Abstract Book

Cutting edge dermatologic surgery in the Island of Gods  

Congress President: Lis Surachmiati Suseno, M.D./Indonesia Congress President: Eckart Haneke, M.D./Germany 

ISDS Honorary Congress President: Marwali Harahap, M.D./Indonesia Perdoski President: Titi Lestari Sugito, M.D./Indonesia 

 info@isdsworld.com // www.isdsworld.com 

ISDS.Bali.2011@gmail.com // http://isdsbali2011.com 

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AA -- CC __________________ PAGE 03 – 06

DD -- HH __________________ PAGE 07 – 12

II -- LL __________________ PAGE 13 – 20

MM -- QQ __________________ PAGE 21 – 27

RR -- SS __________________ PAGE 28 – 38

TT -- ZZ __________________ PAGE 39 – 45

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AA -- CC Sri Lestari, Gardenia Akhyar, Padang/Indonesia ELLIPTICAL EXCISION OF AN EPIDERMOID CYST

ON THE LEFT TEMPLE __________ page 04

A. Al Hinai, R. Al Hajri, E. Al Lawati, K. Al Albri, E. Al Naamani, Muscat/Sultanate of Oman; L. Field, Foster City/USA

AN UNUSUAL DERMATOLOGIC SURGICAL WORKSHOP (SULTANATE OF OMAN): FRUIT, VEGETABLES, SHEETS, AND TOWELS __________ page 04

Afaf Agil Al Munawwar, Ferdinand, Yuli Kurniawati, Palembang/Indonesia

DIGITAL MYXOID CYST __________ page 05

Anis Irawan Anwar, Macazzart/Indonesia

DERMAROLLER UPDATE __________ page 05

Sri Lestari, Ennesta Asri; Padang/Indonesia

ELLIPTICAL EXCISION OF NEVUS PIGMENTOSUS ON THE LEFT SIDE OF CHEEK __________ page 06

Imelda F. Cervantes, Makati City/Philippines

DERMABRASION FOR ACNE SCARS __________ page 06

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ELLIPTICAL EXCISION OF AN EPIDERMOID CYST ON THE LEFT TEMPLE Sri Lestari, Gardenia Akhyar, Dermato-Venereology Department of Dr M Djamil Hospital/Faculty of Medicine of University of Andalas, Padang Background : Epidermoid cyst is a keratin-filled epithelial-lined cysts. Removal of the entire cyst wall is required to prevent cyst recurrence. Elliptical excision can removed the cyst totally. The size of the lesion and location is one of the factors to consider in choosing excision type. Case : We reported a 40 year old male with epidermoid cyst 1.5 cm in diameter on his left temple. He complained that the cyst became bigger so he preferred to remove the cyst. We marked an elliptical line smaller than cyst size. We did elliptical excision using local anesthesia with pehacaine (lidocaine 2% and epinephrine 1: 80.000), infiltrated beneath the nevus and peripherally around the nevus site, totally 2 cc. All incisional borders where then infiltrated superficially with pehacaine, accomplishing “bilevel anesthesia”. We incised and then pushed out the content of the cyst, it made easier to remove entire wall of the cyst. We released entire the wall of the cyst from surrounding the tissue. The defect was closed with chromic 5.0 at the dermis and subcutaneous. At the epidermis anastomosed with prolene 6.0 interrupted sutures. Discussion : We have done the elliptical incision smaller than epidermoid cyst size to decreased the length of the linear scar. AN UNUSUAL DERMATOLOGIC SURGICAL WORKSHOP (SULTANATE OF OMAN) : FRUIT, VEGETABLES, SHEETS, AND TOWELS A. Al Hinai*, R. Al Hajri*, E. Al Lawati*, K. Al Albri, E. Al Naamani*, L. Field** *Al Nahdha hospital, Department of Dermatology, Muscat , Sultanate of Oman ** Inaugural Traveling Chair of Dermatologic Surgery, ISDS During a previously non-scheduled and informal visit, access to the department and its patients was not possible, despite appropriate pleas from faculty, staff, residents, and the senior author. The lecture facilities of a sport medicine center were subsequently utilized, affording a room for lectures and for a variety of surgical demonstrations. The latter included surgery on oranges, tomatoes, potatoes, tumescent infiltration below sheets (“Tulip” applicators), and undermining demonstrations on folded towels. One attending lady dermatologist was treated on site demonstrating “No-Kor” subcision and intra-tunnel deposition of silicone. Delivery of limited knowledge was nevertheless accomplished, and the attendees were pleased with ISDS’ efforts in their behalf. Failure of those in positions of charge to afford all possible opportunities for learning are unfortunate.

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DIGITAL MYXOID CYST Afaf Agil Al Munawwar, Ferdinand, Yuli Kurniawati; Department of Dermatovenereology, Medical Faculty of Sriwijaya University/Dr. Mohammad Hoesin General Hospital Palembang Background: Digital myxoid cyst or mucoid pseudocyst is solitary, clear or flesh-colored nodule that develop on the dorsal digits between the distal interphalangeal joint and the proximal nail fold. The cysts can be asymptomatic, or they can cause pain, tenderness, or deformity of the nail. Simple surgical technique by incision and drainage are procedure to remove cyst with good result. Case: A 52-years-old woman, present to dermatovenereology clinic with a greenpeal-size nodule on the left thumb since 2 months ago, enlarged and painful with pressure. Physical examination: lateral first finger on the left hand: solitary, 1x1x0,4 cm, smooth, flesh-coloured nodule, soft on palpation, mobile, tenderness. Clinical diagnosis: digital myxoid cyst. Therapy: incision surgery using scalpel no.11 and drainage. Incision results clear gelatinous fluid mingled with slightly blood. Discussion: Digital myxoid cysts or often termed as pseudocyst because a cellular cyst wall can seldom be demonstrated. Patient’s incidence predominantly between 40 and 70 years, approximately 70% of patients being women. There are many conservative approaches, including incision surgery and drainage, injected sclerosant or steroid, cryosurgery, laser, and infrared photocoagulation. This patient treated with incision surgery and drainage as simple treatment with good result. DERMAROLLER UPDATE Anis Irawan Anwar, Departement of Dermatology and Venereology Medical Faculty of Hasanuddin University, Dr. Wahidin Sudirohusodo Hospital, Macazzart/Indonesia Dermaroller is a new method to fix skin problems which become more popular nowadays. This method was first introduced by using a cylinder-shaped device with hundreds of micro-sized needles on its surface. Updated the technology, this device has been developed electronically operated to have more effective achievement. Micro-sized needles operated runs over skin surfaces to form micro-sized wounds approximately 1,5 -2 mm depth in the skin. Recently, dermaroller become one of options for acne scarring mangement by stimulating collagen synthesis formation in the dermis. Through micro wounds created by the device, new collagen and elastine fiber will increase producing and fill the scar.

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ELLIPTICAL EXCISION OF NEVUS PIGMENTOSUS ON THE LEFT SIDE OF CHEEK Sri Lestari, Ennesta Asri; Dermatology-Venereology Departement of Dr M. Djamil Hospital/Medical Faculty of Andalas University, Padang, West Sumatra/Indonesia Background : Nevus pigmentosus is a benign pigmented melanocytic proliferation, develop after birth, slowly enlarge symmetrically, stabilize, and after period of time may regress. Therapy for nevus pigmentosus is complete removal of nevi which is the best accomplished by excision. Case : We reported a 20 year old male with a nevus pigmentosus, 8 mm diameter on the left cheek. He preferred to remove that nevus because it’s became bigger, black and sometimes itchy. We did elliptical excision using local anesthesia with pehacaine (lidocaine 2% and epinephrine 1: 80.000), infiltrated beneath the nevus and peripherally around the nevus site for presumed flap mobilization. All incisional borders where then infiltrated superficially with pehacaine, accomplishing “bilevel anesthesia”. After 20 minutes we excised the nevus pigmentosus by making an ellips incision. The defect was closed with chromic 5.0 at the dermis and subcutaneous. At the epidermis anastomosed with prolene 6.0 interrupted sutures. Discussion : We have done excision of nevus pigmentosus on the left side of the cheek by elliptical excision, using “bilevel anesthesia” with a good result. Patology anatomy result was naevus intradermal with non specific granuloma. DERMABRASION FOR ACNE SCARS Imelda F. Cervantes, Makati City/Philippines Before the advent of lasers, microneedles and diamond peels, the treatment of choice for moderate to severe acne scars is dermabrasion. Dermabrasion is a procedure that uses a diamond fraise (burr) or a wire brush to abrade or remove the superficial layer of the skin, the epidermis and upper dermis. This technique became less popular because of higher complications and longer healing time compared to other methods. Proper assessment of its indication is very important. I believe that dermabrasion has still a room in the treatment of moderate to severe acne scars that will give better results than the new popular ones.

