Delayed-Onset Nodules to Differentially Crosslinked Hyaluronic Acids: Comparative Incidence and Risk Assessment

BACKGROUND

Robust and long-term data on true incidence of delayed-onset nodules and immune tolerance of hyaluronic acid (HA) fillers are lacking.

OBJECTIVE

To characterize the incidence of delayed nodules in Vycross (VYC) HA fillers compared with previously reported FDA and non-FDA data of all HA fillers.

METHODS AND MATERIALS

The incidence of delayed nodules in all patients who had received VYC fillers in a 12-month period was assessed through a retrospective chart review. Nodule incidence for currently approved nonanimal-stabilized hyaluronic acid (NASHA) fillers was assessed using the FDA Summary of Safety and Effectiveness Data.

RESULTS

Overall, 1,029 patients received 1,250 VYC filler treatments. Five patients developed delayed nodules to VOB, with an incidence of 1.0% per patient and 0.8% per syringe. No nodules were observed in patients who received VLR or VOL. All nodules were treated successfully using a combination of intralesional triamcinolone and hyaluronidase. Compared with other currently approved NASHA fillers, VOB is associated with a higher incidence of nodule formation.

CONCLUSION

The introduction of VYC HAs has introduced a new variable that may be changing the immune tolerance of these substances, resulting in a higher incidence of delayed nodules than previously expected.

Setting appropriate pain expectations: Lessons learned from a clinical trial

OBJECTIVE

This retrospective study compares subject-reported pain levels and expectations set forth by industry and treating physicians during a clinical trial of an energy based device. The physiologic and emotional aspects of pain expectations are discussed and recommendations are made for strategic patient counseling.

MATERIALS AND METHODS

Average and mode pain scores were collected from the records of a previously conducted clinical trial investigating a radiofrequency microneedling device at three different settings. The trial protocol and device manual were reviewed to ascertain language regarding procedural pain. Treating physicians were asked how they learned about procedural pain and how they described it to subjects. Subject-reported pain scores and verbal pain descriptors from the device manual and trial protocol were translated onto validated pain scales, the Numerical Rating Scale (NRS), and the Verbal Rating Scale (VRS), for comparison.

RESULTS

A total of 90 procedural pain scores were collected from 30 subject charts. The average procedural pain scores for three different device settings were 5.3, 6.7, and 4.6 out of 10 and the mode pain score was 6 out of 10. This translated to a 5-6 and 7-8 on the NRS, respectively and classification as "painful but bearable" and "considerable pain" on the VRS. Industry sourced pain levels translated to a 2-4 on the NRS and classification as "little pain" on the VRS.

CONCLUSION

Subject-reported pain scores were higher than those set forth by industry materials and personnel. Physicians should be wary of manufacturer materials or anecdotal evidence that might mislead patients and cause undue physiological or emotional stress. Lasers Surg. Med. 9999:XX-XX, 2018. © 2018 Wiley Periodicals, Inc.

Demographic and Tumor Characteristics of Patients Younger Than 50 Years With Nonmelanoma Skin Cancer Referred for Mohs Micrographic Surgery

BACKGROUND

An increase in nonmelanoma skin cancer (NMSC) in younger patients has been reported. Many are treated with Mohs micrographic surgery (MMS).

OBJECTIVE

Investigate patient and tumor characteristics in patients less than 50 years undergoing MMS for NMSC at a large, referral-based practice.

METHODS & MATERIALS

Retrospective chart review of 1,332 tumors occurring in 1,018 consecutive patients over a five-year period.

RESULTS

81.7% of tumors were BCC and 55.3% occurred in women. Patients less than 30 years were more likely to be female (P equals 0.016) and women were more likely to have BCC (P equals 0.010). SCCs were more likely with increasing age (P less than 0.001). Of all tumors, 3.6% were recurrent, 2.7% had diameters ≥ 2 centimeters, and 5.5% of all BCCs had a high-risk histologic subtype. Women were more than twice as likely as men to be referred to plastic surgery for repair (P equals 0.020).

CONCLUSION

Patients < 50 years with NMSC may represent a growing population referred for MMS, especially young women with BCC. High-risk tumor features were rare among young patients, and female gender was associated with an increased rate of referral for repair by a plastics subspecialty. Study was performed at the Laser & Skin Surgery Center of New York.

IRB STATUS

Approved by Essex Institutional Review Board, Protocol #MOHS40-65 <p><em>J Drugs Dermatol. 2018;17(5):499-505.</em></p>.

