Treatment of perioral rhytides: a comparison of dermabrasion and superpulsed carbon dioxide laser.

OBJECTIVE: To directly compare the cosmetic outcome and adverse effects of dermabrasion and superpulsed carbon dioxide laser for the treatment of perioral rhytides. DESIGN: Subjects were randomly assigned to receive treatment with carbon dioxide laser resurfacing to one side of the perioral area and dermabrasion to the other side in a prospective, comparative clinical study. The duration of follow-up by blinded observers was 4 months. SETTING: University hospital-based dermatologic surgery clinic. PATIENTS: Fifteen healthy fair-skinned volunteers with moderate to severe perioral rhytides and no history of prior cosmetic surgical procedures to the same anatomic area. INTERVENTIONS: One half of the perioral area was treated with the LX-20SP Novapulse carbon dioxide laser (Luxar Corp, Bothell, Wash), and the other half was treated with dermabrasion using either a hand engine-driven diamond fraise or a medium-grade drywall sanding screen (3M Corp, St Paul, Minn). MAIN OUTCOME MEASURES: Improvement in rhytides, patients' subjective reports of postoperative pain, time to reepithelialization, degree of postoperative crusting, and duration of postoperative erythema were observed for both methods. Standardized scoring systems were used to quantify outcome measures. Paired t tests were used for statistical comparisons of the 2 resurfacing methods. RESULTS: The difference in rhytide scores for the 2 methods was not statistically significant (P= .35) at 4 months. Less postoperative crusting and more rapid reepithelialization were noted with the dermabrasion-treated skin. Postoperative erythema was of longer duration on laser-treated skin. Patients reported less pain with dermabrasion treatment. Subtle differences that were difficult to quantify were also noted between the methods. CONCLUSIONS: Both dermabrasion and carbon dioxide laser resurfacing are effective in the treatment of perioral rhytides. Both methods have unique advantages and disadvantages.

Incidence of residual basal cell carcinoma in patients who appear tumor free after biopsy.

BACKGROUND: Basal cell carcinoma (BCC) biopsy sites often heal with no clinical evidence of residual tumor. OBJECTIVE: The purpose of our study is to determine whether such patients require further therapy. If biopsies can be curative, health care costs can be reduced by avoiding unnecessary surgery. METHODS: We prospectively evaluated 41 consecutive subjects with 42 biopsy-confirmed BCCs who appeared disease free. Each biopsy site was excised and processed by the Mohs micrographic technique. The tissue block was sectioned horizontally at 30-micrometer intervals until exhausted. Sections were stained and examined microscopically for residual tumor. RESULTS: Tumor was identified in 28 (66%) of 42 cases. No statistically significant relationship was found between the presence or absence of residual tumor and the following variables: age, sex, tumor location, biopsy technique, histopathologic subtype, scar size, time from biopsy to surgery, and extent of inflammation in histologic sections. CONCLUSION: Our data suggest that patients with small (< 1 cm) primary BCCs that appear to be completely removed after a biopsy procedure are at risk for recurrence without further treatment.

Acute excisional wounds treated with a tissue-engineered skin (Apligraf).

BACKGROUND: Tissue-engineered products are usually composed of living cells and their supporting matrices that have been grown in vitro, using a combination of engineering and life sciences principles. Apligraf is a bilayered product composed of neonatal-derived dermal fibroblasts and keratinocytes, and Type I bovine collagen. OBJECTIVE: To evaluate in a prospective, multicentered open study, the effects of tissue therapy with a tissue-engineered skin (Apligraf) with partial or full-thickness excisional wounds. METHODS: One hundred and seven patients participated in this study. The tissue-engineered skin was applied once, immediately after excisional surgery, usually for skin cancer, and patients were followed for up to one year. RESULTS: The safety results were impressive, with no clinical or laboratory evidence of rejection. Clinically, graft persistence was good to excellent in 77 of 105 (73.3%) of patients at one week, falling to 56.6% and 53.6% at two weeks and one month respectively. CONCLUSION: To date, this is the largest experience with a tissue-engineered skin product in acute wounds, and this study suggests that tissue therapy may be safe and useful.

Botulinum A toxin for glabellar wrinkles. Dose and response.

BACKGROUND: Botulinum A exotoxin injection is a well-established method for treatment of glabellar frown lines, crow's feet, and horizontal furrows of the forehead. However, there is no consensus as to the optimal dosage per injection site or the concentration of injectate to be used. OBJECTIVE: The purpose of this study was to determine the minimal effective dose per injection site to be used as well as the effect of concentration in response to treatment. RESULTS: A total of 46 subjects were divided into ten groups and injected with escalating doses and concentrations of botulinum toxin. The response and longevity of treatment were then followed on a monthly basis. A dose between 2.5-4 U per injection site (12.5-20 U total) was determined to be an effective starting dose, with a duration of 2-5 months (median 14 weeks). CONCLUSIONS: There was no statistically significant difference in safety or efficacy for concentrations ranging from 50 to 200 U/ml of botulinum toxin.

