Face-lifting: an overview.

Numerous adaptations of face-lift techniques have been devised, and each surgical approach has its own risks and benefits, as well as proponents and detractors. All of the conventionally accepted techniques achieve removal of redundant skin. However, its the variations in approach to the deeper soft tissue structures that separate the many face-lifting procedures. A skin only face-lift was the earliest form of surgical rhytidectomy, but failed to achieve significant long-term benefit. Cosmetic surgeons of various backgrounds thus sought to achieve a more durable benefit from the surgery. While certain techniques have been classically ascribed to a particular surgeon, innovation does not occur in a vacuum and many surgeons are responsible for our current state of knowledge with regards to facial rhytidectomy surgery.

Electrosurgical standing cutaneous cone modification.

BACKGROUND: Tissue redundancy manifesting as a standing cutaneous cone is a common surgical problem. OBJECTIVE: To describe the use of electrosurgery to modify standing cutaneous cones. METHODS: Electrical current is applied via an electrosurgical needle to deep dermis and subcutaneous fat. The superficial dermis and epidermis are left undisturbed. In properly selected standing cones, correction of the standing cone is achieved without scar lengthening. RESULTS: Use of the technique can provide standing cone correction without lengthening the surgical scar. There has been no increase in wound failure or infection with the described technique. CONCLUSION: Electrosurgical modification complements existing surgical techniques for standing cutaneous cone repair.

Topical tacrolimus in the treatment of bovine collagen hypersensitivity.

BACKGROUND: Soft tissue augmentation with bovine collagen is a common and safe aesthetic procedure. Despite adequate pretreatment testing, allergic reactions can develop. The medical literature provides little guidance to the clinician in the management of bovine collagen hypersensitivity. OBJECTIVE: We describe a case of bovine collagen allergy treated with 0.1% topical tacrolimus and corticosteroids. METHODS: Clinical evaluation and management of a patient with bovine collagen hypersensitivity. RESULTS: Our patient responded to combined therapy with oral corticosteroids and topical tacrolimus. CONCLUSION: Topical tacrolimus may be a useful first-line or adjuvant therapy in the management of bovine collagen allergic reactions. Further clinical experience with its use for bovine collagen hypersensitivity is required to determine its true efficacy in this condition.

Inverted pyramidal biopsy.

We describe a biopsy technique that is simple, rapid, and effective for numerous cutaneous lesions. The inverted pyramidal biopsy (IPB) creates an acute geometric tissue defect with an apex located in the dermis. A cosmetically pleasing result, while still providing adequate tissue to render a histologic description and diagnosis, is obtained. The technique can also be employed to remove a host of benign lesions, including dermatofibroma, fibrous papules, and chalazion, among others.

The apical angle: a mathematical analysis of the ellipse.

BACKGROUND: The elliptical excision is a common surgical procedure. The dermatologic literature predominantly describes an excisional geometry with a 3:1 length:width ratio and an apical angle of 30 degrees. OBJECTIVE: To analyze the elliptical excision by applying mathematical principles and define the apical angle and its relationship to the length:width ratio. METHODS: We examined numerous examples of elliptical excisions as presented in the dermatologic literature. We analyzed the geometry of the excisions and defined it mathematically. RESULTS: The apical angle of a 3:1 elliptical excision is not 30 degrees. The true apical angle varies from 37 degrees to 74 degrees depending on excisional geometry. CONCLUSION: The commonly presented apical angle of 30 degrees is incorrect and does not reflect the true apical angle of elliptical excisions.

Series spiral advancement flap: an alternative to the ellipse.

BACKGROUND: Surgical excision of skin lesions is a common dermatologic procedure. OBJECTIVE: An alternative to the elliptical excision is described. METHODS: We present an excisional technique that creates a series of nonepidermal outwardly spiraling flaps. The surgical defect is closed with specially tunneled absorbable suture. RESULTS: There has been no increase in infectious complications or wound failures compared with standard ellipses. Proper patient and lesion selection aids in obtaining an acceptable outcome. CONCLUSION: The series spiral advancement flap has the potential to become a useful and common surgical technique.

Flap minimization via peripheral recruitment.

PURPOSE: To describe tissue-conserving modifications to traditional flap design such as the use of beveled incisions and the pattern of the incisions. These techniques should maintain flap viability and enhance cosmesis. METHODS: We describe the techniques of peripheral flap recruitment. RESULTS: Flaps conformed to reduced geometry, beveled incisions and bases, and tapered ends maximize vascularity. Peripheral tissues are recruited to fill primary defects; smaller flaps thus can be used to fill larger defects. Additionally, this flap design enhances cosmetic results and maintains a high probability for flap survival. CONCLUSION: The described novel flap design has many potential advantages over traditional designs. Correctly applied, these flap techniques spare tissue, decrease scarification, trauma and bleeding, and reduce the need for secondary procedures. Potential drawbacks of this flap design include temporary anatomic distortion especially over rounded structures such as the nose. Complications are minimal.

Cyclin D1 as an aid in the diagnosis of mantle cell lymphoma in skin biopsies: a case report.

Mantle cell lymphoma (MCL), an uncommon and aggressive form of non-Hodgkin lymphoma, typically involves lymph nodes. It usually only secondarily involves extranodal sites. We describe an unusual case of a MCL that presented and relapsed in the earlobes. Light microscopic findings were initially regarded as suggestive of small lymphocytic lymphoma, although subsequent analysis of fresh tissue by flow cytometry led to the diagnosis of MCL. Retrospective application of a broad panel of recently developed markers suitable for analysis of routinely processed tissue yielded results that also permitted a diagnosis of MCL. If these results had been available at the time of initial presentation, they would have obviated the need for rebiopsy. Greater awareness not only of the phenotypic criteria by which lymphomas are classified but of the lymphoma markers available for evaluation of routinely processed tissue should facilitate the accurate diagnosis of diseases like MCL and minimize the risk of misdiagnosis as an indolent disorder.

