the eposition o m ximum tot l e m energy in the
599
5 upper l yer o the skin, resulting in potenti l
s rring.
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26:13– 21.
I rkening is o serve , the s me test re shoul
10. V sol R, N rm nn N, Ultri h H, et l. ttoo pigments re
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is still onsi er le room or improvement in terms o 13. Ferguson JE, An rew SM, Jones CJ. T e Q-swit he neo-
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Surg Med. 2008;40(4):231– 232. 1994;6:5.
94. Engl n RW, Vog l P, H g n L. Imme i te ut neous hyper- 104. Ferguson J, August P. Ev lu tion o the N :YAG l ser or
sensitivity ter tre tment o t ttoo with N :YAG l ser: A tre tment o m teur n pro ession l t ttoos. Br J Derma-
S
se report n review o the liter ture. Ann Allergy Asthma tol. 1996;135(4):586– 591.
Immunol. 2002;89:215– 217. 105. An erson RR. Derm tologi history o the ru y l ser: T e
c
t
i
95. D ve R, M h ey PJ. Su ess ul tre tment o n llergi long story o the short pulse. Arch Dermatol. 2003;139:
o
n
re tion in re t ttoo with the N :YAG l ser. Br J Pla st 70– 74.
5
Surg. 2002;55:456. 106. Kilmer SL. L ser tre tment o t ttoos. Dermatol Clin. 1997;
96. Kuperm n-Be e M, Levine VJ, Ashino R. L ser remov l 15(3):409– 417.
:
:
o t ttoos. Am J Clin Dermatol. 2001;2(1):21– 25. 107. Kossi , Riqopoulos D, K ts m s A, An erson RR.
97. Jimenez G, Weiss E, Spen er JM. Multiple olor h nges Optim l t ttoo remov l in single l ser session se on
A
ollowing l ser ther py o osmeti t ttoos. Dermatol Surg. the metho o repe te exposures. J Am Acad Dermatol.
s
t
2002;28:177– 179. 2012;66(2):271– 277.
h
98. Nelson JS, Apple um J. re tment o super i l ut neous 108. Izikson L, F rinelli W, S k moto F, nnous Z, An erson
t
i
c
lesions y mel nin-spe sele tive photothermolysis using RR. S ety n e e tiveness o l k t ttoo le r n e in
P
the Q-swit he ru y l ser. Ann Pla st Surg. 1992;29:231– 237. pig mo el ter single tre tment with novel 758 nm 500
r
o
99. Dover JS, M rgolis RJ, Poll LL, et l. Pigmente guine pi ose on l ser: A pilot stu y. La ser Surg Med. 2010;42(7):
l
pig skin irr i te with Q-swit he ru y l ser pulses. 640– 646.
m
s
602
 Ch a p t e r

51
Noninvasive Scar Treatment
Anna Chacon, Katlein Franca, Jennifer Ledon, Jessica Savas, &
Keyvan Nouri

In t r o d u c t Io n however, recent evidence has shown that pressures much

lower than this have been associated with improved clin-
ical outcomes.4
Scars are the result o connective tissue that has replaced
lost substance in the dermis or deeper tissue due to injury
or disease as part o a normative process. Scar character- SIl Ic o n e el a St o mer Sh ee t In g
istics, such as shape and size, are determined by previous
damage. Scars can be thin or atrophic, boxcar, or may Silicone elastomer sheeting has been used in scar man-
develop into a hypertrophic scar or keloid. agement since the early 1980s.5 he exact mechanism
by which silicone sheeting improves hypertrophic scars
and keloids has not yet been completely elucidated. It is
t o pIc a l t r ea t men t o f Sc a r S hypothesized that its bene icial e ects occur primarily
through occlusion and hydration. Resultant decreases
opical therapies or scars have gained popularity among in capillar y activity, hyperemia, and ibroblast-induced
both physicians and patients or their ease o use, wide- collagen deposition aid in extracellular matrix remod-
spread availability, and relatively low cost. T is section will eling and improvement in the clinical appearance o
review pressure therapy, silicone sheeting, onion-extract scars.6
gels, topical vitamin preparations, imiquimod cream, and Silicone gel sheeting should be worn or 12 to 24 hours a
topical corticosteroids or the treatment o scars. day or at least 2 to 3 months to be e ective. Daily cleaning
may be required to prevent irritation, rash, skin macera-
pr eSSu r e t h er a py tion, and pruritus.7
Although large, controlled, clinical trials support-
Despite a paucity o controlled studies supporting its ing the e cacy o silicone sheeting are lacking, several
e cacy, pressure dressings have long been a mainstay in smaller studies have documented its scar-reducing ben-
the prevention and minimization o hypertrophic scars ef ts. Investigation into its utility or scar prophylaxis
and keloids.1 T e proposed mechanism o action o pres- is also currently ongoing. Clinically, silicone sheeting
sure dressings centers upon the acceleration o wound appears to be an e ective means o treating and possibly
maturation through several pressure-related e ects, preventing mature scars while posing minimal risk to the
including thinning o the dermis, decreased edema, and patient. Silicone gel sheeting is, there ore, almost always
reduction o blood ow and oxygen through the compres- a part o the therapeutic regimen or hypertrophic scars
sion o small vessels.2 T e hypoxic environment created and keloids.
by continuous pressure is thought to decrease collagen
ormation and increase collagen lysis through the induc-
tion o enzymes and cytokines that promote extracellular o n Io n ex t r a c t
matrix remodeling.3
Pressure dressings provide the most clinical benef t Onion-extract– based gel (Mederma, Merz Pharmaceu-
in the early, active stages o scarring, becoming less ticals, Greensboro, NC) is an over-the-counter, inexpen-
e cacious a ter 6 months.2 T ese custom-made elas- sive, easy to use, natural option or wound management.
tic garments are worn or approximately 1 year, with Allium cepa, the active ingredient derived rom quer-
replacement dressings applied every 6 to 8 weeks. While cetin, possesses inherent anti-in ammatory, bacterio-
inexpensive, the disadvantages o this orm o therapy static, and collagen down regulatory properties that aid
are primarily related to patient compliance due to dis- in scar remodeling.8While previous studies have been
com ort and inconvenience. T e dressings must be worn unable to f nd signif cant clinical benef t rom onion
at all times and are cumbersome in areas o anatomic extract– based products, a recent randomized, double-
depression or associated with requent motion, such as blinded study showed a statistically signif cant di erence
exural areas. In addition, they carry the potential or in mean improvement o lesion induration, pigmenta-
skin breakdown and ulceration i the pressure is too great tion, tenderness, and overall cosmetic appearance when
or unevenly distributed. Furthermore, there is no con- compared to placebo.9 Because o its potential e cacy,
sensus on the optimal pressure to achieve maximal e - low cost, ease o use, and low risk or adverse e ects,
cacy while maintaining minimal adverse e ects. Current onion-extract– based gels can be considered or the topical
thought asserts that a pressure o 25 mm Hg is su cient; treatment o scars.
5 c o n t r a c t u bex ® ImIq u Imo d 5%
When onion extract is combined with heparin and allan- Imiquimod is a topical immunomodulatory agent
toin, the product is called Contractubex®. Contractubex® that stimulates pro-in ammatory cytokines, namely
is a commercial preparation that has been clinically and inter eron-α . Inter eron-α promotes collagen breakdown
experimentally proven to improve scars through the inhi- and alters the expression o genes involved in apoptosis,
bition o f broblast proli eration and downregulation o which is help ul in preventing keloid recurrence a ter
glycosaminoglycan synthesis.10 A 2006 study showed that excision. Preliminary studies investigating the e cacy o
Contractubex®was signif cantly more e ective than topi- topical imiquimod or hypertrophic scars and keloids have
cal corticosteroids with respect to normalization o scar shown promising results.15 Side e ects are consistent with
erythema, pruritus, and consistency. Moreover, a more a local in ammatory response and are characterized by
avorable side e ect prof le and decrease in the amount erythema, pain, and pinpoint bleeding.15
o time to normalization o these parameters was ound
with Contractubex®when compared to the corticosteroid-
c o r t Ic o St er o Id S
S
treated group.11
e
c
t
i
Intralesional corticosteroid delivery is widely used in
o
n
VIt a mIn S the treatment o mature scars; however, corticosteroids
5
are occasionally applied topically, either with or without
:
occlusion. While associated with ewer adverse e ects
:
VIt a mIn a when compared to intralesional or systemic therapy, cuta-
A
e
neous use in isolation has not been shown to be e ective.16
s
t
Vitamin A unctions to maintain the integrity o mucosal
h
A recent study ound that a popular over-the-counter
e
and epithelial sur aces and, there ore, may be o some ben-
t
0.5% hydrocortisone, silicone, and vitamin E prepara-
i
c
ef t in the prevention and/or management o scars. Studies
P
tion yielded the highest mean percent improvement in
r
conducted to investigate this theoretical benef t used vita-
o
almost all scar parameters when compared to an onion-
b
min A in the orm o 0.5% retinoic acid applied daily. T is
l
extract– based product and placebo.9 opical corticoste-
e
m
topical therapy reduced scar size and associated pruritus roid combination preparations, there ore, may play a role
s
and resulted in skin so tening, attening, and improved in the treatment o hypertrophic scars and keloids; how-
color.12 T e disadvantages o topical vitamin A therapy ever their use is not recommended as monotherapy.
include the risks o teratogenicity and hypervitaminosis,
which limit its utility in the treatment o scars.
In t r a l eSIo n a l t r ea t men t
VIt a mIn e o f Sc a r S
Vitamin E is a lipid-soluble antioxidant that exerts its T e majority o intralesional scar therapies are designed
e ects primarily within the reticular dermis by prevent- or the reduction o hypertrophic and keloidal scars, with
ing reactive oxygen species-mediated damage to DNA, varying success. Many orms o intralesional therapy are
cell membranes, and lipids. It also unctions to stabilize currently available, including, but not limited to steroids,
membranes through alteration o collagen and glycos- cryotherapy, chemotherapeutic agents, and f llers. Intral-
aminoglycan production as well as inhibition o cellular esional therapy or hypertrophic and keloid scars is aimed
membrane lipid peroxidation.12 Baumann et al. looked at at altering this abnormal cell signaling and proli eration.
the improvement in the appearance o scars with topi-
cal vitamin E versus a standard emollient. New surgical
scars a ter Mohs surgery were ound not to di er signif - c o r t Ic o St er o Id S
cantly in cosmetic outcome between the topical vitamin
E and placebo groups. Furthermore, a signif cant amount Considered the gold standard or intralesional treatment
o patients in the group treated with vitamin E developed o hypertrophic and keloidal scars, corticosteroids are
contact dermatitis.13 Because o its lack o proven e cacy thought to improve the appearance o these lesions by
and potential or irritation and scar worsening, topical inhibiting f broblast growth and promoting collagen deg-
vitamin E is not recommended or the treatment o scars. radation.17 riamcinolone, the most requently used cor-
ticosteroid or this technique, is typically injected into the
mid-dermis to avoid scar atrophy. Un ortunately, e ective
VIt a mIn d treatment is not guaranteed, typically requiring many ses-
sions, and it is not unusual or patients to prematurely stop
Vitamin D has also been investigated or use in hypertro- treatment secondary to pain.18
phic scar treatment and prevention. Its anti-in ammatory O the possible side e ects secondary to intralesional
properties and modulation o keratinocytes and Lang- triamcinolone therapy, pain, atrophy, and changes in pig-
erhans cells may o er a benef t in wound maturation. mentation are most common. Although rare, systemic
However, a recent randomized controlled trial ound no e ects such as iatrogenic Cushing’s syndrome are also pos-
di erence in scar thickness or prevalence o hypertrophic sible.19 o minimize pain associated steroid administra-
scars a ter treatment with topical calcipotriol when com- tion, a 1:1 mixture o 2% lidocaine and 0.5% bupivacaine
604 pared to placebo.14 can be injected subcutaneously beneath and around the
keloid edge 3 minutes prior to treatment, with special care
to avoid piercing normal skin, thus inducing new lesions.20
contact cryotherapy plus intralesional triamcinolone or
lesions greater than 100 mm 2.38– 40
5
opical lidocaine application may be o benef t as well.21 Although resulting in DNA damage similar to that ol-
Given the requirement or many sessions, the large lowing X-irradiation, local administration o low-dose
size o many lesions, and the tendency or these lesions bleomycin is not associated with systemic e ects and is
to recur, intralesional steroid therapy may become costly. considered sa e in human skin.41,42 At the cellular level,
When evaluating the cost-e ectiveness o this procedure, intralesional bleomycin was ound to result in necrosis
one study showed that by initially starting treatment with and dyskeratosis o keratinocytes as well as reduced col-
low-dose steroids and then advancing to high-dose ste- lagen synthesis by f broblasts.42,43 T is dose-dependent
roids in later sessions, treatment is most cost e ective in ammatory response resolves a ter several days with
with the lowest risk o recurrence.22 residual post-in ammatory hyperpigmentation.42

c r yo t h er a py o t h er c h emo t h er a peu t Ic S

C
Because o clinical improvement seen in some scars ol- Intralesional inter eron-α 2b, mitomycin C, and tumor

h
a
p
lowing topical cryotherapy, it has been suggested that necrosis actor-alpha ( NF-α ) have also been studied to

t
e
intralesional cryotherapy may be more e cacious in larger, determine their role in the improvement o keloidal or

r
5
bulkier scars. Weshahy f rst attempted intralesional appli- hypertrophic scars. Inter erons are thought to improve

1
cation o cryosurgery in 1993 with the use o cryosurgery hypertrophic or keloidal scars by inhibition o collagen

:
:
needles.23 By directly targeting the deeper layers o keloids synthesis by f broblasts, specif cally collagens I and III.44,45
and hypertrophic scars with extreme cold, intralesional Inter eron-alpha 2 is also known to increase collagenase

N
o
cryotherapy can reduce the number o f broblasts and production.46 Success with this modality varies, however,

n
i
n
mast cells and thus revert scars’ collagen structure to a and side e ects may be systemic, including u-like symp-

v
a
more normal organization.24 toms.47,48

s
i
v
T e clinical e cacy o intralesional cryotherapy has Although topical mitomycin C a ter scar excision was

e
ranged rom 20% to greater than 75% scar volume reduc- ound to improve the appearance o hypertrophic or

S
c
a
tion.25– 28 Reported side e ects include pain, edema, mild keloidal scars, intralesional mitomycin C may not be as

r
T
epidermolysis, and temporary hypopigmentation, but promising, as it was ound to worsen lesions and cause

r
e
pain may be less than that o contact cryotherapy.26,29 ulcerations.49 In addition, while NF-α was e ective in

a
t
m
Decreased skin sur ace temperature during intralesional reducing pruritus associated with scars, intralesional tri-

e
n
cryotherapy, as opposed to contact, may also spare mela- amcinolone was more e cacious in scar improvement

t
nocyte destruction thus explaining the reduced incidence overall.50
o hypopigmentation.30
Ver a pa mIl
5-f l u o r o u r a c Il
Several mechanisms have been implicated or verapamil’s
Shown to inhibit f broblast proli eration in rabbit cell cul- role in the improvement o keloid or hypertrophic scars.
ture, 5- uorouracil (5-FU) has been more recently dem- Calcium antagonists have been shown to reduce extracel-
onstrated to induce f broblast apoptosis without necrosis, lular matrix production, induce f broblast procollagenase
an important actor in scar prevention, via G2/M cell cycle synthesis, and inhibit interleukin-6, vascular endothelial
arrest.31,32 Furthermore, 5-FU is known to inhibit trans- growth actor and cellular proli eration o f broblasts.51– 53
orming growth actor-beta ( GF-β ) signaling in collagen In addition, as mentioned previously, quantities o deco-
I production, a pathway that is considered to be awry in rin may be decreased in hypertrophic and keloid scars.
keloid genesis.33 As such, the calcium channel blocker verapamil has been
Although 5-FU is typically used or triamcinolone shown to augment decorin expression in animal models.54
re ractory scars, there is a paucity o studies directly com- Finally, verapamil was shown to inhibit proli eration and
paring the two modalities. Success rates with 5-FU are vari- GF-β 1 expression in f broblasts and induce apoptosis.55
able, with greater improvement in younger scars.34 Pain Clinically, verapamil has shown to be o benef t ollowing
and hyperpigmentation are common side e ects.32,34,35 surgical excision o hypertrophic and keloidal scars.56– 58
In a head-to-head analysis with triamcinolone, although
both improved the appearance o proli erative scars, vera-
bl eo myc In pamil had a reduced incidence o adverse e ects.59
Bodokh and Brun 36 f rst studied the e ects o intralesional
bleomycin on keloids or hypertrophic scars in 1996. f Il l er S
36 scars were treated with three to f ve sessions o intra-
lesional bleomycin within a 1 month period with total Although most o the intralesional therapies or scars are
regression seen in 80% o lesions. T ese promising results aimed at hypertrophic or proli erative scars, f llers may
subsequently led to several studies evaluating bleomy- replace lost volume in large atrophic areas or depressed
cin or this purpose. Complete or signif cant scar at- scars. Used or mild, moderate, and severe acne scarring,
tening has been reported in 66% to 100% o lesions.37– 39 dermal f llers can be comprised o bovine or human collagen,
Furthermore, bleomycin was ound to be better than hyaluronic acid, silicones, or numerous polyacrylamides.60 605
5 apy, 5-FU, inter eron-alpha 2b, and topical steroids have
all been considered as adjuvant therapies to intralesional
triamcinolone, with varying success. As mechanisms o
action di er or each o these modalities, it may be that
targeting di erent aberrant pathways can lead to greater
clinical e cacy.

f u t u r e d Ir ec t Io n S
It is important to note that these are only some o the more
common intralesional therapies or hypertrophic scars.
Botulinum toxin A has been shown to minimize scar ten-
sion and improve erythema, pruritus, and pliability.63,64
Pentoxi ylline, a methylxanthine derivative, has also been
S
e
shown to improve the elasticity o hypertrophic scars.65 In
c
Figure 51-1 A patient’s scalp status posttransposition
t
animal models, minocycline reduced hypertrophy by 85%
i
o
f ap with a Z-plasty a ter Mohs micrographic surgery.
n
and collagen-glycosaminoglycan copolymers have been
5
used as adjuvant therapy in human chest keloids with suc-
:
cess.47,66,67 Finally, due to its success in treating cutaneous
:
In mild scarring, human collagen or hyaluronic acid is
hemangiomas, intralesional propranolol is being consid-
A
pre erred over more permanent options. With severe
e
ered as well.68
s
and di use atrophic scarring, at replacement may be the
t
h
best option.61 Fillers such as hyaluronic acid or calcium
e
t
i
hydroxyapatite may also be used or atrophic scars that
c
d er ma br a SIo n
P
result rom indicated surgical procedures, such as Mohs
r
o
micrographic surgery (Figs. 51-1 and 51-2).62 aking care
b
l
e
to avoid injection into vessels is essential to avoid vascular Dermabrasion is a acial resur acing technique that
m
mechanically ablates aged or damaged skin to promote
s
occlusion and ulceration.
re-epithelialization.69 It allows the epidermis to regener-
ate as a smooth sur ace a ter the de ective dermis and
c o mbIn a t Io n t h er a py epidermis have been removed. T e procedure involves
the use o a device that scrapes o the scarred outer lay-
Several combinations o intralesional therapies or the ers o skin so that new skin growth is encouraged. T e
treatment o scars have been studied. Contact cryother- epidermis will regenerate rom the epidermal append-
ages located in the remaining dermis. T is process may
improve the skin sur ace and appearance o scars. T e
re-epithelialization process is usually complete in 5 to
7 days and residual er ythema is common or up to 4
weeks.70 Several methods and instruments are currently
being employed or dermabrasion, which are detailed
below.71
Small, portable hand-held dermabraders are the most
popular units available and are able to generate rotation
speeds o 18,000 to 35,000 revolutions per minute. End
pieces, including wire brushes, diamond raises, and ser-
rated wheels, are attached to the end o the dermabrader
to allow precise resur acing and treatment. T e surgeon
can usually control speed with a oot pedal.70
Dermabrasion should be per ormed by a trained and
skilled surgeon and can be associated with other derma-
tologic procedures including chemical ex oliation, so t tis-
sue augmentation and laser procedures.70

In d Ic a t Io n S
Dermabrasion was initially developed to treat acne scars
and traumatic acial scars. Other indications are par-
tial-thickness Mohs surgical de ects and rhinophyma,
improvement o actinic keratoses, seborrheic keratoses,
angiof bromas, syringomas, solar elastosis, epidermal
Figure 51-2 The patient has developed a pink, raised scar nevi, and tattoo removal.70,72 Nowadays it is primarily used
606 6 weeks a ter suture removal. or cosmetic acial resur acing.73
 Dermabrasion remains an important tool when used in
combination or treating acne scarring, especially cystic
In d Ic a t Io n S
5
acne.74 Cai et al. per ormed a study in 2005 to investigate
Chemical peels are used to improve the appearance o f ne
the application o dermabrasion in the treatment o acne
lines and wrinkles, sun damage, skin discoloration, and mild
scars. A total o 110 patients were treated with dermabra-
acne scars. Chemical peels with both α- and β-hydroxy acids
sion and postoperatively, curative results were achieved in
have been used to improve acne scarring with pigmentation.80
45 cases; good results in 40 cases, and e ective results in
25 cases.75
For surgical and traumatic scars, the contour, thickness, t ypeS
and overall appearance are routinely improved with post-
operative dermabrasion. T e procedure is best per ormed T e most common chemical peels used to treat scars
6 to 8 weeks a ter the initial surgery or wounding event.74 include glycolic acid, lactic acid, salicylic acid, and trichlo-
In 2003, Poulos et al.76 suggest an improvement o surgi- roacetic acid ( CA).
cal scars o the ace in 80% o patients a ter 6 months o
treatment.

