Aesthetic Dermatology

Margaret W. Mann, MD, Melanie D. Palm, MD, and Roberta D. Sengelmann, MD

Although suction-assisted liposuction under tumescent anesthesia remains the traditional method for body sculpting, newer technologies promise to increase efficiency, decrease surgeon fatigue, and minimize complication. Power-, ultrasound-, and laser-assisted devices are ideal in large volume cases and in areas of fibrous tissues as an adjunct to traditional liposuction. Although skepticism remains chemical lipolysis, more commonly termed mesotherapy or lipodissolve may be an alternative to surgical treatment of localized fat. This article reviews the recent advancements in the field of liposuction and the current literature which support their use.

*For a PDF of the full article, click on the link to the left of this introduction.

Margaret W. Mann, MD, Melanie D. Palm, MD, and Roberta D. Sengelmann, MD

Although suction-assisted liposuction under tumescent anesthesia remains the traditional method for body sculpting, newer technologies promise to increase efficiency, decrease surgeon fatigue, and minimize complication. Power-, ultrasound-, and laser-assisted devices are ideal in large volume cases and in areas of fibrous tissues as an adjunct to traditional liposuction. Although skepticism remains chemical lipolysis, more commonly termed mesotherapy or lipodissolve may be an alternative to surgical treatment of localized fat. This article reviews the recent advancements in the field of liposuction and the current literature which support their use.

*For a PDF of the full article, click on the link to the left of this introduction.

Margaret W. Mann, MD, Melanie D. Palm, MD, and Roberta D. Sengelmann, MD

Although suction-assisted liposuction under tumescent anesthesia remains the traditional method for body sculpting, newer technologies promise to increase efficiency, decrease surgeon fatigue, and minimize complication. Power-, ultrasound-, and laser-assisted devices are ideal in large volume cases and in areas of fibrous tissues as an adjunct to traditional liposuction. Although skepticism remains chemical lipolysis, more commonly termed mesotherapy or lipodissolve may be an alternative to surgical treatment of localized fat. This article reviews the recent advancements in the field of liposuction and the current literature which support their use.

*For a PDF of the full article, click on the link to the left of this introduction.

CHICAGO — A technique that combines occlusion coils and alcohol sclerosis is the latest addition to the array of catheter-based approaches available to treat varicose veins.

"We have yet another tool in an area where I don't think we needed another tool; it's coil occlusion and sclerosis," Dr. Thom W. Rooke, head of vascular medicine at the Mayo Clinic, Rochester, Minn., said at a symposium on vascular surgery sponsored by Northwestern University. "It's definitely a feasible alternative to stripping or other catheter ablation mechanisms."

Potential advantages include no tumescent anesthesia and no potential for thermal skin damage. Radiofrequency and laser technologies have the potential—despite the use of tumescent anesthesia—to cause thermal injury, particularly in patients with relatively thin skin or in whom the veins are very superficial; they also have the potential to produce clots in the saphenous vein that may propagate into the femoral vein with the attendant risks of pulmonary embolism.

The new procedure is relatively simple and easy to incorporate, if the practitioner is already using fluoroscopy and catheterization in the daily routine. "And the final punch line: This [procedure] may be very cost effective, although we haven't analyzed that yet," he said.

Dr. Rooke reported results from a retrospective study of 96 patients (mean age 53 years) with incompetent saphenous veins, in whom the use of coil occlusion and sclerosis resulted in complete occlusion of the target vein in 94% of 119 limbs, and partial occlusion in the remaining 6%.

Nearly all of the patients were being treated for significant symptoms, such as discomfort/pain, edema, stasis changes, and ulceration, rather than for cosmetic indications.

Venous refilling rates dropped from a preprocedural mean of 11.6 mL/minute per 100 g (which corresponds to "moderate" venous incompetence at the Mayo Clinic), to a "normal" value of 5.4 mL/min per 100 g after the outpatient procedure. At a mean follow-up of 14 weeks, symptoms were resolved or markedly improved in 94% of patients, were partially improved in 4%, and showed no change in 2%.

A small, asymptomatic arteriovenous fistula in the region of the saphenofemoral junction was observed on follow-up ultrasound in one patient; two patients developed symptomatic superficial phlebitis; and none developed deep venous thrombosis, said Dr. Rooke, professor of vascular medicine at the Mayo Medical College, also in Rochester. In three limbs, the coils were inappropriately placed and had to be repositioned.

Interventional radiologists have been using various occlusion coils and sclerosing agents (typically ethanol) for decades to successfully and safely obliterate arteriovenous malformations, varicoceles, and other unwanted veins, so their application to varicose veins seemed a logical extension to physicians at the Mayo Clinic, Dr. Rooke explained.

