Damian McNamara

MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.

"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.

The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."

Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.

"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).

"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.

"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.

Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.

The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.

"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."

Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."

The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.

Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.

Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.

MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.

"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.

The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."

Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.

"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).

"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.

"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.

Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.

The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.

"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."

Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."

The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.

Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.

Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.

MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.

"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.

The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."

Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.

"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).

"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.

"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.

Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.

The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.

"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."

Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."

The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.

Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.

Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.

ORLANDO – Short, fixed cannulas can deliver filler products to augment multiple areas of the face, including nasolabial folds, the dorsum of the nose, and under the eyes, according to Dr. Doris Hexsel.

The small caliber, short cannulas also offer greater precision for filler placement, compared with the longer, flexible cannulas currently on the market, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande (Brazil) do Sul.

Cannulas are disposable, can be attached to different syringe types, and can replace needles for most facial filler indications, Dr. Hexsel said. One notable exception is in the treatment of superficial lines or defects, where she said she still recommends the use of a needle.

Cannulas can deliver a wide range of filler products. "Anything we inject with needles we can also inject with cannulas," Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

All cannulas with a rounded end typically cause less bruising and trauma, compared with needles. Cannulas also help to avoid other needle-related adverse events, Dr. Hexsel said. Perforation of the veins or arteries and accidental injection of fillers into vessels are the most serious examples.

Facial augmentation via cannula is "particularly useful for patients taking anticoagulants or who cannot bruise because they have a social event," Dr. Hexsel said. Reduction of the risk of a sharps injury is a plus for physicians, she added.

Cannulas cannot puncture the skin, so a needle stick is still required to make an entry hole. Proponents of long cannulas will point to a need for only one entry point, Dr. Hexsel said, but "a single orifice and use of a long cannula cannot reach all indications." Nasolabial folds, for example, require at least two entry points to treat.

Dr. Hexsel designed a cannula that she and her colleagues compared with a standard needle in a prospective, randomized, phase II bilateral study of 25 women (Dermatol. Surg. 2011 Oct. 19 [doi:10.1111/j.1524-4725.2011.02195.x]). The metallic cannula safely and effectively delivered hyaluronic acid for nasolabial fold augmentation and was associated with less pain, edema, hematoma and redness at the site, compared with the side treated with a needle. At day 3, the mean Modified Fitzpatrick Wrinkle Scale was comparable for both treated sides of the face (from 2.40 at baseline to 1.46 on the cannula-injected side and from 2.40 to 1.48 on the needle-injected side).

Photos courtesy Dr. Doris Hexsel

Another use for cannulas is to deliver filler products to correct any defects of the nasal dorsum after rhinoplasty, she said.

Cannulas can also deliver fillers to help improve the appearance of dark circles under the eyes. After Dr. Hexsel cleans and marks the area, she said she injects a small amount of lidocaine anesthetic. She said that she then makes a small hole with a regular needle and introduces the cannula. Only inject a small amount of filler product at a time, she said. "You can ask patients to participate. I can put in a little Restylane under the eyes, give the patient a mirror, and ask them where they want more." The patient leaves with nothing visible; a small micropore dressing can be placed over the entry points.

Dr. Hexsel disclosed holding design patents on cannula devices not yet available in the United States.

ORLANDO – Short, fixed cannulas can deliver filler products to augment multiple areas of the face, including nasolabial folds, the dorsum of the nose, and under the eyes, according to Dr. Doris Hexsel.

The small caliber, short cannulas also offer greater precision for filler placement, compared with the longer, flexible cannulas currently on the market, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande (Brazil) do Sul.

Cannulas are disposable, can be attached to different syringe types, and can replace needles for most facial filler indications, Dr. Hexsel said. One notable exception is in the treatment of superficial lines or defects, where she said she still recommends the use of a needle.

Cannulas can deliver a wide range of filler products. "Anything we inject with needles we can also inject with cannulas," Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

All cannulas with a rounded end typically cause less bruising and trauma, compared with needles. Cannulas also help to avoid other needle-related adverse events, Dr. Hexsel said. Perforation of the veins or arteries and accidental injection of fillers into vessels are the most serious examples.

Facial augmentation via cannula is "particularly useful for patients taking anticoagulants or who cannot bruise because they have a social event," Dr. Hexsel said. Reduction of the risk of a sharps injury is a plus for physicians, she added.

Cannulas cannot puncture the skin, so a needle stick is still required to make an entry hole. Proponents of long cannulas will point to a need for only one entry point, Dr. Hexsel said, but "a single orifice and use of a long cannula cannot reach all indications." Nasolabial folds, for example, require at least two entry points to treat.

Dr. Hexsel designed a cannula that she and her colleagues compared with a standard needle in a prospective, randomized, phase II bilateral study of 25 women (Dermatol. Surg. 2011 Oct. 19 [doi:10.1111/j.1524-4725.2011.02195.x]). The metallic cannula safely and effectively delivered hyaluronic acid for nasolabial fold augmentation and was associated with less pain, edema, hematoma and redness at the site, compared with the side treated with a needle. At day 3, the mean Modified Fitzpatrick Wrinkle Scale was comparable for both treated sides of the face (from 2.40 at baseline to 1.46 on the cannula-injected side and from 2.40 to 1.48 on the needle-injected side).

Photos courtesy Dr. Doris Hexsel

Another use for cannulas is to deliver filler products to correct any defects of the nasal dorsum after rhinoplasty, she said.

Cannulas can also deliver fillers to help improve the appearance of dark circles under the eyes. After Dr. Hexsel cleans and marks the area, she said she injects a small amount of lidocaine anesthetic. She said that she then makes a small hole with a regular needle and introduces the cannula. Only inject a small amount of filler product at a time, she said. "You can ask patients to participate. I can put in a little Restylane under the eyes, give the patient a mirror, and ask them where they want more." The patient leaves with nothing visible; a small micropore dressing can be placed over the entry points.

Dr. Hexsel disclosed holding design patents on cannula devices not yet available in the United States.

ORLANDO – Short, fixed cannulas can deliver filler products to augment multiple areas of the face, including nasolabial folds, the dorsum of the nose, and under the eyes, according to Dr. Doris Hexsel.

The small caliber, short cannulas also offer greater precision for filler placement, compared with the longer, flexible cannulas currently on the market, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande (Brazil) do Sul.

Cannulas are disposable, can be attached to different syringe types, and can replace needles for most facial filler indications, Dr. Hexsel said. One notable exception is in the treatment of superficial lines or defects, where she said she still recommends the use of a needle.

Cannulas can deliver a wide range of filler products. "Anything we inject with needles we can also inject with cannulas," Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

All cannulas with a rounded end typically cause less bruising and trauma, compared with needles. Cannulas also help to avoid other needle-related adverse events, Dr. Hexsel said. Perforation of the veins or arteries and accidental injection of fillers into vessels are the most serious examples.

Facial augmentation via cannula is "particularly useful for patients taking anticoagulants or who cannot bruise because they have a social event," Dr. Hexsel said. Reduction of the risk of a sharps injury is a plus for physicians, she added.

Cannulas cannot puncture the skin, so a needle stick is still required to make an entry hole. Proponents of long cannulas will point to a need for only one entry point, Dr. Hexsel said, but "a single orifice and use of a long cannula cannot reach all indications." Nasolabial folds, for example, require at least two entry points to treat.

Dr. Hexsel designed a cannula that she and her colleagues compared with a standard needle in a prospective, randomized, phase II bilateral study of 25 women (Dermatol. Surg. 2011 Oct. 19 [doi:10.1111/j.1524-4725.2011.02195.x]). The metallic cannula safely and effectively delivered hyaluronic acid for nasolabial fold augmentation and was associated with less pain, edema, hematoma and redness at the site, compared with the side treated with a needle. At day 3, the mean Modified Fitzpatrick Wrinkle Scale was comparable for both treated sides of the face (from 2.40 at baseline to 1.46 on the cannula-injected side and from 2.40 to 1.48 on the needle-injected side).

Photos courtesy Dr. Doris Hexsel

Another use for cannulas is to deliver filler products to correct any defects of the nasal dorsum after rhinoplasty, she said.

Cannulas can also deliver fillers to help improve the appearance of dark circles under the eyes. After Dr. Hexsel cleans and marks the area, she said she injects a small amount of lidocaine anesthetic. She said that she then makes a small hole with a regular needle and introduces the cannula. Only inject a small amount of filler product at a time, she said. "You can ask patients to participate. I can put in a little Restylane under the eyes, give the patient a mirror, and ask them where they want more." The patient leaves with nothing visible; a small micropore dressing can be placed over the entry points.

Dr. Hexsel disclosed holding design patents on cannula devices not yet available in the United States.

MIAM BEACH – Botulinum toxin injections provided good, long-term symptom control for many patients with oromandibular dystonia in a retrospective analysis of a series of patients treated at a single center.

Oromandibular dystonia (OMD) is involuntary, repetitive, or twisting spasms of the muscles around the mouth and lower face. Affected people experience jaw opening, jaw closing, lateral jaw deviation, or a combination of these forms.

"Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms," Dr. Catherine F. Sinclair said at the Triological Society’s Combined Sections meeting. With no cure for the condition and oral medication that only improves symptoms for about one-third of patients, botulinum toxin is considered a treatment option, she added.