C
g l yc o l Ic a c Id

h
a
p
t
c o n t r a In d Ic a t Io n S

e
Glycolic acid (20%– 70%) is commonly used in the treat-

r
5
ment o active acne vulgaris and postacne scarring

1
Dermabrasion is contraindicated or patients who have had and hyperpigmentation.81 T e mechanism o action o

:
:
recent acial surgery, those using isotretinoin within the last α -hydroxy acid is a chemical reaction with the upper layer
6 to 12 months, and with those active herpes or other skin

N
o the epidermis, thereby weakening the cohesion o the

o
in ections. Anti-viral prophylaxis may be appropriate. T e

n
intercellular material o the stratum corneum (SC). T e

i
n
presence o active in ammatory skin disease, or immune result is a uni orm ex oliation o its outermost layers (the

v
a
disorders that could a ect the healing process, as well as stratum disjunctum).82 T is agent can help enhance deliv-

s
i
v
active acne, are also contraindications or this procedure.74 ery o topical medications more deeply into the skin.

e
S
c
a
r
c o n c l u SIo n l a c t Ic a c Id

T
r
e
a
t
m
Dermabrasion is one o many techniques that can be Lactic acid percentages range rom 10% to 70%. T is

e
agent tends to be less irritating than glycolic acid. It is a

n
used to treat scars. It is indicated or surgical or traumatic

t
scarring, acne scars, chickenpox scars, rhinophyma, pre- molecule that penetrates the skin slowly, reducing treat-
malignant actinic damage, and perioral rhytides. When ment-induced in ammation. Its mechanism o action is to
per ormed correctly, the procedure has minimal compli- dissolve the intercellular desmosomes to promote ex olia-
cations. Dermabrasion does not require expensive equip- tion. It is, there ore, use ul to treat superf cial scars.80
ment and should be per ormed by a trained and skilled
surgeon.70 It is an inexpensive technique that can be com- t r Ic h l o r o a c et Ic a c Id
bined with other treatments, such as lasers and chemical
peels or optimization o results. CA is a synthetically derived peeling agent made o acetic
acid and chlorine. Percentages range rom 5% to 100%. T e
mechanism o action o CA is coagulation o proteins and
c h emIc a l peel S necrosis o cells. In higher concentrations (50%–100%), it
is considered a good method o chemical improvement or
A chemical peel is a technique in which a chemical solu- skin scars. T e use o the cross technique has been reported
tion is applied to the skin. It represents accelerated ex o- as an e ective method or treating acne scars. T is method
liation by caustic agents that cause controlled damage, consists o ocal application o CA using a sharpened
ollowed by the release o in ammatory mediators and wooden applicator. It is pressed down f rmly over the entire
cytokines. T e result is thickening o the epidermis, depo- depressed area o the scar, producing multiple, rosted
sition o collagen, reorganization o structural elements, white spots on each scar. T e recovery period and healing
and increases in dermal volume.77 T e strength o the peel process are aster when this technique is used.83,84
per ormed is dependent on skin condition and desired
results. For patients who cannot a ord the costly alterna-
tives or deep scars, repeated peeling will help reduce the Sa l Ic yl Ic a c Id
visibility and depth o the scars.
Chemical peels are classif ed by their depth o action Salicylic acid is a β -hydroxy acid. Although available
into superf cial, medium, and deep peels. Specif c peel- in higher percentages, salicylic acid is typically applied
ing agents should be selected based on the disorder to be in 20% to 30% ormulations.80 It is a hydroxyl derivative o
treated and used with an appropriate peel depth, deter- benzoic acid and is a carboxylic acid attached to an aro-
mined by the severity o skin pathology, histological level, matic alcohol, phenol.80,85 Salicylic acid is a lipophilic kera-
or to maximize success.78,79 Deeper peels target deeper tolytic agent and is use ul or the treatment o superf cial
pathologic processes whereas more superf cial peels scars.80,85 Some ormulations produce a characteristic
address more superf cial pathology, such as pigment. whitening indicating that the peel has sel -neutralized. 607
5 c o mpl Ic a t Io n S
CO 2 lasers were initially used or hypertrophic scars and
subsequently discontinued due to the advent o new and
improved laser techniques. T e pulsed dye laser (PDL) is
Complications such as hyper- or hypopigmentation, ery- currently the gold standard or hypertrophic scars, with
thema, hypertrophic and keloid scars, in ections, and less e ective outcomes noted in keloids.92 PDLs deliver
milia may occur.78 results through selective photothermolysis o blood ves-
sels. Blood vessels contain a large amount o oxyhemo-
c o n c l u SIo n globin, which has peak chromophore absorption peaks
at 418, 542, and 577 nm. Although the exact mechanism
o how the PDL causes improvement in scars is not well
Chemical peels are widely used in dermatological practice.
characterized, recent work by Yang et al.93 has suggested
Several sessions are usually needed to improve the appear-
that PDL treatment o keloids signif cantly downregulates
ance and depth o scars. More superf cial scars have a bet-
connective tissue growth actor (C GF) expression in
ter response to this treatment.
most cases. PDL is thought to cause microvascular dam-
age to the blood supply resulting in ischemia and subse-
S
e
mIc r o n eed l In g quent decrease in scarring.94
c
t
i
o
n
5
Medical microneedling or collagen induction therapy is a In d Ic a t Io n S a n d
procedure in which microneedles, arranged on a drum- c o n t r a In d Ic a t Io n S f o r
:
:
shaped instrument, are passed (rolled) along the skin.
l a Ser Sc a r t r ea t men t
A
T ey produce channels in the dermis, stimulating neo-
e
s
t
collagenesis. A minimum o 6 weeks is recommended
h
Common indications or laser treatment o cutaneous
e
between treatments as it takes that long or new collagen
t
i
scars include unctional impairment, adverse e ects, aes-
c
to orm.86 T e most common device used by dermatolo-
P
thetic desirability, and symptomatic discom ort. T ere ore,
r
gists is the dermaroller. T e microneedles are available in
o
indications or laser treatment o hypertrophic scars usu-
b
a variety o shapes and sizes.
l
e
ally include pruritus, dysesthesias, unctional impairment,
m
and issues regarding appearance. T e expected outcome
s
In d Ic a t Io n S o laser treatment is a reduction in redness and height o
the scar, greater pliability, and symptomatic relie o associ-
Microneedling is used or the treatment o scars especially ated symptoms, such as pruritus. As mentioned previously,
acne scars, burn scars, surgical scars, and or rejuvenation. other items to strongly consider include scar type and skin
type. T is is important because patients with airer skin
types (Fitzpatrick skin types I–III) tend to are better with
r ISkS a n d SId e ef f ec t S more positive outcomes and ewer side e ects rom laser
therapy. On the other hand, patients with Fitzpatrick skin
Side e ects are minimal and include stinging, itching, redness, types IV to VI have an increased risk o laser light absorp-
and slight peeling, which usually subside within 24 hours.87,88 tion by melanin in the epidermis, resulting in less e ec-
In ection is also a risk associated with microneedling. tive targeting o the skin and greater risk o postoperative
hyper- or hypopigmentation. T e type o scar also plays an
important role in success ul management. For example,
c o n c l u SIo n newer lesions (i.e., <1 year old) and scars that are red and
elevated are better suited or laser treatment.94 Lasers may
Microneedling is a simple and inexpensive o ce proce- also be use ul as a preventive measure against scars in
dure, and is sa e in all skin types.87 T is procedure can some cases. For example, the 585/595 nm PDL laser may
be used in association with other treatments like chemi-
prevent development o hypertrophic scars in wounds due
cal peels, microdermabrasion and subcision-a surgical to burns. Furthermore, treatment o surgical scars on day
technique that aims to sever f brous attachments beneath
0, the day o suture removal, has proven benef cial.95
a depressed scar in order to li t up the scar and induce
ormation o connective tissue through normal wound
healing. T e ability to use microneedling with other treat- pr e- a n d po St o per a t IVe
ments allows the procedure to be individualized to maxi-
mize benef ts to patietns.86,89 t ec h n Iq u eS
pr eo per a t IVe ma n a g emen t
l a Ser S f o r Sc a r S
When considering laser treatment o hypertrophic scars or
ba c kg r o u n d keloids, it is important to inquire about scar age, changes,
and previous therapy to determine prognosis. When
T e management o keloids and hypertrophic scars is assessing the scar, one should take note o size, color,
challenging because o the well-known high rates o recur- height, pliability, and associated symptoms. reatment
rence ranging rom 45% to 100% and o ten encountered within the f rst ew months a ter onset is ideal because o
608 side e ects.90,91 T e ablative Er:YAG (Erbium:YAG) and the numerous blood vessels that are present during this
time. Previous treatments (i.e., cryotherapy) may induce
f brosis; thus adjustments o laser parameters and settings
5
may be required, such as the use o higher uences and/or a
greater number o treatment sessions.96 T e location o the
scar is also important. According to Dierickx et al.97 acial
scars respond better to laser therapy. Nouri et al.95 also
ound that acial, shoulder, and arm scars responded better
to treatment than those on the anterior chest wall, while
other investigators have ound no relationship between the
location o a scar and its response to therapy.92

pr o c ed u r e Figure 51-3 Photograph o a 16 year-old patient with

multiple acial acne scars be ore laser therapy.
Everyone present during the procedure must wear pro-

C
tective eyewear at all times corresponding to the specif c

h
occur. I hyperpigmentation results, a bleaching cream,

a
wavelength o laser used. PDL or keloids and hypertro-

p
such as topical hydroquinone cream or gel may be pre-

t
e
phic scars is typically carried out as an outpatient pro-

r
scribed. Strict sun avoidance is also recommended. Fur-

5
cedure and usually does not require anesthesia unless

1
thermore, subsequent sessions may be delayed in order to
specif cally requested. I necessary, a topical anesthetic ensure e ective targeting o the lesion. Uncommon com-

:
:
cream may be placed upon the a ected area 30 to 60 min- plications include crusting, oozing, and development o
utes be ore laser therapy.

N
vesicles.

o
n
An atrophic scar is a depression in the skin due to

i
n
o per a t IVe t ec h n Iq u e destruction o the architecture o dermis and subcutane-

v
a
ous tissue by in ammatory, in ectious, or traumatic pre-

s
i
v
cursors.99 T ese scars result rom acne, varicella in ection,

e
As with all lasers, the device should be appropriately

S
trauma, or striae; nevertheless, they may be treated with

c
calibrated and parameters selected be ore commencing

a
laser therapy once the underlying etiology has resolved.

r
therapy. For the PDL, the ideal setting is 585 nm at 450 µs

T
r
pulse duration, using a spot size o 7 to 10 mm, with a u- Laser resur acing or acne scars may be classif ed as ol-

e
a
lows: ablative, nonablative, and/or ractional.

t
ence range o 3.5 to7.5 J/cm 2. Initial therapy should begin

m
with a lower uence, but when using a smaller spot size, Ablative lasers are e ective, but side e ects including

e
n
excess scarring, in ection, changes in pigmentation, lines

t
the uence should be increased. Lower uences (3– 3.5 J/
cm 2 with a 10 mm spot size) are pre erable or darker skin o demarcation, prolonged redness, and dryness limit its
types to reduce complications. A 10% overlap is acceptable. use. T e most common types o ablative lasers are CO 2
Lasers may be used alone or in conjunction with medi- and Er:YAG lasers. Fractional ablative lasers are now con-
cal therapy, such as intralesional steroids or 5-FU. When sidered the treatment o choice or acne scars and o er
comparing PDL alone to laser therapy combined with promising results (Figs. 51-3 and 51-4). Still, these meth-
intralesional corticosteroids, Alster ound no signif - ods have several disadvantages.
cant di erence and similar e cacy rates.98 However, it ■ T e need or antibiotic prophylaxis to prevent superim-
is important to keep in mind that i intralesional steroids posed bacterial, viral, or ungal in ections.
are going to be used, they should be injected immediately ■ T e need or appropriate anesthesia and sedation;
ollowing laser therapy at a dose o 10 to 40 mg/mL. I some are administered systemically and combined with
injected be ore therapy, blanching o the scar may occur locally injected anesthesia.
and there is considerable risk o losing the laser target. ■ Necessary postoperative care including analgesia,
Finally, multiple treatments may be needed or optimal dressings, and antibiotic coverage.
results. Subsequent laser therapy sessions may be carried ■ Increased risk o postoperative bleeding with Er:YAG
out within 4 to 6 weeks. lasers due to high water absorption; in comparison to
CO 2 lasers, this prevents deep penetration, which pre-
a d Ver Se ef f ec t S o f l a Ser vents the production o su cient heat or blood vessel
Sc a r t r ea t men t coagulation.

A commonly reported complaint rom the patient dur-

ing treatment with the PDL is pain akin to being hit by a
snapped rubber band. Other associated symptoms include
burning sensations or pruritus in the a ected area, but
these typically subside within a ew days. T e most com-
monly expected side e ect is purpura, which appears
immediately a ter the procedure and lasts 7 to 10 days.
T e development o purpura is dependent on both the u-
ence and the pulse duration that are selected or treatment.
Lower uences and longer pulse durations both decrease Figure 51-4 Acne scars a ter immediately a ter treatment
the chance o purpura. Changes in pigmentation may also with a ractional nonablative laser. 609
5 ■ T ere is a considerable tendency or postoperative ery-
thema and changes in pigmentation, which may pro-
Several sources have described how e cacious the
1550 laser system can be or acne scars. In a study on
long down time. T is is especially relevant to patients 53 patients with Fitzpatrick types I to IV, Alster et al.
with darker skin types who may experience permanent used the 1550 nm erbium-doped f ber at uences o
hypo- or hyperpigmentation. 8 to 16 J/cm 2 and densities o 125 to 250 M Z/in 8 to 10
passes in atrophic acne scars. Although multiple treat-
o minimize the disadvantages, some methods that ments were needed, almost 90% o patients achieved
have been employed are preoperative bleaching agents, clinical improvement, with an average improve-
topical anesthesia combined with a regional nerve block, ment o 50% to 75%.113 In a similar study by Lee et al.,
oral analgesia, and sedation or pain management. In addi- 27 patients o Asian extraction with Fitzpatrick skin types
tion, several modalities have been introduced to reduce IV to V were treated or moderate to severe acne scars.
complications. Patients received three to f ve laser sessions every 3 to
4 weeks. Patients demonstrated signif cant improvement
■ T e high-energy short-pulsed CO 2 laser o ers less tis-
3 months a ter the f nal treatment session. According to
sue damage compared to the conventional continuous-
patient ratings regarding improvement, 30% were excel-
S
mode CO 2 laser.
e
lent; 59% were signif cant; and 11% were moderate.114
c
T e variable-pulsed or dual-modality Er:YAG laser has
t
■
i
In a separate investigation by Emmy et al., 961 patients
o
a long pulse duration, which allows deeper penetra-
n
treated with the 1550 nm erbium-doped laser were
5
tion than short-pulse alone; this results in an optimal
reviewed. Complications included temporary erythema,
reaction to stimulate regeneration o the skin and seal-
:
:
pain, and swelling. Only 7.6% o patients developed com-
ing o vessels, which reduces bleeding.100,101 For dual
plications, most requently acnei orm eruptions in 1.87%
A
advantage, the combined-mode Er:YAG and CO 2 laser
e
and episodes o herpes simplex virus in 1.77%. Rare com-
s
t
system o ers ablation rom Er:YAG laser as well as
h
plications included prolonged erythema, swelling, der-
e
coagulation rom the CO 2 laser.102
t
matitis, purpura, and postoperative in ections such as
i
c
P
impetigo.115 Other ractional resur acing options include
r
Although it is a sa e alternative, nonablative laser
o
ractional CO 2 and ractional Er:YAG lasers.
b
resur acing may not be as e ective as ablative resur ac-
l
e
Investigations have shown improvement o scars with
m
ing. Nonablative resur acing became popular due to low
ractional resur acing; however, a small subset o patients
s
complication rates and low downtime compared to other
have experienced adverse e ects.116 Still, optimal laser
treatment modalities such as ablative resur acing, chemi-
parameters to achieve improvement o acne scars with
cal peels, or dermabrasion.
minimal side e ects need to be investigated urther. Frac-
Several laser options that have shown signif cant
tional photothermolysis technology induces microther-
improvement o acne scars include the ollowing: 1064
mal zones o injury, which stimulate rapid wound healing,
nm Q-switched Nd:YAG laser,103 1064 nm long-pulsed
resulting in improvement o various skin conditions
Nd:YAG laser,104,105 1320 nm Nd:YAG laser,106,107 1450 nm
including aesthetic, in ammatory, and pre-neoplastic
diode laser,108 and 1540 nm erbium-doped phosphate glass
disorders.117 Further investigation regarding the proper
laser.109 T e 585 nm ash lamp-pumped PDL and intense
spacing o microthermal zones within the context o scar
pulse light systems have proven to be benef cial or post-
management is also warranted.
acne erythema.110,111 T ese options are help ul or patients
who desire less aggressive orms o treatment.
c o n c l u SIo n S a n d f u t u r e
d Ir ec t Io n S
f r a c t Io n a l r eSu r f a c In g
As mentioned earlier, using PDL or intralesional steroid
Nonablative ractional resur acing is nearly as e ective as therapy may prevent ormation o hypertrophic scars. Evi-
ully ablative lasers and as sa e as nonablative lasers. A ter dence-based medicine suggests that laser therapy, particu-
enduring the high complications o ablative laser options larly PDL, is most e ective or hypertrophic scars and keloids
and the limited benef ts o nonablative techniques, rac- i used early and in conjunction with other techniques.118
tional resur acing was introduced as a technique that However, these methods have their own disadvantages.
o ered the best o both worlds. Fractional resur acing Both 5-FU and intralesional steroids may cause pain, pru-
delivers promising results or acial rejuvenation, melasma, ritus, and purpura at the site o injection, although stud-
and acne scarring. Its mechanism o action utilizes the ies that combine these modalities with PDL have shown
concept o ractional photothermolysis through the cre- promising results thus ar. T e 585/595 nm PDL may be
ation o microscopic zones o thermal injury o controlled used or improving surgical scars on the day o suture
width, depth, and density surrounded by normal skin that removal, and in some instances, hypertrophic and keloid
serves as a reservoir or rapid healing o tissue.112 scars as well. T e ractional ablative and nonablative lasers
Other benef ts include less downtime and ewer com- have emerged as the standard o care or treating acne
plications than conventional ablative lasers as well as and surgical scars. Novel research is demonstrating that
greater e cacy or tissue regeneration than nonablative the ractional CO 2 laser is e ective or treating burn scars,
lasers. Many ractional resur acing devices have been especially contractures.119
launched, both nonablative and ablative. T e most popu- Many patients with scars su er physical and emotional
lar options include erbium-doped, Er:YAG, CO 2, and challenges that may be compounded by ine ective treat-
610 Xenon lights. ment results and unrealistic expectations. How to address
these actors while minimizing adverse e ects or all
patients is one o the primary goals o scar management.
19. Liu MF, Yencha M. Cushing’s syndrome secondary to intral-
esional steroid injections o multiple keloid scars. Otolaryn-
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gol Head Neck Surg. 2006;135(6):960– 961.
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20. Mishra S. Sa e and less pain ul injection o triamcenolone
uture treatment o scars. In addition, urther studies that acetonide into a keloid– a technique. J Pla st Reconstr Aesthet
evaluate combination therapy with short- and long-pulsed Surg. 2010;63(2):e205.
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acetonide or the intralesional treatment o keloids. J Drugs 74. Harmon C, PC Dermabrasion procedures. 2011.
Dermatol. 2008;7(8):757– 761. 75. Cai GB, Li HD, Zhang Y, et al. [Full ace dermabrasion or
51. Lee RC, Ping JA. Calcium antagonists retard extracellular acne scars]. Zhonghua Zheng Xing Wai Ke Za Zhi. 2005;
matrix production in connective tissue equivalent. J Surg 21(3):192– 193.
Res. 1990;49(5):463– 466. 76. Poulos E, aylor C, Solish N. E ectiveness o dermasanding
52. Doong H, Dissanayake S, Gowrishankar R, LaBarbera (manual dermabrasion) on the appearance o surgical scars:
MC, Lee RC. T e 1996 Lindberg Award. Calcium antago- a prospective, randomized, blinded study. J Am Acad Der-
nists alter cell shape and induce procollagenase synthesis in matol. 2003;48(6):897– 900.
keloid and normal human dermal f broblasts. J Burn Care 77. Fabbrocini G. Chemical peels. Medscape. 2012.
Rehabil. 1996;17(6 Pt 1):497– 514. 78. Camacho FM. Medium-depth and deep chemical peels.
53. Giugliano G, Pasquali D, Notaro A, et al. Verapamil inhibits J Cosmet Dermatol. 2005;4(2):117–128.
interleukin-6 and vascular endothelial growth actor pro- 79. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I,
duction in primary cultures o keloid f broblasts. Br J Pla st Wang B. Evidence and considerations in the application o
Surg. 2003;56(8):804– 809. chemical peels in skin disorders and aesthetic resur acing.
54. Yang JY, Huang CY. T e e ect o combined steroid and J Clin Aesthet Dermatol. 2010;3(7):32– 43.
calcium channel blocker injection on human hypertrophic 80. Sachdeva S. Lactic acid peeling in superf cial acne scarring
scars in animal model: a new strategy or the treatment o in Indian skin. J Cosmet Dermatol. 2010;9(3):246– 248.
hypertrophic scars. Dermatol Surg. 2010;36(12):1942– 1949. 81. Garg VK, Sinha S, Sarkar R. Glycolic acid peels versus sal-
55. Xu SJ, eng JY, Xie J, Shen MQ, Chen DM. [Comparison icylic-mandelic acid peels in active acne vulgaris and post-
o the mechanisms o intralesional steroid, inter eron or acne scarring and hyperpigmentation: a comparative study.
verapamil injection in the treatment o proli erative scars]. Dermatol Surg. 2009;35(1):59– 65.
Zhonghua Zheng Xing Wai Ke Za Zhi. 2009;25(1):37– 40. 82. Fartasch M, eal J, Menon GK. Mode o action o glycolic
56. D’Andrea F, Brongo S, Ferraro G, Baroni A. Prevention and acid on human stratum corneum: ultrastructural and unc-
treatment o keloids with intralesional verapamil. Dermatol- tional evaluation o the epidermal barrier. Arch Dermatol
ogy. 2002;204(1):60– 62. Res. 1997;289(7):404– 409.
57. Skaria AM. Prevention and treatment o keloids with intral- 83. Fabbrocini G, Cacciapuoti S, Fardella N, Pastore F, Mon re-
esional verapamil. Dermatology. 2004;209(1):71. cola G. CROSS technique: chemical reconstruction o skin
58. Lawrence W . reatment o earlobe keloids with surgery scars method. Dermatol T er. 2008;21(Suppl 3):S29–S32.
plus adjuvant intralesional verapamil and pressure earrings. 84. Bhardwaj D, Khunger N. An assessment o the e cacy
Ann Pla st Surg. 1996;37(2):167– 169. and sa ety o CROSS technique with 100% CA in the
59. Margaret Shanthi FX, Ernest K, Dhanraj P. Comparison o management o ice pick acne scars. J Cutan Aesthet Surg.
intralesional verapamil with intralesional triamcinolone in 2010;3(2):93– 96.
the treatment o hypertrophic scars and keloids. Indian J 85. Fung W, Orak D, Re A, Haughey DB. Relative bioavail-
Dermatol Venereol Leprol. 2008;74(4):343– 348. ability o salicylic acid ollowing dermal application o
60. Goodman GJ, Baron JA. T e management o postacne scar- a 30% salicylic acid skin peel preparation. J Pharm Sci.
ring. Dermatol Surg. 2007;33(10):1175– 1188. 2008;97(3):1325– 1328.
61. Coleman SR. Structural at gra ting: more than a permanent 86. Doddaballapur S. Microneedling with dermaroller. J Cutan
612 f ller. Pla st Reconstr Surg. 2006;118(Suppl 3):108S– 120S. Aesthet Surg. 2009;2(2):110– 111.
 87. Sharad J. Combination o microneedling and glycolic acid
peels or the treatment o acne scars in dark skin. J Cosmet
104. Keller R, Belda Júnior W, Valente NY, Rodrigues CJ. Nonab-
lative 1064-nm Nd:YAG laser or treating atrophic acial
5
Dermatol. 2011;10(4):317– 323. acne scars: histologic and clinical analysis. Dermatol Surg.
88. Majid I. Microneedling therapy in atrophic acial scars: an 2007;33(12):1470– 1476.
objective assessment. J Cutan Aesthet Surg. 2009;2(1):26– 30. 105. Yaghmai D, Garden JM, Bakus AD, Massa MC. Compari-
89. Badran MM, Kuntsche J, Fahr A. Skin penetration enhance- son o a 1064 nm laser and a 1320 nm laser or the nonab-
ment by a microneedle device (Dermaroller) in vitro: depen- lative treatment o acne scars. Dermatol Surg. 2005;31(8 Pt
dency on needle size and applied ormulation. Eur J Pharm 1):903– 909.
Sci. 2009;36(4– 5):511– 523. 106. Rogache sky AS, Hussain M, Goldberg DJ. Atrophic and
90. Berman B, Bieley HC. Keloids. J Am Acad Dermatol. a mixed pattern o acne scars improved with a 1320-nm
1995;33(1):117– 123. Nd:YAG laser. Dermatol Surg. 2003;29(9):904– 908.
91. Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hyper- 107. Sadick NS, Schecter AK. A preliminary study o utilization
trophic scars: a comprehensive review. Pla st Reconstr Surg. o the 1320-nm Nd:YAG laser or the treatment o acne scar-
1989;84(5):827– 837. ring. Dermatol Surg. 2004;30(7):995– 1000.
92. Alster S, Nanni CA. Pulsed dye laser treatment o hyper- 108. Chua SH, Ang P, Khoo LS, Goh CL. Nonablative 1450-nm
trophic burn scars. Pla st Reconstr Surg. 1998;102(6): diode laser in the treatment o acial atrophic acne scars in
2190– 2195. type IV to V Asian skin: a prospective clinical study. Derma-

