Preface:
The dynamic nature of the medical sciences presents a constant challenge for the
dermatologist, but the past 25
years have necessitated a shift in approach to the profession. With the increasing
influx of biological data,
and developments in diagnostic and treatment techniques, our armamentarium has expanded
to treat an
increasing number of pathologies and enabled the vast advancement in corrective
procedures. In addition, the
recent prevalence of tumor pathologies––in particular, the tumors of
the skin––has resulted in a growing
number of patients to seek out the dermatologist for treatment.
Dermatologists are now required to continually update their knowledge of and techniques
in dermatological
surgery. As many as 350 pathologies can now be treated by surgery. Also dermatologists
are now dealing with
an increasing number of cosmetic surgery treatments, which require the use of several
devices (eg, lasers,
ultrasounds, and radiofrequencies, etc.). Such high-tech devices, and their evident
biological action, can
only be properly used by dermatologists after having acquired the proper expertise.
Many countries all
over the world have developed communities: national societies, conferences, and
educational outlets, to
address these surgical topics. This textbook was written in the spirit of these
dermatological communities;
as a tool to improve surgical knowledge and technique; and, mostly, to assist the
dermatologist in meeting
the rising medical needs of today’s patient.
Luigi Rusciani
Perry Robins
Review
From : James M. Spencer MD MS, JOURNAL OF DRUGS IN DERMATOLOGY, MAY
2008
Dermatologic surgery is now a major component of dermatology, with an increasingly
complex skill set and knowledge base required for contemporary practice. Despite
the importance of surgery to residents and practitioners alike, the standard encyclopedic
texts of dermatology devote surprising little to this area. The Textbook of Dermatologic
Surgery, edited by Luigi Rusciani MD and Perry Robins MD, represents a significant
achievement: a scholarly reference text that will find an important place in every
dermatologist’s library. This 2-volume book covers all aspects of dermatologic
surgery in a readable, well-illustrated manner. The first volume thoroughly covers
all fundamental aspects of cutaneous surgery and proceeds through a lengthy section
on special considerations by regional anatomy followed by an excellent section on
cutaneous oncology. The second volume covers special topics and cosmetic surgery.
The text is extensive and encyclopedic, and I think greatly strengthened by a truly
international list of authors. The various chapters have been written by faculty
from all parts of the world, with a particular heavy representation from Europe.
This international perspective affords the reader a wider perspective than is customarily
seen in dermatology texts in the US. The first volume is written in a clear style
free of jargon and will be a useful reference source for beginning surgeons as well
as experienced practitioners. Following a complete discussion of the fundamentals
of cutaneous surgery, there are a series f chapters covering special considerations
by anatomic area, such as eyelid surgery or surgery of the nail unit. A third section
covers cutaneous oncology in depth. ... The bulk of the second volume covers cosmetic
techniques. This volume is particularly enhanced by its international authors. ...
This valuable 2-volume text will be an irreplaceable resource for any practice in
dermatologic surgery.
Chapters:
VOLUME I
GENERAL CUTANEOUS SURGERY
CHAPTER 1
THE DERMATOSURGICAL PATIENT
(G. Agostinacchio) ........................................ 3
Introduction ................................................ 3
Preparation of a Dermatologic Surgical
Procedure................................................ 3
Patient History............................................ 4
Preparation of a Healthy Patient for
Surgical Procedures ............................ 5
References .................................................. 10
CHAPTER 2
INFORMED CONSENT IN CUTANEOUS SURGERY
(D.J. Goldberg) .............................................. 11
New York § 2805-d. .............................. 15
Iowa 147.37 Consent in Writing ............ 15
Nebraska § 44-281 ................................ 16
New Jersey title 8, §43G-4.1 Patient
rights.................................................... 16
Connecticut §19-13 D3 .......................... 16
CHAPTER 3
CUTANEOUS SURGERY IN OUTPATIENT AND OPERATING ROOM SETTINGS
(M. Simonacci, M. Sigona, A. Bettacchi,
R. Gasco)........................................................ 19
The Dermatological Outpatient Surgery
Unit ........................................................ 20
The Operating Room .................................. 21
References .................................................. 23
CHAPTER 4
SURGICAL INSTRUMENTS ...................... 25
(G. Guerriero) ................................................ 25
Scalpels .................................................. 25
Scissors .................................................. 26
Needle Holders ...................................... 26
Forceps .................................................. 27
Hemostats .............................................. 27
Curettes .................................................. 28
Retractors .............................................. 28
Towel Clamps ........................................ 28
Containers and Forceps for Preparing
the Operative Field .............................. 28
Electrocoagulator .................................. 28
Dermabrader .......................................... 29
Liposuction Apparatus............................ 29
Miscellaneous Equipment and Supplies 29
Conclusions ............................................ 29
CHAPTER 5
STERILIZATION AND DISINFECTION OF SURGICAL INSTRUMENTS
(M. Dal Canton) ............................................ 31
Introduction ................................................ 31
Definitions .................................................. 31
Decontamination .................................... 31
Cleaning ................................................ 32
Disinfection ............................................ 32
Sterilization ............................................ 32
Antisepsis .............................................. 33
Decontamination ........................................ 33
Cleaning ................................................ 34
Sterilization ................................................ 35
General Concepts .................................. 35
CONTENTS xiii
Heat Sterilization........................................ 37
Dry Sterilization .................................... 37
Steam Sterilization ................................ 38
Gas Sterilization ........................................ 42
Chemical Disinfection................................ 44
Glutaraldehyde ...................................... 45
Ortho-Phtalaldehyde .............................. 46
Peracetic Acid ........................................ 46
TAED (Tetra-Acetyl Ethylen-Diammine) 47
Instrument Care .......................................... 48
Inspection and Care ................................ 48
Lubrication ............................................ 48
Packaging of Surgical Instruments ........ 49
Loading the Steam Autoclave ................ 50
