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Objective To ascertain and clarify the effectiveness and advantages of the geometric staged excision technique for the removal of lentigo maligna (LM) and lentigo maligna melanoma (LMM). Design This was a retrospective review of a patient database composed of 293 cases of LM and LMM. Setting The Laser and Dermatologic Surgery Center in St Louis, Missouri, an academic-affiliated, private dermatologic surgery center. Patients All patients with a diagnosis of LM and LMM treated by staged excision from 1999 to 2007. Main Outcome Measures The overall rate of recrudescence, margins required for clearance, stages required for clearance, and lesional characteristics were examined. Results The rate of recrudescence after geometric staged excision was 1.7% (4/239), with a mean of 32.3 months of follow-up. The mean margin to clearance after excision was 6.6 mm for LM and 8.2 mm for LMM. A total of 11.7% of LMM was initially diagnosed as LM on biopsy, with the invasive component discovered during the excision. Conclusions Geometric staged excision is an optimal method of removal of LM and LMM given its low rate of recrudescence and ability for complete examination of the peripheral and deep margins of the specimens.

To the Editor.— Mycobacterium bovis infection in man has been controlled, but not completely eradicated, in the industralized world with universal mandatory pasteurization of milk products and screening for tuberculous infection among farm animals. 1 We present a newly diagnosed case of cutaneous M bovis disease of extremely long duration, spanning at least 40 years. Report of a Case.— A 57-year-old white man presented to the Mohs Surgery Clinic at the University of Wisconsin, Madison, for the treatment of actinic keratoses. A right upper arm lesion was incidentally noted. The patient stated that it had been present, asymptomatic and unchanging, ever since he could remember. It had been diagnosed as a hemangioma on several occasions in the past. From childhood through college, he spent a lot of time on a New Jersey farm drinking unpasteurized milk on numerous occasions. There was a long history of positive purified protein derivative

Cosmetic Laser Surgery is a multiauthored atlas of the burgeoning field of aesthetic laser surgery intended for several different types of specialists. Some chapters are mainly written for dermatologists by covering laser hair transplantation and the laser treatment of vascular lesions, scars, tattoos, and pigmented lesions. Other chapters that cover endoscopic laser rhytidectomy, blepharoplasty, and meloplasty will be mostly appreciated by plastic, facial plastic, and oculoplastic surgeons. The chapter dealing with laser uvulopalatoplasty for snoring is of interest to otolaryngologists. The laser skin resurfacing for rhytides and facial scars section is the 1 truly multispecialty chapter. The chapters directed to nondermatologists are worthwhile mainly as a brief overview of what other specialists are doing with lasers. This is a very attractive and inviting book to read with its many outstanding full-color illustrations. As behooves an atlas, the text is appropriately brief taking less than 3 hours to be read cover

We thank Dr McGrae for his interest in our article. His letter reminds us of several important points. Dr McGrae suggests that this eruption is clinically and histologically similar to asteatotic dermatitis. We certainly agree, and as stated in our article, the eruption presents as a relatively nonspecific dermatitis. The distinguishing feature is that saphenous vein graft donor site dermatitis is unilateral and limited only to the leg where the saphenous vein was harvested and that it immediately overlies the distal end of the scar. In addition, in our cases the dermatitis was localized to an area of sensory neuropathy and resolved with resolution of the sensory loss. Further, we point out, as Dr McGrae does, that neuralgia in this location would likely exacerbate xerosis and the dermatitis by external influences, such as overbathing or other incidental trauma, supporting the possible significance of neuropathy in this setting. Our patients did

THERE HAS been a great increase in the understanding of laser tissue interactions in the 11 years since the last laser editorial in theArchivesby Arndt and Noe. 1 This has resulted in the development of numerous new-generation laser systems that take full advantage of the unique properties of laser light to achieve very specific and confined effects in tissue while minimizing collateral damage. All three laser studies in this issue of theArchivesare good examples of the progress that has been achieved. 2-4 ORIGINAL LASERS IN DERMATOLOGY The first laser to be used in humans was a ruby laser studied by Leon Goldman, a dermatologist, in the early 1960s. 5 He made numerous observations regarding laser tissue interaction with the ruby laser. He demonstrated specific laser effects on epidermal components of the skin and tested the laser on various benign as well as malignant lesions. 5-7 The

