© 2001 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0512/01/$15.00/0 • Dermatol Surg 2001;27:608–610

DEPARTMENTS /

LETTERS TO THE EDITOR

Regarding Temporal Artery Biopsy Technique

To the Editor:When I first read the article on temporal artery biopsyby Dr. Albertini et al. (Dermatol Surg 1999;25:501–8), Iwas struck by what a meticulous tour de force it was!Having just re-read the article in light of the recent oneon the complication of a temporal artery biopsy (Der-matol Surg 2001;27:15–7), the opinion is undiminished.However, with respect to the described and depictedtechnique of performing a temporal artery biopsy, I ammoved to think now, as I was then, “Is this approach re-ally necessary?”

It is interesting to me that the technique I have beenusing for temporal artery biopsy for approaching thirtyyears was not specifically mentioned in these articles. Iam referring to biopsy of the superficial temporal ar-tery through a simple skin crease incision, in the imme-diate preauricular region. While I have always had theutmost respect for this sometimes technically challeng-ing little operation, I have never previously questionedthe wisdom of the actual site of the biopsy. This is be-cause I have done it the way I was originally taught bymy surgical mentors. Perhaps naively, I have assumedthat the condition of giant cell arteritis would be rep-resented, at least at a microscopic level, in all “tempo-ral arteries” in the area. Dr. Albertini’s article impliesthat this is not the case. I have certainly seen many“positive” biopsy results when the artery was not clini-cally involved preoperatively, although some lateralityis usually suggested by the referring physician.

Dr. Albertini concludes that “temporal artery biopsyis a quick, safe, straightforward office procedure. . .” Iventure to suggest that the technique he describes, and soelegantly demonstrates pictorially, is far more complexthan necessary, The preauricular wrinkle crease providesan ideal site for a temporal artery biopsy in the elderlypatients that are usually involved, and cosmetic healing isvirtually assured. In addition, injury to the facial nervewould seem rather unlikely through his approach.

I wish to emphasize that my position is predicatedon the assumption that the use of a standardized bi-opsy site, chosen for surgical convenience, is acceptablefrom a diagnostic standpoint, in the condition of giantcell arteritis. I will welcome any comments or advicethat might follow from this correspondence.

Peter Charlesworth, BSc, MBChB, FRACS

Remuera, Auckland, New Zealand

Regarding Tretinoin Peeling

To the Editor:I write this letter in response to the recent article in Der-matologic Surgery by Cuce et al. (Tretinoin peeling. Der-

matol Surg 2001;27:12–4). We have previously publishedan article, “High-strength tretinoin: a method for rapidretinization of facial skin” (J Am Acad Dermatol 1998;39:S93–7). We studied fifty female subjects with photo-damage, hyperpigmentation, rosacea, melasma, and acnevulgaris. We used all-trans-retinoic acid (0.25%) in a so-lution of 50% ethanol and 50% polyethylene glycol 400.This paper includes histology, clinical assessment and bio-physical measurements of skin replica analysis, hydration,elasticity, and distensibility. These subjects were retinizedwithin four weeks. In our discussion, we state, “we viewour approach as analogous to superficial facial chemi-cal peels.” The subjects began treatment with every othernight application. After two weeks, at which point ac-commodation was seen, they applied it once a day.

We view the current paper by Cuce et al. as a cor-roboration of what we published some time ago. How-ever, we feel it is important to point out that there essen-tially is nothing novel in their publication and certainlythe authors should give acknowledgment of our previ-ously published work. We would also like to questionsome inaccuracies in their materials and methods. Onecannot make a 1% solution of tretinoin in 50% ethanoland 50% propylene glycol. This yields a suspension con-taining crystalline tretinoin. Additionally, our experienceshows that it is not correct to say that “the peeling pro-cess of the skin is mild, causing no great discomfort tothe patient.” There is a variability of response and somepatients peel extremely heavily over the first week to tendays of treatment. Furthermore, the response of patientsto 0.25% all-trans-retinoic acid is so marked that in-creasing the concentration to 1% (regardless of the vehi-cle) should add very little to the therapeutic effect.

Douglas E. Kligman, MD, PhD

Conshohocken, Pennsylvania

Islam, Teaching Dermatologic Surgery, and Porcine Parts

To the Editor:While participating at the Praket Bedah Kulit (Surgeryof the Skin) National Indonesian Course of Dermato-logic Surgery, organized by Prof. Dr. Marwali Harahap,Faculty of the Universitas Sumatera Utara Medan (Uni-versity of Medan, Indonesia), in Solo, Java, Indonesia,attempts to teach suturing techniques and dermatologicsurgery were critically compromised by the initial use ofcow skins for the demonstrations. These hair-bearingraw hides were impossible to adequately manipulate,bending needles and breaking sutures with complete ease.Desperate attempts to use even straight needles with 1-0silk sutures failed most completely to replicate actual sur-gical experience on human skin.

