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Background Surgical reconstruction of the anterior surface of the ear (concha, antihelix, scapha, and triangular fossa) is complicated by the paucity of mobile local skin. Objective This is a retrospective study of the transcartilage island pedicle flap for reconstruction of surgical defects of the anterior ear. Methods and materials Two hundred thirty-two Mohs micrographic surgery defects were included in the study. The technique involves circumferential incision of the flap in the postauricular sulcus, transfer of the flap to the anterior ear through a surgically created cartilage slit, suturing of the flap on the anterior surface of the ear, and repair of the secondary postauricular defect. Preoperative, intraoperative, and postoperative details of each case were tabulated and analyzed. Results The mean defect size was 1.9 × 1.5 cm. Complications included flap edema (n = 6, 2.6%), postoperative bleeding (n = 4, 1.7%), partial thickness flap necrosis (n = 2, 0.9%), pinning back of the ear (n = 2, 0.9%), and central flap dimpling (n = 2, 0.9%). There was 1 acute staphylococcal abscess and 1 sterile abscess that developed 13 months postoperatively. All complications resolved with medical or surgical management. Conclusion Transcartilage island pedicle flaps may be considered for single-stage surgical reconstruction of defects involving the anterior ear.

BACKGROUND Lower eyelid margin defects can be a reconstructive challenge. A possible alternative is second intention healing of the lower eyelid margin. OBJECTIVE To determine the cosmetic outcomes and patient satisfaction of second intention healing of the lower eyelid margin after Mohs micrographic surgery (MMS). MATERIALS AND METHODS A retrospective chart review was performed on patients who underwent MMS of the lower eyelid margin. Patient information was gathered on age, sex, diagnosis, postoperative size, number of Mohs stages, thickness of defect, and clinical photographs. The preoperative and postoperative photographs were evaluated with a physician assessment scale and patients completed a satisfaction survey. RESULTS In all 17 patients (100%), the cosmetic results obtained were considered good to excellent. The objective outcomes were graded as excellent, very good, good, satisfactory, unsatisfactory, and poor. The patient satisfaction survey was divided into excellent, good, satisfied, and unsatisfied. Patient satisfaction ranged from satisfied to excellent. The incidence of complications was low with one report of trichiasis. CONCLUSION Second intention healing of the lower eyelid margin can produce good cosmetic results and patients are generally satisfied with their outcomes.

Background A vasovagal reaction is a commonly encountered event in outpatient procedures. There is a paucity of discussion on vasovagal reactions (VVRs) in the dermatologic surgery literature. However, recent investigations in the physiology, evaluation, and treatment of VVRs have been reported in other specialties. Objective A comprehensive review of the physiology, evaluation, treatment, and prevention of VVRs. Materials and methods A search as performed using the PubMed/MEDLINE databases. Search terms included "vasovagal," "vasovagal reaction," "syncope," "reflex syncope," "neurocardiogenic syncope," and "fainting." Results Studies demonstrate greater understanding in the physiology of a vasovagal reaction. Although permanent sequelae are uncommon, it is important to respond in a prompt manner. A variety of treatment and prevention options are presented. Conclusion Vasovagal reactions should be carefully evaluated. Additional studies may provide greater data in understanding and managing vasovagal reactions.

BACKGROUND The patient consent process traditionally relies on conversations between the physician and the patient and rarely utilizes supplemental multimedia aids. OBJECTIVE To determine whether the addition of an educational video on Mohs micrographic surgery (MMS) can improve patient satisfaction with the consent process. MATERIALS AND METHODS This prospective observational quality improvement study compared the outcomes of traditional patient consent alone versus standard consent plus an educational video among patients undergoing their first MMS for a primary skin cancer. End points were patient satisfaction and preferences measured by postprocedure questionnaires. RESULTS The addition of a supplemental video to the consent process did not affect overall patient satisfaction, which was very high in both video and control groups. However, specific components of patient satisfaction were improved such as patient perception of the opportunity to ask questions and understand the procedure. CONCLUSION Multimedia aids can be effective tools in the patient consent process.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening drug-induced reaction. Though the most common clinical manifestations are eosinophilia, fever, rash, and lymphadenopathy, patients can also present with severe organ dysfunction. The pathogenesis of DRESS syndrome is only currently partially understood, though it is known that DRESS syndrome is commonly associated with infection or viral reactivation; specifically, human herpes viruses 6 and 7 and Epstein-Barr virus have been implicated in the pathogenesis. We present the first case of DRESS syndrome in the context of serology-proven influenza virus.

