Aesthetic Dermatology

NEWPORT BEACH, CALIF. — Peri-oral injections of Botox may be a remedy when patients have lines radiating from the lips, a hollow appearance around the mouth, or an elongated upper lip often associated with aging, Joel Cohen, M.D., said at the annual meeting of the Pacific Dermatologic Association.

Injecting a total of 6–10 U of botulinum toxin type A into the orbicularis oris muscle can soften the lines and give the patient a more animated expression. The treatment also augments the upper lip in some patients, giving them a fuller lip without having to use fillers, said Dr. Cohen, a clinical assistant professor of dermatology at the University of Colorado, Denver.

Identify the injection sites by having the patient purse her lips. Inject the Botox superficially, into the peaks of the musculature. Treat the lower lip as well as the upper lip, "or it will look funny, and may accentuate any hyperfunctional musculature of the lower lip," he said.

Proper placement of the injections is important. Go too lateral, and you may weaken the lip elevators, which could result in a drooping lip and a risk of drooling. Injecting too medially or right at the midline could flatten the Cupid's bow.

Even under the best of circumstances, Botox treatments around the mouth may impair the patient's ability to purse her lips, whistle, drink from a straw, or pronounce the letters P and B. For those reasons, Dr. Cohen does not recommend this procedure to actors, singers, broadcast journalists, woodwind musicians, or scuba divers.

Moving farther down the face, Dr. Cohen said he has achieved good results injecting Botox into people with a dimpled, "golf-ball chin" that becomes especially prominent when they talk or chew. Feel along the chin for the bony margin, and inject 3–5 U into the belly of the mentalis muscle. With use of such small quantities, the treatment can be considered a "lunchtime" procedure.

Dr. Cohen offered a few pearls for maximizing cosmetic results and patient comfort during a lower-face procedure:

▸ Everyone has some naturally occurring lip asymmetry. Document this in photographs before the procedure, in case there's any question about it later. Some patients may benefit from a touch-up procedure a few weeks after the initial one.

▸ Makeup can obscure facial landmarks or small potential pitfalls such as vascular structures. Have the patient wipe it off before you administer the injections.

▸ Diluting the Botox makes the injections easier to perform, with no difference in cosmetic results as long as you're using an appropriate total dose. Dr. Cohen uses preserved saline, which decreases the pain.

▸ A 31-gauge syringe with a short hub also makes the procedure less painful.

NEWPORT BEACH, CALIF. — Peri-oral injections of Botox may be a remedy when patients have lines radiating from the lips, a hollow appearance around the mouth, or an elongated upper lip often associated with aging, Joel Cohen, M.D., said at the annual meeting of the Pacific Dermatologic Association.

Injecting a total of 6–10 U of botulinum toxin type A into the orbicularis oris muscle can soften the lines and give the patient a more animated expression. The treatment also augments the upper lip in some patients, giving them a fuller lip without having to use fillers, said Dr. Cohen, a clinical assistant professor of dermatology at the University of Colorado, Denver.

Identify the injection sites by having the patient purse her lips. Inject the Botox superficially, into the peaks of the musculature. Treat the lower lip as well as the upper lip, "or it will look funny, and may accentuate any hyperfunctional musculature of the lower lip," he said.

Proper placement of the injections is important. Go too lateral, and you may weaken the lip elevators, which could result in a drooping lip and a risk of drooling. Injecting too medially or right at the midline could flatten the Cupid's bow.

Even under the best of circumstances, Botox treatments around the mouth may impair the patient's ability to purse her lips, whistle, drink from a straw, or pronounce the letters P and B. For those reasons, Dr. Cohen does not recommend this procedure to actors, singers, broadcast journalists, woodwind musicians, or scuba divers.

Moving farther down the face, Dr. Cohen said he has achieved good results injecting Botox into people with a dimpled, "golf-ball chin" that becomes especially prominent when they talk or chew. Feel along the chin for the bony margin, and inject 3–5 U into the belly of the mentalis muscle. With use of such small quantities, the treatment can be considered a "lunchtime" procedure.

Dr. Cohen offered a few pearls for maximizing cosmetic results and patient comfort during a lower-face procedure:

▸ Everyone has some naturally occurring lip asymmetry. Document this in photographs before the procedure, in case there's any question about it later. Some patients may benefit from a touch-up procedure a few weeks after the initial one.

▸ Makeup can obscure facial landmarks or small potential pitfalls such as vascular structures. Have the patient wipe it off before you administer the injections.

▸ Diluting the Botox makes the injections easier to perform, with no difference in cosmetic results as long as you're using an appropriate total dose. Dr. Cohen uses preserved saline, which decreases the pain.

▸ A 31-gauge syringe with a short hub also makes the procedure less painful.

NEWPORT BEACH, CALIF. — Peri-oral injections of Botox may be a remedy when patients have lines radiating from the lips, a hollow appearance around the mouth, or an elongated upper lip often associated with aging, Joel Cohen, M.D., said at the annual meeting of the Pacific Dermatologic Association.

Injecting a total of 6–10 U of botulinum toxin type A into the orbicularis oris muscle can soften the lines and give the patient a more animated expression. The treatment also augments the upper lip in some patients, giving them a fuller lip without having to use fillers, said Dr. Cohen, a clinical assistant professor of dermatology at the University of Colorado, Denver.

Identify the injection sites by having the patient purse her lips. Inject the Botox superficially, into the peaks of the musculature. Treat the lower lip as well as the upper lip, "or it will look funny, and may accentuate any hyperfunctional musculature of the lower lip," he said.

Proper placement of the injections is important. Go too lateral, and you may weaken the lip elevators, which could result in a drooping lip and a risk of drooling. Injecting too medially or right at the midline could flatten the Cupid's bow.

Even under the best of circumstances, Botox treatments around the mouth may impair the patient's ability to purse her lips, whistle, drink from a straw, or pronounce the letters P and B. For those reasons, Dr. Cohen does not recommend this procedure to actors, singers, broadcast journalists, woodwind musicians, or scuba divers.

Moving farther down the face, Dr. Cohen said he has achieved good results injecting Botox into people with a dimpled, "golf-ball chin" that becomes especially prominent when they talk or chew. Feel along the chin for the bony margin, and inject 3–5 U into the belly of the mentalis muscle. With use of such small quantities, the treatment can be considered a "lunchtime" procedure.

Dr. Cohen offered a few pearls for maximizing cosmetic results and patient comfort during a lower-face procedure:

▸ Everyone has some naturally occurring lip asymmetry. Document this in photographs before the procedure, in case there's any question about it later. Some patients may benefit from a touch-up procedure a few weeks after the initial one.

▸ Makeup can obscure facial landmarks or small potential pitfalls such as vascular structures. Have the patient wipe it off before you administer the injections.

▸ Diluting the Botox makes the injections easier to perform, with no difference in cosmetic results as long as you're using an appropriate total dose. Dr. Cohen uses preserved saline, which decreases the pain.

▸ A 31-gauge syringe with a short hub also makes the procedure less painful.

VANCOUVER, B.C. — Simple measures taken at the time of ambulatory surgery, such as the use of clonidine, can significantly reduce patients' postprocedure pain, Dr. Scott S. Reuben said at the annual meeting of the American Pain Society.

On a scientific front, "there has been an explosion in our understanding of pain management in the past 4 or 5 years," said Dr. Reuben, director of the acute pain service at Baystate Medical Center, Springfield, Mass., at which 35,000 ambulatory surgeries are performed each year.

