Aesthetic Dermatology

BALTIMORE — Patients seeking leg vein treatment have the best outcome when clinicians selectively choose to treat varicosities and telangiectasias with sclerosants or lasers, Margaret A. Weiss, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

Learning the proper sclerotherapy technique is necessary for physicians who are going to offer laser treatment for leg veins because the leg vein treatment typically involves a combination approach, advised Dr. Weiss, of the department of dermatology at Johns Hopkins University, Baltimore.

“Offering a combination of treatments is helpful because treating reticular veins with lasers tends to be very painful,” she said. Laser treatments usually are more expensive and painful than sclerotherapy, and as a result, the overwhelming majority of her patients—about 95%—opt for sclerotherapy.

If a patient is interested in getting laser treatment for leg veins, Dr. Weiss said she often will give a laser treatment to a test area on the patient's leg and ask for the patient's feedback.

But before treating reticular veins and telangiectasias associated with incompetent great or short saphenous veins, endovenous techniques—which have replaced surgical stripping—must be used to cut off reflux from the saphenofemoral and saphenopopliteal junctions.

Ambulatory phlebectomy still is used for tributary veins about 4 mm or greater in size off the great saphenous vein, but it is gradually being replaced by foam sclerotherapy.

At the group practice she runs with her husband, Robert A. Weiss, M.D., in Hunt Valley, Md., Dr. Weiss usually treats reticular veins with about three to five treatments of foam sclerotherapy injections per area rather than treating them with lasers or intense pulsed light. Each treatment session is spaced in 3-week intervals.

The foam technique is inexpensive and increases the potency of any detergent solution such as Sotradecol (sodium tetradecyl sulfate injection), approved by the Food and Drug Administration, or polidocanol.

“I don't use polidocanol because it's not FDA approved,” she said.

Dr. Weiss uses the Tessari technique for making foamed sclerosant by connecting color-coded syringes—one with 0.1% or 0.2% Sotradecol and one with air—via a simple, latex-free, intravenous stopcock to agitate the solution. The mixture becomes a 3:1 or 4:1 ratio of air to solution. Dr. Weiss massages veins after each injection to increase the spread of the foamed sclerosant.

The foam acts on the principle that “by holding the solution in and dispersing it in theses bubbles, it adheres better to the vein wall,” she said. The bluish-green reticular vein will get lighter in color as the foam flows through it; the foam acts as a great visualization technique when using duplex ultrasound, she noted.

“We're really at the frontier of the expansion of this technique,” she said.

In many cases where Dr. Weiss now uses foamed Sotradecol at 0.1%, she said she used a 0.2% solution of Sotradecol in the past before the introduction of foam techniques. But because the foam technique doubles the potency of the sclerosant, the risk of hyperpigmentation increases.

Injection of foam Sotradecol into a telangiectasia results in a characteristic inflamed, elevated appearance.

Glycerine, a complex sugar classified as a toxic or corrosive agent, “is a great injectable for small telangiectasia as well as telangiectatic matting,” she said. Some pharmacies will compound a solution of glycerine at 72% in water. Dr. Weiss routinely uses glycerine to treat vessels less than 0.4 mm in diameter.

Treatment of leg veins with a laser is typically not as messy as it is with sclerosants since the appearance of veins becomes blurred and redder, without bleeding, whereas sclerotherapy injections may cause urticarial wheals, itching, and more postprocedure bruising and bleeding or oozing, Dr. Weiss said at the meeting.

Dr. Weiss said she would consider using lasers for leg veins for patients who have contraindications or a poor response to sclerotherapy, telangiectatic matting, or isolated, fine telangiectasia, which are often difficult to treat with sclerotherapy.

Overall, the best lasers for leg veins have a wavelength that is selectively absorbed by deoxyhemoglobin. Lasers with longer wavelengths penetrate deeper, and “that's important on the legs, since some of the inherent difficulties in treating leg veins as opposed to facial veins are that there is a much broader range of size and [the leg veins are] deeper under the skin,” she noted. This makes it harder to treat them without damaging the surrounding tissue.

High-fluence, long-pulse 1,064-nm lasers work well on leg veins because they target water and deoxyhemoglobin preferentially over melanin.

Smaller vessels need a shorter pulse duration, while larger vessels need a longer pulse duration of about 30–100 milliseconds, which “can get very painful even with the use of topical anesthetic creams,” she noted. Lasers used in treating leg veins have fluences in J/cm

To avoid damage to the epidermis, some lasers use cold gel, contact cooling, dynamic cooling spray, or cold blown air. Longer wavelength lasers, especially infrared, will cause less epidermal damage.

Intense pulsed light is most effective against superficial telangiectasias 0.2–0.3 mm in size in patients with Fitzpatrick skin types I to III, but the procedure is very technique sensitive and is dependent on the thickness and temperature of the gel, Dr. Weiss said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

BALTIMORE — Patients seeking leg vein treatment have the best outcome when clinicians selectively choose to treat varicosities and telangiectasias with sclerosants or lasers, Margaret A. Weiss, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

Learning the proper sclerotherapy technique is necessary for physicians who are going to offer laser treatment for leg veins because the leg vein treatment typically involves a combination approach, advised Dr. Weiss, of the department of dermatology at Johns Hopkins University, Baltimore.

“Offering a combination of treatments is helpful because treating reticular veins with lasers tends to be very painful,” she said. Laser treatments usually are more expensive and painful than sclerotherapy, and as a result, the overwhelming majority of her patients—about 95%—opt for sclerotherapy.

If a patient is interested in getting laser treatment for leg veins, Dr. Weiss said she often will give a laser treatment to a test area on the patient's leg and ask for the patient's feedback.

But before treating reticular veins and telangiectasias associated with incompetent great or short saphenous veins, endovenous techniques—which have replaced surgical stripping—must be used to cut off reflux from the saphenofemoral and saphenopopliteal junctions.

Ambulatory phlebectomy still is used for tributary veins about 4 mm or greater in size off the great saphenous vein, but it is gradually being replaced by foam sclerotherapy.

At the group practice she runs with her husband, Robert A. Weiss, M.D., in Hunt Valley, Md., Dr. Weiss usually treats reticular veins with about three to five treatments of foam sclerotherapy injections per area rather than treating them with lasers or intense pulsed light. Each treatment session is spaced in 3-week intervals.

The foam technique is inexpensive and increases the potency of any detergent solution such as Sotradecol (sodium tetradecyl sulfate injection), approved by the Food and Drug Administration, or polidocanol.

“I don't use polidocanol because it's not FDA approved,” she said.

Dr. Weiss uses the Tessari technique for making foamed sclerosant by connecting color-coded syringes—one with 0.1% or 0.2% Sotradecol and one with air—via a simple, latex-free, intravenous stopcock to agitate the solution. The mixture becomes a 3:1 or 4:1 ratio of air to solution. Dr. Weiss massages veins after each injection to increase the spread of the foamed sclerosant.

The foam acts on the principle that “by holding the solution in and dispersing it in theses bubbles, it adheres better to the vein wall,” she said. The bluish-green reticular vein will get lighter in color as the foam flows through it; the foam acts as a great visualization technique when using duplex ultrasound, she noted.

“We're really at the frontier of the expansion of this technique,” she said.

In many cases where Dr. Weiss now uses foamed Sotradecol at 0.1%, she said she used a 0.2% solution of Sotradecol in the past before the introduction of foam techniques. But because the foam technique doubles the potency of the sclerosant, the risk of hyperpigmentation increases.

Injection of foam Sotradecol into a telangiectasia results in a characteristic inflamed, elevated appearance.