Background The apical triangle of the upper cutaneous lip, also known as the alar-facial sulcus, is an anatomical structure bound medially by the nasal ala, laterally by the medial cheek, and inferiorly by the remainder of the upper cutaneous lip. During reconstruction, retaining the central concavity and the convex lateral and medial outlines of this location is required to maintain midfacial symmetry. Objective This is a retrospective study of our use of the melolabial rotation flap for reconstruction of surgical defects of the apical triangle. Methods and materials Eighty-six surgical defects involving the apical triangle that were repaired with melolabial rotation flaps were included. All tumors were treated with Mohs micrographic surgery before reconstruction. Preoperative, intraoperative, and postoperative details of each case were analyzed. Results Of the 86 defects included in the study, 68 (79%) were evaluated postoperatively. The apical triangle was preserved in all cases. Clinical asymmetry was noted in 3 patients (3.4%). No major complications were noted, and no patient required surgical revision. Conclusion Melolabial rotation flaps may be considered for single-stage reconstruction of surgical defects involving the apical triangle.

Background Histologic examination of tissue is the foundation of Mohs micrographic surgery because determination of surgical margins influences whether additional tissue will be taken. Currently, there is no large focused study comparing toluidine blue (TB) and hematoxylin and eosin (H&E) stains in the evaluation of squamous cell carcinoma (SCC). Objective This study evaluates whether TB and H&E are comparable in assessing the presence of tumor in frozen sections of SCC. Materials and methods One hundred eighty-six randomized slides representing 93 tissue pieces from 36 tumors were examined by 3 Mohs surgeons (1 Accreditation Council for Graduate Medical Education fellow and 2 fellowship-trained surgeons) and compared using a template that documented the presence and location of tumor on the slides. Results The evaluation of SCC with H&E and TB stains was highly concordant, with concordant identification of SCC in 96%, 96%, and 94% of tissue layers among the 3 Mohs surgeons ARS, LHG, and AK-A, respectively. Conclusion Toluidine blue and H&E stains are statistically similar in their ability to detect SCC and guide Mohs surgical decision-making.

Subungual amelanotic melanoma can masquerade as onychomycosis. Recently a man whose amelanotic nail bed melanoma presented as persistent onychodystrophy was reported in the Dermatology Online Journal. The patient had a persistent nail dystrophy; culture and biopsy of the nail demonstrated Candida and dermatophyte infection, respectively. However, he subsequently presented with a nodule that was biopsied and demonstrated melanoma. Similar to that patient, we recently described a 67-year-old woman with a four-year history of persistent nail dystrophy of the left fourth fingernail who had a periodic acid-Schiff staining of the nail plate demonstrating fungal hyphae. Her nail plate subsequently detached, demonstrating a friable nodule; a biopsy of the nodule demonstrated melanoma. In conclusion, in individuals with new morphologic changes to a dystrophic nail or with persistent nail dystrophy despite appropriate therapy, it is important for clinicians to consider performing additional evaluation and possible biopsy to exclude malignancy.

Actinic keratoses (AKs) are in situ epidermal tumors that may progress to invasive squamous cell carcinomas. Liquid nitrogen is used during cryotherapy to freeze the epidermis and upper dermis and is the standard treatment for individual AKs.To evaluate the efficacy of a cryosurgery device incorporating an infrared sensor to measure the temperature at the skin surface while spraying liquid nitrogen on the surface of the skin during the treatment of AKs.Thirty-six patients with 180 thin AKs were treated with liquid nitrogen spray to a temperature of -5°C using the sensor to control the temperature at the skin surface. Patients were evaluated for cure rate, side effects, and healing time.At the 1-week follow-up, 66.7% of the lesions were cleared. By the 6-week follow-up, there was a 100% cure rate. Side effects were limited to redness, blistering, crusting, oozing, and ulceration at the 1-week follow-up and were resolved by the 6-week follow-up. No recurrence of AK, scarring, or hypopigmentation was noted.Cryotherapy with an integrated sensor for temperature control is an effective, safe, and precise treatment, allowing for a 100% short-term cure rate of AKs.

Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities.To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method.Eight female patients (Fitzpatrick skin type II-IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3- to 8-week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8-10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow-up visit 7 to 36 months (mean 13.5 months) after the last treatment session.At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow-up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted.FP is a safe and effective treatment for refractory melasma, with long-term remission.

BACKGROUND AND OBJECTIVES Acne scars affect the entire population, causing significant distress and concern. Previous treatments for acne scars have yielded varying degrees of success and associated side effects. Fractional photothermolysis has been shown to improve scars, including surgical scars, hypopigmented scars, and atrophic acne scars. The newest system has the option of increased fluences for greater depth of penetration and variable treatment coverage. Our aim was to determine the efficacy and safety of the second-generation erbium-doped 1,550-nm fractional photothermolysis laser (1,550nm Fraxel SR laser, Reliant Technologies Inc.) in the treatment of all types of acne scars and of all severities. STUDY DESIGN/MATERIALS AND METHODS Twenty-nine patients (20 females and 9 males, ages 15–65 years), Fitzpatrick Skin Types I to V, were treated with two to six treatments with the second-generation erbium-doped 1,550-nm fractional photothermolysis laser at 1-month intervals. Fluences ranged from 35 to 40mJ/microthermal zone. Treatment levels varied from 7 to 10 and ‘‘Advanced Level 1,’’ corresponding to treatment coverage of 20% to 35%. Patients were graded on a 4-point scale by three independent physicians using digital photography. RESULTS The majority of patients achieved a 50% to 75% improvement in facial and back acne scarring (18 of 29 patients). Five patients had an improvement of greater than 75% in acne scarring, 5 patients had a 25% to 50% improvement in acne scarring, and 1 patient had less than a 25% response to treatment. The patients’ degree of satisfaction paralleled the physicians’ assessment. Side effects were minimal and no posttreatment pigmentary changes were noted. CONCLUSION Fractional photothermolysis is a safe and efficacious treatment modality for the treatment of all types of acne scars of all severities. No adverse effects were noted, including in patients with Fitzpatrick Skin Types III to V. The authors have indicated no significant interest with commercial supporters.

An 80-year-old man with a history of nonmelanoma skin cancers of the head and neck presented for treatment of a basal cell carcinoma of the nose. Physical examination revealed a poorly defined, exophytic, ulcerated nodule of the mid-dorsal nose. Given the size, location, and ill-defined margins of the tumor, Mohs micrographic surgical excision was indicated. The tumor was excised in three stages with microscopic control. The final defect was full thickness of the dermis, sparing the underlying muscle and measuring 3.2 x 2.4 cm on the mid-dorsal, supratip, and lateral aspects of the nose (Figure 1). How would you repair this defect?

BACKGROUNDLaser treatment for photoaging of the hands should ideally address pigmentary alteration as well as associated skin roughness and wrinkling. Fractional resurfacing has been previously shown to effectively treat facial rhytids and dyschromia.OBJECTIVEWe examined the effect of fractional res

BACKGROUND There are numerous blades available for use in dermatologic procedures. There are different advantages that are inhere.nt to different blades due to their shape and size. One aspect of the blade that is instrumental to its performance, but is not objectively defined, is sharpness. This information could be useful when choosing a blade for a particular procedure. OBJECTIVE This study aims to objectively define the sharpness of blades used in dermatologic surgery. METHODS AND MATERIALS The Sharpness Tester (Cutlery and Allied Trades Research Association, Sheffield, UK) was used to test the force in Newtons a blade requires to cut through a silicone cylinder. New blades were used to determine a standard for the sharpness of new blades. Blades used for surgery were tested to determine the sharpness after use. RESULTS The sharpest blade is the double-edged razor blade (0.395 N) followed by the dermablade (0.46 N), plastic handled #15 (0.541 N), #15c (0.575 N), #10 (0.647 N), and the #15 blade (0.664 N). CONCLUSION The sharpness of a blade is an important factor in its ability to perform a task and should be taken into account when choosing a particular blade for a particular procedure.

Poikiloderma of Civatte refers to a change in the skin where there is atrophy, hyper- and hypopigmentation, and dilation of fine blood vessels (telangiectasia). These alterations often cause cosmetic disfigurement, most commonly in middle-aged or elderly women with a fair complexion. Several treatment modalities, based on the theory of selective photothermolysis, including argon lasers, KTP lasers, pulsed dye lasers, and intense pulsed light devices, have been used to treat this condition in the past. Clinical experience has shown that complete clearing is difficult to achieve. Moreover, depending on the modality used, adverse effects, such as scarring with irregular hypopigmentation, post-inflammatory hyperpigmentation, post-treatment purpura, mottled appearance, crusting, and erythema, have been reported. Multiple sessions with these treatments are usually necessary to obtain optimal clearing.