A side-by-side comparison of carbon dioxide resurfacing lasers for the treatment of rhytides.

BACKGROUND: The use of cutaneous resurfacing lasers to treat rhytides is widely accepted. Several carbon dioxide lasers, many using fundamentally different technologies, are available. OBJECTIVE: The purpose of this study was to compare the results obtained and side effects after treating rhytides with 3 different carbon dioxide resurfacing lasers. METHODS: We performed a randomized, blinded, prospective study wherein 16 subjects had either periorbital or perioral rhytides resurfaced with 1 of 3 carbon dioxide lasers on either side of the face. RESULTS: We were unable to demonstrate any significant differences in improvement in rhytides, patient satisfaction, posttreatment erythema, or other side effects. CONCLUSION: Our results suggest that operator technique and patient selection are more important factors than laser type with respect to outcome.

Burn scar carcinoma. Diagnosis and management.

BACKGROUND: The term Marjolin ulcer is now synonymous with malignant transformation of chronic ulcers, sinus tracts, and burn scars. OBJECTIVE: To illustrate the importance of incisional or excisional biopsies in cases of suspected burn scar carcinoma. METHODS: Case report and review of the literature. RESULTS: Multiple punch biopsies were negative while a complete excision revealed the diagnosis of squamous cell carcinoma. CONCLUSION: Because of the focal nature of malignant change in burn scars, incisional or excisional biopsy should be performed.

An estimate of the annual direct cost of treating cutaneous melanoma.

BACKGROUND: Although the survival benefits of early stage melanoma have been clearly documented, the potential economic impact of early versus late stage disease has not been assessed. OBJECTIVE: Our purpose was to estimate the annual direct cost of diagnosing and treating melanoma, based on the number of projected cases of melanoma entering each stage in 1997. METHODS: A model was constructed with assumptions derived from the literature and clinical experience at the Massachusetts General Hospital Melanoma Center and the Boston University Medical Center. Cost estimates were based on 1997 Boston area Medicare reimbursements. RESULTS: The annual direct cost of treating newly diagnosed melanoma in 1997 was estimated to be $563 million. Stage I and II disease each comprised about 5% of the total cost; stage III and stage IV disease consumed 34% and 55% of the total cost, respectively. About 90% of the total annual direct cost of treating melanoma in 1997 was attributable to less than 20% of patients (those patients with advanced disease, that is, stage III and stage IV). CONCLUSION: In addition to the potential survival advantages, aggressive primary prevention through sun protection and intensive screening to enhance earlier detection should reduce the economic burden of melanoma care.

New approaches to treating advanced melanoma: adjuvant treatment of high-risk primary melanoma and boron neutron capture therapy.

Malignant melanoma is associated with an excellent long-term prognosis when detected and treated at an early stage. Surgery alone is sufficient for patients with thin melanomas. Patients with thicker tumors, who are at higher risk for metastasis, may benefit from additional therapy beyond surgical removal of the tumor. Adjuvant therapies are designed to reduce the risk of melanoma recurrence. In particular, the immunotherapies, which boost the host's immune response to the cancer, are proving to be valuable adjuncts to surgery. Once melanoma has metastasized to a visceral organ, the prognosis is poor. Metastatic melanoma has a poor response to most conventional treatments. Boron neutron capture therapy is a novel approach to cancer management. It is a binary therapy combining low energy, nonionizing neutron irradiation with a stable isotope of naturally occurring boron avidly absorbed by the tumor. The combined approach currently under investigation results in highly selective tumor destruction.

Accelerated Early Growth of Rice at Elevated CO2 (Is It Related to Developmental Changes in the Shoot Apex?).

The influence of elevated CO2 on the development of the shoot apex and on subsequent vegetative growth and grain yield was investigated using rice (Oryza sativa L. cv Jarrah) grown in flooded soil at either 350 or 700 [mu]L CO2 L-1. At 8 d after planting (DAP), elevated CO2 increased the height and diameter of the apical dome and lengths of leaf primordia and tiller buds but had no effect on their numbers. By 16 DAP, there were five tiller buds in the apex at 700 [mu]L CO2 L-1 compared with only three tiller buds at 350 [mu]L CO2 L-1. These changes in development of the shoot apex at high CO2 were forerunners to faster development of the vegetative shoot at elevated CO2 between 11 and 26 DAP as evidenced by increases in the relative growth rates of the shoot and tillers. Accelerated development at high CO2 was responsible for the 42% increase in tiller number at the maximum tillering stage and the 57% enhancement of grain yield at the final harvest. The link between high CO2 effects on development during the first 15 DAP and final tiller number and grain yield was demonstrated by delaying exposure of plants to high CO2 for 15 d. The delay totally inhibited the tillering response to high CO2, and the increase in grain yield of 20% arose from a greater number of grains per panicle. Consequently, it can be concluded that accelerated development in the shoot apex early in development is crucial for obtaining maximum increases in grain yield at elevated atmospheric CO2 concentrations.