Testing and Validation of the Sterilization
Process.................................................... 52
Physical Monitors .................................. 52
Chemical Monitors ................................ 53
Biologic Indicators ................................ 54
Issues on Dermatologic Surgery Instruments 55
Electrosurgical Units .............................. 55
Dermabrasion Equipment ...................... 55
Hair Transplant Equipment .................... 56
Current Issues in Disinfection and
Sterilization of Surgical Instruments .. 56
References .................................................. 57
CHAPTER 6
LOCAL ANESTHETIC TECHNIQUES
(R. Bono, G. Rossi) ........................................ 61
Introduction ................................................ 61
The Physiology of Pain Perception ........ 61
Drugs Used to Produce Local and Regional
Anesthesia .............................................. 62
The Mechanism of Action of Local
Anesthetics .......................................... 62
The Chemical Structure of Local
Anesthetics .......................................... 62
Vasoconstrictors ........................................ 63
Adverse Effects of Local and Regional
Anesthesia .............................................. 64
Local Adverse Effects ............................ 64\p
Systemic Adverse Effects ...................... 64
Drug Interactions.................................... 66
Pregnancy .............................................. 67
Preventing and Managing Side Effects .. 67
Pre-Anesthetic Evaluation of Patients........ 68
Anesthetic Techniques................................ 69
Local Anesthesia .................................... 69
Regional Anesthesia (Peripheral Nerve
Block) .................................................. 69
Sedation ...................................................... 70
Setting Equipment and Assistance ........ 71
Patient Evaluation .................................. 71
Drugs used.............................................. 71
References .................................................. 72
CHAPTER 7
HAEMOSTASIS
(N. Frasca) .................................................... 73
Physical Agents ...................................... 73
Physiologic Agents ................................ 73
Topical-Chemical Agents ...................... 74
Thermal Devices .................................... 74
References .................................................. 74
CHAPTER 8
SUTURING TECHNIQUES AND MATERIALS
(A. Cimitan).................................................... 75
Suturing Materials ...................................... 75
Threads .................................................. 75
Staples .................................................... 77
Wound Closure Adhesive Tapes ............ 78
Surgical Needles ........................................ 78
Suturing Techniques .................................. 78
Most Common Suturing Techniques ...... 79
Special Sutures .......................................... 82
References .................................................. 84
CHAPTER 9
TOPOGRAPHICAL ANATOMY AND CUTANEOUS SURGERY
(G. Leigheb, P. Boggio, G. Cristiani) ............ 85
The Fronto-Occipital Region .................... 85
The Temporal Region ................................ 86
The Auriculo-Mastoid Region.................... 87
The Orbital Region .................................... 88
The Eyelids ............................................ 88
The Lacrimal Apparatus ........................ 88
Vessels and Nerves ................................ 89
The Nasal Region ...................................... 91
Nasal Support System ............................ 91
Superficial Structures ............................ 91
The Superficial Plains ............................ 91
Vessels and Nerves ................................ 93
The Lips .................................................... 93
The Cheeks ................................................ 94
The Hand .................................................... 94
The Volar Surface of the Hand .............. 94
The Dorsal Surface of the Hand ............ 95
The Fingers ............................................ 95
References .................................................. 96
xiv
CHAPTER 10
CUTANEOUS BIOPSY
CONTENTS
Clinical Examples ...................................... 117
References .................................................. 120
(G. Guerriero) ................................................ 97
Preparing the Patient .................................. 97
Planning the Biopsy .................................. 97
Disinfection and Anesthesia ...................... 98
Instruments ................................................ 98
Biopsy Techniques .................................... 99
Incisional and Excisional Biopsies ........ 99
Shave Biopsy.......................................... 99
Punch Biopsy.......................................... 99
Fine-Needle Biopsy................................ 100
Nail Biopsy ................................................ 100
Biopsy of the Oral Cavity .......................... 100
Complications ............................................ 101
References .................................................. 101
CHAPTER 11
CUTANEOUS FLAPS
I - Advancement Flaps .................................. 103
(J. Ocaña Sierra, M.L. Wilhelmi) .................. 103
Basic Techniques ........................................ 103
Rectangular Advancement Flap ............ 104
Triangular Advancement Flap ................ 104
Trapezoidal Advancement Flap .............. 104
VY or YV Advancement Flaps .............. 107
A-T Flap ................................................ 107
Double Crescent Perialar Excision ........ 107
Bipedicle Double Flap............................ 108
Crescentic Advancement Flap ................ 108
Special Techniques .................................... 110
Advancement Flaps of Suprauricular
Region ................................................ 110
Advancement Flaps of Eyelids .............. 110
Advancement Flaps of the Nose ............ 110
Advancement Flaps of Lips.................... 110
Advancement Flaps of the Cheek
and Chin .............................................. 110
References .................................................. 113
II - Rotation Flaps .......................................... 114
(P. Robins, C.H. Schmults) ............................ 114
Classic Rotation Flap .................................... 114
Variations of the Rotation Flap ...................... 115
Hatchet Flap .......................................... 115
Double Rotation Flaps............................ 116
Techniques to Avoid Common Errors ........ 117
Raise the Leading Edge.......................... 117
Widen the Tip of the Flap ...................... 117
Pay Attention to Cosmetic Units and
Skin Tension Lines .............................. 117
Consider the Effect of Secondary Motion 117
III - Transposition Flaps ................................ 121
(A. Rusciani, G. Guerriero, A. Paradisi) ...... 121
Rhombic Flap ................................................ 122
Classic Limberg Rhombic Flap .............. 122
Dufourmentel Flap ................................ 123
Webster Flap .......................................... 123
Rhombic Flap on a Circular Defect........ 124
Nasolabial Flap .......................................... 126