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DD –– HH

Irmadita Citrashanty, M. Yulianto Listiawan; Surabaya/Indonesia

COMBINATION OF POLYURETHANE TRANSPARENT FILM AND CALCIUM ALGINATE DRESSING IN WOUND MANAGEMENT - A CASE REPORT __________ page 09

Reni Wiyakti Nanda Dewi, Bandung/Indonesia

CHEMICAL PEELING FOR ACNE AND MELASMA __________ page 09

N. Gantsho, N. Khumalo, Cape Town/South Africa; M. Al-Anwer, Al-Minya/Egypt; L. Field, Foster City/USA

EXCISION OF ACNE KELOIDALIS NUCHAE WITH HEALING BY SECONDARY INTENTION __________ page 10

S. Rojhirunsakool, S. Pootongkam, S. Wichyanrat, S. Tanratanakorn, W. Tanasarnaksorn; Bangkok/Thailand; L. Field, International Traveling Chair of Dermatologic Surgery (ISDS)

MONO-FOCAL LUPUS PANNICULITIS OF THE CHEEK – RX WITH LIPO-TRANSPLANT & RE-ACTIVATION IN 2 MOS __________ page 10

A. Suwanchinda, C. Treewittayapoom, S. Rojhirunsakool, S. Pootongkam, Y. Wisessiri, Bangkok/Thailand; L. Field, Traveling Chair of Dermatologic Surgery (ISDS) __________ page 11

RECURRENT SCC - RIGHT LOWER LATERAL ORBIT – A SAGA OF ERRORS, MISREPRESENTATIONS, AND

MISCOMMUNICATIONS

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The Faculty of: Division of Dermatology, Dermatologic Surgery Unit, Ramathibodi University Hospital & Mahidol University Hospital, Bangkok/Thailand; L. Field, Inaugural International Traveling Chair of Dermatologic Surgery (ISDS)

THE ISDS’ TRAVELING CHAIR PROGRAM – BANGKOK, THAILAND 2009 __________ page 11

Sri Lestari, Lusita Sylvia, Elhuda, Rahmah Hidayah, Padang/Indonesia

EXICISION OF NEVUS PIGMENTOSUS ON THE RIGHT NASOLABIAL FOLD __________ page 12   

Sri Lestari, Taufik Hidayat, Padang/Indonesia

AXILARRY HIPERHIDROSIS AND BROMHIDROSIS TREATED WITH SUCTIONING OF GLANDS BY CASSIO VILLACA CANNULA UNDER LOCAL ANESTHESIA OF TUMESCENT __________ page 12

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COMBINATION OF POLYURETHANE TRANSPARENT FILM AND CALCIUM ALGINATE DRESSING IN WOUND MANAGEMENT - A CASE REPORT Irmadita Citrashanty, M. Yulianto Listiawan; Department of Dermatovenereology, Airlangga University faculty of Medicine, Dr. Soetomo General Hospital Surabaya/Indonesia Background. The practice of wound management has seen much change over the past decade. Scientific evidence demonstrated both experimentally and clinically that wounds re-epithelialize more rapidly under moist condition than under dry. Case. A 63 year-old woman suffered from a traumatic wounds on her right lower leg since 5 weeks before admission. There were ulcers with diameter 8 cm and 3 cm, and half cm depth. All wounds were covered with pus and necrotic tissues. Before admitted, she already treated the wounds with NaCl 0,9% wet dressing and oral antibiotic for 3 weeks, but there was no improvement. In this case, she was treated with calcium alginate covered with polyurethane transparent film as the secondary dressing for 6 days, continued with transparent film dressing singly for 3 days. Significant improvement was achieved in 9 days. The diameter of the first wound decreased to 5x3 cm, no pus and necrotic tissue, and almost complete re-epithelialization on other wounds. Discussion. Calcium alginate dressing is used in exudative wound. It has an absorbent, bacteriostatic and self debridement effects. Transparent film dressing can be used as primary or secondary dressing. The moist condition is achieved by covering wounds with transparent film dressing, thereby it promotes more rapidly healing process. It also has advantage on clear observation of wounds progression. Angiogenesis, the development of new blood vessels, is a vital part of wound healing, re-establishing circulation at the injury site, thereby limiting ischemic necrosis and permitting repair. CHEMICAL PEELING FOR ACNE AND MELASMA Reni Wiyakti Nanda Dewi, Santosa Bandung International Hospital, Cibabat General Hospital Chemical peel, also known as chemexfoliation or derma-peeling, is a skin treatment used to improve the appearance of the skin. A chemical solution is applied to the skin, which causes it to "blister" and eventually peel off. The new, regenerated skin is usually smoother and less wrinkled than the old skin. The new skin also is temporarily more sensitive to the sun. Chemical peels are performed on the face, neck or hands. They can be used to reduce fine lines under the eyes and around the mouth, treat wrinkles caused by sun damage, aging and hereditary factors, improve the appearance of mild scarring, treat certain types of acne, reduce age spots, freckles and dark patches due to pregnancy or taking birth control pills and melasma. Peels is classified based on the histology depth of penetration into: superficial peels – epidermal, medium peels - epidermal into papillary dermis, and deep peels - papillary dermis into reticular dermis. Careful analysis of the patient’s skin with respect to skin type, amount of pigmentation, and extent of photo-aging is the starting point of the rejuvenation process. The Fitzpatrick skin types classification and Glogau photo-aging classification can be used. Superficial peels are considered safe for all skin types, but pigmentary complications can be significat with medium to deep peels. Indications for superficial peels include mild acne and melasma. Superficial peeling agents are α-hydroxy acids such as glycolic acid 20 – 70%; salicylic acid (β-hydroxy acid) 20 – 30%; lower concentration of trichloroacetic acid (TCA) 10 – 30%; and Jessner’s solution. Indications for medium-depth peels include mild acne scars and melasma. Medium-depth peeling agents are Glycolic acid 70% and greater; TCA 35 - 50%; Jessner’s solution and TCA 35%; Glycolic acid and TCA 35%, .

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EXCISION OF ACNE KELOIDALIS NUCHAE WITH HEALING BY SECONDARY INTENTION N. Gantsho*, N. Khumalo*, M. Al-Anwer**, L. Field*** * Groote Schur Hospital , Dermatology, University of Cape Town/South Africa ** Dermatology Department, Al-Minya University, Al-Minya/Egypt *** Inaugural International Traveling Chair of Dermatologic Surgery, ISDS, Darmstadt/Germany Excision of Acne Cheloidalis can be a most challenging task, given the difficulties of anesthesia and of the surgery itself. A previous presentation has called attention to the ease of anesthetic installation using Tulip Company’s (San Diego, CA) larger multi-port infiltrators. Once Bi-level surgical tumescent anesthesia (Field) has been delivered and the sub-cheloidal subcutaneous space has been hydro-dissected, blunt undermining and scissors shearing maneuvers are sufficient. Focal deeper lesions of pili incarnati and / or cicatrix cana be removed with varying sized punches. There are no risks of general anesthesia, sharp dissection, adverse bleeding, or untoward cosmetic compromise. MONO-FOCAL LUPUS PANNICULITIS OF THE CHEEK – RX WITH LIPO-TRANSPLANT & RE-ACTIVATION IN 2 MOS S. Rojhirunsakool, S. Pootongkam, S. Wichyanrat, S. Tanratanakorn, W. Tanasarnaksorn; Division of Dermatology, Ramathibodi University Hospital, Bangkok/Thailand; L. Field, International Traveling Chair of Dermatologic Surgery (ISDS)

A 40 yr old female presented with a 2-3 yr Hx of LE panniculitis (Bx-proven) of the right cheek. The area had been biologically inactive for over one year, with restoration of contour requested. Systemic Rx with hydroxy-chloroquine was ongoing for 1 year. It was decided the potential gain outweighed any possible problem evolving in the limited space. Under sterile conditions, the area was flooded with a surgical tumescent solution (Field), closely observing for release of the overlying skin from any deeper fixation. Observing this to occur, a small quantity of fat was harvested from one abdominal quadrant. A vertically-held syringe allowed layering and disposal of undesirable infra-natant material (blood, lipids, tumescent solution) . The area was then cross-infiltrated with a layered fat deposit, and held in place with a “U”-shaped adhesive tape “cast” . The immediate post-op result appeared to be excellent, but re-activation of the LE process occurred after 2 months. Serial photographs will be presented.

