ETAS_15 derm surgery


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ETAS_15 derm surgery

  1. 1. 15  Dermatologic and Cosmetic Surgery Kelley Redbord, MD Alysa R. Herman, MD C o n t e n t s 15.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491 15.2 Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 15.3 Antimicrobial Agents . . . . . . . . . . . . . . . . . . . . . . . . . . 496 15.4 Prophylactic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . 496 15.5 Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498 15.6 Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 15.7 Flaps and Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501 15.8 Chemical Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 15.9 Botox and Cosmetic Fillers . . . . . . . . . . . . . . . . . . . . 503 15.10 Photoaging and Cosmeceutical Rejuvenation . . 504 15.11 Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 15.12 Lasers and Radiofrequency . . . . . . . . . . . . . . . . . . . . 505 15.13 Mohs Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506 15.14 Chemotherapeutic Agents . . . . . . . . . . . . . . . . . . . . . 508 15.15 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508 15.16 On the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509 Dermatologic and Cosmetic Surgery  489
  2. 2. Committed to Your Future For practice exam questions and interactive study tools, visit the Dermatology In-Review Online Practice Exam and Study System at by
  3. 3. 15.1  ANATOMYHead and Neck MNEMONIC Superficial Musculoaponeurotic System (SMAS) SCALP • Contribute to RSTL (perpendicular to muscles) Skin • Role in facial expression Connective Tissue • Galea aponeurotica of scalp and superficial temporal fascia - thick Aponeurosis (galea) SMAS Loose CT • Rejuvenation such as facelifts relies on redistribution and plication of Periosteum SMAS • Discrete fibromuscular layer enveloping and interlinking muscles of facial expression • It extends from the temporalis muscles laterally to the platysma inferiorly, the trapezius posteriorly and the frontalis superiorly Cranial Nerve V Trigeminal nerve, 3 branches, primarily sensory, but motor supply to muscles of mastication • Ophthalmic (V1) – Supratrochlear – Infratrochlear – Supraorbital – External nasal – Lacrimal • Maxillary (V2) – Infraorbital – Zygomaticotemporal – Zygomaticofacial • Mandibular (V3) – Emerges from foramen ovale – Mental – Auriculotemporal Damage = Frey’s – Buccal Danger Zones During Surgery 1.) Superior orbital rim in the mid-pupillary line; injury to the supraorbital and supratrochlear branches of V1; lies anterior to the SMAS; resulting in numbness of the forehead, upper eyelid, nasal dorsum, and scalp 2.) ne centimeter below the inferior orbital rim in the mid-pupillary line; injury to the O  infraorbital branch of V2; lies anterior to the SMAS; resulting in numbness of the nasal sidewall, cheek, upper lip, and lower eyelid 3.)Mid-mandible below the second premolar; injury to the mental branch of V3; lies anterior to the SMAS; resulting in numbness of ipsilateral lower lip and chin Key Facts • Trigeminal trophic syndrome causes anesthesia, paresthesia, and erosion of the nasal ala (APE); results from injury or surgery that damages CN V at the gasserian ganglion, or due to encephalitis or leprosy; may clinically mimic basal cell carcinoma • Frey’s syndrome (auriculotemporal syndrome): pain, vasodilation, and hyperhidrosis of the cheeks when eating (gustatory sweating); occurs following parotid gland surgery; thought to involve haphazard nerve regeneration whereby parasympathetic fibers rather than sympathetic fibers innervate the sweat glands and blood vessels of the skin Dermatologic and Cosmetic Surgery  491
  4. 4. Cranial Nerve VII MNEMONIC Emerges from stylomastoid foramern To Zanzibar By Motor Car Facial nerve, primarily motor, sensory to conchal bowl and anterior tongue, its branches can be remembered by the mnemonic Temporal Zygomatic “To Zanzibar By Motor Car” Buccal Danger Zones During Surgery Marginal mandibular 1.) A rectangular box 2 cm in height extending from the lateral Cervical eyebrow to the anterior hairline; injury to the temporal branch of VII; lies beneath the SMAS; results in inability to raise eyebrow or completely close the eye  2.) Mid-mandible 2 cm posterior to the oral commissure; injury to the marginal mandibular branch of VII; lies beneath the SMAS; results in drooping of the corner of the mouth Table 15-1. Cranial Nerves and Muscles it Supplies Temporal Branch • Frontalis muscle (m.) • Corrugator supercilii m. • Orbicularis ocull m. (upper portion) • Auricular m. (anterior and superior; also known as the temporoparietalis m.) Posterior Auricular Branch • Occipitalis m. • Auricular m. (posterior) Zygomatic Branch • Orbicularis oculi m. (lower portion) • Nasalis m. (alar portion) • Procerus m. • Upper lip muscles - Levator anguli oris m. - Zygomaticus major m. Buccal Branch • Buccinator m. (muscle of mastication) • Depressor septi nasi m. • Nasalis m. (tranverse portion) • Upper lip muscles - Zygomaticus major and minor m. - Levator labii superioris m. - Orbicularis oris m. - Levator anguli oris m. • Lower lip muscles (orbicularis oris m.) Marginal Mandibular Branch • Lower lip muscles - Orbicularis oris m. - Depressor anguli oris m. - Depressor labil inferioris m. - Mentalis m. • Risorius m. • Platysma m. (upper portion) Cervical Branch • Platysma m.492  2011/2012 Dermatology In-Review l Committed to Your Future
