Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates

Surgeons have constantly sought to achieve the most aesthetic scar. A major factor determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. Since Theodor Kocher pioneered the alignment of skin incisions with Langer's lines in 1892, surgical techniques that attempt to overcome closing tension have become standard. Yet, no treatment has been available to minimize underlying muscle contractions, which are the major cause of this tension. Botulinum toxin A is a potent drug that produces temporary muscular paralysis when injected locally. It has proven to be safe and effective in the treatment of a variety of disorders, including hyperkinetic facial lines. The objective of this randomized, double-blind, placebo-controlled primate study was to investigate the efficacy of a single injection of botulinum toxin A to improve the cosmetic appearance of cutaneous scars. Symmetric pairs of standardized excisions were performed on either side of the forehead of six primates. The half foreheads were randomized to the botulinum toxin A treatment side versus the placebo injection side. A panel of three blinded facial surgeons assessed the cosmetic appearance of the mature scars 3 months postoperatively. The wounds that had been immobilized with botulinum toxin A were rated as significantly better in appearance than the control wounds (p < 0.01). Histologic examination confirmed that all scars were mature. Blinded, randomized, placebo-controlled human clinical trials are presently under way at the Mayo Clinic.

The management of melanoma and nonmelanoma skin cancer: a review for the primary care physician

In the United States, the incidence of skin cancer is greater than that of all other cancers combined, and early diagnosis can be lifesaving. A substantial public health concern, skin cancer is increasingly being diagnosed and managed by primary care physicians. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) (known collectively as nonmelanoma skin cancer) and malignant melanoma are the most common cutaneous malignancies. Shave biopsy is usually performed if BCC is suspected; punch biopsy is preferred if SCC is thought to be present. The choice of biopsy techniques depends on the presumed depth of the lesion. Treatment has 3 goals: complete eradication of the cancer and preservation or restoration of normal function and cosmesis. Risk of recurrence or metastasis determines whether the tumor is high risk or low risk. Based on the level of risk, treatment options are considered, including whether the patient can be treated by a primary care physician or should be referred to a dermatologist. Choice of treatment approach depends on the tumor's location, size, borders, and growth rate. The standard treatment approaches are superficial ablative techniques (electro-desiccation and curettage and cryotherapy) used primarily for low-risk tumors and full-thickness techniques (Mohs micrographic surgery, excisional surgery, and radiotherapy) used to treat high-risk tumors. Removal of the entire tumor is essential to limit and prevent tumor recurrence.

Skin cancer in liver transplant recipients

Skin cancer is the most common malignancy arising in the posttransplantation setting. Multiple factors contribute to the high risk for cutaneous carcinoma in immunosuppressed organ-transplant recipients. We review the phenomenon of skin cancer in solid-organ transplant recipients and further delineate the problem in the context of liver transplantation. Skin cancer is a significant medical and surgical problem for organ-transplant recipients. With prolonged allograft function and patient survival, the majority of solid-organ transplant recipients will eventually develop skin cancer. Although squamous cell carcinoma is the most common cutaneous malignancy in this population, basal cell carcinoma, melanoma, and Kaposi's sarcoma, as well as uncommon skin malignancies, may occur. Highly susceptible patients may develop hundreds of squamous cell carcinomas, which may be life threatening. Management strategies focus on regular full-skin and nodal examination, aggressive treatment of established malignancies, and prophylactic measures to reduce the risk for additional photodamage and malignant transformation. Skin cancer is a substantial cause of morbidity and even mortality among solid-organ transplant recipients. As a byproduct of immunosuppression, liver transplant recipients experience a high incidence of skin cancer and should be educated and managed accordingly.

Reduction of immunosuppression for transplant-associated skin cancer: expert consensus survey

BACKGROUND

Reduction of immunosuppression is considered a reasonable adjuvant therapeutic strategy in solid-organ transplant recipients experiencing multiple or high-risk skin cancers. However, the literature provides no guidance about what threshold of cancer development would warrant initiation of reduction of immunosuppression.

OBJECTIVES

To develop expert consensus guidelines for initiation of reduction of transplant-associated immunosuppression for solid-organ transplant recipients with severe skin cancer.

