Cutaneous Surgery Research Articles

Continuous Aspirin Use Does Not Increase Bleeding Risk of Split-Thickness Skin Transplantation Repair to Chronic Wounds.

Discontinuation of aspirin therapy before cutaneous surgery may cause serious complications. The aim of this prospective study was to evaluate the bleeding risk of split-thickness skin transplantation repair to chronic wounds in patients on aspirin therapy. A total of 97 patients who underwent split-thickness skin transplantation surgery of chronic wounds during a 2-year period were enrolled. They were categorized on the basis of aspirin therapies. The primary outcome was postoperative bleeding and bleeding complications. Univariate analysis was performed to examine the association between aspirin and bleeding complications. Among the 26 patients taking aspirin continuously in group A, there were 5 bleeding complications (19.23%). Among the 55 nonusers in group B, there were 10 bleeding complications (18.18%). Among the 16 discontinuous patients in group C, there were 3 bleeding complications (18.75%). No statistical differences were found among the groups ( P = .956). Univariate analysis showed that continuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.933; 95% confidence interval, 0.283-3.074; P = .910 in the aspirin and control groups) and that discontinuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.963; 95% confidence interval, 0.230-4.025; P = .959 in the aspirin and control groups; odds ratio, 0.969; 95% confidence interval, 0.198-4.752; P = .969 in the aspirin and discontinuous groups). Continuous aspirin use does not produce an additional bleeding risk in patients who undergo split-thickness skin transplantation repair of chronic wounds.

Addressing Practice Gaps in Cutaneous Surgery: Advances in Diagnosis and Treatment.

Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making. To present the newest and best evidence to close common practice gaps in cutaneous surgery. We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms "cutaneous surgery," "Mohs micrographic surgery," "plastic surgery," in combination with "safety," "cost," "anesthesia," "anti-coagulation," "bleeding," "pain," "analgesia," "anxiety," or "infection," among others. Bibliographies from these references, as well as meta-analyses, were also reviewed. A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications. Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.

Laser Safety in Isotretinoin Use: A Survey of Expert Opinion and Practice

Reports of poor wound healing in the setting of isotretinoin treatment have created a conservative standard of care in which laser and phototherapy treatment of patients receiving isotretinoin is relatively contraindicated. A survey of 220 nationally recognized experts in cutaneous laser surgery was conducted to evaluate physician experience and opinion pertaining to laser and light procedures in patients treated with isotretinoin, including perceived risk and actual complications. There was a 42% response rate. Seventy-six percent of respondents have never seen in their own clinical practices any cases of complications arising in patients treated with laser while receiving isotretinoin or within 6 months of completing a course of therapy. Almost half of respondents have treated patients in this subpopulation with laser, although only a small minority have done so with ablative devices. Common concerns among respondents regarding isotretinoin patients are the risks of poor wound healing and scarring, but the most often reported concern is medicolegal risk (74%). It would seem that the risk of performing laser procedures on patients receiving isotretinoin or having recently completed a course, as estimated and observed by cutaneous laser experts, is lower than the currently perceived risk among the general medical community.

A Review of Local Anesthetics: Minimizing Risk and Side Effects in Cutaneous Surgery.

The specialty of dermatology relies heavily on local anesthesia for diagnosis and management of skin disease. The appropriate selection, preparation, administration, and monitoring of these medications affect surgical outcome and patient safety and satisfaction. To perform a comprehensive literature review of the side effects and risks associated with local anesthetics used in cutaneous surgery. Current recommendations to reduce risk and minimize side effects are reviewed. A comprehensive review of the English-language medical literature search was performed. No current review articles of the side effects and risks of local anesthetics were identified. This review serves to discuss local anesthetics commonly used in dermatology and cutaneous surgery along with practical information regarding prevention of adverse outcomes and addressing local and systemic reactions when they arise. Local anesthetics commonly used in cutaneous surgery have potential risks and side effects. Appropriate selection and utilization of local anesthetics and knowledge of the means to prevent and address these risks can impact surgical outcomes, patient satisfaction and safety, and ultimately patient experience in the dermatology clinic.

Biodynamic Excisional Skin Tension (BEST) Lines: Revisiting Langer’s Lines, Skin Biomechanics, Current Concepts in Cutaneous Surgery, and the (lack of) Science behind Skin Lines used for Surgical Excisions

Biodynamic Excisional Skin Tension (BEST) Lines: Revisiting Langer’s Lines, Skin Biomechanics, Current Concepts in Cutaneous Surgery, and the (lack of) Science behind Skin Lines used for Surgical Excisions

Should Advertising by Aesthetic Surgeons be Permitted?