Glycerine, a complex sugar classified as a toxic or corrosive agent, “is a great injectable for small telangiectasia as well as telangiectatic matting,” she said. Some pharmacies will compound a solution of glycerine at 72% in water. Dr. Weiss routinely uses glycerine to treat vessels less than 0.4 mm in diameter.

Treatment of leg veins with a laser is typically not as messy as it is with sclerosants since the appearance of veins becomes blurred and redder, without bleeding, whereas sclerotherapy injections may cause urticarial wheals, itching, and more postprocedure bruising and bleeding or oozing, Dr. Weiss said at the meeting.

Dr. Weiss said she would consider using lasers for leg veins for patients who have contraindications or a poor response to sclerotherapy, telangiectatic matting, or isolated, fine telangiectasia, which are often difficult to treat with sclerotherapy.

Overall, the best lasers for leg veins have a wavelength that is selectively absorbed by deoxyhemoglobin. Lasers with longer wavelengths penetrate deeper, and “that's important on the legs, since some of the inherent difficulties in treating leg veins as opposed to facial veins are that there is a much broader range of size and [the leg veins are] deeper under the skin,” she noted. This makes it harder to treat them without damaging the surrounding tissue.

High-fluence, long-pulse 1,064-nm lasers work well on leg veins because they target water and deoxyhemoglobin preferentially over melanin.

Smaller vessels need a shorter pulse duration, while larger vessels need a longer pulse duration of about 30–100 milliseconds, which “can get very painful even with the use of topical anesthetic creams,” she noted. Lasers used in treating leg veins have fluences in J/cm

To avoid damage to the epidermis, some lasers use cold gel, contact cooling, dynamic cooling spray, or cold blown air. Longer wavelength lasers, especially infrared, will cause less epidermal damage.

Intense pulsed light is most effective against superficial telangiectasias 0.2–0.3 mm in size in patients with Fitzpatrick skin types I to III, but the procedure is very technique sensitive and is dependent on the thickness and temperature of the gel, Dr. Weiss said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

BALTIMORE — Patients seeking leg vein treatment have the best outcome when clinicians selectively choose to treat varicosities and telangiectasias with sclerosants or lasers, Margaret A. Weiss, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

Learning the proper sclerotherapy technique is necessary for physicians who are going to offer laser treatment for leg veins because the leg vein treatment typically involves a combination approach, advised Dr. Weiss, of the department of dermatology at Johns Hopkins University, Baltimore.

“Offering a combination of treatments is helpful because treating reticular veins with lasers tends to be very painful,” she said. Laser treatments usually are more expensive and painful than sclerotherapy, and as a result, the overwhelming majority of her patients—about 95%—opt for sclerotherapy.

If a patient is interested in getting laser treatment for leg veins, Dr. Weiss said she often will give a laser treatment to a test area on the patient's leg and ask for the patient's feedback.

But before treating reticular veins and telangiectasias associated with incompetent great or short saphenous veins, endovenous techniques—which have replaced surgical stripping—must be used to cut off reflux from the saphenofemoral and saphenopopliteal junctions.

Ambulatory phlebectomy still is used for tributary veins about 4 mm or greater in size off the great saphenous vein, but it is gradually being replaced by foam sclerotherapy.

At the group practice she runs with her husband, Robert A. Weiss, M.D., in Hunt Valley, Md., Dr. Weiss usually treats reticular veins with about three to five treatments of foam sclerotherapy injections per area rather than treating them with lasers or intense pulsed light. Each treatment session is spaced in 3-week intervals.

The foam technique is inexpensive and increases the potency of any detergent solution such as Sotradecol (sodium tetradecyl sulfate injection), approved by the Food and Drug Administration, or polidocanol.

“I don't use polidocanol because it's not FDA approved,” she said.

Dr. Weiss uses the Tessari technique for making foamed sclerosant by connecting color-coded syringes—one with 0.1% or 0.2% Sotradecol and one with air—via a simple, latex-free, intravenous stopcock to agitate the solution. The mixture becomes a 3:1 or 4:1 ratio of air to solution. Dr. Weiss massages veins after each injection to increase the spread of the foamed sclerosant.

The foam acts on the principle that “by holding the solution in and dispersing it in theses bubbles, it adheres better to the vein wall,” she said. The bluish-green reticular vein will get lighter in color as the foam flows through it; the foam acts as a great visualization technique when using duplex ultrasound, she noted.

“We're really at the frontier of the expansion of this technique,” she said.

In many cases where Dr. Weiss now uses foamed Sotradecol at 0.1%, she said she used a 0.2% solution of Sotradecol in the past before the introduction of foam techniques. But because the foam technique doubles the potency of the sclerosant, the risk of hyperpigmentation increases.

Injection of foam Sotradecol into a telangiectasia results in a characteristic inflamed, elevated appearance.

Glycerine, a complex sugar classified as a toxic or corrosive agent, “is a great injectable for small telangiectasia as well as telangiectatic matting,” she said. Some pharmacies will compound a solution of glycerine at 72% in water. Dr. Weiss routinely uses glycerine to treat vessels less than 0.4 mm in diameter.

Treatment of leg veins with a laser is typically not as messy as it is with sclerosants since the appearance of veins becomes blurred and redder, without bleeding, whereas sclerotherapy injections may cause urticarial wheals, itching, and more postprocedure bruising and bleeding or oozing, Dr. Weiss said at the meeting.

Dr. Weiss said she would consider using lasers for leg veins for patients who have contraindications or a poor response to sclerotherapy, telangiectatic matting, or isolated, fine telangiectasia, which are often difficult to treat with sclerotherapy.

Overall, the best lasers for leg veins have a wavelength that is selectively absorbed by deoxyhemoglobin. Lasers with longer wavelengths penetrate deeper, and “that's important on the legs, since some of the inherent difficulties in treating leg veins as opposed to facial veins are that there is a much broader range of size and [the leg veins are] deeper under the skin,” she noted. This makes it harder to treat them without damaging the surrounding tissue.

High-fluence, long-pulse 1,064-nm lasers work well on leg veins because they target water and deoxyhemoglobin preferentially over melanin.

Smaller vessels need a shorter pulse duration, while larger vessels need a longer pulse duration of about 30–100 milliseconds, which “can get very painful even with the use of topical anesthetic creams,” she noted. Lasers used in treating leg veins have fluences in J/cm

To avoid damage to the epidermis, some lasers use cold gel, contact cooling, dynamic cooling spray, or cold blown air. Longer wavelength lasers, especially infrared, will cause less epidermal damage.

Intense pulsed light is most effective against superficial telangiectasias 0.2–0.3 mm in size in patients with Fitzpatrick skin types I to III, but the procedure is very technique sensitive and is dependent on the thickness and temperature of the gel, Dr. Weiss said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

CHICAGO — Open surgery bypass graft for repairing the diabetic foot is still the most commonly used therapy for revascularization, and is considered by most to be the preferred method. However, it is part of a complex algorithm of treatment that grows in complexity as more and more considerations come into play, Gary Gibbons, M.D., said at the Vascular Annual Meeting.

"To achieve the most rapid and durable healing, what you want to do is restore a pulse to the foot by whatever means you can," he explained. Typically, this is still through an open bypass, according to Dr. Gibbons, professor of surgery at Boston University and executive director, Foot Care Specialists of Boston Medical Center.

But the open bypass procedures—which are dictated by the status of the patient's vascular anatomy and wound morphology—can be quite complex.

In order to be prepared for the almost inevitable surprises upon exploring the foot, "I tell my residents every time they're with me that I want three approaches to do this operation, because it is the nature of diabetic vascular disease [that] oftentimes approach No. 1 isn't going to work," he said.

