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ImportanceExcisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery.ObjectiveTo systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology.Evidence reviewSurvey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations.FindingsIn total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions.Conclusions and relevanceWhen definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.

Healthcare is a potent emitter of greenhouse gases amounting up to 7% of total estimated greenhouse gas emissions (CO2e) for Australia. Australia has one of the highest incidences of skin cancer in the world but there is a paucity of data on the ecological impact of skin cancer excision/dermatologic surgery. The authors reviewed the various impact inventories in order to perform a life cycle assessment of skin cancer excision. A total of 8641 tonnes of estimated CO2e are produced from dermatologic surgery annually in Australia (6751 tonnes from private clinical rooms and 1890 tonnes from hospitals) and the waste generated contributes significantly to terrestrial ecotoxicity and acidification of land and water. Various means can be carried out to reduce this impact, ranging from simple behavioural changes to larger, policy changes. [ABSTRACT FROM AUTHOR]

The increasing number of patients undergoing antithrombotic therapy and a higher prevalence of skin neoplasia implies an adequate management of these drugs in the perioperative period during dermatological surgery. The authors present and discuss the protocol for clinical practice followed in the Dermatology and Venereology Department of Centro Hospitalar Universitário São João. Suspension or maintenance of therapy with antiplatelet and/or anticoagulant drugs should be assessed individually, taking into account the patient and intervention's bleeding risk and the degree of thrombotic risk of the patient. In these patients, local hemostatic measures are particularly relevant in the management of perioperative haemorrhage and should be thorough. The Immunohemotherapy Department provides collaboration in situations of difficult bleeding management. [ABSTRACT FROM AUTHOR]

Introduction: Keloids are benign skin tumors caused by changes in the wound healing process. There are various therapeutic options available and the combination of techniques is commonly used. Conclusion: Five patients underwent a combined treatment of surgical resection of a keloid in the earlobe with subsequent placement of a pressure earring and were evaluated using sterile plungers of 5 mL syringes. The procedures were performed at Jean Bitar Hospital in the state of Pará from 2019 to 2020. No local recurrence was observed. The earring production was considered low cost, easily reproducible, good aesthetic appearance, and good tolerability. [ABSTRACT FROM AUTHOR]

Objective: Multiple techniques are available for closing skin defects, such as skin grafts, flaps and tissue expansion. The tissue extender MID SEW (MID, France) was developed to achieve dermatotraction or suture reinforcement. The aim of this study was to evaluate the effectiveness and safety of this innovative silicone extender for large surgical wounds., Method: A single-centre retrospective and observational study on an unselected consecutive cohort of patients treated with a tissue extender was conducted. Indications, initial and final wound surfaces, and adverse events (AEs) were retrieved from electronic medical records. The main outcome measure was the time to complete wound closure., Results: We identified 50 patients from July 2017 to December 2018. Patients underwent cutaneous tumour-wide excision (n=44), or pilonidal disease surgical treatment (n=6). The average initial wound area was 53.3±42.4cm 2 . Healing was complete, without secondary dehiscence, within the first seven days after device withdrawal for 41 patients (82%). At least one AE was experienced by eight patients (16%) during the study period: five inflammation; five wound dehiscence; two skin necrosis; and one pain., Conclusion: This case series suggests that the tissue extender may be effective and safe in its dermatotraction and suture reinforcement indications in the treatment of large wounds after wide excision of skin cancer or treatment of pilonidal disease., Declaration of Interest: This work was supported in part by the Hospices Civils de Lyon, France and in part by the University Claude Bernard Lyon 1, France. OB co-owns the patent on the MID SEW system. The authors have no other conflicts of interest to declare.