  5. 5. Key Facts • The facial nerve exits the stylomastoid foramen and quickly penetrates the parotid gland and bifurcates • Provides motor innervation to the muscles of facial expression and sensory innervation to the conchal bowl and the anterior tongue • The temporal and marginal mandibular are the branches most at risk during surgery because they have very superficial rami. Injury to temporal nerve causes inability to elevate eyebrows or close eyelids • Undermine in the superficial fat above the SMAS to avoid injury to the temporal branch • The marginal mandibular nerve lies beneath the platysma muscle; it is most at risk from injury along the jawline. Injury causes corner mouth droop • The nerves innervate the facial muscles deeply at their undersurfaces, except for the buccinator, which is innervated at its superficial surface • Damage zygomatic branch causes eyelid ectropion and inability to close eyelid • Inability to smile - damage to buccal branch • Innervation of post ear - greater auricular nerve • Nerve for Conchal bowl - Vagus nerve Sensory Nerves of the Neck and Posterior Scalp Great Auricular (C2, C3), Lesser Occipital (C2), Greater Occipital (C2), Transverse Cervical (C2, C3), Supraclavicular (C3, C4) • The nerve supply to the lateral neck and posterior scalp is from the cervical plexus • C2 (lesser occipital) supplies sensory innervation to the scalp posterior to the ear and the superior portion of the posterior auricle • C2, C3 (great auricular) supplies the sensory innervation to the skin overlying the parotid, the lower anterior ear, the lower posterior ear, and the mastoid process • C2 (greater occipital) supplies sensory innervation to the occipital scalp • C2, C3 (transverse cervical) supplies sensory innervation to the anterior portion of the neck • C3, C4 (supraclavicular) supplies sensory innervation to the lower neck, clavicle, and shoulder Danger Zones During Surgery 1.) Approximately 6.5 cm below the external auditory canal along the posterior border of the sternocleidomastoid muscle; injury to the great auricular nerve (C2, C3); lies posterior to the SMAS; results in numbness of the inferior two-thirds of the ear and the adjacent  cheek and neck 2.) Erb’s point near the mid-posterior sternocleidomastoid muscle helps locate the greater auricular, lesser occipital, and spinal accessory nervesInnervation to Other Areas of the Body Spinal Accessory Nerve • Injury results in the inability to elevate the shoulder on the affected side, winged scapula, and the inability to initiate arm abduction Sural Nerve • Innervates the posteriolateral sole Posterior Tibial Nerve • Innervates the anteromedial sole Deep Peroneal Nerve • Innervates the great toe and toe cleft between 1st and 2nd toes Dermatologic and Cosmetic Surgery  493
  6. 6. Superficial Peroneal Nerve • Innervates the dorsum of the foot Arterial and Venous Supply to the Face and Scalp • ICA supplies eyelids, upper nose, nasal dorsum, forehead, scalp via ophthalmic branch • ECA supplies rest of face • The six major arteries supplying the face: 1.) Facial: Angular artery anastomoses with dorsal nasal branch of ophthalmic artery in periocular region 2.) Superficial temporal: Comes off the ECA, and palpable at the superior pole of the parotid gland; branches into the transverse facial and frontal arteries 3.) Maxillary: Comes off the ECA, and branches into the infraorbital, buccal, and inferior alveolar (mental) arteries 4.) Posterior auricular: Off the ECA 5.) Occipital: Off the ECA 6.) Ophthalmic: Comes off the ICA, and branches into the supraorbital, supratrochlear, palpebral, dorsal nasal, and lacrimal arteries; this network anastomoses with the ECA, specifically, the angular artery anastomosis with uTIP the dorsal nasal branch asters are metabolized in the plasma E • Facial veins lack valves by pseudocholinesterase and therefore • Drain into cavernous sinus should not be used in patients with pseudocholinesterase deficiency15.2  ANESTHETICS Classified into two main classes, amides and esters, based on the linkage in the intermediate chain. Three portions of the chemical structure: 1.) Aromatic; responsible for onset of activity  2.) Intermediate (middle) chain; determines class (amide vs. ester) 3.) Amine; determines duration of action • The amides are metabolized in the liver by the p 450 enzymes • Esters may cross react with STPP [sulfa, thiazides, PABA, PPD (paraphenylenediamine)] • Block neural transmission by displacing calcium ions from receptor and control sodium permeability • Prilocaine: risk of methemoglobinema (treat with methylene blue or ascorbic acid) • Methemoglobinemia also seen in patients on dapsone and with G6PD—can use cimetidine with dapsone to decrease risk. • Bupivicane: cardiotoxicity • Benzocaine: safe in liver disease patients • Avoid benzocaine in patients allergic to parapheylinediamine • Tetracaine: longest acting • Procaine: shortest active494  2011/2012 Dermatology In-Review l Committed to Your Future
  7. 7. Table 15-2. Anesthetics Name Type Metabolism Onset Duration without Duration with Pregnancy Epinephrine Epinephrine Category Cocaine Ester Plasma Rapid 45 mins n/a C - only vasoconstrictors Procaine Ester Plasma Rapid 15-30 mins 30-90 mins Shortest duration of action Tetracaine Ester Plasma Slow 120-240 mins 240-480 mins Lidocaine Amide Hepatic Rapid 30-130 mins 60-400 mins B Bupivicaine Amide Hepatic Slow 120-240 mins 240-480 mins C Most Toxic Mepivicaine Amide Hepatic Rapid 30-120 mins 60-400 mins C Prilocaine Amide Hepatic Slow 30-120 mins 60-400 mins B Etidocaine Amide Hepatic Rapid 200 mins 300 mins B Key Facts • ymptoms of lidocaine toxicity are directly related S u TIP to the serum lidocaine level; with increasing serum a upivicaine, etidocaine, and ropivacaine B have the longest duration of action + concentrations, the following signs and symptoms occur: tetracaine (BET) circumoral paresthesia; tinnitus; visual disturbances; a ocaine is the most vasoconstrictive C seizures; coma; cardiopulmonary arrest. First sign is anesthetic perioral tingling. Occurs at 1-6 mg/ml of lidocaine • Recommended maximum dosage of lidocaine in a igital tourniquets can be safely left on D for 10–15 minutes adults: 4.5 mg/kg without epinephrine; 7.0 mg/kg with epinephrine; 55 mg/kg used in tumescent anesthesia for liposuction • 1% lido with epi (1:100,00) 10,g/ml a 70 kg man can have 50ml max of lido • Recommended maximum dosage of lidocaine in children is 1.5-2 mg/kg without epi; 3-4 mg/kg with epi • Anesthetics work by blocking sodium influx in unmyelinated fibers • Upon administration of anesthesia, the loss of sensation or function occurs in the following order: temperature, pain, touch, pressure, vibration, proprioception, motor function • Peak epinephrine activity 5-10 min • Epinephrine toxicity manifested by tremor, increased heart rate, diaphoresis, palpitations, headache, increase in blood pressure, and chest pain • Peak activity 5-10 minutes • Max time to blanching 5-30 minutes • Epinephrine drug interactions: MAOI’s, tricyclic antidepressants, phenothiazines, propranolol, amphetamines, digitalis • Epinephrine contraindications: peripheral vascular disease, acute angle glaucoma, hyperthyroidism, pregnancy, severe hypertension or cardiovascular disease • Parabens in the anesthetic can cause allergic contact dermatitis • Buffered lidocaine contains one part 8.4% sodium bicarbonate solution and 10 parts lidocaine with epinephrine (less painful) • Alternative injectable anesthetic agents include promethazine, benadryl, and normal saline if allergic Dermatologic and Cosmetic Surgery  495
