Search

BACKGROUND Psoriasis affects an estimated 3% of the world's population. Many are on chronic immunosuppressive therapy for the cutaneous and joint manifestations of this disorder. The management of these medications in the perioperative period is controversial. Psoriasis and psoriatic arthritis medications can affect wound healing, hemostasis, and infection risk during cutaneous surgery. OBJECTIVES The objective of this article is to provide a critical review of various medications used for care of the psoriatic patient and their potential effect on cutaneous surgical procedures. CONCLUSIONS This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.

Background. Solid-organ transplant recipients (OTRs) with sun-sensitive skin, a history of sun exposure, and clinical signs of photoaging have an increased risk of developing squamous cell carcinoma. Objective. The objective of this study was to compare the sun protection attitudes and behaviors of OTRs with those of the general public. Methods. In spring 2003, a telephone survey of 200 OTRs and a random sample of 1091 U.S. residents were performed with standardized questions previously used in population surveys. Results. Seventy-nine percent of OTRs and 69% of the U.S. public believe that the appearance of a tan is attractive. The attitude was expressed more often by men than by women and is not related to the education of the person. A greater proportion of OTRs believed that people looked “healthier” with a tan and 88% of OTRs were not aware of their increased risk of developing skin cancer. Thirty-five percent of OTRs reported regularly using sunscreen, which is the principal form of sun protection used. Women report more regular use of sunscreen than men. OTRs wear less protective clothing and seek less shade when outdoors than the public. Sunburning was reported by 35% of OTRs, which is similar to the rate reported by the public. Conclusion. OTRs' attitude that people look “better, healthier” with a tan inhibits effective sun protection. Although physicians who care for OTRs provide patient education in the hope that it increases their awareness of their risk of developing skin cancer and will promote change in their sun protection behaviors, the OTRs' perception of risk is influenced by many concerns. Interpersonal motives, particularly for OTRs, the self-presentational ones related to appearance and the social image or prototype of a tanned person being healthy, mitigate risk perception of the health problem. Risk perception does not always inhibit risk behavior; therefore, unprotected sun exposure occurs in OTRs.

Suspension, pexing, or tacking sutures were used in facial cosmetic surgery and have recently been used in facial reconstruction.Suspension sutures are used to fix the closure line at the junction of cosmetic units, to prevent distortion of free margins secondary to wound contraction (e.g., ectropion or eclabium), to reform a fold that would be obliterated by the motion of tissue, and to prevent tenting across concavities. Although suspension sutures may help to reduce the spreading of scars in wounds closed under tension, they do not prevent some spreading.The suturing technique requires a stable structure for attachment of the suspension sutures and lax tissue to advance into the wound. On the face, a stable base exists under junctions of cosmetic units along the orbital rim, zygomatic arch, nasal vestibule, and mental crease of the chin. When the deep roll of the needle includes superficial musculoaponeurotic system with the first segment or the pulling arm of the suspension suture, tissue advancement is obtained. The second or anchoring segment is placed with the needle encompassing a very tight arc traveling in a U-shaped pass into the fascia extending to the periosteum.Suspension sutures enable linear closures, prevent distortion of free margins, prevent tenting across concavities, and fix the closure line at the junction of cosmetic units. By redirecting tension, suspension sutures mold surface contours to mimic the natural folds and curves of the face. Judicious use of suspension sutures permits simpler aesthetic reconstructive procedures than might be achieved without their use. Suspension sutures used in this manner help to apply the theoretical concepts of facial reconstruction using facial cosmetic units by performing segmental facial reconstruction.