The technique begins with a local injection of lidocaine to anesthetize the skin just above or below the knee, followed by an ultrasound-guided puncture of the greater saphenous vein. Fluoroscopy is used to guide a 5 French end-hole catheter to the saphenofemoral junction, after which a 4- to 14-mm Nester coil (Cook Medical Inc.) is placed near the junction with one end anchored into an appropriately positioned tributary. Once this coil is secure, 2 to 10 additional coils (average, 3) are added as needed.

After radiographic confirmation of occlusion is obtained, lidocaine (3 cc of 1% solution) is injected into the lumen of the vein and allowed to sit for a few minutes. The catheter is then slowly withdrawn, and ethanol (1–6 mL) is infused throughout the length of the saphenous vein.

Finally, the catheter is withdrawn, and full-length, graduated compression stockings are applied to the leg. The stockings should be worn continuously for 3 days, followed by daytime-only usage for about 10 days. Patients can ambulate immediately after the procedure, with no limitations placed on their routine, Dr. Rooke said.

In some cases, sodium tetradecanal sulfate (3%) was used instead of absolute alcohol because there are anecdotal reports of toxicity, especially to the lungs, with ethanol, Dr. Rooke said in an interview. However, most of the clinic's radiologists, who are more familiar with the alcohol, have returned to using ethanol as their preferred agent.

Coil occlusion and sclerosis have also been used to treat perforator veins and the shorter saphenous vein, with good results, he added. Dr. Rooke reported that he has no conflict to disclose with regard to this research.

The coil occlusion and sclerosis technique is easy to incorporate and could prove to be cost effective. DR. ROOKE

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — A technique that combines occlusion coils and alcohol sclerosis is the latest addition to the array of catheter-based approaches available to treat varicose veins.

"We have yet another tool in an area where I don't think we needed another tool; it's coil occlusion and sclerosis," Dr. Thom W. Rooke, head of vascular medicine at the Mayo Clinic, Rochester, Minn., said at a symposium on vascular surgery sponsored by Northwestern University. "It's definitely a feasible alternative to stripping or other catheter ablation mechanisms."

Potential advantages include no tumescent anesthesia and no potential for thermal skin damage. Radiofrequency and laser technologies have the potential—despite the use of tumescent anesthesia—to cause thermal injury, particularly in patients with relatively thin skin or in whom the veins are very superficial; they also have the potential to produce clots in the saphenous vein that may propagate into the femoral vein with the attendant risks of pulmonary embolism.

The new procedure is relatively simple and easy to incorporate, if the practitioner is already using fluoroscopy and catheterization in the daily routine. "And the final punch line: This [procedure] may be very cost effective, although we haven't analyzed that yet," he said.

Dr. Rooke reported results from a retrospective study of 96 patients (mean age 53 years) with incompetent saphenous veins, in whom the use of coil occlusion and sclerosis resulted in complete occlusion of the target vein in 94% of 119 limbs, and partial occlusion in the remaining 6%.

Nearly all of the patients were being treated for significant symptoms, such as discomfort/pain, edema, stasis changes, and ulceration, rather than for cosmetic indications.

Venous refilling rates dropped from a preprocedural mean of 11.6 mL/minute per 100 g (which corresponds to "moderate" venous incompetence at the Mayo Clinic), to a "normal" value of 5.4 mL/min per 100 g after the outpatient procedure. At a mean follow-up of 14 weeks, symptoms were resolved or markedly improved in 94% of patients, were partially improved in 4%, and showed no change in 2%.

A small, asymptomatic arteriovenous fistula in the region of the saphenofemoral junction was observed on follow-up ultrasound in one patient; two patients developed symptomatic superficial phlebitis; and none developed deep venous thrombosis, said Dr. Rooke, professor of vascular medicine at the Mayo Medical College, also in Rochester. In three limbs, the coils were inappropriately placed and had to be repositioned.

Interventional radiologists have been using various occlusion coils and sclerosing agents (typically ethanol) for decades to successfully and safely obliterate arteriovenous malformations, varicoceles, and other unwanted veins, so their application to varicose veins seemed a logical extension to physicians at the Mayo Clinic, Dr. Rooke explained.

The technique begins with a local injection of lidocaine to anesthetize the skin just above or below the knee, followed by an ultrasound-guided puncture of the greater saphenous vein. Fluoroscopy is used to guide a 5 French end-hole catheter to the saphenofemoral junction, after which a 4- to 14-mm Nester coil (Cook Medical Inc.) is placed near the junction with one end anchored into an appropriately positioned tributary. Once this coil is secure, 2 to 10 additional coils (average, 3) are added as needed.