  8. 8. • Topical anesthesia: EMLA is an eutectic mixture of 2.5% lidocaine and 2.5% prilocaine; ELA- Max is composed of 4% lidocaine; unlike EMLA, ELA-Max does not need to be applied under occlusion to be effective, EMLA should not be used on infants younger than 3 months old because metabolites of prilocaine can form methemoglobin • Epinephrine prolongs duration of anesthesia and decreases lidocaine absorption allowing higher amounts to be used • Vasoconstriction takes 15 min to develop • Anesthetics work better in alkalin pH and increases onset of action15.3  ANTIMICROBIAL AGENTS Table 15-3. Antiseptics Group Spectrum Class Onset Sustained Comments Activity Alcohol Gram + Ethanol (ethyl Fast None No killing alcohol), of spores, Isopropanol fungi virus, (isopropyl antibacterial alcohol) only, defats skin Iodine Gram +, Gram – Halogen Fast None May sensitize patient, allergic contact dermatitis Iodophor Gram +, Gram – Halogen Moderate Up to 1 hr Absorbed (Betadine) through skin, must be dry to be effective, tissue damaging, inactivated by blood ACD Hexachlorophene Gram + Phenol Slow Yes Teratogen, (pHisoHex) neurotoxic Chlorohexadine Gram +, Gram – Biguanide Fast Yes Low skin (Hibiclens) absorption irritates eyes, ototoxic Benzalkonium Gram +, Gram – Cationic Slow None Nonirritating to Sulfactant tissues15.4  PROPHYLACTIC ANTIBIOTICS • Absolute indications: Artificial heart valve, artificial joint within 6 months, h/o endocarditis, h/o RF, MVP with holosystolic murmur • Discretionary: Surgery on mucous membranes, open wounds greater than 24 hours, immunosuppression496  2011/2012 Dermatology In-Review l Committed to Your Future
  9. 9. Table 15-4. Healting Sterilization MethodsMethod Advantages DisadvantagesSteam autoclave Most popular in office; easiest; Must use 20-30 min at 2 atm safest pressure and 121C; corrosive; may dull sharp instrumentsChemiclave Lower humidity than Special chemical needed (mixture steam; less dulling of sharp of formaldehyde, methyl ethyl instruments; instruments are ketone, acetone and alcohols) drierDry heat (oven) Inexpensive; no corrosion or High temperature, longer time (1 dulling h at 171 C; 6 n at 121C); cannot use cloth, paper or plasticGas sterilization Good for large volumes Expensive equipment; prolonged (mostly used in hospitals) times (1d for paper, 7 d polyvinyl chloride); toxic, mutagenic gasCold sterilization (alcohol, Simple, inexpensive Irritating to skin, not alwaysdetergent, quaternary effective against bacterial sporesammonium, or more effective or hep Bglutaraldehyde solutions) Table 15-5. Dressing TableDressing CharacteristicsAlginate (ca alginate, seaweed) Most absorptive, exudate turns into gelHydrocolloids (duoderm) Fibrinolytic, angiogenesis, inhibit keratinocyte migration, antibacterial increases healing rate, can cause surrounding macerationHydrofilms Occlusive, allow gas and water vaporHydrogels Good for dry painful woundsFoams Absorptive Table 15-6. Topical Antibacterial AgentsType Composed of Spectrum CommentsGentamicin Gram – ResistanceNeomycin Gram – No pseudomonas coveragePolymyxin B Gram – Pseudomonas coverageBacitracin Gram + Allergic contact dermatitisNeosporin Neomycin/Bacitracin/ Broad Allergic contact dermatitis Polymixin BPolysporin Bacitracin/Polymyxin B Broad Allergic contact dermatitisBactroban Mupirocin Gram + Allergic contact dermatitisSilvadene Silver Sulfadiazine Broad Reports of neutropenia and kernicterus; contact dermatitis in those with sulfa allergy Dermatologic and Cosmetic Surgery  497
  10. 10. 15.5  WOUND HEALING Table 15-7. Chemical Mediators of Inflammation that Play a Role in Wound Healing Chemical Mediator Action Histamine Increase vascular permeability Serotonin Stimulate fibroblast prolif Kinins Increase vascular permeability Prostaglandins Increase vascular permeability, sensitize pain receptors, increase GAGs Complement Increase vascular permeability, increase phagocytosis, mast cells, and basophil activity Wound healing involves the following phases, which occur as a continuum 1.)Vascular phase – Occurs when the integrity of the skin is compromised. Involves an initial vasoconstriction followed by vasodilatation. Net result is the formation of a hemostatic plug. Platlets first cell to appear after wounding. Platlets release fibrinogen, fibronectin, PDGF 2.)Inflammatory phase (6 hours - 10 days) – Macrophages are the most important inflammatory cell in the wound healing process. They are the only cells which can tolerate low oxygen tension. They secrete factors that stimulate angiogenesis, wound debridement and collagen synthesis. Fibronectin is vital to healing. Produced by fibroblasts and endothelial cells • 6 hours-3 days: PMNS infiltrate wound, wound debride and bacterial ingestion • Day 6: Lymphocytes infiltrate wound 3.)Proliferative phase (24 hours - day 14) – Cells from the wound margin and the adnexa begin reepithelialization within the first 24 hours of injury. Fibronectin is believed to be important in this process. Occluded wounds will heal more rapidly because occlusion facilitates keratinocyte migration. Type III collagen is the first collagen to be synthesized in a wound. Then Type I later on. Fibroblasts synthesize collagen, elastin, proteoglycans. Newly formed connective tissue (1/2 collagen and 1/2 PG/glycosaminolycans) 4.)Wound contraction and remodeling (10 day - 1 year) – Tensile strength increases with time but never reaches more than 70-80% of the original strength of the skin prior to injury. Tensile strength is approximately 5% of its original strength at one week postoperatively and reaches 70% approximately 8 weeks after wounding. Contraction of wound greates from 5-15 days mediated by myofibroblast • Factors affection wound healing: Poor surgical technique (tension), vascular disorders, tissue ischemia, infection, topical meds (steroids), hemostatic agents (alum chloride), dry wounds, malnutrition, systemic diseaseCryotherapy • LN2: -196 or -320 F • CO2: -78.5 C • Melanocyte necrosis: -5 C • Keratinocyte treatment: -25 C • Treat Cancer: -50 C • Cryonecrosis: -25 C (benign lesion)498  2011/2012 Dermatology In-Review l Committed to Your Future
