Faculty Bibliography

BACKGROUND: Recent reports have indicated secondary intention (SI) healing utilization for Mohs surgical defects beyond conventionally accepted indications. OBJECTIVE: To characterize potentially more expansive guidelines for when SI healing is indicated or appropriate in dermatologic surgery. METHODS: A survey study was e-mailed to the American College of Mohs Surgery in 2015. A group of 293 respondents addressed factors influencing decisions to heal surgical defects secondarily. RESULTS: The most experienced surgeons were significantly more likely to heal deep and larger wounds secondarily. Many surgeons elect SI healing in patients with current or previous wound dehiscence, flap necrosis, or infection; in patients who have undergone skin cancer excisions before, or who are elderly, and; if the lesion was sent for permanent section, or when treating high-risk, large, recurrent, or aggressive tumors. CONCLUSION: Broader indications for SI healing of Mohs surgical defects may be appropriate than previously understood. In addition to concave, temporal, periocular, perinasal, and periauricular sites, SI healing may be appropriate for convex sites such as the scalp and anterior lower extremity, deep wounds, and large wounds, as well as wounds with dehiscence, flap necrosis, or infection. Certain patient-specific and lesional factors are also appropriate indications for SI healing.

BACKGROUND:VYC-15L (Juvéderm Volbella XC) is a nonanimal crosslinked hyaluronic acid (HA) gel with lidocaine. OBJECTIVE:To evaluate the safety and effectiveness of VYC-15L for lip and perioral enhancement versus a nonanimal stabilized HA with lidocaine (Restylane-L; NASHA). METHODS:This prospective multicenter study randomized 225 adults with minimal, mild, or moderate lip fullness on the validated 5-point Allergan Lip Fullness Scale (LFS) to treatment with VYC-15L or NASHA; optional touch-up was administered 30 days later. Subjects were followed for 1 year. The primary effectiveness end point was noninferiority of VYC-15L versus NASHA by mean change in LFS score from baseline to Month 3. RESULTS:The primary end point was met. At Month 3, LFS responder rates were 80.3% for VYC-15L versus 70.8% for NASHA. LFS responder rates exceeded 60% through 1 year with VYC-15L. Perioral lines severity improved for 65.4% and 66.2% of VYC-15L subjects at Month 3 and Year 1, respectively. At Month 3, 96.1% and 88.2% of subjects reported improvement in FACE-Q Satisfaction With Lips and Satisfaction With Lip Lines, respectively. Severe injection site responses were reported less frequently with VYC-15L than NASHA. CONCLUSION/CONCLUSIONS:VYC-15L was safe and effective for lip and perioral enhancement, with treatment effects lasting through 1 year.

BACKGROUND: Pulsed dye laser (PDL) is the treatment of choice for port-wine stains (PWS). Some PWS are recalcitrant to this modality. A number of reasons for PDL treatment resistance have been described, including inadequate heat generation. OBJECTIVE: We evaluated PDL combined with radiofrequency (RF) energy into a single device to target larger and deeper blood vessels and overcome PDL resistance. METHOD: This was an open-label, prospective, single-center investigation of a novel device combining RF energy with PDL conducted to treat recalcitrant PWS. Ten patients with 11 recalcitrant PWS were enrolled. Each PWS was divided into 5 treatment areas: PDL alone, RF alone, PDL+RF, RF+PDL, and untreated control. Patients underwent a maximum of 6 treatments, scheduled 4 to 6 weeks apart with follow-up evaluation at 4 and 12 weeks after the final treatment. Colorimetry and standardized digital photography were performed at all visits. Lesional biopsy specimens were collected for selected patients. RESULTS: Areas treated with RF followed by PDL and PDL followed by RF showed the greatest improvement based on blinded review of digital photographs, reaching statistical significance (P value < .05) at the 12-week follow-up evaluation when compared with baseline. Adverse events, including purpura, erythema, edema, scabbing, crusting, and blistering, resolved without sequelae; a small residual scar was noted in 1 patient. LIMITATIONS: Small sample size and short follow-up period are limitations. CONCLUSION: Combined RF/PDL technology is promising for the treatment of recalcitrant PWS.

