"Musculoskeletal disorders and ergonomics in dermatologic surgery: a survey of mohs surgeons in 2010"Liang, Christine A; LEVINE, VICKI J; Dusza, Stephen W; Hale, Elizabeth K; Nehal, Kishwer S
BACKGROUND: Dermatologic surgeons perform numerous procedures that put them at risk of developing work-related musculoskeletal disorders. OBJECTIVE: To study the prevalence of work-related musculoskeletal disorders and role of ergonomics in dermatologic surgery. METHODS AND MATERIALS: A survey study was sent to members of the American College of Mohs Surgery in 2010. The main outcome measures were survey responses relating to surgeon demographics, musculoskeletal symptoms, workstyle habits and attitudes, and ergonomic practices. RESULTS: Ninety percent of respondents reported some type of musculoskeletal symptoms or injuries. The most common complaints were neck, lower back, shoulder, and upper back pain. Most respondents were not using ergonomic modifications in their practice. CONCLUSION: Mohs surgeons have a high prevalence of musculoskeletal disorders. Symptoms present early and persist throughout the careers of Mohs surgeons. The nature of the occupation leaves the surgeon vulnerable to injury. Ergonomic modifications in behavior and workplace are recommended to reduce pain and injury to surgeons..
"Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents"Lee, Erica H; Nehal, Kishwer S; Dusza, Stephen W; Hale, Elizabeth K; LEVINE, VICKI J
BACKGROUND: Given the expanding role of multiple surgical procedures in dermatology, resident training in procedural dermatology must be continually assessed to keep pace with changes in the specialty. OBJECTIVE: We sought to assess the third-year resident experience in procedural dermatology during residency training. METHODS: This survey study was mailed to third-year dermatology residents at 107 Accreditation Council for Graduate Medical Education (ACGME)-approved dermatology residency programs in 2009. RESULTS: A total of 240 residents responded (66%), representing 89% of programs surveyed. Residents assume the role of primary surgeon most commonly in excisional surgery (95%) and flap and graft reconstruction (49%) and least often in Mohs micrographic surgery (18%). In laser and cosmetic procedures, the resident role varies greatly. Residents believed they were most prepared in excisional surgery, botulinum toxin, and laser surgery. Residents believed it was sufficient to have only knowledge of less commonly performed procedures such as hair transplantation, tumescent liposuction, and ambulatory phlebectomy. Of responding residents, 55% were very satisfied with their procedural dermatology training during residency. LIMITATIONS: Individual responses from residents may be biased. Neither residency program nor dermatologic surgery directors were surveyed. CONCLUSION: This survey confirms dermatology residents received broad training in procedural dermatology in 2009, in keeping with ACGME/Residency Review Committee program guidelines. The results provide feedback to dermatology residency programs and are an invaluable tool for assessing, modifying, and strengthening the current procedural dermatology curriculum.
"Novel PRKAR1A gene mutations in Carney Complex"Pan, Lorraine; Peng, Lan; Jean-Gilles, J; Zhang, Ximin; Wieczorek, Rosemary; Jain, Shilpa; LEVINE, VICKI; Osman, Iman; Prieto, Victor G; Lee, Peng
Carney complex is a syndrome that may include cardiac and mucocutaneous myxomas, spotting skin pigmentation, and endocrine lesions. Many patients with Carney complex have been shown to have a stop codon mutation in the PRKAR1A gene in the 17q22-24 region. Here we present the case of a 57 year-old man with multiple skin lesions and cardiac myxomas. Histology of the skin lesions showed lentigenous melanocytic hyperplasia and cutaneous myxomas, confirming the diagnosis of Carney complex. Lesional and control normal tissue from the patient were identified and sequenced for the PRKAR1A gene. A germline missense mutation was identified at exon 1A. This is the first report of this mutation, and one of the few reported missense mutation associated with Carney complex. This finding strengthens the argument that there are alternative ways in which the protein kinase A 1-alpha subunit plays a role in tumorigenesis.