Bilobed Flap .............................................. 128
Z-Plasty ...................................................... 130
Complications ............................................ 130
References .................................................. 131
CHAPTER 12
CUTANEOUS GRAFTS
(A. Picoto) ...................................................... 133
Introduction ................................................ 133
Types of Skin Grafts .............................. 133
Autografts .................................................. 134
Cutting the Split-Thickness Skin Graft .. 135
Cutting the Full-Thickness Skin Graft .. 135
Donor Areas............................................ 135
Cutting the Graft .................................... 136
Mesh Grafts ............................................ 138
References .................................................. 138
CHAPTER 13
WOUNDS: CLASSIFICATION AND SURGERY
(R. Baiocchi, M. Serrai, G. Maccanti) .......... 139
Introduction ................................................ 139
Trophic Ulcers of the Lower Limbs .......... 140
Venous Ulcers ........................................ 140
Arterial Ulcers ........................................ 141
Ulcers Due to Vasculitis ........................ 142
Infection-Based Ulcerations ...................... 142
Gangrene ................................................ 145
Pressure Sores ............................................ 146
Preparation for Surgery .......................... 147
Operative Technique .............................. 148
Review of Operative Techniques .......... 148
Treatment of Multiple Pressure Sores .... 153
Conclusion.............................................. 153
Diabetic Foot .............................................. 155
Surgical Treatment ................................ 156
Conclusion.............................................. 158
Traumatic Wounds...................................... 161
Contusion .............................................. 162
CONTENTS xv
Excoriations............................................ 162
Lacerated and Contused Wounds .......... 162
Flap Wounds .......................................... 162
Defect Wounds ...................................... 162
Pilonidal Sinus .......................................... 166
Considerations and Conclusions ............ 166
References .................................................. 167
CHAPTER 14
SURGICAL WOUND DRESSING
(L.M. Chinni, M.T. Viviano, M. Papi) ............ 171
Introduction ................................................ 171
Types of Cutaneous Wounds ...................... 171
Physiology of Wound Healing .................. 172
Phases of Wound Healing ...................... 172
What is the Ideal Characteristic of a
Wound Dressing? .................................. 172
Occlusive and Semi-Occlusive Dressing .. 173
Polymer Films ............................................ 174
Polymer Foams .......................................... 174
Hydrocolloids ............................................ 174
Hydrogels .................................................. 175
Alginates .................................................... 175
Miscellaneous ............................................ 176
Adhesive Tapes and Bandages .................. 176
Tactifiers .................................................... 176
References .................................................. 176
CHAPTER 15
SURGICAL COMPLICATIONS
(K. Nouri, H. Chen, V. Vejjabhinanta,
A.R. Patel) ...................................................... 179
Introduction ................................................ 179
Intra-Operative .......................................... 179
Bleeding ................................................ 179
Damage to Nerves or Surrounding
Vital Organs ........................................ 180
Anesthetic Side Effects/Drug Interactions 181
Electrocautery Associated Complications 181
Post-Operative ............................................ 181
Contact Dermatitis.................................. 181
Infection ................................................ 182
Chondritis .............................................. 182
Wound Dehiscence ................................ 183
Necrosis of the Skin .............................. 183
Suture Spitting........................................ 183
Suture Tracking ...................................... 183
Excessive Granulation Tissue ................ 184
Non-Healing Wounds ............................ 184
Pigment Change .................................... 184
Scars/Hypertrophic Scarring/Keloids .... 184
Conclusion.................................................. 184
References .................................................. 185
CHAPTER 16
PHOTOGRAPHIC DOCUMENTATION IN DERMATOLOGY
(E. Vigl, Pf. Zampieri) .................................... 187
Introduction ................................................ 187
Rules for Correct Documentation .............. 188
Try to Show Only the Clinical Sign ...... 188
Pay attention to the Background ............ 190
Choose the Right Detail ........................ 192
When Taking a Photograph Consider
the Angle Carefully ............................ 194
Using the Correct Lighting .................... 194
Keep the Slides Clean ............................ 199
Do Not Make Inappropriate Use of
Other People’s Documentation............ 200
Do Not “Modify” Therapeutic Results
Obtained .............................................. 200
Pay Careful Attention to the Order of the
Caption and the Written Text .............. 200
Do Not Present An Excessive Number of
Slides .................................................. 201
Respect the Privacy Data Protection Law! 201
References .................................................. 202
REGIONAL DERMATOLOGIC SURGERY
CHAPTER 17
SURGERY OF THE EYELID REGION
(F. Camacho-Martínez) .................................. 205
Introduction ................................................ 205
General Considerations .............................. 206
Anatomic Considerations ...................... 206
Lacrimal Apparatus ................................ 206
Functional Considerations...................... 207
Surgical Considerations.......................... 207
Tarsorrhaphy .......................................... 207
Surgical Techniques .................................. 208
Defects on the Lower Lids ........................ 208
Small Defects ........................................ 208
Medium-Sized Defects .......................... 208
Complete Loss of the Lower Eyelid ...... 213
Defects on the Upper Lids.......................... 217
Small Defects ........................................ 217
Complete Loss of the Upper Lid ............ 220
Skin Defects .......................................... 221
Defects on the Lateral Canthus .................. 224
Defects Only on the Lateral Canthus .... 224
Defects on the Lateral Canthus and
Small Defects of Whole Thickness on
Both Lids ............................................ 225
Defects on the Lateral Canthus and Small
or Medium-Sized Cutaneous Defects on
Both Lids ............................................ 225
Defects on the Inner Canthus .................... 226
xvi
Defects on the Inner Canthus and
Small Defects of Whole Thickness on
CONTENTS
CHAPTER 20
SURGERY OF THE LIPS AND THE
Both Lids ............................................ 226
