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Subcuticular suture is an important technique for achieving optimum wound closure, and there has been no comprehensive summary of subcuticular sutures to date.To summarize the origin and development of interrupted subcuticular suture to help clinicians improve their wound closure skills.A comprehensive review of subcuticular suture techniques was conducted in PubMed to summarize the advantages and disadvantages of various methods and clinical indications.Buried suture is the oldest subcuticular suture technique, followed by buried vertical mattress suture, intracutaneous butterfly suture, modified/variant buried vertical mattress suture, intradermal buried vertical mattress suture, buried horizontal mattress suture, wedge-section and modified buried vertical mattress suture, set-back suture, and modified buried horizontal mattress suture, which have gradually been applied in clinical practice. Buried vertical mattress suture is currently the most widely used subcuticular suture technique.Patients can certainly benefit from the appropriate application of subcuticular suture. There is also no single ideal method for achieving optimal results in all cases. Fully understanding the history of subcuticular suture can help doctors improve their wound closure technique.

Plasma IQ™, the first FDA-cleared hand-held plasma energy device, is indicated for removal and destruction of skin lesions and coagulation of tissue. Treatment involves use of an electrostatic plasma spark to heat the skin and create discrete microthermal wounds.Microthermal wounds on pre-auricular and upper eyelid skin from two individual subjects were created using multiple treatment parameters to assess the impacts of power, pulse duration and needle electrode type on wound depth, width and thermal spread, and analyzed using histology to characterize treatment effects.Device power had a statistically significant impact on upper eyelid skin microthermal wound depth and width (2-sided t-test p 0.0001 for both) but not on thermal spread (p = 0.1171). No meaningful differences in wound width, depth, or thermal spread were observed based on pulse duration or electrode type. All microthermal wounds demonstrated dual zones of tissue injury and extended to the superficial reticular dermis.Treatment with the Plasma IQ™ device creates focal microthermal wounds of reproducible depth and width that are comprised of dual thermal injury zones similar to other plasma energy skin rejuvenation devices. Device power is the most important factor determining microthermal wound depth and width.

INTRODUCTION The American Society for Dermatologic Surgery (ASDS) established a cosmetic dermatologic surgery fellowship in 2013. Programs often outline details of fellowships on their websites to help prospective applicants make informed decisions. Our primary goal was to evaluate the content quality of online information for all ASDS-accredited cosmetic dermatologic surgery fellowships on program websites and the ASDS website. Our secondary goal was to describe program activity on social media platforms as another avenue for applicant recruitment. METHODS Program websites were assessed using an aggregate score from twenty-one standardized content quality variables. Social media activity on Facebook and Instagram from January 6 2021, to March 6, 2021, was categorized. RESULTS Among 24 cosmetic dermatologic surgery fellowship programs, 23 had websites. Basic information was provided across most websites or the ASDS website (eg, address, 95.8%), but more qualitative variables like research opportunities or didactic schedule were not consistently reported. Most programs had highly active social media accounts (91.7% on Facebook and 79.2% on Instagram). CONCLUSION There is a gap of information availability between the ASDS website and individual cosmetic dermatologic surgery fellowship websites. Increasing information availability may enhance the applicant recruitment process and serve as a low-cost intervention to ensure optimal fit.