At the same time, surveys suggest that pain care following ambulatory surgery is not getting better and may even be getting somewhat worse, as the number and types of surgery have grown, Dr. Reuben said.

"We're doing a horrible job managing postoerative pain," he said.

Preemptive techniques are key to addressing this situation because it is now known that pain control before and during a surgical procedure can prevent the trauma from causing central sensitization, which lowers the pain threshold in the postoperative period.

Good short-term pain control may even prevent chronic, postoperative pain from developing, he said.

Some of the methods used at his center to preempt central sensitization include:

▸ Local analgesia. Even with general anesthesia, local pain control is important during surgery, Dr. Reuben said. "General anesthesia does nothing to block central sensitization of the nervous system. Local anesthetics can."

At his center, local anesthesia for joint surgery includes a combination of agents, clonidine, bupivacaine, and morphine. The surgeons use ice as well.

▸ Clonidine. Alpha2-agonists used locally cause vasoconstriction that prevents dispersion of other local anesthetics, and that is probably one reason clonidine has been shown to increase the duration of local bupivacaine action, by 20%–30% according to one study, Dr. Reuben said.

Clonidine itself also is an analgesic. It "has fantastic analgesic properties to control perioperative pain," he said.

▸ Opioids. The administration of an opioid before surgery acts centrally to prevent the hyperexcitability response produced by surgery, and this can mean less need for analgesics afterward. But more importantly, it is now known that there are local opioid receptors, and that even bone has them. "We have published about 12 studies on putting peripheral morphine in the knee for arthroscopy, with significant analgesic effects," Dr. Reuben said.

When morphine is used locally, very little is needed to control pain, and, as with clonidine, there appears to be a synergistic effect when it is used with other agents. Dr. Reuben's research group has shown that clonidine alone used locally produces significant analgesia for up to 7 hours, clonidine and bupivacaine produce analgesia for 10 hours, and clonidine, bupivacaine, and morphine combined produce 17 hours, he said.

VANCOUVER, B.C. — Simple measures taken at the time of ambulatory surgery, such as the use of clonidine, can significantly reduce patients' postprocedure pain, Dr. Scott S. Reuben said at the annual meeting of the American Pain Society.

On a scientific front, "there has been an explosion in our understanding of pain management in the past 4 or 5 years," said Dr. Reuben, director of the acute pain service at Baystate Medical Center, Springfield, Mass., at which 35,000 ambulatory surgeries are performed each year.

At the same time, surveys suggest that pain care following ambulatory surgery is not getting better and may even be getting somewhat worse, as the number and types of surgery have grown, Dr. Reuben said.

"We're doing a horrible job managing postoerative pain," he said.

Preemptive techniques are key to addressing this situation because it is now known that pain control before and during a surgical procedure can prevent the trauma from causing central sensitization, which lowers the pain threshold in the postoperative period.

Good short-term pain control may even prevent chronic, postoperative pain from developing, he said.

Some of the methods used at his center to preempt central sensitization include:

▸ Local analgesia. Even with general anesthesia, local pain control is important during surgery, Dr. Reuben said. "General anesthesia does nothing to block central sensitization of the nervous system. Local anesthetics can."

At his center, local anesthesia for joint surgery includes a combination of agents, clonidine, bupivacaine, and morphine. The surgeons use ice as well.

▸ Clonidine. Alpha2-agonists used locally cause vasoconstriction that prevents dispersion of other local anesthetics, and that is probably one reason clonidine has been shown to increase the duration of local bupivacaine action, by 20%–30% according to one study, Dr. Reuben said.

Clonidine itself also is an analgesic. It "has fantastic analgesic properties to control perioperative pain," he said.

▸ Opioids. The administration of an opioid before surgery acts centrally to prevent the hyperexcitability response produced by surgery, and this can mean less need for analgesics afterward. But more importantly, it is now known that there are local opioid receptors, and that even bone has them. "We have published about 12 studies on putting peripheral morphine in the knee for arthroscopy, with significant analgesic effects," Dr. Reuben said.

When morphine is used locally, very little is needed to control pain, and, as with clonidine, there appears to be a synergistic effect when it is used with other agents. Dr. Reuben's research group has shown that clonidine alone used locally produces significant analgesia for up to 7 hours, clonidine and bupivacaine produce analgesia for 10 hours, and clonidine, bupivacaine, and morphine combined produce 17 hours, he said.

VANCOUVER, B.C. — Simple measures taken at the time of ambulatory surgery, such as the use of clonidine, can significantly reduce patients' postprocedure pain, Dr. Scott S. Reuben said at the annual meeting of the American Pain Society.

On a scientific front, "there has been an explosion in our understanding of pain management in the past 4 or 5 years," said Dr. Reuben, director of the acute pain service at Baystate Medical Center, Springfield, Mass., at which 35,000 ambulatory surgeries are performed each year.

At the same time, surveys suggest that pain care following ambulatory surgery is not getting better and may even be getting somewhat worse, as the number and types of surgery have grown, Dr. Reuben said.

"We're doing a horrible job managing postoerative pain," he said.

Preemptive techniques are key to addressing this situation because it is now known that pain control before and during a surgical procedure can prevent the trauma from causing central sensitization, which lowers the pain threshold in the postoperative period.

Good short-term pain control may even prevent chronic, postoperative pain from developing, he said.

Some of the methods used at his center to preempt central sensitization include:

▸ Local analgesia. Even with general anesthesia, local pain control is important during surgery, Dr. Reuben said. "General anesthesia does nothing to block central sensitization of the nervous system. Local anesthetics can."

At his center, local anesthesia for joint surgery includes a combination of agents, clonidine, bupivacaine, and morphine. The surgeons use ice as well.

▸ Clonidine. Alpha2-agonists used locally cause vasoconstriction that prevents dispersion of other local anesthetics, and that is probably one reason clonidine has been shown to increase the duration of local bupivacaine action, by 20%–30% according to one study, Dr. Reuben said.

Clonidine itself also is an analgesic. It "has fantastic analgesic properties to control perioperative pain," he said.

▸ Opioids. The administration of an opioid before surgery acts centrally to prevent the hyperexcitability response produced by surgery, and this can mean less need for analgesics afterward. But more importantly, it is now known that there are local opioid receptors, and that even bone has them. "We have published about 12 studies on putting peripheral morphine in the knee for arthroscopy, with significant analgesic effects," Dr. Reuben said.

When morphine is used locally, very little is needed to control pain, and, as with clonidine, there appears to be a synergistic effect when it is used with other agents. Dr. Reuben's research group has shown that clonidine alone used locally produces significant analgesia for up to 7 hours, clonidine and bupivacaine produce analgesia for 10 hours, and clonidine, bupivacaine, and morphine combined produce 17 hours, he said.

FLORENCE, ITALY — An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.

Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.

To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%–30%.

Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.

Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.

By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.

"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.

"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.

The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.

Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.

The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.

Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.

When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.

Granulation tissue is removed with large and deep excisions.

The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël

FLORENCE, ITALY — An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.

Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.

To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%–30%.

Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.

Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.

By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.

"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.

"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.

The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.

Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.

The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.

Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.

When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.

Granulation tissue is removed with large and deep excisions.

The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël

FLORENCE, ITALY — An alternative to the classic, 150-year-old surgical technique for repairing ingrown toenails may be associated with fewer recurrences and a much-improved aesthetic result, two Swiss dermatologists reported at the 13th Congress of the European Academy of Dermatology and Venereology.

Bernard Noël, M.D., and his coauthor Renatto G. Panizzon, M.D., maintain that their new technique is superior to Emmert plasty, a procedure that consists of a rather superficial wedge excision of granulation tissue, as well as both the adjacent nail bed and the corresponding matrix.

