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background. Chemical peeling has become increasingly popular. Technique is more critical in medium depth peeling than with deeper peels because of variable penetration of the trichloroacetic acid, objective. This article describes a novel use of two caustic agents, glycolic acid and trichloroacetic acid, to effect a predictable approach to medium depth peeling, methods. Without other skin preparation, 70% glycolic acid was applied to the entire face and diluted with water after 2 minutes. Then, 35% trichloroacetic acid was applied over the same areas. Biopsies were done on selected patients after 24 hours and 30, 60, and 90 days, results. Both clinically and histologically the glycolic trichloroacetic acid peel resulted in medium depth injury. Improvement in pigmentary dyschromias and actinic damage was impressive, conclusion. The GA-TCA peel provides a consistent approach to medium depth peeling to add to the armamentarium of the dermatologic surgeon

The harvesting of fat for autologous implantation into the hands via the tumescent technique is presented. The tumescent technique, which involves the administration of large volumes of dilute local anesthetic into the donor site, results in low serum concentrations of anesthetic and produces long-lasting anesthesia while providing vasoconstriction and a firmness of the subcutaneous compartment ideal for lipoextraction. The tumescent technique has proven to be an important advance in reduction liposuction surgery. We describe our experience with the tumescent technique as applied to microlipoinjection for hand augmentation of aged and sun-damaged skin.

Many cosmetic surgery procedures performed today were either developed or refined by dermatologic surgeons. The role played by dermatologic surgeons in the development of dermabrasion, hair transplantation, liposuction, blepharoplasty, face-lift, cutaneous implants, fat transplantation, chemical peel, and sclerotherapy is described.

BACKGROUND Soft tissue augmentation with processed fat has been used clinically for several years. This material has been termed "autologous collagen" since it was presumed it was composed primarily of collagen and fibrous tissue from lipocyte cell walls. OBJECTIVE To examine the histologic behavior of dermis implanted with processed fat. METHOD Volunteers were injected with processed fat intradermally in the post auricular area and these sites were biopsied at one week, one month, and three months. RESULTS Early biopsies revealed no intact adiopocytes but a significant inflammatory infiltrate. Subsequently biopsies revealed replacement of the inflammatory reaction with cellular fibrosis and expansion of the dermis. CONCLUSION Intradermal injection of processed fat results in deposition of fibrous material and collagen due to the response of the recipient site. The material itself contains very little collagen.

BACKGROUND. Facial telangiectasia is extremely common in patients with fair complexion. Electrosurgery has been the primary form of treatment in the past. OBJECTIVES. The authors retrospectively evaluated over 300 patients treated with sclerotherapy for facial telangiectasias. METHODS. Retrospective analysis of over 300 patients with facial telangiectasia treated with sclerotherapy and 55 facial spider telangiectasias treated with laser. RESULTS. Sclerotherapy utilizing hypertonic saline, Sclerodex, polidocanol, and sodium tetradecyl sulfate resulted in-between 50 and 100% resolution of facial telangiectasia with minimal complications. CONCLUSION. The treatment of facial telangiectasia should include sclerotherapy and laser treatment modalities, which effect a higher rate of clearance with less adverse sequela. LEARNING OBJECTIVES. After studying the following article the participants should be able to: 1 Understand the classification of superficial cutaneous facial vessels and identify their morphology. 2 Show an awaremenss of the benefits and risks of utilizing microsclerotherapy as a treatment for certain facial telangiectasias. 3 Recognize the role of laser surgery and electrosurgery as primary or secondary techniques in treating facial telangiectasias.

background : The tumescent local anesthetic approach is now being used more widely in dermatologic surgery. Although the original formula contains 12.5 mEq sodium bicarbonate per 50 mL of lidocaine, traditionally buffered solutions contain 1 mEq per 10 mL. objective : This study examines the effects of changing the concentrations of sodium bicarbonate in the tumescent formula. methods : Various concentrations of sodium bicarbonate in tumescent anesthetic preparations were measured for pH. results : Tumescent anesthetic preparations containing 5 mEq/L have a more physiologic pH (7.41) than the classic formula of 12.5 mEq/L (7.73). Clinical use of this reduced sodium bicarbonate solution showed no difference from the original formula. CONCLUSIONS: Sodium bicarbonate can be used in a 1 mEq per 10 mL of lidocaine ratio similar to other buffered anesthetic solutions. This solution is physiologic in pH. However, some thought should also be given to the pKa of lidocaine, which is at pH 7.9. To achieve this even higher concentration (20 mEq/L) bicarbonate must be added to the tumescent solution. Thought must be given to these concepts when tumescent solutions are used in large volumes. J Dermatol Surg Oncol 1992;18:973 -975.

Application of the tumescent anesthetic technique in scalp surgery, dermabrasion, and soft tissue reconstruction is discussed. Vasoconstriction achieved by using tumescent anesthesia reduces bleeding even with dilute (1:320,000) epinephrine. Tumescent anesthesia also offers the advantages of decreased absorption at the site of infiltration, increased anesthetic infiltration, delayed absorption and lower peak blood plasma levels, and a longer lasting anesthetic effect.

Clinical trials were carried out to determine if analgesia induced by nitrous oxide and oxygen could be useful as an adjunct to local anesthesia in dermatologic surgery. Patients readily accepted the procedure. The analgesia obtained reduced anxiety and pain, and no important adverse side effects were encountered. Overall, the agents and method are effective and have advantages over more commonly used agents and methods used as adjuncts to local anesthesia.

Noncosmetic applications of liposuction have continued to appear since its introduction into the United States in 1982. Although the most common use is in removing lipomas, liposuction has also been used for benign symmetric lipomatosis, flap undermining, flap defatting, gynecomastia, pseudogynecomastia, breast reduction, buffalo hump, hypertrophic insulin lipodystrophy, lymphedema, evacuating hematomas, emergency neck defatting for airway restoration, and axillary hyperhidrosis. Other uses remain to be discovered.

Limiting liposuction volumes to avoid transfusion is sound surgical practice. Although the plastic surgery literature reports frequent use of transfusions in liposuction surgery, dermatologists almost never use blood replacement after liposuction. Techniques which favor less bleeding include sufficient use of fresh epinephrine, cryoanesthesia, use of smaller cannulas, fluid preloading, proper preoperative evaluation, serial liposuction, intramuscular steroids, and rapid application of pressure garments. A review of the literature and personal experience are detailed.

Thirty-eight cases of lentigo maligna and 22 cases of lentigo maligna melanoma, were reviewed in order to compare cure rates of various methods of treatment. Surgical excision resulted in the best cure rate (91%); destructive modalities were less successful (45%). All lesions treated with 5% 5-fluorouracil recurred.