Along with colleagues Dr. Lowell E. Gurey and Dr. Andrew Blitzer, Dr. Sinclair reported on a series of 59 patients treated with onabotulinumtoxinA (Botox) for OMD since 1995. They assessed the long-term management of the patients and also sought to develop a treatment algorithm for OMD and compare the current series with an original cohort of 20 OMD patients treated by Dr. Blitzer in the 1980s (Ann. Otol. Rhinol. Laryngol. 1989;98:93-7).

In the current series, 10 patients required only one treatment session, another 10 had two sessions, and 39 returned more than twice for subsequent injections of onabotulinumtoxinA. Functional response determined the need and timing of subsequent injections. For example, patients with less than a 50% improvement on a 1 to 100 function rating scale were re-injected less than a month following their initial treatment. The overall median time between treatments was 3 months.

An advantage of onabotulinumtoxinA injections, compared with oral medications, is a greater ability to tailor the treatment. "Injections can be titrated by dose and site to address the predominant muscle systems involved," Dr. Sinclair said at the meeting, which was jointly sponsored by The Triological Society and the American College of Surgeons.

Initial injection dosage ranged from 2.4 U to 5.0 U onabotulinumtoxinA. "Regardless of clinical type, if a patient experiences no response or less than 50% functional improvement, they should be re-injected with either the same dose as the initial injection or with a dose increase of 5 U to 10 U botulinum toxin," said Dr. Sinclair, an otolaryngology fellow at St. Luke’s–Roosevelt Hospital in New York. Also consider treatment of additional muscles, she added.

OMD subtype dictated the specific muscles injected. The masseter and/or temporalis muscles were most often injected for the jaw closing subtype, for example. The internal pterygoid was most often injected for the jaw opening and lateral deviation types of OMD. All injections were percutaneous except for external pterygoid injections, where were done intra-orally, Dr. Sinclair said.

One major caveat is to avoid significant post-injection dysphagia. For this reason, Dr. Sinclair said, anterior digastric muscle injections are performed superficially to avoid diffusion into the underlying floor of the mouth and tongue base musculature. In the study patients, automated machine guidance coupled with visual inspection of areas of maximum muscular hypertrophy determined initial needle placement. Optimal placement was confirmed with voluntary movement.

Not surprisingly, large muscles such at the masseter and temporalis typically receive higher toxin dose and a higher median number of injections. For example, these two muscles are typically injected at five sites, compared with three each for the pterygoid or digastric muscles, Dr. Sinclair said.

The injections appear to be relatively safe in this population. There were no complications reported post-injection by any patient in the current series, Dr. Sinclair said.

The mean age among the 59 patients was 57 years, and 72% were women. The mean follow-up time was 4.3 years.

"Of note, significantly more patients with jaw opening form of OMD were treated in the more recent data set," Dr. Sinclair said. "In line with this, there was an increase in lateral pterygoid and anterior digastric injections," compared with the older series. Despite the increase in jaw opening dystonia in more recent years, the majority of patients (65%) still presented with the jaw closing form.

Dr. Sinclair reported having no relevant financial disclosures.

MIAM BEACH – Botulinum toxin injections provided good, long-term symptom control for many patients with oromandibular dystonia in a retrospective analysis of a series of patients treated at a single center.

Oromandibular dystonia (OMD) is involuntary, repetitive, or twisting spasms of the muscles around the mouth and lower face. Affected people experience jaw opening, jaw closing, lateral jaw deviation, or a combination of these forms.

"Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms," Dr. Catherine F. Sinclair said at the Triological Society’s Combined Sections meeting. With no cure for the condition and oral medication that only improves symptoms for about one-third of patients, botulinum toxin is considered a treatment option, she added.

Along with colleagues Dr. Lowell E. Gurey and Dr. Andrew Blitzer, Dr. Sinclair reported on a series of 59 patients treated with onabotulinumtoxinA (Botox) for OMD since 1995. They assessed the long-term management of the patients and also sought to develop a treatment algorithm for OMD and compare the current series with an original cohort of 20 OMD patients treated by Dr. Blitzer in the 1980s (Ann. Otol. Rhinol. Laryngol. 1989;98:93-7).

In the current series, 10 patients required only one treatment session, another 10 had two sessions, and 39 returned more than twice for subsequent injections of onabotulinumtoxinA. Functional response determined the need and timing of subsequent injections. For example, patients with less than a 50% improvement on a 1 to 100 function rating scale were re-injected less than a month following their initial treatment. The overall median time between treatments was 3 months.

An advantage of onabotulinumtoxinA injections, compared with oral medications, is a greater ability to tailor the treatment. "Injections can be titrated by dose and site to address the predominant muscle systems involved," Dr. Sinclair said at the meeting, which was jointly sponsored by The Triological Society and the American College of Surgeons.

Initial injection dosage ranged from 2.4 U to 5.0 U onabotulinumtoxinA. "Regardless of clinical type, if a patient experiences no response or less than 50% functional improvement, they should be re-injected with either the same dose as the initial injection or with a dose increase of 5 U to 10 U botulinum toxin," said Dr. Sinclair, an otolaryngology fellow at St. Luke’s–Roosevelt Hospital in New York. Also consider treatment of additional muscles, she added.

OMD subtype dictated the specific muscles injected. The masseter and/or temporalis muscles were most often injected for the jaw closing subtype, for example. The internal pterygoid was most often injected for the jaw opening and lateral deviation types of OMD. All injections were percutaneous except for external pterygoid injections, where were done intra-orally, Dr. Sinclair said.

One major caveat is to avoid significant post-injection dysphagia. For this reason, Dr. Sinclair said, anterior digastric muscle injections are performed superficially to avoid diffusion into the underlying floor of the mouth and tongue base musculature. In the study patients, automated machine guidance coupled with visual inspection of areas of maximum muscular hypertrophy determined initial needle placement. Optimal placement was confirmed with voluntary movement.

Not surprisingly, large muscles such at the masseter and temporalis typically receive higher toxin dose and a higher median number of injections. For example, these two muscles are typically injected at five sites, compared with three each for the pterygoid or digastric muscles, Dr. Sinclair said.

The injections appear to be relatively safe in this population. There were no complications reported post-injection by any patient in the current series, Dr. Sinclair said.

The mean age among the 59 patients was 57 years, and 72% were women. The mean follow-up time was 4.3 years.

"Of note, significantly more patients with jaw opening form of OMD were treated in the more recent data set," Dr. Sinclair said. "In line with this, there was an increase in lateral pterygoid and anterior digastric injections," compared with the older series. Despite the increase in jaw opening dystonia in more recent years, the majority of patients (65%) still presented with the jaw closing form.

Dr. Sinclair reported having no relevant financial disclosures.

MIAM BEACH – Botulinum toxin injections provided good, long-term symptom control for many patients with oromandibular dystonia in a retrospective analysis of a series of patients treated at a single center.

Oromandibular dystonia (OMD) is involuntary, repetitive, or twisting spasms of the muscles around the mouth and lower face. Affected people experience jaw opening, jaw closing, lateral jaw deviation, or a combination of these forms.

"Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms," Dr. Catherine F. Sinclair said at the Triological Society’s Combined Sections meeting. With no cure for the condition and oral medication that only improves symptoms for about one-third of patients, botulinum toxin is considered a treatment option, she added.

Along with colleagues Dr. Lowell E. Gurey and Dr. Andrew Blitzer, Dr. Sinclair reported on a series of 59 patients treated with onabotulinumtoxinA (Botox) for OMD since 1995. They assessed the long-term management of the patients and also sought to develop a treatment algorithm for OMD and compare the current series with an original cohort of 20 OMD patients treated by Dr. Blitzer in the 1980s (Ann. Otol. Rhinol. Laryngol. 1989;98:93-7).

In the current series, 10 patients required only one treatment session, another 10 had two sessions, and 39 returned more than twice for subsequent injections of onabotulinumtoxinA. Functional response determined the need and timing of subsequent injections. For example, patients with less than a 50% improvement on a 1 to 100 function rating scale were re-injected less than a month following their initial treatment. The overall median time between treatments was 3 months.

An advantage of onabotulinumtoxinA injections, compared with oral medications, is a greater ability to tailor the treatment. "Injections can be titrated by dose and site to address the predominant muscle systems involved," Dr. Sinclair said at the meeting, which was jointly sponsored by The Triological Society and the American College of Surgeons.

Initial injection dosage ranged from 2.4 U to 5.0 U onabotulinumtoxinA. "Regardless of clinical type, if a patient experiences no response or less than 50% functional improvement, they should be re-injected with either the same dose as the initial injection or with a dose increase of 5 U to 10 U botulinum toxin," said Dr. Sinclair, an otolaryngology fellow at St. Luke’s–Roosevelt Hospital in New York. Also consider treatment of additional muscles, she added.

OMD subtype dictated the specific muscles injected. The masseter and/or temporalis muscles were most often injected for the jaw closing subtype, for example. The internal pterygoid was most often injected for the jaw opening and lateral deviation types of OMD. All injections were percutaneous except for external pterygoid injections, where were done intra-orally, Dr. Sinclair said.

One major caveat is to avoid significant post-injection dysphagia. For this reason, Dr. Sinclair said, anterior digastric muscle injections are performed superficially to avoid diffusion into the underlying floor of the mouth and tongue base musculature. In the study patients, automated machine guidance coupled with visual inspection of areas of maximum muscular hypertrophy determined initial needle placement. Optimal placement was confirmed with voluntary movement.

Not surprisingly, large muscles such at the masseter and temporalis typically receive higher toxin dose and a higher median number of injections. For example, these two muscles are typically injected at five sites, compared with three each for the pterygoid or digastric muscles, Dr. Sinclair said.

