Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers.

IMPORTANCE: Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES: To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE: Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS: Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE: Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Nonablative radiofrequency treatment of facial laxity.

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.

Evaluation of the S-Caine Peel for induction of local anesthesia for laser-assisted tattoo removal: randomized, double-blind, placebo-controlled, multicenter study.

BACKGROUND: Topical anesthetics are important tools for many dermatologic procedures. The S-Caine Peel is composed of a 1:1 (w:w) eutectic mixture composed of lidocaine base 7%, USP, and tetracaine base 7%, USP. It is applied as a cream, dries on exposure to air, and forms a flexible membrane, which can be easily peeled off. OBJECTIVE: To evaluate the effectiveness of the S-Caine Peel in providing clinically useful local dermal anesthesia for laser-assisted tattoo removal and to monitor the nature and frequency of adverse events associated with the safety of the S-Caine Peel. METHODS: Thirty adult patients undergoing laser-assisted tattoo removal were enrolled in this multicentered, randomized, double-blind, placebo-controlled study. Each subject received both the S-Caine Peel and placebo simultaneously for 60 minutes. The primary efficacy parameter was a 100 mm visual analog scale (VAS) for patient self-assessment of pain. Secondary efficacy parameters included both the investigator's and an independent observer's evaluation of subject pain (4-point categorical scale: no pain through severe pain) and the patient's and the investigator's overall impression of the local anesthetic. RESULTS: Mean VAS scores were 42 mm for the S-Caine Peel and 66 mm for placebo treatment sites (p=.001). Patients received adequate pain relief in 50% of S-Caine Peel sites versus 7% of placebo sites (p=.002). The percentage of those who would like to use the S-Caine Peel again were 43% for the S-Caine Peel compared with 7% for placebo (p=.005). Investigators' evaluations revealed that 70% of patients had less pain at S-Caine Peel treatment sites compared with 10% with less pain at placebo sites (p<.001), and 70% of the S-Caine Peel-treated sites achieved adequate anesthesia versus 10% of placebo sites (p<.001). The independent witness assessed less pain in 67% of S-Caine Peel-treated sites versus 10% of the placebo sites (p=.002). One occurrence of moderate to severe erythema was noted at both an S-Caine Peel and a placebo treatment site on removal of the S-Caine Peel after 60 minutes, which self-resolved quickly. There was no statistical difference between the two groups. Other side effects were limited to local mild, transient erythema at the application sites. CONCLUSION: Administration of the S-Caine Peel for 60 minutes prior to laser-assisted tattoo removal was effective in significantly reducing pain levels associated with the procedure.

Two randomized, double-blind, placebo-controlled studies evaluating the S-Caine Peel for induction of local anesthesia before long-pulsed Nd:YAG laser therapy for leg veins.

BACKGROUND: Topical anesthetics are valuable tools for many dermatologic procedures. OBJECTIVE: To evaluate the efficacy and safety of S-Caine Peel composed of 1:1 (wt:wt) mixture of 7% lidocaine and 7% tetracaine in the induction of local anesthesia before long-pulsed Nd:YAG laser therapy for leg veins. METHODS: Two randomized, double-blinded, placebo-controlled trials were performed. In study 1, 60 adults received S-Caine Peel and placebo cream for 30 or 60 minutes. Efficacy was evaluated by a patient visual analog scale and impression. The pain scale and impression were evaluated by the investigator and an independent observer. In study 2, 40 adults received 60- and 90-minute applications. RESULTS: In study 1, the 30- and 60-minute application times were grouped: Patients had adequate pain relief in 48% of S-Caine sites versus 23% of placebo sites (P<0.001). Investigators reported none-to-mild pain in 50% of active sites versus 33% of placebo sites (P=0.007), with adequate anesthesia in 65% of active sites versus 43% of placebo sites (P=0.002). The independent witness assessed none-to-mild pain in 52% of active sites versus 37% of placebo sites (P=0.067). In study 2, investigators rated none-to-mild pain in 75% of 60-minute and 85% of 90-minute S-Caine sites versus 30% and 50% of placebo sites (P=0.012 and P=0.002, respectively), with adequate anesthesia in 70% and 85% of 60- and 90-minute of active sites versus 25% and 20% of placebo sites (P=0.029 and P=0.001, respectively). The independent witness rated none to mild pain in 80% and 85% of 60 and 90 minute of S-Caine sites versus 35% and 50% of placebo sites (P=0.008 and P=0.004). CONCLUSION: The S-Caine Peel provides safe and highly effective local anesthesia when applied for at least 60 minutes for laser therapy of leg veins. Facile removal of the peel provides a unique advantage and ease in administration.

Superficial morphea.

The superficial variant of morphea is a recently described entity that differs in its clinical and histologic presentation from classic morphea. The condition has been reported only in females to date and is characterized by minimal to no induration and hypopigmented or hyperpigmented patches without associated symptoms, systemic involvement, contractures, or atrophy. We present the unique clinical and histopathologic findings in a 77-year-old woman.