  11. 11. Electrosurgery • Electrosection: Low voltage, high current, pure cutting, sine wave • Electrodessication: Superficial ablation with monoterminal device; high voltage, low amp, electrode contacts the skin • Electrofulguration: Superficial ablation with monoterminal and spark; high voltage, low amps, does not touch patient’s skin • Electrocoagulation: Biterminal, ddper, low voltage, high amps/current, damped • Electrosection: Biterminal, cuts, low voltage, high amps, undamped current • Galvanic current (DC): Direct current, electrolysis and iontophoresis and electrocauter, low voltage and low amps • Electrocautery works in wet field with no current through patient, direct heat transfer, low volt, high current, use with defibrillators Table 15-8. Electrosurgery Tissue Contact Air-Gap Tube Procedure Circuit w/ Active Voltage Amperage Histology Output Output Electrode Elecrofulguration Monoterminal No High Low Markedly Tisue damped desiccation: cell outlines preserved, but shrunken. Nuclei elongated. Some vessel thrombosis Electrodesiccation Monoterminal Yes High Low Markedly Tissue damped desiccation: cell outlines preserved, but shrunken. Nuclei elongates. Some vessel thrombosis Electrocoagulation Biterminal Yes Low High Moderately Partially Tissue damped rectified coagulation: cell outlines lost from massive protein denaturation. Homogeneous hyalinized appearance. Vessel thrombosis Electrosection with Biterminal Yes Low High Slightly Fully Cell disintegra- coagulation damped rectified tion forming approximately 0.1 mm inci- sion; adjacent cellular outline elongation and mild coagulation effect Dermatologic and Cosmetic Surgery  499
  12. 12. Table 15-8. Electrosurgery (cont.) Tissue Contact Air-Gap Tube Procedure Circuit w/ Active Voltage Amperage Histology Output Output Electrode Electrosection Biterminal Yes Low High Undamped Filtered, Cell disintegra- fully tion forming rectified approximately 0.1 mm incision; min coagulation effect Electrocautery None (hot Yes Low High n/a n/a Amorphous wire) tissue with charred foci and formation of steam spaces15.6  SUTURES Table 15-9. Nonabsorbable Sutures Suture Origin Filament Reactivity Tensile Handling Strength Silk Silk Braided or High 0-50% at 1 yr Mucosal Twisted periocular Good Ethilon Nylon Monofilament Low High Poor Dermalon Nylon Monofilament Low High Poor Prolene Polypropylene Monofilament Least Good Poor Dacron Polyester Braided Low High Good Ethibond Polyester Braided Novafil Polybutester Mono Low High • Memory - Propensity of suture to maintain its natural configuration defines stiffness • Capillarity - Capacity of suture to absorb and transfer fluid • Elasticity - Ability of the suture to regain its original form and length after deformation • Plasticity: Ability to stretch and maintain its new length. • 4-0 vicryl vs 5-0 vicryl: 4-0 vicryl has higher tensile strength Table 15-10. Absorbable Sutures Suture Origin Filament Absorption Reactivity Tensile Strength Surgical gut Animal collagen Twisted 80 d Moderate Poor Vicryl Copolymer of glycolide Braided 80 d Low Good (polyglactin 910) and L-lactide Dexon (polyglycolic Polymer of glycolic acid Braided 90 d Low Good acid)500  2011/2012 Dermatology In-Review l Committed to Your Future
  13. 13. Table 15-10. Absorbable Sutures (cont.) Suture Origin Filament Absorption Reactivity Tensile Strength PDS (polydioxanone) Polymer of paradioxanone Monofilament 180 d Low Greatest - lasts longest Maxon Glycolic acid Monofilament 180 d Low Good (glycolic acid) • Basting stitch anchors tissue to bed of wound; it ensures apposition of a full-thickness skin graft to the recipient bed • Running locked stitch is used for wounds under tension and to provide hemostasis • Suspension or tacking sutures hold skin to periosteum or perichondrium to permanently elevate an area, maintain a concavity, or alter the tension vector near a free margin • Vertical mattress suture functions to relieve tension while placing other sutures; it produces eversion and approximation of the skin edges and it eliminates dead space • Horizontal mattress suture functions mainly to remove tension from the edges of a wound; it also assists with hemostasis • Running subcuticular suture avoids the possibility of track marks since the suture does not cross the epidermis; best performed with Prolene due to the low coefficient of friction of this suture • Tip stitch is a half-buried horizontal mattress suture designed to align tissue and prevent vascular compromise • Suture needles are composed of stainless steel; the needle is divided into the point, body, and shank; the largest diameter of the needle determines the size of the suture tract • Three types of needle points: cutting, reverse cutting, round with tapered point • Most common shape is 3/8 circle • Reverse cutting used most frequently in cutaneous surgery as the outside cutting edge is directed away from the wound edge thereby minimizing the potential of the suture to tear through tissue • The number used to classify a suture specifies the diameter of that suture material that is required to produce a certain tensile strength; the smaller the cross-sectional diameter of a suture material, the higher the USP number that is assigned15.7  FLAPS AND GRAFTSGrafts • For surgical defects that cannot be closed primarily or with adjacent skin flap • A full-thickness skin graft (FTSG) is composed of the entire epidermis and dermis. Subcutaneous tissue must be removed since the fat may compromise the viability of the graft. Typically, FTSGs are taken from the head and neck. A FTSG contracts by approximately 15% once removed from the donor site • A split-thickness skin graft (STSG) contains epidermis and variable amounts of dermis. The anterolateral thigh is the site most often used for STSGs - Thin: 0.008-0.012in - Medium: 0.012-0.018in - Thick: 0.018-0.028in Dermatologic and Cosmetic Surgery  501