The injections appear to be relatively safe in this population. There were no complications reported post-injection by any patient in the current series, Dr. Sinclair said.

The mean age among the 59 patients was 57 years, and 72% were women. The mean follow-up time was 4.3 years.

"Of note, significantly more patients with jaw opening form of OMD were treated in the more recent data set," Dr. Sinclair said. "In line with this, there was an increase in lateral pterygoid and anterior digastric injections," compared with the older series. Despite the increase in jaw opening dystonia in more recent years, the majority of patients (65%) still presented with the jaw closing form.

Dr. Sinclair reported having no relevant financial disclosures.

ORLANDO – Cosmetic dermatologists can easily perform a skin pinch blepharoplasty to remove excess skin from a patient’s lower eyelid, according to N. Fred Eaglstein, D.O.

"This is a very simple technique, especially for derm surgeons used to doing large skin flaps and grafts," said Dr. Eaglstein at the annual meeting of the Florida Society of Dermatologic surgeons. "I do all these procedures in my office."

The "pinch bleph" can be performed alone or in conjunction with laser resurfacing to improve the appearance of dermatochalasis and thin, wrinkled, sun-damaged lower eyelid skin, Dr. Eaglstein said. Not all patients are candidates, however. Because the technique removes only excess skin, it is not indicated for patients with lower, orbital, fat-pad protrusion.

Following a baseline ophthalmology examination, instruct the patient to discontinue aspirin, NSAIDs, and any herbal products that could prolong bleeding. Exclude or get clearance for patients with significant medical problems such as thyroid disease, Dr. Eaglstein said.

To determine how much skin to remove, pinch the lower eyelid skin together using blunt forceps until the eyelid margins start to evert. Then, mark the area with a fine tip gentian violet marker. He said that he crushes the excess skin using a curved hemostat and excises the tissue with Westcott or sharp iris scissors. He recommends 6-0 nylon sutures or 6-0 fast absorbing gut sutures to close the wound. "I use 6-0 fast absorbing."

"Don’t take too much skin if you plan to do laser resurfacing. You don’t want to get too much tightening [if you also plan to do] erbium laser resurfacing," said Dr. Eaglstein, a private practice dermatologist in Orange Park, Fla.

Expected complications include ecchymosis and edema. Less commonly, patients can experience hematoma, infection, scleral show, or ectropion.

"The pinch blepharoplasty is a simple, safe, and effective surgical procedure for the derm surgeon interested in providing cosmetic rejuvenation of the lower eyelid," Dr. Eaglstein said.

For more information, Dr. Eaglstein recommended a report by Joesph Niamtu III, D.M.D. on his lower eyelid blepharoplasty technique and experience (Cosmetic Derm. 2008;21:652-7).

He also recommended a report on a series of 77 candidates for traditional lower blepharoplasty who underwent a pinch blepharoplasty (Plast. Reconstr. Surg. 2005;115:1405-12). The author reported no significant scleral show or ectropion adverse events.

Dr. Eaglstein reported having no relevant conflicts of interest.

ORLANDO – Cosmetic dermatologists can easily perform a skin pinch blepharoplasty to remove excess skin from a patient’s lower eyelid, according to N. Fred Eaglstein, D.O.

"This is a very simple technique, especially for derm surgeons used to doing large skin flaps and grafts," said Dr. Eaglstein at the annual meeting of the Florida Society of Dermatologic surgeons. "I do all these procedures in my office."

The "pinch bleph" can be performed alone or in conjunction with laser resurfacing to improve the appearance of dermatochalasis and thin, wrinkled, sun-damaged lower eyelid skin, Dr. Eaglstein said. Not all patients are candidates, however. Because the technique removes only excess skin, it is not indicated for patients with lower, orbital, fat-pad protrusion.

Following a baseline ophthalmology examination, instruct the patient to discontinue aspirin, NSAIDs, and any herbal products that could prolong bleeding. Exclude or get clearance for patients with significant medical problems such as thyroid disease, Dr. Eaglstein said.

To determine how much skin to remove, pinch the lower eyelid skin together using blunt forceps until the eyelid margins start to evert. Then, mark the area with a fine tip gentian violet marker. He said that he crushes the excess skin using a curved hemostat and excises the tissue with Westcott or sharp iris scissors. He recommends 6-0 nylon sutures or 6-0 fast absorbing gut sutures to close the wound. "I use 6-0 fast absorbing."

"Don’t take too much skin if you plan to do laser resurfacing. You don’t want to get too much tightening [if you also plan to do] erbium laser resurfacing," said Dr. Eaglstein, a private practice dermatologist in Orange Park, Fla.

Expected complications include ecchymosis and edema. Less commonly, patients can experience hematoma, infection, scleral show, or ectropion.

"The pinch blepharoplasty is a simple, safe, and effective surgical procedure for the derm surgeon interested in providing cosmetic rejuvenation of the lower eyelid," Dr. Eaglstein said.

For more information, Dr. Eaglstein recommended a report by Joesph Niamtu III, D.M.D. on his lower eyelid blepharoplasty technique and experience (Cosmetic Derm. 2008;21:652-7).

He also recommended a report on a series of 77 candidates for traditional lower blepharoplasty who underwent a pinch blepharoplasty (Plast. Reconstr. Surg. 2005;115:1405-12). The author reported no significant scleral show or ectropion adverse events.

Dr. Eaglstein reported having no relevant conflicts of interest.

ORLANDO – Cosmetic dermatologists can easily perform a skin pinch blepharoplasty to remove excess skin from a patient’s lower eyelid, according to N. Fred Eaglstein, D.O.

"This is a very simple technique, especially for derm surgeons used to doing large skin flaps and grafts," said Dr. Eaglstein at the annual meeting of the Florida Society of Dermatologic surgeons. "I do all these procedures in my office."

The "pinch bleph" can be performed alone or in conjunction with laser resurfacing to improve the appearance of dermatochalasis and thin, wrinkled, sun-damaged lower eyelid skin, Dr. Eaglstein said. Not all patients are candidates, however. Because the technique removes only excess skin, it is not indicated for patients with lower, orbital, fat-pad protrusion.

Following a baseline ophthalmology examination, instruct the patient to discontinue aspirin, NSAIDs, and any herbal products that could prolong bleeding. Exclude or get clearance for patients with significant medical problems such as thyroid disease, Dr. Eaglstein said.

To determine how much skin to remove, pinch the lower eyelid skin together using blunt forceps until the eyelid margins start to evert. Then, mark the area with a fine tip gentian violet marker. He said that he crushes the excess skin using a curved hemostat and excises the tissue with Westcott or sharp iris scissors. He recommends 6-0 nylon sutures or 6-0 fast absorbing gut sutures to close the wound. "I use 6-0 fast absorbing."

"Don’t take too much skin if you plan to do laser resurfacing. You don’t want to get too much tightening [if you also plan to do] erbium laser resurfacing," said Dr. Eaglstein, a private practice dermatologist in Orange Park, Fla.

Expected complications include ecchymosis and edema. Less commonly, patients can experience hematoma, infection, scleral show, or ectropion.

"The pinch blepharoplasty is a simple, safe, and effective surgical procedure for the derm surgeon interested in providing cosmetic rejuvenation of the lower eyelid," Dr. Eaglstein said.

For more information, Dr. Eaglstein recommended a report by Joesph Niamtu III, D.M.D. on his lower eyelid blepharoplasty technique and experience (Cosmetic Derm. 2008;21:652-7).

He also recommended a report on a series of 77 candidates for traditional lower blepharoplasty who underwent a pinch blepharoplasty (Plast. Reconstr. Surg. 2005;115:1405-12). The author reported no significant scleral show or ectropion adverse events.

Dr. Eaglstein reported having no relevant conflicts of interest.

Pediatricians can optimize their communication and outreach to parents, other physicians, and their community through appropriate use of social media, but they have to know the boundaries.

"If you are a child advocate like me, you can use social media to help get good information out for parents to use as a bridge to you," Dr. Gwenn Schurgin O’Keeffe said in an interview. "I use social media to get people to my website so they can see useful information, for example, on how kids should spend time online or use cell phones."

"The benefit for other pediatricians who may be following me is they can then take my articles, post them, and spread them around," said Dr. O’Keeffe, a pediatrician in Wayland, Mass., and CEO of Pediatrics Now (www.pediatricsnow.com).

"As a health expert, you are immediately respected online, but you want to be respected for providing the right information."

Know your boundaries and what you are willing to say and not to say, whether you are communicating through a closed health system patient portal or via open social media like Facebook or Twitter, Dr. O’Keeffe said. "Be thoughtful and use these platforms wisely."

Think before you post, said Dr. Bryan S. Vartabedian, a pediatrician and frequent Twitter user. "Always keep in mind your digital footprint. That’s the permanent record of everything you’ve said or recorded on the Web. Whatever you say can usually be found, so think before you hit ‘publish.’" Dr. Vartabedian is on the pediatrics faculty in the division of gastroenterology, hepatology, and nutrition at Baylor College of Medicine in Houston.

Most patients – and in pediatrics this includes parents – like using some form of social media or online connection to their physician or physician’s office, Dr. O’Keeffe said. They might find your practice more user friendly if they can make an appointment, request a prescription refill, or get test results online.

"There seems to be a limit to what people want to connect to their doctor for," Dr. O’Keeffe said. "There is a feeling that that sort of ‘connectedness’ is not appropriate for bad test results, for example, or discussing a diagnosis."