METHODS

An expert consensus panel was convened by the International Transplant Skin Cancer Collaborative and Skin Care for Organ Transplant Patients Europe Reduction of Immunosuppression Task Force. Thirteen hypothetical patient scenarios with graduated morbidity and mortality risks were presented and mean and mode expert opinions about appropriate level of reduction of systemic immunosuppression (mild, moderate, severe) were generated.

RESULTS

Mild reduction of transplant-associated immunosuppression was considered warranted once multiple skin cancers per year developed or with individual high-risk skin cancers. Moderate reduction was considered appropriate when patients experienced > 25 skin cancers per year or for skin cancers with a 10% 3-year risk of mortality. Severe reduction was considered warranted only for life-threatening skin cancers.

CONCLUSIONS

Reduction of immunosuppression is considered a reasonable adjuvant management strategy for transplant recipients with numerous or life-threatening skin cancers. Proposed guidelines are presented for the graduated reduction of immunosuppression coincident with the increasing skin cancer risks.

Melanoma in solid organ transplant recipients

This manuscript outlines estimated risk and clinical course of pretransplant MM, donor-transmitted MM and de novo MM posttransplantation and includes an analysis of risk factors for metastasis, data from clinical studies and current and proposed management. MM in situ and thin melanoma (<1 mm) in the transplant population has similar recurrence and survival estimates to those in the general population. A minimum wait time of 2 years prior to transplantation is suggested for MM with a Breslow depth <1 mm and no clinical evidence of metastasis. More advanced MM may adopt a more aggressive course in transplant recipients. Sentinel lymph node biopsy may be of additional prognostic benefit. Revision of immunosuppression in the management of de novo melanoma in collaboration with the transplant team should be considered. Larger studies utilizing uniform staging criteria or at minimum Breslow depth, are required to assess true risk and outcome of MM in the immunosuppressed transplant population. Emphasis remains on patient education and regular screening to provide early detection of MM.

Alar batten cartilage grafting in nasal reconstruction: functional and cosmetic results

BACKGROUND

Alar batten cartilage grafts can restore form and function to a compromised ala, prevent stenosis of the nasal valve, and maintain unrestricted air movement. Soft tissue reconstructive options can be combined with alar batten grafts.

OBJECTIVE

Our purpose was to analyze functional and cosmetic outcomes in a series of patients undergoing alar batten cartilage grafting.

METHODS

We analyzed the functional and cosmetic outcomes of 25 patients in whom reconstruction involved alar batten cartilage grafts. Assessment included defect characteristics, function and cosmesis (rated by physician and patient), and complications.

RESULTS

Eighty-three percent of patients had good to excellent functional and cosmetic results by patient and physician assessment. Three patients were rated as having poor cosmetic results by the physician; all 3 patients graded these results as good. One episode of graft failure occurred, and recipient and donor site complications were minor.

CONCLUSION

Alar batten cartilage grafts appear to be an excellent option for reconstruction of substantial alar defects.

Factitious disease of periocular and facial skin

PURPOSE

To describe the clinical appearance of factitious (or self-inflicted) lesions on periocular skin and face.

METHODS

All patients with factitious cutaneous disease who were examined at Mayo Clinic, Rochester, Minnesota, between 1985 and 1997 were identified. For patients with lesions on the face and periocular skin, the demographic features, clinical descriptive characteristics of their lesions, associated psychopathology, and treatments were ascertained.

RESULTS

Of 38 patients with factitious dermatitis, 18 (47%) had facial lesions. Of these 18 patients, 15 (83%) were female. The mean age (+/- SD) of the patients with facial lesions was 35.2 +/- 15.7 years (range, 9 to 66 years). Eight patients (44%) had neurotic excoriations, nine (50%) had dermatitis artefacta, and one (6%) had trichotillomania. The working diagnoses of five patients cared for initially in the Department of Ophthalmology were corneal epithelial and facial desquamation associated with severe pain of unknown cause, medial cicatricial ectropion of probable vasculitic cause, basal cell carcinoma of the nasojugal fold, recurrent preseptal cellulitis resistant to medical treatment, and madarosis of the upper eyelids of unknown cause.