  14. 14. • Composite grafts are made up of more than one tissue type, typically skin and cartilage. They are commonly used to repair ear and nasal ala defects. Composite grafts have the greatest metabolic demands of all types of grafts and therefore show the highest rates of failure • All successful grafts go through the following stages: 1.) Imbibition – For the first 48 hours the graft is sustained by plasma from the recipient bed, hyperemia 1-3 days 2.) Inosculation – On day 2-3 blood vessels in the graft establish connections with the wound bed 3.) Neovascularization – Ingrowth of new vessels into the graft occurs at approximately one week 4.) Maturation – Months post-grafting, sensory innervation occurs and the graft becomes paler • Exposed bone and cartilage are poorly vascularized tissues and are therefore not successful locations for graftingSecond Intention Healing • Concave sites: temple, medial canthus, conchal bowl, alar creaseTypes of Flaps • Compared with grafts, flaps offer the advantage of better color and texture match and the ability to be used to cover exposed bone and cartilage Advancement • Incisions are made on either side of the wound and extended in a parallel fashion. Tissue is then moved in a linear fashion to cover the defect • Examples include the O to T, A to T, island pedicle and postauricular flaps, H plasty, Burow’s triangle flap, V+H plasty, double island Rotation • Tissue is recruited from a distant site, rotated and then draped to cover the wound. Maximum tension of this flap is at the pivot. These flaps have a high survival rate because of their large pedicle • O to Z is an example of a rotation flap • Mustarde flap, back cut rotation flap, spiral flap, dorsal nasal flap or glabella turndown Transposition • Transposition flaps are designed to move over normal tissue to then cover the defect • All transposition flaps create secondary defects, which must be closed • Examples include the rhombic, paramedian forehead, bilobed, Z-plasty and nasolabial flaps, note (flag or banner) flaps • Z-plasty is commonly used in scar revision. Its main uses are to lengthen a scar and to reorient a scar • Staged forehead interpolation - Axial pattern flap Interpolation Flaps • Axial flaps which cross on intact, complete bridge of skin to fill a defect • E.g., Island flap (tunnels under skin) Paramedian forehead flap502  2011/2012 Dermatology In-Review l Committed to Your Future
  15. 15. 15.8  CHEMICAL PEELSKey Concepts • The degree of clinical improvement with chemical peeling is directly proportional to the depth of injury • Patients should receive prophylactic antiviral therapy prior to medium-depth or deep resurfacing • Superficial peels cause necrosis of the epidermis, medium depth peels cause wounding to the level of the papillary dermis while deep peels result in injury to the depth of the reticular dermis • Jessner’s solution is composed of salicylic acid, lactic acid, resorcinol and ethanol • Salicylic acid, 25%-30% trichloroacetic acid (TCA) and 70% glycolic acid produce a superficial peel 35% TCA and combination peels produce medium depth ablation. TCA 50% and phenol peels produce deep ablation u TIP • All peeling agents have the potential to cause ahenol is cardiotoxic, nephrotoxic and hepatotoxic. P pigmentary alterations, milia and scarring. Patients must have cardiac monitoring during Prolonged erythema is a side effect most phenol peeling to detect cardiac arrhythmias commonly associated with phenol peeling a hemical peeling of the neck is generally avoided C • Baker-Gordon peel - 88% phenol, tap water, because of the risk of hypertrophic scarring croton oil, and Septisol. Croton oil most important for effiancy15.9  BOTOX AND COSMETIC FILLERSKey Concepts • Botulinum toxin (BTX) cleaves proteins (collectively called the SNARE complex) in the presynaptic neuron, which are required for the release of acetylcholine. Injection into the muscles of facial expression results in a chemical denervation of these striated muscles and thus a temporary paralysis • BTX-A (Botox) cleaves the SNAP-25 protein whereas BTX-B (Myobloc) cleaves the synaptobrevin protein of the SNARE complex • Botox is FDA-approved for the treatment of glabellar rhytids and hyperhidrosis, however, reports in the literature have also shown efficacy in the treatment of crow’s feet, perioral rhytids, facial flushing, and contouring of enlarged masseter and gastrocnemius muscles  • Injectable bovine collagen products include Zyderm I, Zyderm II and Zyplast. They are composed of 95% type I collagen, 5% type III collagen, saline and lidocaine • Dysport (abobotulinum toxin A) is another botulinum toxin recently approved by the FDA for glabellar rhytids • Zyderm is used for superficial rhytides, while Zyplast is better for deeper furrows • 3-5% of the population reacts to bovine collagen, therefore two skin tests are performed at six weeks then at two weeks prior to the first collagen treatment • Artecoll is a permanent filler composed of nonbiodegradable polymethylmethacrylate microspheres, which are suspended in bovine collagen. Pre-treatment skin testing is required with Artecoll as with all bovine collagen injectables • CosmoDerm and CosmoPlast are bioengineered human-derived collagen products obtained from neonatal foreskin. They are comparable in performance to their bovine collagen counterparts and offer the advantage of obviating pre-treatment hypersensitivity testing Dermatologic and Cosmetic Surgery  503
  16. 16. • Radiesse is an injectable, biodegradable filler that is composed of uTIP calcium hydroxylapatite microspheres. Calcium hydroxylapatite a n acute angioedema-type A hypersensitivity reaction has is a normal constituent of bone and thus can be seen on been reported with Restylane radiographic imaging, and can make collagen. Lasts 8-12 months, injection into the lip aboid lip area as can cause nodules • Hyaluronic acid is a natural component of human connective tissue. It binds water to create volume and plump the skin; its duration of action of approximately 6-12 months - 1 gram of HA binds 6 grams of H20; can cause blue nodules from Tyndall effect - Examples of HA are Perlane, Restylane, Juvederm, Prevelle Silk, Hylaform, and Hydrelle - HA is derived from the cok’s combs of domestic fowl or fermentation by streptococci bacteria • Restylane (hyaluronic acid) is a clear material, however, granulomatous foreign body reactions can occur and blue nodules may appear in the skin due to the Tyndall effect • Sculptra (called New-Fill outside of the U.S.) is a biocompatible, biodegradable injectable polymer of poly-L-lactic acid. It is FDA-approved for the treatment of HIV-associated lipoatrophy and facial wrinkles. Initial reports suggest that Sculptra may have a longer duration period than other currently available biodegradable fillers 3+ years. Stimulates collagen, biostimulatory agents, injected deep SQ • Silicone is a synthetic, viscous compound that