Mohs micrographic surgery of a plexiform fibrohistiocytic tumor

BACKGROUND

Plexiform fibrohistiocytic tumor (PFT) is a rare mesenchymal neoplasm first described by Enzinger and Zhang in 1988. Clinically it is characterized by slow growth, frequent local recurrences, and rare systemic metastasis. These tumors occur chiefly in children and young adults and are most commonly located on the shoulders and forearms.

OBJECTIVE

To present a case report of an incompletely excised PFT, its complete resection using simple excision and Mohs micrographic surgery, and review of the literature.

METHODS

An 11-year-old Hispanic girl was evaluated for the treatment of an incompletely excised plexiform fibrohistiocytic neoplasm located in the right axilla. Mohs micrographic surgery (MMS) was chosen because of the ill-defined borders and the need for tissue conservation. The patient underwent a two-stage, six section, micrographically controlled excision. Upon completion of the MMS a 2 mm final stage, taken as a peripheral and deep section around and underneath the cleared area, was submitted for paraffin embedding. Residual plexiform histiocytic tumor was found at the margin of resection in one location. Reevaluation of the Mohs slides demonstrated the possible presence of tumor at one deep focus. The tumor was reexcised with a 5 mm margin and repeat hematoxylin and eosin staining showed no residual tumor. There has been no evidence of recurrence in 4 years.

RESULTS

Complete resection of the PFT and absence of tumor recurrence 4 years later.

CONCLUSION

Over the past few years the list of neoplasms for which MMS is the treatment of choice has steadily grown. PFT is a recently described locally aggressive mesenchymal neoplasm with potential for distant metastasis. To our knowledge this is the first time MMS has been used to resect this tumor. To ensure the chance of complete extirpation we recommend the harvest of an additional stage for hematoxylin and eosin staining, as is done in some aggressive squamous cell carcinomas.

The S-lift facelift featuring the U-suture and O-suture combined with skin resurfacing

BACKGROUND

A short-flap S-lift may be helpful for minor jowling or submental laxity in cases of early facial ptosis, revision facelifts, or where skin resurfacing is combined with neck lifting.

OBJECTIVE

To develop a safe and effective method to lift the jowl either as a single procedure or combined with other rejuvenation methods.

METHODS

After the induction of monitored anesthesia care the skin resurfacing is completed, if necessary, and the submental and lateral S-lift incisions are marked next to the tragus. The submental area is hydrodissected with modified tumescent solution. After a 15-minute waiting period, the submental area is debulked with small spatula cannulas using reduced pressure liposuction. Often the platysma bands are tied together with a running locked suture. The right cheek area is hydrodissected and debulked in a similar fashion. A 3-4 cm flap is elevated. If necessary, further blunt dissection is passed through the anterior mandible ligament and the nasolabial fold. Care is taken to keep the skin trabeculae intact. The SMAS is plicated with a U-shaped and O-shaped purse-string suture. Following this tightening of the subcutaneous tissue, the skin is closed with a double-layer closure. The face is dressed in two layers of tube gauze. Sutures are removed in 7-9 days.

RESULTS

This S-lift gives a pleasing rejuvenation of the jowl and submental area. It is also possible to combine this procedure with other procedures such as corset platysmaplasty, skin resurfacing, fat augmentation, a browlift, or blepharoplasty.

CONCLUSION

The S-lift provides a safe and effective method for rejuvenation of the early sagging face or for revision facelift.

Lip rejuvenation

BACKGROUND

The management of the senile lip remains a dilemma. Allogenic fillers often feel unnatural, lip resurfacing is not adequate, and fat transfers may disappear.

OBJECTIVE

To develop a more reliable step-by-step approach to lip augmentation.

METHOD

Lips were divided into types: (1) the simple senile lip that had lost its fullness-treated with fat augmentation; (2) the lip with rhagades-treated with fat augmentation and laser resurfacing; and (3) the duckbill lip-treated with lip advancement, fat augmentation, and laser resurfacing. Tattooing to increase the degree of redness was performed on all types of lips.

RESULT

If there had been a previously full lip, it was possible to rejuvenate the lip by simple augmentation with autologous fat transfer. The average number of fat transfer sessions to generate this pleasing lip was two to three. The lip with rhagades required fat filling, with laser resurfacing to achieve a new contour. The duckbill lip required a lip advancement along with lipofilling and laser resurfacing. All types benefited from lip tattooing.

CONCLUSIONS

It was possible with fat augmentation and/or laser resurfacing to generate a pleasing lip in type 1 and 2 lips. Lip type 3 required a lip advancement along with fat augmentation and laser resurfacing. Lip tattooing accentuated all the lip types.

Modified tumescent liposuction

BACKGROUND

Tumescent liposuction has been found to be safe and effective. However, there are still many refinements that may be possible, such as varying the size and tips of the cannulas, varying the types of infiltrate and associated anesthesia, and the method of compression.

OBJECTIVE

To examine possible variables in tumescent liposuction techniques such as the most efficient liposuction cannulas, to determine an effective tumescent fluid, and to examine the extent of compression provided by different garments.