The most critical consideration, outside of the surgery itself, is the overall control of sepsis before and after the operation. "We used to think, just get the blood sugar down to maybe 200 [mg/dL], but now we really, really like to have very low blood sugars in the postoperative course. It's the greatest way to determine how well you drain sepsis, because the blood sugar will not fall until you have adequately debrided and controlled sepsis," Dr. Gibbons said.

After surgery, the effects of revascularization on infection can become quickly evident. "Don't be surprised if you have to take the patient immediately back into the operating room 24 hours later to further control sepsis because you have woken the bacteria up," he said.

Although these bypasses are durable, limb salvage is ultimately more important than patency, he added. "The thing to remember is that a third of these patients are going to be dead in 5 years. But the thing is, they want to die intact."

Additionally, Dr. Gibbons said, "I am on a mission for protecting the other leg and foot. Anywhere from 24% to 48% [of these patients] will have a contralateral extremity problem within the next 3 years," and therefore they must be monitored carefully long after surgery on the currently affected foot.

Dr. Gibbons said that his center is doing more and more endovascular treatment of diabetic foot patients. For many of the more complex wounds with damaged vasculature, a bypass can salvage a foot in the only way possible.

CHICAGO — Open surgery bypass graft for repairing the diabetic foot is still the most commonly used therapy for revascularization, and is considered by most to be the preferred method. However, it is part of a complex algorithm of treatment that grows in complexity as more and more considerations come into play, Gary Gibbons, M.D., said at the Vascular Annual Meeting.

"To achieve the most rapid and durable healing, what you want to do is restore a pulse to the foot by whatever means you can," he explained. Typically, this is still through an open bypass, according to Dr. Gibbons, professor of surgery at Boston University and executive director, Foot Care Specialists of Boston Medical Center.

But the open bypass procedures—which are dictated by the status of the patient's vascular anatomy and wound morphology—can be quite complex.

In order to be prepared for the almost inevitable surprises upon exploring the foot, "I tell my residents every time they're with me that I want three approaches to do this operation, because it is the nature of diabetic vascular disease [that] oftentimes approach No. 1 isn't going to work," he said.

The most critical consideration, outside of the surgery itself, is the overall control of sepsis before and after the operation. "We used to think, just get the blood sugar down to maybe 200 [mg/dL], but now we really, really like to have very low blood sugars in the postoperative course. It's the greatest way to determine how well you drain sepsis, because the blood sugar will not fall until you have adequately debrided and controlled sepsis," Dr. Gibbons said.

After surgery, the effects of revascularization on infection can become quickly evident. "Don't be surprised if you have to take the patient immediately back into the operating room 24 hours later to further control sepsis because you have woken the bacteria up," he said.

Although these bypasses are durable, limb salvage is ultimately more important than patency, he added. "The thing to remember is that a third of these patients are going to be dead in 5 years. But the thing is, they want to die intact."

Additionally, Dr. Gibbons said, "I am on a mission for protecting the other leg and foot. Anywhere from 24% to 48% [of these patients] will have a contralateral extremity problem within the next 3 years," and therefore they must be monitored carefully long after surgery on the currently affected foot.

Dr. Gibbons said that his center is doing more and more endovascular treatment of diabetic foot patients. For many of the more complex wounds with damaged vasculature, a bypass can salvage a foot in the only way possible.

CHICAGO — Open surgery bypass graft for repairing the diabetic foot is still the most commonly used therapy for revascularization, and is considered by most to be the preferred method. However, it is part of a complex algorithm of treatment that grows in complexity as more and more considerations come into play, Gary Gibbons, M.D., said at the Vascular Annual Meeting.

"To achieve the most rapid and durable healing, what you want to do is restore a pulse to the foot by whatever means you can," he explained. Typically, this is still through an open bypass, according to Dr. Gibbons, professor of surgery at Boston University and executive director, Foot Care Specialists of Boston Medical Center.

But the open bypass procedures—which are dictated by the status of the patient's vascular anatomy and wound morphology—can be quite complex.

In order to be prepared for the almost inevitable surprises upon exploring the foot, "I tell my residents every time they're with me that I want three approaches to do this operation, because it is the nature of diabetic vascular disease [that] oftentimes approach No. 1 isn't going to work," he said.

The most critical consideration, outside of the surgery itself, is the overall control of sepsis before and after the operation. "We used to think, just get the blood sugar down to maybe 200 [mg/dL], but now we really, really like to have very low blood sugars in the postoperative course. It's the greatest way to determine how well you drain sepsis, because the blood sugar will not fall until you have adequately debrided and controlled sepsis," Dr. Gibbons said.

After surgery, the effects of revascularization on infection can become quickly evident. "Don't be surprised if you have to take the patient immediately back into the operating room 24 hours later to further control sepsis because you have woken the bacteria up," he said.

Although these bypasses are durable, limb salvage is ultimately more important than patency, he added. "The thing to remember is that a third of these patients are going to be dead in 5 years. But the thing is, they want to die intact."

Additionally, Dr. Gibbons said, "I am on a mission for protecting the other leg and foot. Anywhere from 24% to 48% [of these patients] will have a contralateral extremity problem within the next 3 years," and therefore they must be monitored carefully long after surgery on the currently affected foot.

Dr. Gibbons said that his center is doing more and more endovascular treatment of diabetic foot patients. For many of the more complex wounds with damaged vasculature, a bypass can salvage a foot in the only way possible.

PARIS — Technological advances in lasers and flashlamp devices have given rise to several hair removal myths, including the belief that permanent hair removal requires only a single treatment, that it can be performed on all hair colors and skin types, and that it is without side effects, Christine Dierickx, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

Each laser treatment will temporarily remove all the hair and permanently remove about 20%. A hair-free period of about 1–3 months follows most laser treatments, which is then followed by partial regrowth of about 80% of the hairs.

The percentage of new hairs decreases with each laser treatment because additional permanent hair loss with each laser treatment is about 20%, she said.

Patients typically need five treatments, and they should be warned not to pluck or wax their hair because photothermal energy is absorbed by melanin in the hair shaft.

"Without the target, there is no effect," said Dr. Dierickx, director of the Skin and Laser Center, Brussels.

She was unsuccessful in her attempt to create a target by dying white hair, and has had mixed results with the use of radio frequency energy.

Because melanin in the epidermis presents a competing site for energy absorption, hair removal in patients with Fitzpatrick skin types IV-VI is challenging. Such patients can be safely treated with longer wavelength lasers such as an 800-nm diode or 1,067-nm long-pulsed YAG laser.

However, tanned skin is "merciless," and hair removal should typically be delayed 10–12 weeks after tanning, according to Dr. Dierickx.

Photopneumatic therapy or PPx (Aesthera Corp.) is a new treatment modality that combines light-based hair removal and vacuum suction to lift the skin.

The technology manipulates the optical characteristics of the skin, potentially allowing four to five times more energy to be transmitted to the follicles, Dr. Dierickx said.

Preliminary 3-month results were comparable with conventional 800-nm and 1,064-nm lasers, with 5 of 19 patients achieving 90% hair clearance.

No hair removal system is without risks. Recent reports (J. Am. Acad. Dermatol. 2004;51:774–7) and personal experiences show that livedo reticularis is a new possible side effect of laser-assisted hair removal, she said.

PARIS — Technological advances in lasers and flashlamp devices have given rise to several hair removal myths, including the belief that permanent hair removal requires only a single treatment, that it can be performed on all hair colors and skin types, and that it is without side effects, Christine Dierickx, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

Each laser treatment will temporarily remove all the hair and permanently remove about 20%. A hair-free period of about 1–3 months follows most laser treatments, which is then followed by partial regrowth of about 80% of the hairs.

