Confocal examination of nonmelanoma cancers in thick skin excisions to potentially guide mohs micrographic surgery without frozen histopathology.

Precise removal of nonmelanoma cancers with minimum damage to the surrounding normal skin is guided by the histopathologic examination of each excision during Mohs micrographic surgery. The preparation of frozen histopathology sections typically requires 20-45 min per excision. Real-time confocal reflectance microscopy offers an imaging method potentially to avoid frozen histopathology and prepare noninvasive (optical) sections within 5 min. Skin excisions ( approximately 1 mm thick) from Mohs surgeries were washed with 5% acetic acid and imaged with a confocal cross-polarized microscope. The confocal images were compared with the corresponding histopathology. Acetic acid causes compaction of chromatin that increases light back-scatter and makes the nuclei bright and easily detectable. Crossed-polarization strongly enhances the contrast of the nuclei because the compacted chromatin depolarizes the illumination light whereas the surrounding cytoplasm and normal dermis does not. Fast low-resolution examination of cancer lobules in wide fields of view followed by high-resolution inspection of nuclear morphology in small fields of view is possible; this is similar to the procedure for examining histopathology sections. Both the Mohs surgeon and the patient will potentially save several hours per day in the operating room. Fast confocal reflectance microscopic examination of excisions (of any thickness) may improve the management of surgical pathology and guide microsurgery of any human tissue.

Rapid HMB-45 staining in Mohs micrographic surgery for melanoma in situ and invasive melanoma.

BACKGROUND: Accurate interpretation of frozen sections in the treatment of melanoma by Mohs micrographic surgery may be difficult. OBJECTIVE: Our purpose was to review the literature on the role of Mohs micrographic surgery in the treatment of melanoma and to demonstrate the added benefits of using rapid HMB-45 staining in Mohs micrographic surgery for the treatment of melanoma. METHODS: Twenty cases of melanoma were included in our study. Histologic diagnosis in each case was made by means of excisional biopsy specimens and permanent sections. Mohs micrographic surgery was performed with 3-mm margins used for each stage. Each Mohs frozen section was stained with HMB-45. In addition, routine frozen sections stained with hematoxylin-eosin were also prepared for comparison. All tissues were also sent for permanent sections. These permanent sections were cut similarly to Mohs-oriented sections because they were sectioned horizontally. Since they were serving as the standard, no staining with HMB-45 was performed on these permanent sections. Further stages with 3-mm margins were taken until tissues stained negative. Frozen sections were compared with permanent sections at each stage of resection. RESULTS: Eleven of the 20 cases stained positive with HMB-45 antibody on the first Mohs stage. These results were consistent with findings on permanent sections. Ten of the 11 cases were cleared by the first stage. One of the 11 cases required 3 stages because margins were not cleared and the specimens stained HMB-45 positive. However, permanent sections in this case revealed no tumor in the second stage. Nine of 20 cases did not stain with HMB-45 on the first layer of Mohs excision. This was consistent with findings on permanent sections. CONCLUSION: HMB-45 staining serves as a rapid technique to aid in the interpretation of frozen sections during Mohs micrographic surgery in the treatment of melanoma.

In vivo fluorescence spectroscopy of nonmelanoma skin cancer.

In vivo and ex vivo tissue autofluorescence (endogenous fluorescence) have been employed to investigate the presence of markers that could be used to detect tissue abnormalities and/or malignancies. We present a study of the autofluorescence of normal skin and tumor in vivo, conducted on 18 patients diagnosed with nonmelanoma skin cancers (NMSC). We observed that both in basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) the endogenous fluorescence due to tryptophan residues was more intense in tumor than in normal tissue, probably due to epidermal thickening and/or hyperproliferation. Conversely, the fluorescence intensity associated with dermal collagen crosslinks was generally lower in tumors than in the surrounding normal tissue, probably because of degradation or erosion of the connective tissue due to enzymes released by the tumor. The decrease of collagen fluorescence in the connective tissue adjacent to the tumor loci was validated by fluorescence imaging on fresh-frozen tissue sections obtained from 33 NMSC excised specimens. Our results suggest that endogenous fluorescence of NMSC, excited in the UV region of the spectrum, has characteristic features that are different from normal tissue and may be exploited for noninvasive diagnostics and for the detection of tumor margins.