CONCLUSION

Cutaneous factitious disease may masquerade as numerous clinical entities and should be included in the differential diagnosis of lesions of the periocular skin.

Mycobacterium marinum infections in transplant recipients: case report and review of the literature

Infections due to Mycobacterium marinum are rarely encountered following organ and tissue transplantation. Herein, we report a case of M. marinum infection in a kidney and pancreas transplant recipient who manifested clinically with multiple locally spreading sporotrichoid-like cutaneous nodules in his left forearm. In order to provide a general overview of post-transplant M. marinum infections, we reviewed and summarized all previously reported cases of this infection that occurred after transplantation. Including our index case, all 6 cases presented with multiple cutaneous and subcutaneous nodules that had spread locally in the involved extremity. One patient had lesions located in non-contiguous body sites suggesting either systemic dissemination or multiple sites of inoculation. In all but 1 patient, the cutaneous nodules appeared in an ascending pattern and following exposure to fish tanks or after contact with the marine environment. The diagnosis of M. marinum infection was suspected on clinical grounds and confirmed by mycobacterial culture. Treatment consisted of at least 2 active antibiotics (such as rifamycins, ethambutol, tetracyclines, or macrolides) for 4-9 months, resulting in clinical cure or improvement. Relapse was observed in 1 patient despite completing 6 months of antibiotic therapy. One patient had surgical excision of the lesions. In conclusion, M. marinum should be considered as the cause of cutaneous and subcutaneous nodules in transplant recipients, particularly in the context of fish tank or marine exposure. Compared with the immunocompetent hosts, M. marinum infection may have a more aggressive clinical course after transplantation, and may require a longer duration of antibiotic treatment. Early diagnosis and treatment may prevent local spread and potential systemic dissemination.

Medium-depth chemical peeling

Trichloroacetic acid (TCA) alone or in combination with other agents is the mainstay of medium-depth chemical peels. Indications for medium-depth chemical peels include both medical conditions, such as diffuse photodamage with contiguous actinic keratoses, and cosmetic conditions, such as the aging face and solar lentiginosis. Medium-depth chemical peeling with TCA is relatively simple and is associated with a favorable risk/benefit ratio. However, proper patient selection, with attention to both medical and psychological factors, requires significant experience. The histological basis of the rejuvenating effects of TCA peels is well established, with a consistent correlation between wound depth and TCA concentration. The clinical effects of medium-depth chemical peels are generally gratifying for both patient and physician.

Reduction of immunosuppression for transplant-associated skin cancer: thresholds and risks

BACKGROUND

Although evidence supports the efficacy of reducing immunosuppression for transplant-associated skin cancer, clinical thresholds for and risks associated with reduction are not well defined.

OBJECTIVES

In this study, experienced transplant physicians were surveyed regarding appropriate thresholds for consideration of reduction of immunosuppression and the likelihood of rejection and allograft compromise associated with various levels of reduction.

PATIENTS AND METHODS

Fifty-two transplant physicians reviewed 13 hypothetical patient scenarios with graduated morbidity and mortality risk and provided opinions on the degree of reduction of immunosuppression that was warranted and the risks associated with various degrees of reduction.

RESULTS

Renal, liver and cardiac transplant physicians generally concurred on the level of reduction of immunosuppression warranted by various degrees of skin cancer. As morbidity and mortality from skin cancer increased, physicians were more likely to accept risk to allograft function from more aggressive reduction.

CONCLUSIONS

Reduction of immunosuppression is considered a reasonable adjuvant strategy in recipients of solid organ transplants who have substantial morbidity and mortality risk from skin cancer. Physicians are willing to accept an increased risk of allograft compromise when confronted by severe or extensive skin cancer. Further research is needed to define the precise correlation among levels of reduction of immunosuppression, therapeutic efficacy, and concomitant risks.

Spectrum of cartilage grafting in cutaneous reconstructive surgery

BACKGROUND

The use of cartilage grafts in cutaneous reconstructive surgery is becoming increasingly common among dermatologic surgeons.