Cosmetic, aesthetic and cutaneous surgical procedures require qualified specialists trained in the various procedures and competent to handle complications. However, it also requires huge investments in terms of infrastructure, trained staff and equipment. To be viable advertising is essential to any establishment which provides cosmetic and aesthetic procedures. Business men with deep pockets establish beauty chains which also provide these services and advertise heavily to sway public opinion in their favour. However, these saloons and spas lack basic medical facilities in terms of staff or equipment to handle any complication or medical emergency. To have a level playing field ethical advertising should be permitted to qualified aesthetic surgeons as is permitted in the US and UK by their respective organisations.

La dermatologie instrumentale avant la « dermatochirurgie », plus de 2 000 ans d’histoire

Surgical dermatology has probably existed since the first steps of antique medicine, especially for cutaneous cancer excision and wound reparation. Wonderful descriptions of surgical flaps can be found in the Encyclopedy of Celse, a Roman doctor living in the first century AC. Major progresses in local anesthesy were achieved at the end of the XIXth century, allowing the first dermatologists of the XXth century to perform biopsies and cutaneous surgery with a good control of patient’s pain. Electricity was introduced in medicine at the end of the XIXth century, and our ancestors dermatologists used it for electrocoagulation, cauterization and electric hair removal. In the « Pratique dermatologique », the first encyclopedy of dermatology published in 1900, many chapters show how important instrumental and surgical dermatology was.Pigmentary changes induced by surgery and other procedures were probably well known then but were less important than troubles due to scarring, which are mentioned in the early literature. Spontaneous or post-interventional cheloids are well discussed in the early works of Alibert, in the years 1810.This article shows that surgical dermatology is far more ancient than the creation of societies dedicated to it in the XXth century.

276P - Electrochemotherapy for breast cancer - results from the INSPECT database

Cutaneous recurrence from breast cancer can pose a clinical challenge. It may be the only disease site, or be part of disseminated disease, and often profoundly impacts quality of life. Electrochemotherapy is a palliative treatment for cutaneous metastases. Using electric pulses to locally permeabilize tumor cells, bleomycin cytotoxicity is significantly increased. Collaborating in the International Network for sharing Practice on ElectroChemoTherapy (INSPECT), we consecutively and prospectively accrued data on patients treated with electrochemotherapy for skin metastases of breast cancer. Patients with cutaneous metastases were treated with electrochemotherapy at 10 European centers. Treatment data and results were entered into the INSPECT database. Patients were treated with either local injection (1000 IU/ml intratumoral injection) or systemic infusion (15.000 IU/m2) of bleomycin, and under either local or general anesthesia, depending on tumor size. Pulse sequences (8 pulses of 0.1 ms) were sequentially applied to the tumor area, using an electroporation system with needle or plate electrodes (IGEA, Italy). 104 patients were included. Median age was 65 years. Patients had previous received chemotherapy (87%), radiotherapy (83%), endocrine therapy (46%) and HER2 targeted therapy (20%). Primary location was the chest (87%), median diameter of the cutaneous metastases being 26 mm (range 1 mm to 550 mm). 75 patients were available for response evaluation after 2 months. Complete response was observed in 38 (51%) patients, partial response in 13 (17%), stable disease in 14 (19%), and progressive disease in 5 (9%), 3 patients were not evaluable. Common side effects were ulceration, long lasting hyperpigmentation, and slight increase in pain. No serious adverse events were observed. Electrochemotherapy showed high response rates, particularly in smaller metastases. Electrochemotherapy has high response rates seen after a single treatment, with few side effects and can be used as an adjunct to systemic therapies as well as a sole treatment. We therefore highly recommend to consider electrochemotherapy for patients with cutaneous metastases, where radiotherapy and surgery is not an option.

Stress coping strategies for the optimal treatment of melanoma.