"Public platforms are good for the sharing of general information, such as educational material, news, or links," Dr. Vartabedian said.

How receptive a patient or parent might be to communicating online really depends on the scope of the intended interaction, one study has shown.

"I don’t think it’s a good idea to have physicians communicating directly with patients [or parents] ... when it comes to general social media like Twitter and Facebook," Dr. O’Keeffe said. An inability to protect patient privacy is one major reason.

Appropriate use of a Facebook page could include providing information on your practice, such as office hours, or educational material, she said. Also, you can use Facebook to promote a community event or health campaign as long as your official role, if any, is appropriately disclosed. "If it’s Immunization Awareness Week, you can use your Facebook page to post information, and you can be part of national events that way."

"As a health expert, you are immediately respected online, but you want to be respected for providing the right information," she said.

Most physicians understand the benefits of Facebook, but "they either get Twitter or they don’t," said Dr. O’Keeffe, who goes by @DrGwenn on Twitter.

Dr. Vartabedian explained it this way: Twitter allows a doctor to tailor a digital signal such that he or she receives information from a select group of individuals. "To me this is the biggest advantage or benefit of Twitter," he said.

The big caveat is that things can sometimes be misunderstood in the context of 140 characters, said Dr. Vartabedian, who is @Doctor_V on Twitter. Also, "we have to pay strict attention to the idea that doctor-doctor and doctor-patient dialogue should never involve the discussion of patient-specific information," he said.

"I advise pediatricians just starting out online to be concerned about who they are connecting with and not about the numbers," Dr. O’Keeffe said. It should be about the quality of connections, not a competition for numbers, she added.

"Whatever you say can usually be found, so think before you hit 'publish.'"

You also can use social media like Twitter to connect with physician colleagues. "I have found Twitter to be invaluable at some of the major medical meetings I’ve attended," Dr. Vartabedian said. "It is allowing the emergence of a ‘back channel’ dialogue which offers invaluable input." In other words, attendees fill each other in via Twitter on the relevance of a particular study or provide additional context beyond what a presenter is saying at the podium.

Electronic medical record systems can foster consultations between physicians also, Dr. O’Keeffe said. One physician can e-mail or message another within the same system privately and forward a copy of a patient’s chart. "It’s not social media per se, but it’s social. It’s a closed loop through the electronic medical record system and a good way to get an opinion from a colleague on a specific patient." She added: "It can be very helpful when you’re just not sure." As an added benefit, the consultation becomes part of the permanent medical record.

No matter which platform or site you choose for online communication, it is important not to misrepresent yourself. "Because of the anonymity of all of these platforms, it can be easy to overstate your position or come on too strong," she said. "I’ve seen some people banter more on social media than when you see them in person – or the opposite can happen, and they are very outspoken in person and very meek online."

Dr. O’Keeffe and Dr. Vartabedian said they had no relevant financial disclosures.

Pediatricians can optimize their communication and outreach to parents, other physicians, and their community through appropriate use of social media, but they have to know the boundaries.

"If you are a child advocate like me, you can use social media to help get good information out for parents to use as a bridge to you," Dr. Gwenn Schurgin O’Keeffe said in an interview. "I use social media to get people to my website so they can see useful information, for example, on how kids should spend time online or use cell phones."

"The benefit for other pediatricians who may be following me is they can then take my articles, post them, and spread them around," said Dr. O’Keeffe, a pediatrician in Wayland, Mass., and CEO of Pediatrics Now (www.pediatricsnow.com).

"As a health expert, you are immediately respected online, but you want to be respected for providing the right information."

Know your boundaries and what you are willing to say and not to say, whether you are communicating through a closed health system patient portal or via open social media like Facebook or Twitter, Dr. O’Keeffe said. "Be thoughtful and use these platforms wisely."

Think before you post, said Dr. Bryan S. Vartabedian, a pediatrician and frequent Twitter user. "Always keep in mind your digital footprint. That’s the permanent record of everything you’ve said or recorded on the Web. Whatever you say can usually be found, so think before you hit ‘publish.’" Dr. Vartabedian is on the pediatrics faculty in the division of gastroenterology, hepatology, and nutrition at Baylor College of Medicine in Houston.

Most patients – and in pediatrics this includes parents – like using some form of social media or online connection to their physician or physician’s office, Dr. O’Keeffe said. They might find your practice more user friendly if they can make an appointment, request a prescription refill, or get test results online.

"There seems to be a limit to what people want to connect to their doctor for," Dr. O’Keeffe said. "There is a feeling that that sort of ‘connectedness’ is not appropriate for bad test results, for example, or discussing a diagnosis."

"Public platforms are good for the sharing of general information, such as educational material, news, or links," Dr. Vartabedian said.

How receptive a patient or parent might be to communicating online really depends on the scope of the intended interaction, one study has shown.

"I don’t think it’s a good idea to have physicians communicating directly with patients [or parents] ... when it comes to general social media like Twitter and Facebook," Dr. O’Keeffe said. An inability to protect patient privacy is one major reason.

Appropriate use of a Facebook page could include providing information on your practice, such as office hours, or educational material, she said. Also, you can use Facebook to promote a community event or health campaign as long as your official role, if any, is appropriately disclosed. "If it’s Immunization Awareness Week, you can use your Facebook page to post information, and you can be part of national events that way."

"As a health expert, you are immediately respected online, but you want to be respected for providing the right information," she said.

Most physicians understand the benefits of Facebook, but "they either get Twitter or they don’t," said Dr. O’Keeffe, who goes by @DrGwenn on Twitter.

Dr. Vartabedian explained it this way: Twitter allows a doctor to tailor a digital signal such that he or she receives information from a select group of individuals. "To me this is the biggest advantage or benefit of Twitter," he said.

The big caveat is that things can sometimes be misunderstood in the context of 140 characters, said Dr. Vartabedian, who is @Doctor_V on Twitter. Also, "we have to pay strict attention to the idea that doctor-doctor and doctor-patient dialogue should never involve the discussion of patient-specific information," he said.

"I advise pediatricians just starting out online to be concerned about who they are connecting with and not about the numbers," Dr. O’Keeffe said. It should be about the quality of connections, not a competition for numbers, she added.

"Whatever you say can usually be found, so think before you hit 'publish.'"

You also can use social media like Twitter to connect with physician colleagues. "I have found Twitter to be invaluable at some of the major medical meetings I’ve attended," Dr. Vartabedian said. "It is allowing the emergence of a ‘back channel’ dialogue which offers invaluable input." In other words, attendees fill each other in via Twitter on the relevance of a particular study or provide additional context beyond what a presenter is saying at the podium.

Electronic medical record systems can foster consultations between physicians also, Dr. O’Keeffe said. One physician can e-mail or message another within the same system privately and forward a copy of a patient’s chart. "It’s not social media per se, but it’s social. It’s a closed loop through the electronic medical record system and a good way to get an opinion from a colleague on a specific patient." She added: "It can be very helpful when you’re just not sure." As an added benefit, the consultation becomes part of the permanent medical record.

No matter which platform or site you choose for online communication, it is important not to misrepresent yourself. "Because of the anonymity of all of these platforms, it can be easy to overstate your position or come on too strong," she said. "I’ve seen some people banter more on social media than when you see them in person – or the opposite can happen, and they are very outspoken in person and very meek online."

Dr. O’Keeffe and Dr. Vartabedian said they had no relevant financial disclosures.

Pediatricians can optimize their communication and outreach to parents, other physicians, and their community through appropriate use of social media, but they have to know the boundaries.

"If you are a child advocate like me, you can use social media to help get good information out for parents to use as a bridge to you," Dr. Gwenn Schurgin O’Keeffe said in an interview. "I use social media to get people to my website so they can see useful information, for example, on how kids should spend time online or use cell phones."

"The benefit for other pediatricians who may be following me is they can then take my articles, post them, and spread them around," said Dr. O’Keeffe, a pediatrician in Wayland, Mass., and CEO of Pediatrics Now (www.pediatricsnow.com).

"As a health expert, you are immediately respected online, but you want to be respected for providing the right information."

Know your boundaries and what you are willing to say and not to say, whether you are communicating through a closed health system patient portal or via open social media like Facebook or Twitter, Dr. O’Keeffe said. "Be thoughtful and use these platforms wisely."

Think before you post, said Dr. Bryan S. Vartabedian, a pediatrician and frequent Twitter user. "Always keep in mind your digital footprint. That’s the permanent record of everything you’ve said or recorded on the Web. Whatever you say can usually be found, so think before you hit ‘publish.’" Dr. Vartabedian is on the pediatrics faculty in the division of gastroenterology, hepatology, and nutrition at Baylor College of Medicine in Houston.

Most patients – and in pediatrics this includes parents – like using some form of social media or online connection to their physician or physician’s office, Dr. O’Keeffe said. They might find your practice more user friendly if they can make an appointment, request a prescription refill, or get test results online.

"There seems to be a limit to what people want to connect to their doctor for," Dr. O’Keeffe said. "There is a feeling that that sort of ‘connectedness’ is not appropriate for bad test results, for example, or discussing a diagnosis."

"Public platforms are good for the sharing of general information, such as educational material, news, or links," Dr. Vartabedian said.

How receptive a patient or parent might be to communicating online really depends on the scope of the intended interaction, one study has shown.