C
93. Yang Q, Ma Y, Zhu R, Huang G, Guan M, Avram M, Lu Z. tol Surg. 2004;30(10):1287– 1291.

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T e e ect o ashlamp pulsed dye laser on the expression o 109. Lupton JR, Williams CM, Alster S. Nonablative laser skin

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connective tissue growth actor in keloids. La sers Surg Med. resur acing using a 1540 nm erbium glass laser: a clinical and

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e
2012;44(5):377– 383. histologic analysis. Dermatol Surg. 2002;28(9):833– 835.

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5
94. Vejjabhinanta V, Patel S, Elsaie M, Nouri K. Laser or scars. 110. Alster S, McMeekin O. Improvement o acial acne scars

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In: Nouri K, ed. La sers in Dermatology and Medicine. by the 585 nm ashlamp-pumped pulsed dye laser. J Am
London:Springer-Verlag; 2011;45– 51. Acad Dermatol. 1996;35(1):79– 81.

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:
95. Nouri K, Jimenez GP, Harrison-Balestra C, et al. 585-nm 111. Cartier H. Use o intense pulsed light in the treatment o

N
pulsed dye laser in the treatment o surgical scars starting on scars. J Cosmet Dermatol. 2005;4(1):34– 40.

o
the suture removal day. Dermatol Surg. 2003;29(1):65– 73; 112. Jih MH, Kimyai-Asadi A. Fractional photothermolysis: a

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i
discussion 73. review and update. Semin Cutan Med Surg. 2008;27(1):

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96. Alster . Laser revision o scars and striae. In: Alster , ed. 63– 71.

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Manual of Cutaneous La ser echniques. Philadelphia, PA: 113. Alster S, anzi EL, Lazarus M. T e use o ractional laser

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Lippincott; 2000:89– 107. photothermolysis or the treatment o atrophic scars. Der-

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97. Dierickx C, Goldman MP, Fitzpatrick RE. Laser treatment matol Surg. 2007;33(3):295– 299.

c
a
o erythematous/hypertrophic and pigmented scars in 26 114. Lee HS, Lee JH, Ahn GY, et al. Fractional photothermoly-

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patients. Pla st Reconstr Surg. 1995;95(1):84– 90; discussion sis or the treatment o acne scars: a report o 27 Korean

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91– 92. patients. J Dermatolog reat. 2008;19(1):45– 49.

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98. Alster . Laser scar revision: comparison study o 585-nm 115. Graber EM, anzi EL, Alster S. Side e ects and complica-

m
pulsed dye laser with and without intralesional corticoste- tions o ractional laser photothermolysis: experience with

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roids. Dermatol Surg. 2003;29(1):25–29. 961 treatments. Dermatol Surg. 2008;34(3):301– 305; discus-

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99. Bayat A, McGrouther DA, Ferguson MW. Skin scarring. sion 305– 307.
BMJ. 2003;326(7380):88– 92. 116. Avram MM, ope WD, Yu , Szachowicz E, nelson JS.
100. Pozner JM, Goldberg DJ. Histologic e ect o a variable Hypertrophic scarring o the neck ollowing ablative rac-
pulsed Er:YAG laser. Dermatol Surg. 2000;26(8):733– 736. tional carbon dioxide laser resur acing. La sers Surg Med.
101. anzi EL, Alster S. reatment o atrophic acial acne scars 2009;41(3):185– 188.
with a dual-mode Er:YAG laser. Dermatol Surg. 2002;28 117. ierney EP, Kouba DJ, Hanke CW. Review o ractional pho-
(7):551– 555. tothermolysis: treatment indications and e cacy. Dermatol
102. Goldman MP, Marchell N, Fitzpatrick RE. Laser skin resur- Surg. 2009;35(10):1445– 1461.
acing o the ace with a combined CO2/Er:YAG laser. Der- 118. Alster S. Improvement o erythematous and hypertrophic
matol Surg. 2000;26(2):102–104. scars by the 585-nm ashlamp-pumped pulsed dye laser.
103. Friedman PM, Jih MH, Skover GR, Payonk GS, Kimyai-Asadi Ann Pla st Surg. 1994;32(2):186– 190.
A, Geronemus RG. reatment o atrophic acial acne scars 119. Cho SB, Lee SJ, Chung WS, Kang JM, Kim YK. reatment
with the 1064-nm Q-switched Nd:YAG laser: six-month o burn scar using a carbon dioxide ractional laser. J Drugs
ollow-up study. Arch Dermatol. 2004;140(11):1337– 1341. Dermatol. 2010;9(2):173– 175.

613
 Ch a p t e r Laser and Light-Based Treatment

52 of Vascular Lesions
Kathryn S rowka & Krist n M. K lly

In t r o d u c t Io n cool to one-hal o the original temperature. T e thermal

relaxation time is directly proportional to the square o
the diameter o the target and inversely proportional to
Vascular lesions are a commonly encountered problem in
the thermal di usivity o the tissue. Larger target chro-
procedural dermatology, and patients requently desire
mophores should be targeted with longer pulse durations,
their removal. Light-based devices such as lasers and
whereas smaller chromophores necessitate shorter pulse
intense pulsed light (IPL) are among the most utilized
durations. Pulse durations that are longer than the thermal
technologies or removal o these lesions. T is chapter will
relaxation time o the target chromophore tend to create
discuss the evolution o light-based therapies, the treat-
more heat than can be absorbed by the target chromo-
ment o vascular lesions using the principles o photother-
phore. T is extra heat di uses away rom the target chro-
molysis, and will review diagnostic criteria and suggested
mophore and creates generalized nonselective heating o
treatments or many vascular lesions including port wine
the surrounding tissue. T e nal principle is the need or
stain (PWS) birthmarks, in antile hemangiomas (IHs),
a uence that will treat the target chromophore, but will
venous mal ormations (VMs), telangiectasias and rosacea,
minimize nonspeci c thermal related injury.4 T e chro-
cherry and spider angiomas, poikiloderma o Civatte, and
mophore classically targeted in selective photothermolysis
angiokeratomas.
o vascular lesions is oxyhemoglobin. Oxyhemoglobin has
its peak absorptions at 418, 542, and 577 nm (Fig. 52-1).
By targeting oxyhemoglobin, it is possible to trans er heat
to the vessel walls, causing subsequent coagulation and
LIg h t d ev Ic es u s ed t o t r ea t destruction o the vessels.
va s c u La r Les Io n s T e ashlamp-pumped pulsed-dye laser (PDL) was the
rst laser developed to treat vascular lesions on the basis o
One o the rst indications or the use o lasers in derma- selective photothermolysis.5 T e rst generations o PDLs
tologic surgery was or the treatment o vascular lesions. had wavelengths o 577 or 585 nm and pulse durations o
In 1968, the argon laser was one o the rst lasers used 0.3 to 0.5 ms.6 T e wavelength o 577 nm was originally
to treat PWS and IH.1 T e argon laser is a continuous chosen to correspond with the last peak in the absorption
wave laser that produces blue-green light rom 488 to spectrum o the target chromophore, oxyhemoglobin (418,
514 nm. T e blue-green light is pre erentially absorbed 542, and 577 nm).4,7 T is wavelength was ound pre erable
by its complementary color, red. It is thus absorbed by to both lower absorption peaks, 418 and 542 nm, because
hemoglobin in the super cial vessels o vascular lesions.2 it imparted a better penetration depth and less competi-
It is this heating o the blood vessels that leads to thermal
damage and thrombosis, which can be demonstrated on
histology.3 Although the argon laser, and other continu- 418 nm
ous and quasi-continuous wave lasers such as the cop- Oxyhe moglobin
per vapor, krypton-ion, argon-pumped dye, and carbon
dioxide lasers, improved the color o the vascular lesions, Me la nin
they also caused a large amount o nonselective heating 577 nm
due to long pulse durations and unwanted absorption by 542 nm
epidermal melanin. Scarring and dyspigmentation were
n
common. T ese lasers are no longer used or treatment
o
i
t
p
o vascular lesions, as the theory o selective photother-
r
o
s
molysis revolutionized the use o lasers or treatment o
b
A
skin lesions.
755 nm
T e theory o selective photothermolysis, de ned in
1983 by Anderson and Parrish, comprises three governing
principles.4 T e rst principle is to select a wavelength that
has a greater optical absorption by the target chromophore
than by the surrounding tissue. Secondly, the pulse dura-
tion should be matched to the thermal relaxation time o 400 450 500 550 600 650 700 750
the target chromophore. T e thermal relaxation time is Wave le ngth (in nm)
de ned as the time required or the heat, which is gen- Figure 52-1 Sch matic drawing of th absorption curv
erated within the chromophore by the absorbed light, to for oxyh moglobin and m lanin.
tive absorption with melanin. Melanin, the major compet-
ing chromophore, has its peak absorption in the UV range
mum penetration ranges rom 1 to 2 mm.8 o treat these
deeper vessels, near-in rared lasers, such as the alexan-
5
with decreasing absorption as the wavelength o light drite, diode and the neodymium:yttrium– aluminum–
increases through the visible spectrum (Fig. 52-1).8 Using garnet (Nd:YAG) lasers, can be utilized. Each o these
shorter wavelengths that all in the melanin absorption near-in rared lasers penetrates 50% to 75% more deeply in
spectrum not only increases the risk o adverse events such the skin than the PDL.15 T e 755 nm alexandrite laser has
as dyspigmentation secondary to melanin absorption, but selective absorption peaks that correspond more closely
also decreases ef cacy by decreasing the amount o light with deoxyhemoglobin than with oxyhemoglobin, allow-
that reaches the vessels in the dermis (longer wavelengths ing the selective targeting o veins rather than arteries.15
penetrate more deeply).4 T e 1064 nm Nd:YAG laser targets oxyhemoglobin in a
Modi cation o the original PDL design gave rise to a manner similar to that o the PDL.16 For these more deeply
number o later generation models that incorporated more penetrating lasers, very high energies have to be used as
exible settings and included larger spot sizes, epidermal they target a lower peak on the hemoglobin absorption
cooling, higher uences, varying pulse durations, and curve ( rom 700 to 1200 nm). T e energies required to

C
h
longer wavelengths.9 Spot size re ers to the diameter o obtain adequate oxyhemoglobin absorption at these

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the emitted beam o light that hits the sur ace o the skin. wavelengths and the depth o penetration o these devices

t
Increasing spot size decreases the amount o scattering, increase the risk or scarring, especially with the 1064 nm

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5
allowing more light energy to penetrate to the target chro- Nd:YAG laser.

2
mophore. Larger spot sizes also allow or aster treatment An additional laser which may be used or the treatment

:
:
o large lesions.10 o vascular lesions is the requency doubled Nd:YAG laser,
T e addition o epidermal cooling to current generation also known as the potassium titanyl phosphate (K P) laser.

L
a
s
PDLs allows or the use o higher uences. Epidermal cool- o create the K P laser, the light rom the Nd:YAG laser

r
ing decreases the temperature o the skin sur ace allowing is passed through a K P crystal. Its wavelength o 532 nm

a
n
light energy to pass through the epidermis without causing can be used to target oxyhemoglobin at its 542 nm absorp-

d
L
injury. Ideally the blood vessels in the dermis are not cooled tion peak (Fig. 52-1); however, its short wavelength lim-

i
g
and this allows light absorption with subsequent damage o its its depth o penetration to less than that o the PDL.

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the targeted vessels. Initially ice bags were applied to the 532 nm also has higher melanin absorption, increasing the

B
a
skin in an attempt to impart epidermal cooling.11 T ese risk o dyspigmentation, especially in patients with darker

s
d
attempts were messy and not very success ul because the skin types.

T
skin quickly reached a steady-state temperature, at which IPL is a noncoherent ashlamp device that produces

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any decrease in the epidermal temperature was o set by light with wavelengths rom 515 to 1200 nm with varying

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a similar decrease in the temperature o the dermal blood pulse durations. By using a selective light lter, it is possible

n
vessels, preventing the desired injury to the target. In 1994, to screen out shorter wavelengths o light and these devices

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Nelson et al.12 rst introduced the concept o cryogen spray may also be used to treat vascular lesions.

f
V
cooling. By applying a cryogen spray to the epidermis or a In the next section, we will review diagnostic criteria and

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millisecond period o time, it is possible to cool the epider- suggested treatments or some speci c vascular lesions.