After radiographic confirmation of occlusion is obtained, lidocaine (3 cc of 1% solution) is injected into the lumen of the vein and allowed to sit for a few minutes. The catheter is then slowly withdrawn, and ethanol (1–6 mL) is infused throughout the length of the saphenous vein.

Finally, the catheter is withdrawn, and full-length, graduated compression stockings are applied to the leg. The stockings should be worn continuously for 3 days, followed by daytime-only usage for about 10 days. Patients can ambulate immediately after the procedure, with no limitations placed on their routine, Dr. Rooke said.

In some cases, sodium tetradecanal sulfate (3%) was used instead of absolute alcohol because there are anecdotal reports of toxicity, especially to the lungs, with ethanol, Dr. Rooke said in an interview. However, most of the clinic's radiologists, who are more familiar with the alcohol, have returned to using ethanol as their preferred agent.

Coil occlusion and sclerosis have also been used to treat perforator veins and the shorter saphenous vein, with good results, he added. Dr. Rooke reported that he has no conflict to disclose with regard to this research.

The coil occlusion and sclerosis technique is easy to incorporate and could prove to be cost effective. DR. ROOKE

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — A technique that combines occlusion coils and alcohol sclerosis is the latest addition to the array of catheter-based approaches available to treat varicose veins.

"We have yet another tool in an area where I don't think we needed another tool; it's coil occlusion and sclerosis," Dr. Thom W. Rooke, head of vascular medicine at the Mayo Clinic, Rochester, Minn., said at a symposium on vascular surgery sponsored by Northwestern University. "It's definitely a feasible alternative to stripping or other catheter ablation mechanisms."

Potential advantages include no tumescent anesthesia and no potential for thermal skin damage. Radiofrequency and laser technologies have the potential—despite the use of tumescent anesthesia—to cause thermal injury, particularly in patients with relatively thin skin or in whom the veins are very superficial; they also have the potential to produce clots in the saphenous vein that may propagate into the femoral vein with the attendant risks of pulmonary embolism.

The new procedure is relatively simple and easy to incorporate, if the practitioner is already using fluoroscopy and catheterization in the daily routine. "And the final punch line: This [procedure] may be very cost effective, although we haven't analyzed that yet," he said.

Dr. Rooke reported results from a retrospective study of 96 patients (mean age 53 years) with incompetent saphenous veins, in whom the use of coil occlusion and sclerosis resulted in complete occlusion of the target vein in 94% of 119 limbs, and partial occlusion in the remaining 6%.

Nearly all of the patients were being treated for significant symptoms, such as discomfort/pain, edema, stasis changes, and ulceration, rather than for cosmetic indications.

Venous refilling rates dropped from a preprocedural mean of 11.6 mL/minute per 100 g (which corresponds to "moderate" venous incompetence at the Mayo Clinic), to a "normal" value of 5.4 mL/min per 100 g after the outpatient procedure. At a mean follow-up of 14 weeks, symptoms were resolved or markedly improved in 94% of patients, were partially improved in 4%, and showed no change in 2%.

A small, asymptomatic arteriovenous fistula in the region of the saphenofemoral junction was observed on follow-up ultrasound in one patient; two patients developed symptomatic superficial phlebitis; and none developed deep venous thrombosis, said Dr. Rooke, professor of vascular medicine at the Mayo Medical College, also in Rochester. In three limbs, the coils were inappropriately placed and had to be repositioned.

Interventional radiologists have been using various occlusion coils and sclerosing agents (typically ethanol) for decades to successfully and safely obliterate arteriovenous malformations, varicoceles, and other unwanted veins, so their application to varicose veins seemed a logical extension to physicians at the Mayo Clinic, Dr. Rooke explained.

The technique begins with a local injection of lidocaine to anesthetize the skin just above or below the knee, followed by an ultrasound-guided puncture of the greater saphenous vein. Fluoroscopy is used to guide a 5 French end-hole catheter to the saphenofemoral junction, after which a 4- to 14-mm Nester coil (Cook Medical Inc.) is placed near the junction with one end anchored into an appropriately positioned tributary. Once this coil is secure, 2 to 10 additional coils (average, 3) are added as needed.

After radiographic confirmation of occlusion is obtained, lidocaine (3 cc of 1% solution) is injected into the lumen of the vein and allowed to sit for a few minutes. The catheter is then slowly withdrawn, and ethanol (1–6 mL) is infused throughout the length of the saphenous vein.