"Teens and tanning knowledge and attitudes"Ashinoff, Robin; LEVINE, VICKI J; Steuer, Alexa B; Sedwick, Carly
Background: The incidence of skin cancer, including melanoma, continues to increase. Teenagers are especially vulnerable, as are young females. The incidence of melanoma among young women in their twenties and thirties has begun to increase again. These young people are also the population that frequent tanning salons. Objective: This voluntary, anonymous, New York University, Institutional Review Board-approved survey was given to students in grades 9 through 12 to ascertain their understanding of what causes skin cancers and the dangers of excessive sun exposure and tanning salons. Methods and materials: An Institutional Review Board-approved, 22-question survey was administered anonymously to more than 450 students with 368 returned responses. The survey was administered to students in grades 9 through 12 at two high schools in New York and New Jersey. Results: More than 80 percent of students view movie stars as tan and almost 60 percent see 'tan' people as better looking. In addition, more than 90 percent believe that a tan does not prevent further damage to the skin (as opposed to the customary belief that a 'base' tan can protect against extreme sun exposures, such as when on a tropical vacation). There appears to be a disconnect between knowledge and sun tanning behaviors. Most teenagers still believe that tans are attractive and teenage girls continue to use tanning salons and tan naturally. We need to address the connection between sun tanning in youth and skin cancers years later. Legislation to limit access of tanning salons to teenagers needs to be enacted.
"Analysis of vector alignment with the Zitelli bilobed flap for nasal defect repair: a comparison of flap dynamics in human cadavers"Zoumalan, Richard Abraham; Hazan, Carole; LEVINE, VICKI J; Shah, Anil R
OBJECTIVE: To determine whether differences of angles between the alar rim and the long axis of the secondary defect in a Zitelli bilobed flap affect alar displacement in a fresh cadaver model. METHODS: In fresh cadaver heads, identical, unilateral 1-cm circular defects were created at the superior alar margin. Three different laterally based bilobed flap templates for reconstruction were used. One template, used on 3 cadavers, had an angle of 60 degrees between the alar rim and the long axis of the secondary defect. Another template, used on 3 cadavers, had an angle of 90 degrees . The last template had an angle of 135 degrees and was used on 2 cadavers. Photographs were taken before the repair and after with the camera and cadaver heads in the same spatial relationship to each other. RESULTS: In the 3 cadavers that had repair using an angle of 60 degrees , all cadavers experienced alar retraction, with a mean displacement of 1.3 mm. This was not a statistically significant change (P = .07). In the defects that had repair using an angle of 90 degrees , there was also no significant alar displacement (P = .72). In the 2 cadavers that underwent repair using an angle of 135 degrees , both ala underwent depression by 1.0 mm. When the differences achieved between the different angles were compared, there was a significant difference in measured distortion between the cadavers that had 90 degrees and 60 degrees vector placement (P = .02). There were no measurable changes to the contralateral maximal nostril distance. CONCLUSIONS: Vector alignment can have an impact on nostril displacement. In bilobed flaps, the axis of the secondary defect may play an important role. This study suggests that secondary defects aligned perpendicular to the nostril have the least amount of alar distortion.
"Keratoacanthoma arising from an excisional surgery scar"Kimyai-Asadi, Arash; Shaffer, Christy; LEVINE, VICKI J; Jih, Ming H
A causal relationship between keratoacanthomas and a variety of preceding traumatic events has been postulated in the literature. We report a patient who developed a keratoacanthoma at the site of a recent cutaneous excision site, demonstrating that surgical trauma can precede the development of keratoacanthomas.
"Laser treatment of congenital and acquired vascular lesions. A review"Rothfleisch, Jeremy E; Kosann, Meredith Klein; LEVINE, VICKI J; Ashinoff, Robin
Several quasi-continuous-wave and pulsed lasers can effectively treat a variety of vascular lesions. The pulsed dye laser and its newer variants were specifically designed to target hemoglobin and, by increasing their wavelengths slightly, have successfully achieved greater depths of penetration. When used in to compliance with the theory of selective photothermolysis, these systems have been shown to be safe and to have a low incidence of adverse sequelae. With the concomitant use of epidermal cooling systems, side-effect profiles have been further reduced. Although great progress has been made in the laser treatment of leg telangiectasias, even the newest laser systems have failed to meet patient expectations. Continuing advances in laser technology, however, will probably lead to enhanced clinical results, decreased side-effect profiles, improved hardware, and reduced costs.