OBJECTIVE

Our purpose was to describe the indications, technical application, results, and complications associated with cartilage grafting in cutaneous reconstructive surgery.

METHODS

The spectrum of cartilage grafting is reviewed, and illustrative examples are provided.

RESULTS

A well-planned application of cartilage grafts in cutaneous reconstructive surgery can provide exceptional results, permitting restoration of impaired anatomic free margins as well as maintenance of the functional patency of key anatomic structures such as the nasal valve.

CONCLUSION

Cartilage grafting in cutaneous reconstructive surgery is an important method to ensure optimal reconstructive outcomes. Dermatologists involved in reconstructive surgery will experience improved results through the application of these techniques.

Preoperative and postoperative topical tretinoin on high-tension excisional wounds and full-thickness skin grafts in a porcine model: A pilot study

BACKGROUND

Tretinoin induces neovascularization and the formation of collagen when applied topically.

OBJECTIVE

The goal was to determine whether preoperative and postoperative treatment with tretinoin enhances the healing of high-tension, full-thickness excisional wounds and the survival of full-thickness skin grafts.

METHODS

A blinded, randomized, placebo-controlled pilot study involved high-tension excisional wounds and full-thickness skin grafts treated perioperatively with tretinoin in a porcine model.

RESULTS

Perioperative treatment of high-tension excisional surgery sites with tretinoin appeared to have no consistent beneficial or adverse effects on wound healing or scar spreading. In the full-thickness skin graft model, a trend toward impaired wound healing was noted.

CONCLUSION

The collagen-inducing effects of topical tretinoin do not appear to enhance the healing of high-tension excisional surgery wounds in a porcine model. Tretinoin does not appear to improve the survival of full-thickness skin grafts and, in fact, a detrimental effect was apparent in our model.

Anxiolysis with oral midazolam in pediatric patients undergoing dermatologic surgical procedures

BACKGROUND

Pediatric patients undergoing dermatologic surgical procedures often experience high levels of anxiety. Oral midazolam is a short-acting benzodiazepine that can ameliorate procedure-related anxiety.

OBJECTIVE

Our purpose was to determine the safety and efficacy of oral midazolam as an adjuvant anxiolytic agent for pediatric patients undergoing dermatologic surgical procedures.

METHODS

A prospective series of pediatric patients undergoing dermatologic surgical procedures who received oral midazolam were monitored, and efficacy and complications were recorded.

RESULTS

Oral midazolam provided good to excellent anxiolytic effects in most pediatric patients undergoing painful dermatologic surgical procedures. Because midazolam does not provide analgesic effects, local anesthesia is necessary. Complications were uncommon and minor.

CONCLUSION

Oral midazolam is an effective anxiolytic agent in pediatric patients undergoing dermatologic surgical procedures.

Reinnervation of flaps and grafts of the face

BACKGROUND

The degree to which disruption of sensory innervation is affected by flaps and grafts on the face has not been explored. The decision to choose a flap or a graft for reconstruction may affect future sensation at the surgical site.

OBJECTIVES

To characterize the clinical recovery of sensory innervation after facial reconstructive surgery with flaps and grafts and to offer clinical guidelines on the recovery of sensation in reconstructed sites involving flaps and grafts of the face.

METHODS

Seventy patients who underwent Mohs surgery and subsequent repair by either a flap or a graft were evaluated at different postoperative intervals. Fifty patients underwent flap reconstruction and 20 patients underwent graft reconstruction. Three principal modes of sensation were objectively assessed: light touch, temperature, and pinprick.

RESULTS

Median time of evaluation after surgery was 11 months. The most common locations tested were the nose (36 patients) and the forehead (9 patients). Postoperative evaluation showed that flap sensation recovery to light touch was present in 10% of patients before 3 months, 41% of patients from 3 to 12 months, 27% of patients from 1 to 2 years, and 75% of patients after 2 years. Graft sensation recovery to light touch was present in no patients evaluated less than 2 years after surgery and in 29% of patients evaluated more than 2 years after surgery. After adjustments for postoperative size and interval, patients with flaps were more likely than those with grafts to have touch sensation at the time of testing (adjusted odds ratio, 8.91; 95% confidence interval, 1.06-74.62; P = .04), to be able to distinguish between warm and cold (adjusted odds ratio, 3.99; 95% confidence interval, 1.05-15.16; P = .04), and to be able to distinguish between sharp and dull (adjusted odds ratio, 27.31; 95% confidence interval, 2.20-339.71; P = .01).