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I have had a long and extensive previous experienceusing pigs’ feet and pigs’ ears in the teaching of derma-tologic surgery. The difficulties of using cow hides weretransparently obvious to one able to compare. How-ever, to those for whom contact with porcine parts hadbeen presumably forbidden, that comparative knowl-edge was absent. The authors’ suggestion that the useof procine parts for educational purposes might well beconsidered appropriate by religious authorities was im-mediately accepted, and consultation with the mejlis(religious governing body) was subsequently obtained.

Extensive deliberations were undertaken, and multi-ple sources consulted.

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It was the absolute opinion ofthe religious governing group that the use of porcineparts for the proper education of dermatologic sur-geons when no reasonable alternative to human skinwas available was appropriate and not “haram” (for-bidden by God), so long as the parts were not ingested.

In Surubaya, Indonesia, meat from the pig was onlyavailable at meat markets run by Chinese Buddhists.Large pieces of pork with the skin still attached were se-lected. The skin was subsequently detached and cleansedwith alcohol, and finally nailed onto wooden plankswhere varying basic flaps were demonstrated and repro-duced.

In the future, dermatologic surgery courses at theRumah Sakit “PKU Muhammadiyah” (Hospital forSociety and Developmental Welfare for Mulims—non-sectarian), Jl. Ronggowarsito, Sukarta, Indonesia willbe able to use porcine parts. The hospital staff at alllevels will be appraised of the propriety of that usageprior to its introduction, and be told the mejlis had re-searched the problem at the request of the dermatol-ogy department and had agreed to its usage. No futureproblems are expected at any level, for the ground-work already done should preclude any objectionsbased upon lack of knowledge.

In summary, after being faced with great practicaldifficulties in teaching suturing and dermatologic sur-gical techniques using cowhides in Islamic Indonesia,consultations with proper religious authorities wereinstituted. After appraising them of the difficulties ofusing cows’ parts, and informing them of the similar-ity of pig skin to human skin, it was agreed that theuse of pig skin for the teaching of cutaneous surgerywas not forbidden by Islamic law. It will be possible inthe future to use porcine parts without the oppositionof some uninformed individuals, appropriate permis-sion having been preliminarily sought and obtained.This opinion is applicable to the entire Islamic worldin the teaching of dermatologic surgery, and should beapplicable to orthodox Judaism as well.

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Presented at the 2nd Egyptian International Confer-ence of Dermatologic Surgery, Cairo, Egypt, September1996, and the CVIIIth Congress of the International So-

ciety for Dermatologic Surgery, Tel Aviv, Israel, Septem-ber 1996.

Lawrence M. Field, MD, FIACS

Inaugural International Traveling Chairof Dermatologic Surgery

(International Society for Dermatologic Surgery)Stanford, California

References

1. von Grunebaum GE. Unity and Variety in Muslim Civilization, 7thedn. Chicago: University of Chicago Press, 1995.

2. Rahman F. Major Themes of the Qur’an. Minneapolis: Biblioteca Is-lamica, 1980.

3. Al Qur’an. Introduction and Sample Texts.4. Buccaile M. The Bible, the Qur’an, and Science. Indianapolis, 1979.5. Ali M. The Qur’an. Pitchal (with translation in English), 1959.6. Al Qur’an surah II, ayat (verse 173): “The God Allah forbid us just to

eat meat of pork. So to eat meat of pork is haram (forbidden).”7. Hamidy Immam HM. Personal communications, 1995. According

to his “ishtihaz” (interpretation/opinion) from the Uztad, “to touchpork skin for teaching, in the purpose for science and human beingis no problem.”

8. Israel Rabbi RR, Talmudic scholar. Personal communication, 1996.Collel de Sarcelles, Paris, France. “Il est permis detiner profit du porcpour des experimentations chirurgicales.”

Regarding Appropriate Delays in Reconstructing Large, Deep, or Extensive Midfacial Defects Following Surgical Management of Skin Cancer

To the Editor:In reviewing old journals (as we all should do on occa-sion), I again read the results and admired the esthetic re-constructions obtained by Baker and Swanson depicted intheir article concerning the role of tissue expansion in thereconstruction of midfacial defects following skin cancerremovals.

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The following commentary has nothing to dowith expander techniques or their applications, but rather,on principles of properly timed reconstructive efforts.

While realizing all three of the authors’ cases werebasal cell carcinomas rather than the even more dan-gerous squamous cell carcinomas, one must questionwhether the immediate reconstructions performed incases 2 and 3 should not have been delayed, as wasdecided in the authors’ case 1 “because of the exten-siveness of the neoplasm and the concern for possiblerecurrence.” The defect in case 2 was “approximately4

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5 cm” in size and required the sacrifice of carti-lage. “Exposed nasal bones” and extension of the de-fect on the medial cheek required combining both asplit-thickness graft and a midline forehead flap for im-mediate reconstruction. Case 3 involved a 3-time recur-rent carcinoma and an “approximately 4 cm” defect,again repaired with immediate reconstruction.

