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Subcision, short for “subcutaneous incisionless” surgery (Orentreich and Orentreich, Dermatol Surg 21(6):543–549, 1995), is a minor surgical intervention that is useful in the treatment of several types of scars and other contour defects. The procedure involves the insertion of a beveled needle into the skin adjacent to a scar which is advanced forward, backward, and side-to-side to create a pocket underneath the scar, ultimately allowing the skin surface to float up to a more normal level. This procedure is indicated in the treatment of rolling acne scars, depressed scars and contours (due to many causes including skin grafts, surgical wounds, and malar grooves), and wrinkles. While it has also been proposed for treating cellulite dimples, striae, and axillary osmohydrosis, the evidence for improvement in these conditions with subcision is scarce (2b) (Balighi et al., J Eur Acad Dermatol Venereol 22(6):707–711, 2008). Refer to Table 22.1 for a summary of indications.

The prevalence and emotional impact of acne scarring are underestimated by the medical community. Dermatology providers should be able to evaluate the acne scar patient and discuss treatment options. Important aspects of the patient history include current treatments, prior acne scar procedures, and the patient's goals for treatment. During the physical examination, the scars are assessed and classified by scar morphology and overall severity of scarring. Finally, a treatment plan is developed in which the most appropriate procedures are matched with the scars that will work the best. Helping the patient understand likely expectations for improvement will increase overall satisfaction.

Atypical fibroxanthomas (AFX) are rare skin tumors. These generally are superficial tumors, usually 376 colonies. The patient could not tolerate additional chemotherapy. She was therefore treated with the oral targeted agent pazopanib. The patient developed a dramatic biopsy-confirmed complete response. After 11 months of pazopanib treatment, a repeat CTC-derived culture sample grew only 8 colonies/10 ml blood. The complete response to pazopanib is still ongoing at over 41 months. To our knowledge, this is the first demonstration of clinical complete response of a PDS tumor following targeted therapy. An additional novel feature was the demonstration that CTC-derived colonies could be grown from the blood of a PDS patient. The number of colonies appeared to correlate with the clinical treatment response and seemed to function as a potential prognostic marker.

Vismodegib is an oral inhibitor of the Hedgehog signaling pathway and has been used to treat basal cell carcinoma (BCC) in adults. This article reports clearance of a nodular BCC of the nasal tip in an 8-year-old boy with xeroderma pigmentosum (XP). BCC can pose therapeutic challenges when located in areas that are not amenable to traditional therapies such as Mohs micrographic surgery or topical agents. Vismodegib was used at a dose of 150 mg/day to treat the boy's BCC. After 4 months of therapy, we achieved complete clinical clearance. During 21 months of follow-up, the patient's nose remained clinically clear of tumor. Vismodegib was successfully used to treat a child with XP and nodular BCC. Our goal in using vismodegib was tumor regression while avoiding cosmetic and functional disfigurement. Vismodegib was effective in clinically clearing the tumor, and the patient has shown no signs of recurrence. Further studies are warranted.

The prevalence and emotional impact of acne scarring are underestimated by the medical community. Dermatology providers should be able to evaluate the acne scar patient and discuss treatment options. Important aspects of the patient history include current treatments, prior acne scar procedures, and the patient's goals for treatment. During the physical examination, the scars are assessed and classified by scar morphology and overall severity of scarring. Finally, a treatment plan is developed in which the most appropriate procedures are matched with the scars that will work the best. Helping the patient understand likely expectations for improvement will increase overall satisfaction.

Wound infection is a dreaded complication in Dermatologic Surgery, which is associated with increased cost and patient morbidity. Wound infection occurs when an inoculum of virulent pathogens is deposited at the wound site and overwhelms the host defenses, causing a variety of problems, including pain, dehiscence, abscesses, poor healing, or even sepsis. Wound infection is defined by the CDC as an infection at the site of a procedure within 30 days of the procedure [1]. Infection can occur in any procedure in which the skin barrier is compromised, including excisional surgery, Mohs micrographic surgery, biopsies, all type of reconstructions, chemical peels, dermabrasion, laser resurfacing, liposuction, blepharoplasty, injections, or other procedures [2]. Most infections are bacterial; however, viral, fungal, and mycobacterial infections may occur. Some dermatologic procedures have a higher risk of infection than others due to their location on the body, surface area of involvement, risk of ­contamination, duration of procedure, or other characteristics (Table 10.1). Other risk factors such as the patient’s host defenses and pre and postoperative care may increase the risk of postsurgical infection and should be ­considered by the surgeon (Table 10.2). The risk of surgical infection can be conceptualized according to the equation in Fig. 10.1.

Atrophic acne scarring is an unfortunate, permanent complication of acne vulgaris, which may be associated with significant psychological distress. General dermatologists are frequently presented with the challenge of evaluating and providing treatment recommendations to patients with acne scars. This article reviews a practical, step-by-step approach to evaluating the patient with atrophic acne scars. An algorithm for providing treatment options is presented, along with pitfalls to avoid. A few select procedures that may be incorporated into a general dermatology practice are reviewed in greater detail, including filler injections, skin needling, and the punch excision.

Stephanie A. St Pierre, MD; Jennee Rommel, MD; Ana Ciurea, MD; Douglas Fife, MD; Simon S. Yoo, MD; Mary Martini, MD; Timothy M. Kuzel, MD; Jeffrey Wayne, MD; Alfred Rademaker, PhD; Dennis P. West, PhD; Murad Alam, MD; Department of Dermatology (Drs St Pierre, Yoo, Martini, and West) and Robert H. Lurie Comprehensive Cancer Center (Drs Yoo, Martini, Kuzel, Wayne, Rademaker, West, and Alam), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Dermatology and Department of Medicine, Washington Hospital Center, Washington, DC (Dr Rommel); Department of Dermatology, MD Anderson Cancer Center, Houston, Texas (Dr Ciurea); Surgical Dermatology and Laser Center, Las Vegas, Nevada (Dr Fife); and Division of Hematology-Oncology (Dr Kuzel), Division of Surgical Oncology (Dr Wayne), and Department of Preventive Medicine (Dr Rademaker) and Dermatology (Dr Alam), Northwestern University, Chicago

Radiofrequency (RF) devices and infrared broadband light (IBBL) are nonablative energy sources designed to volumetrically heat the dermis and subcutaneous tissue with the goal of skin tightening or girth reduction. They have been used successfully and safely in all skin types on the large areas of the body listed in Table 26.1. IBBL devices (wavelength 850-1350 nm or 1100-1800 nm) penetrate deeply to bulk-heat the dermis without melanin absorption. RF generates heat via the tissue resistance to an electric current passed through the skin, which causes tightening through presumed collagen remodeling. Unipolar (also called monopolar) RF systems use a ground electrode applied to an area of the body away from the current source and create a high power area at the electrode tip. Bipolar RF systems rely on two electrodes located within the handpiece.