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RECURRENT SCC - RIGHT LOWER LATERAL ORBIT – A SAGA OF ERRORS, MISREPRESENTATIONS, AND MISCOMMUNICATIONS A. Suwanchinda*, C. Treewittayapoom*, S. Rojhirunsakool*, S. Pootongkam*, Y. Wisessiri**, L. Field*** *Division of Dermatology, Ramathibodi University Hospital, Bangkok/Thailand **Department of pathology, Ramathibodi University Hospital, Bangkok, Thailand ***Traveling Chair of Dermatologic Surgery (ISDS) A 73 Year old Caucasian male underwent excision of a microscopically-cleared infiltrative squamous cell carcinoma 2 years prior to being seen again. He then presented with a rapidly growing, keratoacanthoma-like tumor just inferior to the previous scar. Because a recurrent lesion below the location of a previous SCC must be considered SCC until proven otherwise, an aggressive removal with borders was undertaken. An angled V- plasty excision including both the tumor and pre-existent scar was designed (Mohs / Tromovitch). An Esser-like modification utilizing temple skin to get additional tissue transferred below the eyelid was designed. Bi-level anesthesia (Field) was accomplished, the subcutaneous infiltration being carefully observed for tumor fixation (Field / Leventer). The excisional specimen was marked with dye on its medial side and then quadrisected . However the pathologist, due to miscommunication of orientation, cut across all 4 tumor pieces, revealing tumor in all. Deeper and wider resection was requested. Because orbital fat was already in evidence, referral to a tumor board was suggested. None being available, consultation with radiation oncology became mandatory, for microscopic clearance could not be determined. But first, the surgeons insisted on reviewing the pathology themselves! Serial clinical and microscopic photographs will document the drama. References: Field, L., The Lower Eyelid Curved V-to-T Plasty. The Journal of Dermatologic Surgery and Oncology, ll:4, 378-38l April l985 Field,L., Bilevel Anesthesia and Blunt Dissection: Rapid and Safe Surgery, Dermatologic Surgery, 2001 Vol. 27, No. 11, Pp. 989-991 November Field, L., Bilevel Anesthesia and Blunt Dissection, Innovative Techniques in Skin Surgery, Harahap, M., Editor, Marcel Dekker, Part V (Anesthesia), Chapter 32, Pp. 185-189 May 2002 Leventer, M., Field, L., Tumescent Infiltration - A Useful Tool In Determination Of Tumor Depth, Its Lateral Extension And Fixation, European Academy of Dermatology & Venerology, Prague/Czech Republic 2002. THE ISDS’ TRAVELING CHAIR PROGRAM – BANGKOK, THAILAND 2009 The Faculty of: Division of Dermatology, Dermatologic Surgery Unit, Ramathibodi University Hospital & Mahidol University Hospital, Bangkok/Thailand; L. Field, Inaugural International Traveling Chair of Dermatologic Surgery (ISDS) A two week surgical exchange visit to Thailand provided a wide variety of clinical challenges within a social and cultural milieu which every Member might envy. Sights of cases and environment will be intermixed in this photographic presentation.

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EXICISION OF NEVUS PIGMENTOSUS ON THE RIGHT NASOLABIAL FOLD Sri Lestari, Lusita Sylvia, Elhuda, Rahmah Hidayah; Dermato-Venerological Departement of Dr.M.Djami Hospital/Faculty of Medicine, University of Andalas, Padang/Indonesia An excision of a nevus pigmentosus was performed on the right nasolabial fold. Case report: A nevus pigmentosus 8 x 7 x 5 mm on the right side nasolabial fold was removed. We applied bethadine and alcohol 70 % as antiseptics, then marking the incision lines (ellips design L:W =3:1). We delivered tumescent solution of lidocaine 2% + pehacaine (lidocaine 2% with epinephrine 1 : 80.000) in a total volume of 4 cc (epinephrine 1 : 160.000), infiltrated beneath the nevus and peripherally around the nevus site for presumed flap mobilization. All incisional borders were then infiltrated superficially with pehacaine, accomplishing “bilevel anesthesia”(Field). After 15 minutes, we excised the nevus by making an incision. After blunt undermining, we cut the lesion. The defect was closed with chromic 5.0 at the dermis and subcutaneous. At the epidermis anastomosed with prolene 6.0 interrupted sutures. We gave ciprofloxacin 2 x 500mg and mefenamic acid 3 x 500mg. Sutures were removed on seven days with a good result. Conclusion: We have done excision of nevus pigmentosus on the right nasolabialfold using “bilevel anesthesia”. The wound sites were anastomosed using interrupted sutures of 6.0 prolene. AXILARRY HIPERHIDROSIS AND BROMHIDROSIS TREATED WITH SUCTIONING OF GLANDS BY CASSIO VILLACA CANNULA UNDER LOCAL ANESTHESIA OF TUMESCENT Sri Lestari, Taufik Hidayat; Dermato-Venereology Department, Dr M Djamil Hospital/Medical faculty of Andalas University, Padang/Indonesia

Background: Hyperhidrosis is excessive sweating condition coming out from the skin especially the axilla. Bromhidrosis is body odor may become excessive or particularly unpleasant that arises from apocrine sweat glands. Removal of glands with curettage surgery was more conservative and relatively minimal risk. Identification location of hyperhidrosis axilaris required, before performing this action by calorimetric techniques using starch. Identification of bromhidrosis due to unpleasant body odor, that smells by patient and doctor. Case report: An Indonesian female, 20 yo, came to policlinic of Dermatology of Dr M Djamil Hospital Padang on with symptoms of excessive sweat and unpleasant body odor in the both of axilla especially in right. She wants to eliminate her excessive sweat and unpleasant body odor of axillary. We did removal of the glands in each axilla under local anesthesia (Lillis tumescent solution) 50 cc each axilla, using the blunt-ended "Cassio Villaca Currett Cannula no. 4 (" Richter Industries LTD -Sao Paulo, Brazil). Aggressively and repeatedly curettage to the entire sub cutis in a very superficial plane until the axillary skin thinned. The incision points were not closed, then pressure with thick, absorbent gauze on the axillary’s folds and will heal in 3 days. The histopathology result found cluster of wider ducts apocrine glands between the connective tissue and fat. Discussion: This technique gives satisfactory results with a single surgery without causing complications, compared to technique gland resection and closure with flap.

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II -- LL

Indiarsa Arief L, Marsudi Hutomo; Surabaya/Indonesia

TCA TREATMENT IN TRICHOEPITHELIOMA PATIENT __________ page 15

Istvan Juhasz, Debrecen/Hungary

A NOVEL SUBCUTANEOUS PEDICLED “PROPELLER” FLAP METHOD TO REPAIR PERIOCULAR DEFECTS __________ page 15

Indah Julianto, Julianto Danukusumo, Moerbono Mochtar; Surakarta/Indonesia

BROMHIDROSIS - SURGICAL AND NON SURGICAL APPROACHES __________ page 16

Indah Julianto, Endra Yustin, Ari Kusumawardhani; Surakarta/Indonesia

INJECTION AUTOLOGOUS PLATELET CONCENTRATE WITH GROWTH FACTIOR OR PRP – ACCELERATE CHRONICAL WOUND HEALING __________ page 17

Lora Desika Kaban, Sri Wahyuni Purnama; Medan/Indonesia

TREATMENT OF KELOID ON SUBMANDIBULAR USING COMBINATION SURGICAL TECHNIQUE AND INTRALESIONAL TRIAMSINOLONE ACETONIDE INJECTION __________ page 18

Joseph Kang, Singapore

KIKUCHI FUJIMOTO DISEASE – A COMMON MISDIAGNOSED LYMPHADENOPATHY __________ page 18

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Lili Legiawati, Sondang M.H. Aemilia Pandjaitan Siraitt; Jakarta/Indonesia

ONE CASE ANGIOKERATOMA OF THE SCROTUM SUCCESFULLY TREATED WITH PULSED DYE LASER CASE REPORT __________ page 19

Sri Lestari, Yanhendri, Yosse Rizal; Padang/Indonesia

TUMESCENT LIPOSUCTION FOR LIPOMA ON THE RIGHT BACK __________ page 19

Sri Lestari, Padang/Indonesia

COMPLICATIONS OF LIPOSUCTION AND HOW TO PREVENT THEM __________ page 20

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TCA TREATMENT IN TRICHOEPITHELIOMA PATIENT Indiarsa Arief L, Marsudi Hutomo; Departement of Dermato-Venereology, Medical Faculty of Airlangga University/Dr. Soetomo General Hospital, Surabaya/Indonesia

Background: Trichoepithelioma is a benign adnexal neoplasm. The gene involved in the familial form is located on band 9p21. In United States, frequency reported 2.14 and 2.75 cases of trichoepithelioma per year (9000 specimens). Clinically is slow-growing, single or multiple papules or nodules are typically observed on the face. The treatment is primarily surgical. Case Report: a 24 years old woman presented with skin colored nodule on face region since 10 years ago. Firstly skin colored nodule on face region is single and the age growing up later the nodule growing multiple and become larger. There is no family history suffer the same dissease. Histophatology examination confirmed the diagnosis of trichoepithelioma.. These trichoepithelioma treated by TCA 50% every two weeks until 9 weeks. After treatment, the erosion were appeared and treated with mupirosin ointment. Discussion: The gene associated with the familial type of trichoepithelioma links to the short arm of chromosome 9 is related with trichoepithelioma. In many options of treatment modalities for trichoepithelioma, tricholoacetic acid 50% in this case had given an excellent outcome. A NOVEL SUBCUTANEOUS PEDICLED “PROPELLER” FLAP METHOD TO REPAIR PERIOCULAR DEFECTS Istvan Juhasz, Head of Burn and Dermatosurgery Unit, Department of Dermatology, University of Debrecen, Medical and Health Science Centre, Debrecen/Hungary Removal of tumors below the lower eyelid with margin control (Mohs micrographic surgery, etc.) on the face leaves large defects on a cosmetically very important area. There are numerous options to reconstruct the defect. Most of the methods require the mobilization of large healthy tissue (Imre’s flap, large rotation flaps), or are cosmetically inadequate (free grafting). One surgical gem is proposed in the paper. Usually the skin on the lateral facial plane is loose enough to allow rotation into the defect. The shape of the flap can be easily adjusted to the requirements, defined by the special location. An asymmetrically designed subcutaneously pedicled flap can be made with a curved fusiform shape that fits into the cosmetic unit. In our clinical experience the described flap closure is minimally invasive, while the rotation of the pedicle does not compromise blood supply, and the occasional initial bulkiness will disappear over the time.