The percentage of new hairs decreases with each laser treatment because additional permanent hair loss with each laser treatment is about 20%, she said.

Patients typically need five treatments, and they should be warned not to pluck or wax their hair because photothermal energy is absorbed by melanin in the hair shaft.

"Without the target, there is no effect," said Dr. Dierickx, director of the Skin and Laser Center, Brussels.

She was unsuccessful in her attempt to create a target by dying white hair, and has had mixed results with the use of radio frequency energy.

Because melanin in the epidermis presents a competing site for energy absorption, hair removal in patients with Fitzpatrick skin types IV-VI is challenging. Such patients can be safely treated with longer wavelength lasers such as an 800-nm diode or 1,067-nm long-pulsed YAG laser.

However, tanned skin is "merciless," and hair removal should typically be delayed 10–12 weeks after tanning, according to Dr. Dierickx.

Photopneumatic therapy or PPx (Aesthera Corp.) is a new treatment modality that combines light-based hair removal and vacuum suction to lift the skin.

The technology manipulates the optical characteristics of the skin, potentially allowing four to five times more energy to be transmitted to the follicles, Dr. Dierickx said.

Preliminary 3-month results were comparable with conventional 800-nm and 1,064-nm lasers, with 5 of 19 patients achieving 90% hair clearance.

No hair removal system is without risks. Recent reports (J. Am. Acad. Dermatol. 2004;51:774–7) and personal experiences show that livedo reticularis is a new possible side effect of laser-assisted hair removal, she said.

PARIS — Technological advances in lasers and flashlamp devices have given rise to several hair removal myths, including the belief that permanent hair removal requires only a single treatment, that it can be performed on all hair colors and skin types, and that it is without side effects, Christine Dierickx, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

Each laser treatment will temporarily remove all the hair and permanently remove about 20%. A hair-free period of about 1–3 months follows most laser treatments, which is then followed by partial regrowth of about 80% of the hairs.

The percentage of new hairs decreases with each laser treatment because additional permanent hair loss with each laser treatment is about 20%, she said.

Patients typically need five treatments, and they should be warned not to pluck or wax their hair because photothermal energy is absorbed by melanin in the hair shaft.

"Without the target, there is no effect," said Dr. Dierickx, director of the Skin and Laser Center, Brussels.

She was unsuccessful in her attempt to create a target by dying white hair, and has had mixed results with the use of radio frequency energy.

Because melanin in the epidermis presents a competing site for energy absorption, hair removal in patients with Fitzpatrick skin types IV-VI is challenging. Such patients can be safely treated with longer wavelength lasers such as an 800-nm diode or 1,067-nm long-pulsed YAG laser.

However, tanned skin is "merciless," and hair removal should typically be delayed 10–12 weeks after tanning, according to Dr. Dierickx.

Photopneumatic therapy or PPx (Aesthera Corp.) is a new treatment modality that combines light-based hair removal and vacuum suction to lift the skin.

The technology manipulates the optical characteristics of the skin, potentially allowing four to five times more energy to be transmitted to the follicles, Dr. Dierickx said.

Preliminary 3-month results were comparable with conventional 800-nm and 1,064-nm lasers, with 5 of 19 patients achieving 90% hair clearance.

No hair removal system is without risks. Recent reports (J. Am. Acad. Dermatol. 2004;51:774–7) and personal experiences show that livedo reticularis is a new possible side effect of laser-assisted hair removal, she said.

LAS VEGAS — The new 1,550-nm erbium Fraxel laser, by creating minuscule dots of destruction in the surface of the skin, produces color and texture changes, and may have the ability to significantly reduce wrinkles at high fluences, Mark Rubin, M.D., said at a facial cosmetic surgery symposium.

"This, in my mind, is a therapy in flux. It's where Thermage was 2 years ago," said Dr. Rubin at the symposium, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

The Fraxel laser was approved by the Food and Drug Administration in March.

Using company-suggested parameters, the device can deliver perceptible improvement in the skin with significantly less traumatic healing than is required after carbon dioxide (CO₂) laser treatments.

Still, "the color and texture is really what knocks you out," said Dr. Rubin, who has no financial interest in, and receives no funding from, Fraxel manufacturer Reliant Technologies Inc.

"The big issue for me is what's happening wrinklewise. So far, my experience has been very variable," Dr. Rubin said.

It may be that very high fluences are necessary to dramatically alter wrinkles with the novel system. Dr. Rubin noted that a colleague had been experimenting with aggressive settings, and was finding "much more profound changes" than could be produced by a nonablative laser.

He suggested that it may take some time to work out the ideal ways to use the Fraxel laser for different purposes.

"Nobody really knows how to use it correctly," he said, urging colleagues to "look at it again in 6 months."

Dr. Rubin, who practices dermatology in Beverly Hills, Calif., purchased a Fraxel laser in hopes of finding the holy grail of skin resurfacing: a device capable of smoothing moderate to deep wrinkles without provoking a lengthy, complication-ridden healing period.

"The ablative therapies are spectacular, but no fun for you or the patient. There's risk. There's [a] nasty-looking [healing period] when you have to see patients every couple of days. There are reasons not everyone is dying to do this."

Nonablative devices seemed like a good idea—Dr. Rubin bought several of them—but they proved to be poor substitutes for the steamroller effect that ablative lasers had on deep wrinkles.

Fraxel seemed to him to be a potential bridge between the two types of skin rejuvenation therapies, creating "little islands of ablated skin in a sea of normal skin."

"Rather than burning everything off, can we burn just little tiny bits at a time to sort of fool the skin into thinking it's not been wounded so badly?" he asked.

The answer is—maybe.

The epidermis remains intact, even when the laser's energy reaches depths of 700 micrometers and beyond, a level deep enough to promote collagen remodeling. But are the pinpoints of energy enough? And are the surface areas of each microthermal zone (estimated to number 2,000 per cm

About 20% of the facial surface area is impacted during each treatment session at a low fluence, typically four to six passes, Dr. Rubin said. However, "in reality, as you go back and forth like this, you're never really where you're supposed to be. In certain places you hit the same spot two times, three times, four times, who knows? And in other places, you skip."

It may be that the microscopic zones of destruction are so small that overlap does not matter, either in terms of results or side effects, he said. However, it remains to be seen whether consistency will be achieved as the laser makes its way into general clinical practice.

A clear advantage of Fraxel lasers over CO₂ lasers is the healing process, according to Dr. Rubin. "These patients aren't weeping fluid. They're not bleeding," he explained.

When low fluences are used, edema typically lasts 1–2 days, and erythema lasts 1–3 days. Flaking and bronzing of the skin are common. Makeup can be worn because there is no open wound, but most patients need heavy makeup to cover the transient effects of the treatment.

"They certainly don't look normal enough to be fully functional a day or 2 days later. It's nonablative, but there is an impact on patient's lives as a result of this," Dr. Rubin said.

A topical anesthetic is used, and some patients require supplemental oral pain medications. A blue dye is used to enhance skin surface contours for optical scanning.

Patients, said Dr. Rubin, "look like [performers in] Blue Man Group," but the dye washes away within a day.

A grid is used to guide the laser.

Patients return for multiple treatments until 100% of the skin's surface is treated.

At low fluences with high density, the laser's zone of thermal injury extends to the superficial papillary dermis, producing excellent improvement in the appearance of actinic dyschromia and photodamage.