Defects on the Inner Canthus and Small
or Medium-Sized Cutaneous Defects on
Both Lids ............................................ 227
References .................................................. 230
CHAPTER 18
AESTHETIC BLEPHAROPLASTY
(J. Carruthers, A. Carruthers) ...................... 233
The Presurgical Evaluation .................... 233
History of Any Previous Peri-Ocular
Treatments .......................................... 233
Evaluation of Subject’s Preoperative
Expectations ........................................ 234
Necessary Documentation to Achieve
Surgical Goals .................................... 234
Cosmetic Upper Eyelid Blepharoplasty .... 237
Cosmetic Lower Eyelid Blepharoplasty .... 238
Traditional Infralash Blepharoplasty ...... 238
Lateral Canthopexy ................................ 238
Skin Redraping ...................................... 238
Transconjunctival Lower Eyelid
Blepharoplasty ........................................ 238
Transconjunctival Blepharoplasty with
Anterior Fat Transposition: the Newest
Lower Eyelid Rejuvenative Procedure 239
Blepharoplasty Plus Resurfacing .......... 239
Keratoconjunctivits Sicca ...................... 240
Complications and their Management.... 240
Complications Related to the Use of the
CO2 Laser for Aesthetic Blepharoplasty 241
Postoperative Care Regime ........................ 241
Ice Positioning and Wound Care ............ 241
Summary ................................................ 242
References .................................................. 242
CHAPTER 19
NASAL PYRAMID SURGERY
(C. Alfano, A. Rusciani, S. Chiummariello,
C. Pagliarello)................................................ 243
Introduction ................................................ 243
General Principles ...................................... 243
Reconsctruction of the upper Part of the
Nose (Dorsum and Lateral Faces) .......... 244
Reconstruction of the Lower Nose ............ 245
Axial Flaps ................................................ 247
Technical Tips ............................................ 248
References .................................................. 249
ORAL CAVITY
(W.A. Pagani) ................................................ 251
General Considerations .............................. 251
I- Anatomy and Physiology.................... 251
The Lips and Oral Cavity ...................... 251
Muscles .................................................. 251
Innervation and Blood Circulation of the
Lips...................................................... 252
Regional Lymphatic System .................. 252
II- Cancer Ablative Surgery .................. 252
Reconstructive Surgery .............................. 254
Lips: Superficial Defect Repair .............. 254
Lips: Full-Thickness Defect Repair ...... 255
Corner of the Mouth Reconstruction...... 257
Vermilion Border Restoration and
Principles of Oral Mucosa Surgery .... 258
Acknowledgments .................................. 265
References .................................................. 265
CHAPTER 21
SURGERY OF THE AURICULAR REGION
(H. Breuninger) .............................................. 267
Introduction ................................................ 267
Ensuring Tumor-free Three Dimensional
Incision Margins (3D-Histology) .......... 267
Indications .............................................. 269
Pre-Therapeutic Diagnostics ...................... 270
Anesthesia .................................................. 270
Planning the Operation .............................. 271
Operation .................................................... 271
Suture Techniques ...................................... 275
Aftercare .................................................... 275
References .................................................. 275
CHAPTER 22
SURGERY OF THE EXTREMITIES
(S. Serrano-Ortega) ...................................... 277
Upper Extremities ...................................... 278
Axillae .................................................... 278
Arms and Forearms ................................ 280
Hands...................................................... 280
Lower Extremities ...................................... 283
Inguino-Crural Region .......................... 283
Thighs .................................................... 283
Leg.......................................................... 285
Feet ........................................................ 289
References .................................................. 291
CHAPTER 23
NAIL SURGERY
CONTENTS xvii
CHAPTER 26
SQUAMOUS CELL CARCINOMA
(E. Haneke) .................................................... 293
Surgical Anatomy and Physiology of the
Nail ........................................................ 293
Preoperative Examination and Preparation
for Surgery.............................................. 295
Anaesthesia and Instrumentation .............. 296
Nail Avulsion and Biopsies ........................ 297
Characteristic Nail Lesions ........................ 299
Surgery of Benign Tumours ...................... 304
Longitudinal Melanonychia ...................... 305
Surgery of Malignant Tumours .................. 306
Traumatic Lesions ...................................... 308
Grafts and Flaps ........................................ 308
References .................................................. 309
SURGERY OF CUTANEOUS CANCERS
CHAPTER 24
BENIGN EPITHELIAL CANCERS
(G. Zumiani, L. Castellani) ............................ 315
Neoplasms of Viral Origin ........................ 315
Common Warts ...................................... 316
Flat Warts .............................................. 317
Condylomata Acuminata ........................ 317
Molluscum Contagiosum ...................... 318
Fibroepithelial Polyps ................................ 319
Seborrheic Keratosis .................................. 319
Dermatosis Papulosa Nigra .................... 320
Stucco Keratosis .................................... 320
Clear-Cell Acanthoma ................................ 321
Keratoacanthoma........................................ 321
Comedone (Blackhead) .............................. 322
Verrucous Epidermal Naevus .................... 322
Actinic Keratoses ...................................... 323
Becker’s Naevus ........................................ 324
Adnexal Neoplasm .................................... 325
References .................................................. 334
CHAPTER 25
SURGICAL MANAGEMENT OF BASAL CELL CARCINOMAS
(J.F. Sei) ........................................................ 335
Tumor Size ................................................ 337
Location...................................................... 338
Histologic Type .......................................... 338
Primary or Recurrent Tumor ...................... 340
Severity score ............................................ 341
Results of Treatment .................................. 344
Conclusion.................................................. 344
References .................................................. 344
(J. Hafner, M. Hess Schmid, S. Läuchli,
L. Schärer, G. Burg) ...................................... 347
Treatment Modalities and Prognosis of
Squamous Cell Carcinoma of the Skin 347
Precursors of Squamous Cell Carcinoma .. 351
Specific Variants of Low-Grade Squamous
Cell Carcinoma.................................... 355