Die Inzidenz von Hautkrebs steigt weltweit seit Jahrzenten. Die operative Entfernung ist die Therapie der ersten Wahl in solchen Fällen und hat sich alleine in Deutschland in den letzten Jahren vervielfacht. Eine genauere Charakterisierung der Patienten, welchen sich dermatochirurgische Eingriffe jährlich unterziehen, existiert jedoch nicht. Dieses Patientenkollektiv hinsichtlich anamnestischer Daten, Komorbiditäten und perioperativer Risiken näher zu beschreiben ist das Ziel dieser Arbeit. Hierfür wurden die Daten derjenigen Patienten mit Hauttumoren erhoben und analysiert, die in der Universitätsklinik für Dermatologie und Allergologie Ulm von Anfang Juni 2012 bis Ende Juni 2013 operativ versorgt wurden. Die Analyse dieser Daten soll eine Besserung der dermatochirurgischen Therapie im Sinne einer Optimierung der perioperativen Betreuung der Patienten und Risikominimierung ermöglichen. Die erhobenen Daten der in der Studie eingeschlossenen 198 dermatochirurgischen Patienten und der 537 durchgeführten operativen Eingriffe wurden mithilfe der deskriptiven Statistik analysiert. In dieser Arbeit ergeben sich als Fazit klare Anhaltspunkte für die Etablierung eines optimierten perioperativen Managements dermatochirurgischer Patienten, das zu einer Verbesserung der Betreuung dieser Patienten führen würde. Die erhaltenen Ergebnisse sollen außerdem dabei helfen, die Entscheidung über die Durchführung dermatochirurgischer Eingriffe im ambulanten Setting bzw. unter stationären Bedingungen anhand des Risikoprofils der Patienten zu treffen.

ObjectiveTo analyse the treatment results of bilobed flap reconstruction performed for skin defects after parotid carcinoma surgery.MethodTen patients who underwent bilobed flap reconstruction for skin defects after parotid carcinoma surgery in our hospital, from 2014 to 2020, were retrospectively enrolled.ResultsAll patients underwent bilobed flap reconstruction for skin defects after parotid carcinoma surgery. The size of the skin defect was 2.7 × 2.2 cm in the smallest dimension and 9.0 × 6.3 cm in the largest dimension. All bilobed flaps except one healed without any problems. One patient developed partial flap necrosis in the retroauricular region, and was treated with skin grafts after removal of the necrotic tissue under local anaesthesia. All bilobed flaps, including the cases in which skin grafts were performed, survived after post-operative radiotherapy or chemotherapy.ConclusionA bilobed flap is a good reconstruction option for skin defects after parotid carcinoma surgery in some cases.

Introduction: An escharotomy is an effective surgical procedure for the rapid decompression of a constricting and unyielding eschar, to permit restoration of blood flow. However, an escharotomy is also a full-thickness incision, which adds additional scarring to the burn injury area. The cosmetic and functional morbidity of escharotomy scarring in children is poorly characterised. Methods: Children who required a burn wound escharotomy at the Queensland Children's Hospital (QCH) between May 2011 and May 2020 were included. Demographics of these children were described. In addition, the number of operations for revision of escharotomy scars was recorded as an indicator of functional or cosmetic concern. Results: A total of 19 patients required an escharotomy after a burn injury. Children with 1% to 96% TBSA burns required an escharotomy, with a median of 28% (IQR 10–39%) TBSA. Two patients (81% and 96% TBSA) died. Seventy-one percent (12/17) of survivors had operative revisions of their escharotomy scars. The median time from burn to first scar intervention was 35 weeks (IQR 19–70 weeks). Conclusion: There is substantial morbidity associated with escharotomies in children. Further investigation of the current methods of decompression after burn injury, and the long-term morbidity of escharotomy, is required.

BACKGROUND Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Background: Venous malformations (VMs) are congenital vascular malformations that grow progressively and never resolve on their own. Cutaneous VMs are difficult to treat due to risk of injury and d...

Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs.

Undermining in difficult-to-reach positions often requires a shift in body position or stretching over the surgical field to obtain adequate reach. We propose a technique of reversing the grip on undermining scissors that improves efficiency without sacrificing technique.

