Faculty Bibliography

BACKGROUND:Carbon dioxide laser resurfacing has recently come into favor for the treatment of photodamaged skin. While the clinical and histologic effects of high-energy short-pulse carbon dioxide lasers on human skin have been investigated, the ultrastructural effects of these lasers have not been documented. Our objective was to study the ultrastructural effects of a high-energy pulsed carbon dioxide laser on photodamaged human skin. OBSERVATIONS/METHODS:Before laser surgery, the ultrastructural changes characteristic of photodamaged skin were evident. Immediately after treatment, there was extensive coagulation necrosis of the epidermis and papillary dermis. Thirty days after treatment, there was no evidence of intercellular or intracellular edema, and ordered differentiation of the epidermal keratinocytes, with a loss of keratinocyte dysplasia, was seen. Increased numbers of desmosomes and tonofibrils were noted. New deposition of collagen was present in the papillary dermis. The ultrastructural findings seen at 90 days after treatment were similar to those seen at 30 days, apart from increased organization of collagen fibers in the papillary dermis. CONCLUSIONS:Treatment with the high-energy pulsed carbon dioxide laser appears to reverse the epidermal and dermal changes of photoaging on an ultrastructural level. These changes appear morphologically to be consistent with previously described clinical and histologic changes following laser resurfacing.

Free skin grafts for soft tissue reconstruction can be classified into four types: full-thickness skin grafts, split-thickness skin grafts, composite grafts, and free cartilage grafts. The indications, techniques, donor site considerations, and postoperative complications of each type of skin graft are reviewed.

BACKGROUND:Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor of the skin; its microscopic extent of invasion beyond the grossly visible tumor is frequently difficult to appreciate. Although wide local excision has been the standard treatment of DFSP, recurrence rates range from 11% to 53%. Because Mohs micrographic surgery allows the extent of excision to be tailored to the microscopic extent of tumor, we evaluated this technique for the treatment of primary and recurrent DFSP. OBJECTIVE:Our purpose was to determine the local recurrence rate and microscopic extent of spread of primary and recurrent DFSP after treatment with Mohs micrographic surgery. METHODS:The records of 58 patients with primary and recurrent DFSP treated with Mohs micrographic surgery at three institutions were reviewed and the macroscopic and microscopic extents of tumor were recorded. RESULTS:One patient with a twice-recurrent DFSP had another recurrence after Mohs micrographic surgery, for an overall local recurrence rate of 2% (zero for primary tumors and 4.8% for recurrent tumors). There were no cases of regional or distant metastases. Macroscopic tumor size ranged from 0.3 x 0.6 cm to 30 x 20 cm, whereas microscopic (postoperative) size ranged from 1.8 x 1.0 cm to 35 x 40 cm. We calculated the likelihood that a given width of excision around the macroscopic tumor would clear the entire microscopic extent of tumor. Standard wide excision with a width of 1 cm around the primary tumor would have left microscopic residual tumor in 70.7%; a width of 2 cm, 39.7%; 3 cm, 15.5%; and 5 cm, 5.2%. Even an excision width of 10 cm would not have cleared the microscopic extent of some tumors, despite taking a huge excess of normal tissue. CONCLUSION/CONCLUSIONS:Treatment of primary and recurrent DFSP by Mohs micrographic surgery results in a low recurrence rate because of the ability of the technique to permit the detection and excision of microscopic tumor elements in even the most asymmetric tumors. Whatever type of surgery is chosen to treat DFSP, it is necessary to assess the entire perimeter of the tumor for microscopic extension and to achieve tumor-free margins in all directions.

BACKGROUND:Full-thickness defects of the nasal alar rim are relatively common following Mohs micrographic surgery for the treatment of long-standing or recurrent skin tumors. Composite grafts provide an excellent cosmetic and functional alternative for the repair of such defects. OBJECTIVE:A useful technique of auricular composite graft placement for reconstruction of full-thickness nasal alar rim defects is described. METHODS:The cartilaginous portion of the graft is extended beyond the borders of the soft tissue defect so that two cartilaginous pegs frame the lateral aspects of the graft. These pegs are then inserted into pockets prepared within the alar tissue of both sides of the defect, such that the graft interlocks with its recipient bed. A series of diagrams as well as a set of photographs from a representative case are provided, along with accompanying commentary, so as to enable the surgeon to incorporate this technique easily into his/her practice. CONCLUSION/CONCLUSIONS:The interlocking auricular composite graft technique permits increased graft stability, with decreased shearing forces of the graft over its recipient bed, and a larger surface area for revascularization, resulting in an increased probability of graft survival. This technique provides an elegant single stage alternative to current reconstructive techniques for full-thickness nasal alar rim defects measuring less than 1.5 cm in diameter.

Microscopic control of surgical margins has made Mohs' micrographic surgery an increasingly appealing option for patients with large, recurrent, or difficult-to-treat basal cell and squamous cell carcinomas who require precise and effective surgical management. Understanding the pre-, peri-, and postoperative considerations in Mohs' surgery will help dermatology nurses better prepare and educate patients who undergo this procedure.

There is a need for surgeons to be able to make a logical decision regarding which suture materials to use in a given clinical situation because the choice of wound-closure materials may make a difference in wound healing and the ultimate functional and cosmetic result obtained. This article will review the basic physical, handling, and tissue-reaction characteristics of commonly used suture materials. Basic suturing techniques are also reviewed. Knowledge of multiple suturing techniques provides versatility, individuality, and optimal closure of surgical wounds.