Cellulite is the common rippling or dimpling of skin of the thighs and buttocks of women, formed from a confluence of skin laxity, tethering fibrous septa, and fat herniation. We describe an anatomical approach to evaluating the cellulite patient and selecting the best treatment from among available non-invasive, minimally invasive, and invasive therapies. It is crucial to consider the anatomy of the patient and the morphology of cellulite while choosing a treatment. Diffuse rippling represents increased adiposity and/or increased skin laxity which may stand to benefit from lipolytic and skin tightening modalities. Dimpling represents tethering by fibrous septa which may stand to improve from subcision by minimally invasive devices such as Cell na. Patients with both morphologies may be treated with a combination of treatments or Cellulaze. Careful evaluation of the patient can help identify the best therapeutic strategy. J Drugs Dermatol. 2017;16(1):58-61.

BACKGROUND: Laser therapy is a continuously evolving treatment option for scars, and the underlying therapeutic mechanisms continue to be elucidated. OBJECTIVE: To comprehensively review the literature to summarize the role of elastin in the formation scars, as well as treatment via therapeutic lasers. METHODS: Review of the PubMED/MEDLINE database for available studies pertaining to the role of elastic fibers in scar formation and after laser-based therapy. RESULTS: The loss and disorganization of elastic fiber components plays a role in the development of atrophic, hypertrophic, and keloid scars. While the majority of histologic studies focus on the underlying changes in collagen, neoelastogenesis and reorganization of elastic fibers have also been demonstrated in studies using ablative, nonablative, and fractional laser devices for the treatment of scars. CONCLUSION: Production of novel elastin and normalization of elastic fiber organization occur after a variety of resurfacing procedures to treat scarring. As the treatment modalities to manage scars continue to evolve, further characterization of the role of elastin in the skin and in scar formation is merited.

BACKGROUND:Photodynamic therapy (PDT) is an FDA approved treatment for actinic keratoses (AK's) although multiple off-label indi- cations are reported. Despite frequent use for AK's, no clear consensus exists regarding protocols for overall treatment parameters. METHODS:Retrospective chart review of 1,491 subjects who underwent PDT between 2007 and 2011 at a high volume laser surgery center. Demographic information, clinical history, treatment data, and subsequent diagnosis of skin cancers were recorded. An ex- ploratory subgroup analysis was performed for patients treated for AK and/or squamous cell carcinoma (SCC) that developed SCC or remained SCC-free one year after treatment. RESULTS:The most common indications for PDT were actinic keratoses (n=1404, 94.9%) then NMSC (n=45, 3.0%) The most common treatment site was the head and neck (n=1274, 86.1%). Blue light activation (405-420nm) was used more frequently than red light and visible light. (73.8% vs. 22.8% vs. 6.8%). The most commonly used photosensitizer was aminolevulinic acid (ALA) (98.6%, n=1456). Topical application (97.7% n=1437) of photosensitizer was used more frequently than intralesional administration (2.0%, n=29). 580 patients met subgroup analysis criteria. 66 developed SCC at treatment site (11%). Factors associated with developing SCC were older age, SCC history, Fitzpatrick skin-type 1, and sixty-minute or less incubation times (P less than 0.05 for all factors). The SCC subgroup had a unique distribution of treatment sites (P less than.001). No statistically significant differences were observed for gender or wavelength. CONCLUSION/CONCLUSIONS:There are differences in protocols based on indication and location of lesion. Blue light is preferable for superFIcial lesions and red light for deeper lesions. Intralesional delivery is used more commonly for NMSC. Extremities require longer incubation times. PDT may be more effective with younger patients and longer than sixty-minute incubation times. PDT chemoprevention is independent of light source used. <em>J Drugs Dermatol. 2016;15(11):1420-1426.</em>.