Background: With the increasing demand for surgical procedures in dermatology, resident education in surgical dermatology has become important for delivering high-quality treatment. However, it remains unclear if a sufficient number of residency programs with quality standards exist, as there has been little research on this subject in South Korea., Objective: To identify the status of surgical dermatology education among residents and assess dermatologists' perceptions of the subject., Methods: A 35-question survey was developed and distributed to all resident training hospitals and local clinics listed by the Korean Society of Dermatologic Surgery. Only third- and fourth-year residents were included and board-certified specialists from training hospitals and local clinics responded to the surveys., Results: Survey participants included 88 residents and 120 specialists of whom one-quarter of the residents attended regular monthly educational sessions. Most residents (93%) participated in cosmetic procedures, and many performed laser therapy. However, the opportunity for toxin or filler injection was rare, with only 12% of the residents having experience with filler injections. In response, 49% of residents and 32% of specialists said that more cosmetic training was required, whereas 28% of residents and 50% of specialists said that more training for both cosmetic and conventional surgeries was necessary., Conclusion: The survey demonstrated a need for more training programs in surgical dermatology during residency and a perception gap between residents and specialists. Therefore, developing educational residency programs that focus on basic dermatologic surgery principles and their applications in cosmetic procedures is essential., Competing Interests: The authors have nothing to disclose., (© 2024 The Korean Dermatological Association and The Korean Society for Investigative Dermatology.)

Competing Interests: Conflicts of interest None disclosed.

Objective: Family physicians (FPs) in Canada routinely perform in-office cutaneous surgery. There is strong evidence to support a moist wound healing environment, resulting in faster healing times and improved cosmesis. However, the wound care practices of FPs have not been previously studied. We aimed to examine the postoperative wound care practices of FPs after in-office cutaneous surgery., Method: An online survey was distributed to Canadian FPs to determine post-surgical wound care practices. The survey examined moist versus dry wound healing and the reasons for these recommendations were explored. Additional wound care practices were also studied. Appropriate statistical analyses were undertaken., Results: A total of 573 (91.5%) FPs completed the survey. Just under half (49.2%) of FPs recommended moist wound healing to their patients, while the remaining respondents (50.8%) recommended dry wound healing. The most endorsed reason for both moist and dry wound care recommendations was prior training (63.1% and 65.3%, respectively). Most physicians (57.2%) recommended the use of a cream or ointment postoperatively. While there appeared to be consensus on recommending sun avoidance after cutaneous surgery (77.7%), additional wound care practices varied, including: the use of dressings; cleansing practices; smoking cessation; reduction in physical activity; photoprotection; water exposure; and scar treatment/cosmetic use., Conclusion: Almost half of FPs in Canada responding to the survey did not recommend moist wound healing despite strong evidence to support this practice. We also noted a diverse range of postoperative wound care practices after in-office cutaneous surgery. Therefore, these results highlight a critical need for consistent wound care recommendations following cutaneous surgery for FPs in Canada.

Competing Interests: Conflicts of interest Author Kim is a paid consultant at Verve Therapeutics and SeQure Dx, unrelated to this research. Author Kim’s interests were reviewed and are managed by Mass General Brigham in accordance with their conflict-of-interest policies. Author Shiau, Author Young, Author Baker, and Dr Bae have no conflicts of interest to declare.

At the 2024 American Academy of Dermatology annual meeting in San Diego, California, attendees explored the latest advancements in clinical and surgical dermatology and physician well-being. Key takeaways for residents included enhancing surgical experiences, adapting ergonomic practices, and prioritizing both patient and physician well-being. The meeting underscored the importance of combining technical proficiency with compassionate patient care and continuous learning in dermatology.

Competing Interests: Conflicts of interest None disclosed.

Recent advances in optical technologies have produced laser systems capable of optimizing the appearance of scars from various etiologies. Laser treatment can commence as early as the time of the initial injury and as late as several years after the injury. Optimal results can now be attained with minimal down time. Herein, we review several available optical technologies for treatment of surgical, traumatic, and inflammatory scars, based upon our clinical experience.

Introduction: Basal cell carcinomas are mostly treated surgically, mostly by surgery with postoperative histopathologic margin evaluation (“conventional surgery”), but large long-term data regarding recurrence by completeness of excisions is limited. Methods: Retrospective cohort study of basal cell carcinomas treated by conventional surgery at different medical specialties in a large tertiary centre, between 2008 and 2014. Survival analysis with a Cox proportional-hazards was performed, stratified by completeness of excision (complete excision/incomplete excision) and adjusted to several potentially confounding covariates. Results: A total of 2876 basal cell carcinomas were identified, of which 2306 (2100 primary, 206 recurrent) were considered eligible for analysis. During the 5-years of follow-up, there were 80 (4%) recurrences among 1980 complete excisions (16/1000 cases-year) and 83 (23.9%) recurrences among 348 incomplete excisions (100/1000 cases-year). Survival analysis was performed with multivariable adjustment. In the final adjusted model, we identified an association between relapse and re-intervention on recurrent tumors [adjusted Hazard Ratio (HR) 2.20 (95% Confidence interval (IC), 1.26-3.84), p=0.006], a wrong preoperative clinical diagnosis/surgery devoid of preoperative biopsy [adjusted HR 2.75 (95% CI, 1.68-4.5), p