"There's no question color- and texturewise, these patients can really do profoundly well. Although just 20% of the epidermis is being treated [at each session], they don't look 20% better; they look 40%–50% better.

"I don't know why; it doesn't make sense. It obviously has to do with our ability to perceive changes in the skin," he said.

A greater challenge is the best and safest use of the device at high fluences with low density. In this scenario, a deep wound is created over a smaller total area of the skin—about 10% per treatment session. Associated edema and erythema may persist for some time, but the potential exists for improvement of deeper wrinkles, just as he was hoping for, Dr. Rubin said.

Fraxel Could Be Well Suited for Some

The Fraxel 1,550-nm erbium laser may fill a niche for certain patients desiring skin rejuvenation, Dr. Rubin said.

These include:

▸ Patients with dark skin prone to hyperpigmentation. Because the damage inflicted by the Fraxel laser is done with microscopic pinpoints, it does not create the persistent erythema that often leads to hyperpigmentation following ablative therapies. Used at low fluences, it may be an excellent option for these patients.

▸ Patients with melasma. Melasma is essentially a condition of "misbehaving melanocytes," according to Dr. Rubin.

"When melanocytes aren't functioning appropriately, we would love to kill them without killing the surrounding tissue and creating hypopigmentation."

The selective action of the Fraxel laser may be able to "gently" knock out enough melanocytes to control melasma without tipping the balance too far, he said.

Results in melasma patients at 1–2 months are "intriguing," he said, although 6–8 months of clearance would be necessary to prove that the therapy is a significant advance.

▸ Patients desiring significant rejuvenation of nonfacial skin. Ablative CO₂ laser treatments are risky in areas of the body with few pilosebaceous units to assist in reepithelialization. Because the Fraxel laser does not produce a widespread wound, it may be better at safely treating the skin of the neck, chest, hands, and arms.

Dr. Rubin has no financial interest in the Fraxel laser and receives no funding from its manufacturer, Reliant Technologies.

LAS VEGAS — The new 1,550-nm erbium Fraxel laser, by creating minuscule dots of destruction in the surface of the skin, produces color and texture changes, and may have the ability to significantly reduce wrinkles at high fluences, Mark Rubin, M.D., said at a facial cosmetic surgery symposium.

"This, in my mind, is a therapy in flux. It's where Thermage was 2 years ago," said Dr. Rubin at the symposium, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

The Fraxel laser was approved by the Food and Drug Administration in March.

Using company-suggested parameters, the device can deliver perceptible improvement in the skin with significantly less traumatic healing than is required after carbon dioxide (CO₂) laser treatments.

Still, "the color and texture is really what knocks you out," said Dr. Rubin, who has no financial interest in, and receives no funding from, Fraxel manufacturer Reliant Technologies Inc.

"The big issue for me is what's happening wrinklewise. So far, my experience has been very variable," Dr. Rubin said.

It may be that very high fluences are necessary to dramatically alter wrinkles with the novel system. Dr. Rubin noted that a colleague had been experimenting with aggressive settings, and was finding "much more profound changes" than could be produced by a nonablative laser.

He suggested that it may take some time to work out the ideal ways to use the Fraxel laser for different purposes.

"Nobody really knows how to use it correctly," he said, urging colleagues to "look at it again in 6 months."

Dr. Rubin, who practices dermatology in Beverly Hills, Calif., purchased a Fraxel laser in hopes of finding the holy grail of skin resurfacing: a device capable of smoothing moderate to deep wrinkles without provoking a lengthy, complication-ridden healing period.

"The ablative therapies are spectacular, but no fun for you or the patient. There's risk. There's [a] nasty-looking [healing period] when you have to see patients every couple of days. There are reasons not everyone is dying to do this."

Nonablative devices seemed like a good idea—Dr. Rubin bought several of them—but they proved to be poor substitutes for the steamroller effect that ablative lasers had on deep wrinkles.

Fraxel seemed to him to be a potential bridge between the two types of skin rejuvenation therapies, creating "little islands of ablated skin in a sea of normal skin."

"Rather than burning everything off, can we burn just little tiny bits at a time to sort of fool the skin into thinking it's not been wounded so badly?" he asked.

The answer is—maybe.

The epidermis remains intact, even when the laser's energy reaches depths of 700 micrometers and beyond, a level deep enough to promote collagen remodeling. But are the pinpoints of energy enough? And are the surface areas of each microthermal zone (estimated to number 2,000 per cm

About 20% of the facial surface area is impacted during each treatment session at a low fluence, typically four to six passes, Dr. Rubin said. However, "in reality, as you go back and forth like this, you're never really where you're supposed to be. In certain places you hit the same spot two times, three times, four times, who knows? And in other places, you skip."

It may be that the microscopic zones of destruction are so small that overlap does not matter, either in terms of results or side effects, he said. However, it remains to be seen whether consistency will be achieved as the laser makes its way into general clinical practice.

A clear advantage of Fraxel lasers over CO₂ lasers is the healing process, according to Dr. Rubin. "These patients aren't weeping fluid. They're not bleeding," he explained.

When low fluences are used, edema typically lasts 1–2 days, and erythema lasts 1–3 days. Flaking and bronzing of the skin are common. Makeup can be worn because there is no open wound, but most patients need heavy makeup to cover the transient effects of the treatment.

"They certainly don't look normal enough to be fully functional a day or 2 days later. It's nonablative, but there is an impact on patient's lives as a result of this," Dr. Rubin said.

A topical anesthetic is used, and some patients require supplemental oral pain medications. A blue dye is used to enhance skin surface contours for optical scanning.

Patients, said Dr. Rubin, "look like [performers in] Blue Man Group," but the dye washes away within a day.

A grid is used to guide the laser.

Patients return for multiple treatments until 100% of the skin's surface is treated.

At low fluences with high density, the laser's zone of thermal injury extends to the superficial papillary dermis, producing excellent improvement in the appearance of actinic dyschromia and photodamage.

"There's no question color- and texturewise, these patients can really do profoundly well. Although just 20% of the epidermis is being treated [at each session], they don't look 20% better; they look 40%–50% better.

"I don't know why; it doesn't make sense. It obviously has to do with our ability to perceive changes in the skin," he said.

A greater challenge is the best and safest use of the device at high fluences with low density. In this scenario, a deep wound is created over a smaller total area of the skin—about 10% per treatment session. Associated edema and erythema may persist for some time, but the potential exists for improvement of deeper wrinkles, just as he was hoping for, Dr. Rubin said.

Fraxel Could Be Well Suited for Some

The Fraxel 1,550-nm erbium laser may fill a niche for certain patients desiring skin rejuvenation, Dr. Rubin said.

These include:

▸ Patients with dark skin prone to hyperpigmentation. Because the damage inflicted by the Fraxel laser is done with microscopic pinpoints, it does not create the persistent erythema that often leads to hyperpigmentation following ablative therapies. Used at low fluences, it may be an excellent option for these patients.

▸ Patients with melasma. Melasma is essentially a condition of "misbehaving melanocytes," according to Dr. Rubin.

"When melanocytes aren't functioning appropriately, we would love to kill them without killing the surrounding tissue and creating hypopigmentation."

The selective action of the Fraxel laser may be able to "gently" knock out enough melanocytes to control melasma without tipping the balance too far, he said.

Results in melasma patients at 1–2 months are "intriguing," he said, although 6–8 months of clearance would be necessary to prove that the therapy is a significant advance.

▸ Patients desiring significant rejuvenation of nonfacial skin. Ablative CO₂ laser treatments are risky in areas of the body with few pilosebaceous units to assist in reepithelialization. Because the Fraxel laser does not produce a widespread wound, it may be better at safely treating the skin of the neck, chest, hands, and arms.