is composed of long polymers of dimethylsiloxanes. Silicone is not currently FDA-approved for soft tissue augmentation. In addition to hypersensitivity reactions and product migration, granuloma formation can occur, even many years post-treatment15.10 PHOTOAGING AND COSMECEUTICAL REJUVENATION • Tretinoin is the gold standard in topical photorejuvenating agents. It normalizes epidermal atypia, increases dermal collagen deposition and increases new blood vessel formation • Topical ascorbic acid (Vitamin C) has both antioxidant and anti-inflammatory properties. It has been shown to increase the dermal production of collagen, reduce phototoxicity due to ultraviolet light and lighten hyperpigmentation • Sunscreen, PDT, chemical peeling, IPL • Glycolic and lactic acids (alpha hydroxyl acids) induce exfoliation of photodamaged skin and increase mucopolysaccharide and collagen synthesis which may improve the appearance of fine wrinkles • Beta-hydroxy acids (salicylic acid) promote exfoliation of the skin by increasing epidermal cell turnover. They do not penetrate the dermis and therefore their effects are confined to the epidermal layer • Topical alpha-lipoic acid is a potent antioxidant that protects intracellular vitamin C and vitamin E. It is absorbed to the level of the subcutaneous fat and has been shown to diminish fine lines presumably through induction of collagen synthesis • Topical human growth factors (like transforming growth factor beta) causes epidermal thickening and new collagen formation • Peptides (argireline and copper peptides, for example) which biologically play a role in wound healing and enzymatic processes are emerging as novel treatments for photoaged skin due to their ability to increase collagen and elastin production and potentially influence neurotransmitter release • Niacinamide has been shown to reduce facial erythema, improve skin texture and hyperpigmentation and may also diminish fine lines504  2011/2012 Dermatology In-Review l Committed to Your Future
  17. 17. 15.11  LIPOSUCTION u TIP • Tumescent local anesthesia is performed with 0.05% a he maximum safe dose of lidocaine T lidocaine and epinephrine in a 1:1,000,000 ratio when used in adults for tumescent • Infusion occurs in 90-120 minutes at a rate of local anesthesia is 55mg/kg approximately 150 ml/min • Peak plasma levels of lidocaine occur at 12 hours post infusion • CNS toxicity occurs when blood levels of lidocaine reach 5-6µg/ml • Paradoxical breast augmentation has been observed in patients after tumescent liposuction and is believed to be due to hormonal shifts •  bdominal perforation, respiratory failure and pulmonary embolus are complications A that are seen almost exclusively in liposuction patients that receive general anesthesia, intravenous sedation, and undergo multiple procedures at the same time rather than ambulatory tumescent local anesthesiaPDT • Topical photsensitizer (ALA or MAL) plus light source (IPL, blue light, red light, pulsed dye laser) • Treats aks, photoaging, nmsc15.12  LASERS AND RADIOFREQUENCYKey Concepts • LASER is an acronym for light amplification by stimulated emission of radiation • To exert a biologic effect, light must be absorbed by a target referred to as a chromophore; the major chromophores in the skin are melanin, hemoglobin and water • The theory of selective photothermolysis describes how a laser of a given wavelength produces selective heating in its target chromophore. Selective thermal injury occurs when the target chromophore absorbs well at the wavelength of the selected laser, and when the time of laser exposure (the pulse duration) is shorter than the cooling time (thermal relaxation time) of the chromophore • The intense pulsed light (IPL) source is not defined as a laser since it neither has coherent light nor does it emit light at a single wavelength. The IPL emits non-coherent light within the 515nm-1200nm range of the electromagnetic spectrum. Clinically, this light source has found application in the treatment of vascular lesions, pigmented lesions, hair removal and nonablative dermal remodeling. IPL is also used for photorejuvenation and when combined with aminolevulinic acid, is an effective treatment for actinic keratoses • Ocular damage is a potential risk of laser treatment. The cornea is an aqueous structure and is particularly at risk for damage when using lasers whose target chromophore is water (carbon dioxide, erbium:YAG). The retina contains pigment and thus is susceptible to injury from lasers used to treat pigmented lesions • Thermage – a nonablative radiofrequency-based system which uses volumetric heating to induce tightening of the skin and dermal remodeling. Lipoatrophy is a potential late- occurring complication of this technology • Fraxel SR Laser: Fraxel SR is a new laser whose technology is based on the science of “fractional” photothermolysis. “Fractional” wound healing results in rapid reepithelialization and collagen remodeling. Treats photoaging, pigmentary and textural changes associated with photoaging Dermatologic and Cosmetic Surgery  505
  18. 18. • LHR: Long pulsed ruby (694 nm), long pulsed alexandrite (755 nm), diode (800-810 nm), long pulsed NDYag (1064 nm) • Larger spot size = less scattering of energy and deeper penetration • Smaller spot size requires higher energy to compensate for increased scattered effect15.13  MOHS SURGERYKey Concepts • Mohs micrographic surgery utilizes fresh tissue and examines 100% of the peripheral margin of the excised lesion • Tumor that grows as a contiguous lesion is a requirement for Mohs micrographic surgery. If a tumor exhibits discontiguous growth, discrete foci may be missed and thereby lead to a false-negative pathology interpretation • Histologic sections are cut in a horizontal plane so that the total margin may be examined • Anticoagulants such as warfarin and aspirin (if u TIP medically indicated) should be continued during a ccepted indications for Mohs surgery include, A Mohs surgery. Aspirin taken for primary prevention but not limited to: recurrent tumor; aggressive can be discontinued in patients without prior histologic subtype; high-risk anatomic location (ear, lip) and tumor size (2cm). Tumors arising history of thromboembolic or cardiovascular events. in irradiated skin or in scars and tumors in immu- Nonpharmaceutical agents such as Vitamin E, nosuppressed patients are often indications for gingko