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Background Skin grafting is a commonly performed operation in plastic and reconstructive surgery. The tie-over dressing is an effective technique to secure the grafted skin by delivering persistent downward pressure. However, if an additional dressing is required due to incomplete graft healing, the process of re-implementing the tie-over dressing may be frustrating for both patients and surgeons. Therefore, we introduce the double tie-over dressing, which readily allows for an additional tie-over dressing after the first dressing, and we present a comparison of its effectiveness with that of the simpler bolster dressing.

Objective: Rare disease Background: Primary cutaneous cribriform apocrine carcinoma is a histopathological variant of apocrine adenocarcinoma (AA) of the skin, which is a rare, low-grade malignancy. While low-grade in nature, cutaneous cribriform apocrine carcinoma can mimic a metastatic manifestation of a visceral or breast malignancy, and is important to distinguish as primary through clinical history, histology, and immunohistochemical studies, if indicated. Case Report: A 56-year-old man with past medical history remarkable for basal cell carcinoma and hypertension presented with a 12-month history of a slowly enlarging, asymptomatic nodule on his right anterior medial lower leg. Physical examination revealed a 12×9 mm indurated and erythematous nodule with no other masses or lymphadenopathy detected. Histology demonstrated a well-circumscribed proliferation of epithelial cells in fibrosing granulation tissue-like stroma having the delicate cross-bridging of a cribriform carcinoma. Immunohistochemical studies were significant for positive high-molecular-weight keratin and cytokeratin, focal positivity for carcinoembryonic antigen (CEA) and S100, with negative results for prostate-specific antigen (PSA) and cytokeratin 20. Conclusions: Clinicians should maintain a high index of suspicion for metastasis when cutaneous cribriform apocrine carcinoma is diagnosed. The use of clinical history and appropriate laboratory workup with parameters such as age and sex can guide workup. After a wider excision with clear margins, follow-up for evidence of recurrence or metastasis is recommended, as the limited number of reported cases suggests that this assumption cannot be made with certainty. [ABSTRACT FROM AUTHOR]

BackgroundAblative fractional carbon dioxide (CO(2)) laser treatments have gained popularity due to their efficacy, shortened downtime, and decreased potential for scarring in comparison to traditional ablative CO(2) resurfacing. To date, scarring with fractional CO(2) lasers has not been reported.ObjectiveFive patients treated with the same fractional CO(2) laser technology for photodamage of the neck were referred to our practices 1-3 months after treatment. Each patient developed scarring. Of the five cases, two are discussed in detail. The first was treated under general anesthesia on the face and anterior neck at a pulse energy of 30 mJ (859 microm depth) with 25% coverage. Eleven days after treatment, three non-healing areas along the horizontal skin folds of the anterior neck were noted. At 2 weeks after CO(2) ablative fractional resurfacing, these areas had become thickened. These raised areas were treated with a non-ablative fractionated 1,550 nm laser to modify the wound healing milieu. One week later, distinct firm pale papules in linear arrays with mild hypopigmentation had developed along involved neck skin folds. Skin biopsy was performed. For the second patient, the neck was treated at a pulse energy of 20 mJ (630 microm depth) with 30% coverage of the exposed skin, with a total treatment energy of 5.0 kJ. Minimal crusting was noted on the neck throughout the initial healing phase of 2 weeks. She then experienced tightness on her neck. Approximately 3 weeks after treatment, she developed multiple vertical and horizontal hypertrophic scars (HS).ResultsHistopathology for the first case confirmed the presence of a hypertrophic scar. The papules in this case completely resolved with mild residual hypopigmentation after treatment with topical corticosteroids. HS failed to resolve in the second case to date after 1 month.ConclusionAs with traditional ablative CO(2) laser resurfacing, HS is a potential complication of ablative fractional CO(2) laser resurfacing, particularly on the neck. With early diagnosis and appropriate treatment HS of neck skin may be reversible. We urge caution when treating the neck with this device and close attention to wound care in the post-operative period.

