Mohs micrographic surgery is accurate 95.1% of the time for melanoma in situ: a prospective study of 167 cases.

BACKGROUND: Mohs micrographic surgery (MMS) represents a promising option for treatment of melanoma in situ (MIS). However, interpretation of melanocytic lesions by fresh frozen sections may be difficult. OBJECTIVE: The objective of this study was to determine if margins called clear by MMS were clear by subsequent paraffin-embedded sections and to compare cure rate with available data for MMS and standard excision. MATERIALS AND METHODS: A total of 167 patients with MIS, including 116 patients with MIS in sun-exposed skin of lentigo maligna (LM) type, were treated by MMS with subsequent evaluation of the final margin with paraffin-embedded sections that were cut en face, over a period of 12 years. A total of 143 patients were available for follow-up from 6 months to 12 years (mean, 50 months; median 48 months; 594.5 patient-years), and 109 patients were available for follow-up from 2 to 12 years (mean, 63 months; median, 60 months; 569 patient-years). RESULTS: The clearance rate by MMS technique using frozen sections was 94.1% for MIS non-LM type, 95.7% for MIS LM type, and 95.1% for both. The cure rate was 97.8% for MIS non-LM type, 99.0% for MIS LM type, and 98.6% for both for mean follow-up of 50 months and 97.4% for MIS non-LM type, 98.6% for MIS LM type, and 98.2% for both for mean follow-up of 63 months. CONCLUSION: MMS is a viable option for treatment of MIS that may increase cure rate and reduce the size of the defect especially in cosmetically and functionally sensitive areas.

Office surgery incidents: what seven years of Florida data show us.

BACKGROUND: In the wake of increased media attention focusing on human error in medicine, numerous state medical boards and legislatures have drafted, and are continuing to draft, regulations aimed at protecting patients undergoing procedures in the office setting. These regulations will have a considerable impact on patient access to medically necessary procedures, and any regulations should be based on good data. This report summarizes 7 years of prospective data from the state of Florida, the best data available on office surgery incidents. OBJECTIVE: The objective was to determine the nature and incidence of hospital transfers and deaths resulting from office procedures. METHODS: This study is a compilation of mandatory reporting by Florida physicians to a central agency of all in-office adverse incidents resulting in death, serious injury, or hospital transfer in the State of Florida from March 2000 to March 2007. Telephone and internet follow-up was conducted to determine reporting physician board certification, hospital privileges, and office accreditation. RESULTS: In 7 years there were 31 deaths and 143 procedure-related complications and hospital transfers. Liposuction and liposuction with abdominoplasty or another cosmetic procedure resulted in 24 complications and 8 deaths. Of the offices reporting adverse incidents, 38.5% were accredited by an independent accrediting agency, 92.5% of the physicians were board-certified, and 96.6% had hospital privileges. A total of 58% (18/31) of the deaths and 61% (87/143) of the complications were associated with nonmedically necessary (cosmetic) procedures. A total of 78% (14/18) of these deaths were in ASA Class 1 patients. Plastic surgeons were responsible for 48% of all deaths (83% of cosmetic surgery deaths) and for 52% of all hospital transfers (83% of cosmetic surgery complications and hospital transfers). CONCLUSION: Plastic surgeons were responsible for an inordinate number of deaths and hospital transfers. Requiring physician board certification and physician hospital privileges would not seem to increase safety, because most physicians already have these credentials, and physicians without these credentials were not responsible for a disproportionate share of incidents. These data do not show an emergent hazard to patients from medically necessary office surgery. Liposuction under general anesthesia deserves continued scrutiny because deaths due to this procedure continue to occur and this procedure can be performed with dilute local anesthesia, with which no deaths were reported. Mandatory reporting of office incidents should be strongly supported, as well as reporting of incidents that occur after surgery in the hospital outpatient department and ambulatory surgery center. These data should be available for analysis after protecting patient confidentiality. A national debate needs to occur to determine how many deaths and injuries are acceptable from cosmetic procedures performed under general and intravenous anesthesia.

Prospective clinical evaluation of 1440-nm laser delivered by microarray for treatment of photoaging and scars.

BACKGROUND AND OBJECTIVES: The use of thermal heating in microscopic zones is generically termed "microrejuvenation." The objective of this study was to evaluate the benefits of using a novel 1440-nm Nd:YAG laser (Affirm, Cynosure, Westford, MA) with a novel approach for microscopic heating. This device utilizes a microarray of lenses delivering a 10-mm beam as hundreds of high-fluence beamlets interspersed with a relatively uniform low-fluence background irradiation. STUDY DESIGN: Forty subjects (N = 40) at 2 study sites presenting with superficial rhytides and other symptoms of photoaging or scars received 3 treatments at 4-week intervals using a T-250 lens array. Total fluence ranged from 3.0 to 7.0 J/cm2. Zimmer air cooling was used for all treatments. No topical anesthetic was required. RESULTS: The most common immediate and expected clinical effects were erythema and edema lasting less than 24 hours, although 6 patients reported edema lasting for up to 1 week. There were no permanent side effects. In total, 2.7% of treatments resulted in temporary side effects, the most significant of which was a slight depression on the cheek (n = 1), which completely resolved within 3.5 months. Other side effects included localized areas of acneiform subcutaneous erythematous papules (n = 4) and a linear superficial crust (n = 1) with the original tip, all of which resolved within 1 week. One patient reported small erythematous subcutaneous nodules resolving in 17 days. Tenderness of the neck lasting from 2 weeks (n = 2) to 3 weeks (n = 1) was also reported. RESULTS: In all, 92% of the patients completed 3 treatments. Of these, 85% completed the 1-month follow-up. At the follow-up, 94% of subjects exhibited improvement in one or more categories, 82% exhibited mild to moderate improvement, and 12% exhibited good improvement. Side effects were minimal and included mild posttreatment erythema and edema resolving within 24 hours. Pain during treatment was judged minimal to moderate. Postauricular histology showed areas of thermal injury up to 250 microm deep and 150 microm wide. CONCLUSIONS: A 1440-nm beam split by a microlens array is a promising new approach for inducing nonablative neocollagenesis in the remodeling of scars and rhytids. Histologic evidence confirms the microcolumnar nature of collagen heating using this microarray.

Unusual cutaneous manifestation of angiocentric T-cell lymphoma: a case report.

Angiocentric T-cell lymphoma may clinically present with a broad variety of cutaneous manifestations, including papules, nodules, and ulcerated tumors, and may mimic cutaneous vasculitis and Wegener granulomatosis. Histologic diagnosis of angiocentric T-cell lymphoma also may present a challenge because of variations in the degree of cellular infiltrate and cellular atypia. The correct diagnosis is critical because of the importance of choosing the correct therapeutic modality-chemotherapy or x-ray radiation. We report a case of angiocentric T-cell lymphoma with extensive necrotic facial ulcers that responded to treatment with fludarabine, cyclophosphamide, and prednisone.