Faculty Bibliography

BACKGROUND: Cosmetic dermatologic procedures offer the promise of visible aesthetic enhancement with minimal risk. While in recent years the number of available procedures has proliferated, there are few objective methods for evaluating the relative quality of these procedures for particular indications or specific patients. OBJECTIVE: (A) To develop a simple, easy-to-use numerical rating scale to assess the quality of cosmetic surgical procedures on a range of parameters pertaining to clinical efficacy and patient satisfaction; (B) to statistically validate the discriminative value of this rating scale. METHODS: (A) Patient and physician interviews were performed to elicit a list of factors that may collectively characterize the clinical efficacy and patient tolerability of cosmetic dermatologic procedures. A 0-100 point rating scale was developed based on these factors, with the face-validity of this scale checked by a group of patients and physicians; (B) Statistical analysis of the questionnaire was performed by asking 15 expert cosmetic dermatologic surgeons to use it to rate 23 common cosmetic dermatologic procedures, and analyzing the results. RESULTS: (A) An easy-to-use scale was constructed to assess the quality of cosmetic dermatologic procedures by rating the associated cost, risk, time (procedure and recovery), discomfort, results, and longevity of benefit. A 'physician adjustment factor' was used to further increase the relevance of this 0-100 point scale for specific patients; (B) Repeated-measures analysis of variations (ANOVAs) performed on the data from the survey of experts demonstrated that this scale can be used to discriminate between common dermatologic procedures. The differences in mean subscores and total scores among procedures grouped by anatomic site and target lesion-type were significant at the level of P < .05. LIMITATIONS: Patient preferences exogenous to the rating scale may increase or decrease the suitability of specific procedures. CONCLUSIONS: Common cosmetic dermatologic procedures are of uniformly high quality, as per expert ratings on a systematic measure. This quality rating scale appears statistically valid and robust, given that expert raters assigned similar ratings to the same procedures but mean ratings were different across procedures. In the future, this quality rating scale can be used to assess novel interventions, and to help dermatologic surgeons faced with patient concern to optimally select among alternative procedures for a given indication

An 89-year-old white male presented for Mohs micrographic surgical extirpation of an invasive squamous cell carcinoma on his right lower lip. Extirpation required two stages of Mohs surgery and produced a 1.5 x 3.7 cm partial-thickness defect involving both the cutaneous and the vermilion lip, with little loss to the underlying orbicularis oris muscles (Figure 1). How would you repair the defect?

BACKGROUND: We studied the safety and efficacy of a 1,064 nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with a 300-micron fiber for the reduction of small unwanted fat areas. METHODS: Thirty subjects with focal areas of fat less than 100 cc were enrolled. Ten subjects were treated with laser lipolysis and had magnetic resonance imaging (MRI) at baseline and 3 months post-treatment. Ten subjects had laser lipolysis followed by biweekly treatments with the Tri-active system. The last group of 10 subjects served as control. Patients were seen at baseline and 1-week, 1-month, and 3-month follow-up visits. RESULTS: Twenty-nine patients completed the study. Self-assessment evaluations reported an improvement of 37% at the 3-month follow-up visit. MRI demonstrated an average 17% reduction in fat volume. Smaller baseline volume areas, such as the submentum, had better results, suggesting a dose-response relationship. The most common side effects were mild bruising and swelling resolving within 2 weeks. CONCLUSION: Laser lipolysis using the 1,064 nm Nd:YAG laser with a 300-micron fiber appears to be a very promising procedure that delivers good, reproducible results safely and effectively. The advantages include excellent patient tolerance, quick recovery time, and the benefit of dermal tightening

BACKGROUND AND OBJECTIVES: Photomodulation has been described as a process which modifies cell activity using light sources without thermal effect. The objective of this study was to investigate the use of a non-thermal low dose light emitting diode (LED) array for improving the appearance of photoaged subjects. STUDY DESIGN/MATERIALS AND METHODS: This prospective study investigated a random cohort of patients (N = 90) with a wide range of photoaged skin treated by LED photomodulation using a full panel 590 nm non-thermal full face LED array delivering 0.1 J/cm(2) with a specific sequence of pulsing. Subjects were evaluated at 4, 8, 12, 18 weeks and 6 and 12 months after a series of 8 treatments delivered over 4 weeks. Data collected included stereotactic digital imaging, computerized optical digital profilometry, and peri-ocular biopsy histologic evaluations for standard stains and well as collagen synthetic and degradative pathway immunofluorescent staining. RESULTS: Digital imaging data showed a reduction of signs of photoaging in 90% of subjects with smoother texture, reduction of peri-orbital rhytids, and reduction of erythema and pigmentation. Optical profilometry showed a 10% improvement by surface topographical measurements. Histologic data showed markedly increased collagen in the papillary dermis of 100% of post-treatment specimens (N = 10). Staining with anti-collagen I antibodies demonstrated a 28% (range: 10%-70%) average increase in density while staining with anti-matrixmetalloproteinase (MMP)-1 showed an average reduction of 4% (range: 2%-40%). No side effects or pain were noted. CONCLUSIONS: Photomodulation to reverse photoaging is possible with a specific array of LEDs with a specific fluence using a precise pulsing or 'code' sequence. Skin textural improvement by digital imaging and surface profilometry is accompanied by increased collagen I deposition with reduced MMP-1 (collagenase) activity in the papillary dermis. This technique is a safe and effective non-painful non-ablative modality for improvement of photoaging