Dermatologic TherapyVolume 30, Issue 1 e12421 Journal Highlights Stress coping strategies for the optimal treatment of melanoma Katlein França, Corresponding Author Katlein França k.franca@med.miami.edu Department of Dermatology & Cutaneous Surgery; Department of Psychiatry & Behavioral Sciences, Institute for Bioethics & Health Policy- University of Miami Miller School of Medicine - Miami, FL, USA Professor; Centro Studi per la Ricerca Multidisciplinare e Rigenerativa- Università Degli Studi “G. Marconi”, Rome, ItalyCorrespondence Katlein Franca, Department of Dermatology & Cutaneous Surgery; Department of Psychiatry & Behavioral Sciences; Institute for Bioethics & Health Policy-University of Miami Miller School of Medicine - Miami, FL, USA. Email: k.franca@med.miami.eduSearch for more papers by this authorTorello Lotti, Torello Lotti Professor; Centro Studi per la Ricerca Multidisciplinare e Rigenerativa- Università Degli Studi “G. Marconi”, Rome, Italy Chair of Dermatology- University of Rome “G.Marconi”, Rome, ItalySearch for more papers by this author Katlein França, Corresponding Author Katlein França k.franca@med.miami.edu Department of Dermatology & Cutaneous Surgery; Department of Psychiatry & Behavioral Sciences, Institute for Bioethics & Health Policy- University of Miami Miller School of Medicine - Miami, FL, USA Professor; Centro Studi per la Ricerca Multidisciplinare e Rigenerativa- Università Degli Studi “G. Marconi”, Rome, ItalyCorrespondence Katlein Franca, Department of Dermatology & Cutaneous Surgery; Department of Psychiatry & Behavioral Sciences; Institute for Bioethics & Health Policy-University of Miami Miller School of Medicine - Miami, FL, USA. Email: k.franca@med.miami.eduSearch for more papers by this authorTorello Lotti, Torello Lotti Professor; Centro Studi per la Ricerca Multidisciplinare e Rigenerativa- Università Degli Studi “G. Marconi”, Rome, Italy Chair of Dermatology- University of Rome “G.Marconi”, Rome, ItalySearch for more papers by this author First published: 04 September 2016 https://doi.org/10.1111/dth.12421 [Correction added on 3 October 2016, after first online publication: the word “copying” has been changed to “coping” to accurately reflect the title of the article.] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume30, Issue1January/February 2017e12421 RelatedInformation

Use of Porcine Xenografts in Dermatology Surgery: The Mayo Clinic Experience.

Knowledge regarding the use of xenografts in cutaneous surgery is limited. We sought to better understand the utility, outcomes, and complications of porcine xenograft applications in cutaneous surgery. A single center, retrospective study of patients with porcine xenograft applications was completed. Characteristics of tumors, surgical procedures, resulting wound beds, follow-up care, and final length of follow-up were determined, and statistical analysis was conducted. Of 225 porcine xenograft placements in 220 patients, the majority of tumors were nonmelanoma skin cancers (89%) and similarly divided between the head (excepting nose/ear), nose, ear, and extremities. Both Mohs and standard excision resulted in a 5.7 cm mean area of surgical defect, with the majority closed by porcine xenograft only (84.1%), and healing by secondary intention (97.3%). The area of surgical defect and topical antibiotics contributed to increased length of time to final follow-up. The data represent the largest series of biologic dressings in cutaneous surgery and demonstrate the applicability and safety of porcine xenografts. We recommend consideration of porcine xenografts in the appropriate clinical context, to augment secondary intention.

A New Skin Tensiometer Device: Computational Analyses To Understand Biodynamic Excisional Skin Tension Lines.

One of the problems in planning cutaneous surgery is that human skin is anisotropic, or directionally dependent. Indeed, skin tension varies between individuals and at different body sites. Many a surgeon has tried to design different devices to measure skin tension to help plan excisional surgery, or to understand wound healing. However, many of the devices have been beset with problems due to many confounding variables - differences in technical ability, material (sutures) used and variability between different users. We describe the development of a new skin tensiometer that overcomes many historical technical issues. A new skin tension measuring device is presented here. It was designed to be less user-dependent, more reliable and usable on different bodily sites. The design and computational optimizations are discussed. Our skin tensiometer has helped understand the differences between incisional and excisional skin lines. Langer, who pioneered the concept of skin tension lines, created incisional lines that differ from lines caused by forces that need to be overcome when large wounds are closed surgically (excisional tension). The use of this innovative device has led to understanding of skin biomechanics and best excisional skin tension (BEST) lines.

Tattoos and Beyond: the Clinical Evolution of Picosecond Laser Technology

Picosecond lasers are a new commercial development in cutaneous laser surgery. While the importance of short picosecond laser pulses for the treatment of tattoos has long been known, the development of picosecond lasers has only recently been commercially viable. The picosecond lasers are able to photomechanically fragment tattoo ink particles more effectively than traditional Q-switched lasers. Similarly, pigmented lesions can be effectively treated with picosecond technology. New handpieces are able to fractionate and focus the picosecond laser pulse to cause light-induced optical breakdown in the dermis. The nonthermal dermal injury stimulates collagen production benefitting those with cutaneous scarring and photoaging. As newer systems are developed with multiple picosecond wavelengths, the clinical indications for their use will continue to expand.