biloba and ginseng have antiplatelet activity Mohs surgery and should be discontinued prior to surgery • Immunostains can be helpful during Mohs surgery. Cytokeratin 7 is a structural component of the cytoskeleton that stains poorly differentiated tumors of the epithelium and positively stains Paget cells. Melan-A is a melanosome-associated glycoprotein also known as MART-1 (melanoma antigen recognized by T-cells) that is present in 80% of melanomas. It does not reliably stain desmoplastic or spindle cell melanomas • Tensile strenth of wound 6 months after surgery is 70%; tensile strength never excees 80% of intact skin strength • 2 weeks after surgery 5-10% strength, 3 weeks 20%, 4 weeks 50% strength Table 15-11. Lasers and Dermatology Laser Type Wavelength / Color Dermatologic Application Argon (continuous wave) 488/514 nm / Blue Vascular lesions Argon-pumped tunable dye 577/585 nm Vascular lesions Copper vapor/bromide 510/578 nm / Green Pigmented lesions, vascular lesions Potassium-titanyl-phosphate 532 nm / Green Pigmented lesions, vascular lesions (KTP) Nd: YAG (frequency doubled) 532 nm Pigmented lesions, red/orange/ yellow tattoos Pulsed dye 510 nm / Yellow Pigmented lesions V Beam 585-595 nm Vascular lesions, hypertrophic/keloid scars, striae, verrucae, nonablative dermal remodeling506  2011/2012 Dermatology In-Review l Committed to Your Future
  19. 19. Table 15-11. Lasers and Dermatology (cont.) Laser Type Wavelength / Color Dermatologic Application Ruby 694 nm / Red Q-switched Pigmented lesions, blue/black/green tattoos Normal mode Hair removal Alexandrite 755 nm / Red Pigmented lesions, blue/black/green Q-switched tattoos Normal mode Hair removal, leg veins Diode 800-810 nm Hair removal, leg veins Nd: YAG 1064 nm Q-switched Pigmented lesions, blue/black tattoos Hair removal, leg veins, nonablative Normal mode dermal remodeling Nd: YAG (long-pulsed) 1320 nm Nonablative dermal remodeling Diode (long-pulsed) 1450 nm Nonablative dermal remodeling, acne Erbium: glass 1540 nm Nonablative dermal remodeling Erbium:YAG (pulsed) 2940 nm Ablative skin resurfacing, epidermal lesions Carbon dioxide (continuous wave) 10,600 nm Actinic cheilitis, verrucae, rhinophyma Carbon dioxide (pulsed) 10,600 nm Ablative skin resurfacing, epidermal/dermal lesions Intense pulsed light source 515-1200 nm Superficial pigmented lesions, vascular lesions, hair removal, nonablative dermal remodelingAdapted from Tanzi EL, Lupton JR and Alster TS. Lasers in dermatology: Four decades of progress. J AmAcad Dermatol 2003; 49: 1-31. Table 15-12. Lasers and Ocular Risk Laser Ocular Risk PDL - 595 Retina Erb:YAG - 2940 Cornea Co2 - 10600 Cornea Ruby - 694 Retina Table 15-13. Lasers and Structure Damaged nm Structure Damaged Laser 320 Cornea Excimer 320-400 Lens Excimer 400-700 Retina Choroids PDL, Nd:YAG, Ruby Dermatologic and Cosmetic Surgery  507
  20. 20. Table 15-13. Lasers and Structure Damaged (cont.) nm Structure Damaged Laser 780-1400 Lens, Vitreous, Retina Diode, Nd:YAG 1400 Cornea Co2, Erb:YAG15.14  CHEMOTHERAPEUTIC AGENTS • Imiquimod (Aldara) is a topical immunomodulator which induces the production of Th-1 cytokines and TLR7 (toll like receptor). It is FDA-approved for the treatment of genital warts, actinic keratoses and superficial basal cell carcinoma in adults with normal immune systems. Eruptive epidermoid cysts are a newly reported side effect resulting from imiquimod treatment • 5-Fluorouracil (Efudex, Carac) is a topical chemotherapy which interferes with the synthesis of DNA by inhibiting thymidylate synthetase. It is FDA-approved for the treatment of actinic keratoses and superficial basal cell carcinoma • Rapamycin (also called sirolimus) is a macrolide antibiotic and a structural analog of FK 506. It is a potent immunosuppressive agent which inhibits mTOR (a member of P13K family kinases). Despite its immunosuppressive effects, preliminary data show a decreased incidence of skin cancer in organ transplant patients treated with rapamycin and postulate that it may exert a protective effect against cutaneous malignancies • Retinoids act chemopreventively by inducing apoptosis of tumor cells and by modulating the differentiation of keratinocytes. Acitretin has been shown to inhibit the development of skin cancers in organ transplant recipients and is an effective adjuvant therapy for patients who are actively developing large numbers of cutaneous malignancies15.15  COMPLICATIONS • Wound Infection: Sutures should be removed as they can serve as a nidus for infection. The wound should be cultured, irrigated and then allowed to heal by second intention. Antibiotics should be initiated • Hematoma formation will inhibit healing of a wound, prevent graft survival and serve as a source of infection. The sutured wound should be opened and the hematoma drained • Hypergranulation Tissue: If left in place, this tissue will serve as a physical barrier to epidermal migration. It may be removed mechanically with a curette and chemically with agents such as silver nitrate and trichloroacetic acid • Chondritis: Can develop when cartilage is exposed. May be prevented by instituting prophylactic antibiotics postoperatively • Trapdoor Deformity: Believed to be caused by insufficient undermining. May be treated with intralesional corticosteroids • Chronic Edema: Seen commonly on the lower extremities. May result from blockage or interruption of lymphatic drainage • Black Graft: If the epidermal surface of a graft becomes black and necrotic, it does not necessarily signify graft failure. The epidermal portion of the graft may slough with subsequent re-epithelialization. In this situation, the best treatment is observation • Motor or Sensory Loss: Severing of nerves during surgery can result in permanent sensory or motor loss as well as the development of painful neuromas at the site of the transected nerve. Injured nerves may regenerate but return of nerve function may take many months508  2011/2012 Dermatology In-Review l Committed to Your Future