Surgical Repair According to the Anatomical
Regions of the Head ............................ 357
Nose............................................................ 358
Flaps and Grafts of the Nose .................. 358
Ear .............................................................. 363
Flaps and Grafts of the Ear .................... 363
Lips ............................................................ 364
Flaps and Grafts of the Lips .................. 364
Cheek.......................................................... 366
Flaps and Grafts of the Cheek ................ 367
Forehead .................................................... 369
Flaps and Grafts of the Forehead .......... 369
Scalp .......................................................... 371
Flaps and Grafts of the Scalp ................ 371
References .................................................. 373
CHAPTER 27
PIGMENTED LESIONS
(J.S. Conejo-Mir, A. Serrano,
L. Rodriguez-Freire, C. Hernandez) .............. 377
Solar Lentigo .............................................. 377
Treatment................................................ 377
Becker’s nevus .......................................... 378
Clinical manifestation ............................ 378
Histologic Findings ................................ 379
Treatment................................................ 379
Congenital Nevi ........................................ 379
Clinical Manifestations .......................... 379
Histological Features.............................. 380
Treatment................................................ 380
Acquired Nevocytic Nevi .......................... 384
Clinical and histological features .......... 384
Management .......................................... 384
Dysplastic Nevi .......................................... 385
Clinical Features .................................... 385
Histological Features.............................. 385
Management .......................................... 386
References .................................................. 387
CHAPTER 28
MALIGNANT MELANOMA
(M.I. Perez, T.C. Yu) ...................................... 391
References .................................................. 395
xviii
CHAPTER 29
THE SENTINEL LYMPH NODE
CONTENTS
Diagnosis of Pigmented Skin Lesions........ 426
Differentiation Between Melanocytic
(G. Landi, M. Polverelli, C. Landi) ................ 397
Introduction ................................................ 397
The Orderly Lymphatic Progression of
Melanoma............................................ 398
Morton’s Experience .................................. 400
Preoperative Lymphoscintigraphy ............ 401
Intraoperative Gamma Probe .................... 404
Surgical Technique .................................... 406
Histopathologic Investigation .................... 408
Regional Complete Nodal Dissection ........ 410
New Strategies .......................................... 411
Sentinel Node Biopsy in Other Tumors .... 412
Personal Results ........................................ 412
Complications ............................................ 414
Limits of the Procedure and Controversies 414
References .................................................. 416
CHAPTER 30
EPILUMINESCENCE MICROSCOPY
(R. Pellicano, M. Lomuto).............................. 419
Introduction ................................................ 419
Historical Overview .................................. 419
Observation Techniques ............................ 420
Dermoscopic Criteria ................................ 420
Pigment Network (Typical Atypical) .... 421
Streaks (Regular Irregular) .................... 421
Dots/Globules (Regular Irregular) ........ 422
Blue-Whitish Veil .................................. 423
Regression Structures (White Areas/Blue
Areas) .................................................. 423
Hypopigmented Areas (Focal Multi-Focal
Diffuse)................................................ 423
Blotches (Localised Diffuse Regular
Irregular).............................................. 423
Multiple Milia-Like Cysts ...................... 424
Comedo-Like Openings
Leaf-Like Areas .................................. 424
Red-Blue Lacunas .................................. 424
Vascular Pattern...................................... 424
and Non-Melanocytic Lesions ................ 426
Differentiation Between Melanocytic
lesions and melanoma ............................ 427
Conclusions ................................................ 431
References .................................................. 432
CHAPTER 31
MALIGNANT TUMORS OF THE DERMIS AND SUBCUTANEOUS TISSUE
(P.G. Lang, Jr.) .............................................. 435
Merkel Cell Carcinoma .......................... 435
Malignant Granular Cell Tumor ............ 437
Pilomatrix Carcinoma ............................ 438
Sebaceous Gland Carcinoma.................. 438
Sarcomas ................................................ 440
Dermatofibrosarcoma Protuberans ........ 440
Atypical Fibroxanthoma ........................ 442
Malignant Fibrous Histiocytoma............ 443
Leiomyosarcoma .................................... 444
Angiosarcoma ........................................ 446
Epitelioid Sarcoma ................................ 448
Fibrosarcoma .......................................... 449
Liposarcoma .......................................... 450
Cutaneous Rhabdomyosarcoma ............ 450
Malignant Peripheral Nerve Sheath
Tumor .................................................. 450
Sweat Gland Carcinomas ...................... 450
Aggressive Digital Papillary Adenoma .. 451
Signet Ring Carcinoma .......................... 451
Malignant Eccrine Spiradenoma and
Malignant Cylindroma ........................ 451
Mucinous Carcinoma ............................ 452
Malignant Mixed Tumor ........................ 452
Malignant Clear Cell Hidradenoma ...... 452
Porocarcinoma........................................ 453
Primary Cutaneous Adenoid Cystic
Carcinoma .......................................... 454
Apocrine Carcinoma .............................. 454
Microcystic Adnexal Carcinoma ............ 455
References .................................................. 457
CONTENTS xix
VOLUME II
SPECIAL CUTANEOUS SURGERY
CHAPTER 32
CURETTAGE AND ELECTRODESICCATION
(Arash Kimyai-Asadi, Ming H. Jih) .............. 473
Introduction ................................................ 473
Procedure.................................................... 473
Efficacy ...................................................... 474
Indications and Contraindications .............. 475
Conclusions ................................................ 475
References .................................................. 476
CHAPTER 33
CRYOSURGERY
(P. Mintzias) .................................................. 477
Historical Background .............................. 477
Cryobiology................................................ 477
Vascular changes ........................................ 479
Cryoimmunology ...................................... 479
Equipment - Techniques of treatment ........ 479
Dipstick Technique ................................ 480
Cryoprobe Technique ............................ 481
Spray Technique .................................... 482
Intralesional Technique (Weshahy’s
Technique) .......................................... 483