"I don’t think it’s a good idea to have physicians communicating directly with patients [or parents] ... when it comes to general social media like Twitter and Facebook," Dr. O’Keeffe said. An inability to protect patient privacy is one major reason.

Appropriate use of a Facebook page could include providing information on your practice, such as office hours, or educational material, she said. Also, you can use Facebook to promote a community event or health campaign as long as your official role, if any, is appropriately disclosed. "If it’s Immunization Awareness Week, you can use your Facebook page to post information, and you can be part of national events that way."

"As a health expert, you are immediately respected online, but you want to be respected for providing the right information," she said.

Most physicians understand the benefits of Facebook, but "they either get Twitter or they don’t," said Dr. O’Keeffe, who goes by @DrGwenn on Twitter.

Dr. Vartabedian explained it this way: Twitter allows a doctor to tailor a digital signal such that he or she receives information from a select group of individuals. "To me this is the biggest advantage or benefit of Twitter," he said.

The big caveat is that things can sometimes be misunderstood in the context of 140 characters, said Dr. Vartabedian, who is @Doctor_V on Twitter. Also, "we have to pay strict attention to the idea that doctor-doctor and doctor-patient dialogue should never involve the discussion of patient-specific information," he said.

"I advise pediatricians just starting out online to be concerned about who they are connecting with and not about the numbers," Dr. O’Keeffe said. It should be about the quality of connections, not a competition for numbers, she added.

"Whatever you say can usually be found, so think before you hit 'publish.'"

You also can use social media like Twitter to connect with physician colleagues. "I have found Twitter to be invaluable at some of the major medical meetings I’ve attended," Dr. Vartabedian said. "It is allowing the emergence of a ‘back channel’ dialogue which offers invaluable input." In other words, attendees fill each other in via Twitter on the relevance of a particular study or provide additional context beyond what a presenter is saying at the podium.

Electronic medical record systems can foster consultations between physicians also, Dr. O’Keeffe said. One physician can e-mail or message another within the same system privately and forward a copy of a patient’s chart. "It’s not social media per se, but it’s social. It’s a closed loop through the electronic medical record system and a good way to get an opinion from a colleague on a specific patient." She added: "It can be very helpful when you’re just not sure." As an added benefit, the consultation becomes part of the permanent medical record.

No matter which platform or site you choose for online communication, it is important not to misrepresent yourself. "Because of the anonymity of all of these platforms, it can be easy to overstate your position or come on too strong," she said. "I’ve seen some people banter more on social media than when you see them in person – or the opposite can happen, and they are very outspoken in person and very meek online."

Dr. O’Keeffe and Dr. Vartabedian said they had no relevant financial disclosures.

ORLANDO – A higher than expected number of malpractice claims related to dermatologic surgery and treatment of psoriasis – as well as relatively few related to cosmetic dermatology were among the surprises revealed in a review of closed malpractice claims in Florida.

"There is a significant risk of malpractice actions in dermatology and dermatologic surgery," Dr. Ferdinand F. Becker said at the meeting. "Dermatologic surgeons would be well advised to be vigilant in diagnosis and appropriate treatment with the goal of avoiding complications at all cost."

General Dermatology Claims

Of 180 claims against dermatologists and dermatologic surgeons over a decade, 43 claims or 24% involved a general dermatology treatment. Of these, "44% were adjudicated or settled in favor of the plaintiff and 56% in favor of the defendant, so we came out better there," Dr. Becker said.

A total of 18 cases were adjudicated or settled in favor of the plaintiff – including 2 settled for an unknown amount. The largest settlement, $1 million, went to a patient who complained of meningoencephalitis and cerebral palsy secondary to failure to diagnose herpes simplex virus (conjunctival herpes simplex virus was the initial diagnosis). "This was the biggest claim in the whole shooting match," Dr. Becker said.

Another 25 of the general dermatology cases were decided or settled for the defendant physician, including 22 suits dropped by the plaintiff. Of the three remaining cases, two were summary judgments for the defendant and one judgment awarded the physician $50,000. In this case, the plaintiff had claimed avascular necrosis from treatment of chronic dermatitis with long-term steroid therapy.

Of note, a failure to diagnose Lyme disease when a patient presented with a rash of the axilla and groin resulted in a judgment for the plaintiff for $20,000, Dr. Becker said.

Psoriasis Claims

Dr. Becker identified seven claims involving psoriasis when he culled through the closed claims data from Florida’s Office of Insurance Regulation from January 2000 to December 2009. "I made a separate category for psoriasis because ... treatment of psoriasis is particularly problematic in general dermatology."

Four psoriasis treatment claims were settled in favor of the plaintiff from $500 to $250,000. The largest settlement involved a complaint of Stevens-Johnson syndrome with skin sloughing, oozing, and weeping sores resulting from methotrexate treatment. The defendant physician prevailed in three other cases – two dropped lawsuits and one summary judgment in which the patient had claimed steroids used to treat psoriasis had caused osteoporosis.

Cosmetic Dermatology Claims

A total of 28 claims or 16% involved cosmetic dermatology procedures. Outcomes were approximately split, with 54% adjudicated or settled in favor of the plaintiff and 46% in favor of the defendant.

"The majority were cases of laser hair removal," said Dr. Becker, a facial plastic surgeon and otolaryngologist in private practice in Vero Beach, Fla. Twelve of the 17 claims for laser hair removal were settled for the plaintiff for $2,500-$90,000. The biggest settlement followed a complaint of depigmentation and scarring related to laser hair removal. The remaining five laser cases involved complaints of burning, scarring, and/or pigmentary changes and were subsequently dropped by the plaintiff.

Dr, Becker found five suits involving Botox and filler treatments, each dropped by the plaintiff in favor of the defendant. Three plaintiffs claimed adverse reactions, one was unhappy with results, and one "patient left unattended after treatment, fell to the floor and broke three teeth, injured jaw, and cut lip."

Based on this lower number of malpractice claims, Botox and filler treatment "appears to be quite safe," Dr. Becker said.

The cosmetic dermatology category also included three claims involving liposuction, two settled in favor of the plaintiff and the other – a patient unhappy with abdominal liposuction results – dropped.

There was also a case involving sclerotherapy settled for $13,195 in favor of the plaintiff. The patient in this case claimed chronic ulceration resulting from treatment of spider veins.

A claim of pain, suffering, and a need for reconstructive surgery associated with a blepharoplasty resulted in a settlement of $100,000 for the plaintiff. Another suit, filed after a chemical facial peel, alleged facial burns and scarring ensued when the physician’s aesthetician acted outside the scope of her job.

Skin Cancer Claims

The highest percentage of claims in Florida (57%) involved skin cancer diagnosis and treatment. Of these, 57% were settled or adjudicated in favor of the plaintiff, 35% in favor of the defendant, and 8% were settled out of court for an unknown amount.

The greatest amount paid for non-melanoma skin cancer, $500,000, involved a patient treated with a biopsy and excision of a basal cell carcinoma on the upper lip. The patient filed suit, claiming they had to be referred for Mohs surgery and then experienced extensive scarring.

This and 19 other non-melanoma skin cancer malpractice claims were settled in favor of the plaintiff; 3 resulted in summary judgments for the defendant; 8 were settled out of court; and 15 suits were dropped by the plaintiff in favor of the physician defendant.

Melanoma diagnosis and/or treatment were cited in 17 malpractice cases. The second largest settlement to a plaintiff (out of the 180 cases reported) was $900,000 to a patient with malignant melanoma who had a biopsy but no pathology results or other follow-up. This and six other melanoma cases were settled in favor of the plaintiff. One case went to court and the plaintiff received $679,000 for severe scarring of his/her back related to malignant melanoma.

Another four melanoma cases were settled for an unknown amount and five claims were dropped by the plaintiff in favor of the defendant.

Mohs Surgery Claims

Mohs surgery comprised another major category with 29 malpractice claims. The largest settlement for a plaintiff was $875,000, stemming from Mohs surgery to remove a tumor from the arm. The patient lost the arm and claimed the dermatologic surgeon failed to diagnose malignant fibrous histiocytoma.

Two Mohs surgery claims were adjudicated as summary judgments for the defendant. Another ten cases were suits dropped by the plaintiff in favor of the defendant physician.

"This is the opposite of what I expected. I thought there would be more cases in the cosmetic derm area and less in derm surgery," Dr. Terry Cronin Jr., a private practice dermatologist in Melbourne, Fla., said during a Q and A session.

"I was surprised about this, too," Dr. Becker replied.

Overall, only 11 of the 180 closed claims actually went to court. Dr. Becker said, "The large majority [eight of these] were settled by the court with a summary judgment. This is the best news."

A meeting attendee asked if it is better to be direct with the patient or to call a lawyer if something does not go well. Dr. Becker replied: "Talking to your patient directly is a good idea and talking to your lawyer is also a good idea."

Dr. Becker said he had no relevant financial disclosures.

ORLANDO – A higher than expected number of malpractice claims related to dermatologic surgery and treatment of psoriasis – as well as relatively few related to cosmetic dermatology were among the surprises revealed in a review of closed malpractice claims in Florida.

"There is a significant risk of malpractice actions in dermatology and dermatologic surgery," Dr. Ferdinand F. Becker said at the meeting. "Dermatologic surgeons would be well advised to be vigilant in diagnosis and appropriate treatment with the goal of avoiding complications at all cost."