V-Y Advancement Flap for Defects of the Lid-Cheek Junction

We report a series of 10 patients who underwent inferolaterally based V-Y advancement flaps for reconstruction of defects involving the lower eyelid and infraorbital cheek junction. Defects ranged from 1.7 to 2.9 cm in largest diameter, and patients ranged from 59 to 84 years of age. All patients had excellent functional and cosmetic outcomes without subsequent surgical or laser revision. There were no instances of flap necrosis, hematoma, or ectropion. Vertically oriented V-Y flaps are often underused in this setting largely due to the perceived increase risk of ectropion. We describe a modification of the flap with lateral orientation that both diminishes the downward tension vector, which threatens ectropion, and conceals incision scars within resting tension lines, providing superior functional and aesthetic outcomes. Our series demonstrates that a properly designed and well-executed inferiorly based V-Y advancement flap can be used as a safe reconstructive modality for defects involving the lid–cheek junction.

Simplifying Forehead Reconstruction: A Review of More Than 200 Cases

The forehead is a unique facial region with distinct boundaries and variability in shape from patient to patient. When reconstructing the forehead, it is critical to take into account the regional boundaries as their distortion may result in noticeable facial asymmetry. We propose subdividing the forehead into newly defined zones and put forth a rational algorithm for forehead repair based on these divisions. We retrospectively reviewed a single surgeon's (F. H. S.) experience with Mohs excision and immediate reconstruction of the forehead over a 3-year period. A total of 227 consecutive post-Mohs forehead reconstructions were identified, and the reconstructive technique for a given defect size and location and postoperative complications were recorded. The average patient age was 69 years and 114 (50%) patients were female. Reconstructive techniques varied based on defect size and location within the five distinct forehead zones. Primary closure was the favored technique when appropriate, with variation in orientation based on forehead zone. Modified Burow's advancement flap was the most commonly utilized reconstruction for defects of midlateral forehead and suprabrow area, accounting for 51.7 and 62.5% of repairs, respectively. Other techniques included A-to-T flaps, rotation flaps, and full-thickness skin grafting. Using our defined zones, most common repair techniques, and final outcomes, a reconstructive algorithm for post-Mohs excisions on the forehead was derived. Consideration of the five distinct forehead zones and application of an algorithm to guide technique selection for post-Mohs forehead defect repair can lead to consistent results.

Chronic actinic dermatitis occurring in an adult with atopic dermatitis

Chronic actinic dermatitis (CAD) is a photosensitivity disorder that is characterized by a persistent eczematous eruption in sun-exposed sites. The hallmark of CAD is a reduced minimal erythema dose (MED) to ultraviolet B (UVB), ultraviolet A (UVA), and/or to visible light, which makes phototesting the essential diagnostic investigation. The uncommon subgroup of patients with atopic dermatitis (AD) that are affected by CAD has primarily been described in young patients in the United Kingdom. We present an atopic adult women with CAD who was diagnosed years after symptoms began. We believe it is important that dermatologists perform phototests on AD patients with features of a photoaggravated dermatitis in order to avoid delay in diagnosis of a true photosensitivity condition and provide appropriate management.

Extragenital bullous lichen sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory dermatosis that is characterized by pruritic, white, atrophic plaques that classically affect the anogenital region of postmenopausal women. Extragenital involvement also may occur with several reported morphologic variants. Extragenital bullous LS is a rare variant, which presents as flaccid bullae that favor the trunk and proximal aspects of the extremities. The treatment of extragenital bullous LS is similar to that of genital LS. However, extragenital LS is often less responsive and may present a therapeutic challenge. We describe a 65-year-old woman with a two-year history of vulvar and extragenital LS, who developed a bullous eruption within a pre-existing patch of lichen sclerosis on the breast. We review the clinical and histopathologic features of extragenital bullous LS and discuss current treatment options, which include those for recalcitrant cases.

Modification of Burow's advancement flap: avoiding the secondary triangle

IMPORTANCE

Burow's advancement flap is a frequently used and versatile flap in cutaneous surgery because it provides an excellent method for repair of large defects in proximity to free margins. Its execution typically requires excision of 2 standing cones, which increases scarring and flap size. We describe a modification of this flap achieved with a simple, reproducible suturing technique that eliminates one of the standing cones and both minimizes suture lines and optimizes cosmesis at a variety of surgical sites.

OBSERVATIONS

We describe 5 cases in which we successfully used our modified Burow's advancement flap to repair Mohs surgical defects in various cosmetic subunits of the face.

CONCLUSIONS AND RELEVANCE

A simple suturing technique is proposed that can eliminate the need for a secondary triangle in Burow's advancement flaps. By implementing the "rule of halves" in suturing wound edges of unequal length, one can evenly distribute redundant tissue along the length of the flap, which avoids additional incisions, minimizes scarring, and allows for repair within a single cosmetic subunit.

LEVEL OF EVIDENCE

NA.