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Cosmetic Techniques Help to Limit Mohs Scarring


 

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen

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