  21. 21. • Contracture: Wound contraction is maximal approximately two months after re-epithelialization has occurred. Scar relaxation occurs three months to a year postoperatively and will lessen the final degree of contracture15.16  ON THE HORIZON • Isolagen: An emerging technology whereby a patient’s own fibroblasts are extracted, reproduced and then re-introduced into the patient’s treatment site • Phosphatidylcholine: A lecithin-derived phospholipid which induces lipolysis when injected into adipose tissue. Dissolution of fat is likely due to a detergent effect produced by the phosphatidylcholine • Aptos Subdermal Suspension Thread: A minimally invasive procedure which targets the ptotic changes seen with facial aging. 2-0 and 3-0 polypropylene threads are tunneled in the dermis to lift and suspend the skin and subcutaneous tissue • Resiquimod: The next generation of topical chemotherapeutic agents in the class of immune response modifiers. Researchers believe it is a more potent and specific immunomodulator than its predecessor imiquimod (Aldara) • Hyalite: (Puragen in Europe) a non-animal-derived hyaluronic acid. Its advantages are that it contains lidocaine and that its novel double cross-linking may confer a longer duration in action • S-Caine Peel: A novel topical 1:1 eutectic mixture of 7% lidocaine and 7% tetracaine which dries upon exposure to air to an easily peeled off flexible membrane. Preliminary studies have demonstrated adequate anesthesia is achieved for both laser and minor surgical procedures • PlasmaKinetic Rejuvenation: Plasma energy is used to produce radiofrequency fluences that are capable of both vaporizing tissue and sealing blood vessels. Plasmakinetic energy can be used in both nonablative and ablative modes. Preliminary clinical trials have shown improvements in fine wrinkles, skin tone, texture and hyperpigmentation • Photo-Pneumatic Technology: New technology which uses a broadband spectrum of light in combination with pneumatic energy. The anticipated benefits are decreased fluence requirements, epidermal protection and decreased patient discomfort • Electro-optical Synergy: New nonablative technology which blends optical and electrical radiofrequency energies that are simultaneously applied to tissue. Currently studied applications for this technology include hair removal, leg vein treatment and skin rejuvenation Dermatologic and Cosmetic Surgery  509
  22. 22. V= Sensory and motor of mastication = V1 = V2 = V3 Figure 15-1. Nerves of the Face Anterior branch S uperfic. temp. a. Parietal branch S uperfic. temp. a. Occipital a. Middle temp. a. S up . temp. a Zygom.-orbit. a. Angular a. Transv. facial a. Post. auricular a. Occipital a. Superior labial a. External carotid a. Facial a. Inte r ior labial a. S ub mental a. Internal carotid a. Lingual a. S up eior thyroid a. Common carotid a. ICA - Ophthalmic - – Branches into inferior and superior labial and ? Dorsal Nasal Figure 15-2. Facial Nerves ECA - Facial-Angular Figure 15-3. Carotid Artery510  2011/2012 Dermatology In-Review l Committed to Your Future
  23. 23. Figure 15-4. Frontal ViewFrontalis mm: Loss of function results in flattening of forehead skin tension lines, droopingeyebrow. Temporal branch of facial nCorrugator supercilii mm: “Scowling”- draws eyebrows medially down; temporal br. Of facial nOrbicularis oculi: major mm of eyelid/periorbital skin. To close eyelid. intertwined w/ procerus,corrugator, frontalis; zygomatic brProcerus mm: Over nasal bone “rabbit lines” (exagerated wrinkling of nose) – zygomatic branchof facial nNasalis mm: Across nasal dorsum. Facilitates alar “flaring.” Zygomatic buccal branchesOrbicularis oris: Purses/puckers lips – buccal and marginal mandibular branchesZygomaticus major minor: Main contributors to smile, lip elevators. Buccal nLevators: Also innervated by buccal branch - elevate lipRisorius mm: Also contributes to smiling, draws back corners of mouth – marginal mandib n.(other elevators of lip are buccal n)Modiolus: Formed by convergence of fibers from orbicularis oris and lip elevators anddepressors. Accounts for “dimples” in someBuccinator mm: mm of mastication. Parotid duct pierces this mm. buccinator + orbic oris allowswhistling. Buccinator keeps cheek flat against teeth. Buccal branch of nDepressor anguli, depressor labii, and mentalis mm: Are lip depressors: marginal mandibular n. Chin dimple is formed between bellies of mentalis mmsPlatysma: Innervated by marg mandibular and cervical n’s. platysma provides only a thin coverto the marginal mandibular n Dermatologic and Cosmetic Surgery  511
  24. 24. Figure 15-5. The Ear Tension Tension on donor site closure Figure 15-6. M-plasty Figure 15-7. Rhomboid Flap 512  2011/2012 Dermatology In-Review l Committed to Your Future
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  28. 28. 83. Friedman PM et al. Treatment of Atrophic Facial Acne Scars With the 1064-nm Q-switched Nd:YAG Laser: Six-Month follow-up Study. Arch Dermatol 2004;140:1337-1341.84. Lapidoth M et al. Reticulate erythema following diode laser-assisted hair removal: A new side effect of a common procedure. J Am Acad Dermatol 2004;51:774-777.85. Leonhardt et al. Angioedema Acute Hypersensitivity Reaction to Injectable Hyaluronic Acid. Dermatol Surg 2005;31:577-579.86. Alajlan A et al. Paradoxical hypertrichosis after laser epilation. J Am Acad Dermatol 2005;53(1):85-88.87. www.mentorcorp.com88. Brody HJ. Relevance of Cosmeceuticals to the Dermatologic Surgeon. Dermatol Surg 2005;31:796-798.89. Farris PK. Topical Vitamin C: A Useful Agent for Treating Photoaging and Other Dermatologic Conditions. Dermatol Surg 2005;31:814-818.90. Fitzpatrick RE. Endogenous Growth Factors as Cosmeceuticals. Dermatol Surg 2005;31:827-831.91. Lupo MP. Cosmeceutical Peptides. Dermatol Surg 2005;31:832-836.92. Bissett DL et al. Niacinamide: A B Vitamin that Improves Aging Facial Skin Appearance. Dermatol Surg 2005;31:860-865.93. Eruptive Epidermoid Cysts Resulting from Treatment with Imiquimod. Dermatol Surg 2005;31:780-783.94. Chen et al. Evaluation of the S-Caine Peel for Induction of Local Anesthesia for Laser-Assisted Tattoo Removal: Randomized, Double-Blind, Placebo-Controlled, Multicenter Study. Dermatol Surg 2005;31:281-286.95. Lask GP. Identifying a Role for PlasmaKinetic Rejuvenation in Dermatology. Practical Dermatol 2005;4:56.96. Narurkar VA. Novel Photo-Pneumatic Technology Delivers High-Efficiency Photons to Dermal Targets. Cosmet Dermatol 2005;18(2):115-120.97. Sadick NS. Electro-optical Synergy in Aesthetic Medicine: Novel technology, Multiple Applications. Cosmet Dermatol 2005;18(3):201-206.516  2011/2012 Dermatology In-Review l Committed to Your Future
  29. 29. NOTES Dermatologic and Cosmetic Surgery  517
  30. 30. NOTES518  2011/2012 Dermatology In-Review l Committed to Your Future