One cannot question the expertise of either physician in-volved here, but my experiences over many years at the Vi-

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sual Tumor Clinic, University of San Francisco, in listeningto Drs. Tromovitch, Stegman, and Glogau (the second au-thor of this article, NS, heard the same concepts espousedwhile a young Moghs Fellow there) would lead most to ex-teme caution in all of these cases. I believe those same reser-vations would have been repeatedly voiced by the presentchief of the surgical service at UCSF, Dr. Grekin. Immedi-ate reconstruction with heavy flaps over neoplastic involve-ment possibly involving bone and cartilage carries a statis-tically significant risk of recurrence deeply hidden underthe overlying tissue. Though the authors do warn us of“subclinical extension which is not always apparent. . .along nerve sheaths and blood vessels by invasion of theperineural sheath and adventitia of arteries in the area.. . .”, they proceeded with immediate forehead-to-noseflap reconstruction in both cases 2 and 3.

My concern is that many of the Journal’s readers inthis world who are far less qualified for such undertak-ings might or will embark on similar courses after havingread or reviewed this article, with very significant prob-lems ensuing. Although Baker and Swanson themselvescleared the borders with Mohs micrographic surgery, andthey do accept the alternative approach of “frozen sectioncontrol of all wound margins”

2,3

even these may not offera statistical cure rate sufficient to replace long-term sur-veillance and later reconstruction after many months(even 1-3 years) have passed without evidence of recur-rence. Involvement with squamous cell carcinoma ratherthan basal cell carcinoma should even increase our con-cern for appropriate time intervals to pass before exten-sive flap reconstructions are undertaken. Excellent in-terim prostheses are certainly available for patients whohave undergone mutilating procedures to assist them inthe prolonged but necessary waiting interval.

Lawrence M. Field, MD, FIACS

Inaugural Traveling Chair of Dermatologic Surgery(International Society for Dermatologic Surgery)

University of California, San FranciscoStanford University, Stanford, California

Foster City, California

References

1. Baker S, Swanson N. Reconstruction of midfacial defects followingsurgical management of skin cancer. J Dermatol Surg Oncol 1994;20:133–40.

2. Gross D, Field L. Coorperative frozen section surgery. J DermatolSurg Oncol 1987;13:1085–8.

3. Field L, Collins P, Johnson C. Variations of micrographic surgerywith considerations of aesthetic reconstruction. Presented at the an-nual meeting of the American Academy of Cosmetic Surgery. LosAngeles, CA: January 1989.

Commentary on HIV Lipodystrophy

Editor’s Note

. This is a Commentary that should haveappeared with the article, HIV Lipodystrophy: Review

of the Syndrome and Report of a Case, by M. Chastainet al. that appeared in the May issue of

DermatologicSurgery

(2001;27:497–500).

The authors of this review should be commended onbringing attention to a problem that is becoming epi-demic among those affected with HIV. I have performedseveral liposuction procedures on dorso-cervical fat accu-mulations associated with HIV. All patients did wellwith significant or complete reduction in hump size, andno major postoperative complications. The fat accumu-lations have not reappeared in the majority treated andpatient satisfaction is high. Other liposuction surgeonswho treat large numbers of patients with HIV-relateddorso-cervical fat accumulations report similar results.This is a safe, effective procedure that should be offeredto otherwise healthy patients seeking treatment for thiscondition. Of note, the dorso-cervical fat accumulationin these patients is very fibrous, which necessitates amore aggressive liposuction technique. Furthermore, Ihave had many patients say that they feel stigmatized bythe term “buffalo hump” that is used by many medicalprofessionals to refer to the condition. Therefore, I preferthe term, “dorso-cervical fat accumulation.”

Within the spectrum of symptoms comprising HIVlipodystrophy, dorso-cervical fat accumulation is rel-atively infrequent. A much more common, disfigur-ing, demoralizing and stigmatizing problem for pa-tients is lipoatrophy of facial buccal fat pads. I treatlarge numbers of these patients with soft tissue aug-menting agents. I prefer larger volume Zyplast collagen(3–5 cc) injected into the subdermal plane. Other sub-stances such as Dermologen, Fascian, or Cymetra ap-pear to last less long than Zyplast and are frequentlyassociated with more swelling and bruising. Correctionwith any of these substances is temporary and expen-sive. What are needed are less expensive, safe, effec-tive, and more permanent soft tissue augmenting sub-stances. Researchers in Brazil have had very good andlong-lasting results injecting these patients with polyme-thylmethacrylate suspended in hydromethylcellulose.Artecoll, which consists of polymethylmethacrylate sus-pended in bovine collagen, is currently undergoing FDAapproval studies and may be available for use within 12to 18 months. Furthermore, studies are currently beingdesigned in the US to study newer injectable forms ofsilicone, which show great promise. Other surgeonshave had success with facial implants made of goretex,silicone, or alloderm. Further studies are needed to de-termine which of these treatments will be most effec-tive and affordable to the large numbers of patients af-fected by this condition.

Derek Jones, MD

Beverly Hills, California