Electrosurgical modification of orbicularis oculi hypertrophy.

PURPOSE: To assess two electrosurgical approaches for the modification of orbicularis hypertrophy that may be used in conjunction with, or separate from, lower lid blepharoplasty. The hypothesis to be tested is that purely electrosurgical nonexcisional techniques may be used to modify orbicularis oculi muscle. METHODS: Electrosurgical techniques to treat orbicularis hypertrophy with an "open" and a "closed" technique are described. The open technique is performed in conjunction with transconjunctival blepharoplasty. The closed technique requires a 1-mm to 2-mm dermal incision, 2 minutes of surgical time per eyelid, and a specially insulated and formed electrosurgical needle. A review and case series are presented to illustrate and describe the techniques and results. RESULTS: Results for both techniques were rated by both patients and surgeons using the categories of poor, fair, good, or excellent. The open technique was performed in conjunction with transconjunctival blepharoplasty on 23 patients during 2 years with a minimum follow-up of 6 months. Results for the open technique were considered "excellent" by 14 patients and "good" by 9 patients. The operating surgeons evaluated the improvement as "excellent" in 4, "good" in 11, and "fair" in 8 patients. The closed technique was performed on eight patients. Results for patient satisfaction for the closed technique were considered "good" by 4, "excellent" by 2, "fair" by 1, and the final patient abstained from categorization. Operating surgeon evaluation of the closed technique revealed "excellent" outcomes in 3, "good" in 3, and "fair" for 2 patients. CONCLUSION: Electrosurgical techniques may be used to modify orbicularis hypertrophy. Drawbacks include a significant learning curve, potential cutaneous ulceration, and occasional temporary anatomic distortion as manifested by scleral show. Complications are minimal, and the technique was safe in all patients studied.

Mohs surgery and processing: novel optimizations and enhancements.

OBJECTIVE: Simple yet effective modifications to Mohs surgery and processing may enhance procedural efficiency, ensure proper tissue orientation and tracking, while greatly reducing "recuts." Using the methods described, Mohs specimens no longer need to be incised or excised with any bevel, thus conserving tissue and facilitating closure. METHODS: A streamlined Mohs surgical tray is convertible to a closure tray within seconds. The excised tissue specimen is oriented on a sterile paper square on a reusable sterilized aluminum palette where partial thickness circumferential and radial scalpel cross-hatching allows epidermal edges complete freedom to later adhere to a flattening glass. The sterile paper can be labeled with patient name, stage number, and chuck number; then the specimen is inked. Rapid chuck freezing in a specially positioned liquid nitrogen immersion is followed by OCT (embedding compound) application. Uniquely numbered and modified cryostat chucks eliminate the possibility of OCT-chuck disunion. Rapid liquid nitrogen immersion of a glass surface allows the inked, cross-hatched specimen's epidermal edges and base to lay perfectly flat once forced against the supercooled glass surface using a special polymer glove. Inversion of the specimen-containing glass onto a frozen and gel state OCT interface of the chuck completes the embedding. RESULTS/CONCLUSION: These reproducible approaches to Mohs surgery described herein utilize multiple modifications that enhance the speed, efficiency, and reproducibility of Mohs specimen embedding, specimen preparation, while maintaining accuracy of interpretation.

Self-limited adverse reaction to human-derived collagen injectable product.

BACKGROUND: Soft tissue augmentation is a common and safe cosmetic and reconstructive procedure. OBJECTIVE: We describe a temporary and self-limited adverse reaction to Dermalogen. METHODS: Clinical and histologic evaluation following an adverse reaction noted at a Dermalogen skin test site. RESULTS: Our patient was found to have a foreign body reaction to Dermalogen. CONCLUSION: Dermalogen, a form of acellular human collagen, may induce a foreign body reaction.

Electrosurgical suspension apparatus.

BACKGROUND: Dermatologic surgeons commonly employ electrosurgery. OBJECTIVE: We describe a novel, yet simple, electrosurgical suspension apparatus and variations that facilitate the performance of excision and repair, Mohs micrographic surgery, cosmetic surgery, and other forms of dermatologic surgery. METHODS: The described techniques result from more than a decade of use and refinements in electrosurgical suspension apparatuses. RESULTS: The use of an electrosurgical suspension device has eliminated electrosurgical needle stick injuries, facilitated surgery, and reduced the risk of surgical field contamination via the electrosurgical handpiece or wiring. CONCLUSION: The use of a suspended electrosurgical handpiece results in reduced surgical time, eliminates many of the inconveniences associated with the current use of electrosurgery, and facilitates the use of electrosurgery as a tool of the dermatologic surgeon.

Autoimmune progesterone dermatitis: onset in a women without previous exogenous progesterone exposure.

Autoimmune progesterone dermatitis is a rare clinical entity that may be seen by the family practitioner, gynecologist, or dermatologist. Recognition of the entity is paramount in the therapy of this easily treated condition. We report a case of a 36-year-old woman with a recurrent facial dermatitis of many months' duration. We found the cutaneous eruption to be temporally related to her menstrual cycle. The patient denied any changes in her diet, cosmetics, medications, or soaps that could account for the dermatitis. Despite no previous exposure to exogenous progesterone, the diagnosis of autoimmune progesterone dermatitis was made. The patient was cured by oophorectomy.