Buried absorbable polyglactin 910 sutures do not result in stronger wounds in porcine full thickness skin incisions

ObjectiveTo test the hypothesis that the mechanical strength of wounds closed with a combination of buried dermal absorbable sutures and superficial nonabsorbable nylon sutures will be higher than wounds closed with only superficial nonabsorbable nylon sutures. MethodsFour Yucatan pigs were anesthetized and each received four 4.5cm full thickness incisions on their dorsal surfaces, placed 8cm apart. Half of all incisions were randomly allocated and repaired with 3–0 polyglactin 910 (Vicryl™) buried dermal absorbable sutures and superficial 3–0 nylon sutures, using a simple interrupted pattern. The other half received only 3–0 nylon sutures. Two pigs were humanely euthanized at day 10, with specimen harvest for mechanical testing; the other two pigs had superficial nylon sutures removed at day 10, as per current clinical practice, and were humanely euthanized at day 42, with specimen harvest for mechanical testing. Tensile loads were applied perpendicularly to the wounds with a displacement rate of 40mm per minute. ResultsWounds at day 42 were >9 times stronger than wounds at day 10 (p<0.0001). There was no difference in average wound strength at either day 10 or day 42 between wounds with and without buried dermal absorbable sutures. SignificanceBuried dermal absorbable sutures failed to provide additional wound support at either 10 or 42 days. This result may have immediate implications for clinicians who perform cutaneous surgery and keep superficial sutures in for at least 10 days. Future research will be directed to shorter time studies, other buried dermal absorbable suture materials, and alternatives to buried dermal absorbable sutures.

Utility of recorded guided imagery and relaxing music in reducing patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures: A single-blinded randomized controlled trial

Guided imagery and music can reportedly reduce pain and anxiety during surgery, but no comparative study has been performed for cutaneous surgery toour knowledge. We sought to determine whether short-contact recorded guided imagery or relaxing music could reduce patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures. Subjects were adults undergoing excisional surgery for basal and squamous cell carcinoma. Randomization was to guided imagery (n=50), relaxing music (n=54), or control group (n=51). Primary outcomes were pain and anxiety measured using visual analog scale and 6-item short-form of the State-Trait Anxiety Inventory, respectively. Secondary outcomes were anxiety of surgeons measured by the 6-item short-form of the State-Trait Anxiety Inventory and physical stress of patients conveyed by vital signs, respectively. There were no significant differences in subjects' pain, anxiety, blood pressure, and pulse rate across groups. In the recorded guided imagery and the relaxing music group, surgeon anxiety was significantly lower than in the control group. Patients could not be blinded. Short-contact recorded guided imagery and relaxing music appear not to reduce patient pain and anxiety during excisional procedures under local anesthetic. However, surgeon anxiety may be reduced when patients are listening to such recordings.

Potential for innate-like responsiveness of resident T cells in human skin: a new perspective on tissue immune-surveillance

BackgroundThe skin contains many resident immune cells that are key for tissue homoeostasis. In mouse skin, a distinct population of T cells have the innate-like capacity to respond rapidly to markers of tissue stress, rather than requiring clonal, antigen-specific activation. This lymphoid stress surveillance response (LSSR) is key to host immunity, contributing to cancer immunosurveillance and cutaneous atopy. We sought to identify whether the potential for LSSR exists in human skin. MethodsWe adapted a novel skin explant protocol to study the skin-resident lymphocyte compartments of over 100 healthy donors. Normal adult skin was obtained as discarded material after cutaneous surgery. Skin-resident lymphocytes were characterised by flow cytometry, and their functional potentials assessed in vitro with different models of activation. Ethics approval was granted by a local research ethics committee (REC 06/Q0704/18) FindingsWe established that human skin contains a large reproducible population of γδ T cells, which were distinct from γδ T cells in the blood. These cells displayed features of tissue-resident memory T cell receptor (TCR) αβ+ cells, but strikingly had the capacity to become activated by ligands for the NKG2D receptor, independent of the TCR, which is analogous to innate-like T cells in mouse skin. Such responsiveness was not seen in other NKG2D+ T cells. Upon NKG2D-mediated activation, skin-resident γδ T cells showed robust T helper-1-like and cytotoxic effector responses, and in some donors interleukin 13 production. These cells also displayed profound cytolytic activity against transformed epithelial cells in vitro, in part mediated via NKG2D. InterpretationTo our knowledge, these data provide the first clear identification of human tissue-resident innate-like T cells, which strongly argues for the existence of LSSR in human tissues and places skin-resident γδ T cells in the early afferent phase of the immune response. This finding offers a new perspective on tissue immune surveillance, possibly representing a common feature of barrier tissues, and has implications for future studies in human skin immunobiology. FundingMedical Research Council, Wellcome Trust, Cancer Research UK.