To refine Emmert plasty, however, they first had to scrutinize its steps to understand why it has a recurrence rate as high as 10%–30%.

Dr. Noël and Dr. Panizzon, professor of dermatology at the University of Lausanne (Switzerland), theorized that recurrences may be related to the surgical target of Emmert plasty: the nail, which is narrowed by the radical surgery and sometimes left in a dystrophic state that may be vulnerable to the same pressure that led to the development of the ingrown nail initially.

Moreover, when a significant portion of the nail bed is sacrificed and the nail width is permanently reduced, aesthetic results are often "unsatisfactory," according to Dr. Noël, chief of dermatologic surgery and the wound healing clinic at Centre Hospitalier Universitaire Vaudois of the University of Lausanne.

By contrast, their approach preserves the nail apparatus while deeply targeting the granulation tissue and reducing the size of the toe itself.

"The breadth of the toe extremity is clearly reduced in a way that radically reduces the lateral pressure exerted by the shoes," Dr. Noël said.

"The great toe looks thinner, with a nail plate covering almost completely the distal phalange, reducing, therefore, the risk of recurrence," he noted.

The procedure is performed using a digital block and tourniquet at the toe base. Large, deep excisions remove granulation tissue before the wounds are closed in standard fashion.

Among 10 patients followed for a year or more, there has been a 100% success rate and no incidence of recurrence, Dr. Noël and Dr. Panizzon reported in their detailed poster presentation.

The authors believe their findings bode well for patients who are prone to develop ingrown toenails, which are the most common of all toenail disorders, believed to account for as many as 20% of foot-related physician visits.

Excessive pressures on the lateral toenail because of body weight, the wearing of ill-fitting shoes, or the practice of improperly cutting toenails all have been cited as contributors to the inflammation and the formation of granulation tissue that causes nails, usually of the great toe, to become ingrown.

When patient education and conservative therapy fail, repeated recurrences can lead to infections and extreme discomfort.

Granulation tissue is removed with large and deep excisions.

The toe extremity is narrowed but the nail appartatus is entirely preserved. Photos courtesy Dr. Bernard Noël

NEW YORK — Herb-using individuals who are at risk of bleeding should be advised to use caution, despite uncertainty about the actual degree of risk that may be involved, Adrian Fugh-Berman, M.D., said at a meeting on botanical medicine sponsored by Columbia University and the University of Arizona.

"Actual, theoretical, and fanciful herbal adverse events and interactions infest the medical literature," said Dr. Fugh-Berman of Georgetown University, Washington.

Given the level of uncertainty, it is prudent to check international normalized ratio (INR) of anticoagulated patients 7–14 days after starting any herbal, dietary supplement, or weight-loss regimen. By the same token, all herbs and supplements should be discontinued 2 weeks before surgery, she said.

Many herbs contain coumarins, most of which are benign. Some inhibit platelet aggregation in vitro, but few have been associated with actual bleeding episodes.

In one study, a 10-g dose of ginger decreased platelet aggregation 4 hours later, and a case was reported in which a 76-year-old woman developed nosebleeds and showed changes in INR after eating dried ginger and drinking tea made from it for several weeks. But three clinical studies found that up to 4 g of fresh ginger daily had no effect on bleeding.

Garlic oil has been shown to decrease platelet aggregation for up to 6 hours, and two cases of excessive postsurgical bleeding have been reported in which patients had consumed garlic-laden meals the night before.

"Tell patients not to consume meals heavy in garlic within a few days of surgery," Dr. Fugh-Berman advised.

Ginkgolide B, a component of Ginkgo biloba, is a known platelet aggregation factor antagonist, and the herb, alone or with analgesics, has been associated with intracranial bleeding events.

Clinical studies, however, found that one standardized ginkgo preparation (EGb761) had no effect on hemostasis, coagulation, or fibrinolysis in healthy men, and another (Bio-Biloba) did not change INR in patients who had been stabilized on warfarin.

NEW YORK — Herb-using individuals who are at risk of bleeding should be advised to use caution, despite uncertainty about the actual degree of risk that may be involved, Adrian Fugh-Berman, M.D., said at a meeting on botanical medicine sponsored by Columbia University and the University of Arizona.

"Actual, theoretical, and fanciful herbal adverse events and interactions infest the medical literature," said Dr. Fugh-Berman of Georgetown University, Washington.

Given the level of uncertainty, it is prudent to check international normalized ratio (INR) of anticoagulated patients 7–14 days after starting any herbal, dietary supplement, or weight-loss regimen. By the same token, all herbs and supplements should be discontinued 2 weeks before surgery, she said.

Many herbs contain coumarins, most of which are benign. Some inhibit platelet aggregation in vitro, but few have been associated with actual bleeding episodes.

In one study, a 10-g dose of ginger decreased platelet aggregation 4 hours later, and a case was reported in which a 76-year-old woman developed nosebleeds and showed changes in INR after eating dried ginger and drinking tea made from it for several weeks. But three clinical studies found that up to 4 g of fresh ginger daily had no effect on bleeding.

Garlic oil has been shown to decrease platelet aggregation for up to 6 hours, and two cases of excessive postsurgical bleeding have been reported in which patients had consumed garlic-laden meals the night before.

"Tell patients not to consume meals heavy in garlic within a few days of surgery," Dr. Fugh-Berman advised.

Ginkgolide B, a component of Ginkgo biloba, is a known platelet aggregation factor antagonist, and the herb, alone or with analgesics, has been associated with intracranial bleeding events.

Clinical studies, however, found that one standardized ginkgo preparation (EGb761) had no effect on hemostasis, coagulation, or fibrinolysis in healthy men, and another (Bio-Biloba) did not change INR in patients who had been stabilized on warfarin.

NEW YORK — Herb-using individuals who are at risk of bleeding should be advised to use caution, despite uncertainty about the actual degree of risk that may be involved, Adrian Fugh-Berman, M.D., said at a meeting on botanical medicine sponsored by Columbia University and the University of Arizona.

"Actual, theoretical, and fanciful herbal adverse events and interactions infest the medical literature," said Dr. Fugh-Berman of Georgetown University, Washington.

Given the level of uncertainty, it is prudent to check international normalized ratio (INR) of anticoagulated patients 7–14 days after starting any herbal, dietary supplement, or weight-loss regimen. By the same token, all herbs and supplements should be discontinued 2 weeks before surgery, she said.

Many herbs contain coumarins, most of which are benign. Some inhibit platelet aggregation in vitro, but few have been associated with actual bleeding episodes.

In one study, a 10-g dose of ginger decreased platelet aggregation 4 hours later, and a case was reported in which a 76-year-old woman developed nosebleeds and showed changes in INR after eating dried ginger and drinking tea made from it for several weeks. But three clinical studies found that up to 4 g of fresh ginger daily had no effect on bleeding.

Garlic oil has been shown to decrease platelet aggregation for up to 6 hours, and two cases of excessive postsurgical bleeding have been reported in which patients had consumed garlic-laden meals the night before.

"Tell patients not to consume meals heavy in garlic within a few days of surgery," Dr. Fugh-Berman advised.

Ginkgolide B, a component of Ginkgo biloba, is a known platelet aggregation factor antagonist, and the herb, alone or with analgesics, has been associated with intracranial bleeding events.

Clinical studies, however, found that one standardized ginkgo preparation (EGb761) had no effect on hemostasis, coagulation, or fibrinolysis in healthy men, and another (Bio-Biloba) did not change INR in patients who had been stabilized on warfarin.