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BROMHIDROSIS - SURGICAL AND NON SURGICAL APPROACHES Indah Julianto, Julianto Danukusumo, Moerbono Mochtar, Department of Dermatology and Venereology, Sebelas Maret Medical Faculty/Dr.Moewardi General Hospital Surakarta/Indonesia Bromhidrosis is a condition where the body emits abnormal or offensive body odor. It is also known as bromidrosis and body odor. In rare cases, bromhidrosis may become particularly overpowering and can even affect an individual's life. The human body has two types of secretory glands: apocrine and eccrine. It is the apocrine glands that most commonly cause bromhidrosis. The distribution of apocrine glands is limited to the axilla, genital skin and breasts. The strong odor of Bromhidrosis is caused by the bacterial decomposition of apocrine secretion—which creates ammonia and short-chain fatty acids. This odor has been described as being pungent, rancid, musty or sour in character. The eccrine glands are distributed over the entire body and their secretions are usually odorless. However, the ingestion of certain substances, such as garlic, spices, alcohol or certain drugs, may lead to an offensive odor being emitted. It is also possible for this form of bromhidrosis to be causedApocrine Bromhidrosis Most Common in Post-Puberty Males by an underlying disease or metabolic disorder. Apocrine Bromhidrosis Most Common in Post-Puberty Males Apocrine bromhidrosis is most common in males—probably due to the apocrine glands being more active in males. It also only occurs after puberty and is rare in the elderly. The condition is also more prevalent in dark-skinned people. Diagnosis of bromhidrosis is most common in Asian countries. (This does not necessarily indicate that the condition itself is more common in these countries but rather that medical treatment is more often sought.) In most Asian cultures, any body odor is associated with personal distress. Eccrine Bromhidrosis Most Common in Children Eccrine bromhidrosis occurs in all races and is most common in children. Examination of the skin’s surface in both forms of the condition will usually show no signs of abnormality. Bromhidrosis can be treated conservatively by undertaking methods to reduce bacterial flora and maintaining a dry environment. Improving hygiene and washing susceptible areas with an antiseptic soap will help. Using a topical deodorant, shaving the affected areas, and removing sweaty clothing promptly will also help to limit the odor. Surgical Care Surgical treatment for axillary bromhidrosis has been used in a limited fashion in the United States; however, several surgical techniques are used more widely in Asian countries, where axillary odor causes more social and psychological distress. Clearly, surgical reduction in the number of apocrine glands diminishes apocrine secretion, and because some histologic evidence to suggest overactive apocrine sweat glands contributes to bromhidrosis, surgical techniques may be the most satisfactory methods of treatment. Surgical treatment improves the long-term management of bromhidrosis, but it is associated with an increased risk of morbidity, including scarring, surgical complications, and risk of recurrence. In recent years, new techniques with less morbidity have been developed.

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INJECTION AUTOLOGOUS PLATELET CONCENTRATE WITH GROWTH FACTIOR OR PRP - ACCELERATE CHRONICAL WOUND HEALING Indah Julianto, Endra Yustin, Ari Kusumawardhani; Department of Dermatology Medical Faculty of Sebelas Maret University/Dr. Moewardi General Hospital Surakarta/Indonesia Platelet-rich plasma (PRP) has been utilized in aesthetic medicine to rejuvenate and ameliorate the aging process and face,include an increase in soft tissue wound healing and a decrease in post cutaneous surgery inflammation, infection and pain(Marx RE.:2004.,Valerio Cervelli.,et al.:2009).This refers to mesenchymal and epithelial rejuvenation by application of the persons own enriched autologous plasma. Recently, PRP/ autologous platelets concentrate with growth factor (APCG), has been pioneered in South Africa during 1996 by Professor Donald du Toit, from Cape Town for facial rejuvenation in select patients with chronological aging, and solar damage. In addition to their well known function in hemostasis, platelets also release substances that promote tissue repair, angiogenesis and Inflammation (Valerio Cervelli.,et al.:2009). At the site of the injury, platelets release an arsenal of potent inflammatory and mitogenic substances that are involved in all aspects of the wound healing process (Beasly,LS & Einhorn,TA;2000). Wound healing is a complex process characterized by stages inflammation, proliferation, repair and remodeling (Marx RE.:2004.,Valerio Cervelli.,et al.:2009). Platelets contain at least five growth factors that may contribute to tissue formation and epithelization: platelet-derived growth factor (PDGF), transforming growth factor (TGF-β), vascular endothelial grwoth factor (VEGF) and platelet-derived epidermal growth factor (PDEGF), and Insulin-like growth factor-1 (IGF-1) (Robert E Marx,2001). These are variously involved in stimulating chemotaxis, cell proliferation and maturation in wound healing (Anna Falabella.,2006.,Valerio Cervelli.,et al.:2009). Chronic wounds may, in some cases, lack of growth factors. Decrease growth factor avaibility may be a results of decreased production, decrease release, trapping excess degradation, or a combination of these mechanisms (Marx RE.:2004).Recent studies have found that autologous platelet concentrate with growth factor (APGF) or platelet-rich plasma (PRP) may accelerate wound healing (David M Dohan.et.al:2006). As such wound healing enhancement by PRP remain largely anecdotal, the authors present their My own methode of 25 cases, by injections APGF in finger, abdominal wall, lower extremity chronical ulcer.

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TREATMENT OF KELOID ON SUBMANDIBULAR USING COMBINATION SURGICAL TECHNIQUE AND INTRALESIONAL TRIAMSINOLONE ACETONIDE INJECTION Lora Desika Kaban, Sri Wahyuni Purnama, Department of Dermatology and Venerology Faculty of Medicine, University of Sumatra Utara, Haji Adam Malik General Hospital Medan/Indonesia Background : Keloid is a benign, hard and persistent fibrous proliferation that develop in predisposed person at site of cutaneuos injury. It result from uncontrolled synthesis and excessive deposition of collagen at sites of prior dermal injury that often occur after local skin trauma. There are 3 treatment options for keloid scar: non-surgical interventions, surgical removal and combination. Case : A case of 15 years old boy with submandibular keloid was reported. The diagnosis was based on clinical finding. This patient has a history of keloid removal by excision before, but after excision, keloid getting bigger than the last. We make an incision at the margin of keloid and move the collagens, after almost the mass of collagens remove, we suture the wound with nylon 5.0. After a complete wound healing process, we inject triamsinolon acetonide intralesional with interval one week. The combination therapy for keloid that is merging surgical technique and intralesion triamsinolon acetonide injection show better result and the time consume is shorter than just using triamsinolon acetonide injection alone as therapy for keloid KIKUCHI FUJIMOTO DISEASE – A COMMON MISDIAGNOSED LYMPHADENOPATHY Joseph Kang, Singapore Kikuchi-fujimoto disease, also known as histiocytic necrotizing lymphadenitis, is a self-limiting condition characterized by lymphadenopathy, pyrexia and neutropenia.1 The key distinguishing pathological characteristics required to diagnose KFD include necrotizing lymphadenitis with karyorrhexis and paucity of granulocytes.2 In addition to cervical lymphadenopathy, other systemic manifestations that have been reported to be in association with KFD include sore throat, fever, weight loss, rash, hepatosplenomegaly. Laboratory investigations will yield derangements ranging from leucopenia,anemia, raised erythrocyte sedimentation rate and high tansaminases.3 The exact etiology of KFD is still unknown, although an association with viral infections and autoimmune processes have been proposed. To our knowledge, there is no literature in the region that documents Kikuchi-Fujimoto disease. This paper contains one of the largest case series in the world and aims to influence the approach and management of this disease. 1 Recurrent Kikuchifujimoto disease: Case report. Sunil K.sah, British journal of Oral and maxillofacial surgery December 2005. P231 - 233 2 Recurrent Kikuchifujimoto disease: Case report. Sunil K.sah, British journal of Oral and maxillofacial surgery December 2005. P231 - 233 3 Kucukardali Y, Solmazgul E, Kunter E, Oncul O, Yildirim S, Kaplan M. Kikuchi–Fujimoto Disease: analysis of 244 cases. Clin Rheumatol 2007;26:50–4.

