Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Amelanotic melanoma: a detailed morphologic analysis with clinicopathologic correlation of 75 cases.

Amelanotic melanoma can have a varied appearance both clinically and microscopically. Here, we present our experiences with 75 cases of amelanotic melanoma defined clinically as a non-pigmented lesion and histopathologically as a tumor lacking significant melanization. We evaluated microscopic features such as morphology, mitotic count, nuclear atypia and presence of solar elastosis. Our amelanotic melanomas exhibited the following morphology: epitheloid (72%), spindled (18.7%) or desmoplastic (5.3%). In addition, we obtained patient information and clinical presentations on most of the cases (74/75; 98.7%) and follow-up data on 40% (30/75) of the cases. The majority of amelanotic melanomas in men were found on the trunk (13/45; 29%), head and neck (12/45; 26.7%), and lower limb (13/45; 29%) and in women were found on the lower limb (12/30; 40%), upper limb (10/30; 33.3%) and head and neck (6/30; 20%). In addition, we found that an increase in mitotic index correlated with worse survival (p < 0.026), whereas there were no differences in survival for other pathological features, such as nuclear atypia or solar elastosis. Furthermore, in cases with available tissue, all amelanotic melanoma expressed microphthalmia-associated transcription factor and tyrosinase, suggesting that the tumor cells retained melanocytic lineage and an enzyme in melanin formation, respectively. As the occurrence of amelanotic melanoma and the expression melanoma markers were similar to pigmented melanoma, we favor that amelanotic melanoma represents a subtype of melanoma rather than poorly differentiated or de-differentiated melanoma.

Rapid preparation of high-quality frozen sections using a membrane and vacuum system embedding machine.

BACKGROUND: A wide variety of embedding techniques have been employed to process frozen sections for Mohs micrographic surgery. Prospective data comparing different techniques are lacking. OBJECTIVE: The purpose of this study was to compare tissue processing times and slide quality using the three embedding techniques. METHODS: Seventy-five consecutive Mohs surgery tissue specimens, measuring 1 cm in diameter, were prospectively randomized to processing with the CryoHist, the Cryocup, or the Miami Special. Tissue preparation times were recorded, and slide quality was evaluated. Tissue specimen preparation was standardized to exclude the use of relaxing incisions or other tissue manipulations. In a separate evaluation, slide quality was retrospectively evaluated for 50 large specimens (>2.5 cm) processed with the CryoHist machine. RESULTS: The mean tissue processing time was 11.4 minutes using the CryoHist, 12.9 minutes using the Cryocup, and 12.6 minutes using the Miami Special. Slide quality, using epidermal edge as a primary end point, was superior with the CryoHist compared to the other methods. For large (>2.5 cm) en bloc Mohs specimens processed using the CryoHist, the slide quality was excellent with 92.3% of epidermal edge obtained. CONCLUSIONS: The fully automated CryoHist embedding machine enables high-quality frozen sections to be processed in less time than the Cryocup or the Miami Special. Slide quality is excellent, even for larger specimens.

Second intention healing for intermediate and large postsurgical defects of the lip.

BACKGROUND: The lip plays critical roles in both function and cosmesis. Many options exist for postsurgical reconstruction following excision or Mohs micrographic surgery on the lip. Second intention healing is generally reserved only for superficial and small postsurgical defects of the lip vermilion. METHODS: We sought to evaluate second intention healing of the lip for intermediate and large partial thickness, postsurgical defects through a retrospective review of medical charts in conjunction with telephone interviews. Complication rates, time to reepithelialization, and patient satisfaction were determined for 25 patients who underwent second intention healing on the lip following Mohs micrographic surgery for non-melanoma skin cancer. RESULTS: The majority of patients in the study demonstrated good to excellent cosmetic and functional results with minimal complications. Time to complete reepithelialization averaged 25 days. Patient satisfaction with both the healing process and final cosmetic result was very high. LIMITATIONS: The study is a small retrospective case series. Using patient satisfaction as a primary endpoint, a limiting factor may be recall bias. CONCLUSION: Second intention healing is an effective and satisfactory management strategy for intermediate and large postsurgical defects of the lip vermilion, including those with extension to cutaneous lip and underlying orbicularis muscle.

Perioperative management of von Willebrand disease in dermatologic surgery.

