Laser and Skin Surgery Center of Indiana

Hashemi, David A. MD, MBA; Tao, Joy MD; Wang, Jordan V. MD, MBE, MBA; Geronemus, Roy G. MD Author Information

Microscopic interpretation represents the central tenet for diagnosis and eradication of cutaneous tumors. Standard microscopes are limited by relatively high-powered objectives and smaller viewable diameter. Newer equipment offers optional lower powered objectives including 1X and 2X objectives and can be combined with super widefield eyepieces to greatly enhance the viewable area during pathologic interpretation of slides. Mohs micrographic surgery represents one of the most useful areas in which the dermatologic surgeon gleans multiple efficiencies from these microscope systems. One such system that was recently trialed, the Nikon 80i microscope, proved to be incredibly easy to use and multiple efficiencies were quickly realized.

Studies of injectable poly-L-lactic acid (PLLA) in human immunodeficiency virus (HIV)-associated facial lipoatrophy have predominantly included male Caucasians. To report cumulative year 2 interim study results examining the safety and efficacy of injectable PLLA in subjects with HIV categorized according to Fitzpatrick skin type and sex. This is an ongoing open-label, multicenter, 5-year study of 290 treated subjects. After correction with injectable PLLA, subjects are being followed annually. Primary end points include incidence and severity of treatment-emergent adverse events (TEAEs). Secondary end points include mean change from baseline of James scale severity grade and treatment satisfaction. At 2 years, TEAE incidences were: potentially related to study product (n = 53,18.3%) or injection procedure (n = 71, 24.5%), injection-site nodules (n = 24, 8.3%) and papules (n = 25, 8.6%). No hypertrophic scars, keloids, or product-related serious TEAEs were reported. Mean improvement in James scale grade for all groups was 1.4 (p < .001), and 89.4% of subjects and 95.5% of physicians rated treatment satisfaction as very good or excellent. At 2 years, injectable PLLA is a safe and effective long-term treatment for HIV-associated facial lipoatrophy regardless of Fitzpatrick skin type; confirmation of these results will be needed at the completion of this 5-year study.

The prevalence of physician extenders (PEs) has increased significantly in dermatologic surgery over the last decade. An analysis was performed of the staff in dermatologic surgery practices, roles of PEs, and level of supervision. Mohs fellowship-trained (MMSFT) dermatologic surgeons were more likely to employ registered nurses (n=85, 73.9%) than non-fellowship-trained (NMMSFT) surgeons (n=65, 50.0%, p<.05) (dermatologists who reported performing Mohs without having completed a Mohs College fellowship). NMMSFT surgeons (n=46, 35.4%) were 33% more likely to employ physician assistants than MMSFT surgeons (n=30, 26.1%, p=.05). Both surgeon types reported that their physician assistants and nurse practitioners spent the majority of their time treating medical dermatology patients, but NMMSFT surgeons were twice as likely as MMSFT surgeons to have their PEs involved in performing or assisting with cosmetic procedures. MMSFT surgeons (38.5%) were twice as likely to have direct supervision of their PEs as NMMSFT surgeons (16.1%, p=.01). PEs are highly prevalent in dermatologic surgery practices and are playing direct roles in the delivery of dermatologic care. Promoting patient safety through appropriate extender supervision and reporting of patient outcomes are highly needed as this sector of the dermatologic surgery workforce continues to expand.

Indianapolis, Ind. From the Laser and Skin Surgery Center of Indiana. Received for publication December 16, 2010; accepted December 16, 2010. Disclosure:C. William Hanke, M.D., declares financial interest as a shareholder in Medicis and Allergan. In addition, he declares having been the recipient of research support from Medicis, Allergan, Merz, Dermik, and Galderma. This supplement in its entirety is jointly published by the Journal of the American Academy of Dermatology and Plastic and Reconstructive Surgery. Citation of the articles in PRS follows this format: Rohrich RJ, Hanke CW. Facial Soft-Tissue Fillers: Assessing the State-of-the-Science Conference—Proceedings Report. Plast Reconstr Surg. 2011;127(Suppl 2):9S–21S. Citation of the articles in JAAD follows this format: Hanke CW, Rohrich RJ, Busso M, Carruthers A, Carruthers J, Fagien S, et al. Facial Soft-Tissue Fillers: Assessing the State-of-the-Science Conference—Proceedings Report. J Am Acad Dermatol 2011;64(Suppl):S53–S65. C. William Hanke, M.D., M.P.H., Laser and Skin Surgery Center of Indiana, 13400 N. Meridian Street, Suite 290, Carmel, Ind. 46032, [email protected]

With an incidence of over 3.5 million nonmelanoma skin cancers (NMSCs) per year in the United States, there is an increasing need for effective, cost-effective treatments for NMSC. When surgical excision is impractical or not feasible, methyl aminolevulinate photodynamic therapy (MAL-PDT) has demonstrated consistently high long-term cure rates ranging from 70-90%, with superior cosmetic outcomes compared with other treatment modalities. With the exception of invasive squamous cell carcinoma, MAL-PDT has been successful in treating all types of NMSC, especially in patients with multiple comorbidities, field cancerization, and lesions in cosmetically sensitive locations. Herein, a step-by-step description of the procedure for MAL-PDT is provided, followed by a review of outcomes from large clinical trials performed over the past 15 years for each variant of NMSC. After reading this review, clinicians should have a thorough understanding of the benefits and limits of MAL-PDT, and should be able to add this valuable procedure to their armamentarium of therapies for NMSC.

Port wine stains (PWS) are congenital malformations of capillaries, where with progression, blood vessels become ectatic and result in disfiguring nodules. To search the MEDLINE database and review literature on the treatment of PWS and present 2 cases of adults with PWS, complicated by hypertrophic and nodular lesions, treated successfully with CO2 laser. Two patients with PWS, with nodular and hypertrophic areas, were treated with CO2 laser. With the first patient, improvement of 90% or greater was noted in the 14 discrete nodules present within the PWS in a V2 distribution. At baseline, ectropion of the lower eyelid was noted which resolved completely after CO2 laser. With the second patient, improvement was noted as 90% or greater in the 40 of 51 discrete nodules present within the PWS extending across the right V1-V2 distribution. Carbon dioxide ablative laser resurfacing is safe and highly effective in the treatment of the nodular and hypertrophic components of PWS. Future treatment of PWS will likely involve a hybrid approach of utilizing nonablative lasers of varying wavelengths and pulse durations and treatment with novel laser devices, with the goal of early treatment to prevent progression of PWS to disfiguring lesions.