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u
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mis without a ecting the temperature o the deeper ves-

a
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sels. Epidermal cooling allows or use o increased uences

L
without injury and thus, increased ef cacy o laser treat-

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c a t eg o r Iz a t Io n o f In f a n t

i
o
ment o vascular lesions. In addition, epidermal cooling

n
s
improves patient com ort. ypes o cooling devices now a n d c h ILd h o o d va s c u La r
available include cryogen sprays,12 contact cooling, and
chilled air cooling.13 a n o ma LIes
Current PDLs can have pulse durations which vary
between 0.45 and 40 ms. Having the option to use lon- Mulliken and Glowacki17 rst categorized the di erences
ger pulse durations o ers the advantage o being able between vascular anomalies o childhood and in ancy in
to treat without purpura. Short pulse durations lead to 1982 on the basis o di erences in cell turnover, natural
rapid heating and can result in vessel rupture with associ- history, and histology. Using these criteria they were able
ated bruising. T e use o longer pulse durations, but not to de ne two unique categories: vascular mal ormations
so long as to allow heating o tissue surrounding blood and vascular tumors. In 1996, the International Society
vessels, prolongs the delivery o energy over an extended or the Study o Vascular Anomalies (ISSVA) updated this
period o time, allowing or more gentle heating o target classi cation system ( able 52-1).18
vessels without sudden vessel rupture.14 It was discovered Vascular mal ormations are vascular lesions comprised
that or selective photothermolysis to occur, wavelength o dysplastic vessels which never involute or regress and
does not have to correspond exactly with the absorption have endothelium which shows normal mitotic activity.19
peak o the target chromophore, as long as pre erential T ey are categorized by a predominant vessel type, which
absorption is still present. Longer wavelengths such as can be any o the ollowing: capillaries, veins, arteries,
585 nm and subsequently 595 nm became pre erable as or lymphatics. However, many lesions have more than
these wavelengths penetrate more deeply and are more one type o vessel. Examples o capillary mal ormations
e ective.8 include PWS are capillary mal ormations. T ese lesions
One important limitation to the treatment o vascular may thicken over time. Progression is o ten gradual but
lesions with PDL is that, even with longer wavelengths, may be accelerated by certain conditions such as preg-
yellow light cannot reach deep dermal vessels, as its maxi- nancy or trauma. 615
5 TABLe 52-1
with resultant glaucoma. T e pathogenesis is incompletely
understood at this time. Neurological presenting symptoms
c p i v l t v l include seizures, which may be resistant to anticonvulsant
m l i therapy, hemiparesis, and hemiplegia.26 In ants with a V1
distributed PWS should be evaluated by a neurologist
v l t v l m l i amiliar with this syndrome i SWS is suspected. Early test-
Infantil h mangioma Port win stains ing may include ultrasound or electroencephalogram (EEG)
Kaposiform V nous malformation and eventually magnetic resonance imaging (MRI) with and
H mangio ndoth lioma Lymphatic malformation without contrast. I MRI is per ormed early, it should be
Art rial malformation repeated a ter 1 year o age to provide de nitive in orma-
Art riov nous malformation tion. Ocular involvement can present as glaucoma at birth,
Incr as d mitotic activity Normal ndoth lial c ll mitotic
but pressures may also increase over time, so it is important
in ndoth lial c lls activity to continue ophthalmologic examinations and monitor eye
pressures, even i an initial examination is negative. Patients
May b pr s nt at birth or Pr s nt at birth with bilateral PWS have a higher risk o SWS and a worse
S
aris shortly aft r prognosis.27
c
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i
Klippel– renaunay syndrome is a congenital syn-
o
Rapid growth follow d by Growth proportional with
n
rapid involution phas growth of child drome characterized by the triad o an extremity PWS,
5
lymphatic/venous mal ormation, and hypertrophy o so t
:
:
tissues and/or bone.28 Klippel– renaunay syndrome is
considerably more common on the lower extremities as
A
Lesions that all under the classi cation o “vascular compared to the upper extremities, occurring there 85% o
s
t
h
tumors” are characterized by a growth phase o proli erat- the time and only 15% o the time on the upper extremity.
t
ing endothelial cells that can be seen as increased mitotic Eighty- ve percent o cases are unilateral. As many as 10%
i
c
P
gures on pathology.19 T e prototypical vascular tumor is o patients may have involvement o both the upper and
r
o
the IH. In IH, but not in all vascular tumors, this growth lower extremities.29 Evaluation may be done with ultraso-
b
l
phase is subsequently ollowed by an involutional phase. nography, Doppler ultrasonography, MRI, and sometimes
m
T is involution is due in part to a rapid decrease in the lymphoscintigraphy.
s
density o the endothelial cells. Once the tumor has com- PWSs begin as well-demarcated, at, light pink to red
pleted its involution, only a ew capillaries with thickened patches that tend to progressively darken to purple as the
basement membranes remain. Other examples o vascular individual ages. By adulthood, they will o ten become
tumors include Kaposi orm hemangioendothelioma and raised and take on a more cobblestoned appearance due
tu ted angioma. to the ormation o vascular papules and nodules. T ese
changes in color and texture may be attributed to the
progressive ectasia o the dysplastic vascular plexus. One
large study demonstrated that two-thirds o patients will
Po r t WIn e s t a In s have hypertrophy and nodularity by age 46 years.30 T e
exact mechanisms or the progressive ectasia o PWS
PWSs are vascular mal ormations comprised o ectatic remain unclear. T e most likely hypothesis suggests that
capillaries and postcapillary venules o the super cial it may result rom an abnormality in neuronal control o
capillary plexus. T e greatest density o dilated vessels is the vasculature, which can be demonstrated by a decrease
in the upper 0.46 mm o the dermis.20 T e vessels range in neuronal mass ound within these lesions. As a result
in size rom 10 to 300 µm, and tend to increase in size as o decreased neuronal control, the dysplastic vessels are
the patient ages.20,21 T ese vessels are characterized by unable to contract appropriately and there ore dilate over
decreased vascular tone, and decreased density o auto- time. T ere are several medical complications that accom-
nomic nerves.22 pany the progressively dilating vessels o an aging PWS.
PWSs occur in 0.3% o live births and are equally dis- T ese can include spontaneous bleeding and/or bleed-
tributed among both sexes and all racial groups.23 T ey ing with minimal trauma, development o glaucoma, and
usually arise sporadically, but amilial cases and rare hypertrophy o the underlying so t tissues.
acquired cases have been described.24 T ere are approxi- In addition to medical complications, PWS can be asso-
mately 900,000 people in the United States and 20 million ciated with long-lasting detrimental e ects on a child’s
people worldwide with PWS.23 While PWSs may be ound psychological, social, interpersonal, and cognitive devel-
anywhere on the body or in a segmental distribution, they opment.31– 33 Personality development can be adversely
are most commonly ound on the head and neck. T eir a ected in children with PWS, secondary to the nega-
association with many congenital syndromes pinpoints tive reaction o others.34 For the above reasons, treatment
their development to within the rst 5 to 8 weeks o ges- should be initiated early and continued until acceptable
tation.25 Some o the syndromes that are associated with cosmesis is achieved.
PWS, which are important to identi y, include Sturge– Many modalities or the treatment o PWS have been
Weber syndrome (SWS) (encephalotrigeminal angioma- tried in the past, but most have met with only limited suc-
tosis) and Klippel– renaunay syndrome. cess. With advances in selective photothermolysis, laser
SWS is de ned as a acial PWS, usually in the V1 distri- therapy has become the gold standard or the treatment
bution, in association with ipsilateral leptomeningeal vas- o PWS and is essentially the only acceptable treatment
616 cular anomalies and ipsilateral choroidal vascular lesions option or the vast majority o cases.
 T e PDL is the most commonly used laser to treat
PWS. T e goals o treatment are to decrease the red/
PWSs are characterized by a large amount o ves-
sel heterogeneity.20 Using a variety o pulse durations,
5
violaceous color o the lesion, to prevent spontaneous spot sizes and increasing radiant exposures with time
bleeding, to prevent and reverse bleb ormation, and to (as long as epidermal injury is not occurring) will help
improve psychological discom ort. PDL is considered sa e to improve treatment response. When initiating therapy
and e ective with 80% o lesions showing improvement in a child, pulse durations and wavelengths should be
with treatment, although only 20% completely clear. Mul- shorter to target the small (30– 50 µm) diameter vessels
tiple treatments are needed.35– 37 One characteristic that seen in pediatric PWS. Settings to consider include a 7
makes a PWS less likely to respond to therapy is older to 10 mm spot size, a pulse duration o 0.45 to 6 ms, and
patient age.35,38,39 In a retrospective study o 133 patients, a uence o 5.5 to 9.5 J/ cm 2 with appropriate epidermal
Fitzpatrick et al.40 ound 89.4% and 90% o patients with cooling. Lower energies are used with larger spot sizes.
PWS aged 0 to 5 years and 6 to 10 years, respectively, had Longer pulse durations can improve sa ety in darker skin
good or excellent responses as compared with 66.7% o types, but may also limit lesion response. Parameters
those older than 50 years. We start treatments as soon vary by device.

C
h
as possible, ideally within a ew weeks o age. T e optical Short-term side e ects that are expected a ter treat-

a
p
advantages to treating earlier in li e include the presence ment include postoperative edema, erythema, and pur-

t
o less melanin to compete or laser light absorption, less pura. While edema and erythema generally resolve within

r
5
dermal collagen to cause backscattering o light out o 48 hours a ter treatment, the “bruising e ect” may take

2
the skin, and a thinner dermis which allows more light up to 2 weeks to resolve completely. T e decrease in the

:
:
to reach the PWS vessels. Other predictors o poorer blood volume in the dermis that is achieved when treat-
response include location on the trunk, distal extremity, ing PWS is seen clinically as lesional blanching. Unwanted

L
a
s
or central ace (medial cheek, upper lip, nose); violaceous side e ects, such as dyspigmentation, may occur. Hyper-

r
color; and nodular sur ace. pigmentation usually resolves in weeks or months.

a
n
o treat a PWS with PDL, the laser handpiece is guided Hypopigmentation may indicate more serious damage to

d
L
across the a ected area in a systematic ashion deliver- melanocytes, and while it may resolve, it can be perma-

i
g
ing pulses evenly across the sur ace using spot size o 7 to nent and should be avoided. Using longer pulse durations

h
t
12 mm. A variety o actors go into selection o treatment and appropriate epidermal cooling can help minimize

B
a
parameters, including lesion location, patient skin type, pigmentary changes. reatment intervals may need to be

s
d
and the number and e ect o previous treatments. As increased in patients with darker skin, to allow or resolu-

T
noted above, the larger the spot size the deeper the laser tion o pigmentary changes prior to additional procedures.

r
a
light will penetrate.10 T ere ore, using the largest spot size Hair loss can occur and while it o ten resolves, it can be

t
m
that allows suf cient uence to achieve the desired end- permanent, especially in pediatric patients with dark hair.

n
point is recommended. T e thermal relaxation time or Surgilube can be placed over eyebrows and eyelashes to

t
o
PWS blood vessels, which have a diameter o 50 to 300 prevent removal with the laser.

f
V
µm, is calculated to be approximately 1 to 10 ms.41,42 We Almost all PWSs will lighten to some extent, but ew

a
s
generally use 0.45 or 1.5 ms. It is most important to watch will achieve complete clearance with PDL (Fig. 52-3).

c
u
l
tissue response and adjust settings based on observations. One study noted a 79% improvement with an average o

a
r
T e outcome desired is immediate purpura (Fig. 52-2). A 9 treatments.43 Sessions are spaced 4 to 8 weeks apart.44 It

L
con uent gray color is a warning sign that the uence is is common to require many (15 or more) sessions be ore

s
i
o
too high and epidermal injury may be occurring. Using reaching a plateau in ading or achieving the desired

n
s
a standard ormula to determine settings is not recom- response. Even lesions that initially respond well to PDL
mended and can lead to complications. may reach a plateau at which they become unresponsive to

Figure 52-3 PWS r sistant to PDL, som improv m nt

Figure 52-2 Appropriat imm diat purpura with PDL. with al xandrit las r, tr atm nt ongoing. 617
5 urther treatments, a phenomenon known as “treatment
resistance.”16 reatment resistance can be partially attrib-
utilized, especially in China. A vascular speci c photosen-
sitizer is administered intravenously to the patient and a ter
uted to optical absorption and scattering which limits the a preselected time interval, during which the photosensi-
penetration depth o the PDL to 1 to 2 mm, whereas many tizer reaches the target tissue, light is applied that allows or
PWS can extend as deep as 3 to 5 mm.8 In addition, hyper- speci c absorption by the photosensitizer. A photochemi-
trophic and thickened PWS in adults may be less respon- cal reaction occurs that results in generation o ree radical
sive to PDL. species, causing irreversible damage to the target tissue. An
Hypertrophic and thickened PWS may respond bet- advantage o PD is the ability to treat all skin types. One
ter to a long-pulsed 755 nm alexandrite laser. T e 755 nm disadvantage is that administration o the photosensitizer
wavelength is pre erentially absorbed by deoxyhemoglobin leads to skin photosensitization or 3 to 30 or more days,
over oxyhemoglobin, allowing targeting o veins over arter- depending on the photosensitizer used. Combining photo-
ies.45 T e desired end point is a subtle blue-gray discol- dynamic and photothermal injury has also been explored
oration that is ollowed a ter several minutes by a deeper experimentally and may o er an improved treatment
purpura. A sustained gray color indicates that the uence approach.51
is too high with an associated risk o scarring. Side e ects Most recently, the combination o PDL therapy with
S
o the alexandrite laser are similar to those o the PDL with posttreatment administration o agents that modi y the
c
t
i
increased risk or permanent hair reduction and scarring wound healing response has been investigated. Imiquimod
o
n
due to deeper penetration. Clinicians using this laser to 5% cream applied 3 times per week or 8 weeks immedi-
5
treat vascular lesions must be aware o the desired tissue ately a ter PDL therapy was shown to enhance treatment
:
:
response and must watch the treated areas closely to avoid response. T erapy was well tolerated with only minor irri-
complications. tation reported.52 Rapamycin (RPM) is a speci c inhibitor
A
T e long-pulsed Nd:YAG laser (i.e., 1064 nm), another o mammalian m OR, which has antiangiogenic proper-
s
t
h
near-in rared laser, has a higher absorption coef cient or ties via the downregulation o hypoxia-inducible actor
t
blood compared to the surrounding dermis. T is property (HIF-1α). Phase I trials with oral RPM plus PDL showed
i
c
P
allows or laser penetration to blood vessels deeper in the promising results,53 leading to the development o topi-
r
o
dermis (>2 mm), making it another treatment option or cal ormulations to reduce risks associated with systemic
b
l
hypertrophic PWS. However, unlike the 755 nm wave- drug exposure. opical ormulations used in combination
m
length, the 1064 nm wavelength pre erentially targets with PDL on normal skin also demonstrated inhibition o
s
arteries over veins and has a narrow therapeutic window. regrowth and neo-angiogenesis o blood vessels.54
Fluences o only 1.2 times that o the minimal purpu-
ric dose can produce extensive deep dermal damage and
result in scarring.16 T is narrow therapeutic window may In f a n t ILe h ema n g Io ma s
be explained by the partial conversion o oxyhemoglobin
to methemoglobin by the 1064 nm wavelength. Methemo- IH is the most common benign vascular tumor o chil-
globin has a high absorption or light at 1064 nm and leads dren. T ese lesions arise in 1% to 3% o neonates,23 and
to a steep uence–response curve. T ese devices should be can a ect up to 10% o in ants within the rst year o
used with caution or PWS. li e.55,56 While some IH may be present at birth, most arise
Long-pulsed requency doubled Nd:YAG lasers (i.e., within the rst 2 to 3 weeks o li e and then rapidly enlarge
532 nm), also known as K P lasers, have been shown to (Fig. 52-4). T is is in contrast to vascular mal ormations,
be e ective or PDL-resistant PWS.46 Dual wavelength which are present at birth and expand only in concordance
systems combining 532 and 1064 nm lasers have also been with the child’s growth. T ey may be either super cial (cap-
proposed as treatment options. By using both wavelengths illary), deep (cavernous), or a mixture o the two. Super cial
at uences lower than their therapeutic thresholds, there lesions, which involve the papillary dermis, appear as bright
is a lower-risk pro le. T us ar, equivalent ef cacy to K P
has been demonstrated with these lasers, with 30% less
irradiant exposure at 532 nm.47
IPL has also been studied or the treatment o PDL-
resistant PWS. In theory, IPL could achieve good results
because longer pulse durations and multiple pulse
sequences can be applied, allowing or the treatment
o larger blood vessels which may be resistant to other
devices. Furthermore, the range o IPL wavelengths
should allow or the targeting o all the absorption peaks
o oxyhemoglobin and the simultaneous treatment o both
super cial and deep vessels.48 Despite these theoretical
considerations, a side-to-side study concluded that a single
treatment o PDL remains superior to a single treatment o
IPL or inducing lesion clearance.49 However, one study did
show that in treatment-resistant PWS not in the V2 dis-
tribution, approximately 50% o patients had greater than
50% reduction in their lesions with IPL.50
T ere are several other modalities being evaluated or
618 treatment o PWS. Photodynamic therapy (PD ) has been Figure 52-4 Infantil h mangioma in a 1 month old infant.
red papules, plaques, or nodules. Deeper lesions, occurring
in the reticular dermis or subcutaneous at, with little to no
develop complications, such as in ection, ulceration, or
bleeding, and or those that impair vital unctions (block-
5
involvement o the overlying papillary dermis, appear as ing vision, obstructing the airway, obstructing the auditory
esh colored or bluish subcutaneous nodules. T e incidence canal), and or those at sites that may develop signi cant
o IHs is inversely proportional to gestational age at birth, de ormity ollowing involution. More recently, however,
with higher incidences occurring in premature in ants.57,58 it has been shown that early treatment may prevent scar-
T ey are also much more commonly ound in emales with ring as well as the psychological consequences that may
almost a 3:1 ratio over males. T ey may occur anywhere on arise i the lesions are allowed to run their natural course.
the skin but the head and neck are the most common loca- Lesions in cosmetically sensitive areas should be strongly
tions. IHs can be di erentiated rom other vascular tumors considered or early treatment and include lesions on the
and vascular mal ormations by their GLU -1 expression. nose, glabella, lips, and especially in emales, the chest.
GLU -1 is a etal-type endothelial glucose transporter.59 reatment should be tailored to each patient by taking into
wo rare types o GLU -1 negative hemangiomas, which consideration the depth and size o the lesion, as well as
may also be present at or soon a ter birth are noninvoluting any unctional impairment that it may cause. reatment

C
h
hemangiomas (NICHs) and rapidly involuting hemangio- options include topical treatments, intralesional cortico-

a
p
mas (RICHs). steroids, β-blocker systemic therapy, laser, and surgical

t
T e natural history o IH is to progress through three excision. Some combination o the above may provide the

r
5
stages: a growth stage which generally occurs over the rst best overall response.

2
5 to 6 months o li e, a stable phase, and a slower regres- opical treatments or IHs include high-potency topical

:
:
sion phase. As a general rule o thumb, IHs regress at a rate steroids, topical timolol, and possibly topical imiquimod.
o approximately 10% per year. For example, 30% will have

L
Superpotent topical steroids have shown some ef cacy or

a
s
regressed by age 3, 50% by age 5, and 90% by age 9.60 Speed the treatment o small, super cial IH and have mostly been

r
o regression has not been ound to correlate with lesion studied in the periocular region. Disadvantages include

a
n
size, number o lesions, site, or age at rst appearance.60 possible systemic absorption, cutaneous atrophy, and lim-

d
L
T e earliest sign o regression is white streaks o brosis ited penetration limiting e ectiveness (especially i the

i
g
appearing on the sur ace o the lesion. A ter regression, lesion has a deep component).67 opical timolol gel, twice a

h
t
many IHs will leave behind bro- atty tissue, atrophy, and day or 16 weeks, has recently been reported to be e ective

B
a
telangiectasia.19 in the treatment o super cial IHs o the head and neck.68,69

s
d
Most patients have only a single lesion, but up to 15% to Rare reports o systemic adverse events, including wheez-

T
20% o patients will have multiple lesions. T e presence o ing, respiratory distress, and bradycardia, have been noted.

r
a
three or more IHs has been associated with visceral involve- T ese events are more likely to occur when using topical

t
m
ment, and has been re erred to as di use neonatal heman- timolol over an extended time period or over a widespread

n
giomatosis.61 Ultrasound and MRI imaging may be use ul area.70 In addition, the ophthalmic solution has signi -

t
o
or detecting visceral lesions in a patient with multiple cuta- cantly higher systemic bioavailability when compared to

f
V
neous lesions. It may also be use ul to check a ecal occult gel ormulation.71 Imiquimod has shown some ef cacy or

a
s
blood, which can detect GI tract involvement. T e organs the treatment o super cial uncomplicated hemangiomas,

c
u
l
most commonly a ected are the gastrointestinal tract, but its use is controversial. Ef cacy has not been studied in

a
r
brain, liver, and lung. Complications include high-output mixed or complicated hemangiomas.72