BACKGROUND: Von Willebrand disease (VWD) is the most common inherited bleeding disorder, affecting an estimated 0.1% to 1% of the population. It is caused by a qualitative or quantitative defect of von Willebrand factor. Primary manifestations include intractable mucocutaneous bleeding after surgery or trauma. OBJECTIVE: The objective was to review the pathophysiology and clinical features of VWD and to propose a perioperative management strategy for patients with this condition undergoing dermatologic surgery. METHODS AND MATERIALS: Literature is reviewed. RESULTS: The various types and clinical manifestations of this condition are reviewed, and a perioperative strategy is presented for managing patients with VWD who undergo cutaneous oncologic or cosmetic surgical procedures. CONCLUSIONS: In most cases, dermatologic surgery can be safely performed in patients with VWD. The use of appropriate therapeutic prophylaxis in conjunction with a hematologist is indicated in high-risk, nonelective procedures.

Issues affecting specialty career paths in dermatology.

As the field of medicine changes, physicians deal with ever-increasing challenges and pressures. An overview of broad career paths within the specialty of dermatology is presented and important issues affecting these subspecialty tracks are discussed. These issues include increasing regulatory controls, the medical liability crisis, competitive forces, corporate and global outsourcing threats, managed care, and reimbursement.

A protocol for facial volume restoration with poly-L-lactic acid.

Poly-L-lactic acid is a biodegradable synthetic polymer used in an injectable form for subcutaneous volume restoration. Volumetric correction following subcutaneous and deep dermal injection of poly-L-lactic acid is thought to occur through a foreign body tissue response leading to increased production of fibroblasts and subsequent neocollagenesis. Despite the growing popularity and use of this material, there has been a scarcity of published information describing proper injection technique, and many practitioners remain unfamiliar with its use. Appropriate injection technique is critical since incorrect placement of the material can lead to long-lasting unintended results. We present a protocol for successful injection of poly-L-lactic acid into the submalar and buccal regions.

Treatment of giant keratoacanthoma with intralesional 5-fluorouracil.

Giant keratoacanthomas measure greater than 2 cm and have a predilection for the nose and eyelids. As a result, they often present a significant therapeutic challenge. A 36-year old woman was referred for evaluation of a 4.0 x 4.0 cm giant keratoacanthoma on the nose. The patient was treated with intralesional 5-fluorouracil, and the tumor underwent complete regression leaving a full thickness nasal cleft. The defect was then reconstructed with a paramedian forehead flap with good cosmesis.

Cutaneous malignant melanoma.

Skin cancer has become the most common neoplasm in the United States. With early diagnosis and appropriate management, most skin cancers have an overall 5-year survival rate of 95%. Cutaneous malignant melanoma (CMM), however, has a significantly higher morbidity and mortality, resulting in 65% of all skin cancer deaths. Although the long-term survival rate for patients with metastatic melanoma is only 5%, early detection of CMM carries an excellent prognosis, with surgical excision often being curative. Primary care physicians can play a critical role in reducing morbidity and mortality from CMM by recognizing patients at risk, encouraging the adoption of risk-reducing behaviors, and becoming adept at identifying suspicious lesions.

A case of livedoid vasculopathy in a 22-year-old man.

A 23-year-old man presented with a 3-year history of painful ulcerations and retiform scarring of his lower extremities. Skin biopsy revealed evidence of thrombotic vasculopathy. Livedoid vasculopathy is an uncommon condition presenting as painful lower extremity ulceration and scarring in the form of irregular, ivory-white, stellate plaques. Its pathogenesis is unclear, but it is thought to result from coagulation and fibrinolytic disorders causing occlusion of dermal vessels.

Palmoplantar keratoderma of Sybert.

A 13-year-old boy and a 7-year-old boy, who are brothers, presented with a life-long history of erythema, hyperkeratosis, and desquamation of the hands and feet. Symptoms improved with the use of topical glucocorticoids and keratolytics. PPK of Sybert is characterized by palmoplantar hyperkeratosis with transgrediens, autosomal dominant inheritance, and the absence of associated systemic features.

Sarcoidosis.

A 54-year-old man presented with symmetric, bulbous, nodular enlargement of the nasal tip and alae nasi. At first inspection, the changes appeared to be consistent with rhinophyma, but a biopsy specimen showed noncaseating granulomata that were consistent with sarcoidosis. His laboratory, radiographic, and pulmonary function studies were consistent with systemic involvement.

Epidermal nevus.

A 20-year-old woman presented with an asymptomatic, life-long, verrucous, hyperpigmented plaque on the face and neck that corresponded to the lines of Blaschko. Histopathologic examination shows an epidermal nevus. This nevus presents a challenge in management because of the location and extent of the lesion.

A case of sarcoidosis mimicking rhinophyma.

A 54-year-old man presented with symmetric, bulbous, nodular enlargement of his nasal tip and ala. At first inspection, the changes appeared to be consistent with rhinophyma, but biopsy revealed noncaseating granulomata consistent with sarcoidosis. His laboratory, radiographic, and functional studies were consistent with systemic involvement of his disease.