BACKGROUND/AIM This study evaluated the incidence of perioperative complications in jejunal flap compared with the free tissue flap approach. PATIENTS AND METHODS This study included 75 patients who underwent free flap reconstruction for hypopharyngeal carcinoma. The primary outcome was the incidence of pharyngocutaneous fistula, and the secondary outcomes were perioperative complications. RESULTS Pharyngocutaneous fistula developed in 7% of patients who underwent jejunal flap procedures and 6% of patients who underwent free tissue flap procedure. Flap sampling site complications occurred in 23% of patients who underwent jejunal flap procedures and in none of the patients who underwent free tissue flap procedure. CONCLUSION No significant difference was observed in the incidence of pharyngocutaneous fistula between the two groups (p=0.99), but complications at the flap sampling site were significantly more common in jejunal flap procedures than in free tissue flap procedures (p=0.03). Free tissue flap procedures are potential reconstruction methods superior to jejunal flap methods.

Significant variation exists in the surgical suture materials and techniques used for dermatological surgery. Many wound-closure techniques are now practised, including use of sutures, staples and topical adhesives. The focus of our review article is to summarize the latest evidence relating to suture materials and wound-closure techniques, considering the following areas: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases Medline, PubMed and Embase using the keywords 'skin surgery', 'dermatologic surgery', 'sutures', 'suture techniques', 'suturing techniques' and 'surgical techniques' to identify relevant English-language articles. Absorbable superficial sutures may be a preferred alternative to nonabsorbable sutures by both patients and surgeons. Subcuticular sutures may be preferable to simple interrupted sutures for superficial wound closure, and there may also be a role for skin staples in dermatological surgery, particularly on the scalp. However, there remains limited evidence specific to dermatological surgery supporting the use of particular suture materials and suturing techniques. Further high-quality research is required, including multicentre randomized trials with larger cohorts.

Background Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. Objective To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. Materials and methods Multi-center, prospective discrete choice experiment (DCE). Results Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. Conclusion Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

Thermal ablation is an efficient method of medical treatment, such as cancer therapy, wound closure, laser cutting, freckle removal and other treatments. In order to guarantee the curative effect and the safety of the patients, the thermal response of the tissue which is subjected to the heat source need to be carefully monitored. However, it is too difficult to achieve real-time monitoring on the full-field temperature. In the present study, efforts were made to build up a theoretical model for the prediction of the thermal response in the human skin. The Dual-Phase-Lag (DPL) bio-heat transfer model and the Henrique’s burn assessment model were employed to describe the interaction of multi-pulse heat source and the skin. The repeated multi-pulse laser is a common heat source in the thermal treatment and the thermal responses of the skin would be complicated under the common effects of the non-Fourier effects and the multi-pulse source. The Green’s function approach was used to solve the governing equations analytically. The closed-form solution for the temperature distribution of the skin was obtained and the thermal damage was estimated based on the temperature results. The influences of the biological parameters (the phase lags of the heat flux and the temperature gradient) and the heat source parameters (the pulse number and the duty ratio) on the temperature distribution, the burn degree and the irreversible burn depth of the irradiated region were discussed.

Rhinophyma affects predominantly the Caucasian population and is rare in those with Fitzpatrick skin type IV–VI. Diagnosis is based on clinical evaluation. Prominent features include abnormal coloration and texture of skin, impaired vascularity, irregular nodular exophytic growth and telangiectasia. Management can be surgical or dermatological. Surgery remains the mainstay of treatment but achieving an acceptable aesthetic result can be challenging, particularly in those with pigmented skin. Postsurgical hyper- and hypopigmentation make for unpredictable outcomes requiring appropriate preoperative counselling. We present a case that exemplifies this issue and discuss our recommended approach to counselling, consenting and managing such dilemmas in these patients, and a proposal for further investigation into the role of autologous melanocyte transplantation in reducing the effect particularly of hypopigmentation on aesthetic outcomes in this group.