Background and objectiveDue to the significant risk profile associated with traditional ablative resurfacing, a safer and less invasive treatment approach known as fractional deep dermal ablation (FDDA) was recently developed. We report the results of the first clinical investigation of this modality for treatment of photodamaged skin.Study design/materials and methodsTwenty-four subjects received treatments on the inner forearm with a prototype fractional CO(2) laser device (Reliant Technologies Inc., Mountain View, CA) at settings of 5-40 mJ/MTZ and 400 MTZ/cm(2). Clinical and histological effects were assessed by study investigators 1 week, 1 month, and 3 months following treatment. Thirty subjects were then enrolled in a multi-center study for treatment of photodamage using the same device. Subjects received 1-2 treatments on the face and neck, with energies ranging from 10 to 40 mJ/MTZ and densities ranging from 400 to 1,200 MTZ/cm(2). Study investigators assessed severity of post-treatment responses during follow-up visits 48 hours, 1 week, 1 month, and 3 months following treatment. Using a standard quartile improvement scale (0-4), subjects and investigators assessed improvement in rhytides, pigmentation, texture, laxity and overall appearance 1 and 3 months post-treatment.ResultsClinical and histologic results demonstrated that fractional delivery of a 10,600 nm CO(2) laser source offers an improved safety profile with respect to traditional ablative resurfacing, while still effectively resurfacing epidermal and dermal tissue. Forearm and facial treatments were well-tolerated with no serious adverse events observed. Eighty-three percent of subjects exhibited moderate or better overall improvement (50-100%), according to study investigator quartile scoring.ConclusionsFDDA treatment is a safe and promising new approach for resurfacing of epidermal and deep dermal tissue targets.

BackgroundAlthough cryogen spray cooling (CSC) is used to minimize the risk of epidermal damage during laser dermatologic surgery, concern has been expressed that CSC may induce cryo-injury. In order to address this concern, it is necessary to evaluate the effects of prolonged exposure of human skin phantoms (HSP) to CSC.ObjectiveTo measure the minimum surface temperature (T(min)) and the time at which it occurs (t(Tmin)) as well as determine the time the sprayed HSP surface remains below 0 degrees C (sub-zero time, Deltat(s)) and -26 degrees C (residence time, Deltat(r)) during the application of single (SCS) and multiple (MCS) cryogen spurts. Two initial HSP substrate temperatures were studied, T(i): 23 and 70 degrees C.Study design/materials and methodsAn epoxy-based HSP was constructed to measure T(min), t(Tmin), Deltat(s), and Deltat(r), for 17 spray patterns: 1 SCS with a total cryo-delivery time (Deltat(c)) of 40 milliseconds; 8 MCS patterns with identical Deltat(c), but with a total cooling time (Deltat(total)) varying from 50 to 280 milliseconds; and 8 SCS patterns that matched the Deltat(total) of the MCS patterns.ResultsFor both T(i), our results show that it is possible to distinguish between two different cooling regimes. For Deltat(total) ConclusionsThese results suggest that: (1) similar epidermal protection may be attained with SCS and MCS for Deltat(total)

Cryogenic sprays are used for cooling human skin during laser dermatologic surgery. In this paper, six straight-tube nozzles are characterized by photographs of cryogenic spray shapes, as well as measurements of average droplet diameter, velocity, and temperature. A single-droplet evaporation model to predict average spray droplet diameter and temperature is tested using the experimental data presented here. The results show two distinct spray patterns--sprays for 1.4-mm-diameter nozzles (wide nozzles) show significantly larger average droplet diameters and higher temperatures as a function of distance from the nozzle compared with those for 0.5-0.8-mm-diameter nozzles (narrow nozzles). These results complement and support previously reported studies, indicating that wide nozzles induce more efficient heat extraction than the narrow nozzles.

Fast heat extraction is critically important to obtain the maximal benefit of cryogen spray cooling (CSC) during laser therapy of shallow skin lesions, such as port wine stain birthmarks. However, a film of liquid cryogen can build up on the skin surface, impairing heat transfer due to the relatively low thermal conductivity and higher temperature of the film as compared to the impinging spray droplets. In an attempt to optimize the cryogen mass flux, while minimally affecting other spray characteristics, we apply a series of 10 ms spurts with variable duty cycles. Heat extraction dynamics during such intermittent cryogen sprays were measured using a custom-made metal-disc detector. The highest cooling rates were observed at moderate duty cycle levels. This confirms the presence, and offers a practical way to eliminate the adverse effect of liquid cryogen build-up on the sprayed surface. On the other hand, lower duty cycles allow a substantial reduction in the average rate of heat extraction, enabling less aggressive and more efficient CSC for treatment of deeper targets, such as hair follicles.