General Dermatology Claims

Of 180 claims against dermatologists and dermatologic surgeons over a decade, 43 claims or 24% involved a general dermatology treatment. Of these, "44% were adjudicated or settled in favor of the plaintiff and 56% in favor of the defendant, so we came out better there," Dr. Becker said.

A total of 18 cases were adjudicated or settled in favor of the plaintiff – including 2 settled for an unknown amount. The largest settlement, $1 million, went to a patient who complained of meningoencephalitis and cerebral palsy secondary to failure to diagnose herpes simplex virus (conjunctival herpes simplex virus was the initial diagnosis). "This was the biggest claim in the whole shooting match," Dr. Becker said.

Another 25 of the general dermatology cases were decided or settled for the defendant physician, including 22 suits dropped by the plaintiff. Of the three remaining cases, two were summary judgments for the defendant and one judgment awarded the physician $50,000. In this case, the plaintiff had claimed avascular necrosis from treatment of chronic dermatitis with long-term steroid therapy.

Of note, a failure to diagnose Lyme disease when a patient presented with a rash of the axilla and groin resulted in a judgment for the plaintiff for $20,000, Dr. Becker said.

Psoriasis Claims

Dr. Becker identified seven claims involving psoriasis when he culled through the closed claims data from Florida’s Office of Insurance Regulation from January 2000 to December 2009. "I made a separate category for psoriasis because ... treatment of psoriasis is particularly problematic in general dermatology."

Four psoriasis treatment claims were settled in favor of the plaintiff from $500 to $250,000. The largest settlement involved a complaint of Stevens-Johnson syndrome with skin sloughing, oozing, and weeping sores resulting from methotrexate treatment. The defendant physician prevailed in three other cases – two dropped lawsuits and one summary judgment in which the patient had claimed steroids used to treat psoriasis had caused osteoporosis.

Cosmetic Dermatology Claims

A total of 28 claims or 16% involved cosmetic dermatology procedures. Outcomes were approximately split, with 54% adjudicated or settled in favor of the plaintiff and 46% in favor of the defendant.

"The majority were cases of laser hair removal," said Dr. Becker, a facial plastic surgeon and otolaryngologist in private practice in Vero Beach, Fla. Twelve of the 17 claims for laser hair removal were settled for the plaintiff for $2,500-$90,000. The biggest settlement followed a complaint of depigmentation and scarring related to laser hair removal. The remaining five laser cases involved complaints of burning, scarring, and/or pigmentary changes and were subsequently dropped by the plaintiff.

Dr, Becker found five suits involving Botox and filler treatments, each dropped by the plaintiff in favor of the defendant. Three plaintiffs claimed adverse reactions, one was unhappy with results, and one "patient left unattended after treatment, fell to the floor and broke three teeth, injured jaw, and cut lip."

Based on this lower number of malpractice claims, Botox and filler treatment "appears to be quite safe," Dr. Becker said.

The cosmetic dermatology category also included three claims involving liposuction, two settled in favor of the plaintiff and the other – a patient unhappy with abdominal liposuction results – dropped.

There was also a case involving sclerotherapy settled for $13,195 in favor of the plaintiff. The patient in this case claimed chronic ulceration resulting from treatment of spider veins.

A claim of pain, suffering, and a need for reconstructive surgery associated with a blepharoplasty resulted in a settlement of $100,000 for the plaintiff. Another suit, filed after a chemical facial peel, alleged facial burns and scarring ensued when the physician’s aesthetician acted outside the scope of her job.

Skin Cancer Claims

The highest percentage of claims in Florida (57%) involved skin cancer diagnosis and treatment. Of these, 57% were settled or adjudicated in favor of the plaintiff, 35% in favor of the defendant, and 8% were settled out of court for an unknown amount.

The greatest amount paid for non-melanoma skin cancer, $500,000, involved a patient treated with a biopsy and excision of a basal cell carcinoma on the upper lip. The patient filed suit, claiming they had to be referred for Mohs surgery and then experienced extensive scarring.

This and 19 other non-melanoma skin cancer malpractice claims were settled in favor of the plaintiff; 3 resulted in summary judgments for the defendant; 8 were settled out of court; and 15 suits were dropped by the plaintiff in favor of the physician defendant.

Melanoma diagnosis and/or treatment were cited in 17 malpractice cases. The second largest settlement to a plaintiff (out of the 180 cases reported) was $900,000 to a patient with malignant melanoma who had a biopsy but no pathology results or other follow-up. This and six other melanoma cases were settled in favor of the plaintiff. One case went to court and the plaintiff received $679,000 for severe scarring of his/her back related to malignant melanoma.

Another four melanoma cases were settled for an unknown amount and five claims were dropped by the plaintiff in favor of the defendant.

Mohs Surgery Claims

Mohs surgery comprised another major category with 29 malpractice claims. The largest settlement for a plaintiff was $875,000, stemming from Mohs surgery to remove a tumor from the arm. The patient lost the arm and claimed the dermatologic surgeon failed to diagnose malignant fibrous histiocytoma.

Two Mohs surgery claims were adjudicated as summary judgments for the defendant. Another ten cases were suits dropped by the plaintiff in favor of the defendant physician.

"This is the opposite of what I expected. I thought there would be more cases in the cosmetic derm area and less in derm surgery," Dr. Terry Cronin Jr., a private practice dermatologist in Melbourne, Fla., said during a Q and A session.

"I was surprised about this, too," Dr. Becker replied.

Overall, only 11 of the 180 closed claims actually went to court. Dr. Becker said, "The large majority [eight of these] were settled by the court with a summary judgment. This is the best news."

A meeting attendee asked if it is better to be direct with the patient or to call a lawyer if something does not go well. Dr. Becker replied: "Talking to your patient directly is a good idea and talking to your lawyer is also a good idea."

Dr. Becker said he had no relevant financial disclosures.

ORLANDO – A higher than expected number of malpractice claims related to dermatologic surgery and treatment of psoriasis – as well as relatively few related to cosmetic dermatology were among the surprises revealed in a review of closed malpractice claims in Florida.

"There is a significant risk of malpractice actions in dermatology and dermatologic surgery," Dr. Ferdinand F. Becker said at the meeting. "Dermatologic surgeons would be well advised to be vigilant in diagnosis and appropriate treatment with the goal of avoiding complications at all cost."

General Dermatology Claims

Of 180 claims against dermatologists and dermatologic surgeons over a decade, 43 claims or 24% involved a general dermatology treatment. Of these, "44% were adjudicated or settled in favor of the plaintiff and 56% in favor of the defendant, so we came out better there," Dr. Becker said.

A total of 18 cases were adjudicated or settled in favor of the plaintiff – including 2 settled for an unknown amount. The largest settlement, $1 million, went to a patient who complained of meningoencephalitis and cerebral palsy secondary to failure to diagnose herpes simplex virus (conjunctival herpes simplex virus was the initial diagnosis). "This was the biggest claim in the whole shooting match," Dr. Becker said.

Another 25 of the general dermatology cases were decided or settled for the defendant physician, including 22 suits dropped by the plaintiff. Of the three remaining cases, two were summary judgments for the defendant and one judgment awarded the physician $50,000. In this case, the plaintiff had claimed avascular necrosis from treatment of chronic dermatitis with long-term steroid therapy.

Of note, a failure to diagnose Lyme disease when a patient presented with a rash of the axilla and groin resulted in a judgment for the plaintiff for $20,000, Dr. Becker said.

Psoriasis Claims

Dr. Becker identified seven claims involving psoriasis when he culled through the closed claims data from Florida’s Office of Insurance Regulation from January 2000 to December 2009. "I made a separate category for psoriasis because ... treatment of psoriasis is particularly problematic in general dermatology."

Four psoriasis treatment claims were settled in favor of the plaintiff from $500 to $250,000. The largest settlement involved a complaint of Stevens-Johnson syndrome with skin sloughing, oozing, and weeping sores resulting from methotrexate treatment. The defendant physician prevailed in three other cases – two dropped lawsuits and one summary judgment in which the patient had claimed steroids used to treat psoriasis had caused osteoporosis.

Cosmetic Dermatology Claims

A total of 28 claims or 16% involved cosmetic dermatology procedures. Outcomes were approximately split, with 54% adjudicated or settled in favor of the plaintiff and 46% in favor of the defendant.

"The majority were cases of laser hair removal," said Dr. Becker, a facial plastic surgeon and otolaryngologist in private practice in Vero Beach, Fla. Twelve of the 17 claims for laser hair removal were settled for the plaintiff for $2,500-$90,000. The biggest settlement followed a complaint of depigmentation and scarring related to laser hair removal. The remaining five laser cases involved complaints of burning, scarring, and/or pigmentary changes and were subsequently dropped by the plaintiff.

Dr, Becker found five suits involving Botox and filler treatments, each dropped by the plaintiff in favor of the defendant. Three plaintiffs claimed adverse reactions, one was unhappy with results, and one "patient left unattended after treatment, fell to the floor and broke three teeth, injured jaw, and cut lip."

Based on this lower number of malpractice claims, Botox and filler treatment "appears to be quite safe," Dr. Becker said.

The cosmetic dermatology category also included three claims involving liposuction, two settled in favor of the plaintiff and the other – a patient unhappy with abdominal liposuction results – dropped.

There was also a case involving sclerotherapy settled for $13,195 in favor of the plaintiff. The patient in this case claimed chronic ulceration resulting from treatment of spider veins.

A claim of pain, suffering, and a need for reconstructive surgery associated with a blepharoplasty resulted in a settlement of $100,000 for the plaintiff. Another suit, filed after a chemical facial peel, alleged facial burns and scarring ensued when the physician’s aesthetician acted outside the scope of her job.

