Reconstructing the nasal dorsum.

The skin of the nasal dorsum and bridge is more forgiving in terms of reconstructive options. Individual differences in skin laxity, nasal length and sebaceous composition impact on reconstructive choice as do the size, depth and exact location of the surgical defect. For many, if not all, defects in this area there are multiple different reconstructive options available all of which can result in equivalent and excellent results. Oftentimes there is no clear advantage of one repair over another and the choice becomes one of personal preference based on experience. No proscriptive approach or algorithm can be usefully applied in this setting. Key considerations include the location of the defect (distal vs. proximal nasal dorsum), the position of the defect (midline or off-centre) and the texture of the skin involved (sebaceous vs. non-sebaceous). Defects may be considered complex if they border on, or cross onto adjacent cosmetic units. Examples include defects extending onto the nasal tip, tip-ala junction, sidewall, nasal root-glabella and medial canthus. The adjacent reservoirs of tissue redundancy that can be utilized in flap reconstruction include the nasal sidewall, the nasal dorsum itself, the glabella, the midline/paramedian forehead and the medial cheek. Nearly all flaps on the nasal dorsum require subnasalis muscle dissection to effect sufficient movement and to ensure adequate flap vascularity and viability. The nasal bridge and glabella have much thicker skin and it is usually sufficient to dissect in the subcutaneous plane rather than disrupting the deeper procerus and corrugator muscles. Thick sebaceous skin is generally stiffer, moves less easily and closures may result in greater wound tension. These factors together with a tendency for sutures to tear through easily potentially increases the risk of complications. Greater consideration should be given to the exact type of flap or graft chosen in these patients.

Photodynamic therapy with topical methyl aminolaevulinate for 'difficult-to-treat' basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) may be difficult to treat by conventional means, particularly if the lesions are large or located in the mid-face (H-zone). Photodynamic therapy (PDT) using topical methyl aminolaevulinate (MAL) may be a good noninvasive option for these patients. OBJECTIVES: To investigate the efficacy and safety of PDT using MAL for BCCs defined as 'difficult to treat', i.e. large lesions, in the H-zone, or in patients at high risk of surgical complications. METHODS: This was a prospective, multicentre, noncomparative study. Patients were assessed 3, 12 and 24 months after the last PDT treatment. One hundred and two patients with 'difficult-to-treat' BCC were treated with MAL PDT, using 160 mg g(-1) cream and 75 J cm(-2) red light (570-670 nm), after lesion preparation and 3 h of cream exposure. Results Ninety-five patients with 148 lesions were included in the per protocol analysis. The histologically confirmed lesion complete response rate at 3 months was 89% (131 of 148). At 12 months, 10 lesions had reappeared, and therefore the cumulative treatment failure rate was 18% (27 of 148). At 24 months, an additional nine lesions had reappeared, resulting in a cumulative treatment failure rate of 24% (36 of 148). The estimated sustained lesion complete response rate (assessed using a time-to-event approach) was 90% at 3 months, 84% at 12 months and 78% at 24 months. Overall cosmetic outcome was judged as excellent or good in 79% and 84% of the patients at 12 and 24 months, respectively. Follow-up is continuing for up to 5 years. CONCLUSIONS: MAL PDT is an attractive option for 'difficult-to-treat' BCC. Because of the excellent cosmetic results, the treatment is particularly well suited for lesions that would otherwise require extensive surgical procedures.

A comparison of photodynamic therapy using topical methyl aminolevulinate (Metvix) with single cycle cryotherapy in patients with actinic keratosis: a prospective, randomized study.

BACKGROUND: Actinic keratosis (AK) is a very common condition, which has the potential of progressing to squamous cell carcinoma. The present study is a prospective, randomized study comparing the lesion response, cosmetic outcome, patient satisfaction and tolerability of a new treatment modality, photodynamic therapy (PDT), using topical methyl aminolevulinate (Metvix), with the most commonly used standard therapy for AK, cryotherapy. METHODS: A total of 204 patients with clinically diagnosed AK were randomized to either cryotherapy or PDT. The PDT patients were further assigned to an active or placebo group in a random, double-blind manner. Cryotherapy was performed using liquid nitrogen spray in a single freeze-thaw cycle. PDT was performed using 160 mg/g methyl aminolevulinate cream or placebo, a 3-hour application time, red light (570-670 nm) and a total light dose of 75 J/cm(2). PDT was repeated after 7 days. Two sessions of PDT were undertaken, as a previous study had shown a single session had similar efficacy to cryotherapy. Lesion response was assessed clinically after 3 months (complete response or non-complete response). RESULTS: The lesion response rate was 91% in the methyl aminolevulinate PDT group, 68% in the cryotherapy group and 30% in the placebo PDT group. Methyl aminolevulinate PDT was statistically significantly better than both cryotherapy and placebo PDT in terms of response rates and cosmetic outcome. Most patients preferred PDT to other treatments. CONCLUSIONS: PDT with methyl aminolevulinate is an excellent treatment option, particularly for patients with widespread damage or AK lesions in cosmetically sensitive areas.

Antibiotic prophylaxis for full-face laser resurfacing: is it necessary?