L
cardiac ailure, gastrointestinal bleeding, hydrocephalus, Ulceration is the most common complication in IHs and

s
i
o
and consumption coagulopathy. T e mortality rate remains occurs in 5% to 15% o lesions, generally during the proli -

n
s
very high or these patients and usually results rom high- erative phase.73,74 Ulcerated hemangiomas may be treated
output cardiac ailure. Some in ants may have multiple with topical wound care, topical barrier creams, topical
cutaneous IHs, but no evidence o visceral involvement, in antibiotics, topical becaplermin gel (a recombinant human
which case benign neonatal hemangiomatosis can be diag- platelet– derived growth actor),75 and occlusive dressings.
nosed.62 T ese in ants tend to ollow a benign course. Lasers may also be very use ul or treatment o ulcerated
In patients with large acial hemangiomas, PHACE hemangiomas (see next page).
syndrome must be considered. PHACE is an acronym Systemic treatments are indicated when unctions are
or a neurocutaneous syndrome consisting o posterior threatened ( or example vision, breathing), when lesion
ossa mal ormations o the brain, large acial hemangio- progression will be dis guring, when there is signi cant
mas, arterial anomalies, cardiac anomalies, aortic coarc- ulceration or there is associated morbidities such as con-
tation, and eye abnormalities. I the child also has ventral gestive heart ailure. Historically, oral steroids were the
midline de ects, such as sternal cle ting and/or a supraum- treatment o choice or these IHs; however, they are associ-
bilical raphe, then PHACE syndrome becomes PHACES ated with many side e ects including adrenal suppression,
syndrome.63 PHACE syndrome has a striking emale pre- growth suppression, cataract development, osteoporo-
dominance. Approximately 70% o the in ants with PHACE sis, and increased in ection risk.76 Propranolol was rst
syndrome have no more than one extracutaneous mal or- reported as ef cacious or the treatment o IHs by Léauté-
mation.64,65 Children with large acial hemangiomas should Labrèze et al.77 in 2008; since this time it has become a
have, at minimum, appropriate CNS imaging studies and a rst-line option or the treatment o IH. However, close
cardiac evaluation. monitoring or bradycardia, hypotension, bronchospasm,
Many questions have been raised about the need to treat and hypoglycemia is required.In addition, β-blockers may
IHs due to their natural tendency to involute.66 Historically, blunt the signs o high-output cardiac ailure that can
most lesions have been treated conservatively with watch- be associated with large or miliary hemangiomas.78 T e
ul waiting, reserving aggressive treatments or lesions that level o monitoring required when starting propranolol is 619
5 controversial, and hospitalization or the rst 48 to 72
hours o therapy is standard at some centers.79 Contraindi-
levels were shown to dramatically improve in these stud-
ies; or example all nine patients treated by Morelli et al.87
cations or use include history o bronchospasm or asthma, showed improvement in their pain levels. David et al.89
cardiac disease, and CNS vascular anomalies (such as showed 91% improvement with a mean o 2 treatments in
those associated with PHACE syndrome). Propranolol can 78 patients with ulcerated hemangiomas.
be used but should be approached with caution in patients Laser treatment is also used to improve the appearance
with diabetes mellitus and chronic renal insuf ciency.80,81 o involuted hemangiomas with residual lesion. PDL may
T e role o lasers or the treatment o IHs is controver- help to improve the redness and telangiectasia that remains
sial and accurate ef cacy rates are dif cult to determine. a ter involution.90 Fractionated ablative and nonablative
Super cial lesions respond better to laser treatment than lasers can be added to improve the appearance o remain-
mixed and deeper lesions. PDL is the most commonly ing bro- atty residua and epidermal atrophy, and to
used device or treatment o IHs. T e long-pulsed PDL at reduce redundant skin.91,92
595 nm showed, in several uncontrolled studies, quicker Other light-based devices which have been used to
resolution and improved clinical clearance with signi - treat IHs include the requency doubled Nd:YAG (K P)
cantly lower rates o adverse events when compared to the and IPL. T e K P laser was compared to the PDL in 50
S
585 nm.82,83 A randomized trial compared a group treated in ants with super cial IHs and was ound to have ewer
c
t
i
with a 585 nm PDL without epidermal cooling to a group side e ects and to cause less pain, but also demonstrated
o
n
treated with a 595 nm PDL with cryogen spray cooling. In lower ef cacy than the PDL.93 IPL has demonstrated ef -
5
this trial, while almost the same number o children had cacy or the treatment o both centro acial hemangiomas
:
:
complete to almost complete clearing at 1 year ( 60%), and ulcerated hemangiomas.94 One case report noted re-
children in the group treated with the 595 nm PDL with epithelialization and pain control in an ulcerated heman-
A
dynamic cooling were ound to have signi cantly shorter gioma a ter one IPL treatment.95
s
t
h
times o maximum proli eration (106 vs. 177 days) and
t
lower risk or laser-induced adverse events such as hyper-
i
c
P
pigmentation, hypopigmentation, and atrophy.84 More
v en o u s ma Lf o r ma t Io n s
r
o
recently, a retrospective study noted that combination
b
l
propranolol and PDL demonstrated greater improvement
m
over propranolol alone. Patients who were treated with Venous mal ormations clinically present as so t, com-
s
combination therapy demonstrated greater overall ading pressible, nonpulsatile blue-violaceous papules and nod-
and obtained clearance over a shorter period o time (150 ules. T ey are slow- ow mal ormations that are present at
vs. 228 days) than those treated with propranolol alone. birth (although not always clinically apparent at birth) and
In addition, propranolol alone tended to leave residual slowly enlarge throughout li e. Venous mal ormations are
super cial hemangioma that responded well to PDL ther- nonproli erating, vascular birthmarks caused by local-
apy, either concurrently or subsequently to propranolol ized errors in the embryologic ormation o the venous
treatment.85 system. Histologically, there are collections o abnormal
Settings or the treatment o IHs with the 595 nm PDL venous channels with vessel walls that are commonly cal-
should be selected based on multiple patient actors. First, ci ed. Most are solitary, but 1% o patients will have mul-
the stage o the lesion, proli erating versus involuting, will tiple lesions, especially i they are associated with amilial
a ect the settings selected. PDL treatment or proli erat- venous mal ormation syndromes, including amilial cuta-
ing IHs should be approached cautiously, with lower u- neous and mucosal venous mal ormation syndrome and
ences, as this will minimize risk or ulceration that can blue rubber bleb nevus syndrome, which are caused by a
result in scarring. Lower uences and longer pulse dura- mutation in VMCM1 on chromosome 9p21, resulting in
tions should be used in darker skinned patients. Epider- a gain o unction in the tyrosine kinase receptor, IE2.96
mal cooling should always be used. Parameters vary by Symptoms are related to the size and the location o the
device. Multiple treatments are usually required. For pro- lesion and can include pain, unctional impairment, and
li erating and ulcerated lesions, treatments can be spaced bleeding. MRI can be utilized to determine the extent o
approximately 2 to 4 weeks apart. For stable and involut- the lesion.97
ing lesions, treatments can be every 4 to 6 weeks. reatment options include surgical resection, sclero-
T e most common side e ect o treatment is bruising therapy, and percutaneous or intralesional laser therapy.
and/or temporary local swelling. Other risks o treatment Recurrence rates with sclerotherapy and laser therapy
include ulceration, scarring, and hypopigmentation. Using alone are high; thus, i easible, these treatments should
appropriate epidermal cooling and avoiding excessively be ollowed by surgical excision o all or large parts o the
high uences minimize the risk o ulceration and bleed- remaining lesion.98 Due to the deep nature o these lesions,
ing.86 In addition, patients with di use segmental hemangi- lasers in the in rared spectrum which have deeper penetra-
omas should be approached with extra caution as they may tion, such as diode or Nd:YAG lasers, are utilized when laser
be at increased risk or adverse e ects.67,86 therapy is pursued. Bene ts o the Nd:YAG laser include
T e use o PDL or the treatment o ulceration has been increased brosis in the upper dermis, tissue shrinkage,
supported by several uncontrolled trials and is generally and improved color, all o which may increase the e ec-
regarded as e ective. Goals o treatment or ulcerated tiveness o subsequent sclerotherapy and/or surgical
IHs include decreasing pain, decreasing bleeding, and excision, while decreasing side e ects, include tissue swell-
decreasing risk o in ection by inducing re-epitheliali- ing, blistering, scarring, and discoloration.99 reatment
zation o the skin. PDL has even been shown to induce o these lesions should be approached by an experienced
620 healing as early as a ter one treatment session.87,88 Pain multidisciplinary team.
 Fitzpa trick s kin type Cons ider:
5
Re fe rra l to • Ultra sound
I Always burns, neve r ta ns V1 Cons ide r ophtha lmology • MRI with
dis tribute d S turge – to monitor for and without
II Us ua lly burns, minima lly ta ns P WS in a n We be r s igns a nd contra s t
infa nt Syndrome symptoms of • Refe rral to
gla ucoma neurologis t
III S ome time s burns, mode ra te ly ta ns familia r with
SWS
IV S e ldom burns, ta ns e a s ily

V Ra rely bu rns, ta ns profus e ly Che ck for de e p Cons ide r

Cons ide r va s cula r re fe rra l to
Extre mity Klippe l– involve me nt: inte rventiona l
VI Neve r burns, de e ply pigme nte d P WS Tre na unay ra diologist
• Cons ide r
Syndrome ima ging familia r with
s tudie s condition
For da rke r s kin type s cons ide r:

C
h
hydroquinone 4% QHS prior to

a
Che ck for

p
proce dure (hold for irrita tion) a dditiona l

t
a noma lie s :

r
5
pos te rior fos s a Re fe rra l to

2
S te p 1: Initia l cons ulta tion - At the initia l cons ulta tion ma ke ma lforma tions neurology and
of the bra in, cardiology and
dia ga nos is, dis cus s tre a tme nt options, a nd de te rmine s kin Cons ide r

:
La rge fa cia l

:
a rte ria l ophthalmology
type. Be fore tre a tme nt a ppointme nt, pa tie nt s hould us e P HACE
he ma ngioma a noma lie s,
syndrome as needed for

L
good s un prote ction. If pa tie nt ha s a ta n, tre a me nt s hould ca rdia c

a
a ppropria te

s
be de laye d a s this incre a s e s ris k for hype rpigme nta tion, a noma lie s, workups
a ortic

r
blis te ring a nd s ca rring.

a
coa rcta tion,

n
eye

d
a bnorma litie s

L
i
g
h
t
S te p 2: If a t the initia l workup the re is conce rn for

B
a syndrome or a dditiona l a bnorma litie s, initia te

a
s
a dditiona l workup.

d
T
r
a
t
m
n
t
o
f
V
a
s
c
u
l
a
Good option for
None

r
ma ny pa tie nts

L
s
i
o
n
Lidoca ine without

s
Loca l e pine phrine dire ctly
into the a re a

Re quire s 15–20
Ane s the s ia Ne rve block minute s wa it Expe cte d tis s ue Unexpe cte d tis s ue
be fore s ta rting re s pons e re s pons e

S unburn type pa in Infe ction

IM pa in
De me rol a nd vis ta ril
ma na ge me nt Blis te ring
Bruis ing
Hypopigme nta tion
To be pe rforme d by
Ge ne ra l expe rie nce d pe dia tric/ Swe lling
a dult a ne s the s iologis t S ca rring

S te p 3: Dis cus s a nd pe rs ona lize a ne the s ia for pa tie nt S te p 4: Cons e nt for tre a tme nt

621
5 Prote ctive Me ta l Corne a l
goggle s eye s hie lds s hie ld

• Che ck to confirm • P lace unde r the 3 Be gin tre a tme nt

cove ra ge for the pa tie nt’s eye lid in a sys te ma tic fa s hion.
wave le ngth be ing and over the eye Monitor for a ppropria te
us e d. with the a id of s kin re s pons e.
2 Te s t cooling
• Us e whe n tre a ting • P la ce me ta l s hie lds anes the tic drops
• If not functioning
le s ions not on the or dis pos a ble la s e r and eye lubricant.
prope rly, do NOT
S
he a d. eye s hie lds ove r • Us e whe n tre a t
c
• All provide rs s hould eye s if tre a ting tre a ting le s ions 1 Lay pa tie nt
t
i
we a r throughout le s ion on the fa ce within the bony s upine on
o
n
proce dure. or uppe r body. orbit. table
5
• For fa cia l le s ions , pla ce
pa tie nt in Tre nde le nburg
:
:
S te p 5: Choos e a ppropria te ce rtifie d la s e r s a fe eye prote ction. to incre a s e blood flow
Be s ure to double che ck tha t eve ryone in the room is we a ring
A
eye prote ction prior to s ta rting proce dure. S te p 6: S ta rting tre a tme nt
s
t
h
t
i
c
P
r
o
b
l
m
s
Eleva tion

Appropria te s kin re s pons e

Tyle nol Pos t-ope ra tive
Ice
• P DL- imme dia te purpura P RN pa in ins tructions
a s de mons tra te d he re.
Ne a r-infra re d la s e rs -
tra ns ie nt s ubtle blue -gray
color tha t evolve s into
S un
pe rs is te nt de e p purpura ; prote ction
pe rs is te nt gray is s ign of
ove r tre a tme nt a nd mus t
be avoide d. S te p 8: Give pa tie nt writte n a nd ve rba l pos t-ope ra tive ins tructions
• Long-puls e d 755 nm
la s e r - s ubtle blue -gray
dis colora tion tha t s lowly
evolve s into pe rs is te nt
de e p purpura

S te p 7: Guide ha ndpie ce ove r le s ion in a sys te ma tic fa s hion,

be ing s ure to tre a t the le s ion eve nly. Monitor for a ppropria te
s kin re s pons e.

622
t eLa n g Iec t a s Ia s a n d r o s a c ea tain improvement, as light therapy tends to be e ective,
but is not a cure.
5
elangiectasias are small 0.1 to 1 mm super cial dilated
vessels visible on the skin. T ey can appear spontaneously, c h er r y a n g Io ma s
but they most o ten arise secondary to other conditions.
Causes o telangiectasias include chronic photodamage, Cherry angiomas are the most common vascular lesions
rosacea, connective tissue disease, liver disease, radiation, o the skin. T ey are benign lesions that are highly respon-
genodermatoses (i.e., hereditary hemorrhagic telangiecta- sive to laser therapy, although they may also be treated
sia syndrome, ataxia– telangiectasia) and chronic topical with electrodesiccation or shave excision. T ey are most
steroid use. Patients with large numbers o telangiectasias commonly treated with PDL; however, IPL and K P may
and patients with rosacea will o ten present with com- also be used. Only one treatment is usually required to
plaints o di use acial redness. achieve complete clearance (purpura is the end point) but
reatment is not required or telangiectasias unless large or resistant lesions may require multiple treatments.

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they are cosmetically distressing or the patient. Removal o improve ef cacy or larger lesions, the rst pulse can

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a
is most e ectively accomplished with electrocautery, be delivered while per orming diascopy (compressing the

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IPL, and lasers. Commonly used lasers include PDL and lesion with a glass slide). T is will allow or treatment o

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K P. Spot sizes and shapes (round vs. elliptical) can be

5
the deeper component o the lesion. I purpura does not

2
adjusted and treatment should be tailored to each patient develop a ter the rst pulse, a second pulse may then be
taking into consideration the vessel caliber, patient’s skin

:
:
delivered without diascopy to treat the more super cial
type, and the patient’s tolerance o purpura. In the cos- vasculature. Spider angiomas may also be treated in this

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metic patient, purpura may be unacceptable. However, manner. Settings to consider or the PDL include a 5 to 7

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subpurpuric uences are less e ective than purpuric u-

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mm spot size, 1.5 ms pulse duration, and uences rom 7

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ences or the treatment o acial telangiectasias100,101 and

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to 10 J/cm 2 with appropriate epidermal cooling. Settings

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more treatments are generally required. Multiple passes vary by device used, and should be adjusted or patients

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and care ully used pulse stacking can improve the ef cacy with darker skin types.

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o treatment with subpurpuric uences.102,103 By deliver-

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B
ing additional pulses be ore the target has time to cool

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to its original temperature, target temperature is slowly Po IkILo d er ma o f c Iva t t e

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increased without causing vessel rupture. Pulse stacking

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can be used with some settings but clinician should watch Poikiloderma o Civatte is a variant o telangiectasia pre-

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skin care ully or evidence o epidermal injury. PDL set- senting in sun-exposed skin that is associated with sym-
tings to consider include a 7 to 10 mm spot size, 6 ms pulse metrical atrophy and pigmentary irregularities, usually

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duration, and uence o 6 to 9 J/cm 2 with epidermal cool- a ecting the upper chest, lateral neck, and occasionally the

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ing. Lower energies are used with larger spot sizes. Lower

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lateral cheeks. Characteristically, it spares the area shaded

a
uences should be used in patients with intense acial ery-

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by the chin. When treating poikiloderma o Civatte, it is

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thema and in patients with darker skin types. Longer pulse important to treat the pigmentary and textural changes

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a
durations should also be selected in patients with darker

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in addition to the telangiectasias. PDL has shown accept-

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skin types. Parameters vary by device. End points to look able results,109 but the neck is a sensitive area and needs

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i
or on the skin when treating telangiectasias include vessel

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to be approached with caution and experience, as there is

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clearance, bluish coagulum, transient purpura, or purpura.

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the risk o mottling o the skin due to uneven overlap o
Expected side e ects include erythema and acial swelling. the circular spots, and rarely, scarring. Multiple treatment
A cold pack can be applied post treatment to minimize sessions are almost always needed.110,111 IPL may be a more
swelling, and the patient can be instructed to sleep with appropriate choice in patients with signi cant hyperpig-
their head elevated to minimize swelling. mentation and erythema, since it can simultaneously tar-
K P and IPL lasers have also demonstrated ef cacy or get both the vascular and pigmentary components.
the treatment o acial telangiectasias. Multiple studies
have supported the ef cacy o K P or the treatment o
these lesions, which also causes less swelling, pain, bruis- a n g Io k er a t o ma s
ing, and redness than PDL.104,105 K P can be used to trace
individual vessels. Because o the greater competition Angiokeratomas are super cial ectatic vessels with over-
with melanin at 532 nm, caution must be taken in patients lying hyperkeratosis. T ey commonly appear as asymp-
with darker skin types. Nd:YAG may also be used to treat tomatic 2 to 5 mm blue to red papules. T ey can be
larger vessels, reticular acial veins, and re ractory telangi- categorized into localized and systemic orms. Localized
ectasias, but the therapeutic window is narrow and there orms include: (1) solitary lesions usually ound on the
is a greater risk o scarring. lower extremities, (2) the Fordyce type localized to the
T e background erythema associated with rosacea may genitals, (3) angioma circumscriptum, and (4) the Mibelli
be treated be ore or a ter the telangiectasias. Laser treat- type inherited in an autosomal dominant manner and
ment o rosacea may relieve symptoms o burning and occurring primarily on the dorsal hands and eet. T e gen-
stinging106 and may also decrease the papular and pustu- eralized systemic type, known as angiokeratoma corporis
lar components o rosacea.107 In some patients, antibiotic di usum, is usually associated with metabolic disorders,
doses may be decreased a ter 1 to 3 PDL sessions.108 Inter- most commonly Fabry disease, an X-linked recessive
mittent maintenance treatments are necessary to main- syndrome secondary to a de ciency o α-galactosidase 623
5 A, and ucosidosis. T ese lesions generally do not require
treatment; however, patients may request removal second-
new methodology with preliminary clinical evaluation. Arch
Dermatol. 1995;131(6):695– 700.
13. Raulin C, Greve B, Hammes S. Cold air in laser therapy: rst
ary to bleeding, discom ort, or or cosmesis. PDL, IPL, and
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tomas, although it is important to note that scarring may 14. Garden JM, an O , Kerschmann R, et al. E ect o dye laser
occur and several sessions may be required to penetrate the pulse duration on selective cutaneous vascular injury. J
hyperkeratotic epidermis overlying these lesions.112,113 o Invest Dermatol. 1986;87(5):653– 657.
15. Izikson L, Nelson JS, Anderson RR. reatment o hypertrophic
overcome this hyperkeratosis, ablative lasers such as the CO 2
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tics o the vessels composing these lesions is imperative
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ormations (new issues). Adv Dermatol. 1997;13:375– 423.
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5
outcomes. Many advances have been made in the removal are we at the dawn o a better knowledge? Pediatr Dermatol.
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o vascular lesions, and light-based therapy is a good
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o
hemangioma treatment by ashlamp-pumped (585 nm) and ciated telangiectasia and erythema. J Dermatol Surg Oncol.
b
l
requency-doubled Nd:YAG (532 nm) lasers. La sers Surg 1991;17(6):522– 525.
m
Med. 2001;28(1):40– 43. 109. Ross BS, Levine VJ, Ashino R. Laser treatment o acquired
s
94. Angermeier MC. reatment o acial vascular lesions with vascular lesions. Dermatol Clin. 1997;15(3):385– 396.
intense pulsed light. J Cutan La ser T er. 1999;1(2):95– 100. 110. Wheeland RG, Applebaum J. Flashlamp-pumped pulsed dye
95. Jorge BF, Del Pozo J, Castiñeiras I, Mazaira M, Fernández- laser therapy or poikiloderma o civatte. J Dermatol Surg
orres R, Fonseca E. reatment o ulcerated haemangiomas Oncol. 1990;16(1):12– 16.
with a non-coherent pulsed light source: brie initial clinical 111. Sommer S, Sheehan-Dare RA. Atrophie blanche-like scar-
report. J Cosmet La ser T er. 2008;10(1):48– 51. ring a ter pulsed dye laser treatment. J Am Acad Dermatol.
96. Vikkula M, Boon LM, Carraway KL 3rd, et al. Vascular 1999;41(1):100– 102.
dysmorphogenesis caused by an activating mutation in the 112. Varshney S. Angiokeratoma circumscriptum o the tongue.
receptor tyrosine kinase IE2. Cell. 1996;87(7):1181– 1190. Int J Dermatol. 2005;44(10):886– 888.
97. Dubois J, Garel L. Imaging and therapeutic approach o 113. Ergun S, Mete O, Yeşil S, anyeri H. Solitary angiokera-
hemangiomas and vascular mal ormations in the pediatric toma o the tongue treated with diode laser. La sers Med Sci.
age group. Pediatr Radiol. 1999;29(12):879– 893. 2009;24(1):123– 125.
98. Garzon MC, Huang J , Enjolras O, Frieden IJ. Vascular mal- 114. Kar HK, Gupta L. A case o angiokeratoma circumscriptum
ormations - Part I. J Am Acad Dermatol. 2007;56(3):353– o the tongue: response with carbon dioxide and pulsed dye
370. laser. J Cutan Aesthet Surg. 2011;4(3):205– 207.