Background and objectiveThermal relaxation time (tau(r)) is a commonly-used parameter for estimating the time required for heat to conduct away from a directly-heated tissue region. Previous studies have demonstrated that temperature superposition can occur during multiple-pulse irradiation, even if the interpulse time is considerably longer than tau(r). The objectives of this study were (1) to analyze tissue thermal relaxation following laser-induced heating, and (2) to calculate the time required for a laser-induced temperature rise to decrease to near-baseline values.Study design/materials and methodsOne-dimensional (1-D) analytical and numerical and 2-D numerical models were designed and used for calculations of the time tau(eff) required for the peak temperature (T(peak)) to decrease to values slightly over baseline (DeltaT(base)). Temperature values included T(peak)=65 and 100 degrees C, and DeltaT(base) = 5, 10, and 20 degrees C. To generalize the calculations, a wide range of optical and thermal properties was incorporated into the models. Flattop and gaussian spatial beam profiles were also considered.Results2-D model calculations of tau(eff) demonstrated that tau(eff) (2-D) was as much as 40 times longer than tau(r). For a given combination of T(peak) and DeltaT(base), a linear relationship was calculated between tau(eff) (1-D) and tau(r) and was independent of optical and thermal properties. A comparison of 1-D and 2-D models demonstrated that 1-D models generally predicted longer values of tau(eff) than those predicted with a 2-D geometry when the laser spot diameter was equal to or less than the optical penetration depth.ConclusionRelatively simple calculations can be performed to estimate tau(eff) for known values of tau(r), T(peak) and DeltaT(base). The parameter tau(eff) may be a better estimate than tau(r) of tissue thermal relaxation during multiple-pulse laser irradiation.

Background and objectiveTo evaluate histologically the characteristics of repetitive Er:YAG laser exposure of skin in combination with cryogen spray cooling (CSC), and its potential as a method of laser skin resurfacing.Study design/materials and methodsRat skin was irradiated in vivo with sequences of 10 Er:YAG laser pulses (repetition rate 20 Hz, pulse duration 150 or 550 micros, single-pulse fluence 1.3-5.2 J/cm(2)). In some examples, CSC was applied to reduce epidermal injury. Histologic evaluation was performed 1 hour, 1 day, 5 days, and 4 weeks post-irradiation.ResultsA sequence of ten 550-micros pulses with fluences around 2 J/cm(2) resulted in acute dermal collagen coagulation to a depth of approximately 250 microm, without complete epidermal ablation. CSC improved epidermal preservation, but also diminished the coagulation depth. Four weeks after irradiation, neo-collagen formation was observed to depths in excess of 100 microm.ConclusionsDermal collagen coagulation and neo-collagen formation to depths similar to those observed after CO(2) laser resurfacing can be achieved without complete ablation of the epidermis by rapidly stacking long Er:YAG laser pulses. Application of CSC does not offer significant epidermal protection for a given dermal coagulation depth.

Abstract: Acquired fibrokeratoma is a rare benign skin tumor that usually manifests as a slow-growing solitary nodular lesion of the digits. We report a case of plantar acquired fibrokeratoma evidencing its atypical size and topography, in addition to the treatment with simple surgical excision followed by healing by second intention. Nondigital fibrokeratomas may occur in 18% of cases and rarely affect the palmoplantar region. These lesions are usually asymptomatic and show ≥ 3cm in size at the time of diagnosis due to delayed diagnosis. Complete surgical excision is the treatment of choice, which is usually curative. In general, primary closure is chosen; however healing by second intention becomes an option in regions of difficult approach.