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ONE CASE ANGIOKERATOMA OF THE SCROTUM SUCCESFULLY TREATED WITH PULSED DYE LASER – CASE REPORT Lili Legiawati, Sondang M.H. Aemilia Pandjaitan Sirait, Dermatovenereology Department of Dr Cipto Mangunkusumo Hospital, Faculty of Medicine University Indonesia, Jakarta/Indonesia Angiokeratoma is a benign cutaneous lesion of capillaries and may be misdiagnosed, because of the rarity. We report a case of Angiokeratoma of the scrotum which was previously misdiagnosed as hemangioma. A man 47 years old came to our clinic with a complaint of multiple papules located on the scrotum since 8 months ago. Papules became larger and the lesions spread to covered almost all the scrotum surface. He had several attacks of massive bleeding. There was a history of cardiac catheterization and using anticoagulant drugs since 9 months before the papules appeared. From physical examination there were multiple, blue-to-red papules, 2- to 5-mm in size, with a scaly surface located on the scrotum. The first histopathological expertise revealed non specific granulation. The slide was reexamined and is confirmed as angiokeratoma. We treated the patient with pulsed dye laser 595 nm for 3 times, and most of the papules disappeared. TUMESCENT LIPOSUCTION FOR LIPOMA ON THE RIGHT BACK Sri Lestari, Yanhendri, Yosse Rizal; Department of Dermato-Venereology, Dr. M. Djamil Hospital/Faculty of Medicine, Andalas University, Padang, West Sumatra/Indonesia Background: Tumescent liposuction is a term which combines a technique of local anesthesia with a methodology of subcutaneous fat removal. Tumescent liposuction surgery offers a safe and effective treatment in other circumstances including of lipoma. Case: A 38-year-old woman presented with a lipoma, 10x7x1 cm, on her right back that was removed with tumescent liposuction. The diagnosis of lipoma was based on history, physical finding, and histopathology examination. We did tumescent liposuction using 85cc solution tumescent local anesthesia (Lillis formula) with infiltrator Tulip® cannula. After waiting 20 minutes, we did fat removal using aspiration Tulip® cannula 3.0 mm. There was no complication after procedural therapy. One-week follow-up revealed a good result and improvement. Discussion: Tumescent liposuction is an effective treatment for non-aesthetic indication such as lipoma. It allows a safe removal of excess subcutaneous fat with tumescent local anesthesia. In tumescent liposuction, diluted lidocaine and diluted epinephrine are delivered to subcutaneous making bulge. It causes less bleeding, no pain, and allows for the procedure to be performed completely under local anesthesia.

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COMPLICATIONS OF LIPOSUCTION AND HOW TO PREVENT THEM Sri Lestari, Dermatology-Venereology Department of Dr M Djamil Hospital, Faculty of Medicine, University of Andalas, Padang, West Sumatra/Indonesia Evaluation of a comprehensive perioperative patient can avoid most of the medical and surgical complications of tumescent liposuction. Identify a suitable patient candidates obtained through comprehensive preoperative consultation including screening questionnaire. During the consultation, risk, goals, anticipated and expected to produce post-operative course are discussed. Tumescent technique of liposuction was created to enable more secure. With good technique, large volumes of lidocaine with epinephrine can be administered in dilute concentrations under the skin, resulting in minimal blood levels of lidocaine, without pain, very patient comfort, minimal blood loss, decrease patient morbidity and costs, and elimination of the risk of general anesthesia. Local surgical complications are rare, such as contour irregularities, weight gain influence on the contours of the body, hematoma or seroma, paresthesia, scarring, hypopigmentation, hyperpigmentation, asymmetry, and superficial skin necrosis. Death, infection, fat emboly, emboly lung, and hollow viscus is a systemic complications. Liposuction is characterized by a rapid recovery of patients, is safe and no deaths were reported. Aesthetic complications can be minimized with good patient selection, patient education, the concept of good operations, good technique, aseptic technique and preoperative antibiotics. It is better to do a little rather than too much, and think the most important thing is not what you remove but what you are going and how you left it. It is also important how to avoid complications and treat them. Tumescent technique has virtually eliminates all the complications.

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MM -- QQ Denisa Alinda Medhi, Suysoso Sunarso; Surabaya/Indonesia

NEUROFIBROMATOSIS TYPE 1 AND LIPOMA __________ page 23

Sinar Mehuli, Indah PS, Reny Anggraini, Afaf Agil, Yulia Farida Yahya, Theresia L. Toruan; Palembang/Indonesia

TREATMENT OF NEVUS SEBACEOUS OF JADASSOHN WITH CO2 LASER __________ page 23

Antoni Miftah, Evy Ervianti; Surabaya/Indonesia

VERRUCOUS EPIDERMAL NEVUS - CASE REPORT __________ page 24

Moerbono Mochtar, Endra Yustin, Yuyun Rindiastuti, Solo/Indonesia; Alamanda Murasmita, Asy Syifa Boyolali/Indonesia; Cempaka Kesumaningtias, Solo/Indonesia

STROMAL STEM CELLS DERIVED LIPOASPIRATE FOR CHRONIC ULCER TREATMENT __________ page 24 - 25

Moerbono Mochtar, Solo/Indonesia

LIPOSUCTION FOR LIPOMA __________ page 25

Moerbono Mochtar, Surakarta/Indonesia

PATHOPHYSIOLOGY OF VARICOSE VEINS __________ page 26

I Peros, N Kalogeropoulos/Greece; L M Field, International Traveling Chair of Dermatologic Surgery

NONCOSMETIC APPLICATIONS OF LIPOSUCTION __________ page 26

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Pedia Primadiarti, Marsudi Hutomo; Surabaya/Indonesia

EXTENSIVE LYMPHANGIOMA CIRCUMSCRIPTUM CASE REPORT __________ page 27

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NEUROFIBROMATOSIS TYPE 1 AND LIPOMA Denisa Alinda Medhi, Suysoso Sunarso; Dermatovenerology Departement, Medical Faculty of University of Airlangga, RSUD Dr.Soetomo, Surabaya/Indonesia Background : Neurofibromatosis type 1 (NF1) is an autosomal dominant, multisystem disorder affecting approximately 1 in 3500 people with a nearly even split between spontaneous and inherited mutations. There is no medical therapies for NF1 are currently available Case : A 33 old years woman, presented multiple tumor on almost all over her body, there was café au lait macules and freckling. And there were a lipoma on her buttom. Histopatology revealed neurofibromatosis. Surgical procedure were done to excision the tumors and lipoma on her buttom Discussion : NF1 is a multisystem disorder requiring management by multiple disciplines, often coordinated through a primary care physician or a geneticist. The risk of transmission of NF1 from patients with segmental involvement is unknown. There are several disorders that may share overlapping features with NF1Genetic testing has increased our ability to make the diagnosis in uncertain cases, but has not allowed us to predict a particular patient’s natural history based on the mutation. Surgical treatment approach yielded satisfactory result. TREATMENT OF NEVUS SEBACEOUS OF JADASSOHN WITH CO2 LASER Sinar Mehuli, Indah PS, Reny Anggraini, Afaf Agil, Yulia Farida Yahya, Theresia L. Toruan; Departement of Dermato-Venereology of Medicine Sriwijaya University/Dr. Moh. Hoesin Hospital Palembang/Indonesia Background Nevus sebaceous or nevus sebaceous of Jadassohn or organoid nevus. Excisional treatment of nevus sebaceous lesions is controversial. The case reported before, CO2 (carbon dioxide) laser in sebaceous and epidermal nevi obtained good result about 80-90%. We reported a 18 years old woman with nevus sebaceous treated by CO2 laser with good results. Case A woman 18 years old complained of rough brown papules on the neck since 1 year old. Initially in colli region developed a papule increased number and size in 4 years. Dermatologic examination showed multiple brown verrucous papules, coalesce to form linier as a Blaschko’s lines. It measured approximately 4x1 cm. In the apex of the lesion showed a papule, soliter and no pain. Histopatologic examination revealed nevus sebaceous of Jadassohn. Patient was treated once with the C02 laser 10 watt power countinuous laser. Discussion The diagnosis confirmed by histopatologic examination. Surgical excision of these lesions cosmetically unacceptable, however laser CO2 showed a good outcome and cosmetically acceptable.