Dr. Rubin has no financial interest in the Fraxel laser and receives no funding from its manufacturer, Reliant Technologies.

LAS VEGAS — The new 1,550-nm erbium Fraxel laser, by creating minuscule dots of destruction in the surface of the skin, produces color and texture changes, and may have the ability to significantly reduce wrinkles at high fluences, Mark Rubin, M.D., said at a facial cosmetic surgery symposium.

"This, in my mind, is a therapy in flux. It's where Thermage was 2 years ago," said Dr. Rubin at the symposium, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

The Fraxel laser was approved by the Food and Drug Administration in March.

Using company-suggested parameters, the device can deliver perceptible improvement in the skin with significantly less traumatic healing than is required after carbon dioxide (CO₂) laser treatments.

Still, "the color and texture is really what knocks you out," said Dr. Rubin, who has no financial interest in, and receives no funding from, Fraxel manufacturer Reliant Technologies Inc.

"The big issue for me is what's happening wrinklewise. So far, my experience has been very variable," Dr. Rubin said.

It may be that very high fluences are necessary to dramatically alter wrinkles with the novel system. Dr. Rubin noted that a colleague had been experimenting with aggressive settings, and was finding "much more profound changes" than could be produced by a nonablative laser.

He suggested that it may take some time to work out the ideal ways to use the Fraxel laser for different purposes.

"Nobody really knows how to use it correctly," he said, urging colleagues to "look at it again in 6 months."

Dr. Rubin, who practices dermatology in Beverly Hills, Calif., purchased a Fraxel laser in hopes of finding the holy grail of skin resurfacing: a device capable of smoothing moderate to deep wrinkles without provoking a lengthy, complication-ridden healing period.

"The ablative therapies are spectacular, but no fun for you or the patient. There's risk. There's [a] nasty-looking [healing period] when you have to see patients every couple of days. There are reasons not everyone is dying to do this."

Nonablative devices seemed like a good idea—Dr. Rubin bought several of them—but they proved to be poor substitutes for the steamroller effect that ablative lasers had on deep wrinkles.

Fraxel seemed to him to be a potential bridge between the two types of skin rejuvenation therapies, creating "little islands of ablated skin in a sea of normal skin."

"Rather than burning everything off, can we burn just little tiny bits at a time to sort of fool the skin into thinking it's not been wounded so badly?" he asked.

The answer is—maybe.

The epidermis remains intact, even when the laser's energy reaches depths of 700 micrometers and beyond, a level deep enough to promote collagen remodeling. But are the pinpoints of energy enough? And are the surface areas of each microthermal zone (estimated to number 2,000 per cm

About 20% of the facial surface area is impacted during each treatment session at a low fluence, typically four to six passes, Dr. Rubin said. However, "in reality, as you go back and forth like this, you're never really where you're supposed to be. In certain places you hit the same spot two times, three times, four times, who knows? And in other places, you skip."

It may be that the microscopic zones of destruction are so small that overlap does not matter, either in terms of results or side effects, he said. However, it remains to be seen whether consistency will be achieved as the laser makes its way into general clinical practice.

A clear advantage of Fraxel lasers over CO₂ lasers is the healing process, according to Dr. Rubin. "These patients aren't weeping fluid. They're not bleeding," he explained.

When low fluences are used, edema typically lasts 1–2 days, and erythema lasts 1–3 days. Flaking and bronzing of the skin are common. Makeup can be worn because there is no open wound, but most patients need heavy makeup to cover the transient effects of the treatment.

"They certainly don't look normal enough to be fully functional a day or 2 days later. It's nonablative, but there is an impact on patient's lives as a result of this," Dr. Rubin said.

A topical anesthetic is used, and some patients require supplemental oral pain medications. A blue dye is used to enhance skin surface contours for optical scanning.

Patients, said Dr. Rubin, "look like [performers in] Blue Man Group," but the dye washes away within a day.

A grid is used to guide the laser.

Patients return for multiple treatments until 100% of the skin's surface is treated.

At low fluences with high density, the laser's zone of thermal injury extends to the superficial papillary dermis, producing excellent improvement in the appearance of actinic dyschromia and photodamage.

"There's no question color- and texturewise, these patients can really do profoundly well. Although just 20% of the epidermis is being treated [at each session], they don't look 20% better; they look 40%–50% better.

"I don't know why; it doesn't make sense. It obviously has to do with our ability to perceive changes in the skin," he said.

A greater challenge is the best and safest use of the device at high fluences with low density. In this scenario, a deep wound is created over a smaller total area of the skin—about 10% per treatment session. Associated edema and erythema may persist for some time, but the potential exists for improvement of deeper wrinkles, just as he was hoping for, Dr. Rubin said.

Fraxel Could Be Well Suited for Some

The Fraxel 1,550-nm erbium laser may fill a niche for certain patients desiring skin rejuvenation, Dr. Rubin said.

These include:

▸ Patients with dark skin prone to hyperpigmentation. Because the damage inflicted by the Fraxel laser is done with microscopic pinpoints, it does not create the persistent erythema that often leads to hyperpigmentation following ablative therapies. Used at low fluences, it may be an excellent option for these patients.

▸ Patients with melasma. Melasma is essentially a condition of "misbehaving melanocytes," according to Dr. Rubin.

"When melanocytes aren't functioning appropriately, we would love to kill them without killing the surrounding tissue and creating hypopigmentation."

The selective action of the Fraxel laser may be able to "gently" knock out enough melanocytes to control melasma without tipping the balance too far, he said.

Results in melasma patients at 1–2 months are "intriguing," he said, although 6–8 months of clearance would be necessary to prove that the therapy is a significant advance.

▸ Patients desiring significant rejuvenation of nonfacial skin. Ablative CO₂ laser treatments are risky in areas of the body with few pilosebaceous units to assist in reepithelialization. Because the Fraxel laser does not produce a widespread wound, it may be better at safely treating the skin of the neck, chest, hands, and arms.

Dr. Rubin has no financial interest in the Fraxel laser and receives no funding from its manufacturer, Reliant Technologies.

The Agency for Healthcare Research and Quality has released the booklet "Guide to Health Care Quality: How to Know It When You See It" to help consumers identify high-quality health care. To download a copy, visit www.ahrq.gov/consumer/guidetoq

The Agency for Healthcare Research and Quality has released the booklet "Guide to Health Care Quality: How to Know It When You See It" to help consumers identify high-quality health care. To download a copy, visit www.ahrq.gov/consumer/guidetoq

The Agency for Healthcare Research and Quality has released the booklet "Guide to Health Care Quality: How to Know It When You See It" to help consumers identify high-quality health care. To download a copy, visit www.ahrq.gov/consumer/guidetoq

ORLANDO — A strong edematous response immediately after laser hair removal is not necessary to achieve treatment efficacy, according to a prospective study.

"There is zero need to drive patients into an intense edematous response," Albert J. Nemeth, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Nemeth conducted a study to correlate immediate postlaser response with efficacy of permanent hair removal, which he said is an area with insufficient research.

He also proposed that a less visible immediate reaction might be better for patients. "Selection of more aggressive fluences based on a perceived inadequate immediate response might cause more adverse sequelae," said Dr. Nemeth, who is in private practice in Clearwater, Fla.

Dr. Nemeth assessed 200 patients treated with the MeDioStar 810-nm power-pulsed diode laser (Asclepion Laser Technologies, Jena, Germany).

The average participant age was 36 years, 86% were female, and mean follow-up was 5 months. The majority of patients had Fitzpatrick skin types of I, II, and III.