Occlusive dressing versus oxygen mist therapy following CO2 laser resurfacing.

BACKGROUND: Oxygen is an essential element for collagen synthesis and reepithelialization. The use of topical oxygen after CO2 laser resurfacing has not been studied. OBJECTIVE: To compare the rate and quality of healing in wounds treated with an oxygen mist to those treated with occlusive dressing following CO2 laser resurfacing. METHODS: Three patients underwent CO2 laser resurfacing to each half of the face 3 weeks apart. Postoperatively, half of the face was treated with an oxygen mist protocol for 5 days, while the other half was treated with occlusive dressing for 4 days. RESULTS: At postoperative day 5, significantly less crusting was observed on the half of the face treated with the oxygen mist protocol (p < 0.05). CONCLUSION: The oxygen mist postoperative protocol may offer patients similar overall healing rates and significantly less crusting compared to occlusive dressing.

Treatment of facial rhytids with a nonablative laser: a clinical and histologic study.

BACKGROUND: Current facial resurfacing modalities (laser, chemical peels, and dermabrasion) remove the epidermis and thus cause open wounds which carry significant risks and extended recovery periods. The nonablative laser is a novel Nd:YAG system designed to alleviate facial rhytids without injuring the epidermis. This new modality may offer patients rhytid removal without the risk seen in currently used resurfacing techniques. OBJECTIVE: To describe a novel nonablative laser system and assess its safety profile and efficacy. METHODS: Ten patients received laser treatments of their periocular rhytids and postauricular skin. Clinical variables (rhytid severity, hyperpigmentation, hypopigmentation, scarring, and level of discomfort) were assessed at 1 and 3 months posttreatment. Postauricular skin biopsies were taken both pre- and posttreatment for histologic analysis. RESULTS: Patient discomfort was minimal. Three months posttreatment, 4 of 10 patients showed a one-point improvement in periocular rhytid severity when judged on a six-point scale. The results were not statistically significant. Biopsy analysis showed a small posttreatment increase in the amount of dermal collagen in three patients. A small decrease in collagen was noted in one patient. Three patients also showed a small posttreatment increase in the degree homogenization of dermal collagen. No change from baseline was noted in other assessed histologic parameters. Complications observed included hyperpigmentation in three patients and pitted scarring in three patients. CONCLUSIONS: The nonablative laser gave clinically subtle and statistically insignificant improvement in rhytid severity. Unfortunately its use was associated with complications that included hyperpigmentation and scarring. This technology may eventually offer patients a new resurfacing option, but its efficacy and complication rate must be improved first.

A clinical study of hair removal using the long-pulsed ruby laser.

BACKGROUND: Laser hair removal is rapidly becoming a widely used modality. Clinical studies are needed to assess these hair removal systems. The long-pulsed ruby laser is one such modality for the removal of unwanted hair. OBJECTIVES: To evaluate the efficacy of the long-pulsed ruby laser (694 nm, 3-msec pulsewidth, 7- or 10-mm spot size) in removing unwanted hair, and to provide treatment guidelines for the proper utilization of this laser system. METHODS: Forty-eight areas of unwanted facial and body hair from 25 patients with blonde, brown, or black hair were treated with the long-pulsed ruby laser at fluences between 10 and 40 J/cm2. Hair regrowth was measured at 4 weeks after the first treatment, 4 weeks after the second treatment, 4 weeks after the third treatment, and 16 weeks after the third treatment by counting the number of terminal hairs compared with baseline pretreatment values. All complications and treatment outcomes were documented. RESULTS: The mean percent of regrowth after the first treatment was 65.5%, 41% after the second treatment, and 34% after the third treatment. Overall, regardless of skin type or targeted body region, patients who underwent three treatment sessions demonstrated an average 35% regrowth in terminal hair count compared with baseline pretreatment values 6 months after initial therapy. CONCLUSION: Long-pulsed ruby laser treatment resulted in significant hair growth delay in most cases. Repeated laser treatments produced an increased number of vellus hairs, an increase in growth delay, and a decreased percentage of hair regrowth.