Skin Cancer Claims

The highest percentage of claims in Florida (57%) involved skin cancer diagnosis and treatment. Of these, 57% were settled or adjudicated in favor of the plaintiff, 35% in favor of the defendant, and 8% were settled out of court for an unknown amount.

The greatest amount paid for non-melanoma skin cancer, $500,000, involved a patient treated with a biopsy and excision of a basal cell carcinoma on the upper lip. The patient filed suit, claiming they had to be referred for Mohs surgery and then experienced extensive scarring.

This and 19 other non-melanoma skin cancer malpractice claims were settled in favor of the plaintiff; 3 resulted in summary judgments for the defendant; 8 were settled out of court; and 15 suits were dropped by the plaintiff in favor of the physician defendant.

Melanoma diagnosis and/or treatment were cited in 17 malpractice cases. The second largest settlement to a plaintiff (out of the 180 cases reported) was $900,000 to a patient with malignant melanoma who had a biopsy but no pathology results or other follow-up. This and six other melanoma cases were settled in favor of the plaintiff. One case went to court and the plaintiff received $679,000 for severe scarring of his/her back related to malignant melanoma.

Another four melanoma cases were settled for an unknown amount and five claims were dropped by the plaintiff in favor of the defendant.

Mohs Surgery Claims

Mohs surgery comprised another major category with 29 malpractice claims. The largest settlement for a plaintiff was $875,000, stemming from Mohs surgery to remove a tumor from the arm. The patient lost the arm and claimed the dermatologic surgeon failed to diagnose malignant fibrous histiocytoma.

Two Mohs surgery claims were adjudicated as summary judgments for the defendant. Another ten cases were suits dropped by the plaintiff in favor of the defendant physician.

"This is the opposite of what I expected. I thought there would be more cases in the cosmetic derm area and less in derm surgery," Dr. Terry Cronin Jr., a private practice dermatologist in Melbourne, Fla., said during a Q and A session.

"I was surprised about this, too," Dr. Becker replied.

Overall, only 11 of the 180 closed claims actually went to court. Dr. Becker said, "The large majority [eight of these] were settled by the court with a summary judgment. This is the best news."

A meeting attendee asked if it is better to be direct with the patient or to call a lawyer if something does not go well. Dr. Becker replied: "Talking to your patient directly is a good idea and talking to your lawyer is also a good idea."

Dr. Becker said he had no relevant financial disclosures.

MIAMI BEACH – Antimicrobial resistance to Staphylococcus aureus varies by patient age, agent, and geographic region, but overall resistance patterns have remained steady over 5 years, according to a Florida-based study of nearly 300,000 isolates.

The analysis of 289,584 patient isolates collected in the Sunshine State from 2006 through 2010, revealed S. aureus resistance to oxacillin is running steady at approximately 50% over 5 years. Oxacillin is important because laboratories typically use resistance to this agent as a measure of overall methicillin-resistant S. aureus (MRSA).

With the exception of penicillin, resistance also remains stable for most antibiotics commonly deployed to combat S. aureus. Resistance to penicillin increased slightly from 91% in 2006 to 95% in 2010, said Dr. Richard S. Hopkins, acting state epidemiologist based in Tallahassee.

Quest Laboratories in Tampa provides the health department with a quarterly report of every S. aureus isolate result. Most of the data come from outpatient testing, which "gives you an idea of what is going on in the community," he said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Resistant strains run highest among young children ages 1 year to 4 years old, Resistance to oxacillin exceeds 60% in that age group compared with approximately 50% for infants younger than 1 year and patients older than 4 years. These toddlers also tend to have S. aureus with the highest resistance rates to amoxicillin-clavulanic acid, cefazolin, and erythromycin.

Regarding geographic patterns of resistance, the panhandle of Florida consistently features a higher proportion of resistant S. aureus isolates. In contrast, the proportion tends to be lowest in south Florida. "We don’t know why the pattern is this way," said Dr. Hopkins, who studied geographical distribution along with his colleague, Catherine Lesko, an epidemiologist at the Florida Department of Health.

Although a few isolated S. aureus cases that demonstrate intermediate resistance to vancomycin are reported each year, the state health department has yet to see a strain completely resistant to vancomycin. "When we do, we will need to respond very strongly from a public health and clinical perspective," he said.

The intermediate resistant infections are almost always in hospitalized patients who have been treated with vancomycin, he said. "We think it’s evolution of vancomycin resistance right there in the patient under your care, rather than it is being spread from person to person in the hospital."

Dr. Hopkins is employed by the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – Antimicrobial resistance to Staphylococcus aureus varies by patient age, agent, and geographic region, but overall resistance patterns have remained steady over 5 years, according to a Florida-based study of nearly 300,000 isolates.

The analysis of 289,584 patient isolates collected in the Sunshine State from 2006 through 2010, revealed S. aureus resistance to oxacillin is running steady at approximately 50% over 5 years. Oxacillin is important because laboratories typically use resistance to this agent as a measure of overall methicillin-resistant S. aureus (MRSA).

With the exception of penicillin, resistance also remains stable for most antibiotics commonly deployed to combat S. aureus. Resistance to penicillin increased slightly from 91% in 2006 to 95% in 2010, said Dr. Richard S. Hopkins, acting state epidemiologist based in Tallahassee.

Quest Laboratories in Tampa provides the health department with a quarterly report of every S. aureus isolate result. Most of the data come from outpatient testing, which "gives you an idea of what is going on in the community," he said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Resistant strains run highest among young children ages 1 year to 4 years old, Resistance to oxacillin exceeds 60% in that age group compared with approximately 50% for infants younger than 1 year and patients older than 4 years. These toddlers also tend to have S. aureus with the highest resistance rates to amoxicillin-clavulanic acid, cefazolin, and erythromycin.

Regarding geographic patterns of resistance, the panhandle of Florida consistently features a higher proportion of resistant S. aureus isolates. In contrast, the proportion tends to be lowest in south Florida. "We don’t know why the pattern is this way," said Dr. Hopkins, who studied geographical distribution along with his colleague, Catherine Lesko, an epidemiologist at the Florida Department of Health.

Although a few isolated S. aureus cases that demonstrate intermediate resistance to vancomycin are reported each year, the state health department has yet to see a strain completely resistant to vancomycin. "When we do, we will need to respond very strongly from a public health and clinical perspective," he said.

The intermediate resistant infections are almost always in hospitalized patients who have been treated with vancomycin, he said. "We think it’s evolution of vancomycin resistance right there in the patient under your care, rather than it is being spread from person to person in the hospital."

Dr. Hopkins is employed by the Florida Department of Health Bureau of Epidemiology.

MIAMI BEACH – Antimicrobial resistance to Staphylococcus aureus varies by patient age, agent, and geographic region, but overall resistance patterns have remained steady over 5 years, according to a Florida-based study of nearly 300,000 isolates.

The analysis of 289,584 patient isolates collected in the Sunshine State from 2006 through 2010, revealed S. aureus resistance to oxacillin is running steady at approximately 50% over 5 years. Oxacillin is important because laboratories typically use resistance to this agent as a measure of overall methicillin-resistant S. aureus (MRSA).

With the exception of penicillin, resistance also remains stable for most antibiotics commonly deployed to combat S. aureus. Resistance to penicillin increased slightly from 91% in 2006 to 95% in 2010, said Dr. Richard S. Hopkins, acting state epidemiologist based in Tallahassee.

Quest Laboratories in Tampa provides the health department with a quarterly report of every S. aureus isolate result. Most of the data come from outpatient testing, which "gives you an idea of what is going on in the community," he said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.

Resistant strains run highest among young children ages 1 year to 4 years old, Resistance to oxacillin exceeds 60% in that age group compared with approximately 50% for infants younger than 1 year and patients older than 4 years. These toddlers also tend to have S. aureus with the highest resistance rates to amoxicillin-clavulanic acid, cefazolin, and erythromycin.

Regarding geographic patterns of resistance, the panhandle of Florida consistently features a higher proportion of resistant S. aureus isolates. In contrast, the proportion tends to be lowest in south Florida. "We don’t know why the pattern is this way," said Dr. Hopkins, who studied geographical distribution along with his colleague, Catherine Lesko, an epidemiologist at the Florida Department of Health.

Although a few isolated S. aureus cases that demonstrate intermediate resistance to vancomycin are reported each year, the state health department has yet to see a strain completely resistant to vancomycin. "When we do, we will need to respond very strongly from a public health and clinical perspective," he said.

The intermediate resistant infections are almost always in hospitalized patients who have been treated with vancomycin, he said. "We think it’s evolution of vancomycin resistance right there in the patient under your care, rather than it is being spread from person to person in the hospital."

Dr. Hopkins is employed by the Florida Department of Health Bureau of Epidemiology.

ORLANDO – Dose is the most important consideration when injecting botulinum toxin in the lower face – even more important than during treatment of the upper face, according to Dr. Doris Hexsel.

"You should always use the lowest effective dose in the lower face," said Dr. Hexsel. This strategy reduces the risk for asymmetry, muscle dysfunction, and temporary oral paralysis. "These are dose-related and technique-related side effects."

Botulinum toxin can treat perioral wrinkles and marionette lines, as well as improve the appearance of a patient’s chin or gummy smile. However, only treat one or two areas in the lower face during the same session to minimize the risk of "sum of effect," she said. In other words, the effects of multiple, simultaneous injections around the mouth can be cumulative.