Management of stage I malignant melanoma.

BACKGROUND: Because of the rising incidence of melanoma, dermatologists are increasingly responsible for diagnosing and managing patients with this cutaneous malignancy. Fortunately, with the increased awareness and emphasis on early detection, most patients will present with tumors that have not yet spread beyond their primary focus in the skin (ie, Stage I). Dermatologists must, therefore, be fully versed in the diagnosis and management of Stage I melanoma. OBJECTIVE: This review article focuses on the most important issues related to the diagnosis and management of Stage I melanoma. An emphasis will be placed on surgical management. RESULTS: The mainstay of therapy for most patients with Stage I melanoma is surgery. The important principles of diagnostic biopsy and surgical excision will be discussed. There are several additional modalities that may be useful as adjuvants to surgical therapy or as primary therapy in situations when surgery is not feasible. Those include elective lymph node dissection, hyperthermic isolation limb perfusion, radiotherapy, cryotherapy, chemotherapy, and immunotherapy. These will all be reviewed. CONCLUSIONS: With a thorough understanding of the important principles and controversies related to the management of Stage I melanoma, dermatologists can effectively manage the growing number of patients with this malignancy.

Skin growths in the aged. Treatment considerations.

Skin disorders are very common among elderly people. All physicians who care for this population should possess the ability to recognise common benign growths. Primary care physicians should also have the ability to recognise premalignant and malignant lesions, so that early diagnosis and treatment is possible. It is puzzling that the organ system most amenable to examination is so often overlooked in routine examinations. By simply taking the time to perform a skin examination, morbidity and mortality can be decreased. Through improvements in pharmacotherapy, particularly the development of more effective sunscreens, it may eventually be possible to markedly reduce the development of many benign and malignant skin lesions.

Wound healing and aging.

Age-related differences in wound healing have been clearly documented. Although the elderly can heal most wounds, they have a slower healing process, and all phases of wound healing are affected. The inflammatory response is decreased or delayed, as is the proliferative response. Remodeling occurs, but to a lesser degree, and the collagen formed is qualitatively different. Diseases that affect wound healing are more prevalent in the elderly and have a greater adverse effect on healing than in young adults. Thus, particularly in the elderly, concomitant medical problems should be treated vigorously to allow for maximum healing. Recent trials of novel therapies to enhance wound healing suggest, however, that much can be done to improve the prognosis of elderly patients with risk factors known to adversely affect wound healing.

Klippel-Trenaunay syndrome and cutaneous carcinomas.

A patient with Klippel-Trenaunay syndrome who developed basal cell and squamous cell carcinomas on the limb affected by the vascular malformation, is reported. The nature of this association is discussed.

Melanoma update. Second primary melanoma.

BACKGROUND: Second primary melanoma is not a rare phenomenon. It occurs in at least 3 to 6% of melanoma patients and up to a third of individuals from melanoma-prone families. OBJECTIVE: To review the clinical and histologic features of multiple primary melanoma. A schema for follow-up of these patients is presented. CONCLUSIONS: As the incidence of melanoma continues to rise, we will be faced with an ever increasing number of patients who have survived their tumor. These patients are at risk for subsequent melanomas. This article reviews the literature regarding multiple primary melanoma, and discusses patient management.

Surgical management of stage I malignant melanoma.

In part because of the increased public awareness regarding skin cancer, patients are presenting to their physician with thinner melanomas. Many lesions are now found in the in situ phase. The vast majority of melanomas referred to or diagnosed in the Skin Oncology Program at Boston University are less than 2 mm in thickness. In the increasingly uncommon situation of thicker lesions, the standard 3-cm margin excision continues to be performed until clinical trials indicate that lesser margins are safe. Definitive surgery is only part of the physician's responsibility in caring for the patient with melanoma. These patients need to be followed up on a regular basis for life, because of the long latent period for risk of metastasis and to facilitate early detection of new primary melanomas.

Nonhealing leg ulcers: a manifestation of basal cell carcinoma.

Seven patients with basal cell carcinomas presenting as nonhealing ulcers are reported. The importance of considering malignancy and taking biopsy specimens of leg ulcers that fail to respond to treatment is emphasized.