CONCLUSIONS

Predictable factors are associated with sensation recovery in patients with flaps and grafts. The recovery of sensory innervation after surgery is earlier with flaps than with grafts. Our data provide clinicians with guidelines for recovery of sensation that ultimately will reassure the patient.

Conscious sedation of pediatric patients with combination oral benzodiazepines and inhaled nitrous oxide

BACKGROUND

Pediatric patients undergoing surgical procedures may experience considerable anxiety. Use of conscious sedation may be helpful in managing mild to moderate anxiety.

OBJECTIVE

To assess the effectiveness of combination oral benzodiazepines and inhaled nitrous oxide conscious sedation in pediatric surgical patients.

METHODS

Eleven episodes of conscious sedation in eight pediatric patients were prospectively monitored, with recording of indications, patient characteristics, clinical scenarios, surgical procedure, sedative regimen, quality of sedation, and complications. Extensive training in conscious sedation had been obtained, and emergency preparedness was at a high level.

RESULTS

Combination oral benzodiazepines and inhaled nitrous oxide produced good to excellent results in all patients but one. Complications were uncommon and mild. No emergency intervention was necessary.

CONCLUSION

Monitored use of a combination of oral benzodiazepine and low to moderate concentrations of inhaled nitrous oxide can provide safe and effective conscious sedation in pediatric patients. Training in conscious sedation and emergency preparedness are essential.

Rhinophyma and coexisting occult skin cancers

BACKGROUND

Although coexistent tumors have been reported in patients with rhinophyma, few reports have described the coexistence of rhinophyma and an occult infiltrating squamous cell carcinoma (SCC).

OBJECTIVE

Preoperatively and during rhinophymaplasty, recognition of subtle changes can suggest an underlying malignancy.

METHODS

A large infiltrating SCC was noted during electrosurgical rhinophymaplasty. Mohs micrographic surgery was performed to clear the tumor.

RESULTS

The patient was tumor-free with no evidence of recurrence at 1-year follow-up.

CONCLUSION

In the evaluation of changing rhinophyma or subtle changes in tissue noted during rhinophymaplasty, physicians must consider the possibility of an underlying malignancy.

Oral retinoids for chemoprevention of skin cancers in organ transplant recipients: results of a survey

Systemic retinoid therapy is thought to be beneficial for chemosuppression of skin cancers in solid organ transplant recipients. We present the results of a survey of 28 dermatologists with experience managing transplant recipients to clarify when and how systemic retinoids are used in this population. Almost 80% of respondents use retinoids in some transplant recipients. Factors influencing the use of retinoids include the incidence and aggressiveness of cutaneous squamous cell carcinomas and the extent of concomitant actinic keratoses. Patients are monitored more closely during periods of dose adjustment than during the maintenance phase of therapy. Adverse effects are variably managed symptomatically, with dose adjustment, by discontinuation of retinoids, or by referral to another specialist for further evaluation. In the absence of large randomized controlled trials, the practice habits of experienced physicians serve as a useful guide for the use of oral retinoids in transplant recipients.