Finally, the catheter is withdrawn, and full-length, graduated compression stockings are applied to the leg. The stockings should be worn continuously for 3 days, followed by daytime-only usage for about 10 days. Patients can ambulate immediately after the procedure, with no limitations placed on their routine, Dr. Rooke said.

In some cases, sodium tetradecanal sulfate (3%) was used instead of absolute alcohol because there are anecdotal reports of toxicity, especially to the lungs, with ethanol, Dr. Rooke said in an interview. However, most of the clinic's radiologists, who are more familiar with the alcohol, have returned to using ethanol as their preferred agent.

Coil occlusion and sclerosis have also been used to treat perforator veins and the shorter saphenous vein, with good results, he added. Dr. Rooke reported that he has no conflict to disclose with regard to this research.

The coil occlusion and sclerosis technique is easy to incorporate and could prove to be cost effective. DR. ROOKE

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Most of the estimated 1,000 suture needle sticks endured by surgeons and surgical residents in the United States each day can be prevented by protecting the needle point within the needle driver, according to Dr. Joy Kunishige.

"Before the needle and needle driver are either handed off to the assistant or returned to the surgical tray, pivot the needle 90 degrees toward the instrument joint," said Dr. Kunishige, a dermatology resident at the University of Texas M.D. Anderson Cancer Center in Houston.

"Next, close the needle driver on the body near, but not on, the shank of the needle," she said. "The needle point should be directed toward and almost touching the driver, thereby disarming the needle point."

To avoid dulling the needle, do not grasp the point by the needle driver, Dr. Kunishige said during a poster presentation at the annual meeting of the American Society for Dermatologic Surgery.

"These precautions are especially important in Mohs surgery because you're using the same tray and the same instruments throughout the procedure," she said in an interview. "If your procedure involves three layers, you're going to use the instrument three times plus once more for reconstruction, so the sharps is being constantly moved around, potentially exposing several people to the risk of a needle stick."

A simple and inexpensive solution for disarming a needle that is being temporarily put aside is to use a brightly colored piece of foam, such as that available at arts and crafts stores. "We keep the foam piece in the upper right-hand corner of the field and just stick our needle into that," Dr. Kunishige said.

The worst mistake is to leave an exposed needle on a patient's chest where it can fall when the patient moves. "Placing a tray on a patient's chest can be a mine field," she said.

Even when a needle stick does not cause infection, follow-up testing can cost up to $3,000, she added.

"If you make these little precautions habitual, you'll greatly reduce the risk of needle sticks in your workplace," Dr. Kunishige concluded.

The needle should be grasped in the needle driver as shown in the image above to avoid exposing the point. Courtesy Dr. Joy Kunishige

CHICAGO — Most of the estimated 1,000 suture needle sticks endured by surgeons and surgical residents in the United States each day can be prevented by protecting the needle point within the needle driver, according to Dr. Joy Kunishige.

"Before the needle and needle driver are either handed off to the assistant or returned to the surgical tray, pivot the needle 90 degrees toward the instrument joint," said Dr. Kunishige, a dermatology resident at the University of Texas M.D. Anderson Cancer Center in Houston.

"Next, close the needle driver on the body near, but not on, the shank of the needle," she said. "The needle point should be directed toward and almost touching the driver, thereby disarming the needle point."

To avoid dulling the needle, do not grasp the point by the needle driver, Dr. Kunishige said during a poster presentation at the annual meeting of the American Society for Dermatologic Surgery.

"These precautions are especially important in Mohs surgery because you're using the same tray and the same instruments throughout the procedure," she said in an interview. "If your procedure involves three layers, you're going to use the instrument three times plus once more for reconstruction, so the sharps is being constantly moved around, potentially exposing several people to the risk of a needle stick."

A simple and inexpensive solution for disarming a needle that is being temporarily put aside is to use a brightly colored piece of foam, such as that available at arts and crafts stores. "We keep the foam piece in the upper right-hand corner of the field and just stick our needle into that," Dr. Kunishige said.

The worst mistake is to leave an exposed needle on a patient's chest where it can fall when the patient moves. "Placing a tray on a patient's chest can be a mine field," she said.

Even when a needle stick does not cause infection, follow-up testing can cost up to $3,000, she added.

"If you make these little precautions habitual, you'll greatly reduce the risk of needle sticks in your workplace," Dr. Kunishige concluded.

The needle should be grasped in the needle driver as shown in the image above to avoid exposing the point. Courtesy Dr. Joy Kunishige

CHICAGO — Most of the estimated 1,000 suture needle sticks endured by surgeons and surgical residents in the United States each day can be prevented by protecting the needle point within the needle driver, according to Dr. Joy Kunishige.

