From Centimeters to Millimeters: The Evolution of the Surgical Margins for Melanoma-A Historical Review.

BACKGROUND: With an improved understanding of tumor biology and behavior, the recommended margins for the surgical treatment of melanoma have evolved. OBJECTIVE: We describe the progression of these surgical margins, detailing the historical basis for the 5-cm margin and transitioning to current practice, in which Mohs micrographic surgery (MMS) with immunohistochemistry (IHC) has become increasingly used. METHODS/MATERIALS: We searched PubMed and Google Scholar for articles published between January 2019 and April 2023 describing the use of MMS for melanoma in situ (MIS) and invasive melanomas. RESULTS: We identified 12 articles focusing on the use of MMS for MIS and invasive melanomas: 3 meta-analyses and 9 retrospective studies. Two retrospective analyses documented no differences in overall survival between MMS and wide local excision (WLE) and 2 found improved overall survival for MMS compared with WLE. Three retrospective analyses and 3 meta-analyses demonstrated low recurrence rates after the use of MMS for both MIS and invasive melanomas. Finally, 2 retrospective studies documented the success of MMS with IHC using MART-1. CONCLUSION: Over the past century, the surgical margins for the treatment of melanoma have undergone a marked transformation. MMS with IHC has become increasingly popular given its ability to reliably produce superior clinical outcomes.

Sonic Hedgehog Pathway Inhibition in the Treatment of Advanced Basal Cell Carcinoma.

OPINION STATEMENT: Advanced basal cell carcinoma (BCC) represents a small proportion of BCCs that are not amenable to standard therapies due to lack of efficacy, high recurrence risk, and excessive morbidity. Implication of the Sonic hedgehog (Shh) pathway in the development of BCC has led to the development of systemic Shh pathway inhibitors, providing patients with advanced BCCs new treatment options and improved survival. There are currently two Food and Drug Administration (FDA)-approved Shh inhibitors, vismodegib and sonidegib, for advanced basal cell carcinomas. Vismodegib has approval for locally advanced BCCs (laBCC) and metastatic BCC (mBCC), while sonidegib has approval for laBCC. These agents have also been used for prevention in nevoid basal cell carcinoma syndrome and as neoadjuvant therapy before surgery, and we feel that there is a growing role of Shh inhibitors in these settings. Head-to-head randomized controlled trials comparing vismodegib to sonidegib are lacking. Adverse events can limit the utility of these medications by leading to treatment discontinuation in a large proportion of patients, and it is thus essential that prescribers be able to anticipate and manage the most frequent side effects of muscle spasms, alopecia, dysgeusia, nausea, and weight loss. Other Shh inhibitors, including the antifungal itraconazole, have been investigated in small trials, but further research is needed before recommending their routine clinical use. Additionally, there are several new agents under investigation that may have improved efficacy for resistant tumors by utilizing different mechanisms of action than the two currently approved medications.

Overview of Kybella (Deoxycholic Acid Injection) as a Fat Resorption Product for Submental Fat.

There has been an increasing interest in addressing the issue of submental fat (SMF) when it comes to cosmetic medicine. With the rise of social media, video calls, and the now almost omnipresent accessibility of cameras, there is perhaps now more than ever an emphasis on the facial image. Although invasive procedures such as liposuction and neck lift still play a significant role in reducing SMF, the trend toward minimally invasive methods has finally given rise to a single Food and Drug Administration-approved injectable that is both safe and effective: ATX-101, also known as Kybella in the United States.

Fractional treatment of aging skin with Tixel, a clinical and histological evaluation.