626
 Ch a p t e r

53 Laser Hair Removal

Omar A. I rahimi & Su anne L. Kilmer

In t r o d u c t Io n papilla, a neurovascular structure that supplies the cells

o the proli erating matrix at the base o the ollicle, helps
orm the hair sha t.
T e ability o lasers to nonspeci cally damage hair ol-
Each hair ollicle consists o a permanent (upper) and
licles was noted nearly 50 years ago in the rst reports
nonpermanent (lower) part, with the ollicular bulge
on the use o lasers on human skin.1,2 It was not until the
orming the lowermost aspect o the permanent part. In
theory o selective photothermolysis was proposed by
periods o active growth (anagen) the rapidly developing
Rox Anderson and John Parrish at the Wellman Center
bulbar matrix cells dif erentiate into the hair sha t and
or Photomedicine at Harvard Medical School, however,
the hair lengthens. A transition period ollows in which
that the concept o selectively targeting a particular chro-
mophore based on its absorption spectrum and size was
realized.3 Several years later, this group also reported one Ana tomy of the
o the rst success ul uses o a normal-mode ruby laser or ha ir follicle
long-term and permanent hair removal.4,5
oday, removing unwanted body hair is a worldwide
trend, and photoepilation by laser or other light-based
technology is one o the most highly requested proce-
dures in cosmetic dermatology.6 Alternative methods or
removing unwanted hair include bleaching, plucking,
shaving, waxing, and chemical depilatories. T reading Ha ir s ha ft
is a common practice in some cultures. Un ortunately,
these methods do not provide a permanent solution to
unwanted hair, and can be inconvenient and tedious.7,8
Electrolysis is a method or hair removal in which a ne
S tra tum
needle is inserted deep into the hair ollicle and uses elec- corme um
trical current, thereby destroying the hair ollicle and
allowing or permanent hair removal o all types o hair.9,10 Epide rmis
However, this technique is extremely operator depen-
dent and e cacy in achieving permanent hair removal is
variable among patients.9,10 It is also impractical in terms
o treating large areas. E ornithine is a topical inhibi- S e ba ce ous
gla nd
tor o ornithine decarboxylase that slows the rate o hair
growth, which can be ef ective or decreasing unwanted
acial hair,8 and is currently indicated or the removal o Arre ctor pili
mus cle
unwanted acial hair in women. E ornithine can be com-
bined with lasers and intense pulsed light (IPL) or hair
removal.11,12 In this chapter, we provide a detailed over-
view o laser hair removal (LHR) including a discussion o Bulge re gion
hair ollicle biology, the science behind LHR, key actors in
optimizing treatment, and uture directions.
Pa pilla /ma trix

t h e h a Ir Fo l l Ic l e
T e hair ollicle is a complex, hormonally active struc-
ture with a programmed growth pattern (Fig. 53-1). It
is anatomically divided into the in undibulum (hair ol- Figure 53-1 Hair ollicle anatomy. Reproduced with
licle ori ce to insertion o the sebaceous gland), isthmus permission rom Tsao SS, Hru a GJ. Laser hair removal. In:
(insertion o the sebaceous gland to the insertion o the Ro inson JK, Hanke CW, Sengelmann RD, Siegel DM, eds.
arrector pili muscle), and in erior (insertion o the arrector Surgery of the Skin. Philadelphia, PA: Elsevier Mos y; 2005:
pili to the base o the hair ollicle) segments. T e dermal 575–588. Copyright Elsevier.
5 the bulbar part o the hair ollicle undergoes degradation
through apoptosis (catagen). A resting period (telogen)
and lighter in color. A list o laser and light devices that are
commercially available at the time o this publication or
phase ensues, and regrowth is started once again in early hair removal are summarized in able 53-1.
anagen. Stem cells within the hair ollicle regenerate the
ollicle within or near the hair bulb matrix. Slow-cycling
stem cells have also been ound in the ollicular bulge aris- Key Fa c t o r s In o pt IMIz In g
ing rom the outer root sheath at the site o arrector pili t r ea t Men t
muscle attachment. T e duration o each growth phase is
body site dependent.
T e ability to selectively target hair ollicles with lasers
T ere are three main types o hair: lanugo, vellus, and
and light sources has revolutionized the ability to elimi-
terminal hairs. Lanugo hairs are ne hairs that cover a
nate unwanted hair both temporarily and permanently in
etus and are shed in the neonatal period. Vellus hairs are
many individuals. As laser technology advances, the abil-
usually nonpigmented, and have a diameter o roughly 30
ity to treat individuals o all skin types and all hair colors
to 50 µm. erminal hair sha ts range rom 150 to 300 µm in
broadens. Proper patient selection, preoperative prepara-
cross-sectional diameter. T e type o hair produced by an
S
tion, in ormed consent, understanding o the principles o
e
individual ollicle is capable o change (e.g., vellus to ter-
c
laser sa ety, and laser and light source selection are key to
t
i
minal hair at puberty or terminal to vellus hair in andro-
o
the success o laser treatment. An understanding o hair
n
genic alopecia). Only terminal hair ollicles are responsive
5
anatomy, growth and physiology, together with a thorough
to LHR.
understanding o laser– tissue interaction, in particular
:
:
Hair color is determined by the amount o pigment in the
within the context o choosing optimal laser parameters
hair sha t. Melanocytes produce two types o melanin—
A
or ef ective LHR, should be acquired be ore using lasers
e
eumelanin, a brown-black pigment; and pheomelanin, a
s
or hair removal.
t
h
red pigment. Melanocytes are located in the upper por-
e
t
tion o the hair bulb and outer root sheath o the in un-
i
c
pa t Ien t s el ec t Io n
P
dibulum.
r
o
Excessive and unwanted body hair ranges in severity,
l
Despite the seemingly cosmetic nature o LHR, a com-
e
depending on cultural mores, and can usually be classi-
m
ed as either hypertrichosis or hirsutism.13 Hirsutism is plete medical history, physical examination and in ormed
s
de ned as the abnormal growth o terminal hair in women consent, including setting realistic patient expectations
in male-pattern (androgen-dependent) sites, such as the and discussing potential risks, should be per ormed prior
ace and chest. Hypertrichosis re ers to excess hair growth to any laser treatment ( able 53-2). Any patient with evi-
at any body site that is not androgen dependent.13 In addi- dence o endocrine or menstrual dys unction should be
tion, the use o gra ts and aps in dermatologic and recon- appropriately worked up by an endocrinologist or gyne-
structive surgery can o ten introduce hair to an area that cologist. Similarly, patients with an explosive onset o
causes a displeasing appearance or unctional impairment. hypertrichosis should be evaluated or paraneoplastic
etiologies. reatment o a pregnant woman or nonurgent
conditions is discouraged, although there is no evidence
Mec h a n Is M o F l h r suggesting a potential risk to pregnant women undergo-
ing LHR. T e past medical history should be reviewed to
T e theory o selective photothermolysis enables one to identi y patients with photosensitive conditions, such as
selectively target pigmented hair ollicles by using the the autoimmune connective tissue disorders, or disorders
melanin o the hair sha t as a chromophore.3 As a result, prone to the Koebner phenomenon. A history o recurrent
LHR is only success ul on pigmented terminal hairs. cutaneous in ections such as HSV at or in the vicinity o
Melanin is capable o unctioning as a chromophore or the treatment area might warrant the use o prophylactic
wavelengths in the red and near-IR portion o the electro- medications. Previous methods o hair removal, including
magnetic spectrum.14 However, to achieve permanent hair any past laser treatments, should be reviewed. Any meth-
removal the biologic “target” is likely the ollicular stem ods o epilation, such as waxing or tweezing, that entirely
cells located in the bulge region and/or dermal papilla. remove the target chromophore, render LHR less ef ective
Based on the slight spatial separation o the chromophore or at least 2 weeks. Although there is little evidence to
and desired target, an extended theory o selective pho- con rm the time rame a patient must wait a ter complete
tothermolysis has been proposed, which requires dif u- epilation o the hair sha t and laser treatment, we rec-
sion o heat rom the chromophore to the desired target ommend a minimum o 6 weeks. Shaving and depilatory
or destruction.15 T is requires a laser pulse that is longer creams can be used up to the day o laser treatment as they
in duration than i the actual chromophore and desired do not remove the entire hair sha t.
target were identical. emporary LHR can result when the A thorough medication history should be obtained.
ollicular stem cells are not completely destroyed, primar- Any history o gold intake is a contraindication or laser
ily through induction o a catagen-like state in pigmented therapy. T e use o any photosensitizing medications or
hair ollicles. emporary LHR is much easier to achieve over-the-counter supplements should also delay treat-
than permanent removal, using lower uences. Long-term ment until these medications can be sa ely discontinued.
hair removal depends on hair color, skin color, and toler- T ere is controversy as to whether patients on isotretinoin
ated uence. Roughly 15% to 30% long-term hair loss may should be treated with lasers, although most practitioners
be observed with each treatment when optimal treatment recommend a 6 month to 1 year washout period prior to
628 parameters are used.16 Remaining hairs are also thinner ablative resur acing.17– 19 Whether this recommendation
TAbLE 53-1
5
a
c mm i a i l li s f h i r m

l / p s
li W d i F si
s ( m) s mn m (m ) (J/ m 2) (mm) o F
Long pulsed 694 Ru yStar and Ru y 4 Up to 24 8, 10, 12, Contact cooling
ru y Star+ 18
Long pulsed 755 Apogee Cynosure 0.5–300 25–50 5–15 Cold air or integrated cooling,
alexandrite can add 1064 nm Nd:YAG
module to orm Apogee Elite
Arion Quantel 5–140 Up to 40 6–16 Cold air unit
Derma

C
ClearScan YAG Up to 200 Up to 140 3, 6, and Contact cooling

h
a
Sciton 30 × 30

p
t
Coolglide Cutera 0.1–300 5–300 10 Contact cooling

e
r
Elite Cynosure 0.5–300 25–50 5–15 Cold air cooling, availa le with

5
3
1064 nm Nd:YAG, EliteMPX
model can simultaneously treat

:
:
with 755 nm Alexandrite and

L
1064 nm Nd:YAG

a
s
EpiCare LP/LPX 3–300 22–40 7–16

e
r
Light Age

H
a
GentleLASE, 3 Up to 100 6–18 Dynamic cooling

i
r
Candela

R
e
GentleMax Candela 0.25–300 Up to 600 1.5–18 Dynamic cooling, comes with

m
o
1064 nm Nd:YAG

v
a
Ultrawave 755/II/III Up to 100 up to 125 Up to 16 Availa le with 532, 1064, and

l
AMC Aesthetics and 1320 nm Nd:YAG
Advanced Aesthetic
Concepts
Diode 805 Advantage Lutronic, 5–400 Up to 100 10 × 10, Contact cooling
Freemont, Cali ornia, 10 × 30
USA
800–810 F1 Diode Opusmed 15–40 Up to 40 5, 7 Chiller tip
808, 980 Leda Quantel 6–60 Up to 60 50 × 12, Contact cooling
Derma 10 × 12
810, 940 MeDioStar XT 5–500 Up to 90 6, 12 Integrated scanner with cold air
Aesclepion cooling device
800 LightSheer Duet 5–400 10–100, 9 × 9, 22 Chill tip or smaller handpiece,
Lumenis 4.5–12 × 35 vacuum skin attening or
larger handpiece
810 Soprano XL Alma 10–1350 Up to 120 12 × 10 Contact cooling
Lasers
Long pulsed 1064 Acclaim Cynosure 0.4–300 35–600 1.5–15 Cold air or integrated cooling,
Nd:YAG can add 755 nm Alexandrite
module to orm Apogee Elite
Cynosure
ClearScan YAG 0.3–200 Up to 400 3, 6, and Contact cooling
Sciton 30 × 30
CoolGlide CV/XEO/ 0.1–300 Up to 300 3–10 Contact cooling
Excel/Vantage
Cutera
Cynergy Cynosure 0.3–300 Up to 600 1.5–15 Cold air
Dualis XP, XP Plus, 5–200 Up to 600 2–10 n/a
and XS Max Fotona
GentleYAG Candela, 0.25–300 Up to 600 1.5–18 Dynamic cooling
Wayland, MA
Gemini Iridex 1–100 Up to 990 2, 10 Availa le with 532 nm KTP
LightPod Neo 0.65–1.5 Up to 312 2 built in cooling system
Aerolase
Lyra Iridex 20–100 5–900 1–5, 10 Contact cooling

Continued
629
5 TAbLE 53-1 (Continued )
a
c mm i a i l li s f h i r m

l / p s
li W d i F si
s ( m) s mn m (m ) (J/ m 2) (mm) o F
MultiFlex Ellipse, n/a Up to 600 1.5–5 Equipped with IPL device
Atlanta, GA
Mydon Quantel 0.5–90 10–450 1.5–10 Integrated air cooling
NaturaLase 1064/LP 0.5–100 Up to 400 3–15 Integrated air cooling
Focus Medical
Pro le Sciton 0.1–10,000 Up to 75 n/a Contact cooling, 2940 nm
Er:YAG and 410–1400 nm
ashlamp in same device
S
e
SmartEpil Deka Up to 20 11 2.5, 4,
c
t
i
5, 6
o
n
SP Plus Fotona Up to 300 Up to 600 1–42
5
Synchro_FT Deka 2–30 Up to 50 2.5–13 Availa le with IPL handpiece
Ultrawave II/III AMC Up to 300 5–500 Up to 12 Pulsed cryogen cooling
:
:
Aesthetics, and
A
Advance Aesthetic
e
s
Concepts
t
h
e
Varia CoolTouch 0.6 Up to 500 2–10 Dynamic cryogen cooling
t
i
c
Intense 520–1200 Axiom Viora 25–75 and Up to 39 50 × 25, built in cooling system
P
r
o
pulsed light 2.2–12.5 35 × 15,
sources 20 × 10
l
e
m
420–1400 bbL Sciton Up to 200 Up to 30 15 × 45 built in cooling system
s
560–590 Cynergy Cynosure 0.3–300 Up to 600 n/a built in cooling system
400–1200 Duet/SkinStation/ 3–10 35 22 × 55
SpaTouch II
Radiancy
600–950 Ellipse I2 PL/ 2.5–88.5 4–26 10 × 48 MultiFlex model with long
MultiFlex Ellipse pulsed Nd:YAG
400–1400 EsteLux Palomar 10–100 up to 28 n/a
Medical
Technologies
650–950 Harmony XL Alma 30–50 up to 40 30 × 30 Availa le with 755 nm
Lasers alexandrite and 1064 and
1320 nm Nd:YAG
530–1200 iPulse Dermavista 5–120 Up to 20 89 sq Air cooling
390–1200 Med Flash II General Up to 100 Up to 45 n/a
Project
525–1200 MediLux/StarLux Y, 5–500 Up to 70 28 × 12, 1064 nm Nd:YAG handpiece
Ys, R, Rs Palomar 46 × 16 or StarLux 500
500–1200 MiniSilk_FT Deka 3–8 Up to 160 48 × 13, Contact cooling
23 × 13
400–1200 Mistral Radiancy Up to 80 4–15 25 × 50,
13 × 50,
13 × 35,
12 × 12
640–1400 NannoLight MP50 1–30 2.8–50 40 × 8 Nd:YAG handpiece, optional
Sy aritic cooling
640–1200 NaturaLight Up to 500 Up to 50 10 × 40
Solamed
750–1100 Solera Opus Cutera Auto 3–24 10 × 30
550–950 PhotoSilk/ Up to 30 10–340 21 × 10, Nd:YAG handpiece
PhotoLight/MiniSilk 46 × 10,
Cyanosure 46 × 18
770–1100 ProWave Cutera Auto 5–35 10 × 30
500–1200 Quadra Q4 48 10–20 33 × 15 built in cooling system
DermaMed
695–1200 Quantum HR 15–100 25–45 34 × 8
Lumenis
560–950 SmoothCool 1–60 10–45 8 × 34 Automatic temperature control
630 Eclipse system
530–1200 Trios Viora 25 up to 22 15 × 50
 TAbLE 53-1 (Continued )
5
a
c mm i a i l li s f h i r m

l / p s
li W d i F si
s ( m) s mn m (m ) (J/ m 2) (mm) o F
Fluorescent 615–920 OmniLight/ 2–500 Up to 90 7 × 15, Sapphire tip cooling
pulsed light NovaLight Medical 10 × 20,
bio Care 30 × 30
Optical energy 580–980 eMax/eLight Up to 100 Up to 50 12 × 15 Contact cooling
com ined Syneron optical; up
with RF to 50 J/cm 3
electrical RF

C
energy

h
a
p
Diode 800 eLaser Syneron Up to 100 Up to 50 12 × 15 Contact cooling

t
e
com ined optical; up

r
5
with RF to 50 J/cm 3

3
electrical RF

:
energy

:
L
810 MeDioStar Ef ect UP to 500 Up to 90 10, 12, Acoustic wave technology,

a
s
Aesclepion, Jena, 14 integrated scanner with cold

e
r
Germany air cooling device, 940 nm

H
a
simultaneously

i
r
R
a

e
This ta le is intended only as a re erence aid. The authors have made every attempt to provide an exhaustive list o availa le devices or laser

m
hair removal ut do not guarantee comprehensiveness.