"Before the needle and needle driver are either handed off to the assistant or returned to the surgical tray, pivot the needle 90 degrees toward the instrument joint," said Dr. Kunishige, a dermatology resident at the University of Texas M.D. Anderson Cancer Center in Houston.

"Next, close the needle driver on the body near, but not on, the shank of the needle," she said. "The needle point should be directed toward and almost touching the driver, thereby disarming the needle point."

To avoid dulling the needle, do not grasp the point by the needle driver, Dr. Kunishige said during a poster presentation at the annual meeting of the American Society for Dermatologic Surgery.

"These precautions are especially important in Mohs surgery because you're using the same tray and the same instruments throughout the procedure," she said in an interview. "If your procedure involves three layers, you're going to use the instrument three times plus once more for reconstruction, so the sharps is being constantly moved around, potentially exposing several people to the risk of a needle stick."

A simple and inexpensive solution for disarming a needle that is being temporarily put aside is to use a brightly colored piece of foam, such as that available at arts and crafts stores. "We keep the foam piece in the upper right-hand corner of the field and just stick our needle into that," Dr. Kunishige said.

The worst mistake is to leave an exposed needle on a patient's chest where it can fall when the patient moves. "Placing a tray on a patient's chest can be a mine field," she said.

Even when a needle stick does not cause infection, follow-up testing can cost up to $3,000, she added.

"If you make these little precautions habitual, you'll greatly reduce the risk of needle sticks in your workplace," Dr. Kunishige concluded.

The needle should be grasped in the needle driver as shown in the image above to avoid exposing the point. Courtesy Dr. Joy Kunishige

ORLANDO — CO₂ laser ablation with aggressive curettage proved successful for the treatment of a patient with Darier's disease who had failed other medical therapies.

The CO₂ laser/curettage approach was initially used on one part of the patient's abdomen, and the results compared favorably with results following wire brush dermabrasion on another part of her abdomen, reported Dr. Tri H. Nguyen at the annual meeting of the Florida Society of Dermatologic Surgeons.

The areas looked similar postoperatively, with erythema appearing on the CO₂ laser-treated area at short-term follow-up, and the beginning of hypertrophic scarring in the dermabraded area (this resolved with flurandrenolide tape). The erythema resolved over time.

The patient was greatly affected by this "horrible" disease, said Dr. Nguyen, associate professor of dermatology, and director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston. She had chronic maceration, malodor, repeat infections, and mastitis, and her daily activities were restricted by her symptoms.

After successfully treating a number of cases of Hailey-Hailey disease with the CO₂ laser/curettage approach, Dr. Nguyen thought it might prove useful in this patient since both diseases require treatment that produces lesion destruction and scarring to achieve long-lasting remission.

She had failed numerous other therapies, including systemic and topical antibiotics, topical retinoids, and laser treatments.

The CO₂ laser/curettage treatment was performed under tumescent anesthesia; the patient also received oral anxiolysis with lorazepam and oral oxycodone and acetaminophen (Percocet). The CO₂ laser was used on continuous wave mode at up to 40 W. Sometimes 15–20 W were used, but Dr. Nguyen said he never went below that setting on the first pass "because the plaques were so hyperkeratotic."

The skin was treated in a grid pattern to ensure uniformity.

Based on the initial success, the patient was treated subsequently on other areas where she experienced the most difficulties with symptoms, malodor, and infection. The resulting smooth, flat scars which fade from the initial erythema into hypo- or depigmented scars have proved to be a "much better alternative" to the hyperkeratotic Darier's lesions, he said. The patient has been extremely satisfied with the results, and has returned repeatedly for treatment of additional areas.

Dr. Nguyen had no relevant conflicts of interest to disclose.

The resulting scars have proved to be a 'much better alternative' to the hyperkeratotic Darier's lesions. DR. NGUYEN

ORLANDO — CO₂ laser ablation with aggressive curettage proved successful for the treatment of a patient with Darier's disease who had failed other medical therapies.

The CO₂ laser/curettage approach was initially used on one part of the patient's abdomen, and the results compared favorably with results following wire brush dermabrasion on another part of her abdomen, reported Dr. Tri H. Nguyen at the annual meeting of the Florida Society of Dermatologic Surgeons.

The areas looked similar postoperatively, with erythema appearing on the CO₂ laser-treated area at short-term follow-up, and the beginning of hypertrophic scarring in the dermabraded area (this resolved with flurandrenolide tape). The erythema resolved over time.

The patient was greatly affected by this "horrible" disease, said Dr. Nguyen, associate professor of dermatology, and director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston. She had chronic maceration, malodor, repeat infections, and mastitis, and her daily activities were restricted by her symptoms.