BACKGROUNDInjection of filler materials into the dermis is well tolerated with few mild and transient side effects. Injection necrosis is a rare but clinically important potential complication caused by interruption of the vascular supply to the area by compression, injury, and/or obstruction of the

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm with microscopic similarities to non-cutaneous lymphoepitheliomatous malignancies, particularly undifferentiated carcinoma of the nasopharynx. It can be clinically and histologically confused with other benign and malignant tumors. If not adequately treated, recurrence and distant metastasis are probable. We present two cases of LELCS treated surgically with complete microscopic margin control (one by the Mohs method and the other with en face permanent sections) and review the literature.

Background Squamous cell carcinoma (SCC) of the ear compared with SCC occurring at other skin sites has an increased incidence of recurrence following treatment. Objective To determine the following variables: patient age and gender, life status, tumor location, and recurrence rate following Mohs micrographic surgery (MMS). Methods The charts of 117 patients with 144 invasive SCCs of the auricle were reviewed. The patients were contacted by telephone to confirm tumor recurrence and patients' life status. The range of follow-up was 7 to 67 months (average 34.6 months) after MMS. Results The patients' ages ranged from 34 to 90 years (mean age 71 years). The male to female ratio was 22:1. The helix was the most common site of occurrence (50.7%). Local recurrence after MMS was found in four patients (five tumors). MMS was performed on these five recurrent tumors, with no further recurrences. Telephone confirmation was obtained on 91 patients (26 patients could not be contacted) with 122 tumors, which included the 4 patients with 5 recurrent tumors. There were no additional recurrences. Of these 122 tumors, 35 were followed for less than 2 years (average 16.6 months), and 87 were followed for 2 years or more (average 41.8 months). From the chart review and telephone contact, the 2-year local recurrence rate was 5.7% (5 of 87 tumors) after MMS. The average size of these 87 tumors was 3.5 cm2. Twelve of 91 patients had died with evidence of active disease from causes unrelated to SCC. Conclusion Invasive SCC of the ear was once a formidable disease with a severe prognosis. The course of this disease has been appreciably improved by early diagnosis and treatment with MMS.

Background Full-thickness skin grafting (FTSG) is an option for reconstruction of nasal defects. Objective To correlate the clinical outcome of FTSG on the nose with donor site, location of the defect, and defect size. Methods Patients with FTSG on the nose following Mohs' micrographic surgery were enrolled. Clinical and photographic assessments were performed. Results There were 54 FTSGs; the mean age was 20.6 months, and the average size was 2.1 cm2. The clinical assessment score was significantly different across donor sites, with dog-ear skin providing the best results, followed, respectively, by conchal bowl, preauricular, postauricular, and inner arm skin (p= .006). The global clinical outcome determined from the clinical assessment score was good for inner arm skin and excellent for other sites. The photographic assessment score was not different among donor sites (p= .601). There was no correlation of location and size of the defect to the clinical outcome assessed clinically and photographically (p > .05). Conclusion All potential donor sites should be considered to select the donor site that best matches the defect. SIRUNYA SILAPUNT, MD, S. RAY PETERSON, MD, MURAD ALAM, MD, AND LEONARD H. GOLDBERG, MD, FRCP, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

Background. There are a number of reports in the literature of patients developing thrombotic events after stopping medically necessary antiplatelet and antithrombotic agents. Objective. The objective was to determine whether discontinuation of aspirin taken for primary prophylaxis contributes to the development of thrombotic complications in patients undergoing dermatologic surgery. Methods. A case is reported and the literature is reviewed. Results. We present the first reported case of a postoperative thrombotic event following dermatologic surgery in a patient withholding aspirin that was taken for primary prophylaxis. Conclusion. We believe that the available data make it difficult to implicate aspirin discontinuation in the development of each thrombotic event, given the high baseline risk of thrombotic events in the Mohs surgery patient population and the low risk of developing such events when medications are withheld perioperatively.

