How to Optimize Epidermal Approximation During Wound Suturing Using a Smartphone Camera

Precise wound approximation during cutaneous suturing is of vital importance for optimal closure and long-term scar outcomes. Utilizing smartphone camera technology as a quality-control checkpoint for objective evaluation allows the dermatologic surgeon to scrutinize the wound edges and refine their surgical technique to improve scar outcomes.

Achieving stomal continence with an ileal pouch and a percutaneous implant

In this study, a soft-tissue-anchored, percutaneous port used as a mechanical continence-preserving valve in reservoir ileo- and urostomies was functionally and morphologically evaluated in eight dogs. During follow-up, the skin failed to attach to the implant, but the intestine inside the stoma port appeared to be attached to the mesh. After reaching adequate reservoir volume, the urostomies were rendered continent by attaching a lid to the implant. The experiments were ended at different time intervals due to implant-related adverse events. In only one case did the histological evaluation reveal integration at both the implant-intestine and implant-skin interfaces, with a low degree of inflammation and the absence of bacterial colonisation. In the remaining cases, integration was not obtained and instead mucosal downgrowth and biofilm formation were observed. The skin-implant junction was characterised by the absence of direct contact between the epidermis and the implant. Varying degrees of epidermal downgrowth, granulation tissue formation, inflammatory cell infiltration and bacterial growth and biofilm formation were prominent findings. In contrast, the subcutaneously located anchor part of the titanium port was well integrated and encapsulated by fibrous tissue. These results demonstrate the opportunity to achieve integration between a soft-tissue-anchored titanium port, skin and intestine. However, predictable long-term function could not be achieved in these animal models due to implant- and non-implant-related adverse events. Unless barriers at both the implant-skin and implant-intestine junctions are created, epidermal and mucosal downward migration and biofilm formation will jeopardise implant performance.

#15 Versus #15c Scalpel Blades for Skin Incisions: Accuracy With and Without Magnification

BACKGROUND

Use of a #15 blade is the most popular way for making skin incisions in dermatology. For finer and more accurate incisions, a #15c blade can be used. However, there is no evidence that demonstrates the superiority of the #15c blade over the #15 blade.

OBJECTIVE

This study aimed to compare the skin incisions made with a #15 blade and #15c blade using varied magnifications.

METHODS AND MATERIALS

Twenty fresh chicken thighs with intact skin were used in this study. Incisions were made on the skin using #15 and #15c blades with ×1.0, ×2.5, and ×5.0 magnification. The accuracy of the incision (length and depth) made by the different scalpel blades and magnifications was analyzed using the 2 × 3 chi-squared test. Logistic regression analysis was applied to determine factors of the incision depth and length.

RESULTS

No statistically significant differences were found in the evaluations of length or depth using the 2 × 3 chi-squared test. However, the multiple logistic regression analyses showed that the incision length and depth were associated with use of the #15c scalpel blade.

CONCLUSION

Use of a #15c scalpel blade with ×5.0 magnification is recommended for making incisions when less than 1- to 2-mm accuracy is required.

Dermatologic Laser Side Effects and Complications: Prevention and Management

The evolution of modern laser and light-based systems has mirrored the demand for clinically effective treatments and the need for safer technologies with reduced postoperative recovery, side effects, and complications. With each new generation of lasers, more selective tissue destruction can be achieved with reduced unwanted sequelae. Patient selection and preparation, operator technique, and expeditious recognition and management of post-treatment side effects are paramount in avoiding complications and patient dissatisfaction. An overview of important variables to consider for dermatologic laser treatments are presented in order to provide a framework to reduce the severity and duration of possible post-treatment side effects and complications.

Use of an adherent fenestrated drape to anchor an adjacent vertical sterile surgical towel

Vertical surgical sites or those on reclining patients often present a challenge when establishing and securing a sterile field. The drape or towel most proximal to the physician is often vertically oriented. The forces of gravity and movements of surgery can shift or detach this vertical drape. Sterile clamps are not always available or are needed for securing other instruments. We present a method to secure this vulnerable drape using a central fenestrated adherent drape.

Erosive Pustular Dermatosis of the Leg Successfully Treated With an Oral Retinoid and a Bi-layered Skin Substitute

Erosive pustular dermatosis is a rare inflammatory skin disorder characterized by crusted erosions, sterile pustules, skin atrophy, and scarring alopecia. Cases of involvement of lower extremities, with or without scalp lesions, have been scarcely reported in the literature, and have been denominated Erosive Pustular Dermatosis of the Legs. The disorder usually affects elderly patients associated with chronic venous insufficiency and venous dermatitis. Topical corticosteroids and topical calcineurin inhibitors have been reported to be effective. On the other hand, several treatments have also failed to achieve appropriate results; hence we present a case of erosive pustular dermatosis of the leg, who was unresponsive to compression and antibacterial ointments, but successfully treated systemically with an oral retinoid and locally with the application of a bioengineered bi-layered skin substitute. This condition may be overlooked, which represents its low prevalence in literature. J Drugs Dermatol. 2019;18(3):301-302.