After successfully treating a number of cases of Hailey-Hailey disease with the CO₂ laser/curettage approach, Dr. Nguyen thought it might prove useful in this patient since both diseases require treatment that produces lesion destruction and scarring to achieve long-lasting remission.

She had failed numerous other therapies, including systemic and topical antibiotics, topical retinoids, and laser treatments.

The CO₂ laser/curettage treatment was performed under tumescent anesthesia; the patient also received oral anxiolysis with lorazepam and oral oxycodone and acetaminophen (Percocet). The CO₂ laser was used on continuous wave mode at up to 40 W. Sometimes 15–20 W were used, but Dr. Nguyen said he never went below that setting on the first pass "because the plaques were so hyperkeratotic."

The skin was treated in a grid pattern to ensure uniformity.

Based on the initial success, the patient was treated subsequently on other areas where she experienced the most difficulties with symptoms, malodor, and infection. The resulting smooth, flat scars which fade from the initial erythema into hypo- or depigmented scars have proved to be a "much better alternative" to the hyperkeratotic Darier's lesions, he said. The patient has been extremely satisfied with the results, and has returned repeatedly for treatment of additional areas.

Dr. Nguyen had no relevant conflicts of interest to disclose.

The resulting scars have proved to be a 'much better alternative' to the hyperkeratotic Darier's lesions. DR. NGUYEN

ORLANDO — CO₂ laser ablation with aggressive curettage proved successful for the treatment of a patient with Darier's disease who had failed other medical therapies.

The CO₂ laser/curettage approach was initially used on one part of the patient's abdomen, and the results compared favorably with results following wire brush dermabrasion on another part of her abdomen, reported Dr. Tri H. Nguyen at the annual meeting of the Florida Society of Dermatologic Surgeons.

The areas looked similar postoperatively, with erythema appearing on the CO₂ laser-treated area at short-term follow-up, and the beginning of hypertrophic scarring in the dermabraded area (this resolved with flurandrenolide tape). The erythema resolved over time.

The patient was greatly affected by this "horrible" disease, said Dr. Nguyen, associate professor of dermatology, and director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston. She had chronic maceration, malodor, repeat infections, and mastitis, and her daily activities were restricted by her symptoms.

After successfully treating a number of cases of Hailey-Hailey disease with the CO₂ laser/curettage approach, Dr. Nguyen thought it might prove useful in this patient since both diseases require treatment that produces lesion destruction and scarring to achieve long-lasting remission.

She had failed numerous other therapies, including systemic and topical antibiotics, topical retinoids, and laser treatments.

The CO₂ laser/curettage treatment was performed under tumescent anesthesia; the patient also received oral anxiolysis with lorazepam and oral oxycodone and acetaminophen (Percocet). The CO₂ laser was used on continuous wave mode at up to 40 W. Sometimes 15–20 W were used, but Dr. Nguyen said he never went below that setting on the first pass "because the plaques were so hyperkeratotic."

The skin was treated in a grid pattern to ensure uniformity.

Based on the initial success, the patient was treated subsequently on other areas where she experienced the most difficulties with symptoms, malodor, and infection. The resulting smooth, flat scars which fade from the initial erythema into hypo- or depigmented scars have proved to be a "much better alternative" to the hyperkeratotic Darier's lesions, he said. The patient has been extremely satisfied with the results, and has returned repeatedly for treatment of additional areas.

Dr. Nguyen had no relevant conflicts of interest to disclose.

The resulting scars have proved to be a 'much better alternative' to the hyperkeratotic Darier's lesions. DR. NGUYEN

ORLANDO — Most dermatologic surgery patients don't need perioperative antibiotics, and the routine use of antibiotics to prevent surgical site infection or infective endocarditis should be discouraged, Dr. Steve Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Healthy individuals, those who undergo surgery of a clean site, and those who undergo procedures of limited duration typically do not need prophylactic antibiotics. As for determining which patients do need prophylaxis, a number of variable risk factors should be considered, including HIV-positive status, chronic immunosuppression, age, occupation, and temperature/humidity, all of which could affect infection risk, said Dr. Spencer of Port Charlotte, Fla., noting that these are gray areas that require individualized decision making.

It is clearer, however, that those who are immunocompromised; those undergoing surgery of riskier areas such as the mouth, groin, or axillae, or sites that are already infected; and those who are at high risk of infective endocarditis (see sidebar) should receive prophylaxis, he said. Dr. Spencer cited guidelines on prevention of infective endocarditis published by the American Heart Association last year (Circulation 2007;116:1736–54).