Also consider a combination of the botulinum toxin and filler injections, Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Hexsel shared her expertise with botulinum toxin for the following indications:

• Perioral wrinkles. Injections should be superficial and at least 1.5 cm from the corners of the mouth. Any closer and you increase the risk of undesirable relaxation of the depressor anguli oris muscle, the zygomaticus major muscle, and the risorius muscle, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande do Sul, Brazil.

She said that she typically injects 1.25 U-2.5 U abobotulinumtoxinA (Dysport, Ipsen/Medicis) per point, or 0.5 U-1.0 U onabotulinumtoxinA (Botox, Allergan). With two to six injection points, the total dose varies from 4 U-18 U for abobotulinum toxin or 4 U-10 U for onabotulinumtoxinA.

As a bonus, she said, "We observe a slight increase in the volume of the lips due to just the relaxation."

• "Cellulitic chin." Loss of collagen and subcutaneous fat, along with action of the jaw muscles, can cause a chin to have a cellulitic or "peau d’orange" appearance. Botulinum toxin can treat this area as well, said Dr. Hexsel. "I prefer two point injections – bilaterally at the most distal point of the mentalis muscle.

Again, keep the injections superficial and avoid high doses to minimize undesirable relaxation of the depressor labii inferioris muscle, she said. The total dose for a dimpled chin ranges from 15 U to 20 U of abobotulinumtoxinA and from 5 U to 10 U of onabotulinumtoxinA.

"I touch up patients 15 to 30 days later, if necessary," she added.

• Marionette lines. Botulinum toxin can improve the appearance of patients when the corners of their mouth appear permanently turned down. Better results may be obtained by combining toxin with fillers, she said.

For mild presentations, treat the mentalis muscle first, she advised. Treatment of this muscle also recruits the depressor anguli oris (DAO) muscle less (the mentalis is the agonist muscle to the DAO). Dr. Hexsel said she generally uses a total dose of 10 U-20 U of abobotulinumtoxinA or 3 U-6 U of onabotulinumtoxinA for this indication.

• Gummy smile. Consider botulinum toxin when a patient complains of a gummy smile. To foster a more natural look, also treat any natural asymmetries or posterior gummy smile, Dr. Hexsel said.

To treat posterior gingival exposure, inject two points on either side of the malar region. Inject in the nasolabial fold at the point of greatest lateral contraction during a smile.

Total doses vary from 5 U to 15 U of abobotulinumtoxinA or from 4 U to 10 U of onabotulinumtoxinA.

A final tip is to take before and after clinical photos, both during movement and at rest, when injecting the lower face.

Dr. Hexsel reported receiving grants and research support from Allergan, Galderma, and Ipsen. She also is a consultant for Allergan and Ipsen.

ORLANDO – Dose is the most important consideration when injecting botulinum toxin in the lower face – even more important than during treatment of the upper face, according to Dr. Doris Hexsel.

"You should always use the lowest effective dose in the lower face," said Dr. Hexsel. This strategy reduces the risk for asymmetry, muscle dysfunction, and temporary oral paralysis. "These are dose-related and technique-related side effects."

Botulinum toxin can treat perioral wrinkles and marionette lines, as well as improve the appearance of a patient’s chin or gummy smile. However, only treat one or two areas in the lower face during the same session to minimize the risk of "sum of effect," she said. In other words, the effects of multiple, simultaneous injections around the mouth can be cumulative.

Also consider a combination of the botulinum toxin and filler injections, Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Hexsel shared her expertise with botulinum toxin for the following indications:

• Perioral wrinkles. Injections should be superficial and at least 1.5 cm from the corners of the mouth. Any closer and you increase the risk of undesirable relaxation of the depressor anguli oris muscle, the zygomaticus major muscle, and the risorius muscle, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande do Sul, Brazil.

She said that she typically injects 1.25 U-2.5 U abobotulinumtoxinA (Dysport, Ipsen/Medicis) per point, or 0.5 U-1.0 U onabotulinumtoxinA (Botox, Allergan). With two to six injection points, the total dose varies from 4 U-18 U for abobotulinum toxin or 4 U-10 U for onabotulinumtoxinA.

As a bonus, she said, "We observe a slight increase in the volume of the lips due to just the relaxation."

• "Cellulitic chin." Loss of collagen and subcutaneous fat, along with action of the jaw muscles, can cause a chin to have a cellulitic or "peau d’orange" appearance. Botulinum toxin can treat this area as well, said Dr. Hexsel. "I prefer two point injections – bilaterally at the most distal point of the mentalis muscle.

Again, keep the injections superficial and avoid high doses to minimize undesirable relaxation of the depressor labii inferioris muscle, she said. The total dose for a dimpled chin ranges from 15 U to 20 U of abobotulinumtoxinA and from 5 U to 10 U of onabotulinumtoxinA.

"I touch up patients 15 to 30 days later, if necessary," she added.

• Marionette lines. Botulinum toxin can improve the appearance of patients when the corners of their mouth appear permanently turned down. Better results may be obtained by combining toxin with fillers, she said.

For mild presentations, treat the mentalis muscle first, she advised. Treatment of this muscle also recruits the depressor anguli oris (DAO) muscle less (the mentalis is the agonist muscle to the DAO). Dr. Hexsel said she generally uses a total dose of 10 U-20 U of abobotulinumtoxinA or 3 U-6 U of onabotulinumtoxinA for this indication.

• Gummy smile. Consider botulinum toxin when a patient complains of a gummy smile. To foster a more natural look, also treat any natural asymmetries or posterior gummy smile, Dr. Hexsel said.

To treat posterior gingival exposure, inject two points on either side of the malar region. Inject in the nasolabial fold at the point of greatest lateral contraction during a smile.

Total doses vary from 5 U to 15 U of abobotulinumtoxinA or from 4 U to 10 U of onabotulinumtoxinA.

A final tip is to take before and after clinical photos, both during movement and at rest, when injecting the lower face.

Dr. Hexsel reported receiving grants and research support from Allergan, Galderma, and Ipsen. She also is a consultant for Allergan and Ipsen.

ORLANDO – Dose is the most important consideration when injecting botulinum toxin in the lower face – even more important than during treatment of the upper face, according to Dr. Doris Hexsel.

"You should always use the lowest effective dose in the lower face," said Dr. Hexsel. This strategy reduces the risk for asymmetry, muscle dysfunction, and temporary oral paralysis. "These are dose-related and technique-related side effects."

Botulinum toxin can treat perioral wrinkles and marionette lines, as well as improve the appearance of a patient’s chin or gummy smile. However, only treat one or two areas in the lower face during the same session to minimize the risk of "sum of effect," she said. In other words, the effects of multiple, simultaneous injections around the mouth can be cumulative.

Also consider a combination of the botulinum toxin and filler injections, Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Hexsel shared her expertise with botulinum toxin for the following indications:

• Perioral wrinkles. Injections should be superficial and at least 1.5 cm from the corners of the mouth. Any closer and you increase the risk of undesirable relaxation of the depressor anguli oris muscle, the zygomaticus major muscle, and the risorius muscle, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande do Sul, Brazil.

She said that she typically injects 1.25 U-2.5 U abobotulinumtoxinA (Dysport, Ipsen/Medicis) per point, or 0.5 U-1.0 U onabotulinumtoxinA (Botox, Allergan). With two to six injection points, the total dose varies from 4 U-18 U for abobotulinum toxin or 4 U-10 U for onabotulinumtoxinA.

As a bonus, she said, "We observe a slight increase in the volume of the lips due to just the relaxation."

• "Cellulitic chin." Loss of collagen and subcutaneous fat, along with action of the jaw muscles, can cause a chin to have a cellulitic or "peau d’orange" appearance. Botulinum toxin can treat this area as well, said Dr. Hexsel. "I prefer two point injections – bilaterally at the most distal point of the mentalis muscle.

Again, keep the injections superficial and avoid high doses to minimize undesirable relaxation of the depressor labii inferioris muscle, she said. The total dose for a dimpled chin ranges from 15 U to 20 U of abobotulinumtoxinA and from 5 U to 10 U of onabotulinumtoxinA.

"I touch up patients 15 to 30 days later, if necessary," she added.

• Marionette lines. Botulinum toxin can improve the appearance of patients when the corners of their mouth appear permanently turned down. Better results may be obtained by combining toxin with fillers, she said.

For mild presentations, treat the mentalis muscle first, she advised. Treatment of this muscle also recruits the depressor anguli oris (DAO) muscle less (the mentalis is the agonist muscle to the DAO). Dr. Hexsel said she generally uses a total dose of 10 U-20 U of abobotulinumtoxinA or 3 U-6 U of onabotulinumtoxinA for this indication.

• Gummy smile. Consider botulinum toxin when a patient complains of a gummy smile. To foster a more natural look, also treat any natural asymmetries or posterior gummy smile, Dr. Hexsel said.

To treat posterior gingival exposure, inject two points on either side of the malar region. Inject in the nasolabial fold at the point of greatest lateral contraction during a smile.

Total doses vary from 5 U to 15 U of abobotulinumtoxinA or from 4 U to 10 U of onabotulinumtoxinA.

A final tip is to take before and after clinical photos, both during movement and at rest, when injecting the lower face.

Dr. Hexsel reported receiving grants and research support from Allergan, Galderma, and Ipsen. She also is a consultant for Allergan and Ipsen.