Clinical pearl: mastering the flexible scalpel blade with the banana practice model

This article describes the various applications of the flexible scalpel blade (FSB), the utility of the banana as a convenient and exceptional training instrument, and the intricacies of mastering the technique for students of different training levels.

Magnification for the dermatologic surgeon

Ergonomic practice increases the productivity, quality, and longevity of the dermatologic surgeon. When used properly, magnification devices can be ergonomic and beneficial additions to the dermatologic surgeon's practice. Herein, we review the available magnification options for the dermatologic surgeon and evaluate the options based on cost, design, and functional advantages and disadvantages. Magnification for the dermatologic surgeon may be a useful tool for a healthier, more efficient, and higher-quality practice.

Surgical Treatment of Tattoo Complications

With a continuing increase in the number of tattoos performed worldwide, the need to treat tattoo complications is growing. Earlier treatments of chronic inflammatory tattoo reactions were dominated by a medical approach, or with no active intervention. In this chapter, we will address modern surgical approaches applied to situations when medical treatment is inefficient and lasers are not applicable. Dermatome shaving is positioned as first-line treatment of allergic tattoo reactions and also indicated in a number of other tattoo reactions, supplemented with excision in selected cases. The methods allow fundamental treatment with removal of the culprit pigment from the dermis. The different instruments, surgical methods, and treatment schedules are reviewed, and a guide to surgeons is presented. Postoperative treatments and the long-term outcomes are described in detail. An algorithm on specialist treatment and follow-up of tattoo reactions, which can be practiced in other countries, is presented.

Acne scarring: A review of available therapeutic lasers

BACKGROUND AND OBJECTIVE

The utilization of lasers in dermatology has greatly expanded in recent decades. Acne scarring is a common indication in which lasers play an important therapeutic role.

STUDY DESIGN/MATERIALS AND METHODS

Available lasers include traditional ablative lasers, such as carbon dioxide and erbium lasers, traditional non-ablative lasers, such as neodymium, diode, alexandrite, pulsed dye lasers and intense pulse light, as well as both ablative, and non-ablative fractional laser systems.

CONCLUSION

We sought to provide a framework for understanding the various types of lasers available to treat acne scars and review the primary literature pertaining to the efficacy, safety, and advantages of each laser discussed.

Surgical therapy for pilonidal sinus in adolescents: a retrospective study

AIM

To investigate optimal surgical management of pilonidal sinus (PS) in pre-adolescent and adolescent periods in which it is less common.

METHODS

A retrospective study based on 25 adolescent patients with PS disease that were treated at the Department of Pediatric Surgery, Selcuk University, Konya, Turkey, between 2010 and 2013 was conducted.

RESULTS

Among 25 patients with PS disease 17 (68%) were males and eight (32%) females, with a mean age of 16.08 ± 1.2 years. According to the body mass index (BMI), 17 (68%) of the cases were in the normal range, 4 four (16%) of each were overweight, and obese, respectively. Twenty cases (80%) were managed with total excision and primary closure, while five (20%) cases underwent Limberg flap repair. Four patients were managed with the Limberg procedure due to very large sinuses, while a single patient underwent the procedure due to a recurrence following primary repair.

CONCLUSION

Factors that predispose patients to developing PS include an above average BMI, significant body hair, and prolonged time in a seated position. Elevated BMI as a risk factor for PS is a growing concern given the rise in obesity. Although there are various treatment modalities, total excision and primary closure has demonstrated successful outcomes.

Smart surgical tool

A laser-induced breakdown spectroscopy (LIBS) guided smart surgical tool using a femtosecond fiber laser is developed. This system provides real-time material identification by processing and analyzing the peak intensity and ratio of atomic emissions of LIBS signals. Algorithms to identify emissions of different tissues and metals are developed and implemented into the real-time control system. This system provides a powerful smart surgical tool for precise robotic microsurgery applications with real-time feedback and control.