Fingerprick sites should be inspected regularly for skin necrosis in diabetic patients who have peripheral vascular disease, said Olivier Giannini, M.D., and Michael Mayr, M.D., of the University Hospitals of Basel (Switzerland).

The physicians reported the case of a 59-year-old diabetic man who was hospitalized for amputation of the lower right leg because of severe arterial occlusive disease. While recovering from the surgery, the patient took fingerprick blood samples to monitor his blood sugar. Within a few days, multiple small, well-circumscribed areas of skin necrosis around the fingerprick sites quickly progressed to full necrosis of the distal phalange, despite treatment with iloprost infusions, the investigators said (Lancet 2004;364:980).

Regular inspection of these sites may prevent such deterioration. If it does develop, capillary blood samples could be drawn from the thenar eminence, rather than the fingertips, they added.

Fingerprick sites should be inspected regularly for skin necrosis in diabetic patients who have peripheral vascular disease, said Olivier Giannini, M.D., and Michael Mayr, M.D., of the University Hospitals of Basel (Switzerland).

The physicians reported the case of a 59-year-old diabetic man who was hospitalized for amputation of the lower right leg because of severe arterial occlusive disease. While recovering from the surgery, the patient took fingerprick blood samples to monitor his blood sugar. Within a few days, multiple small, well-circumscribed areas of skin necrosis around the fingerprick sites quickly progressed to full necrosis of the distal phalange, despite treatment with iloprost infusions, the investigators said (Lancet 2004;364:980).

Regular inspection of these sites may prevent such deterioration. If it does develop, capillary blood samples could be drawn from the thenar eminence, rather than the fingertips, they added.

Fingerprick sites should be inspected regularly for skin necrosis in diabetic patients who have peripheral vascular disease, said Olivier Giannini, M.D., and Michael Mayr, M.D., of the University Hospitals of Basel (Switzerland).

The physicians reported the case of a 59-year-old diabetic man who was hospitalized for amputation of the lower right leg because of severe arterial occlusive disease. While recovering from the surgery, the patient took fingerprick blood samples to monitor his blood sugar. Within a few days, multiple small, well-circumscribed areas of skin necrosis around the fingerprick sites quickly progressed to full necrosis of the distal phalange, despite treatment with iloprost infusions, the investigators said (Lancet 2004;364:980).

Regular inspection of these sites may prevent such deterioration. If it does develop, capillary blood samples could be drawn from the thenar eminence, rather than the fingertips, they added.

One of the largest studies to examine the long-term health effects of cosmetic breast implants has found little evidence to advance the debate about whether implants are linked to connective tissue disease.

The retrospective cohort study by the National Cancer Institute was primarily designed to assess cancer occurrence and overall mortality patterns among implant recipients.

Several published reports on that cohort showed no association between implants and subsequent risk of breast cancer or most other cancers.

However, a two- to threefold increase in the rates of respiratory and brain cancers and a four- to fivefold increase in suicide rates were found among women with implants, compared with control patients. (For references, see the NCI's fact sheet at www.nci.nih.gov/newscenter/siliconefactsheet

Findings linking implants with connective tissue disorders (CTDs), however, are far less conclusive.

"Given the diagnostic complexities of these diseases, excess risks, if they exist, may be beyond detection even in a study of this size," wrote principal author Louise A. Brinton, Ph.D., of the National Cancer Institute, Rockville, Md. (Am. J. Epidemiol. 2004;160:619–27).

"The design of the study did not enable us to derive any firm conclusions, but we were able to rule out very large increased risks," she told this newspaper.

Roughly half the 7,234 breast augmentation recipients (49.7%) had received silicone implants, while about 34% received double lumen implants, about 12% received saline implants, and about 4% received other or unspecified implant types.

The 2,138 control patients were of similar age and had had other types of plastic surgery not involving silicone, such as abdominoplasty or liposuction; blepharoplasty or rhytidectomy; and rhinoplasty, otoplasty, mentoplasty, or genioplasty.

Surgeries in both groups had taken place between 1983 and 1984.

Study subjects were mailed questionnaires about demographic information, subsequent plastic surgeries, current health status, and lifestyle factors that could affect their health. They were asked whether they had a physician's diagnosis of a CTD—including rheumatoid arthritis (RA), arthritis of another type, scleroderma, systemic lupus erythematosus (SLE), Sjögren's syndrome, Raynaud's phenomenon, fibrositis/fibromyalgia, vasculitis, chronic fatigue syndrome, or multiple sclerosis.

The study found that 4.8% of implant patients reported a diagnosis of one of four major CTDs (RA, scleroderma, SLE, or Sjögren's syndrome), compared with 2.9% of controls, representing a relative risk of 2.0. This risk elevation was statistically significant, but after controlling for various confounding factors, the investigators concluded that the risks were not significant.

One limitation is that risk estimates were based on patient reports of their CTD diagnosis, rather than on a physician's report.

Two rheumatologists blinded to the implant status of the patients reviewed medical records to determine if each participant's history, physical examination, and radiographic and laboratory findings supported the CTD diagnosis. They then rated each CTD diagnosis as "likely," "unlikely," or "unable to assess."

Although the reviewers were able to access the medical records of only 30%–40% of study participants, they concluded that "most diagnoses were insufficiently supported, either because the records were incomplete or because clinical criteria were not met."

When relative risks were recalculated using only the "likely" diagnoses, the revised estimated relative risk for RA, scleroderma, and Sjögren's syndrome combined was still 2.0, and for RA alone it was 1.3, both of which were not statistically significant, given the smaller sample size.

"We were relying on self-reports of these conditions that even rheumatologists have a hard time diagnosing, and …many of these conditions are extremely rare. So we ended up with very small numbers, and it was really not possible to either confirm or refute whether there is an association," said Dr. Brinton.

The investigators note that their observations of selection and reporting biases underscore the complexities of evaluating the relationship of implants and CTDs.

"Thus, future studies designed to resolve the question of a possible association between breast implants and rheumatoid arthritis or other CTDs would need to be very large and include well-validated and documented cases and unbiased assessments of exposure," they said.

"There were a lot of methodological problems with this study, and the authors did a good job of outlining them," commented Diana Zuckerman, Ph.D., president of the National Center for Policy Research for Women & Families, a Washington-based nonprofit group. "This is the latest of several red flags warning women that the risks of breast implants have not been adequately studied," she said in an interview.

One of the largest studies to examine the long-term health effects of cosmetic breast implants has found little evidence to advance the debate about whether implants are linked to connective tissue disease.

The retrospective cohort study by the National Cancer Institute was primarily designed to assess cancer occurrence and overall mortality patterns among implant recipients.

Several published reports on that cohort showed no association between implants and subsequent risk of breast cancer or most other cancers.

However, a two- to threefold increase in the rates of respiratory and brain cancers and a four- to fivefold increase in suicide rates were found among women with implants, compared with control patients. (For references, see the NCI's fact sheet at www.nci.nih.gov/newscenter/siliconefactsheet

Findings linking implants with connective tissue disorders (CTDs), however, are far less conclusive.

"Given the diagnostic complexities of these diseases, excess risks, if they exist, may be beyond detection even in a study of this size," wrote principal author Louise A. Brinton, Ph.D., of the National Cancer Institute, Rockville, Md. (Am. J. Epidemiol. 2004;160:619–27).

"The design of the study did not enable us to derive any firm conclusions, but we were able to rule out very large increased risks," she told this newspaper.