Freezing Parameters .............................. 483
Monitoring Method .................................... 484
Use of Thermocouple Measurements .... 484
Impedance-Resistance Methods ............ 485
Indications and Contraindications .............. 485
Cryosurgery in Benign Skin Tumours........ 486
Seborrhoeic Warts .................................. 486
Haemangiomas ...................................... 487
Keloids and Hypertrophic scars ............ 487
Pyogenic Granuloma .............................. 487
Warts ...................................................... 488
Cryosurgery in Skin Precancerous
Lesions .................................................... 490
Actinic Keratosis .................................... 490
Bowen’s Disease .................................... 490
Queyrat’s Erythroplasia .......................... 491
Leucoplakia ............................................ 491
Lentigo Maligna .................................... 492
Keratoacanthoma.................................... 492
Cryosurgery in Skin Cancer ...................... 492
Basal Cell Carcinoma (BCC) ................ 493
Squamous Cell Carcinoma (SCC).......... 497
Malignant melanoma.............................. 498
Complications of Cryosurgery .................. 499
Perspectives – Conclusion.......................... 499
References .................................................. 500
CHAPTER 34
ELECTROSURGERY
(E. Sbano, P. Sbano) ...................................... 505
History ........................................................ 505
Basic Principles .......................................... 506
Electrical Circuits. ...................................... 506
Waveforms.............................................. 506
Electrodes .............................................. 506
Devices ...................................................... 508
Techniques.................................................. 508
Clinical Applications .................................. 509
Hazards .................................................. 514
Comparison of Electrosurgery with other
Surgical Methods.................................... 516
References .................................................. 517
CHAPTER 35
DERMABRASION
(J.M. Yarborough, C.B. Harmon) .................. 519
Introduction ................................................ 519
Indications .................................................. 519
Preoperative Consultation and
Examination ..........................................520
Preoperative Medications and Laboratory
Evaluation .............................................. 520
Surgical Technique .................................... 521
Postoperative Wound Care ........................ 523
Complications ............................................ 524
References .................................................. 525
CHAPTER 36
TISSUE EXPANDERS
(I. Zilinsky, Y. Har-Shai, G. Weiss) ................ 527
Microstructure of the Human Skin ............ 527
Terminology .............................................. 527
Bio-Mechanical Properties of Skin ............ 528
Historical Precedence of Stretching Skin .. 530
Histological Changes ................................ 531
Epidermis .............................................. 531
Dermis .................................................... 531
Adnexa .................................................. 532
Subcutaneous Fat.................................... 532
Muscle .................................................... 532
Vascularity .............................................. 532
Capsule .................................................. 532
Long-term Histopathological Results .... 533
Linear Tissue Expansion ............................ 533
Types of Linear Skin-Stretching Devices 534
The sure-closure® skin-stretching system
xx CONTENTS
(SSD) (Zimmer) .................................. 534
The Suture Tension Adjustment Reel
(STAR) .................................................. 536
The External Tissue Extender (ETE® –
Höjmed AB Sweden) .......................... 536
The Frechet Scalp Extender .................. 536
The Constant-Tension Approximator
(Proxiderm – Progressive Surgical Products
Westbury New York) .......................... 536
Spherical Tissue Expansion........................ 539
Clinical Applications of Spherical Devices 539
Breast Reconstruction with a Spherical
Expander.............................................. 540
Giant Congenital Nevi............................ 541
Complications ........................................ 542
References .................................................. 543
CHAPTER 37
SCAR REVISION
(A. Tulli, A. Diociaiuti) .................................. 547
Introduction ................................................ 547
Indications .................................................. 547
Types of Scars ............................................ 548
Hypertrophic Scars ................................ 548
Keloids .................................................. 548
Depressed Scars...................................... 548
Widened Scars ........................................ 548
Long Linear Scars .................................. 548
Pitted Scars ............................................ 548
Trapdoored Scars.................................... 548
Contracted Scars and Webbed Scars ...... 549
Distortion of Free Margins .................... 549
Red Scars................................................ 549
Surgical Technique .................................... 549
Fusiform Excision .................................. 549
Skin Flaps .............................................. 549
Dermal Micrografts ................................ 550
Autologous Grafts .................................. 551
Dermoabrasive Scar Revision ................ 551
Laser Scar Revision................................ 552
Non-Surgical Scar Revision ...................... 552
Corticosteroids ...................................... 552
Pressure .................................................. 552
Radiation Therapy .................................. 552
Cryotherapy ............................................ 552
Medical Therapy .................................... 552
References .................................................. 553
CHAPTER 38
TREATMENT OF VARICOSE VEINS
(S. T’ Kint, D. Roseeuw) ................................ 555
Introduction ................................................ 555
Anatomy .................................................... 555
Venous Pathology .................................. 556
Negative Factors .................................... 556
Positive Factors ...................................... 556
Clinical Features ........................................ 556
The Schwartz Test (Wave Test) .............. 557
Cough Test.............................................. 557
Trendelenburg test .................................. 557
Perthes Test ............................................ 558
Pratt Test ................................................ 558
Linton Test.............................................. 558
Duplex Ultrasonography ........................ 558
Ankle-Arm Index .................................. 558
Venography ............................................ 558
Air Pletysmography................................ 559
Treatment .................................................. 559