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VERRUCOUS EPIDERMAL NEVUS - CASE REPORT Antoni Miftah, Evy Ervianti; Department of Dermatovenereology, School of Medicine Airlangga University/Dr. Soetomo Hospital, Surabaya/Indonesia Background : Verrucous epidermal nevus also known as linear verrucous epidermal nevus or linear epidermal nevus, occurs in 1 : 1000 newborns. 80 % of lesions present within the first year of life and continue to appear over 14 year of age. Male-female prevalence is equal and most cases are sporadic. Characterized by localized or diffuse, closely set, skin-colored, brown or gray-brown verrucous papules, which may coalesce to form well-demarcated papillomatous plaques. Lesions are more common on the limbs, in Blaschko’s lines or in relaxed skin tension lines. Case : A 13-year-old javanese girl with hyperpigmented papules on left hemifacial area, since 8 years ago and getting wider and darker over year. No itchy, no tenderness. The skin lesion became brown verrucous papules and coalesce to form well-demarcated papillomatous plaques. No café-au-lait macules and no family history. Histopathology showed hyperkeratosis, acanthosis, papillomatosis, and elongation of rete ridges. Diagnosis of verrucous epidermal nevus was established. Electrofulguration was performed. The condition is suspected to recur. Discussion : Verrucous epidermal nevus rarely involves the face. In this case the hyperpigmented papules involved left hemifacial area in Blaschko’s lines. Epidermal nevi arise from the pluripotent embryonic basal cell layer. Mutation analysis for fibroblast growth factor receptor 3 (FGFR3) is not performed. Malignant degeneration of epidermal nevi is rare. Treatment of the skin lesion is not necessary except for cosmetic concerns. Recurrence is common especially if only the epidermis is removed. Attempts to remove deeper structures of the skin pose greater risk of scarring. STROMAL STEM CELLS DERIVED LIPOASPIRATE FOR CHRONIC ULCER TREATMENT Moerbono Mochtar *, Endra Yustin*, Yuyun Rindiastutiϒ, Alamanda Murasmita+

Cempaka Kesumaningtiasϒ *Dermatology-Venereology Department of Dr Moewardi Hospital, Solo, Central Java/Indonesia ϒFaculty of Medicine, Sebelas Maret University, Solo, Central Java/ Indonesia +Emergency Department of RSU Asy Syifa Boyolali, Central Java/ Indonesia

Adipose derived stromal stem cells/ mesenchymal stem cells play a key role in skin biology such as wound healing. Adipose tissue contains a large number of stromal stem cells. Since it is easy to obtain in large quantities, adipose tissue constitutes an ideal source of uncultured stromal stem cells. Non enzymatic stromal cell isolation from blood and saline fraction of lipoaspirate is cost efficient. The clinical application of stromal stem cells derived lipoaspirate was expected to be a preliminary study for its effect on wound healing. Seven patients were assessed as having chronic ulcer within 1 up to 5 years, located at inferior extremity. We found out a wound area sized 8x5x1.5 cm in average, well defined, wet without any pus, hyperemia, with fascia and fibrotic tissue as a basis, and mild on sorrounding palpation. Ulcer is diagnosed by clinical findings, while ulcer staging determined by biopsy and histopathological review. At this case, we diagnosed based on clinical finding, a full skin loss followed by the damage of subcutaneous tissue.

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The patient recieved a non culture stromal fraction of lipoaspirate treatment, obtained from non enzymatic blood and saline fraction is.olation. This treatment was given once a time and the ulcer medicated for every 5 days. According to the clinical findings, granulation forming began at fifth day, followed by the decreasing of wound depth. We also found out epithelization from the wound edge itself. This epithelization grew faster after day tenth which continued by wound size reduction. In addition, at the twentieth day almost all this wound area already covered by epitel. Eventually, we discovered that among of the patients got per secundam healing. From this study, we conclude stromal stem cells derived lipoaspirate was potential in enhancing chronic wound healing. These presumed as preliminary investigation of lipoaspirate stromal fraction effect on wound healing. LIPOSUCTION FOR LIPOMA Moerbono Mochtar, Dermatology-Venereology Department of Dr Moewardi Hospital, Faculty of Medicine, University of Sebelas Maret, Solo, Central Java/Indonesia The main principal for lipoma liposuction isn’t far from liposuction concept itself. However, there are certain basics here, which is focused on the tumor ( lipoma ), such as location, and size. Not to forget if there is any contraindication to perform liposuction. The first step is infiltrating these tumescent anesthesia, and wait for approximately 15 minute. Countinued with proceeding suction which pass the lipoma’s shield and directly destroy the tumors. Meanwhile, this removal has been successful if the doctor understands that a ‘pickle fork’ or other device must be used to break the fibrous banding around the lipoma to allow complete evacuation without leaving a shell in which a seroma may form1

2 – 3 mm holes, attached without any suturing process. In a proper condition, this wound closed effortless for 2 to 3 consecutive day. The advantage of lipoma removal using liposuction includes a smaller surgical scar, even with large tumors and a lower risk of bleeding, post surgical pain and infection2

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PATHOPHYSIOLOGY OF VARICOSE VEINS Moerbono Mochtar, Dermatology-Venereology Department of Dr Moewardi Hospital, Faculty of Medicine, University of Sebelas Maret, Surakarta, Central Java/Indonesia There are essentially three compenents of the venous system of the leg that act in concert : deep veins, supervicial veins and perforating veins1

The World Health Organization defines varicose veins as saccular dilatation of the veins which are often tortuous1 . Varicose beins are described also as visible, tortuous elongation and dilatation of larger superficial venous trunk and their tributaries2. Varicose veins differ from non varicose veins in physiologic function1

These are some of theoretical causes of varicose veins like heredity, race, gender, posture, body weight and height or even hormones, but the main pathophysiology it self become widened these years, in summary pathologic development of varicose veins can be devided into four broad categories. Increased deep venous pressure in proximal area such as pelvic obstruction ( inderect ), intra abdominal pressure secondary to Valsava, leg crossing, constrictive clothing, squatting, obesity, saphenofemoral incompetence and venous obstruction. And at the distal part could be developed by perforator valvular incompetence. Moreover, primary valvular incompetence and secondary valvular incompetence could lead into these varicose veins also such as decreased number of venous valves, vein wall weakness, increased venous distensibility through hormonal induced mechanism triggered by pregnancy, systemic estrogens and progesterons ( concentration and ratio dependent ). These may overlap and worsened the varicose veins1 NONCOSMETIC APPLICATIONS OF LIPOSUCTION I Peros, N Kalogeropoulos, Greece; L M Field, International Traveling Chair of Dermatologic Surgery Noncosmetic applications of liposuction have continued to appear since its introduction. Although the most common use is in removing lipomas, liposuction has also been used for benign symmetric lipomatosis, flap undermining, flap defatting, gynecomastia, pseudogynecomastia, breast reduction, buffalo hump and axillary hyperhidrosis. Other uses remain to be discovered.

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EXTENSIVE LYMPHANGIOMA CIRCUMSCRIPTUM – CASE REPORT Pedia Primadiarti, Marsudi Hutomo; Department of Dermatovenereology, Medical Faculty of Airlangga University, Dr Soetomo Hospital, Surabaya/Indonesia Background : lymphangioma circumscriptum (LC) is congenital malformation of the lymphatic system that may involve the skin and subcutaneous tissue. The incidence of LC is 1,2-2,8 per 1000 live birth in US. LC is characterized clinically by the presence of vesicles within a circumscribe area, mostly filled with colourless fluid but occasionally tinged with blood. They may range in size, 2-4mm, and in color, from pink through red to back. These vesicles often resemble frog spawn and tend to increase in number and size. Various methods of treatment LC have been described. Suction assisted lipectomy, radiotherapy, cryosurgery, phototherapy, CO2 ablative laser and surgical excision have all been tried, but recurrent is still a problem Case : A 9 years old boy, with clusters of vesicles on his right soulder, right arm, back, right armpit, and some part of abdomen. These vesicles were pink to red-black in color, 2-4mm in size, and appeared since he was 4 years old. The vesicles ruptured leading to bleed or drainage. The histopathology examination showed the dilatation of lymphatic vessel, contained amorf material, relevant to LC. We give tretinoin 0,05% for hyperkeratosis. We reffered to plastic surgery department for wide excision and skin grafting to cover the defect.. Discussion : diagnosis of LC is made by clinical presentation and histopatology examination. LC is not malignant condition. Various therapy including surgery, radiotherapy, cryosurgery, phototherapy, CO2 laser could be the choice, considering the skin lesion and patient condition. Still we need observation to assess the recurrency after therapy.

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RR –– SS Asri Rahmawati, Indropo Agusni; Surabaya/Indonesia NEUROFIBROMATOSIS TYPE 1 __________ page 31 Muhammad Reza, Iskandar Zulkarnain; Surabaya/Indonesia

HALO NEVUS-TREATMENT USING SHAVING __________ page 31 S. Rojhirunsakool, A. Suwanchinda, C. Treewittayapoom, S. Pootongkam, Bangkok/Thailand; L. Field, International Traveling Chair of Dermatologic Surgery (ISDS)

THE INFRA-ORBITAL ANGLED V-PLASTY __________ page 32

Silonie Sachdeva, Jalandhar Punjab/India LACTIC ACID PEELING IN SUPERFICIAL ACNE SCARRING IN INDIAN SKIN __________ page 32 Adhimukti Sampurna, Herman Cipto, Sondang P. Sirait, Wresti Indriatmi, Aida S.D Suriadiredja; Jakarta/Indonesia

DERMOSCOPIC FEATURE IN VARIOUS HISTOPATHOLOGY SUBTYPE OF SEBORRHEIC KERATOSIS __________ page 33

Matthias Sandhofer, Linz/Austria THE ANATOMIC BASICS FOR FACIAL PROCEDURES __________ page 33 Uta Schlossberger, Köln/Germany

COMBINED TREATMENT MATRIX FOR POST-ACNE SCARRING __________ page 34

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Uta Schlossberger, Köln/Germany

HAND REJUVENATION CASE STUDY COMPARING TREATMENT WITH TCA PEELING AND DIFFERENT LASERS VS. THE COMBINATION WITH HYALURONIC ACID __________ page 34