Roughly half the 7,234 breast augmentation recipients (49.7%) had received silicone implants, while about 34% received double lumen implants, about 12% received saline implants, and about 4% received other or unspecified implant types.

The 2,138 control patients were of similar age and had had other types of plastic surgery not involving silicone, such as abdominoplasty or liposuction; blepharoplasty or rhytidectomy; and rhinoplasty, otoplasty, mentoplasty, or genioplasty.

Surgeries in both groups had taken place between 1983 and 1984.

Study subjects were mailed questionnaires about demographic information, subsequent plastic surgeries, current health status, and lifestyle factors that could affect their health. They were asked whether they had a physician's diagnosis of a CTD—including rheumatoid arthritis (RA), arthritis of another type, scleroderma, systemic lupus erythematosus (SLE), Sjögren's syndrome, Raynaud's phenomenon, fibrositis/fibromyalgia, vasculitis, chronic fatigue syndrome, or multiple sclerosis.

The study found that 4.8% of implant patients reported a diagnosis of one of four major CTDs (RA, scleroderma, SLE, or Sjögren's syndrome), compared with 2.9% of controls, representing a relative risk of 2.0. This risk elevation was statistically significant, but after controlling for various confounding factors, the investigators concluded that the risks were not significant.

One limitation is that risk estimates were based on patient reports of their CTD diagnosis, rather than on a physician's report.

Two rheumatologists blinded to the implant status of the patients reviewed medical records to determine if each participant's history, physical examination, and radiographic and laboratory findings supported the CTD diagnosis. They then rated each CTD diagnosis as "likely," "unlikely," or "unable to assess."

Although the reviewers were able to access the medical records of only 30%–40% of study participants, they concluded that "most diagnoses were insufficiently supported, either because the records were incomplete or because clinical criteria were not met."

When relative risks were recalculated using only the "likely" diagnoses, the revised estimated relative risk for RA, scleroderma, and Sjögren's syndrome combined was still 2.0, and for RA alone it was 1.3, both of which were not statistically significant, given the smaller sample size.

"We were relying on self-reports of these conditions that even rheumatologists have a hard time diagnosing, and …many of these conditions are extremely rare. So we ended up with very small numbers, and it was really not possible to either confirm or refute whether there is an association," said Dr. Brinton.

The investigators note that their observations of selection and reporting biases underscore the complexities of evaluating the relationship of implants and CTDs.

"Thus, future studies designed to resolve the question of a possible association between breast implants and rheumatoid arthritis or other CTDs would need to be very large and include well-validated and documented cases and unbiased assessments of exposure," they said.

"There were a lot of methodological problems with this study, and the authors did a good job of outlining them," commented Diana Zuckerman, Ph.D., president of the National Center for Policy Research for Women & Families, a Washington-based nonprofit group. "This is the latest of several red flags warning women that the risks of breast implants have not been adequately studied," she said in an interview.

One of the largest studies to examine the long-term health effects of cosmetic breast implants has found little evidence to advance the debate about whether implants are linked to connective tissue disease.

The retrospective cohort study by the National Cancer Institute was primarily designed to assess cancer occurrence and overall mortality patterns among implant recipients.

Several published reports on that cohort showed no association between implants and subsequent risk of breast cancer or most other cancers.

However, a two- to threefold increase in the rates of respiratory and brain cancers and a four- to fivefold increase in suicide rates were found among women with implants, compared with control patients. (For references, see the NCI's fact sheet at www.nci.nih.gov/newscenter/siliconefactsheet

Findings linking implants with connective tissue disorders (CTDs), however, are far less conclusive.

"Given the diagnostic complexities of these diseases, excess risks, if they exist, may be beyond detection even in a study of this size," wrote principal author Louise A. Brinton, Ph.D., of the National Cancer Institute, Rockville, Md. (Am. J. Epidemiol. 2004;160:619–27).

"The design of the study did not enable us to derive any firm conclusions, but we were able to rule out very large increased risks," she told this newspaper.

Roughly half the 7,234 breast augmentation recipients (49.7%) had received silicone implants, while about 34% received double lumen implants, about 12% received saline implants, and about 4% received other or unspecified implant types.

The 2,138 control patients were of similar age and had had other types of plastic surgery not involving silicone, such as abdominoplasty or liposuction; blepharoplasty or rhytidectomy; and rhinoplasty, otoplasty, mentoplasty, or genioplasty.

Surgeries in both groups had taken place between 1983 and 1984.

Study subjects were mailed questionnaires about demographic information, subsequent plastic surgeries, current health status, and lifestyle factors that could affect their health. They were asked whether they had a physician's diagnosis of a CTD—including rheumatoid arthritis (RA), arthritis of another type, scleroderma, systemic lupus erythematosus (SLE), Sjögren's syndrome, Raynaud's phenomenon, fibrositis/fibromyalgia, vasculitis, chronic fatigue syndrome, or multiple sclerosis.

The study found that 4.8% of implant patients reported a diagnosis of one of four major CTDs (RA, scleroderma, SLE, or Sjögren's syndrome), compared with 2.9% of controls, representing a relative risk of 2.0. This risk elevation was statistically significant, but after controlling for various confounding factors, the investigators concluded that the risks were not significant.

One limitation is that risk estimates were based on patient reports of their CTD diagnosis, rather than on a physician's report.

Two rheumatologists blinded to the implant status of the patients reviewed medical records to determine if each participant's history, physical examination, and radiographic and laboratory findings supported the CTD diagnosis. They then rated each CTD diagnosis as "likely," "unlikely," or "unable to assess."

Although the reviewers were able to access the medical records of only 30%–40% of study participants, they concluded that "most diagnoses were insufficiently supported, either because the records were incomplete or because clinical criteria were not met."

When relative risks were recalculated using only the "likely" diagnoses, the revised estimated relative risk for RA, scleroderma, and Sjögren's syndrome combined was still 2.0, and for RA alone it was 1.3, both of which were not statistically significant, given the smaller sample size.

"We were relying on self-reports of these conditions that even rheumatologists have a hard time diagnosing, and …many of these conditions are extremely rare. So we ended up with very small numbers, and it was really not possible to either confirm or refute whether there is an association," said Dr. Brinton.

The investigators note that their observations of selection and reporting biases underscore the complexities of evaluating the relationship of implants and CTDs.

"Thus, future studies designed to resolve the question of a possible association between breast implants and rheumatoid arthritis or other CTDs would need to be very large and include well-validated and documented cases and unbiased assessments of exposure," they said.

"There were a lot of methodological problems with this study, and the authors did a good job of outlining them," commented Diana Zuckerman, Ph.D., president of the National Center for Policy Research for Women & Families, a Washington-based nonprofit group. "This is the latest of several red flags warning women that the risks of breast implants have not been adequately studied," she said in an interview.

WASHINGTON — Surgical resection is an effective treatment for primary squamous cell carcinoma arising on the tongue, K. Matsuura, M.D., reported at the Sixth International Conference on Head and Neck Cancer.

Of 313 patients who were evaluated for malignant tongue tumors from July 1992 through June 2000 at the National Cancer Center Hospital East in Kashiwa, Japan, 274 had squamous cell carcinoma (SCC) of the tongue. These 274 patients, with a median age of 59 years, had a median follow-up of 65 months. At presentation, 35% of the patients had stage III or IV SCC, while 28% of patients overall had a nodal metastasis at the first treatment, said Dr. Matsuura of the division of head and neck surgery at the hospital.

Surgical resection of the primary tumor was the only treatment modality in 95% of cases; the remaining 5% received either chemotherapy alone or chemotherapy followed by surgery.