Background. Elliptical excision is a standard form of treatment for cutaneous neoplasms, but routine pathologic sectioning results in incomplete histologic control of surgical margins. Objective. The objective was to describe a technique of complete histologic margin control for tumors removed by excision as an ellipse. Methods. A retrospective study of 100 consecutive nonmelanoma skin cancers of the head and neck removed using elliptical excisions with complete histologic margin control was performed. The technique is described and depicted in detail. Results. Seventy-one tumors were removed in one excision, and 29 required additional excisions for complete histologic tumor clearance. Linear repairs were used for 93 tumors. Conclusion. Elliptical excision, combined with our technique of complete histologic margin control, provides a simple, efficient, and effective method for surgical removal and repair of nonmelanoma skin cancers and provides an alternative variation of performing Mohs micrographic surgery for selected tumors.

Background. Granular cell tumors, also known as granular cell myoblastomas, are uncommon neoplasms of unknown etiology. Most granular cell tumors are benign and present as solitary, painless dermal nodules of the head and neck. Few of these tumors are reported on the lower extremities and only eight cases of granular cell tumor of the foot have been reported. Of these eight, only two clinically benign granular cell tumors occurred on the heel. Objective. The objective was to describe the first reported case of malignant granular cell tumor of the heel. Methods. All reported cases of granular cell tumor of the foot are reviewed and clinical details of a malignant granular cell tumor of the heel are provided. Results. The malignant granular cell tumor of the heel was extirpated with two stages of Mohs microscopic surgery. No recurrence was noted at 22 months. Conclusion. malignant granular cell tumor of the heel is among the rarest of malignancies. In this case, the tumor appears to have been successfully treated with Mohs micrographic surgery.

Background. Advancements in nonablative laser technology necessitate concurrent developments in topical anesthesia, as patients have reported varying degrees of discomfort during these procedures. Although topical anesthetics have proven efficacious, they possess inherent limitations related to ease of use. Objective. To evaluate the efficacy of the S-Caine Peel (ZARS Inc., Salt Lake City, UT), a novel topical anesthetic that dries to form a flexible membrane, for induction of anesthesia after only a 30-minute application period. Method. Twenty patients received concurrent 30-minute applications of both the S-Caine Peel and a placebo cream randomized to the right and left cheeks in a double-blinded manner. After one pass of the 1450-nm diode laser (Smoothbeam, Candela Corp., Wayland, MA), patients' pain levels were recorded on a visual analog scale (VAS). Both the investigator and an independent observer rated perceived discomfort and immediate skin reaction based on a numerical scale. Results. Differences in VAS scores between active sites (average rating of 15 mm) and placebo sites (average rating of 47 mm) were statistically significant (P

Background. Bilobed flaps, transposition repairs used primarily on the nose, recruit tissue from an area of laxity via rotational motion. A variant of the bilobe, the two-lobed flap based on the W-plasty, is a transposition flap that shifts tissue predominantly via advancement. Objective. To apply the two-lobed advancement flap to the problem of reconstructing cutaneous helical rim defects of the ear. Methods. Helical two-lobed advancement flaps were designed and implemented to correct small- to medium-sized defects. Results. The ear helix was successfully repaired with two-lobed advancement flaps. There was minimal distortion of the ear architecture or cartilage, and blood supply was sufficient to ensure flap viability. Conclusions. In selected cases, cutaneous helical rim defects of the ear can be aesthetically repaired with a two-lobed advancement flap derived from the posterior auricular surface.

background. Laser eye protection has been designed to protect operators and patients from severe eye injuries. objective. To describe two cases in which lasers used for cutaneous therapy may have been associated with the induction of vitreous floaters, a subacute eye injury, in physicians operating these devices, and to review the theoretical feasibility of such injuries, prior reports of the same, and strategies for minimizing risk. methods. Report of two cases and review of the literature. results. Given the circumstantial evidence, it is possible that subacute vitreous injuries may be sustained by the operators of dermatologic lasers. Ex vivo experiments and previous case reports have demonstrated the possibility of laser-induced vitreous injury, including changes in vitreous conformation and vitreous hemorrhage, in the absence of permanent retinal deficits. It may be speculated that vitreous floaters are a milder manifestation of such subacute injuries. conclusion. To the extent that vitreous floaters can multiply and presage the onset of severe retinal injury, the risk of their induction by dermatologic lasers should be minimized. Simple strategies and further research can help achieve this goal.