Lita Setyowatie, Iskandar Zulkarnain; Surabaya/Indonesia

CONDYLOMATA ACUMINATA : SEXUALLY TRANSMITTED IN MULTI PARTNER SEXUAL __________ page 35

Sudhir Sharma, India

INTRA-LESIONAL INJECTION OF MELANOCYTES IN STABLE VITILIGO __________ page 35

Sondang M.H.Aemilia Pandjaitan-Sirait, Jakarta/Indonesia AUTOLOGOUS FAT TRANSFER FOR SCAR REVISION

CASE REPORT __________ page 36

Aryani Sudharmono, Naviani Surlinia, Puspita Ningrum; Jakarta/Indonesia

THE EFFICACY AND SAFETY OF ACTIVE FX ULTRAPULSE CO2 FRACTIONAL LASER RESURFACING FOR ACNE SCARS AND PHOTOAGING IN ASIAN PATIENTS __________ page 36

Aryani Sudharmono, Naviani Surlinia, Puspita Ningrum; Jakarta/Indonesia

THE EFFICACY AND SAFETY OF MONOPOLAR RADIOFREQUENCY FOR SKIN TIGHTENING AND CONTOURING IN ASIAN PATIENTS __________ page 37

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Tansil Tan Sukmawati/Indonesia EARLY DIAGNOSIS OF BASAL CELL CARCINOMA

IN YOUNG AGES __________ page 37

Hanny Suwandhani/Indonesia CHEMICAL PEELS FOR INDONESIAN SKIN __________ page 38

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NEUROFIBROMATOSIS TYPE 1 Asri Rahmawati, Indropo Agusni; Dept/SMF Ilmu Kesehatan Kulit dan Kelamin, FK Unair/RSUD dr. Soetomo, Surabaya/Indonesia Background. Neurofibromatosis (NF) is a multisystem genetic disorder that commonly is associated with cutaneous, neurologic, and orthopedic manifestations. NF type 1 (NF1) is differentiated from central NF or NF type 2 in which patients demonstrate a relative paucity of cutaneous findings but have a high incidence of meningiomas and acoustic neuromas (which are frequently bilateral). NF1 has a better prognosis with a lower incidence of CNS tumors than NF2. The estimated incidence of NF1 is 1 in 3000. Case. A 26-year-old woman with Neurofibromatosis type I. The disease started in childhood with the appearance of multiple hyperpigmented skin macules. At the age of 20 a lot of cutaneous tumors appeared and started to increase in size all over the body surface especially on the trunk and limb. No history about other disorder. From physical examination numerous of soft cutaneous tumors, the largest amount being on the trunk and limbs, ranging from a few millimeters to several centimeters in diameter. Multiple café-au-lait spots with diameter > 1,5 cm on trunk and limb. The mucous membranes were not affected. Excision done in some tumor which large and pain on trunk and limb. And give good result. Discussion. Treatment of neurofibromatosis is predominantly surgical. When tumors increase in size or cause pain. But surgical for this patient doesn’t conclude the problem because the lesions still many. Also it need further examination to find genetic disorder and possibility for meningioma and acoustic neuroma. HALO NEVUS-TREATMENT USING SHAVING Muhammad Reza, Iskandar Zulkarnain; Departement of Dermato-Venereology, Airlangga University-School of Medicine, Dr. Soetomo General Hospital, Surabaya/Indonesia Background: Halo nevus is a nevus ( ussually compound or dermal nevus ) that becomes surrounded by a halo of depigmentation. The nevus then typically undergoes spontaneous involution and regression followed by repigmentation of the depigmented area. Case: An 17 years old man came in our clinic with main complaint halo around his nevus on his thorakal area. Shaving has been done at the nevus and sent for histologic evaluation. From histopathology examination, there are confirmed as halo nevus. Discussion: Diagnosis was established from anamnesis, clinical appearance and laboratory examination. There are clinical improvement after shaving at the lession. The nevus is dissappear and halo area become repigmented.

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THE INFRA-ORBITAL ANGLED V-PLASTY S. Rojhirunsakool, A. Suwanchinda, C. Treewittayapoom, S. Pootongkam, Mahidol University Hospital, Bangkok/Thailand; L. Field, International Traveling Chair of Dermatologic Surgery (ISDS) A 40 yr old male presented with a clinical pigmented BCC of the right lower eyelid of 1 year duration. An angled V-plastic excision and closure was designed, thus not compromising the esthetics of the lower eyelid wrinkle system. It was ascertained the lesion was not fixed by utilizing the technique of Field / Leventer in injecting a mass of subcutaneous fluid and observing the immediate elevaton of the lesion from the hydrodissected space. Bilevel anesthesia (Field) was then completed. The carcinoma was then curetted for depth and peripheral margins (technique of Tromovitch), following which the angled specimen was resected and submitted for pathologic examination. Serial photographs from this and other cases will demonstrate the surgical steps of the procedure. References: Field, L, Leventer, M , Tumescent Infiltration - A Useful Tool In Determination Of Tumor Depth, Its Lateral Extension And Fixation), European Academy of Dermatology & Venerology Prague, Czech Republic 2002. Field, L., The Lower Eyelid Curved V-to-T Plasty. The Journal of Dermatologic Surgery and Oncology, ll:4, 378-38l April l985 Field,L., Bilevel Anesthesia and Blunt Dissection: Rapid and Safe Surgery, Dermatologic Surgery, 2001 Vol. 27, No. 11, Pp. 989-991 November Tromovitch, T., Clinical demonstrations, UCSF, San Francisco, CA, circa 1975 LACTIC ACID PEELING IN SUPERFICIAL ACNE SCARRING IN INDIAN SKIN Silonie Sachdeva, Department of Dermatology, Carolena Skin, Laser & Research Centre, Jalandhar Punjab/India Introduction: Chemical peeling with both alpha and beta hydroxy acids has been used to improve acne scarring. Lactic acid, a mild alpha hydroxy acid has been used in treatment of melasma, fine lines and wrinkles but no study is reported in acne scarring in dark skin. Aims: To evaluate the efficacy and safety of Full strength pure Lactic acid 92%, (pH 2.0) chemical peel in superficial acne scarring in Indian skin Patients and Methods: Twelve patients, Fitzpatrick skin type IV-V in age group (20-30) years with superficial acne scarring were enrolled in the study. Chemical peeling was done with Lactic acid at interval of two weeks to maximum of four peels. Pre and post peel clinical photographs were taken at every session. Patients were followed every month for three months after the last peel to evaluate the effects. Results: At the end of three months, evaluation was done by the treating physician, and patients based on clinical response and comparison of pre-peel and post peel pictures. Significant improvement (greater than 75% clearance of lesions) occurred in two patients (16.6%), good improvement (51-75% clearance) in five patients (41.6%), moderate improvement (26-50% clearance) in three patients (25%) and mild improvement (1-25% clearance) in two patients (16.6%). Transient post inflammatory hyperpigmentation was noted in one patient but was effectively treated. Conclusion: Pure Lactic acid full strength peel is an effective treatment for superficial acne scarring in darker skin types.

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DERMOSCOPIC FEATURE IN VARIOUS HISTOPATHOLOGY SUBTYPE OF SEBORRHEIC KERATOSIS Adhimukti Sampurna, Herman Cipto, Sondang P. Sirait, Wresti Indriatmi, Aida S.D Suriadiredja; Dermatovenereology Department, Faculty of Medicine University of Indonesia/dr. Cipto Mangunkusumo Hospital Jakarta/Indonesia Background Diagnosis of seborrheic keratosis (SK) is usually made based on clinical appearance. In some cases SK may resemble malignancy, thus may require additional examination to assist in determining the diagnosis, one of which is dermoscopy. Dermoscopy has seldom been used in the Dermatovenereology department CM Hospital. Therefore, it is necessary to be aware of SK dermatologic features. Objectives To investigate the characteristic of SK based on dermoscopic feature, and histopathology subtype. Subjects and methods Lesions clinically presumed as SK were recruited. Dermoscopy was done using Dermlite®-Hybrid (3Gen, USA) with 70% ethanol as optical linkage fluid. Histopathology specimens were obtained via punch biopsy stained with hematoxylin-eosin and observed with a light microscope. Results Of 77 lesions histopathologically confirmed as SK, the most frequent histopathology subtype found was acanthotic (50.65%). Dermoscopic feature frequently found were sharp demarcation (75.32%), fissure and ridge (71.43%), pseudofollicular opening (66.23%), and milialike cyst (53.25%) respectively. Conclusions Dermoscopic features mainly found in various histopathology subtypes was sharp demarcation + fissure and ridge in acanthotic subtype (11.69%). THE ANATOMIC BASICS FOR FACIAL PROCEDURES Matthias Sandhofer, Linz/Austria Traditionally thinking on facial aging has focused on gravidational DESCENT. More realistic is the concept, the focal loss of volume, often in areas of cutaneous attachement of the skin to deep structures can mimic descent of soft tissue. A significant and most important aspect of aging may be the unveiling of deeper contours caused by focal loss of volume (DEFLATION). Fat along with it’s carrier, the fascia superficialis of the head and neck forms the basic contours of the human face. Also bone, muscle and skin are the other key structural ingredients, fat and fascia superficialis constitute the sine qua non for contour. We all heard the dictum for buying real estate: location, location, location. An analogous dictum applies for performing facial cosmetic procedures: anatomy, anatomy, anatomy.