Immediate perifollicular response and surrounding erythema were rated on a scale of 1 (very mild) to 5 (intense). Patients with a low score still had effective permanent hair reduction.

The laser features a 12-mm actively chilled handpiece with a sapphire spot. "The actively chilled handpiece is vital for epidermal protection," said Dr. Nemeth, also of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

Laser fluences were set between 10 J/cm

"I've never seen such efficacy with other lasers—I think the power pulse makes that much of a difference," he said. Dr. Nemeth disclosed no conflict of interest regarding the MeDioStar laser or its manufacturer.

Multiple treatment sessions were required. After the first treatment, there was a mean 26% reduction in hair. After the second treatment, there was a mean 47% reduction, and after a third session, 64%.

Adverse events were infrequent. These included occasional crusting, and "easily resolvable" postinflammatory hyperpigmentation in 5 out of a total of 978 treatment sessions.

"There is physician supervision without exception for every treatment session," Dr. Nemeth said. A highly trained nurse who also is a licensed electrologist performed all procedures in the study to minimize variations in treatment.

This patient is shown at baseline prior to treatment on his upper lip.

The patient is shown after receiving 810-nm MeDioStar laser hair removal. Photos courtesy Dr. Albert J. Nemeth

ORLANDO — A strong edematous response immediately after laser hair removal is not necessary to achieve treatment efficacy, according to a prospective study.

"There is zero need to drive patients into an intense edematous response," Albert J. Nemeth, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Nemeth conducted a study to correlate immediate postlaser response with efficacy of permanent hair removal, which he said is an area with insufficient research.

He also proposed that a less visible immediate reaction might be better for patients. "Selection of more aggressive fluences based on a perceived inadequate immediate response might cause more adverse sequelae," said Dr. Nemeth, who is in private practice in Clearwater, Fla.

Dr. Nemeth assessed 200 patients treated with the MeDioStar 810-nm power-pulsed diode laser (Asclepion Laser Technologies, Jena, Germany).

The average participant age was 36 years, 86% were female, and mean follow-up was 5 months. The majority of patients had Fitzpatrick skin types of I, II, and III.

Immediate perifollicular response and surrounding erythema were rated on a scale of 1 (very mild) to 5 (intense). Patients with a low score still had effective permanent hair reduction.

The laser features a 12-mm actively chilled handpiece with a sapphire spot. "The actively chilled handpiece is vital for epidermal protection," said Dr. Nemeth, also of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

Laser fluences were set between 10 J/cm

"I've never seen such efficacy with other lasers—I think the power pulse makes that much of a difference," he said. Dr. Nemeth disclosed no conflict of interest regarding the MeDioStar laser or its manufacturer.

Multiple treatment sessions were required. After the first treatment, there was a mean 26% reduction in hair. After the second treatment, there was a mean 47% reduction, and after a third session, 64%.

Adverse events were infrequent. These included occasional crusting, and "easily resolvable" postinflammatory hyperpigmentation in 5 out of a total of 978 treatment sessions.

"There is physician supervision without exception for every treatment session," Dr. Nemeth said. A highly trained nurse who also is a licensed electrologist performed all procedures in the study to minimize variations in treatment.

This patient is shown at baseline prior to treatment on his upper lip.

The patient is shown after receiving 810-nm MeDioStar laser hair removal. Photos courtesy Dr. Albert J. Nemeth

ORLANDO — A strong edematous response immediately after laser hair removal is not necessary to achieve treatment efficacy, according to a prospective study.

"There is zero need to drive patients into an intense edematous response," Albert J. Nemeth, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Nemeth conducted a study to correlate immediate postlaser response with efficacy of permanent hair removal, which he said is an area with insufficient research.

He also proposed that a less visible immediate reaction might be better for patients. "Selection of more aggressive fluences based on a perceived inadequate immediate response might cause more adverse sequelae," said Dr. Nemeth, who is in private practice in Clearwater, Fla.

Dr. Nemeth assessed 200 patients treated with the MeDioStar 810-nm power-pulsed diode laser (Asclepion Laser Technologies, Jena, Germany).

The average participant age was 36 years, 86% were female, and mean follow-up was 5 months. The majority of patients had Fitzpatrick skin types of I, II, and III.

Immediate perifollicular response and surrounding erythema were rated on a scale of 1 (very mild) to 5 (intense). Patients with a low score still had effective permanent hair reduction.

The laser features a 12-mm actively chilled handpiece with a sapphire spot. "The actively chilled handpiece is vital for epidermal protection," said Dr. Nemeth, also of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

Laser fluences were set between 10 J/cm

"I've never seen such efficacy with other lasers—I think the power pulse makes that much of a difference," he said. Dr. Nemeth disclosed no conflict of interest regarding the MeDioStar laser or its manufacturer.

Multiple treatment sessions were required. After the first treatment, there was a mean 26% reduction in hair. After the second treatment, there was a mean 47% reduction, and after a third session, 64%.

Adverse events were infrequent. These included occasional crusting, and "easily resolvable" postinflammatory hyperpigmentation in 5 out of a total of 978 treatment sessions.

"There is physician supervision without exception for every treatment session," Dr. Nemeth said. A highly trained nurse who also is a licensed electrologist performed all procedures in the study to minimize variations in treatment.

This patient is shown at baseline prior to treatment on his upper lip.

The patient is shown after receiving 810-nm MeDioStar laser hair removal. Photos courtesy Dr. Albert J. Nemeth

ORLANDO — Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.

Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.

Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."

Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.

Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.

A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tip—a benefit from this operation she did not expect.

When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.

Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.

Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 2–3 mm, Dr. Toriumi suggested.

A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.

A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.

If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.

"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."

A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance component—few are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.

M-plasty produced a good result after removal of a hemangioma.

Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi

ORLANDO — Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.

Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.

Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."

Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.

Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.

A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tip—a benefit from this operation she did not expect.

When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.

Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.

Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 2–3 mm, Dr. Toriumi suggested.

A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.

A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.

If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.

"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."

A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance component—few are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.

M-plasty produced a good result after removal of a hemangioma.

Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi

ORLANDO — Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.

Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.

Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."

Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.

Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.

A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tip—a benefit from this operation she did not expect.

When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.

Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.

Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 2–3 mm, Dr. Toriumi suggested.

A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.

A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.

If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.

"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."

A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance component—few are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.

M-plasty produced a good result after removal of a hemangioma.

Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi

ORLANDO — Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.

Free borders are mobile facial landmarks—the lips, eyebrows, eyelids, and nasal ala—that can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.

"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.

Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.

▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.

Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.

As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.

▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."

Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."

▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."

▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.

The Mohs defect is visible after local anesthesia and before reconstruction.

The vermillion border is intentionally involved surgically to keep it from being "pushed up."

At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi

ORLANDO — Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.

Free borders are mobile facial landmarks—the lips, eyebrows, eyelids, and nasal ala—that can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.

"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.

Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.

▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.

Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.

As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.

▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."

Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."

▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."

▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.

The Mohs defect is visible after local anesthesia and before reconstruction.

The vermillion border is intentionally involved surgically to keep it from being "pushed up."

At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi

ORLANDO — Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.

Free borders are mobile facial landmarks—the lips, eyebrows, eyelids, and nasal ala—that can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.

"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.

Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.

▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.

Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.

As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.

▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."

Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."

▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."

▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.

The Mohs defect is visible after local anesthesia and before reconstruction.

The vermillion border is intentionally involved surgically to keep it from being "pushed up."