Drugs ...................................................... 559
Mechanical therapy ................................ 559
Sclerotherapy.......................................... 560
Ambulatory Phlebectomy ...................... 561
References .................................................. 564
CHAPTER 39
SCLEROTHERAPY
(S. Rapprich, E. Hasche, M. Hagedorn) ........ 565
Introduction ................................................ 565
Varicosis .................................................... 565
Definition of Varicosis................................ 565
Epidemiology ............................................ 565
Etiology ...................................................... 565
Pathophysiology of Varicosis .................... 566
Clinical investigation and machine
diagnostics .......................................... 566
Phlebologic Anamnesis .......................... 566
Clinical Picture ...................................... 567
Phlebological Investigation .................... 568
Chronic Venous Insufficiency (CVI) .......... 571
Skin Changes with CVI.......................... 572
Therapy of Varicosis .................................. 577
History of Sclerotherapy ............................ 578
Indications of Sclerotherapy ...................... 579
Therapeutic Basics .................................... 580
Sclerosing Agent .................................... 580
Pathophysiology of Sclerotherapy ........ 581
Practical Execution .................................... 582
Puncture and Air-Block Technique ........ 582
Tournay Sclerosing Method .................. 582
Injection.................................................. 583
Sigg Sclerosing Method ........................ 583
Sclerosing Intradermal Varicose Veins .. 584
Therapeutic Procedure............................ 585
Supplementary Measures ...................... 585
CONTENTS xxi
Contraindications ...................................... 586
Complications ............................................ 586
Topical Complications............................ 586
Systemic Reactions ................................ 589
Follow-up Visits ........................................ 590
References .................................................. 590
CHAPTER 40
LASERS AND POLYCHROMATIC LIGHT SOURCES (PCLS) IN DERMATOLOGY
(L. Marini)...................................................... 591
Light-Tissue Interaction ............................ 591
Light-Sources ............................................ 593
Lasers .................................................... 593
PCLS (Polychromatic Light Sources) .... 594
Dosimetry .............................................. 595
Cooling Systems .................................... 595
Surgical Lasers ...................................... 598
Vascular Targets - Vascular Specific Lasers
and IPLS .............................................. 601
Pigmented Targets: Pigment-Specific
Lasers and IPLS .................................. 606
Non-Ablative Collagen Remodeling and
Skin Rejuvenation .............................. 609
Conclusion.................................................. 611
References .................................................. 611
CHAPTER 41
THE CARBON DIOXIDE LASER
(M.A. Trelles, R.G. Calderhead) .................... 615
History and Photobiosurgical Basics.......... 615
Photothermal Bioreactions .................... 615
Irradiance (Power Density) – The Surgical
Key ...................................................... 618
Radiant Flux (Energy Density) – the Laser
“Dose” ................................................ 620
Beam Mode ............................................ 621
Beam Type.............................................. 621
Beam Transmission ................................ 623
Illustrative Examples.................................. 624
Incision .................................................. 624
Excision .................................................. 624
Vaporization .......................................... 625
Coagulation ............................................ 626
Vaporization and Coagulation Combined 626
Variations on a Theme (CO2 ‘Pinhole’ Treatment) 626
CO2 Laser-Assisted Blepharoplasty ...... 628
CO2 Laser: Quo Vadis? .............................. 629
CHAPTER 42
LASER SAFETY WITH THE CO2 LASER
(M.A. Trelles, R.G. Calderhead) .................... 631
CO2 Laser-Related Hazards........................ 631
Electrical Hazards ...................................... 631
Skin or Other Tissue Hazards .................... 632
Carelessness .......................................... 632
Misalignment of the Aiming Beam ........ 632
Accidental Irradiation from Beam
Reflection ............................................ 632
Tissue Protection for the CO2 Laser ...... 632
Optical Hazards .......................................... 633
Fire Hazards .............................................. 634
Laser Plume Hazard .................................. 634
Side Effects ............................................ 634
Common Sense and Hazard Prevention 635
CHAPTER 43
LASER THERAPY IN VASCULAR LESIONS
(J.M. Fernández Vozmediano,
J.C. Armario Hita) ........................................ 637
Introduction ................................................ 637
Treatment of Vascular Lesions .................. 638
Telangiectasias ...................................... 638
Hemangiomas ........................................ 639
Vascular Malformations ........................ 642
Laser Therapy in Vascular Lesions ............ 642
Continuous-Wave Systems ........................ 643
Argon Laser ............................................ 643
Argon-Pumped Tunable Dye Laser
(APTDL) ............................................ 645
Potassium Titanyl Phosphate 532
Nanometer Laser (KPT Laser) ............ 645
Copper Vapor Laser................................ 646
Krypton Laser ........................................ 646
Copper Bromide Laser .......................... 646
Pulsed-Wave systems ................................ 647
Action on Tissues .................................. 647
Method of Application .......................... 647
Contraindications .................................. 648
Complications ........................................ 648
Indications .............................................. 649
Telangiectasias ...................................... 649
Vascular Malformations ........................ 651
Hemangiomas ........................................ 653
Other Vascular Lesions .......................... 654
Other Laser Systems Used in Vascular
Lesions ................................................ 654
Nd:YAG laser ........................................ 654
CO2 laser ................................................ 655
Treatment of Telangiectasias of the Legs 656
Sclerotherapy.......................................... 656
xxii
CONTENTS
Laser Therapy of Leg Veins .................. 657
Dye Laser Systems ................................ 657
Nd:YAG Systems .................................. 658
Long-Pulsed Alexandrite Laser.............. 659
Diode Laser ............................................ 659
Systems of Non-Coherent Light ............ 659
References .................................................. 660
CHAPTER 44
ERBIUM LASERS
(M.G. Onesti) ................................................ 665
Characteristics ............................................ 665