Although the guidelines mainly address dental issues, the AHA noted that infectious endocarditis is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by dental or medical procedures and that prophylaxis is likely to prevent a very small number of cases of infectious endocarditis, if any.

The guidelines also point out that the risks of antibiotic prophylaxis in terms of adverse events exceed the benefits, if any, from antibiotic prophylaxis and recommend that only those with the highest risk of adverse outcomes from endocarditis should undergo antibiotic prophylaxis.

As for procedures on infected skin, skin structures, or musculoskeletal tissue, the AHA noted that, while these infections are typically polymicrobial, only staphylococci and β-hemolytic streptococci are likely to cause infective endocarditis. Therefore, when antibiotic prophylaxis is needed, the drug selected should target the most likely organisms to be encountered and be given prior to the procedure.

Broad-spectrum antibiotics—most often first-generation cephalosporins—are commonly used to treat these species.

Semisynthetic penicillinase-resistant penicillins are good for gram-positive cocci, Klebsiella, Escherichia coli, and Proteus organisms. Clindamycin is an alternative option in penicillin-allergic patients. Erythromycin is almost never used because it is associated with very high staphylococcal resistance, Dr. Spencer said.

Clindamycin also is a good option for patients undergoing surgery of the oral mucosal areas, but cephalosporins may have less cross-reactivity in penicillin-allergic patients. Although trimethoprim-sulfamethoxazole coverage is similar to these, with excellent gram-positive coverage, it does not provide Pseudomonas coverage, he added.

When antibiotic prophylaxis is determined to be necessary, it should be delivered 30–60 minutes before surgery. Since surgical factors are at least as important for preventing infection, sterile techniques and proper sterilization of instruments, avoidance of excess tension on closures, avoidance of excessive suture material, and avoidance of charring also require careful attention, he said.

Conditions With Endocarditis Risk

The American Heart Association guidelines state that the following cardiac conditions have the highest risk of adverse outcomes from endocarditis:

▸ Prosthetic cardiac valve.

▸ Previous infective endocarditis.

▸ Congenital heart disease.

▸ Unrepaired cyanotic CHD, including palliative shunts and conduits.

▸ Completely repaired (with prosthetic material or device) congenital heart defect during first 6 months after the repair.

▸ Repaired CHD with residual defect (at or adjacent to the site of the prosthetic patch or device) that inhibits endothelialization.

▸ Postcardiac transplant cardiac valvulopathy.

ORLANDO — Most dermatologic surgery patients don't need perioperative antibiotics, and the routine use of antibiotics to prevent surgical site infection or infective endocarditis should be discouraged, Dr. Steve Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Healthy individuals, those who undergo surgery of a clean site, and those who undergo procedures of limited duration typically do not need prophylactic antibiotics. As for determining which patients do need prophylaxis, a number of variable risk factors should be considered, including HIV-positive status, chronic immunosuppression, age, occupation, and temperature/humidity, all of which could affect infection risk, said Dr. Spencer of Port Charlotte, Fla., noting that these are gray areas that require individualized decision making.

It is clearer, however, that those who are immunocompromised; those undergoing surgery of riskier areas such as the mouth, groin, or axillae, or sites that are already infected; and those who are at high risk of infective endocarditis (see sidebar) should receive prophylaxis, he said. Dr. Spencer cited guidelines on prevention of infective endocarditis published by the American Heart Association last year (Circulation 2007;116:1736–54).

Although the guidelines mainly address dental issues, the AHA noted that infectious endocarditis is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by dental or medical procedures and that prophylaxis is likely to prevent a very small number of cases of infectious endocarditis, if any.

The guidelines also point out that the risks of antibiotic prophylaxis in terms of adverse events exceed the benefits, if any, from antibiotic prophylaxis and recommend that only those with the highest risk of adverse outcomes from endocarditis should undergo antibiotic prophylaxis.

As for procedures on infected skin, skin structures, or musculoskeletal tissue, the AHA noted that, while these infections are typically polymicrobial, only staphylococci and β-hemolytic streptococci are likely to cause infective endocarditis. Therefore, when antibiotic prophylaxis is needed, the drug selected should target the most likely organisms to be encountered and be given prior to the procedure.

Broad-spectrum antibiotics—most often first-generation cephalosporins—are commonly used to treat these species.

Semisynthetic penicillinase-resistant penicillins are good for gram-positive cocci, Klebsiella, Escherichia coli, and Proteus organisms. Clindamycin is an alternative option in penicillin-allergic patients. Erythromycin is almost never used because it is associated with very high staphylococcal resistance, Dr. Spencer said.