background. Full-thickness skin grafting following Mohs micrographic surgery (MMS) of the nasal tip and ala provides easy postoperative wound care and avoids functional impairment caused by wound contraction of the nasal ala free margins. Direct comparison of immediate and delayed skin grafting determined which offers greater success and defined factors contributing to success. objective. To determine if delayed or immediate full-thickness skin grafting results in better graft survival with improved function and appearance, and to identify the recipient bed characteristics, including the size of the wound, the proportion of the wound base having perichondrium, denuded cartilage, and granulation tissue, and graft survival for each technique. methods. We used a prospective study comparing 200 patients with wounds having a 3–5 cm2 surface area repaired immediately with a full-thickness skin graft (FTSG) to 200 patients with a delayed FTSG. The depth and diameter of the wound of the nasal ala and tip, and characteristics of recipient bed including size (cm2), location, proportion of wound base with perichondrium present, denuded cartilage, granulation tissue, and proportion of graft loss were the main outcomes measured. results. Partial graft loss occurred in 11% of those having delayed skin grafts and 30% of those with immediate repair. Delayed grafting was associated with a larger wound surface area (P < .0001), more denuded cartilage (P = .017), greater exposed perichondrium (P < .0001), and less partial graft loss (P < .001). When partial graft loss occurred, the area of loss was smaller with delayed FTSG (P = .036). Contraction of the wound and subsequent nasal valve impairment occurred less often with delayed FTSG (P < .0001). Graft depression was significantly less with delayed FTSG of the ala (P < .0001) and also improved on the nasal tip (P = .47). conclusion. This prospective clinical trial of immediate and delayed FTSGs of the nasal tip and ala with denuded cartilage showed improved graft survival in cases where grafting was delayed for 12–14 days. During this period, substantial granulation tissue formed in the wound base. Assessment of the wound base and the presence of granulation tissue are key factors in the success of full-thickness skin grafting.

Background. Suspension, pexing or tacking sutures, which have a long history of use in facial cosmetic surgery, have only recently begun use in reconstruction. Objective. In this study, the suspension suture was used to fix the closure line at the junction of cosmetic units, to prevent distortion of free margins secondary to wound contraction, eg, ectropion or eclabium, to prevent tenting across concavities, and to prevent scar spreading of wounds closed under tension. The acute complications and long-term effectiveness of this suturing technique in achieving the 4 desired results were evaluated. Methods. During a 10-year period, 136 cases of surgical defects of the face created by the removal of nonmelanoma skin cancer by Mohs micrographic surgery were repaired using absorbable suspension sutures. The wounds were evaluated initially for acute complications of hemorrhage, infection, dehiscence, and necrosis; and later over 3 years for chronic sequela of hypertrophic scar, spread scar, contraction deformities such as distortion of free margins, and pigmentary changes. Results. Suspension sutures were used in 60 cases of primary layered closure and 76 flaps of the face. Suspension sutures allowed primary closure of defects that would have required flaps in 72% of the cases and prevented distortion of free margins. There were more acute and long-term complications related to excess tension with primary closure than with flaps. Suspension sutures fixed the closure line at the junction of cosmetic units, prevented tenting across concavities, and both features were maintained over the duration of the study. Conclusion. Suspension sutures aided in obtaining linear closures, prevented distortion of free margins, prevented tenting across concavities, and fixed the closure line at the junction of cosmetic units; however, they did not prevent spread scars.

background Bowen's disease (squamous cell carcinoma in situ) is an intraepithelial neoplasm that am transform into invasive squamous cell carcinoma. The preferred method of eradication for Bowen's disease is surgical excision. However, when Bowen's disease occurs on the digit, surgical removal can lead to scar contracture and loss of use of the finger. objective To assess the utility of carbon dioxide (CO2) laser vaporization in eradicating Bowen's disease of the finger while maintaining the full range of motion and use of the digit. methods Five patients were treated with CO2 laser vaporization for Bowen's disease of the digit. Patients were followed postoperatively for recurrence, clinical appearance, especially for scar formation, and function of the involved joints over a 6-month to 3-year period. results Four of five patients had no recurrence. Healing resulted in only modest alterations in the cosmetic appearance in comparison with the surrounding untreated skin. Posttreatment biopsy showed slight thinning of the epidermis and mild fibro-plagia limited to the papillary dermis. Patients reported only mild postprocedure discomfort and no patients had any loss of function of the digit. conclusions CO2 laser vaporization may be a safe and effective means by which to eradicate Bowen's disease of the finger without the risk of scar contracture and loss of function of the digit.

Wound healing of scalpel incisions to the depth of adipose tissue closed with conventional methods was compared with closure by low-output carbon dioxide laser irradiation. In 3 Pitman-Moore minipigs wound healing was evaluated at intervals from 1 to 90 days by the following methods: clinical variables of wound healing; formation of the basement membrane components bullous pemphigoid antigen, laminin, and fibronectin; and histological evaluation of the regeneration of the epidermis, neovascularization, and elastin and collagen formation. There was no significant difference in healing between wounds closed by the various conventional methods and by the low-output carbon dioxide laser.