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

The management of complex diabetic foot wounds with large skin defects poses a challenge for surgeons. We presented a simple skin stretching system and negative pressure wound therapy for the repair of complex diabetic foot wounds to examine the effectiveness and safety.A total of 16 patients with diabetic foot ulcers were retrospectively reviewed between January 2015 and October 2020. All patients underwent the treatment by 3 stages. In stage 2, these difficult-to-close wounds of diabetes foot were residual. This method was applied to the wounds with a median defect size of 20.42 cm2 (range, 4.71–66.76 cm2).The median time for closure of complex diabetic foot wounds was 14 days ranging from 8 to 19 days. With respect to the absolute rates of reduction, it was observed with a median of 1.86 cm2/day, ranging from 0.29 cm2/day to 8.35 cm2/day. In accordance with the localization of the defect, the patients were divided into 3 groups: side of the foot (37.5%), dorsum of the foot (50.0%), and others (12.5%). There was no statistical difference between side of the foot and dorsum of the foot in terms of the median defect size with P = 0.069 (Kruskal–Wallis test). Otherwise, there were statistically significant differences regarding the median time and the median absolute rates (P < 0.05; Kruskal–Wallis test). No severe complications were encountered in this study.In summary, our results show that application of the simple skin stretching system and NPWT is an effective and safe approach to complex diabetic foot wounds. Nevertheless, more attention should be paid to the appropriate patient selection and intraoperative judgment to ensure wound closure and avoid undue complications.

Introduction We evaluate a single center’s, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT). Study design Patients undergoing keloid treatment were identified (2008–2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications. Results 284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1–53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6–30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p Conclusions MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.

Introduction Basal cell carcinoma is the most common cancer. Excisional surgery is associated with a high clearance rate, at the expense of significant functional and aesthetic morbidity, especially within the T-zone or for extensive lesions. We report five-year follow-up outcomes for carbon dioxide laser extirpation of cutaneous basal cell carcinoma, assisted by immediate methyl aminolevulinate photodynamic therapy and cost–benefit considerations. Materials and methods Retrospective cohort database analysis of adult patients with biopsy-proven primary cutaneous basal cell carcinoma, completing five years of follow-up. Direct per-lesion cost was compared with conventional wide local excision. Patients with morphoeic basal cell carcinoma were excluded. Results Treated lesions were up to 1% total body surface area and up to 3.8mm (1.38 ± 0.695cm, mean ± standard deviation) in biopsy-proven depth. At the five-year follow-up mark, 93.6% of treated areas remained free of recurrence. Nodular basal cell carcinoma was the most common subtype (41.5%). A mean tumour depth greater than 2 ± 0.872mm was significantly associated with recurrence (Mann–Whitney, p = 0.0487). For a service delivered through the NHS at 2015 prices, we report a 43% saving, equating to a saving of £235 per basal cell carcinoma or a national annualised saving of £70 million by 2025 for the NHS. Conclusion Our results suggest that CO2-assisted photodynamic therapy is non-inferior to excision but may offer better functional and cosmetic preservation at a fraction of the direct like for like cost of operative surgery. Investigation of this method by randomised controlled methodology is warranted.

BACKGROUND Glomus tumors are benign neurovascular neoplasms, most commonly located in the subungual region. These subcutaneous nodules are characterized by intense pain and temperature sensitivity. Although surgical excision is the curative treatment, permanent nail deformity and recurrence are not uncommon after conventional surgery. OBJECTIVE This study evaluated the long-term efficacy of a modified transungual approach with nail preservation for removing subungual glomus tumors. MATERIAL AND METHODS Thirty-nine patients with clinically diagnosed and histopathologically proven glomus tumors treated at a medical center over a 13-year period (2007-2019) were retrospectively evaluated. RESULTS The 39 patients included 28 women and 11 men (ratio, 2.5:1), with a mean age of 48.9 years. Thirty-four tumors were located in the fingers and 5 in the toes. All patients returned to normal activity soon after the surgery. At a mean follow-up of 28.8 months, all were pain free or experienced minimal pain and were satisfied with treatment outcomes. One patient (2.6%) experienced recurrence. No nail deformity was observed. CONCLUSION The transungual approach with nail plate preservation is a novel and effective method for removing subungual glomus tumors with reduced postoperative pain and rapid healing, while preserving or improving the configuration of the nail.