Video recording surgical procedures is one of the most valuable tools for teaching and self-assessment in Dermatologic Surgery. A number of recording systems have been described in the literature. Nevertheless, they’re usually expensive (~500€) and time-consuming to prepare, the latter being a major disadvantage for a busy surgical speciality such as Dermatology. The authors describe a simple and inexpensive technique for surgical video capture in Dermatologic Surgery. For this setup, the surgeon needs only a smartphone with a camera (which is nowadays ubiquitous), a bike phone holder (10€ to 30€), an adjustable intravenous pole and, optionally, a powerbank. With the patient in position for the surgical intervention (seated or lying on his back on the surgical table, depending on the procedure), the bike phone holder should be attached to the vertically adjustable intravenous pole. The smartphone must be then set on the bike phone holder, with its “recording mode” already started. Optionally, a powerbank can also be attached to the intravenous pole to provide extra charge for longer procedures. The height of the intravenous pole, as well as its position and distance to the surgical table, should be adjusted accordingly before the intervention, in order to provide the best recording definition. The authors describe a simple, easy to setup, inexpensive system to record videos in Dermatologic Surgery.

Aim: Since use of major cutaneous surgeries/reconstructions among patients with cutaneous squamous cell carcinoma (CSCC) is not well described, we sought to quantify major cutaneous surgeries/reconstructions among patients with CSCC who were newly diagnosed and for those treated with systemic therapy, stratified by immune status. Methods: We used the Optum ® Clinformatics ® Data Mart database (2013-2020) and Kaplan-Meier estimators to assess risk of surgeries/reconstructions. Results: 450,803 patients were identified with an incident CSCC diagnosis, including 4111 patients with CSCC who initiated systemic therapy. The respective 7-year risks of major cutaneous surgeries/reconstructions were 10.9% (95% CI: 10.7-11.0) and 21.8% (95% CI: 17.6-25.8). Overall risk of major cutaneous surgeries/reconstructions was higher in patients who were immunocompromised than those who were immunocompetent. Conclusion: Approximately one in nine patients with CSCC will undergo ≥1 major cutaneous surgeries/reconstructions within 7 years of diagnosis; the risk increases in patients who initiate systemic therapy and among those who are immunocompromised.

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: Conflicts of interest The authors declare no conflicts of interest.

Background: Cervical necrotizing fasciitis (CNF) is a rare, aggressive form of deep neck space infection with significant morbidity and mortality rates. Serial surgical debridement acts as the cornerstone of CNF treatment; however, it often results in defects requiring complex reconstructions., Case Summary: We report two cases in which the keystone flap (KF) was used for CNF defect coverage: Case 1, an 85-year-old patient with CNF in the anterior neck, and Case 2, a 54-year-old patient with CNF in the posterior neck. Both patients received empirical intravenous antibiotic therapy and underwent serial debridement, enabling adequate wound preparation and stabilization. The final defect size measured 5.5 cm × 12 cm in Case 1 and 6 cm × 11 cm in Case 2. For defect coverage, we employed an 8 cm × 19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm × 18 cm type II KF based on perforators from the transverse cervical artery in Case 2. Both flaps showed complete survival. No postoperative complications occurred in both cases, and favorable outcomes were observed at 7- and 6-month follow-ups in case 1 and 2, respectively., Conclusion: We effectively treated CNF-associated defects using the KF technique; KF is viable for covering CNF defects in carefully selected cases., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: Conflicts of interest None disclosed.