o
v
a
l
TAbLE 53-2
p i hi f l /l i d i
h i r m is appropriate or other laser procedures is speculative at
best. opical retinoids used in the treatment area should
Presence o conditions that may cause hypertrichosis be discontinued 1 to 2 days prior to treatment to minimize
Hormonal postlaser erythema.
Familial T e physical examination should evaluate the patient’s
Drug i.e., corticosteroids, hormones, immunosuppressives,
Fitzpatrick skin phototype. T is will help determine which
sel or spousal use o minoxidil
lasers and light sources are sa e to use or that patient
Tumor
( able 53-1), because epidermal melanin in darkly pig-
History o local or recurrent skin in ection mented patients can compete with the melanin within hair
History o herpes simplex, especially perioral ollicles as the target chromophore. Importantly, every
patient should always be evaluated or the presence o a
History o herpes genitalis, important when treating the pu ic
tan, and i present, laser treatment should be delayed or
or ikini area
the treatment parameters appropriately adjusted until the
History o keloids/hypertrophic scarring tan has aded. I a patient with a tan is treated, the risk
History o koe neri ing skin disorders such as vitiligo and o side ef ects is increased. Finally, the patient’s hair color
psoriasis should be noted, as the chromophore or LHR is melanin.
erminal black and brown hairs usually contain su cient
Previous treatment modalities—method, requency, and date amounts o melanin to serve as a chromophore or LHR.
o last treatment, as well as response
In contrast, the lack o melanin, paucity o melanin or
Recent suntan or exposure to tanning or light ca inet presence o eumelanin in the hair ollicle, which clinically
Onset o hair regrowth recent correlates to white, gray, or red/blonde hair is predictive
o , at best, a poor response to LHR and the procedure
Tattoos or nevi present should not be per ormed. For patients with little to no
Patient’s expectations melanin in their hair ollicles, attempts have been made
to use an exogenous chromophore that can be topically
Patient’s ho ies or ha its that might inter ere with
delivered to the hair ollicles, thereby making the removal
treatment
o white, gray, red, and blonde hair hypothetically pos-
Present medications sible. T is concept was rst demonstrated with a topical
Photosensiti ing medications carbon solution dissolved in mineral oil.20 However, we
Isotretinoin intake within the past year have noticed very little e cacy o topical chromophores
Gold therapy
in our experience. 631
5 In Fo r Med c o n s en t
within the hair sha t, although the outer root sheath and
matrix area also contain melanin. Melanin is capable o
unctioning as a chromophore or wavelengths in the red
An explanation o the potential risks o LHR should be and near-IR portion o the electromagnetic spectrum,14
reviewed as part o the in ormed consent process. T e and can be targeted by ruby, alexandrite, diode, and
risks include but are not limited to temporary and perma- Nd:YAG lasers, as well as IPL devices.
nent hypo/hyperpigmentation, blister ormation, scar or- T e long-pulsed ruby laser (694 nm) was the rst device
mation, ulceration, hive-like response, bruising, in ection, used to selectively target hair ollicles,5 and to produce
acne are, and olliculitis. For those patients with Fitzpat- long-term ( ollow-up at 2 years) hair loss (6 mm spot
rick skin type IV or greater or o Mediterranean, Middle size, 270 ms pulse duration, and uences 30– 60 J/cm 2).4
Eastern, Asian, or South Asian descent, the low risk o T e long-pulsed ruby laser can be sa ely used in Fitzpat-
paradoxical hypertrichosis (conversion o vellus hairs to rick skin phototypes I to III. A large multicenter trial o
terminal hairs), especially when treating the lateral ace nearly 200 patients showed that the majority o patients
and jaw, should be reviewed.21– 24 Patients should be coun- had >75% hair loss at 6 months ollow-up a ter an average
seled that permanent and complete hair removal is not o our treatments.25 able 53-1 lists the long-pulsed ruby
S
likely but that with multiple treatments, signi cant long-
e
lasers that are commercially available.
c
t
term reduction can be achieved. Hirsute women with hor-
i
T e long-pulsed alexandrite (755 nm) laser has been
o
n
monal abnormalities may require continued maintenance shown to be ef ective or hair removal in multiple stud-
5
therapy and should be advised o this possibility. Proce- ies.26 T e long-pulsed alexandrite laser can be sa ely used
dural pain is expected with LHR but can be minimized
:
:
in Fitzpatrick skin phototypes I to IV, although some
with topical anesthetics and the use o cold air cooling. It is experts limit its use to Fitzpatrick skin phototypes I to III.
A
vital that a minimal amount o local anesthesia be applied
e
A ew studies have demonstrated the sa ety o the long-
s
t
to avoid risk o lidocaine toxicity. Erythema and edema are
h
pulsed alexandrite laser in a large cohort o patients with
e
also expected with treatment and may rarely last up to 1
t
Fitzpatrick skin phototypes IV to VI.27,28 A randomized,
i
c
week. Patients should be made aware o the need or strict
P
investigator-blinded clinical trial29 o subjects with skin
r
sun avoidance or a minimum o 6 weeks be ore and a ter
o
phototypes III to IV treated with a long-pulsed alexandrite
each treatment.
l
e
laser (12 and 18 mm spot size, 1.5 ms pulse duration, and
m
uences o 20 or 40 J/cm 2) or our sessions at 8 week
s
PREOPERATIVE PREPARATION AND LASER intervals showed 76% to 84% hair reduction 18 months
SAFETY. T e need or topical anesthesia is variable a ter the last treatment and provides the best evidence
among patients and anatomic sites. Various topical anes- or long-term hair removal e cacy with the alexandrite
thetics including lidocaine, lidocaine/prilocaine, and other laser. A randomized controlled trial o 144 Asian subjects
amide/ester anesthetic combinations can be used to di- with Fitzpatrick skin types III to V with a long-pulsed alex-
minish the procedural discom ort, and should be applied andrite laser (12.5 mm spot size, pulse duration o 40 ms,
30 minutes to 1 hour be ore treatment under occlusion. uences o 16–24 J/cm 2) ound that subjects undergoing
Care should be taken when using lidocaine or prilocaine three treatments had a 55% hair reduction compared to
to apply these medications to a limited area to diminish subjects treated two times, with a 44% hair reduction, and
the risk o lidocaine toxicity or methemoglobulinemia, re- subjects treated one time, with a 32% hair reduction at 9
spectively. Use o topical anesthesia over large body sur ace months ollow-up.30 Combination treatment with alexan-
areas can be atal. drite and Nd:YAG lasers provides no added bene t over the
Patients should be placed in a room with a treatment alexandrite laser alone.31 T e commercially available long-
chair that makes the desired treatment area easily acces- pulsed alexandrite devices are summarized in able 53-1.
sible. T e room should be adequately cooled to keep the T e long-pulsed diode (800– 810 nm) laser has also been
laser device rom overheating and be ree o any hanging extensively used or LHR.26,32 T e diode laser can be sa ely
mirrors or uncovered windows. A re extinguisher should used in patients with Fitzpatrick skin phototypes I to V.
be readily available, especially i oxygen is being used. wo long-term nonrandomized controlled studies show-
Having a vacuum device on hand during treatment can ing roughly 40% hair reduction at a mean ollow-up o 20
minimize the plume and unpleasant odor created by each months a ter one or two treatments (9 mm spot size, pulse
laser pulse. Because the retina contains melanin, which duration o 5– 30 ms, uences o 15– 40 J/cm 2),33 and 84%
can be damaged by all LHR devices, proper eye protection hair reduction at 1 year ollow-up a ter our treatments
is absolutely critical or both the patient and laser surgeon. (9 mm spot size, pulse duration o 5– 30 ms, uences o
Each device requires the use o protective goggles that are 12– 40 J/cm 2)34 demonstrate the e cacy o the diode laser
unique to the device’s particular wavelengths. Goggles or long-term hair removal.
cannot be interchangeably used with laser or IPL devices T e long-pulsed Nd:YAG laser has been thought to of er
o other wavelengths. Furthermore, because o the risk o the best combination o sa ety and e cacy or Fitzpatrick
retinal damage, it is the authors’ strong opinion that one skin phototype VI patients. We have ound the Nd:YAG
should never treat a patient or LHR within the bony orbit. to of er good e cacy but with higher relative uences
relative to the above wavelengths. A nonrandomized trial
reported a 70% to 90% reduction o acial, axillary, and leg
d ev Ic e va r Ia bl es hair growth 1 year a ter three monthly treatments with an
Nd:YAG laser (5 mm spot size, pulse duration o 50 ms,
WAVELENGTH. T e chromophore or LHR is mela- uences o 40–50 J/cm 2).35 A small study o axillary LHR
632 nin. Within the hair ollicle, melanin is principally located comparing long-pulsed alexandrite, diode, and Nd:YAG
lasers showed that both the alexandrite and diode lasers
were signi cantly more e cacious than the Nd:YAG laser
time ( R ). Higher R s require longer pulse durations
or optimal e cacy. erminal hairs are roughly 300 µm in
5
or LHR.36 diameter, and thus the calculated R o a terminal hair
IPL is composed o polychromatic, noncoherent light ollicle is roughly 100 ms. However, unlike many other la-
ranging rom 400 to 1200 nm. Various lters can be used ser applications, the hair ollicle is distinct in that there is
to target particular chromophores, including melanin, a spatial separation o the chromophore (melanin) within
using IPL. However, long-term (>1 year) hair removal the hair sha t and the biologic “target” stem cells in the
has not been convincingly demonstrated to date. Various bulge and bulb areas o the ollicle. T e expanded theory o
reports have demonstrated some short-term e cacy.37,38 selective photothermolysis15 takes this spatial separation
One study o patients treated with a single IPL session into account and proposes a thermal damage time ( D ),
reported 75% hair removal 1 year a ter treatment.39 Stud- which is thought to be longer than the R . Shorter pulse
ies providing a head-to-head comparison o IPL ver- widths are also capable o removing hair, and it is unclear
sus either the long-pulsed alexandrite laser,40 Nd:YAG which is more ef ective in producing permanent hair
laser,41 or diode laser 66 all ound the IPL to be in erior removal. Longer pulse widths are likely more selective
to laser devices or hair removal. In contrast, a study o or melanin within the hair ollicle and can minimize

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hirsute women, some with a diagnosis o polycystic ovar- epidermal damage as the pulse widths are greater than

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ian syndrome, who underwent a split ace treatment the R o the melanosomes and melanocytes within

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with six IPL or long pulsed diode laser (LPDL), showed the epidermis.

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statistically equivalent reductions in hair counts at 1
(77% vs. 68%, respectively), 3 (53% vs. 60%, respectively), SPOT SIz E. T e spot size is the diameter in millimeters

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and 6 months (40% vs. 34%, respectively) a ter the nal o the laser beam. As photons within a laser beam penetrate

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treatment.42 the dermis, they are scattered by collagen bers, and those

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that are scattered outside the area o the laser beam are

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FLUENCE. Fluence is de

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ned as the amount o energy essentially wasted. Photons are more likely to be scattered

a
delivered per unit area and is expressed as J/cm 2. Higher outside o the beam area or smaller spot sizes, whereas in

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R
uences have been correlated with greater permanent a larger spot size, the photons are likely to remain within

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hair removal,5,44 but are also more likely to cause untow- the beam area ollowing scatter. A double-blind, random-

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ard side ef ects. Recommended treatment uences are o - ized control trial o a long-pulsed alexandrite device or

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ten provided with each individual laser device or inexpe- LHR o the axillary region comparing 18 and a 12 mm
rienced operators. However, a more appropriate method spot sizes at otherwise identical treatment parameters
o determining the optimal treatment uence or a given showed a 10% greater reduction in hair counts with the
patient is to evaluate or the desired clinical end point o larger spot size.44 Recently, a prospective study45 using a
peri ollicular erythema and edema (Fig. 53-2). T e high- LDPL with a large 22 × 35 mm handpiece at low uences
est possible tolerated uence, which yields this end point and no skin cooling was shown to have similar long-term
without any adverse ef ects, is o ten the best uence or hair removal e cacy to published studies o LPDLs using
treatment. a smaller spot size, higher uences, and skin cooling. T us,
larger spot sizes are pre erable to smaller spot sizes.
PULSE DURATION. Pulse duration is de ned as the
duration in seconds o laser exposure. T e theory o selec- SKIN COOLING. T e presence o epidermal melanin,
tive photothermolysis3 enables the laser surgeon to select particularly in darker skin types, presents a competing
an optimal pulse duration based on the thermal relaxation chromophore to hair ollicle melanin, which can be dam-
aged during LHR. Cooling o the skin sur ace can be used
to minimize epidermal damage, while permitting treat-
ment with higher uences.46,47 All skin cooling methods
unction by acting as a heat sink and removing heat rom
the skin sur ace. T e least ef ective type o cooling is the use
o an aqueous cold gel, which passively extracts heat rom
the skin and is not capable o urther skin cooling. Alterna-
tively, cooling with orced chilled air can provide cooling
to the skin be ore, during, and a ter a laser pulse. oday,
most o the commercially LHR devices have a built-in skin
cooling system, which either consists o contact cooling
or dynamic cooling with a cryogen spray. Contact cool-
ing, usually with a sapphire tip, provides skin cooling just
be ore and during a laser pulse. It is most use ul or treat-
ments with longer pulse durations (>10 ms).48 During the
course o a treatment, it is advised that the operator touch
the contact cooling tip to ensure it is cooled appropriate-
ly. Dynamic cooling with cryogen liquid spray47 precools
the skin with a millisecond spray o cryogen just be ore the
laser pulse. A second spray can be delivered just a ter the la-
Figure 53-2 Appropriate clinical end point o peri ollicu ser pulse or postcooling, but parallel cooling during the la-
lar erythema and edema. ser pulse is not possible as the cryogen spray inter eres with 633
5 the laser beam. Dynamic cooling is best suited or use with
pulse durations shorter than 5 ms.
signi cant hair clearance, 54% and 42%, at 6 and 15 month
ollow-up visits ollowing three monthly treatments using a
LPDL using a large handpiece in the largest prospective trial
to date.45 Remaining hairs were also ound to be less thick
po s t pr o c ed u r e c a r e and lighter when they grew back.

It is expected or the patient to have peri ollicular erythema SIDE EFFECTS AND MANAGEMENT OF
and edema in the treatment area ollowing LHR (Figure COMPLICATIONS. LHR was FDA cleared in l996
53-2). T is generally persists or 2 days but rarely can last and has an excellent sa ety and e cacy pro le when per-
or up to 1 week. Ice and application o a topical cortico- ormed by highly trained individuals. Complications are
steroid can be used to shorten the duration o these desired rare i treatments are done care ully and with the patient’s
clinical ndings. Patients will o ten nd that a single treat- skin type in mind. However, a recent analysis o publically
ment o LHR with shorter pulse durations results in nearly available legal documents rom the past 27 years relating
total epilation o the hair ollicles in the treatment area. It to cutaneous laser surgery ound that LHR was the most
is important to counsel the patient that a majority o these common litigated procedure, with a majority o cases in-
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hairs will likely regrow, and that this is not considered a volving nonphysician operators.67
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treatment ailure. Generally, only about 15% o hairs are LHR is not a painless procedure. Most patients experi-
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permanently removed with each laser treatment. On the ence some discom ort during and immediately a ter treat-
5
other hand, LHR treatments with longer pulse durations ment. A topical or local anesthetic can be used be ore
:
may leave behind many hairs, which appear to “grow” ol- treatment as well as cold air cooling be ore, a ter, and
:
lowing treatment. It is important to reassure the patient that during treatment to reduce this ef ect. Peri ollicular ery-
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these “growing” hairs are dislodged rom the hair ollicle thema and edema are expected in many patients treated
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h
and require 1 to 2 weeks to be completely shed. Nearly any with signi cant laser uences. T e intensity and duration
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method o epilation can be used to hasten their removal. depend on hair color and hair density. T is usually lasts a
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T e importance o strict sun precautions ollowing ew hours (Fig. 53-2).
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LHR treatments cannot be overemphasized. T is can be Epidermal damage occurs i excessive uences are used,
l
achieved by the use o topical sunscreens, hats, ultraviolet so appropriate epidermal cooling techniques (i.e., rm and
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light impermeable garments, and strict sun avoidance. ull contact with the contact cooling device) are imperative.
s
Epidermal damage is also more common in patients with
a tan. Herpes simplex outbreaks are uncommon but may
l o n g -t er M eFFIc a c y occur. T ere is a higher risk among patients with a pre-
vious history o herpes simplex and when the perioral,
Dierickx et al.,5 ollowed up 7 o 13 subjects rom the semi- pubic, or bikini areas are treated. T e risk o bacterial
nal study demonstrating the rst example o LHR, 2 years in ection is extremely low. Folliculitis may also occur in
a ter a single treatment with the normal mode ruby laser. O areas treated a ter excessive sweating or vigorous exercise.
the seven subjects, our had evidence o persistent perma- An additional risk is posed by swimming or using a hot-
nent hair reduction at 2 year ollow-up, whereas three sub- tub around the time o treatment sessions. T e most com-
jects experienced complete regrowth. Lou et al.33 reported mon side ef ects are transient pigmentary changes such as
that 18 out o 50 original study subjects showed roughly a hyperpigmentation (Fig. 53-3), which can be prevented
25% to 33% and 36% to 46% hair reduction at a mean ollow- i the appropriate treatment uences are chosen or each
up o 20 months a ter one or two treatments (9 mm spot skin type. Pigmentary abnormalities are mostly seen in
size, pulse duration o 5–20 ms, uences o 15–40 J/cm 2, patients with darker skin types or in patients with a recent
single or triple pulsed), respectively, with a LPDL device. tan.43,50– 52 Permanent pigmentary changes are unlikely
Eremia et al.,34 in a head-to-head trial comparing a LPDL except in dark-skinned individuals (Fig. 53-4).53
to a long-pulsed alexandrite laser, ound a 49% to 94% hair For those patients with Fitzpatrick skin type IV or
reduction at 1 year ollow-up a ter our treatments (9 mm greater, o Mediterranean, Middle Eastern, Asian, or South
spot size, pulse duration o 20 ms, uences o 12–40 J/cm 2) Asian descent, or hirsutism in the “beard” and lateral ace
with the LPDL in 15 subjects. Similar results were achieved distribution, treatment with laser may result in paradoxi-
with the alexandrite laser used in this study. Fi teen o 20 cal hypertrichosis21– 24 (conversion o vellus hairs to termi-
subjects with Fitzpatrick skin phototypes III to IV treated nal hairs). T e incidence o paradoxical hypertrichosis is
with a long-pulsed alexandrite laser (12 and 18 mm spot not clear, although the a orementioned actors are thought
size, 3 ms pulse duration, and uences o 20 or 40 J/cm 2) or to place the patient at risk or this rare and poorly under-
a long-pulsed Nd:YAG laser (12 mm spot size, 3 ms pulse stood phenomenon. Nonetheless, this phenomenon has
duration, and uence o 40 J/cm 2) or our sessions at 8 week also been observed on the back o Caucasian males when
intervals showed 76% to 84% and 74% hair reduction, treated with hair removal lasers. One mechanistic explana-
respectively, 18 months a ter the last treatment.29 Braun 49 tion or paradoxical hypertrichosis is that the scattering o
reported a head-to-head trial o a high- uence LPDL (9 mm photons that occurs at the periphery o a laser beam lowers
spot size, pulse duration o 30 ms, uences o 20–50 J/cm 2) the ef ective uence at the edges and that this low level o
versus a low- uence LPDL (12 × 10 mm spot size, pulse energy at the beam periphery may actually be stimulatory
duration o 20 ms, uences o 5–10 J/cm 2) in 22 subjects and to hair growth rather than resulting in thermal destruction
showed similar, 94% and 90% hair reduction respectively, at o the hair ollicle stem cells.
18 months’ ollow-up ollowing ve treatments spaced 6 Scarring is unlikely except in cases o overaggressive
634 to 8 weeks apart. Finally, we recently reported statistically treatment, treatment o a tanned patient, ailure to protect
 5

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A B

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Figure 53-3 Examples o LHR induced hyperpigmentation.

the epidermis, or postoperative in ection. Loss o reck- or impair the unction o melanocytes but insu cient to
les or lightening o tattoos or pigmented lesions is not damage the hair ollicle cells.
uncommon. Patients should be aware o this possibility. A case o lichen planus triggered by long-pulsed ruby-
Poor operator technique with insu cient amounts o laser treatment or hair removal has been reported.55
overlap between laser pulses can create zones o untreated Logic would suggest that all patients with a history o skin
skin that may leave a displeasing appearance (Fig. 53-5). diseases known to show a Koebner phenomenon, such as
emporary or permanent leukotrichia has been said to psoriasis vulgaris, vitiligo, lichen planus, and Darier’s dis-
develop ollowing laser or IPL hair removal.54 T is nding ease, should be in ormed about this possible adverse ef ect
may be explained by the dif erence in the R s o mela- o treatment; clinically this is rarely seen.
nocytes and germinative cells. T e light absorbed and the Livedo reticularis,56 intense pruritus, and urticaria57
heat produced by melanin may be su cient to destroy have been reported, including a case o intense swelling 635
5

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C D

Figure 53-4 Permanent pigmentation changes resulting rom LHR. A. Temporary hyperpigmentation in a Fit patrick skin
phototype IV treated with an IPL device or hair removal. B. One month later, the hyperpigmented patches were replaced
with persistent hypopigmented patches. C. Temporary hyperpigmentation in a Fit patrick skin phototype VI patient
treated with an Nd:Yag device. D. Two weeks later, the annular hyperpigmented patches were replaced with persistent
hypopigmented patches.

and erythema. T e pathophysiology o these phenom-

ena is not known. Management included topical corti-
costeroids, antihistamines, and discontinuing treatment.
Several cases o induction o hair growth ollowing LHR
in young emale patients with darker skin types have
been reported.21– 24 wo dif erent phenomena have been
observed: conversion o ne vellus hair to dark, coarse ter-
minal hair at the site o treatment or induction o growth
o long ne hairs in the immediate vicinity o the treat-
ment area. Repetitive, low- uence treatments with hair
removal devices have also been reported to induce hair
growth. Further study is ongoing to assess the mecha-
nisms or this response. reatment o this side ef ect has
included continued treatment in some cases.
Light-based hair removal devices are designed or
strong absorption by melanin and deep tissue penetra-
tion. T ese systems are, there ore, capable o causing reti-
nal injury and proper eye protection must be worn by the
patient and operating personnel. reatment near or on the
sur ace o an eye is not recommended. All other body sites
can be treated sa ely.
T e “plume” generated by the vaporized hair sha ts has
a typical sul uric smell and in large quantities, can be irri-
tating to the respiratory tract. A smoke evacuator is rec- Figure 53-5 zones o untreated skin resulting rom poor
636 ommended. operator technique.
c o n c l u s Io n poorly pigmented hair. A study o 40 patients (Fitzpatrick
skin phenotypes II to V) with varied acial and non acial
5
hair colors were treated with combined IPL/RF ELOS
Fu t u r e d Ir ec t Io n s technology. An average clearance o 75% was observed
at 18 months ollowing our treatments. No signi cant
ADVANCES IN PAIN CONTROL. A novel tech- adverse sequelae were noted and there were no treatment
nique to reduce LHR-associated pain is pneumatic skin dif erences between patients o varying skin types or hair
attening (PSF).58 PSF works by coupling a vacuum cham- color.64 Pretreatment with ALA prior to use o a combined
ber to generate negative pressure and atten the skin IPL and RF device has been shown to urther augment the
against the handpiece treatment window. Based on the removal o terminal white hairs.65
gate theory o pain transmission, this technique stimu- In conclusion, hair removal has made a dramatic shi t
lates pressure receptors in the skin immediately prior to rom an art to a science based on the theory o selective
ring o the laser pulse, thereby blocking activation o pain photothermolysis. Since the rst reports o selective hair
bers. PSF is just beginning to be incorporated into com- removal in 1996 by Anderson et al,5 there has been a tre-
mercially available lasers ( able 53-1). A recent study o mendous explosion in the number o devices used or

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LHR using a LPDL with a large spot size and vacuum-as- LHR, making it the most commonly requested cosmetic

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sisted suction showed that the majority o subjects report- procedure in the world. T is review provides the reader

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ed eeling no pain at all or up to moderate pain without the

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with the undamentals o hair ollicle anatomy and physi-

5
use o skin cooling or topical anesthetics.45 Notably, none

3
ology, pearls or patient selection and preoperative prep-
o the subjects in the study reported experiencing severe aration, principles o laser sa ety, an introduction to the

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or intolerable pain. various laser/light devices and a discussion o laser– tissue

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interactions that are vital to optimizing treatment e cacy

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HOME USE LASER AND LIGHT SOURCE

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while minimizing complications and side ef ects.