METHODS

Patient markings, tumescent fluid formulas, methods of infiltration, types of cannulas, skin incisions, and compression garments were compared between the pure tumescent technique and modified tumescent liposuction.

RESULTS

The most efficient cannulas were those with three staggered ports, such as the Mercedes, Cobra-keel, Giorgio Fischer, and Accelerator II tips. When these are combined with modified tumescent fluids and sedation, it is possible to perform total body liposuction in a safe and efficient manner. Multiple ports and compression garments are beneficial to reduce bruising and focal areas of inflammation.

CONCLUSION

The tumescent liposuction technique will continue to be improved. So far, with more efficient cannulas and more efficient tumescent fluids, combined with sedation, it has been possible to increase the yield and decrease the required time for the technique. We call this modified tumescent liposuction.

Neck rejuvenation by combining Jessner/TCA peel, dermasanding, and CO2 laser resurfacing

BACKGROUND

One of the greatest challenges facing facial cosmetic surgeons today is the simultaneous rejuvenation of the neck and face. Laser resurfacing of the face using the carbon dioxide (CO2) laser or the erbium:yttrium-aluminum-garnet (Er:YAG) laser has enjoyed widespread popularity, but the neck and chest are often avoided. It would be quite helpful to rejuvenate the neck at the same time the face is being resurfaced. This would diminish lines of demarcation and help reduce the signs of aging of the neck. There would be a better match between the new skin of the neck and face.

OBJECTIVE

To develop a safe and effective method to rejuvenate the neck.

METHOD

A step-by-step skin care program was instituted. The patients preconditioned their face and neck skin with vitamin A/glycolic skin conditioning lotions for 6-8 weeks prior to surgery. Following this the chest and neck area was treated with the Jessner-trichloroacetic acid (TCA) peel. Then the middle section of the neck was sanded with 150 grit sandscreen. Finally, the central area was resurfaced with the UltraPulse CO2 laser using reduced power settings. Usually two passes was adequate to shrink the skin of this central section of the neck. A petrolatum-based ointment was applied during the initial 7-day postoperative period. After reepithelialization a sunscreen-moisturizer was used during the day and hydrocortisone moisturizer was applied at night.

RESULTS

The neck skin was able to tolerate this step-by-step skin rejuvenation. The blending from the décolleté area to the hairline produced a rejuvenation without a line of demarcation. There were no examples of scarring in the 12 cases that were evaluated for 6 months. Two cases developed persistent erythema that responded to silicone gel sheeting. Although no patients complained of hypopigmentation, a decrease in pigment was found using special UV photography.

CONCLUSION

It is possible with this gradient, step-by-step method to produce a rejuvenation of the neck. An improved texture of the neck developed without visible scarring.

Disappointing results following resurfacing of facial skin with CO2 lasers for prophylaxis of keratoses and cancers

BACKGROUND

With the development of the short-pulse CO2 laser it was hoped that this resurfacing would prevent recurrent actinic keratoses and basal cell cancers similar to resurfacing with dermabrasion, laser abrasion, and deep chemical peel. However, we have begun to see patients that are developing keratoses and cancers within months following laser resurfacing.

OBJECTIVE

To document the problems of recurrent keratoses and basal cell cancers in patients following CO2 laser resurfacing.

METHODS

Thirty-five patients with extreme sun damage were seen at 3, 6, and 12 months following CO2 laser resurfacing for repeat color and ultraviolet photography and clinical examination to look for erythematous dyskeratotic lesions or papules with pearly borders.

RESULTS

Five of our patients (14.3%) who had undergone recent CO2 resurfacing developed actinic keratoses and basal cell cancers.

CONCLUSION

CO2 laser resurfacing is not as effective as dermabrasion, chemabrasion, and deep chemical peel for the prophylaxis of actinic keratoses and basal cell cancers, especially in Fitzpatrick type I and II patients.

Dermabrasion using CO2 dry ice

BACKGROUND

The cosmetic dermatologic surgeon can improve facial scars by using a variety of techniques. Chemical peels, lasers, and dermabrasion are among the most common modalities used. In recent years, laser resurfacing has enjoyed great popularity; however, there is still a role for the time-honored and effective technique of dermabrasion. The recent withdrawal of Freon from the market has made dermabrasion more difficult.

OBJECTIVE

To introduce a novel technique of using solid carbon dioxide (CO2) to freeze the skin before dermabrasion.

METHOD

Twenty-five consecutive patients with facial acne scars underwent a combination of procedures including chemical peeling and CO2 laser resurfacing, followed by freeze-dermabrasion. Compressed CO2 was then used to make a solid ball of dry ice. The ice was used to freeze the skin prior to dermabrasion. After the application of the dry ice ball to the skin for about 4 seconds, the scares were dermabraded with the large mushroom wheel. As the tissue defrosted, the operator started at the outer edge of the freeze and planed into the center. This procedure was repeated until the desired improvement was achieved.

RESULTS

With dry ice, a good skin turgor was achieved. This provided a good foundation for the sanding of the acne scars. The patients were pleased with the results and complications were minimal.

CONCLUSION

"Home-made" dry ice works as well as Freon in providing skin turgor for dermabrasion. CO2 dry ice has the added benefits of being inexpensive and environmentally friendly.