Shifting Trends in Cutaneous and Aesthetic Surgery: A Need for Caution and Regulation.

Shifting Trends in Cutaneous and Aesthetic Surgery: A Need for Caution and Regulation.

Donor Kidney With Renal Cell Carcinoma Successfully Treated With Radiofrequency Ablation: A Case Report

BackgroundThe risk of donor-transmitted cancer is evident. Case ReportWe report the case of a 69-year-old woman who was transplanted with a kidney from a deceased donor. Four days after transplantation a routine ultrasound scan revealed a 3-cm tumor in the middle-upper pole of the allograft. A biopsy showed the tumor to be papillary renal cell carcinoma. The patient was treated with radiofrequency ablation. This procedure was complicated by the development of a cutaneous fistula and open surgery was done with resection of an area of necrosis in the kidney and of the fistula. The maintenance immunosuppressive regimen was modified with a change in treatment to everolimus in combination with reduced dose mycophenolate and low-dose steroids. The patient was followed for 4.5 years and during that time she remained dialysis independent with an excellent allograft function (serum creatinine, 95 μmol/L [1.04 mg/dL]). ConclusionsTo the best of our knowledge, this is the first case in which a donor-transmitted tumor was diagnosed in the renal allograft only 4 days after transplantation and subsequently treated successfully with radiofrequency ablation.

The level of clinical knowledge of cutaneous cancer and reconstructive surgery amongst dentally qualified SHOs

The level of clinical knowledge of cutaneous cancer and reconstructive surgery amongst dentally qualified SHOs

Ex vivo evaluation of acellular and cellular collagen-glycosaminoglycan flowable matrices

Collagen-glycosaminoglycan flowable matrices (CGFM) are increasingly finding utility in a diversifying number of cutaneous surgical procedures. Cellular in-growth and vascularisation of CGFM remain rate-limiting steps, increasing cost and decreasing efficacy. Through in vitro and ex vivo culture methods, this study investigated the improvement of injectable CGFM by the incorporation of hyaluronan (HA) and viable human cells (primary human dermal fibroblasts (PHDFs) and bone marrow-derived mesenchymal stem cells (BM-MSCs)). Ex vivo investigations included the development and evaluation of a human cutaneous wound healing model for the comparison of dermal substitutes. Cells mixed into the Integra Flowable Wound Matrix (IFWM), a commercially available CGFM, were confirmed to be viable and proliferative through MTT assays (p < 0.05). PHDFs proliferated with greater rapidity than BM-MSCs up to 1 week in culture (p < 0.05), with PHDF proliferation further enhanced by HA supplementation (p < 0.05). After scaffold mixing, gene expression was not significantly altered (qRT-PCR). PHDF and BM-MSC incorporation into ex vivo wound models significantly increased re-epithelialisation rate, with maximal effects observed for BM-MSC supplemented IFWM. HA supplementation to PHDF populated IFWM increased re-epithelialisation but had no significant effect on BM-MSC populated IFWM. In conclusion, when combined with PHDF, HA increased re-epithelialisation in IFWM. BM-MSC incorporation significantly improved re-epithelialisation in ex vivo models over acellular and PHDF populated scaffolds. Viable cell incorporation into IFWM has potential to significantly benefit wound healing in chronic and acute cutaneous injuries by allowing a point-of-care matrix to be formed from autologous or allogenic cells and bioactive molecules.

Suturing Techniques for Optimal Surgical Outcomes

Surgical outcomes in cutaneous surgery are impacted by preoperative design, excision, and repair. Optimal suturing technique plays an important role in skin repairs and is achieved through appropriate selection of suture material and needle points, gentle handling of the tissue, and properly placed sutures. This review addresses the above key principles, strategies for correct knot tying, and situations where special sutures may promote a better outcome.