BACKGROUND: The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE: To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS: An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS: Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION: Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

BACKGROUND AND OBJECTIVES: Tattoo removal can inadvertently lead to paradoxical darkening after laser procedure. We present a new laser device that may treat this unwanted outcome. STUDY DESIGN/PATIENTS AND METHODS: We report two cases from a clinical trial, using a novel picosecond 532 nm and 1,064 nm laser to treat unwanted red tattoos. RESULTS: Two cases of paradoxical darkening improved with the use of a novel picosecond 532 nm and 1,064 nm laser. CONCLUSION: The use of a picosecond 532 nm and 1,064 nm laser may treat paradoxical darkening in red colored tattoos. Lasers Surg. Med. (c) 2016 Wiley Periodicals, Inc.

BACKGROUND: Laser therapy in patients with skin of color is associated with an increased rate of complications. The 755-nm picosecond laser with the diffractive lens array (DLA) has been used for the treatment of scars, striae, and rejuvenation. By delivering high energy to focused areas, the DLA minimizes complications. OBJECTIVE: This study explores the adverse events associated with treatment with the 755-nm picosecond laser with DLA in individuals with Fitzpatrick skin type IV to VI. METHOD: A retrospective chart review of patients treated with the 755-nm picosecond laser with DLA with a standardized spot size of 6 mm, fluence of 0.71 J/cm2, and pulse width of 750 to 850 picoseconds was performed. Standard clinical photographs were obtained before treatment and at follow-up. Treatment sites were assessed for dyspigmentation, erythema, edema, and herpetic lesions. RESULTS: A total of 56 patients with Fitzpatrick skin type IV to VI, atrophic and hypertrophic scars, and pigmented lesions or striae were included. Ten patients (17.9%) were lost to follow-up. Transient adverse events, most commonly erythema and hyperpigmentation, were reported after therapy; these resolved in all cases. LIMITATIONS: Retrospective design is a limitation. CONCLUSION: The 755-nm picosecond laser with the DLA device may be a safe therapeutic alternative for unwanted scars, pigmented lesions, and striae in patients with skin of color.

Pilomatricomas are benign adnexal tumors which differentiate towards hair matrix cells. These lesions present most often as firm nodular tumors in the upper extremities, head and neck areas, with rare cases reporting pilomatricomas appearing on the trunk. Pilomatricomas can range from 0.5 to 3 cm in diameter with the classification of "giant" pilomatricoma reserved for tumors exceeding 5 cm in diameter. Four histopathologic stages have been described: early, fully developed, early regressive, and late regressive, all of which involve anucleated squamous cells known as "ghost" or "shadow" cells. There are known associations of this pathology with other conditions, most notably myotonic dystrophy, sarcoidosis, Gardner syndrome, Turner syndrome, Steinart disease, sternal cleft, and coagulative defects. Rarely, pilomatricomas can degenerate into pilomatricoma carcinoma. Treatment of this condition is excision of the tumor and the prognosis is favorable with virtually no recurrence. Pilomatricomas are most often seen in patients in their first two decades of life. We report a case of a 41-year-old Asian woman with no significant medical history who presented with painful lesions on her upper extremities bilaterally. The patient denied a family history of similar lesions and was worried she had skin cancer. On clinical exam, the patient had on each upper extremity, a roundshaped, blue and white colored, firm nodule. The lesions were completely excised without complications and were consistent with pilomatricomas on histology. Prior to our observations, Fernandez-Flores et al reported a 28-year-old male with multiple pilomatricomas associated with seminoma which was diagnosed several months before the pilomatricomas. In another case, a 22-year-old woman, also with no medical history, presented with multiple pilomatricomas distributed on her forearm, trunk, and eyebrow. Nevertheless, multiple pilomatricomas in an older patient and in the absence of associated disorders remains rare, which may be a product of underreporting rather than actual incidence. This case highlights the importance of considering pilomatricomas in the differential diagnosis in the setting of multiple growths, even in older patients