OBJECTIVE: This study presents clinical results of Tixel, a new fractional skin resurfacing system based on thermo-mechanical ablation technology. Tixel employs a hot (400°C) metallic tip consisting of 81 pyramids. Treatment is performed by rapidly advancing the tip to the skin for a preset tip-skin contact duration. Thermal energy transfer to the skin creates micro-craters by evaporation. METHODS: Treatment results with tip types, D and S, with high and low thermal conductivity, were evaluated. Twenty-six subjects received three facial treatments, with 4-5-week intervals between treatments, without analgesia or cooling. In addition, histopathologies of Tixel and CO2 laser were performed. RESULTS: Crater properties are related to contact duration and to thermal conductivity. The D tip created char-free ablative craters 100-320 µm wide with a thermal zone 100-170 µm deep. The S tip created non-ablative coagulation preserving the epidermis. Skin complexion improvement was achieved in all subjects; average treatment pain of 3.1/10, downtime of 0-1 days, and erythema clearance of 3.5 days. Subject's satisfaction was 75% and wrinkle attenuation was achieved in 75% of the cases. There was no incidence of bleeding, scarring, or post-inflammatory hyperpigmentation. CONCLUSIONS: Tixel may be used safely for ablative and non-ablative resurfacing with low pain, low downtime, and quick healing.

A novel non-invasive radiofrequency dermal heating device for skin tightening of the face and neck.

BACKGROUND: Loose, lax skin is a common cosmetic complaint. Previous non-invasive skin tightening devices had modest efficacy and were associated with pain or downtime. New technologies may allow for effective skin tightening with a series of radiofrequency (RF) treatments with no downtime. OBJECTIVE: To evaluate the efficacy and safety of a novel bipolar RF device for skin tightening. METHODS: Fifteen consecutive female patients were enrolled in the case series; 14 completed the study and were included in the analysis. The device under investigation is a novel, bipolar RF device allowing for achievement and maintenance of optimal dermal temperatures to stimulate collagen remodeling and skin tightening. Patients underwent a series of 4-6 weekly treatments. Three blinded, experienced cosmetic physicians evaluated paired pre-treatment and post-treatment photographs and determined the associated improvement, if any. RESULTS: All patients (14/14) were determined to have a clinical improvement, as the pre-treatment and post-treatment photographs were correctly identified by the evaluators. It was observed that 21% (3/14) of patients had significant improvement, 50% (7/14) had moderate improvement, and 29% (4/14) had mild improvement. No pain, side effects, or adverse events were observed. CONCLUSIONS: This novel bipolar RF device represents a safe, effective treatment option for non-invasive skin tightening.

A clinical and biological evaluation of a novel, noninvasive radiofrequency device for the long-term reduction of adipose tissue.

BACKGROUND AND OBJECTIVE: A novel, noninvasive technology, utilizing suction-coupled radiofrequency (RF) heating and ultra-short pulse duration, high-voltage electrical pulses was studied for its efficacy and safety on adipose tissue reduction. METHODS: Twenty-one subjects underwent treatment of their abdominal fat once weekly for 6 weeks. Clinical outcomes including abdominal circumference, adipose tissue thickness (measured by ultrasound), adipose tissue weight, body weight, and clinical photographs were obtained at visits 1 and 3 months after last treatment. Adverse events were recorded. Three subjects, who were undergoing a future elective abdominoplasty, were treated with the same protocol, but on only one side of the abdomen before abdominoplasty. Biopsies from the RF-treated and untreated sides were harvested during abdominoplasty and cultured; measurements of adipocyte size and shape, rate of apoptosis, collagen production, and dermal thickness were determined. RESULTS: Significant clinical improvements (P < 0.05) were observed for the following clinical outcomes: reduction of abdominal circumference (113.4-110.7 cm), reduction of subcutaneous adipose tissue thickness (40.5-38.5 mm), and reduction in adipose tissue weight (32.2-30.7 kg) at 3-month follow-up visits. Overall patient weight also decreased, which was statistically significant at 1-month follow-up, but was not statistically significant at 3-month follow-up (73.9-73.3 kg, P = 0.609). Histologically, adipocytes were observed to have decreased size and withered shape, with increased levels of apoptosis; increased collagen synthesis, with compaction and reorganization of the dermis was also observed. Only minor, transient side effects were reported. CONCLUSIONS: This novel, noninvasive RF device was effective for improving subcutaneous fat, reducing abdominal circumference and reducing subcutaneous fat layer thickness. Histologically, these improvements appear to be partly related to increased adipocyte apoptosis.

Fractional vaporization of tissue with an oscillatory array of high temperature rods: part I: ex vivo study.