"Laser removal of tattoos"Kuperman-Beade M; LEVINE VJ; Ashinoff R
Tattoos are placed for different reasons. A technique for tattoo removal which produces selective removal of each tattoo pigment, with minimal risk of scarring, is needed. Nonspecific methods have a high incidence of scarring, textural, and pigmentary alterations compared with the use of Q-switched lasers. With new advances in Q-switched laser technology, tattoo removal can be achieved with minimal risk of scarring and permanent pigmentary alteration. There are five types of tattoos: amateur, professional, cosmetic, medicinal, and traumatic. Amateur tattoos require less treatment sessions than professional multicolored tattoos. Other factors to consider when evaluating tattoos for removal are: location, age and the skin type of the patient. Treatment should begin by obtaining a pre-operative history. Since treatment with the Q-switched lasers is painful, use of a local injection with lidocaine or topical anaesthesia cream may be used prior to laser treatment. Topical broad-spectrum antibacterial ointment is applied immediately following the procedure. Three types of lasers are currently used for tattoo removal: Q-switched ruby laser (694 nm), Q-switched Nd:YAG laser (532 nm, 1064 nm), and Q-switched alexandrite laser (755 nm). The Q-switched ruby and alexandrite lasers are useful for removing black, blue and green pigments. The Q-switched 532 nm Nd:YAG laser can be used to remove red pigments and the 1064 nm Nd:YAG laser is used for removal of black and blue pigments. The most common adverse effects following laser tattoo treatment with the Q-switched ruby laser include textural change, scarring, and pigmentary alteration. Transient hypopigmentation and textural changes have been reported in up to 50 and 12%, respectively, of patients treated with the Q-switched alexandrite laser. Hyperpigmentation and textural changes are infrequent adverse effects of the Q-switched Nd:YAG laser and the incidence of hypopigmentary changes is much lower than with the ruby laser. The development of localized and generalized allergic reactions is an unusual complication following tattoo removal with the Q-switched ruby and Nd:YAG lasers. Since many wavelengths are needed to treat multicolored tattoos, not one laser system can be used alone to remove all the available inks and combination of inks. While laser tattoo removal is not perfect, we have come a long way since the advent of Q-switched lasers. Current research is focusing on newer picosecond lasers, which may be more successful than the Q-switched lasers in the removal of the new vibrant tattoo links.
"Er:YAG laser for the treatment of actinic keratoses"Jiang SB; LEVINE VJ; Nehal KS; Baldassano M; Kamino H; Ashinoff RA
BACKGROUND: There is no single optimal treatment for multiple facial actinic keratoses. The existing therapies such as topical 5-fluorouracil, chemical peels, cryotherapy, dermabrasion, and CO2 laser resurfacing can produce prolonged recovery time or are often operator dependent. OBJECTIVE: The purpose of this study was to investigate another therapeutic modality which provides a shorter recovery time with uniform results. We performed a prospective pilot study investigating the use of the Er:YAG laser for the treatment of multiple facial actinic keratoses. METHODS: Five patients with multiple facial actinic keratoses were treated with two to three passes of Er:YAG laser. Anesthesia was achieved in all cases by topical application and local infiltration when indicated. All patients were treated with 2.0 J, 5 mm spot size, and a fluence of 10 J/cm2. Clinical and histologic evaluations were performed both pre- and postoperatively. RESULTS: All patients showed a decrease in the total number of clinical actinic keratoses on the face ranging from 86 to 96%. In addition to the reversal of actinic damage in the epidermis, histologic evidence revealed increased fibroplasia and decreased superficial solar elastosis 3 months after the laser resurfacing. Reepithelialization occurred in 5-8 days, and erythema lasted for about 3-6 weeks after the procedure. There was no evidence of scarring or pigmentary changes in any of the patients during the follow-up period. CONCLUSION: Er:YAG laser skin resurfacing is a safe and effective treatment for multiple facial actinic keratoses. Histologic data suggest a new zone of collagen deposition occurs in the superficial papillary dermis. Under our current parameters, Er:YAG laser skin resurfacing has a relatively short recovery period and a low risk of scarring. Unlike the CO2 laser, Er:YAG laser skin resurfacing can be performed with topical anesthesia alone.
"Comparative study of the efficacy of four topical anesthetics"Friedman PM; Fogelman JP; Nouri K; LEVINE VJ; Ashinoff R
BACKGROUND: With the emergence of new laser and dermatologic procedures, the need for more effective topical anesthesia continues to grow. There are now several topical anesthetics that are being used prior to laser and surgical procedures. OBJECTIVE: To compare the degree and duration of anesthesia produced by four commonly used topical anesthetics, we performed a prospective study investigating the efficacy of EMLA (eutectic mixture of local anesthetics), ELA-Max, 4% tetracaine gel, and betacaine-LA ointment (formerly eutectic-LA). METHODS: Equal amounts of the above topical anesthetics plus a control (eucerin cream) were applied to 10 test sites under occlusion on the volar forearms of 12 adult volunteers. After a 60-minute application time, the degree of anesthesia was assessed immediately by a Q-switched Nd:YAG laser at 1064 nm. Pain testing was also performed 30 minutes after the 60-minute application period. Volunteer responses to pain stimuli were recorded using an ordinal scale of 0 (no pain) to 4 (maximal pain). The mean scores for the time intervals were obtained. Analysis of the data was performed using analysis of variance (ANOVA), Newman-Keuls test, Friedman rank order test, and paired t-tests. RESULTS: ELA-Max, EMLA, and tetracaine were statistically superior to control after the 60-minute application period. Thirty minutes later, ELA-Max, EMLA, tetracaine, and betacaine-LA were all statistically superior to the control. Comparing individual anesthetics, ELA-Max and EMLA were the superior anesthetics at both time intervals. Although the mean pain scores for each anesthetic were lower 30 minutes after their removal, the differences did not reach statistical significance. CONCLUSION: This is the first prospective study comparing the efficacy of several new topical anesthetic agents. Using the methodology of this study, in which the anesthetics were applied under occlusion, ELA-Max and EMLA were the superior anesthetics after a 60-minute application time and 30 minutes later. In addition, there was a clinical increase in efficacy suggested with all of the anesthetics 30 minutes after their removal.