OBJECTIVE: To evaluate the need for antibiotic prophylaxis when performing full-face laser resurfacing. METHOD: Prospective study of 31 patients undergoing full-face laser resurfacing, 17 with and 14 without antibiotic prophylaxis. OBSERVATION: Four of 14 patients without antibiotic prophylaxis had microbiologic and clinical evidence of infection. None of the 17 patients with antibiotic prophylaxis had clinical infection. Early treatment prevented adverse sequelae in the 4 patients who developed infection. CONCLUSION: Antibiotic prophylaxis against Staphylococcus aureus is useful but not essential, because meticulous wound care and close clinical monitoring of patients daily with routine bacterial swabs can detect infection early.

A review of 24 cases of Mohs surgery and ophthalmic plastic reconstruction.

PURPOSE: Mohs surgery (micrographically controlled excision) has been advocated as an effective method of dealing with infiltrative periorbital skin tumours. It has been shown to have high rates of tumour clearance with minimal loss of normal tissue, thus making oculoplastic reconstruction easier and functional preservation better. The aim of the present study was to confirm this. Guidelines for the selection of patients for Mohs surgery are discussed. METHODS: We retrospectively reviewed 24 cases of primary (n = 18) and recurrent (n = 6) periorbital basal and squamous cell carcinomas managed by Mohs micrographic excision and plastic reconstruction who presented to the Royal Perth Hospital between 1992 and 1996. RESULTS: Our high rate of tumour clearance (100%) was similar to that of previous studies, although our follow-up period was only 14.6 months. The fact that 50% of our patients with lid involvement had an intact posterior lamella after Mohs excision correlates with the high level of normal tissue preservation. The low rate of postoperative symptomatic problems suggests good maintenance of function. The infiltrative nature of these tumours was highlighted by the substantial proportion of cases (37.5%) that had a much larger excision defect than what was expected prior to excision. CONCLUSIONS: Our analysis confirms that Mohs excision and subsequent oculoplastic reconstruction is an effective method to use when managing periorbital infiltrative skin tumours.

Pulsed dye laser treatment of spider telangiectasia.

Spider telangiectasia is a common benign vascular malformation which can be a source of cosmetic concern for the patient. A retrospective review of 30 adults and children with spider telangiectasia treated by the flashlamp-pumped pulsed dye laser was undertaken. There was complete clearance of treated spider telangiectasia in 93% of patients after a single treatment. There were no reported permanent adverse effects with purpura being the only transient problem. Most patients were satisfied with the eventual results of treatment and would recommend treatment to other people with a similar problem. This laser should be considered as the treatment of choice for spider telangiectasia.

Combination carbon dioxide laser vermilionectomy and wedge excision of the lip.

Dermatologic surgeons are very familiar with the use of the carbon dioxide (CO2) laser for treating actinic cheilitis. When squamous cell carcinoma is proven or suspected in the affected lip, then combined CO2 laser vermilionectomy and wedge excision as a one stage procedure has significant advantages for the patient.

Pulsed dye laser treatment of port-wine stains: a review of patients treated in Western Australia.

OBJECTIVE: To assess the effectiveness of the flashlamp-pumped pulsed dye laser in the treatment of port-wine stains. DESIGN: A retrospective review of medical records and patients. SETTING: Royal Perth Hospital (a tertiary referral hospital), August 1989 to December 1992. SUBJECTS: 186 consecutive patients with port-wine stains treated with a flashlamp-pumped pulsed dye laser. OUTCOME MEASURES: Degree of lesion fading; adverse reactions. RESULTS: Of 131 patients who completed treatment, 78% had better than 50% fading of the lesion and only 9% had less than 25% fading. An average 3.4 treatments were needed to achieve more than 50% fading. The response was better in children than in adults, although the difference was not significant. Anaesthesia was needed for 44% of patients. Pigmentary change (usually transient) occurred in 6.1% of patients and permanent and signficiant adverse effects in only 4.6%. CONCLUSION: This study confirms the efficacy of the flashlamp-pumped pulsed dye laser in the treatment of port-wine stains in children and adults. Early treatment of port-wine stains should be encouraged to reduce the physical and psychological morbidity of disfiguring lesions.

Pulsed dye laser treatment of port-wine stains. A patient questionnaire.

BACKGROUND: The flashlamp-pumped pulsed dye laser is recognized as the treatment of choice for port-wine stains. Most studies assessing its effectiveness are based on clinical reviews by the treating physician. Each patient's assessment of treatment outcome is also important. OBJECTIVE: To assess the patients' attitudes toward laser treatment, satisfaction with treatment outcome, and reasons for withdrawal from treatment. METHODS: A questionnaire was distributed to 186 patients with port-wine stains treated with the flashlamp-pumped pulsed dye laser. Of the 186 patients, 131 had completed treatment and 55 were having ongoing treatment or had withdrawn from treatment. Replies were received from 164 patients, a response rate of 88%. RESULTS: Most patients expressed satisfaction with the present appearance of their treated port-wine stains. The majority of any adverse effects experienced were transient. Over 90% of patients would recommend treatment to other people with port-wine stains. CONCLUSION: The flashlamp-pumped pulsed dye laser improves the appearance of port-wine stains, and is regarded favorably by patients. Patients' assessments of treatment outcomes correlate well with clinical results obtained.