At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi

NAPLES, FLA. — Several new technologies are becoming available to follow and visualize melanomas, but practicing dermatologists will be best served if they focus on learning dermoscopy, Harold S. Rabinovitz, M.D., said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Current estimates are that about 15% of U.S. dermatologists use dermoscopy, said Dr. Rabinovitz, of the department of dermatology at the University of Miami.

Even experienced dermatologists are not perfect at differentiating between malignant melanoma and benign melanocytic nevi, he said. Studies have found the overall diagnostic accuracy of dermatologists to be about 65%. Dermoscopy improves diagnostic accuracy over visual inspection by about 15%, Dr. Rabinovitz said.

Once dermoscopy technique is learned, it does not take much extra time to do, which makes it convenient and practical. The obstacle is learning to do dermoscopy well, he added.

"There is a steep learning curve," he said. "In dermoscopy, a little knowledge is worse than no knowledge. It is only a diagnostic aid, as pathology is the reference standard."

The other melanoma-diagnosing technologies that are available or in development, he said, are impractical or their future is uncertain.

For instance, total-body photography, even with today's digital photography and computer software, requires too much time to take and review the photographs. When Dr. Rabinovitz does total-body photography for appropriate, high-risk patients, he says he gives patients CD copies of the digital photos. When they have a concern about a particular nevus, they can compare it to the photographic record. "Full-body photography, in my opinion, is for the patients."

Confocal imaging, like dermoscopy, allows visualization of structures below the surface, but on the horizontal plane. This imaging system is being used in several studies, including one on tracking imiquimod treatment of in situ melanoma. But confocal imaging is a research tool and probably will remain one, he said, because dermoscopy is available, and because biopsy will remain the standard of diagnosis.

Image-analyzing computer programs for use with dermoscopy and photography are in development, and could have great promise because the computer might be able to pick up things the eye may miss, he said. But their introduction into the market is probably at least a few years away, even if problems in analyzing some histologic features can be worked out.

"My advice to you is to learn dermoscopy," Dr. Rabinovitz said. "Over the years, I believe this will be an important tool and aid for dermatologists in the management of their patients."

Dr. Rabinovitz said he knows of four companies that sell dermoscopy equipment. He did not recommend any one product, but he did advise that the best course of action is to buy the latest model of equipment.

NAPLES, FLA. — Several new technologies are becoming available to follow and visualize melanomas, but practicing dermatologists will be best served if they focus on learning dermoscopy, Harold S. Rabinovitz, M.D., said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Current estimates are that about 15% of U.S. dermatologists use dermoscopy, said Dr. Rabinovitz, of the department of dermatology at the University of Miami.

Even experienced dermatologists are not perfect at differentiating between malignant melanoma and benign melanocytic nevi, he said. Studies have found the overall diagnostic accuracy of dermatologists to be about 65%. Dermoscopy improves diagnostic accuracy over visual inspection by about 15%, Dr. Rabinovitz said.

Once dermoscopy technique is learned, it does not take much extra time to do, which makes it convenient and practical. The obstacle is learning to do dermoscopy well, he added.

"There is a steep learning curve," he said. "In dermoscopy, a little knowledge is worse than no knowledge. It is only a diagnostic aid, as pathology is the reference standard."

The other melanoma-diagnosing technologies that are available or in development, he said, are impractical or their future is uncertain.

For instance, total-body photography, even with today's digital photography and computer software, requires too much time to take and review the photographs. When Dr. Rabinovitz does total-body photography for appropriate, high-risk patients, he says he gives patients CD copies of the digital photos. When they have a concern about a particular nevus, they can compare it to the photographic record. "Full-body photography, in my opinion, is for the patients."

Confocal imaging, like dermoscopy, allows visualization of structures below the surface, but on the horizontal plane. This imaging system is being used in several studies, including one on tracking imiquimod treatment of in situ melanoma. But confocal imaging is a research tool and probably will remain one, he said, because dermoscopy is available, and because biopsy will remain the standard of diagnosis.

Image-analyzing computer programs for use with dermoscopy and photography are in development, and could have great promise because the computer might be able to pick up things the eye may miss, he said. But their introduction into the market is probably at least a few years away, even if problems in analyzing some histologic features can be worked out.

"My advice to you is to learn dermoscopy," Dr. Rabinovitz said. "Over the years, I believe this will be an important tool and aid for dermatologists in the management of their patients."

Dr. Rabinovitz said he knows of four companies that sell dermoscopy equipment. He did not recommend any one product, but he did advise that the best course of action is to buy the latest model of equipment.

NAPLES, FLA. — Several new technologies are becoming available to follow and visualize melanomas, but practicing dermatologists will be best served if they focus on learning dermoscopy, Harold S. Rabinovitz, M.D., said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Current estimates are that about 15% of U.S. dermatologists use dermoscopy, said Dr. Rabinovitz, of the department of dermatology at the University of Miami.

Even experienced dermatologists are not perfect at differentiating between malignant melanoma and benign melanocytic nevi, he said. Studies have found the overall diagnostic accuracy of dermatologists to be about 65%. Dermoscopy improves diagnostic accuracy over visual inspection by about 15%, Dr. Rabinovitz said.

Once dermoscopy technique is learned, it does not take much extra time to do, which makes it convenient and practical. The obstacle is learning to do dermoscopy well, he added.

"There is a steep learning curve," he said. "In dermoscopy, a little knowledge is worse than no knowledge. It is only a diagnostic aid, as pathology is the reference standard."

The other melanoma-diagnosing technologies that are available or in development, he said, are impractical or their future is uncertain.

For instance, total-body photography, even with today's digital photography and computer software, requires too much time to take and review the photographs. When Dr. Rabinovitz does total-body photography for appropriate, high-risk patients, he says he gives patients CD copies of the digital photos. When they have a concern about a particular nevus, they can compare it to the photographic record. "Full-body photography, in my opinion, is for the patients."

Confocal imaging, like dermoscopy, allows visualization of structures below the surface, but on the horizontal plane. This imaging system is being used in several studies, including one on tracking imiquimod treatment of in situ melanoma. But confocal imaging is a research tool and probably will remain one, he said, because dermoscopy is available, and because biopsy will remain the standard of diagnosis.

Image-analyzing computer programs for use with dermoscopy and photography are in development, and could have great promise because the computer might be able to pick up things the eye may miss, he said. But their introduction into the market is probably at least a few years away, even if problems in analyzing some histologic features can be worked out.

"My advice to you is to learn dermoscopy," Dr. Rabinovitz said. "Over the years, I believe this will be an important tool and aid for dermatologists in the management of their patients."

Dr. Rabinovitz said he knows of four companies that sell dermoscopy equipment. He did not recommend any one product, but he did advise that the best course of action is to buy the latest model of equipment.

ORLANDO — Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

He suggested that dermatologic surgeons consider partial closure for:

▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."

▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."

▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.

▸ Surgical sites where complete closure might cause ischemia or necrosis.

"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.

"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.

In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.

"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.

"I let it granulate in. It was very functional, and the patient was very happy."

A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.

A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.

Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."

A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.

Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."

ORLANDO — Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

He suggested that dermatologic surgeons consider partial closure for:

▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."

▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."

▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.

▸ Surgical sites where complete closure might cause ischemia or necrosis.

"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.

"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.

In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.

"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.

"I let it granulate in. It was very functional, and the patient was very happy."

A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.

A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.

Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."

A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.

Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."

ORLANDO — Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

He suggested that dermatologic surgeons consider partial closure for:

▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."

▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."

▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.

▸ Surgical sites where complete closure might cause ischemia or necrosis.

"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.

"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.

In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.

"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.

"I let it granulate in. It was very functional, and the patient was very happy."

A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.

A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.

Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."

A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.

Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."