Introduction: Perioperative counseling regarding activity limitations is critical for patients undergoing dermatologic surgery. Current postoperative instructions regarding activity limitations may be inadequate, but this cannot be determined without knowing patient expectations. The study objective was to elucidate patient expectations for counseling on postoperative activity limitations and to determine if increased counseling would impact patient planning pre or postoperatively., Materials and Methods: Patients who had excisions on the neck, torso, or extremities at one institution in one calendar year by the same surgeon participated in a phone survey. Questions addressed preexisting activity level, activity changes after surgery, amount of counseling received, and perioperative counseling expectations. Multivariable logistic regression was used to determine factors associated with patient perceptions about counseling, activity limitations, and surgical outcomes., Results: Patients counseled on postoperative activity limitations reported they were unlikely to have made further arrangements to their surgical/personavl schedule had they been given additional counseling. The inverse was also true. When patients received the amount of counseling they expected, they were less likely to want to reschedule surgery or adjust personal plans. Younger patients and those with surgery on the lower extremities were more likely to limit their activity for longer periods of time., Conclusions: As instructions on activity limitations become more transparent, patients can make informed decisions regarding their surgical and personal schedules. This study can guide dermatologic surgeons in adjusting postoperative instructions to improve patient understanding of activity limitations, compliance, and the overall quality of their surgical experience., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and objectiveA thermal camera was used to measure surface temperatures during laser skin welding to provide feedback for optimization of the laser parameters.Study design/materials and methodsTwo-centimeter-long, full-thickness incisions were made in guinea pig skin in vitro and in vivo. India ink was applied to the incision edges, which were then mechanically apposed. Continuous-wave, 1.06-microm Nd:YAG laser radiation was scanned over the incisions, producing an effective pulse duration of approximately 100 msec. Cooling durations between scans of 1.6, 4.0, and 8.0 sec were studied in vitro. A 5-mm-diameter laser spot was used with the power kept constant at 10 W. Thermal images were obtained at 30 frames per second with a thermal camera detecting 3-5 microm radiation. Surface temperatures were recorded at 0, 1, and 6 mm from the center line of the incision.Results/conclusionsCooling durations of 1.6 and 4.0 seconds in vitro resulted in temperatures at the weld site that remained above approximately 65 degrees C for prolonged periods of time. Cooling durations of 8.0 seconds were sufficient both in vitro and in vivo to prevent a significant rise in baseline temperatures at the weld site over time.

Z-plasty is a surgical technique classically used to correct scars. It consists of a double transposition of two or more adjacent triangular-shaped flaps resulting in a Z-shaped scar. This procedure is especially advantageous when the surgical incision is not parallel to the skin tension lines as it allows repositioning of the tension vectors, tending to a more favorable cosmetic result and preventing scar retractions. We present the case of a young woman with a left supraciliary basal cell carcinoma whose excision resulted in an extensive surgical defect which was reconstructed using a multiple Z-patch. The authors describe the surgical technique as well as its main advantages and applicability. [ABSTRACT FROM AUTHOR]

Background and objectiveThe pulsed CO2 laser has received attention because of its successful application to dermatologic surgery and burn debridement surgery. Despite impressive results, tissue removal using pulsed CO2 laser irradiation has not been optimized. We examined the ablation processes by performing mass removal and thermal injury experiments at wavelengths where tissue water is the primary absorber (10.6 microm), and where water and collagen have comparable absorption (9.5 microm).Study design/materials and methodsSamples of porcine reticular dermis were irradiated with 180-ns laser pulses at either wavelength. Tissue removal was measured using a digital balance. Thermal injury was assessed using a microscope with a calibrated reticle after hematoxylin and eosin staining.ResultsTissue removal using 10.6-microm radiation resulted in a heat of ablation of 3,740 J/g, an ablation threshold of 1.15 J/cm2, and a zone of thermal injury of 53 microm. By contrast, tissue removal using 9.5-microm radiation resulted in a heat of ablation of 3,330 J/g, an ablation threshold of 1.47 J/cm2, and a zone of thermal injury of 34 microm. The differences in ablation threshold and thermal injury were statistically significant.ConclusionPulsed CO2 laser irradiation at 9.5 microm removes tissue more efficiently and with a smaller zone of thermal injury than at 10.6 microm.

Background and objectiveSeveral published reports describe the benefits of using the carbon dioxide laser for cutaneous resurfacing. The mechanisms on which skin resurfacing work are still not completely understood. This study was performed to obtain quantitative and qualitative information describing the thermal response of skin during high-energy, short-pulsed CO2 laser irradiation.Study design/materials and methodsA Tissue Technologies TruPulse CO2 laser was used to irradiate an in vivo rat model. The laser parameters that were used were a 100-micros pulse width, a 1-Hz repetition rate, a 3 mm x 3 mm square spot size, and 2.4 J/cm2 and 3.9 J/cm2 radiant exposures. A 3-5 microm thermal camera was used to obtain temperature information during irradiation. Single spots were irradiated with one pulse, and the temperature-time history was obtained. In a different experiment, 15 pulses were applied to single spots, and both thermal and video images were obtained.ResultsIrradiation with one pulse at 2.4 J/cm2 and 3.9 J/cm2 led to peak temperatures >100 degrees C. The temperature relaxation time was approximately 25-150 ms. Multiple-pulse irradiation at 2.4 J/cm2 led to a slight rise in the peak temperature with each pulse. At 3.9 J/cm2, the peak temperature increased with successive pulses until pulse 10, after which the peak temperature oscillated between 300 and 400 degrees C. Video images showed concurrent burning events that occurred during pulses 10-15.ConclusionTemperatures >100 degrees C were measured during CO2 laser irradiation of skin. Pulse stacking can lead to peak temperatures approaching 400 degrees C and to tissue charring with as few as three stacked pulses. It is crucial for the physician to manipulate the laser handpiece at parameters with which he or she can avoid pulse overlap.