"Treatment of mature striae with the pulsed dye laser"Nehal KS; Lichtenstein DA; Kamino H; LEVINE VJ; Ashinoff R
INTRODUCTION: Striae are a common cosmetic problem with no effective treatment options. A recent study has shown improvement in the appearance of mature striae following a single 585-nm pulsed dye laser (PDL) treatment at low fluence. OBJECTIVE: To evaluate the effectiveness of treating mature striae with the 585-nm PDL. METHODS: Five patients with mature striae on the abdomen were prospectively treated with the 585-nm PDL at 2-month intervals for 1-2 years. The response of the striae to laser treatment was evaluated in each patient through sequential clinical, photographic, textural, and histologic assessment. RESULTS: All five patients reported a slight overall improvement in the appearance of the striae following multiple PDL treatments. Comparison of pre- and post-treatment photographs, however, failed to reveal improvement in any patients. Optical profilometry performed on striae impressions showed mild improvement in the surface texture of striae in three patients. Histologic comparison of pre- and post-treatment biopsy specimens failed to reveal normalization of skin architecture. CONCLUSIONS: Serial treatment of mature striae with the PDL results in mild, subjective, clinical improvement but no significant photographic, textural or histologic improvement.
"Pulsed dye laser treatment of warts: an update"Ross BS; LEVINE VJ; Nehal K; Tse Y; Ashinoff R
BACKGROUND: Warts are a therapeutic challenge. New studies indicate that pulsed dye laser therapy may be effective, with clearance rates of 72 to 93%. OBJECTIVE: To determine clearance rate in pulsed dye laser treatment of warts and compare our rate to those of other published studies. METHODS: Thirty-three patients with 96 warts received pulsed dye laser treatment for recalcitrant plantar, digital, peri- and subungual, and body warts. RESULTS: Forty-eight percent of patients had complete wart clearance; 45% partially cleared. Sixty-nine percent of those who cleared remained wart-free for an average of 11 months. Mean fluence was 9.4 J/cm2, with an average of 3.4 treatments. Body and palmar warts responded best, digital and peri- and subungual next, and plantar lesions worst. No significant side effects were observed. CONCLUSION: Pulsed dye laser is an effective treatment option for recalcitrant warts with an excellent side effect profile. However, our response rates were not as high as those previously reported, and we feel that further studies would be useful.
"Basal cell carcinoma of the genitalia"Nehal KS; LEVINE VJ; Ashinoff R
BACKGROUND: Basal cell carcinomas (BCC) arising on the genitalia are exceedingly rare with an unclear pathogenesis. OBJECTIVE: To better understand risk factors, tumor characteristics, and the possible role of human papillomavirus (HPV) in the development of BCC of the genitalia. METHODS: 1543 records of Mohs micrographic surgery performed during a 6-year period were reviewed to identify cases of BCC arising on the genitalia. Tumor tissue was analyzed for HPV DNA by in situ hybridization. RESULTS: Four patients with BCC of the genitalia were treated with Mohs micrographic surgery. The malignancies were located on the scrotum, perineum, and perianal areas in the three male patients and on the vulva in the female patient. The mean age was 67 years. None of the patients had prior history of skin cancers. Histologic evaluation of the tumors revealed two nodular subtypes, one superficial subtype, and one with follicular differentiation. In situ hybridization failed to reveal DNA of HPV types 6, 11, 16, 18, 30, 31, 33, 35, 45, 51, and 52. CONCLUSION: In this small series, genital BCC occurred in an older age group with no identifiable predisposing risk factors and did not show evidence of HPV infection.