• Background.— Coronary artery bypass grafting for atherosclerotic heart disease is commonly performed throughout the world. Complications of coronary artery bypass grafting include saphenous neuralgia due to injury to the saphenous nerve during harvest of the saphenous vein. Dermatologic complications of coronary revascularization are infrequently reported and include an eruption overlying the vein donor-site scar. Observations.— We describe two cases of saphenous vein donor site dermatitis associated with sensory peripheral neuropathy in the distribution of the dermatitis. Histopathologic studies revealed a subacute spongiotic dermatitis. The course of the eruption was characterized by exacerbations and remissions with gradual resolution of both the dermatitis and neuropathy over a 1- to 2-year period. Conclusions.— Our cases are unique because the dermatitis developed in the area of the neurologic changes. We propose that the dermatitis may be a trophic change secondary to saphenous neuralgia. (Arch Dermatol.1993;129:609-612)

• The Q-switched ruby laser is used for treatment of tattoos. The effects of Q-switched ruby laser pulses on sunexposed and sun-protected human skin, as well as senile entigines, were investigated with clinical observation, light microscopy, and transmission electron microscopy. A pinpricklike sensation occurred at radiant exposures as low as 0.2 J/cm2. Immediate erythema, delayed edema, and immediate whitening occurred with increasing radiant exposure. The threshold for immediate whitening varied inversely with skin pigmentation, ranging from a mean of 1.4 J/cm2in lentigines to 3.1 J/cm2in sun-protected skin. Transmission electron microscopy showed immediate alteration of mature melanosomes and nuclei within keratinocytes and melanocytes, but stage I and II melanosomes were unaffected. Histologically, immediate injury was confined to the epidermis. There was minimal inflammatory response 1 day after exposure. After 1 week, subthreshold exposures induced hyperpigmentation, with epidermal hyperplasia and increased melanin staining noted histologically. At higher radiant exposures, hypopigmentation occurred with desquamation of a pigmented scale/crust. All sites returned to normal skin color and texture without scarring within 3 to 6 months. These observations suggest that the human skin response to selective photothermolysis of pigmented cells is similar to that reported in animal models, including low radiant exposure stimulation of melanogenesis and high radiant exposure lethal injury to pigmented epidermal cells.

• Q-switched ruby laser pulses cause selective damage to cutaneous pigmented cells. Repair of this selective damage has not been well described. Therefore, using epilated pigmented and albino guinea pig skin, we studied the acute injury and tissue repair caused by 40-ns, Q-switched ruby laser pulses. Gross observation and light and electron microscopy were performed. No specific changes were evident in the albino guinea pigs. In pigmented animals, with radiant exposures of 0.4 J/cm 2 or greater, white spots confined to the 2.5-mm exposure sites developed immediately and faded over 20 minutes. Delayed depigmentation occurred at seven to ten days, followed by full repigmentation by four to eight weeks. Regrowing hairs in sites irradiated at and above 0.4 J/cm 2 remained white for at least four months. Histologically, vacuolation of pigment-laden cells was seen immediately in the epidermis and the follicular epithelium at exposures of 0.3 J/cm 2 and greater. Melanosomal disruption was seen immediately by electron microscopy at and above 0.3 J/cm 2 . Over the next seven days, epidermal necrosis was followed by regeneration of a depigmented epidermis. By four months, melanosomes and melanin pigmentation had returned; however, hair follicles remained depigmented and devoid of melanocytes. This study demonstrates that selective melanosomal disruption caused by Q-switched ruby laser pulses leads to transient cutaneous depigmentation and persistent follicular depigmentation. Potential exists for selective treatment of pigmented epidermal and dermal lesions with this modality. ( Arch Dermatol 1989;125:43-49)

• A 53-year-old man presented to the Manhattan (NY) Veterans Administration Hospital with a 20-year history of generalized atrophic lesions associated with lower extremity ulcerations. Cutaneous biopsy specimens and other laboratory data confirmed the diagnosis of sarcoidosis involving the skin, lungs, eyes, joints, bones, pituitary gland, gonads, and liver. To our knowledge, generalized atrophic sarcoidal lesions have not been described previously in the English literature. Ulcerated cutaneous sarcoidal lesions, though recognized, are only rarely seen in the disease. The ulcerations, but not the atrophic lesions, responded to prednisone therapy. (Arch Dermatol1986;122:320-322)