Primary lymph node-negative carcinoma of the tongue was resected to a safety margin of 10 mm without prophylactic dissection of the neck. But conservative neck dissection was indicated in lymph node-negative patients who underwent surgery with the pull-through method and/or reconstruction, he said, as well as in node-positive patients.

Tumors recurred in 37% of stage I, 44% of stage II, 57% of stage III, and 58% of stage IV cases. A total of 59% of recurrences took place within 6 months of treatment. By 12 months, 77% of tumor recurrences had happened; and by 24 months, 90% of the recurrences had developed. Recurrences were twice as likely in lymph nodes of the neck than at the primary tumor site, Dr. Matsuura pointed out at the meeting, which was sponsored by the American Head and Neck Society.

WASHINGTON — Surgical resection is an effective treatment for primary squamous cell carcinoma arising on the tongue, K. Matsuura, M.D., reported at the Sixth International Conference on Head and Neck Cancer.

Of 313 patients who were evaluated for malignant tongue tumors from July 1992 through June 2000 at the National Cancer Center Hospital East in Kashiwa, Japan, 274 had squamous cell carcinoma (SCC) of the tongue. These 274 patients, with a median age of 59 years, had a median follow-up of 65 months. At presentation, 35% of the patients had stage III or IV SCC, while 28% of patients overall had a nodal metastasis at the first treatment, said Dr. Matsuura of the division of head and neck surgery at the hospital.

Surgical resection of the primary tumor was the only treatment modality in 95% of cases; the remaining 5% received either chemotherapy alone or chemotherapy followed by surgery.

Primary lymph node-negative carcinoma of the tongue was resected to a safety margin of 10 mm without prophylactic dissection of the neck. But conservative neck dissection was indicated in lymph node-negative patients who underwent surgery with the pull-through method and/or reconstruction, he said, as well as in node-positive patients.

Tumors recurred in 37% of stage I, 44% of stage II, 57% of stage III, and 58% of stage IV cases. A total of 59% of recurrences took place within 6 months of treatment. By 12 months, 77% of tumor recurrences had happened; and by 24 months, 90% of the recurrences had developed. Recurrences were twice as likely in lymph nodes of the neck than at the primary tumor site, Dr. Matsuura pointed out at the meeting, which was sponsored by the American Head and Neck Society.

WASHINGTON — Surgical resection is an effective treatment for primary squamous cell carcinoma arising on the tongue, K. Matsuura, M.D., reported at the Sixth International Conference on Head and Neck Cancer.

Of 313 patients who were evaluated for malignant tongue tumors from July 1992 through June 2000 at the National Cancer Center Hospital East in Kashiwa, Japan, 274 had squamous cell carcinoma (SCC) of the tongue. These 274 patients, with a median age of 59 years, had a median follow-up of 65 months. At presentation, 35% of the patients had stage III or IV SCC, while 28% of patients overall had a nodal metastasis at the first treatment, said Dr. Matsuura of the division of head and neck surgery at the hospital.

Surgical resection of the primary tumor was the only treatment modality in 95% of cases; the remaining 5% received either chemotherapy alone or chemotherapy followed by surgery.

Primary lymph node-negative carcinoma of the tongue was resected to a safety margin of 10 mm without prophylactic dissection of the neck. But conservative neck dissection was indicated in lymph node-negative patients who underwent surgery with the pull-through method and/or reconstruction, he said, as well as in node-positive patients.

Tumors recurred in 37% of stage I, 44% of stage II, 57% of stage III, and 58% of stage IV cases. A total of 59% of recurrences took place within 6 months of treatment. By 12 months, 77% of tumor recurrences had happened; and by 24 months, 90% of the recurrences had developed. Recurrences were twice as likely in lymph nodes of the neck than at the primary tumor site, Dr. Matsuura pointed out at the meeting, which was sponsored by the American Head and Neck Society.

PHOENIX, ARIZ. — Younger patients with even a thin melanoma may deserve a sentinel node biopsy because of a much higher likelihood of lymph node metastasis, regardless of any other histologic features, said Vernon K. Sondak, M.D., at the Second International Melanoma Research Congress.

Recent data suggest that a 35-year-old with a melanoma that is just 1 mm thick could have as high as a 20% chance of a positive node, said Dr. Sondak, a surgical oncologist at the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla.

In a talk about sentinel node biopsy, Dr. Sondak defended the procedure as a useful clinical tool—despite disappointment that it does not make a bigger difference in survival—and said that its use probably needs to be expanded.

Currently, most major centers that treat melanoma use a cutoff of about 1–1.5 mm when deciding whether to have a patient undergo sentinel node biopsy. Yet about three-fourths of melanomas diagnosed in this country are less than 1 mm in thickness and at the same time, the absolute number of deaths from thin melanomas is increasing progressively, and the procedure might be a way to make a difference, Dr. Sondak said.

But costs are an issue. It has been estimated that to perform a sentinel node biopsy on every case of melanoma would cost almost $1 million for every patient with a positive node detected, he said.

Using Clark's level of invasion and/or the presence of ulceration as criteria to further winnow the pool of possible candidates for the procedure does not appear to work. Both ulceration and Clark's level predict outcome, but they do not predict positive nodes, Dr. Sondak said.

In previous investigations into predictive markers of risk, factors identified by some, but not all of the studies include younger age, a high mitotic rate, and the Breslow depth of invasion.

The first such study, from the John Wayne Cancer Institute in Santa Monica, Calif., reviewed 512 patients with melanomas less than 1.5 mm in thickness. The investigators reported that positive sentinel nodes were found in 7% of patients with a 1- to 1.5-mm melanoma, in 4% of patients with a 0.75- to 1-mm melanoma, and in 2% of patients with a melanoma thinner than 0.75 mm.

They also found that younger patients were more likely to have a positive node than were older patients.

Based on the results of that study, Dr. Sondak and his colleagues reviewed the records of 419 patients from a registry at the University of Michigan. Their melanomas had a range of thicknesses, and there were similar percentages with positive nodes among the thin melanomas.

This study also found the same connection with age. The percentage of patients older than 60 years who had a positive sentinel node was 12%, and the percentage rose to 19% for those aged 35–60 years and to 26% for those younger than 35 years (Ann. Surg. Oncol. 2004;11:247–58).

The investigators also found that a high mitotic rate—defined as at least 3 mitoses per square millimeter of the lesion—was associated with positive nodes, and was as predictive as the Breslow depth.

Another unpublished study appears to confirm the finding regarding mitotic rate. The study, reported by researchers at the University of Pennsylvania, specifically looked at patients with melanomas that were thin but had already entered a vertical growth phase. It included 167 consecutive patients who all had melanomas of 1 mm or less in thickness.

In those patients, one or more positive nodes were found in 11% of the patients with a melanoma that had a high mitotic rate, but none was found in patients with a low mitotic rate, Dr. Sondak said. The study also found no cases of a positive node in patients older than 60 years.

Although the data about age and mitotic rate are preliminary, Dr. Sondak said he already uses the information in his discussions with patients.

PHOENIX, ARIZ. — Younger patients with even a thin melanoma may deserve a sentinel node biopsy because of a much higher likelihood of lymph node metastasis, regardless of any other histologic features, said Vernon K. Sondak, M.D., at the Second International Melanoma Research Congress.

Recent data suggest that a 35-year-old with a melanoma that is just 1 mm thick could have as high as a 20% chance of a positive node, said Dr. Sondak, a surgical oncologist at the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla.