BACKGROUND: Short pulse duration (∼0.1-5 milliseconds) CO2 lasers are perceived as excellent tools for vaporization of craters arrays in fractional skin resurfacing. OBJECTIVES: To present a thermo-mechanical ablation technology, which affects tissue identically to fractional CO2 lasers, however at a fraction of the size and cost of a laser. MATERIAL AND METHODS: The new technology is based on heating an oscillating array of thin metallic rods to a temperature of 400°C and advancing the rods into tissue down to a precise pre-selected depth for a duration of 0.1-5 milliseconds. As a result, an array of crater is vaporized with identical properties of those produced by CO2 lasers. An ex vivo test was performed with a thermo- metallic rod array prototype. RESULTS: Arrays of 10 × 10 vaporized micro-craters of 350 micron diameter, 200 micron depth have been produced with lateral thermal damage of 80 micron while thermal damage below craters was 80-250 micron. CONCLUSIONS: A resonating thermo-mechanical array of high temperature (350-400°C) rods is capable of producing an array of craters identical to those produced with pulsed CO2 lasers.

Principles and practice of cutaneous laser and light therapy.

Laser technology has evolved rapidly in the last 2 decades. The theory of selective photothermolysis guides the proper selection and use of lasers to safely and effectively treat patients. This review summarizes the basic concepts and adjustable parameters for laser devices, emphasizing the importance of selective photothermolysis in clinical practice. It then covers the clinical applications of laser devices, including vascular lesions, hair removal, tattoo removal, facial rejuvenation, and fractional resurfacing. The authors intend to make the reader feel comfortable with the proper selection and application of lasers to treat their patients.

Comparison of treatment of melomental fold rhytides with cross-linked hyaluronic acid combined with onabotulinumtoxina and cross-linked hyaluronic acid alone.

BACKGROUND: Hyaluronic acid and onabotulinumtoxinA combination therapy has been shown to have greater clinical effectiveness than hyaluronic acid alone for glabellar furrowing, but this is not well documented for melomental fold rhytides. OBJECTIVE: To compare the efficacy of intradermal cross-linked hyaluronic acid (HA) and onabotulinumtoxinA combination therapy with the efficacy of cross-linked HA monotherapy in patients with melomental fold rhytides. METHODS AND MATERIALS: Twenty-two patients received combination therapy to a melomental fold area while also receiving cross-linked HA and a placebo saline injection to the contralateral side. Blinded physician evaluators and patient self-evaluators clinically and photographically assessed responses during standard intervals over 12 months. RESULTS: The melomental folds treated with combination therapy had significantly greater aesthetic improvement than the monotherapy-treated side at 2 weeks and 1 month upon physician photographic review. Furthermore, the median time for return to pretreatment rhytides was 6.5 weeks longer in the combination therapy side. Patient assessment also revealed improvement over baseline for the combination therapy at 1 month. CONCLUSION: Cross-linked HA and onabotulinumtoxinA combination therapy to melomental fold rhytides may provide better overall aesthetic results and longer duration of aesthetic improvement than cross-linked HA monotherapy.

Consensus recommendations on the use of an erbium-doped 1,550-nm fractionated laser and its applications in dermatologic laser surgery.

BACKGROUND: Nonablative fractional photothermolysis has revolutionized the way we treat a number of common skin conditions with laser technology. OBJECTIVE: A comprehensive guide is needed for clinicians using this technology to treat specific skin conditions in various skin types. MATERIALS AND METHODS: Recommendations were made from a recent round table discussion among experienced physicians and a review of recent literature findings. RESULTS: Optimal laser parameters are dependent on patient skin type and condition. We recommended guidelines for the successful treatment of several common skin conditions on and off the face using nonablative fractional photothermolysis. Specific conditions were dyschromia, rhytides, acne scars, surgical scars, melasma, and striae distensae. CONCLUSIONS: We developed reproducible guidelines to most effectively treat a variety of skin types and conditions using nonablative fractional photothermolysis. Future large, multicenter trials are indicated for further optimization of treatment parameters.

Where is it? The utility of biopsy-site photography.