Background and objectiveThe pulsed CO2 laser has received attention because of its successful application to dermatologic surgery and burn debridement surgery. Despite impressive results, tissue removal using pulsed CO2 laser irradiation has not been optimized. We examined the ablation processes by performing mass removal and thermal injury experiments at wavelengths where tissue water is the primary absorber (10.6 microm), and where water and collagen have comparable absorption (9.5 microm).Study design/materials and methodsSamples of porcine reticular dermis were irradiated with 180-ns laser pulses at either wavelength. Tissue removal was measured using a digital balance. Thermal injury was assessed using a microscope with a calibrated reticle after hematoxylin and eosin staining.ResultsTissue removal using 10.6-microm radiation resulted in a heat of ablation of 3,740 J/g, an ablation threshold of 1.15 J/cm2, and a zone of thermal injury of 53 microm. By contrast, tissue removal using 9.5-microm radiation resulted in a heat of ablation of 3,330 J/g, an ablation threshold of 1.47 J/cm2, and a zone of thermal injury of 34 microm. The differences in ablation threshold and thermal injury were statistically significant.ConclusionPulsed CO2 laser irradiation at 9.5 microm removes tissue more efficiently and with a smaller zone of thermal injury than at 10.6 microm.

Background and objectiveThe objective of this study was to determine the effectiveness of a dynamic cooling device (DCD), spraying the skin with a brief spurt of cryogen prior to the laser pulse, in reducing transient pain associated with 585-nm pulsed dye laser (PDL) treatment of port-wine stains (PWS), and reducing epidermal damage (hypo/hyperpigmentation) caused by this laser during PWS treatment.Materials and methodsMatched treatment sites were compared with and without the use of the cryogen spray in 47 patients at two investigational sites. Pain ratings, clearance of the PWS, and pigmentation changes were assessed. The results were analyzed by skin type and patient age.ResultsA statistically significant reduction in pain ratings was found in all patient groups using the DCD without changing the efficacy of PWS clearance. Pain reduction was most remarkable in patients with darker skin types. Dynamic cooling prevented the occurrence of epidermal damage or pigmentation change in most cases.ConclusionsThis study suggests that dynamic cooling can dramatically diminish pain during PWS treatment with the 585-nm PDL without reducing treatment efficacy. The absence of epidermal damage in most patients suggests that precooling with the DCD may allow the use of higher laser fluences to expedite clearance without inducing epidermal change. Dynamic cooling has potential use with other lasers and different lesions where discomfort and epidermal effects limit therapy.

The physical mechanisms that achieve tissue removal through the delivery of short pulses of high-intensity infrared laser radiation, in a process known as laser ablation, remain obscure. The thermodynamic response of biological tissue to pulsed infrared laser irradiation was investigated by measuring and analyzing the stress transients generated by Q-sw Er:YSGG (lambda = 2.79 microns) and TEA CO2 (lambda = 10.6 microns) laser irradiation of porcine dermis using thin-film piezoelectric transducers. For radiant exposures that do not produce material removal, the stress transients are consistent with thermal expansion of the tissue samples. The temporal structure of the stress transients generated at the threshold radiant exposure for ablation indicates that the onset of material removal is delayed with respect to irradiation. Once material removal is achieved, the magnitude of the peak compressive stress and its variation with radiant exposure are consistent with a model that considers this process as an explosive event occurring after the laser pulse. This mechanism is different from ArF- and KrF-excimer laser ablation where absorption of ultraviolet radiation by the collagenous tissue matrix leads to tissue decomposition during irradiation and results in material removal via rapid surface vaporization. It appears that under the conditions examined in this study, explosive boiling of tissue water is the process that mediates the ablation event. This study provides evidence that the dynamics and mechanism of tissue ablation processes can be altered by targeting tissue water rather than the tissue structural matrix.