In a talk about sentinel node biopsy, Dr. Sondak defended the procedure as a useful clinical tool—despite disappointment that it does not make a bigger difference in survival—and said that its use probably needs to be expanded.

Currently, most major centers that treat melanoma use a cutoff of about 1–1.5 mm when deciding whether to have a patient undergo sentinel node biopsy. Yet about three-fourths of melanomas diagnosed in this country are less than 1 mm in thickness and at the same time, the absolute number of deaths from thin melanomas is increasing progressively, and the procedure might be a way to make a difference, Dr. Sondak said.

But costs are an issue. It has been estimated that to perform a sentinel node biopsy on every case of melanoma would cost almost $1 million for every patient with a positive node detected, he said.

Using Clark's level of invasion and/or the presence of ulceration as criteria to further winnow the pool of possible candidates for the procedure does not appear to work. Both ulceration and Clark's level predict outcome, but they do not predict positive nodes, Dr. Sondak said.

In previous investigations into predictive markers of risk, factors identified by some, but not all of the studies include younger age, a high mitotic rate, and the Breslow depth of invasion.

The first such study, from the John Wayne Cancer Institute in Santa Monica, Calif., reviewed 512 patients with melanomas less than 1.5 mm in thickness. The investigators reported that positive sentinel nodes were found in 7% of patients with a 1- to 1.5-mm melanoma, in 4% of patients with a 0.75- to 1-mm melanoma, and in 2% of patients with a melanoma thinner than 0.75 mm.

They also found that younger patients were more likely to have a positive node than were older patients.

Based on the results of that study, Dr. Sondak and his colleagues reviewed the records of 419 patients from a registry at the University of Michigan. Their melanomas had a range of thicknesses, and there were similar percentages with positive nodes among the thin melanomas.

This study also found the same connection with age. The percentage of patients older than 60 years who had a positive sentinel node was 12%, and the percentage rose to 19% for those aged 35–60 years and to 26% for those younger than 35 years (Ann. Surg. Oncol. 2004;11:247–58).

The investigators also found that a high mitotic rate—defined as at least 3 mitoses per square millimeter of the lesion—was associated with positive nodes, and was as predictive as the Breslow depth.

Another unpublished study appears to confirm the finding regarding mitotic rate. The study, reported by researchers at the University of Pennsylvania, specifically looked at patients with melanomas that were thin but had already entered a vertical growth phase. It included 167 consecutive patients who all had melanomas of 1 mm or less in thickness.

In those patients, one or more positive nodes were found in 11% of the patients with a melanoma that had a high mitotic rate, but none was found in patients with a low mitotic rate, Dr. Sondak said. The study also found no cases of a positive node in patients older than 60 years.

Although the data about age and mitotic rate are preliminary, Dr. Sondak said he already uses the information in his discussions with patients.

PHOENIX, ARIZ. — Younger patients with even a thin melanoma may deserve a sentinel node biopsy because of a much higher likelihood of lymph node metastasis, regardless of any other histologic features, said Vernon K. Sondak, M.D., at the Second International Melanoma Research Congress.

Recent data suggest that a 35-year-old with a melanoma that is just 1 mm thick could have as high as a 20% chance of a positive node, said Dr. Sondak, a surgical oncologist at the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla.

In a talk about sentinel node biopsy, Dr. Sondak defended the procedure as a useful clinical tool—despite disappointment that it does not make a bigger difference in survival—and said that its use probably needs to be expanded.

Currently, most major centers that treat melanoma use a cutoff of about 1–1.5 mm when deciding whether to have a patient undergo sentinel node biopsy. Yet about three-fourths of melanomas diagnosed in this country are less than 1 mm in thickness and at the same time, the absolute number of deaths from thin melanomas is increasing progressively, and the procedure might be a way to make a difference, Dr. Sondak said.

But costs are an issue. It has been estimated that to perform a sentinel node biopsy on every case of melanoma would cost almost $1 million for every patient with a positive node detected, he said.

Using Clark's level of invasion and/or the presence of ulceration as criteria to further winnow the pool of possible candidates for the procedure does not appear to work. Both ulceration and Clark's level predict outcome, but they do not predict positive nodes, Dr. Sondak said.

In previous investigations into predictive markers of risk, factors identified by some, but not all of the studies include younger age, a high mitotic rate, and the Breslow depth of invasion.

The first such study, from the John Wayne Cancer Institute in Santa Monica, Calif., reviewed 512 patients with melanomas less than 1.5 mm in thickness. The investigators reported that positive sentinel nodes were found in 7% of patients with a 1- to 1.5-mm melanoma, in 4% of patients with a 0.75- to 1-mm melanoma, and in 2% of patients with a melanoma thinner than 0.75 mm.

They also found that younger patients were more likely to have a positive node than were older patients.

Based on the results of that study, Dr. Sondak and his colleagues reviewed the records of 419 patients from a registry at the University of Michigan. Their melanomas had a range of thicknesses, and there were similar percentages with positive nodes among the thin melanomas.

This study also found the same connection with age. The percentage of patients older than 60 years who had a positive sentinel node was 12%, and the percentage rose to 19% for those aged 35–60 years and to 26% for those younger than 35 years (Ann. Surg. Oncol. 2004;11:247–58).

The investigators also found that a high mitotic rate—defined as at least 3 mitoses per square millimeter of the lesion—was associated with positive nodes, and was as predictive as the Breslow depth.

Another unpublished study appears to confirm the finding regarding mitotic rate. The study, reported by researchers at the University of Pennsylvania, specifically looked at patients with melanomas that were thin but had already entered a vertical growth phase. It included 167 consecutive patients who all had melanomas of 1 mm or less in thickness.

In those patients, one or more positive nodes were found in 11% of the patients with a melanoma that had a high mitotic rate, but none was found in patients with a low mitotic rate, Dr. Sondak said. The study also found no cases of a positive node in patients older than 60 years.

Although the data about age and mitotic rate are preliminary, Dr. Sondak said he already uses the information in his discussions with patients.

LAS VEGAS — When it comes to charting the success of various cosmetic procedures, dermatologists rely too much on standard clinical photos, ill-defined measurement scales, and other subjective measures, Albert M. Kligman, M.D., declared at the 13th International Symposium on Cosmetic Laser Surgery.

Such measurements "often involve vague ratio scales of 1, 2, 3, 4, or scales of various ratios that show much pigment has change or that erythema has gone down by 2 points," said Dr. Kligman, emeritus professor of dermatology at the University of Pennsylvania, Philadelphia.

"All of this is highly suggestive and highly unreliable, and the results are inconsistent. We need more quantitative estimates of what we have done. The real changes are under the surface" of the skin.

He also called for a consistent "physical definition" of skin texture. "Every woman knows what texture is when they're looking at a piece of silk or cloth, but so far, we have no real assessments of what texture is in physical terms," he reported.

Dr. Kligman listed the following technologies as more appropriate ways to measure clinical changes in the skin: UVA photography, ultrasound, polarized light, cross-polarized microscopy, blue light fluorescence, porphyrin fluorescence, glyphic lines by cyanoacrylate video imaging, fringe projection, Luna stain, Cutometer, using Sebutape to measure sebum production, optical coherence tomography, and laser Doppler imaging.

LAS VEGAS — When it comes to charting the success of various cosmetic procedures, dermatologists rely too much on standard clinical photos, ill-defined measurement scales, and other subjective measures, Albert M. Kligman, M.D., declared at the 13th International Symposium on Cosmetic Laser Surgery.