Topical corticosteroids minimise the risk of postinflammatory hyper-pigmentation after ablative fractional CO2 laser resurfacing in Asians

Postinflammatory hyperpigmentation (PIH) is the most common adverse effect of laser treatment in dark-skinned individuals. Little is known whether PIH can be prevented or minimised. The objective of this study was to investigate the effect of short-term application of topical corticosteroids on the incidence of PIH after ablative fractional resurfacing in Asians. Forty subjects with skin phototype IV and atrophic acne scars were treated with a fractional CO2 laser on both sides of the face. Post-operatively, clobetasol propionate 0.05% ointment was applied to one randomly selected side of the face for the first 2 days, followed by an application of petrolatum jelly for the rest of the week (petrolatum was applied to the other side for 7 days). Assessments on the clinical outcome, the wound healing process and the occurrence of PIH were obtained once weekly for the first month and at 2 and 3 months post-treatment. The side of the face treated with petrolatum alone had significantly (p < 0.001) higher incidence of PIH (75%) after laser irradiation than the side of the face treated with topical corticosteroids and petrolatum (40%). The PIH occurring on the petrolatum-treated sides had significantly higher intensity (p < 0.001) and was spread over a significantly larger area (p < 0.001), compared with the corticosteroid- and petrolatum-treated sides. In conclusion, a short-term application of topical corticosteroids postoperatively is associated with a decreased risk of PIH after ablative fractional resurfacing.

The ophthalmology microscalpel versus standard scalpels and wound healing in a rat model

OBJECTIVE

We tested the hypothesis that the ophthalmology microscalpel, compared to standard incisional instruments, causes less trauma during incisions resulting in decreased inflammation and greater tensile strength of wounds.

STUDY DESIGN

Prospective animal study.

SETTING

Animal laboratory.

SUBJECTS AND METHODS

Thirty-four Sprague-Dawley rats received dorsum skin incisions with the microscalpel, electrosurgical device, 11 blade scalpel, and 15 blade scalpel. Wounds were harvested at 1 week, 2 weeks, 3 weeks, and 6 weeks, then analyzed histologically in a blinded manner for inflammation markers and tested for tensile strength.

RESULTS

The microscalpel wounds had significantly higher tensile strength compared to the 15 blade (P = .045) and electrocautery device (P = .000) but equivocal strength to the 11 blade (P = .457). The electrocautery wounds were weaker than all 3 steel blades. No significant difference was found between the microscalpel, 11 blade, and 15 blade incisions for the 5 markers of inflammation. Electrocautery wounds had significantly worse inflammatory scores, specifically, higher angiogenesis and larger wound gap compared to the microscalpel (P = .004, P = .002), 11 blade (P = .007, P = .023), and 15 blade (P = .010, P = .003), respectively.

CONCLUSION

Microscalpel incisions result in less inflammation and increased tensile strength compared with electrocautery and higher tensile strength compared to the 15 blade in the rat model. Inflammation scores were equivocal between the microscalpel, 11 blade, and 15 blade. Our findings support the use of the microscalpel blade for facial plastic and reconstructive procedures. Prospective, randomized human studies are warranted.

A substitute for skin grafts, flaps, or internal tissue expanders in scalp defects following tumor ablative surgery

BACKGROUND

The skin of the scalp is relatively thick, minimally mobile, with distinct hair distribution. TopClosure® is a novel device for skin stretching and secure wound closure.

OBJECTIVES

To evaluate the efficacy of the TopClosure® system in primary closure of moderate and large scalp defects, as a substitute for skin grafts, flaps, and tissue expanders.

METHODS

We report a retrospective series of 8 patients requiring resection of 9 scalp tumors resulting with moderate to large size defects that otherwise would have required reconstruction with skin grafts, flaps, or tissue expanders. TopClosure® was applied for intraoperative cycles of stress-relaxation, followed, when indicated, by additional steps of mechanical creep and scar secure.

RESULTS

Skin defects, averaging 3.5 cm, were managed by TopClosure®, enabling, primary closure in all wounds. Immediate wound edge approximation was reached through stress-relaxation in 2 wounds by heavy tension sutures within one hour. Further skin stretching by mechanical creep was required in 7 wounds, achieving staged primary closure in an outpatient setting. TopClosure® was further applied to secure the skin for up to 3 weeks following surgery.

CONCLUSIONS

The TopClosure system, effectively, aided closure of moderate and large scalp defects by stress-relaxation and mechanical creep and serving as a topical tension-relief platform for tension sutures, allowing mobilization of skin and subcutaneous tissue without undermining or need of drainage, for early, direct wound closure. Local complications were minimal and donor site morbidity was eliminated. Surgical time, hospital stay and costs were reduced, and post-operative wound aesthetics were improved.

An update on super wide field microscopy in dermatologic surgery

Microscopic interpretation represents the central tenet for diagnosis and eradication of cutaneous tumors. Standard microscopes are limited by relatively high-powered objectives and smaller viewable diameter. Newer equipment offers optional lower powered objectives including 1X and 2X objectives and can be combined with super widefield eyepieces to greatly enhance the viewable area during pathologic interpretation of slides. Mohs micrographic surgery represents one of the most useful areas in which the dermatologic surgeon gleans multiple efficiencies from these microscope systems. One such system that was recently trialed, the Nikon 80i microscope, proved to be incredibly easy to use and multiple efficiencies were quickly realized.