Applications .............................................. 666
Erbium Laser and Resurfacing .................. 666
References .................................................. 667
CHAPTER 45
HISTORY OF MOHS MICROGRAPHIC SURGERY
(C.W. Hanke, A.L. Leonard) .......................... 669
The Early Years: the Fixed-Tissue
Technique .............................................. 669
Modern Mohs Micrographic Surgery: the
Fresh-Tissue Technnique ........................ 671
Early Pioneers in Mohs Surgery ................ 671
Modern Mohs Micrographic Surgery:
Expanding Horizons ............................ 673
The Legacy of Frederic Mohs .................... 674
References .................................................. 674
CHAPTER 46
MOHS MICROGRAPHIC SURGERY: A TREATMENT OF FIRST CHOICE FOR DIFFICULT SKIN
CANCERS
(N.W.J. Kelleners-Smeets, H.A.M. Neumann) 677
Introduction ................................................ 677
History ........................................................ 678
Method ...................................................... 679
Indications for Mohs Micrographic
Surgery ................................................ 682
Basal Cell Carcinoma ............................ 682
Squamous Cell Carcinoma .................... 684
Discussion .................................................. 684
Conclusion.................................................. 688
References .................................................. 688
COSMETIC SURGERY
CHAPTER 47
CUTANEOUS AGING: ALTERED SKIN TROPHISM AND WRINKLES
(M.T. Leccia, X. Martinet).............................. 693
Intrinsic Aging and Photoaging: Clinical
and Functional Aspects .......................... 693
Intrinsic Aging and Photoaging:
Histologic Features ................................ 694
Intrinsic Aging........................................ 694
Photoaging.............................................. 695
Pathogenesis of Photoaging: Current
Concepts ................................................ 696
Prevention of Cutaneous Aging ................ 697
References .................................................. 700
CHAPTER 48
CHEMICAL PEEL: CLASSIFICATION, INDICATIONS
(A.D. Katsambas, E. Nicolaidou) .................. 703
Classifications of Peeling Agents .............. 703
Indications of Chemical Peels .................... 705
Facial Skin Peels ........................................ 706
Glycolic Acid Peels ................................ 706
TCA Peels .............................................. 707
Pesorcinol Peels...................................... 708
Phenol Peels .......................................... 708
Salicylic Acid Peels ................................ 709
Non-Facial Skin Peels ................................ 709
References .................................................. 710
CHAPTER 49
CHEMICAL PEELS
(Ming H. Jih, Arash Kimyai-Asadi) .............. 711
Introduction ................................................ 711
Procedure.................................................... 712
Complications ............................................ 713
References .................................................. 713
CHAPTER 50
CHEMICAL PEELING WITH TCA
(A. Camps-Fresneda, G.A. Moreno-Arias) .... 715
Introduction ................................................ 715
Chemical Characteristics of TCA .............. 715
TCA Formulation .................................. 715
What Concentration?.............................. 715
Clinical and Histological Aspects .............. 716
CONTENTS xxiii
Indications and Contraindications .............. 717
Skin Preparation ........................................ 718
The Day of the Peeling .............................. 718
Written Informed Consent & Photographs .. 719
Anesthesia and Sedation ............................ 719
Materials .................................................... 719
Technique .................................................. 719
Postoperative Care .................................... 722
Side Effects and Complications ................ 722
Re-Peeling .................................................. 723
Non-Facial Areas........................................ 723
TCA Combined with Other Agents ............ 725
Conclusion.................................................. 726
Acknowledgments ...................................... 726
References .................................................. 726
CHAPTER 51
GLYCOLIC ACID: INDICATIONS AND APPLICATION
(G. Vezzoni, G.M. Vezzoni) ............................ 727
How Superficial Peeling with Glycolic
Acid Works ............................................ 727
History ........................................................ 728
What Peeling Does .................................... 728
What Peeling Does Not Do ........................ 728
Carrying Out Superficial Peeling with
Glycolic Acid.......................................... 729
Preparing the Patient .............................. 729
Technique for Peeling the Face with 70% Glycolic Acid 729
Summary .................................................... 731
References .................................................. 731
CHAPTER 52
DEEP CHEMICAL PEELING
(G.D. Monheit) .............................................. 733
The Peel...................................................... 737
References .................................................. 740
CHAPTER 53
DERMOFILLERS: COLLAGEN, HYALURONIC ACID, SILICONE, METHACRYLATE ETC
(D. Dasiou-Plakida) ...................................... 741
Introduction ................................................ 741
Fluid Silicone ............................................ 741
Fluid Medical Grade Silicone ................ 741
Tissue Histological and Immuno-
Histological Reaction .......................... 743
Injection Techniques .............................. 744
Methodology .......................................... 745
Indications .............................................. 746
Adverse Reactions.................................. 746
Animal Collagen Implants (Zyderm I
Zyderm II Zyplast) ................................ 747
Skin Test ................................................ 747
Injection Techniques .............................. 748
Scars ...................................................... 748
Nasolabial Furrows and Wrinkles .......... 749
Glabellar Wrinkles.................................. 749
Perioral Vertical Lines ............................ 749
Horizontal Forehead Wrinkles .............. 749
Periorbital Wrinkles................................ 749
Lip Augmentation .................................. 749
Results and Duration of Correction........ 750
Adverse reactions .................................. 750
Fibrel .......................................................... 750
Artecoll ...................................................... 751
Resoplast .................................................... 753
Kokken Atelogen........................................ 753
Injectable Human Tissue Matrix-
Dermalogen ............................................ 753
Isolagen ...................................................... 754
Autologen .................................................. 754
e-Ptee (Soft Form) ...................................... 755
Gore-Tex .................................................... 756
Alloderm .................................................... 756
Products of Hyaluronic Acid ...