Clindamycin also is a good option for patients undergoing surgery of the oral mucosal areas, but cephalosporins may have less cross-reactivity in penicillin-allergic patients. Although trimethoprim-sulfamethoxazole coverage is similar to these, with excellent gram-positive coverage, it does not provide Pseudomonas coverage, he added.

When antibiotic prophylaxis is determined to be necessary, it should be delivered 30–60 minutes before surgery. Since surgical factors are at least as important for preventing infection, sterile techniques and proper sterilization of instruments, avoidance of excess tension on closures, avoidance of excessive suture material, and avoidance of charring also require careful attention, he said.

Conditions With Endocarditis Risk

The American Heart Association guidelines state that the following cardiac conditions have the highest risk of adverse outcomes from endocarditis:

▸ Prosthetic cardiac valve.

▸ Previous infective endocarditis.

▸ Congenital heart disease.

▸ Unrepaired cyanotic CHD, including palliative shunts and conduits.

▸ Completely repaired (with prosthetic material or device) congenital heart defect during first 6 months after the repair.

▸ Repaired CHD with residual defect (at or adjacent to the site of the prosthetic patch or device) that inhibits endothelialization.

▸ Postcardiac transplant cardiac valvulopathy.

ORLANDO — Most dermatologic surgery patients don't need perioperative antibiotics, and the routine use of antibiotics to prevent surgical site infection or infective endocarditis should be discouraged, Dr. Steve Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Healthy individuals, those who undergo surgery of a clean site, and those who undergo procedures of limited duration typically do not need prophylactic antibiotics. As for determining which patients do need prophylaxis, a number of variable risk factors should be considered, including HIV-positive status, chronic immunosuppression, age, occupation, and temperature/humidity, all of which could affect infection risk, said Dr. Spencer of Port Charlotte, Fla., noting that these are gray areas that require individualized decision making.

It is clearer, however, that those who are immunocompromised; those undergoing surgery of riskier areas such as the mouth, groin, or axillae, or sites that are already infected; and those who are at high risk of infective endocarditis (see sidebar) should receive prophylaxis, he said. Dr. Spencer cited guidelines on prevention of infective endocarditis published by the American Heart Association last year (Circulation 2007;116:1736–54).

Although the guidelines mainly address dental issues, the AHA noted that infectious endocarditis is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by dental or medical procedures and that prophylaxis is likely to prevent a very small number of cases of infectious endocarditis, if any.

The guidelines also point out that the risks of antibiotic prophylaxis in terms of adverse events exceed the benefits, if any, from antibiotic prophylaxis and recommend that only those with the highest risk of adverse outcomes from endocarditis should undergo antibiotic prophylaxis.

As for procedures on infected skin, skin structures, or musculoskeletal tissue, the AHA noted that, while these infections are typically polymicrobial, only staphylococci and β-hemolytic streptococci are likely to cause infective endocarditis. Therefore, when antibiotic prophylaxis is needed, the drug selected should target the most likely organisms to be encountered and be given prior to the procedure.

Broad-spectrum antibiotics—most often first-generation cephalosporins—are commonly used to treat these species.

Semisynthetic penicillinase-resistant penicillins are good for gram-positive cocci, Klebsiella, Escherichia coli, and Proteus organisms. Clindamycin is an alternative option in penicillin-allergic patients. Erythromycin is almost never used because it is associated with very high staphylococcal resistance, Dr. Spencer said.

Clindamycin also is a good option for patients undergoing surgery of the oral mucosal areas, but cephalosporins may have less cross-reactivity in penicillin-allergic patients. Although trimethoprim-sulfamethoxazole coverage is similar to these, with excellent gram-positive coverage, it does not provide Pseudomonas coverage, he added.

When antibiotic prophylaxis is determined to be necessary, it should be delivered 30–60 minutes before surgery. Since surgical factors are at least as important for preventing infection, sterile techniques and proper sterilization of instruments, avoidance of excess tension on closures, avoidance of excessive suture material, and avoidance of charring also require careful attention, he said.

Conditions With Endocarditis Risk

The American Heart Association guidelines state that the following cardiac conditions have the highest risk of adverse outcomes from endocarditis:

▸ Prosthetic cardiac valve.

▸ Previous infective endocarditis.

▸ Congenital heart disease.

▸ Unrepaired cyanotic CHD, including palliative shunts and conduits.

▸ Completely repaired (with prosthetic material or device) congenital heart defect during first 6 months after the repair.

▸ Repaired CHD with residual defect (at or adjacent to the site of the prosthetic patch or device) that inhibits endothelialization.

▸ Postcardiac transplant cardiac valvulopathy.