Infiltrating basal cell carcinoma in the setting of a venous ulcer

A 77-year-old man was referred with a 5-year history of an intermittently painful, nonhealing right medial ankle ulcer. The ulcer had not responded to multiple treatment modalities, including Unna boots, compression therapy, sclerotherapy, and split-thickness skin grafting. The past medical history was significant for a deep venous thrombosis in the right leg 30 years earlier (treated with warfarin for 3 months) and a history of greater saphenous vein harvesting for coronary bypass grafting 28 years previously. After the vein stripping, the patient had suffered from increasing right leg edema and stasis changes in the right leg. His history was also remarkable for coronary artery disease, dyslipidemia, and lymphoma treated with chemotherapy 8 years before presentation, with no evidence of recurrence. He had stopped smoking approximately 20 years earlier. Medications included atenolol, simvastatin, nicardipine, nitroglycerin, and aspirin. Skin examination revealed a 3.0 x 3.5-cm ulcer adjacent to the medial malleolus. The edges of the ulcer appeared raised and rolled (Fig. 1). Centrally, there was granulation tissue, which appeared healthy. There were surrounding dermatitic changes. Dorsalis pedis and the posterior tibial pulses were normal. Noninvasive vascular studies revealed severe venous incompetence of the right popliteal and superficial veins. Arterial studies and transcutaneous oximetry were normal. Computed tomographic scan of the pelvis did not reveal any adenopathy, and radiographic imaging did not reveal any bony changes suggestive of osteomyelitis. Biopsy of the ulcer edge and base showed infiltrating basal cell carcinoma (Fig. 2). Mohs' micrographic surgery required three layers; the final extent of the ulcer was 7.8 x 6.9 cm. A split-thickness skin graft was placed.

Induction of Darier-White disease with UVB radiation in a clinically photo-insensitive patient

Combination UVA/UVB radiation and UVB radiation alone have been shown to induce the lesions of Darier-White disease. However, 6% of patients with Darier-White disease claim that sunlight ameliorates their condition. We performed an unblinded, side-by-side controlled trial of UVB, UVA, and combination UVB/UVA phototherapy in a patient with historically photoameliorated Darier-White disease to determine whether phototherapy was beneficial, to determine whether phototherapy-related heat was detrimental, and to confirm, with appropriate controls, the action spectrum of the disease. Phototherapy with radiation in the UVB but not UVA spectrum evoked Darier-White disease in this patient, both clinically and histologically. UVB radiation was capable of inducing Darier-White disease in vivo in spite of a history of photoamelioration, whereas UVA radiation alone and the heat associated with phototherapy in our protocol had no effect on the disease.

Review of sentinel lymph node biopsy and systemic interferon for melanoma: promising but investigational modalities

BACKGROUND

There is conflicting data regarding the efficacy of systemic interferon as adjuvant therapy for high-risk cutaneous melanoma. Sentinel lymph node biopsy has recently gained acceptance in the surgical management of high-risk melanoma, despite a lack of data supporting its efficacy.

OBJECTIVE

To review the evidence concerning interferon and lymph node biopsy in the management of melanoma.

METHODS

A systematic review of all randomized, controlled trials involving adjuvant interferon and sentinel lymph node biopsy in management of melanoma is presented.

RESULTS

Current data regarding the efficacy of adjuvant interferon in the management of melanoma is conflicting. The conflicting results of studies involving both low-dose and high-dose systemic interferon for the adjuvant treatment of melanoma remain unresolved. There is no randomized, controlled data to support the use of sentinel lymph node biopsy in the management of melanoma, despite its widespread acceptance.

CONCLUSION

Sentinel lymph node biopsy and systemic interferon remain promising modalities in the management of melanoma, although there is no affinitive evidence to support their efficacy.

Safe and effective conscious sedation administered by dermatologic surgeons

OBJECTIVE

To review the experience with conscious sedation administered by dermatologic surgeons at an academic medical center.

DESIGN

Retrospective medical chart review.

SETTING

Outpatient dermatologic surgery unit at an academic medical center.

PATIENTS

Fifty episodes of conscious sedation in 37 patients undergoing dermatologic surgical procedures.

INTERVENTION

Intravenous and inhaled conscious sedation was administered with strict monitoring during procedures.

MAIN OUTCOME MEASURES

Efficacy was subjectively recorded by the administering physician and complications were recorded.

RESULTS

Administration of conscious sedation by dermatologic surgeons was associated with good to excellent sedation with minimal complications. Extensive preparation and training were necessary, and strict guidelines devised by a conscious sedation task force were followed. Emergency preparedness was high, although it was not used.

CONCLUSIONS

Conscious sedation can be safely and effectively administered by dermatologic surgeons in a hospital-based outpatient surgical unit after extensive training. Emergency preparedness is essential, and conservative guidelines should be followed.