Granular cell tumor of uncertain malignant potential.

Granular cell tumor is an uncommon soft-tissue tumor that is usually benign and readily treated with complete resection. Malignant granular cell tumors are perhaps the rarest of all soft-tissue tumors, and they commonly metastasize to regional lymph nodes and the lungs. We present a case of granular cell tumor that exhibited both gross and microscopic features suggestive of malignancy without evidence of metastasis through a relatively short 16 months of follow-up and review the literature pertaining to granular cell tumors of uncertain malignant potential.

External ultrasonic tumescent liposuction. A preliminary study.

BACKGROUND: External ultrasonic tumescent liposuction represents a new application of ultrasound energy to the standard tumescent liposuction procedure. Hoping to retain the in vivo properties of ultrasonic delivery while avoiding the growing number of invasive complications, external ultrasonic tumescent liposuction is a new technique with the potential of improving traditional tumescent liposuction therapy. OBJECTIVE: The purpose of this preliminary study was to evaluate the role of external ultrasonic tumescent liposuction as an adjunct to traditional tumescent liposuction. METHODS: Ten patients underwent standard tumescent liposuction with the addition of 10 minutes of preoperative ultrasound therapy applied to one-half of their targeted treatment regions. Both objective and subjective parameters were assessed during the subsequent side-by-side evaluations. RESULTS: Six of the 10 cases had a measurable increase in the amount of supernatant fat extracted per unit of aspirate volume from those regions pretreated with ultrasound energy. In five of the 10 cases, the operating physician noted slightly easier cannula maneuverability through adipose tissue on the ultrasound side. Roughly half of the patients had an improved postoperative course, with less swelling/edema, less bruising or ecchymoses, more skin retraction, and less postoperative pain/discomfort. CONCLUSION: The favorable results of this preliminary study warrant further investigation and research into external ultrasonic tumescent liposuction as an adjunct to the traditional tumescent liposuction procedure.

The use of antibiotics in surgical treatment of the colon.

The judicious use of antibiotics seems to be indicated in operations upon the colon, although these procedures were performed with similar morbidity rates in the 1930's without the use of antibiotics. The results of recent studies indicate that systemic antibiotics administered preoperatively and for a short perioperative interval is the preferred method of treatment because it has little effect on intestinal colonization. Surgical principles have not materially changed over the years and antibiotics are not indicated merely to cover breaks in the operative technique. One must always be cautious of possible untoward reactions and complications. This may be another example of the principle--less is more.

Operations on the colon without preoperative oral antibiotic therapy.

The ideal preparation of the intestine prior to elective colonic resection has been a controversial subject. With the development of new and more effective antibiotics, many modalities of intestinal preparation preoperatively have been used in an effort to reduce the number of infectious complications. Mechanical cleansing of the intestine, when accompanied by perioperative parenteral antibiotics, is adequate preparation prior to resection of the intestine. One hundred consecutive operations upon the colon by one surgeon were the subject of this retrospective study. Approximately 70 per cent of the operations were for carcinoma and the remainder for inflammatory disease. Preparation consisted of the administration of cathartics and saline solution enemas combined with a liquid diet for 48 hours prior to operation. Perioperative parenteral antibiotic therapy was given for 48 to 72 hours or as long as intravenous fluids were administered. All anastomoses were the open, two layer type, using nonabsorbable suture material. All abdominal incisions were closed primarily. There were no operative deaths, anastomotic leaks, intra-abdominal abscesses or fistulas. There were six instances of wound infection. Our results with this type of management compare favorably with those of other surgeons using various modes of preoperative oral antibiotic therapy and suggest that oral preoperative antibiotic therapy may not be necessary in elective operations on the colon.