BACKGROUND: With wrong-site surgery being one of the major causes of medical lawsuits in the United States, tools to confirm location are essential. A previous survey of 300 Mohs surgeons revealed that 14% of malpractice cases were due to wrong-site surgery. In dermatologic surgery, photography is helpful in precisely locating biopsy sites. OBJECTIVES: We present a case series of 34 biopsy-proven cutaneous head and neck malignancies performed in our university-based dermatology clinic, comparing the reliability of patient and blinded dermatologist identification with that of biopsy-site photography. RESULTS: Of 34 biopsy sites, the patient and the blinded dermatologist incorrectly identified four (12%). The patient alone incorrectly identified an additional six biopsy sites, resulting in a total of 10 (29%) cases incorrectly identified by the patient. There were no instances in which the patient correctly identified the biopsy site and the blinded dermatologist incorrectly identified it. CONCLUSION: In our current medical environment, in which more than 90% of health care is delivered in a clinic setting, wrong-site surgery is certainly underreported. In adopting a zero-tolerance policy for wrong-site surgeries, biopsy-site photography saves time, money, and potential frustration, hopefully eliminating the number of excisions performed on the wrong site.

Pneumatic skin flattening (PSF): a novel technology for marked pain reduction in hair removal with high energy density lasers and IPLs.

BACKGROUND: Intense pulsed light (IPL) aesthetic treatment, such as hair removal from large areas, is often very painful. The problems of pain and discomfort can be divided into two different phases: immediate acute pain and the long-term, milder, post-treatment discomfort also associated with erythema. The immediate acute pain is felt during each treatment pulse and can accumulate to an intolerable sensation after a few shots, resulting in the necessity of either using topical analgesic creams which have several limitations or else to considerably slow down the process and/or apply less efficient low-energy densities. The immediate pain is created by the stimulation of sensory nerves located near the basal layer of the epidermis and adjacent to the treated hair follicles. There is an interest in a technology which would significantly reduce acute pain and post-treatment erythema, without the necessity of lowering the energy density or speed of treatments. OBJECTIVES: To examine the advantages of pneumatic skin flattening (PSF) with negative pressure: (i) for the reduction or elimination of pain, without chilling the skin, during hair removal with high energy density IPLs and pulsed lasers; (ii) for the reduction of post-treatment erythema; and (iii) for the enhancement of hair removal. MATERIALS AND METHODS: We have removed hair from large areas such as legs and backs with a high-energy (42 J/cm2) pulsed diode laser and an IPL (15-20 J/cm2). Room temperature gel was applied to the skin before treatment. In all cases but one, skin was not chilled by external cooling devices. We utilized a vacuum chamber and a transparent sapphire window to generate deep negative pressure in the treatment site and flatten the skin against the window. The level of applied vacuum was in the 200-600 mmHg range. We have compared the level of pain (I-V according to a modified McGill Pain Questionnaire) and the efficacy of hair removal on a total of 40 treatment sites The results of the vacuum-assisted treatment sites were compared with the results on adjacent control areas, obtained without the application of vacuum. Post-treatment erythema was also compared. RESULTS AND CONCLUSIONS: PSF significantly reduces pain in all patients, even when higher (+30%) treatment energy levels are applied. Skin is well protected thermally by the conductive sapphire window. Post erythema and edema is considerably reduced, as well. Hair removal efficacy is preserved or enhanced. Treatment is faster and is uninterrupted by pain, without the necessity to apply topical anesthetic over a large area. Blood expulsion resulting from flattening the skin has also enabled the treatment of thin hair in light-skinned patients, using yellow and green wavelengths (540 nm cut-off filter) and short pulse durations with a higher efficacy than with the 650 nm cut-off filter.

Optimal treatments for hyperpigmentation.

The current treatment of hyperpigmentation relies on multiple modalities to achieve satisfactory cosmetic results. Patients are savvy consumers who often present to physicians asking about the latest treatments and breakthroughs. By combining topical bleaching agents, chemical peels, laser therapy, and adequate photo-protection, many pigmentary disorders can be successfully treated. A review of recent trials and new technologies will be discussed.