Such measurements "often involve vague ratio scales of 1, 2, 3, 4, or scales of various ratios that show much pigment has change or that erythema has gone down by 2 points," said Dr. Kligman, emeritus professor of dermatology at the University of Pennsylvania, Philadelphia.

"All of this is highly suggestive and highly unreliable, and the results are inconsistent. We need more quantitative estimates of what we have done. The real changes are under the surface" of the skin.

He also called for a consistent "physical definition" of skin texture. "Every woman knows what texture is when they're looking at a piece of silk or cloth, but so far, we have no real assessments of what texture is in physical terms," he reported.

Dr. Kligman listed the following technologies as more appropriate ways to measure clinical changes in the skin: UVA photography, ultrasound, polarized light, cross-polarized microscopy, blue light fluorescence, porphyrin fluorescence, glyphic lines by cyanoacrylate video imaging, fringe projection, Luna stain, Cutometer, using Sebutape to measure sebum production, optical coherence tomography, and laser Doppler imaging.

LAS VEGAS — When it comes to charting the success of various cosmetic procedures, dermatologists rely too much on standard clinical photos, ill-defined measurement scales, and other subjective measures, Albert M. Kligman, M.D., declared at the 13th International Symposium on Cosmetic Laser Surgery.

Such measurements "often involve vague ratio scales of 1, 2, 3, 4, or scales of various ratios that show much pigment has change or that erythema has gone down by 2 points," said Dr. Kligman, emeritus professor of dermatology at the University of Pennsylvania, Philadelphia.

"All of this is highly suggestive and highly unreliable, and the results are inconsistent. We need more quantitative estimates of what we have done. The real changes are under the surface" of the skin.

He also called for a consistent "physical definition" of skin texture. "Every woman knows what texture is when they're looking at a piece of silk or cloth, but so far, we have no real assessments of what texture is in physical terms," he reported.

Dr. Kligman listed the following technologies as more appropriate ways to measure clinical changes in the skin: UVA photography, ultrasound, polarized light, cross-polarized microscopy, blue light fluorescence, porphyrin fluorescence, glyphic lines by cyanoacrylate video imaging, fringe projection, Luna stain, Cutometer, using Sebutape to measure sebum production, optical coherence tomography, and laser Doppler imaging.

MONT-TREMBLANT, QUE. — A new treatment algorithm for the ThermaCool radiofrequency energy device is producing improved cosmetic results with a reduction in pain and adverse events, Michael Kaminer, M.D., said at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"A year ago we were doing most treatments with one single pass over the face and trying to use as high an energy setting on the machine as our patients could tolerate. The concept was, since we're only going to go over the face once, we should give it as much heat as we could. But it hurt the patients a lot, and it wasn't working that well, so out of necessity we had to rethink this strategy."

Dr. Kaminer, a dermatologist with SkinCare Physicians of Chestnut Hill, Mass., said that he and some of his colleagues discovered the value of performing multiple passes with lower fluences when using ThermaCool (Thermage Inc.). He explained that in the past, roughly 70% of patients had marginal and variable results or did not respond to treatment at all, but the numbers have reversed with the new treatment algorithm; 70% now show good results.

"I call it the Thermage treatment triad—which includes controlling the pain, increasing the number of passes, and lowering the setting on the machine," he said.

With adequate pain control, including a topical anesthetic (LMX 5% lidocaine cream), oral lorazepam (Ativan) 1 mg about an hour beforehand, and then an injection of meperidine (Demerol) about 15 minutes prior to the procedure, Dr. Kaminer said patients can tolerate multiple passes over the face, at a lower setting.

"So we have rapidly moved from one high-energy pass to as many as six and seven passes at very low settings. With the company's new big fast tip, which is a 1.5-cm tip, where we used to use settings ranging from 64 to 65, we now use settings ranging from 62 to 64. And with the older 1-cm tip, where we used to use settings of 75 and 76, we now use settings between 72 and 74," he said.

The added advantage of this approach is that physicians can monitor the effects of the treatment during the procedure.

Dr. Kaminer disclosed that he serves on the board for Thermage.

MONT-TREMBLANT, QUE. — A new treatment algorithm for the ThermaCool radiofrequency energy device is producing improved cosmetic results with a reduction in pain and adverse events, Michael Kaminer, M.D., said at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"A year ago we were doing most treatments with one single pass over the face and trying to use as high an energy setting on the machine as our patients could tolerate. The concept was, since we're only going to go over the face once, we should give it as much heat as we could. But it hurt the patients a lot, and it wasn't working that well, so out of necessity we had to rethink this strategy."

Dr. Kaminer, a dermatologist with SkinCare Physicians of Chestnut Hill, Mass., said that he and some of his colleagues discovered the value of performing multiple passes with lower fluences when using ThermaCool (Thermage Inc.). He explained that in the past, roughly 70% of patients had marginal and variable results or did not respond to treatment at all, but the numbers have reversed with the new treatment algorithm; 70% now show good results.

"I call it the Thermage treatment triad—which includes controlling the pain, increasing the number of passes, and lowering the setting on the machine," he said.

With adequate pain control, including a topical anesthetic (LMX 5% lidocaine cream), oral lorazepam (Ativan) 1 mg about an hour beforehand, and then an injection of meperidine (Demerol) about 15 minutes prior to the procedure, Dr. Kaminer said patients can tolerate multiple passes over the face, at a lower setting.

"So we have rapidly moved from one high-energy pass to as many as six and seven passes at very low settings. With the company's new big fast tip, which is a 1.5-cm tip, where we used to use settings ranging from 64 to 65, we now use settings ranging from 62 to 64. And with the older 1-cm tip, where we used to use settings of 75 and 76, we now use settings between 72 and 74," he said.

The added advantage of this approach is that physicians can monitor the effects of the treatment during the procedure.

Dr. Kaminer disclosed that he serves on the board for Thermage.

MONT-TREMBLANT, QUE. — A new treatment algorithm for the ThermaCool radiofrequency energy device is producing improved cosmetic results with a reduction in pain and adverse events, Michael Kaminer, M.D., said at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"A year ago we were doing most treatments with one single pass over the face and trying to use as high an energy setting on the machine as our patients could tolerate. The concept was, since we're only going to go over the face once, we should give it as much heat as we could. But it hurt the patients a lot, and it wasn't working that well, so out of necessity we had to rethink this strategy."

Dr. Kaminer, a dermatologist with SkinCare Physicians of Chestnut Hill, Mass., said that he and some of his colleagues discovered the value of performing multiple passes with lower fluences when using ThermaCool (Thermage Inc.). He explained that in the past, roughly 70% of patients had marginal and variable results or did not respond to treatment at all, but the numbers have reversed with the new treatment algorithm; 70% now show good results.

"I call it the Thermage treatment triad—which includes controlling the pain, increasing the number of passes, and lowering the setting on the machine," he said.

With adequate pain control, including a topical anesthetic (LMX 5% lidocaine cream), oral lorazepam (Ativan) 1 mg about an hour beforehand, and then an injection of meperidine (Demerol) about 15 minutes prior to the procedure, Dr. Kaminer said patients can tolerate multiple passes over the face, at a lower setting.

"So we have rapidly moved from one high-energy pass to as many as six and seven passes at very low settings. With the company's new big fast tip, which is a 1.5-cm tip, where we used to use settings ranging from 64 to 65, we now use settings ranging from 62 to 64. And with the older 1-cm tip, where we used to use settings of 75 and 76, we now use settings between 72 and 74," he said.

The added advantage of this approach is that physicians can monitor the effects of the treatment during the procedure.

Dr. Kaminer disclosed that he serves on the board for Thermage.