BACKGROUND AND OBJECTIVES: Many pediatric dermatological conditions may be successfully treated with laser surgery. STUDY DESIGN/MATERIALS AND METHODS: The clinical approach to various pediatric dermatological conditions utilizing laser treatment options is discussed. RESULTS: Clinical uses of various modalities such as pulsed dye laser, KTP laser, Nd-YAG laser, Q-switched ruby laser, erbium-YAG laser, diode laser, non-coherent blue light sources, and fractional resurfacing are presented with successful parameters, developed over 22 years, utilized on a daily basis in a laser surgery clinic. CONCLUSION: Laser surgery can make a significant improvement in many pediatric skin lesions, thanks to the unique properties of pediatric skin and a vast array of laser technologies

BACKGROUND: The success of Mohs surgery relies on the ability to histologically differentiate tumor from the normal background tissue of the patient. In most cases of basal cell carcinoma and nonmelanoma skin cancer, this is a relatively straightforward process. However, in distinction, when only subtle histopathologic features differentiate the background tissue from the tumor of interest, the determination of a tumor-free margin becomes more challenging. OBJECTIVE: Our objective is to highlight the histopathologic features that we used to differentiate our patient's near-confluent background of trichoepitheliomas from the basal cell carcinoma that we were extirpating. METHODS: Case report. RESULTS: A 41-year-old white female with a history of familial multiple facial trichoepitheliomas presented for removal of a basal cell carcinoma on her right lower cutaneous lip. Mohs surgery was used to remove the tumor. The characteristic features of basal cell carcinoma and trichoepithelioma were used to differentiate the basal cell carcinoma that we were removing from the surrounding trichoepitheliomatous neoplasia. CONCLUSION: Mohs surgical extirpation of a basal cell carcinoma in a patient with multiple familial trichoepitheliomas requires a clear understanding of the histopathologic features that differentiate a trichoepithelioma from a basal cell carcinoma

OBJECTIVE: To ascertain the immediate and short-term side effects of fractional photothermolysis for the treatment of a variety of skin disorders involving the face, neck, chest, and hands. METHODS: Physician-administered questionnaires were given during 60 follow-up visits for fractional photothermolysis treatment for a variety of facial skin disorders in patients with skin types ranging from I to IV. The questionnaire addressed 14 possible side effects, pain, and limitation of social activities. In addition, all patients were asked about any additional side effects not mentioned in the survey. An analysis of the data was performed once 60 surveys had been collected. RESULTS: All patients (100%) undergoing fractional photothermolysis had transient post-treatment erythema. Other frequently reported post-treatment side effects were transient and included facial edema (82%), dry skin (86.6%), flaking (60%), a few (one to three) small, superficial scratches (46.6%), pruritus (37%), and bronzing (26.6%). Other more rarely reported effects included transient increased sensitivity (10%) and acneiform eruption (10%). Most patients reported that the pain level was easily tolerated, with an average pain score of 4.6 on a scale of 10. Most patients (72%) reported limiting social engagements for an average of 2 days after treatment. There were no long-lasting adverse events noted in our survey. CONCLUSION: Fractional photothermolysis to treat dermatologic conditions on the face, neck, chest, and hands is a well-tolerated and safe procedure with several immediate, and slightly delayed, post-treatment side effects. In our experience, these side effects were transient and limited to erythema, edema, dry skin, flaking skin, superficial scratches, pruritus, increased sensitivity, and acneiform eruption. Importantly, we did not see the development of post-treatment scarring, herpetic activation, hypopigmentation, hyperpigmentation, persistent erythema, persistent edema, or infection

OBJECTIVE: To assess the analgesic effect of a handheld forced cold air device during fractional photothermolysis. METHODS: Twenty patients who were being treated with full-face fractional photothermolysis were asked to rate their pain level with and without the handheld air-cooling device. Pain was rated on a scale of 1 to 10, with 10 being the worst. RESULTS: Nineteen of 20 patients noted decreased pain with the addition of handheld cooling. The mean level of pain without air-cooling was 6.95 +/- 2.0. The mean level of discomfort with air cooling was 4.0 +/- 1.8. The mean decrease in pain with the addition of air-cooling was 2.9 +/- 1.8. CONCLUSION: The addition of a handheld forced cold air device to cool the skin before and after fractional photothermolysis treatment is an effective adjunctive analgesic modality

OBJECTIVE: To share our current experience and review the current literature concerning the use of radiofrequency for the treatment of facial laxity. METHODS: We discuss our experience and review the current literature. RESULTS: Radiofrequency can impart mild tightening of mid- and lower facial laxity as well as periorbital laxity. In addition, it may help acne scars and acne. CONCLUSIONS: Radiofrequency appears to impart mild improvement to facial laxity and is a viable nonsurgical option for patients with mild facial laxity. There is, however, a need for blinded, randomized controlled studies to further validate these claims

BACKGROUND: Light-emitting diode (LED) photomodulation is a novel nonthermal technology used to modulate cellular activity with light. OBJECTIVE: We describe our experience over the last 2 years using 590 nm LED photomodulation within a dermatologic surgery environment. METHODS: Practical use of nonthermal light energy and emerging applications in 3,500 treatments delivered to 900 patients is detailed. RESULTS: LED photomodulation has been used alone for skin rejuvenation in over 300 patients but has been effective in augmentation of results in 600 patients receiving concomitant nonablative thermal and vascular treatments such as intense pulsed light, pulsed dye laser, KTP and infrared lasers, radiofrequency energy, and ablative lasers. CONCLUSION: LED photomodulation reverses signs of photoaging using a new nonthermal mechanism. The anti-inflammatory component of LED in combination with the cell regulatory component helps improve the outcome of other thermal-based rejuvenation treatments