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DEVICES FOR HAIR REMOVAL. In recent years, a

H
a
number o devices have been developed that seek to pro-

i
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r eFer en c es

R
vide patients with the ability to achieve hair removal at

e
m
home. T ese devices are based on IPL, laser, and thermal

o
technologies that target the hair ollicle or destruction. 1. Goldman L, Blaney DJ, Kindel DJ Jr, Franke EK. Ef ect o the

v
a
T ese devices include Spa ouch (Radiancy), ria (Spec- laser beam on the skin. Preliminary report. J Invest Dermatol.

l
traGenics), and no!no! (Radiancy). 1963;40:121– 122.
2. Goldman L, Blaney DJ, Kindel DJ Jr, Rich eld D, Franke EK.
T e evidence behind such devices is scant and lim- Pathology o the ef ect o the laser beam on the skin. Nature.
ited to small noncontrolled studies.59– 61 One recent small 1963;197:912– 914.
trial o 13 subjects showed 44% to 65% hair reduction at 3. Anderson RR, Parrish JA. Selective photothermolysis: precise
12 months a ter eight monthly treatments, thereby sug- microsurgery by selective absorption o pulsed radiation. Sci-
gesting that there is potential or long-term hair removal, ence. 1983;220(4596):524– 527.
4. Dierickx CC, Grossman MC, Farinelli WA, Anderson RR.
albeit with much lower e cacy than traditional laser Permanent hair removal by normal-mode ruby laser. Arch
devices.68 In addition, the risk or devastating eye injuries Dermatol. 1998;134(7):837– 842.
with improper use o laser- and IPL-based devices and 5. Grossman MC, Dierickx C, Farinelli W, Flotte , Anderson
lack o medical training raises a dilemma o how much RR. Damage to hair ollicles by normal-mode ruby laser
autonomy a patient should have when using potentially pulses. J Am Acad Dermatol. 1996;35(6):889– 894.
6. Ibrahimi OA, Avram MM, Hanke CW, Kilmer SL, Anderson
harm ul devices. Nonetheless, the appeal o having a per- RR. Laser hair removal. Dermatol T er. 2011;24(1):94–107.
sonal device to remove unwanted hair in the privacy o 7. Lanigan SW. Management o unwanted hair in emales. Clin
one’s home without the expense and inconvenience o Exp Dermatol. 2001;26(8):644– 647.
multiple dermatologist or spa visits will likely drive the 8. Shapiro J, Lui H. reatments or unwanted acial hair. Skin
development o additional home use devices. T erapy Lett. 2005– 2006;10(10):1– 4.
9. Richards RN, McKenzie MA, Meharg GE. Electroepilation
(electrolysis) in hirsutism. 35,000 hours’ experience on the
ALTERNATIVE TECHNOLOGIES FOR HAIR ace and neck. J Am Acad Dermatol. 1986;15(4 Pt 1):693–
REMOVAL. Photodynamic therapy (PD ) with ami- 697.
nolevulinic acid (ALA) has been shown in a small pilot 10. Richards RN, Meharg GE. Electrolysis: observations rom 13
study to result in up to 40% hair loss with a single treatment, years and 140,000 hours o experience. J Am Acad Dermatol.
1995;33(4):662– 666.
although wax epilation was per ormed prior to treatment in 11. Hamzavi I, an E, Shapiro J, Lui H. A randomized bilateral
this study.62 vehicle-controlled study o e ornithine cream combined with
Electro-Optical Synergy (ELOS) technology combines laser treatment versus laser treatment alone or acial hirsut-
electrical (conducted radio requency [RF]) and optical ism in women. J Am Acad Dermatol. 2007;57(1):54– 59.
(laser/light) energies.63 A hand ul o devices based on this 12. Smith SR, Piacquadio DJ, Beger B, Littler C. E ornithine
cream combined with laser therapy in the management o
technology have been produced ( able 53-1). T e theory unwanted acial hair growth in women: A randomized trial.
behind ELOS is based on the optical component (laser Dermatol Surg. 2006;32(10):1237– 1243.
or IPL) heating the hair sha t, which then is thought to 13. Rosen eld RL. Clinical practice. Hirsutism. N Engl J Med.
concentrate the bipolar RF energy to the surrounding 2005;353(24):2578– 2588.
hair ollicle. Based on this combination, lower uences 14. Anderson RR, Parrish JA. T e optics o human skin. J Invest
Dermatol. 1981;77(1):13– 19.
are needed or the optical component, thereby suggesting 15. Altshuler GB, Anderson RR, Manstein D, Zenzie HH,
that it might be well tolerated in all Fitzpatrick skin photo- Smirnov MZ. Extended theory o selective photothermolysis.
types, and potentially ef ective in the removal o white and La sers Surg Med. 2001;29(5):416– 432. 637
5 16. Grossman MC. Long term comparison o dif erent lasers and
light sources or hair removal. La sers Surg Med. 2000;12(sup-
40. McGill DJ, Hutchison C, McKenzie E, McSherry E, Mackay
IR. A randomised, split- ace comparison o acial hair remov-
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17. Cassano N, Arpaia N, Vena GA. Diode laser hair removal and La sers Surg Med. 2007;39(10):767– 772.
isotretinoin therapy. Dermatol Surg. 2005;31(3):380– 381. 41. Goh CL. Comparative study on a single treatment response
18. Khatri KA. Diode laser hair removal in patients undergoing to long pulse Nd:YAG lasers and intense pulse light therapy
isotretinoin therapy. Dermatol Surg. 2004;30(9):1205– 1207; or hair removal on skin type IV to VI– is longer wavelengths
discussion 1207. lasers pre erred over shorter wavelengths lights or assisted
19. Khatri KA, Garcia V. Light-assisted hair removal in patients hair removal. J Dermatolog reat. 2003;14(4):243– 247.
undergoing isotretinoin therapy. Dermatol Surg. 2006;32(6): 42. Haak CS, Nymann P, Pedersen A , et al. Hair removal in hir-
875– 877. sute women with normal testosterone levels: A randomized
20. Goldberg DJ, Littler CM, Wheeland RG. opical suspension- controlled trial o long-pulsed diode laser vs. intense pulsed
assisted Q-switched Nd:YAG laser hair removal. Dermatol light. Br J Dermatol. 2010;163(5):1007– 1013.
Surg. 1997;23(9):741– 745. 43. Campos VB, Dierickx CC, Farinelli WA, Lin Y, Manuski-
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22. Desai S, Mahmoud BH, Bhatia AC, Hamzavi IH. Paradoxical hy- 2000;26(2):177– 185.
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pertrichosis a ter laser therapy: A review. Dermatol Surg. 2010; 44. Nouri K, Chen H, Saghari S, Ricotti CA Jr. Comparing 18- ver-
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36(3):291– 298. sus 12-mm spot size in hair removal using a gentlease 755-nm
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23. Moreno-Arias G, Castelo-Branco C, Ferrando J. Paradoxi- alexandrite laser. Dermatol Surg. 2004;30(4 Pt 1):494– 497.
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cal ef ect a ter IPL photoepilation. Dermatol Surg. 2002;28 45. Ibrahimi OA, Kilmer SL. Long-term clinical evaluation o
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(11):1013– 1016; discussion 1016. a 800 nm long-pulsed diode laser with a large spot size and
24. Willey A, orrontegui J, Azpiazu J, Landa N. Hair stimulation vacuum-assisted suction or hair removal. Dermatol Surg.
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ollowing laser and intense pulsed light photoepilation: Review 2012;38(6):912– 917.
o 543 cases and ways to manage it. La sers Surg Med. 2007; 46. Zenzie HH, Altshuler GB, Smirnov MZ, Anderson RR. Evalu-
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25. Anderson RR, Burns AJ, Garden J, et al. Multicenter study o Med. 2000;26(2):130– 144.
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long-pulse ruby laser hair removal. La sers Surg Med. 1999;11 47. Nelson JS, Milner E, Anvari B, et al. Dynamic epidermal
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(suppl):14. cooling during pulsed laser treatment o port-wine stain. A
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27. Garcia C, Alamoudi H, Nakib M, Zimmo S. Alexandrite laser 48. Battle EF Jr, Suthamjariya KK, Alora MB, Palli K, Anderson
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hair removal is sa e or Fitzpatrick skin types IV-VI. Dermatol RR. Very long-pulsed (20– 200 ms) diode laser or hair remov-
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Surg. 2000;26(2):130– 134. al on all skin types. La sers Surg Med. 2000;12(suppl):85.
28. Galadari I. Comparative evaluation o dif erent hair removal la- 49. Braun M. Comparison o high- uence, single-pass diode laser
sers in skin types IV, V, and VI. Int J Dermatol. 2003;42(1):68–70. to low- uence, multiple-pass diode laser or laser hair reduc-
29. Davoudi SM, Behnia F, Gorouhi F, et al. Comparison o long- tion with 18 months o ollow up. J Drugs Dermatol. 2011;10
pulsed alexandrite and Nd:YAG lasers, individually and in (1):62– 65.
combination, or leg hair reduction: An assessor-blinded, ran- 50. Nanni CA, Alster S. Laser assisted hair removal: Side ef ects
domized trial with 18 months o ollow-up. Arch Dermatol. o Q-switched Nd:YAG, long-pulsed ruby and alexandrite la-
2008;144(10):1323– 1327. sers. J Am Acad Dermatol. 1999;141:165– 171.
30. Hussain M, Polnikorn N, Goldberg DJ. Laser-assisted hair re- 51. Haedersdal M, Egekvist H, E sen J, Bjerring P. Skin pigmenta-
moval in Asian skin: E cacy, complications, and the ef ect tion and texture changes a ter hair removal with the normal-
o single versus multiple treatments. Dermatol Surg. 2003; mode ruby laser. Acta Derm Venereol. 1999;79(6):465– 468.
29(3):249– 254. 52. Hasan A , Eaglstein W, Pardo RJ. Solar-induced postin am-
31. Khoury JG, Saluja R, Goldman MP. Comparative evaluation matory hyperpigmentation a ter laser hair removal. Dermatol
o long-pulse alexandrite and long-pulse Nd:YAG laser sys- Surg. 1999;25(2):113– 115.
tems used individually and in combination or axillary hair 53. Moreno-Arias GA, if on , Marti , Camps-Fresneda A.
removal. Dermatol Surg. 2008;34(5):665– 670; discussion Long-term hypopigmentation induced by diode laser photo-
670– 671. epilation. J Cutan La ser T er. 2001;3(1):9– 10.
32. Campos VB, Dierickx CC, Farinelli WA, Lin Y, Manuskiatti 54. Radmanesh M, Mostaghimi M, Youse I, et al. Leukotrichia
W, Anderson RR. Hair removal with an 800-nm pulsed diode developed ollowing application o intense pulsed light or
laser. J Am Acad Dermatol. 2000;43(3):442– 447. hair removal. Dermatol Surg. 2002;28(7):572– 574.
33. Lou WW, Quintana A , Geronemus RG, Grossman MC. Pro- 55. Wimmershof MB, Hohenleutner U, Landthaler M. Isomor-
spective study o hair reduction by diode laser (800 nm) with phic phenomenon: Adverse ef ect a ter epilation with the
long-term ollow-up. Dermatol Surg. 2000;26(5):428– 432. long-pulsed ruby laser. Arch Dermatol. 2000;36(12):1570–
34. Eremia S, Li C, Newman N. Laser hair removal with alexandrite 1571.
versus diode laser using our treatment sessions: 1-year results. 56. Lapidoth M, Sha rstein G, Ben Amitai D, Hodak E, Waner M,
Dermatol Surg. 2001;27(11):925–929; discussion 929–930. David M. Reticulate erythema ollowing diode laser-assisted
35. Alster S, Bryan H, Williams CM. Long-pulsed Nd:YAG hair removal: A new side ef ect o a common procedure. J Am
laser-assisted hair removal in pigmented skin: A clinical and Acad Dermatol. 2004;51(5):774– 777.
histological evaluation. Arch Dermatol. 2001;137(7):885– 889. 57. Moreno-Arias GA, if on , Marti , Camps-Fresneda A.
36. Rao J, Goldman MP. Prospective, comparative evaluation o Urticaria vasculitis induced by diode laser photo-epilation.
three laser systems used individually and in combination or Dermatol Surg. 2000;26(11):1082– 1083.
axillary hair removal. Dermatol Surg. 2005;31(12):1671– 1676; 58. Lask G, Friedman D, Elman M, Fournier N, Shavit R, Slat-
discussion 1677. kine M. Pneumatic skin attening (PSF): a novel technology
37. Weiss RA, Weiss MA, Marwaha S, Harrington AC. Hair re- or marked pain reduction in hair removal with high energy
moval with a non-coherent ltered ashlamp intense pulsed density lasers and IPLs. J Cosmet La ser T er. 2006;8(2):76– 81.
light source. La sers Surg Med. 1999;24(2):128– 132. 59. Rohrer E, Chatrath V, Yamauchi P, Lask G. Can patients
38. Sadick NS, Shea CR, Burchette JL Jr, Prieto VG. High-intensity treat themselves with a small novel light based hair removal
ashlamp photoepilation: A clinical, histological, and mechanis- system? La sers Surg Med. 2003;33(1):25– 29.
tic study in human skin. Arch Dermatol. 1999;135(6):668–676. 60. Spencer JM. Clinical evaluation o a handheld sel -treatment
39. Gold MH, Bell MW, Foster D, Street S. One-year ollow-up device or hair removal. J Drugs Dermatol. 2007;6(8):788– 792.
using an intense pulsed light source or long-term hair re- 61. Wheeland RG. Simulated consumer use o a battery-powered,
638 moval. J Cutan La ser T er. 1999;1(3):167– 171. hand-held, portable diode laser (810 nm) or hair removal: A
 sa ety, e cacy and ease-o -use study. Lasers Surg Med. 2007;
39(6):476– 493.
using topical aminolevulinic acid. J Cosmet La ser T er. 2005;
7(1):25– 28.
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62. Grossman M, Dwyer P, Wimberley J, Flotte J. PD or hir- 66. Klein A, Steinert S, Baeumler W, Landthaler M, Babilas P.
sutism. La sers Surg Med. 1995;7(suppl):44. Photoepilation with a diode laser vs. intense pulsed light
63. Waldman A, Kreindle M. New technology in aesthetic medi- (IPL): A randomized, intrapatient le t-to-right trial. Br J Der-
cine: ELOS electro optical synergy. J Cosmet La ser T er. 2003;5 matol. 2013;168(6):1287– 1293. doi:10.1111/bjd.12182.
(3– 4):204–206. 67. Jalian HR, Jalian CA, Avram MM. Common causes o inju-
64. Sadick NS, Shaoul J. Hair removal using a combination o con- ry and legal action in laser surgery. JAMA Dermatol. 2013;
ducted radio requency and optical energies—an 18-month 149(2):188– 193.
ollow-up. J Cosmet La ser T er. 2004;6(1):21– 26. 68. Wheeland RG. Permanent hair reduction with a home-use di-
65. Goldberg DJ, Marmur ES, Hussain M. reatment o termi- ode laser: Sa ety and ef ectiveness 1 year a ter eight treatments.
nal and vellus non-pigmented hairs with an optical/bipolar La sers Surg Med. 2012;44(7):550– 557.
radio requency energy source-with and without pretreatment

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Hanke CW, Kilmer SL, Anderson RR. Laser hair removal. Dermatol T er.

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 Ch a p t e r

54 Eyelid Rejuvenation
Robyn Sackey o, Robert Silich, & Henry M. Spinelli

An At o my o skin that is especially thin over the tarsus and preseptal

areas with minimal to no subcutaneous at. T e middle,
or supportive, layer includes the orbicularis muscles with
T e eyelid is composed o three distinct anatomic layers,
the pretarsal portion lying in ront o the tarsal plate and
similar to those ound in the nose: the external skin, a mid-
the preorbital portion lying anterior to the orbital septum.
dle supportive layer, and an internal lining (Fig. 54-1). One
T e tarsal plate is a rigid cartilaginous-like structure that
should view the eyelids as trilamellar structures, which
measures 4 to 6 mm on the lower eyelid and 8 to 10 mm on
are supported in space across the orbital rim by medial
the upper eyelid. T is structural layer is pierced by glands
and lateral anchors, namely, the medial and lateral can-
that drain posterior to the eyelashes, or ciliary line, and
thal tendons. T e three lamellae include an outside layer
number approximately 10 on the lower lid and 20 on the
upper lid. T ese Meibomian glands and ducts are respon-
sible or oil secretion, and when they become inspissated
Orbicula ris
mus cle S kin they may be responsible or hordeola or styes (acute
Orbita l s e ptum in ammation), chalazia (chronic noncaseating granulo-
Pe rios te um mas), and other in ammatory processes. T ese are also the
Pre a pone urotic orbita l fa t sites or in ammation in the postcosmetic blepharoplasty,
including meibomianitis and blepharitis. T e tarsal plate
Whitna ll’s liga me nt
is particularly important or vertical support o the eyelid,
Leva tor pa lpe bra e which is undamental to maintaining the lower eyelid posi-
a pone uros is tion 1 to 2 mm above the corneoscleral junction or limbus.
T e internal lining o the eyelid is mucosa, which re ects
Mülle r’s mus cle
o the globe and onto the posterior sur ace o the eyelids,
Ta rs a l pla te including the posterior sur aces o the medial and lateral
canthal tendons. T e conjunctival sur ace, rich in secre-
Conjunctiva
tory glands, is a virtually rictionless sur ace or the lids
Ca ps ulopa lpe bra l and globe to move against one another.
fa s cia T e medial canthal tendon envelops the lacrimal sac
Orbita l s e ptum
and is tripartite, with anterior, posterior, and superior
limbs. Like the lateral canthal tendon, its limbs are con-
Figure 54-1 Oblique cross-section o the right orbit and tinuous with the tarsal plate. T e components o this ten-
adnexa beginning anteriorly with the skin and ending pos- don, along with its lateral counterpart, are enveloped by
teriorly with the conjuctiva covering the anterior sclera.
the deep and super cial aspects o the orbicularis muscle,
The orbicularis muscle is contiguous with the rontalis,
which is important in maintaining a unctional, active
occipitalis, and super cial musculoaponeurotic (SMAS)
layer. The orbital septum is con uent with the periosteum lacrimal drainage system. T e upper, lower, and common
o the skull and orbit, as well as the periorbita. The orbital canaliculi closely approximate this tendinous system, and
septum is also used to the levator palpebrae and there- care should be taken to preserve their integrity when alter-
ore serves as a complete boundary between the anterior ing any aspect o the medial canthal tendon. Generally, the
and deep orbit. One cannot access the preaponeurotic at medial canthal apparatus is not directly addressed in cos-
without violating the superior septum. Analogously, the metic approaches to the eyelids; however, it may require an
in erior orbital septum is intimately linked to the perios- elective tightening procedure, especially in cases in which
teum and the capsulopalpebral ascial system. The main a lateral canthal procedure alone would produce punctual
retractors o the upper and lower lids are the levator and and lacrimal dystopia. T e lateral canthal tendon is more
capsulopalpebral ascia, respectively. The levator is sus- commonly addressed surgically than the medial canthal
pended rom the superior orbit by Whitnall’s ligament. apparatus. opographically, it should be inclined 10 to
This structure allows the muscle to change vector orces
15 degrees superiorly with respect to the medial canthal
rom anterior to posterior and superior to in erior, thus
serving as a pulley. The preaponeurotic and precapsulo- tendon, which is the most anatomic and aesthetically
palpebral at is loosely but de nitely linked to the respec- pleasing position. It splits into an anterior and posterior
tive retractors; hence, dehiscence o the levator ascia rom lea et, the anterior being continuous with the orbital rim
the tarsal plate will lead to a superior sulcus de ormity. The periosteum and the posterior element inserting on Whit-
tarsal plates are the end point or retractor insertion and nall’s tubercle. T e lateral horn o the levator aponeurosis
provide lid stability and orientation. also inserts on Whitnall’s tubercle, resulting in a coalescence
o support and suspensory structures serving as anchor
points or the eyelids. It also contains a coalescence o the
muscle that is continuous with the super cial musculo-
aponeurotic system (SMAS), platysma, and rontalis mus-
5
in erior suspensory ligament o Lockwood. T us, simply cles. T e orbicularis unctions as a sphincter or protractor
dividing the lateral canthal tendon will not suf ciently and is divided into the pretarsal, preseptal, and preorbital
mobilize the complex in a repositioning and/or tightening areas. It is innervated by the seventh cranial nerve, and
procedure. hence, with acial nerve paralysis, the cornea and globe
As demonstrated in Figure 54-2, the lower and upper can be exposed secondary to an atonic eyelid with unop-
eyelids and periocular structures are quite similar. Both posed retractor action. T e eyelid retractors are made up
the upper and lower eyelids are composed o the three o the levator palpebrae superioris muscle and a second-
a orementioned structural layers with the tarsal plate o ary sympathomimetically innervated Müller’s muscle.
the upper lid being a little wider. Both lids have a cul- Müller’s muscle is responsible or approximately 2 mm o
de-sac that orms the junction between the parietal and lid elevation during sympathetic stimulation, the so-called
visceral conjunctiva and are surrounded by orbicularis ght or ight responses. T e levator palpebrae superioris
is responsible or the remainder o voluntary lid elevation
and measures approximately 37 mm in length and 4 mm

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in width at the apex o the orbit. It gradually widens ante-

a
Leva tor S upe rior

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riorly until it ans out into an approximately 20 mm long

t
pa lpe bra e re ctus

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mus cle mus cle aponeurosis that expands rom 6 mm at the distal end o

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S kin the levator to a width o 30 mm where it inserts onto the
tarsal plate. T e levator muscle will send some bers to the

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Orbicula ris dermal sur ace o the upper lid creating the lid old. Surgi-

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mus cle
cal manipulation can be a power ul tool or manipulating

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Orbita l s e ptum
upper lid height, which can be achieved through plication,

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advancement, or recession. A normal upper eyelid lies

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Leva tor

e
midway between the upper aspect o the pupillary aper-

j
a pone uros is

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ture and the upper corneal scleral junction/limbus, with

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Mülle r’s mus cle the apex o its arch lying just medial to the pupil, and is an

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t
important landmark in any ptosis correction.

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Conjunctiva T e lower lid retractors are intimately linked to the