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COMBINED TREATMENT MATRIX FOR POST-ACNE SCARRING Uta Schlossberger, Köln/Germany We would like to present a new treatment matrix for reducing the appearance of slight acne scars. In this new concept, we combine several fruit acid sessions with Restylane Vital™ Light in the Restylane® injector (hyaluronic acid, 12 mg/ml, stabilized). From this combination, we develop a treatment scheme which is applicable for slight to moderate acne scars. Furthermore, we would like to include a treatment matrix for moderate to severe acne scars. For this indication, we combine fractional laser therapy (either CO2 or Er:Yag) with hyaluronic acid administered in several treatments using Restylane Vital or Restylane Vital Light in the Restylane Injector. We develop a generally applicable treatment scheme (Combination – Therapy) also for this indication. HAND REJUVENATION CASE STUDY COMPARING TREATMENT WITH TCA PEELING AND DIFFERENT LASERS VS. THE COMBINATION WITH HYALURONIC ACID Uta Schlossberger, Köln/Germany Introduction In our short presentation, we will compare two different treatments for the rejuvenation of hands: Using ONLY a TCA Peeling / ONLY Laser compared to TCA Peeling / Laser combined with several hyaluronic acid treatment sessions (12mg/ml stabilized HA). Materials TCA Peeling 15% Q-Switch Laser 532nm IPL 2nd generation Laser Hyaluronic acid (stabilized 12mg/ml) Method 1st patient: 2-side study – one hand treated with TCA Peeling twice, other hand treated additionally with HA 2nd patient: 2-side study – one hand Q-Switch Laser (532nm) once, other hand treated additionally with HA 3rd patient: 2-side study – one hand treated with IPL 2nd generation Laser, other hand treated additionally with HA Results Clearly visionable difference between both hands. Remarkable better results using HA additionally. Analysis Laser or peeling treatments are able to remove hyper pigmentations. Restoring and improving hydrobalance and skin elasticity and adding volume from within leads to an optimal hand rejuvenation.

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CONDYLOMATA ACUMINATA : SEXUALLY TRANSMITTED IN MULTI PARTNER SEXUAL Lita Setyowatie, Iskandar Zulkarnain; Dermatovenerology Department, Medical Faculty of Airlangga University, Dr. Soetomo Hospital, Surabaya/Indoniesia Backgorund : Condylomata Acuminata (or Genital Warts, Venereal Warts, Anal Warts and Anogenital Warts) is a highly contagious sexually transmitted disease caused by some sub-types of human papillomavirus (HPV), 90% are related with HPV types 6 and 11, multiple sexual partners are one of the risk factors for acquiring condylomata acuminata. Case : Mrs S, 29 years old, pregnant women 16 – 17 weeks, came with warts on her genital area, firstly it was only one and a small size, rapidly become numerous, flesh-colored, accompanied with itchy and burning sensation, not easy to bleed and not fragile, last contact sexual only with her husband. Her husband, Mr H, 34 years old, had a small warts on his penis, sexual intercourse with another women (Ms I, 17 years old) 1 or 2 week before contact with his wife without using condoms. Ms I, had a wart on her genitals too but she did not realized. Clinical manifestation revealed condylomata akuminata with acetowhitening test. The treatment with Hefrycouter and TCA 50 % for pregnant women, showed a good response. Discussion : Condylomata Acuminata is one of the sexual transmitted disease, the risk is correlated with the number of sexual partners, sexual with one partner and safe sex (using condoms and avoid the sexual intercourse during treatment) can stop the transmission. Prognosis became worse if fail to respond to treatment or recurs after adequate response. Recurrence rate exceed 50% after 1 year. INTRA-LESIONAL INJECTION OF MELANOCYTES IN STABLE VITILIGO Sudhir Sharma, Aastha skin and Dermato-Cosmetic Centre/India The treatment of vitiligo has always been a challenge but now with different treatment modalities, both medicinal and surgical, the cure rate has improved .Without going into detail of different treatment modalities which is known to all learned doctors. I would just go briefly about the surgical treatment modalities ,splint thickness graft ,micro graft ,mini micro graft and suction blister techquines and more recently melanocytes transfer procedure has been tried from time to time .The preference of the treatment modalities depends upon the operative surgeon and treatment sites. With any of the procedure the main motive is to bring pigmentation at the lesion but apart from this ,I think cosmetic viability of the procedure also carries an equally important role .We have devised a method where both the things i.e. Pigmentation and cosmetic appearance of the surgery has the best results as compared to any other surgical technique. Procedure was done in 150 lesions with encouraging.Briefly methodology is that the melanocytes are isolated from the normal skin of the patient. The process is almost similar to melanocytes treatment technique but in this case much care is required so that only melanocytes are isolated unlike in melanocytes transfer the area to be treated is not abraded . The isolated melanocytes are taken from the tube and diluted in RL. The amount of solution to be formed depends upon the area to be treated. With a syringe with 21 gauge needle the solution is then injected into the patch above upper dermal level. Dressing and antibiotics are not required. Slight swelling is there for about a week. In about 4 to 6 months, the area starts getting pigmentation which takes another 6-8 weeks to cover the whole area. This technique gives excellent cosmetic results without any sign of any procedure being performed.

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AUTOLOGOUS FAT TRANSFER FOR SCAR REVISION – CASE REPORT Sondang M.H.Aemilia Pandjaitan-Sirait, Erha Skin Center, Jakarta/Indonesia A female 27 years old came to our clinic with a complaint of a severe scarring on both her legs due an accident she had more then 8 years ago. On her right thigh there was a deep retraction of the skin covered by aneutrophic scar. On her right and left calf there were several linear scars with several areas of accidental tattoo. The patient underwent a miniliposuction on her left and right waist. The fat was washed several times until clean with normal saline in a closed syringe. Then it was injected into the retracted area continued by a subscision on several areas where the retraction was still visible. The result was good and the patient was satisfied with the result, although there were still some eutrophic scarring. The accidental tattoo was treated with 1064nm Nd-Yag laser with remarkable result. The second subscision was done one month later for small areas of skin retraction, with even better result. THE EFFICACY AND SAFETY OF ACTIVE FX ULTRAPULSE CO2 FRACTIONAL LASER RESURFACING FOR ACNE SCARS AND PHOTOAGING IN ASIAN PATIENTS Aryani Sudharmono, Naviani Surlinia, Puspita Ningrum; Senopati Skin Center, Jakarta/Indonesia Background: 10,600 nm carbon dioxide (CO2) fractional laser resurfacing is effective treatment for correct fine lines and wrinkles due to aging and photodamage; acne scars; and repair skin discoloration. The results of laser resurfacing are generally quite dramatic and long-lasting. Objectives: To evaluate the efficacy and safety of an ablative Ultrapulse 10,600 nm CO2 fractional laser system on patient with acne scars and photoaging problems. Methods: Six Asian patients with severe atrophic acne scars and photoaging treated with a single session of Ultrapulse Encore laser (Active FX; Lumenis Inc., Santa Clara, CA) were enrolled. The laser fluences were delivered to the skin using the Active FX mode throughout the entire face. Results: Follow up results revealed that acne scars showed excellent clinical improvement (75.83%). The lines, wrinkles, laxity, and skin dischromia had good clinical improvement (respectively 69.16% and 58%). No severe reactions, side effects, or complications after the treatment. The post-treatment erythema and edema subsided in 48 hours. The crusts will disappear in 120 hours. Average down time was less than a week (± 5 days maximum). Conclusion: The Active FX Ultrapulse CO2 fractional laser is effective and safe procedure for patient with acne scars and photoaging problems.

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THE EFFICACY AND SAFETY OF MONOPOLAR RADIOFREQUENCY FOR SKIN TIGHTENING AND CONTOURING IN ASIAN PATIENTS Aryani Sudharmono, Naviani Surlinia, Puspita Ningrum; Senopati Skin Center, Jakarta/Indonesia Background: Monopolar radiofrequency (RF) energy has been used to successfully accomplish noninvasive skin tightening and contouring with minimal or no down time. The new Thermage CPT (Comfort Pulse Technology) System and a vibrating handpiece claimed can give superior results and greater patient comfort. Objectives: To evaluate the efficacy and safety of the novel Thermage CPT system for skin tightening and contouring. Methods and materials: Forty eight Asian patients with mild to severe skin laxity and contouring problems, treated with the new Thermage CPT system. We delivered 900-1200 shots and multiple passes to entire or mid lower face and upper third neck. Results: Follow up results revealed that thirty five patients had moderate to mark clinical improvement (72.92%) and thirteen patients had mild clinical improvement (27.09%). All patients had immediate tightening. Only one patient had blister, and the rest patients had post-therapy erythema which subsided for several hours. Conclusion: The novel Thermage CPT system is an effective and safety procedure for skin tightening and contouring. EARLY DIAGNOSIS OF BASAL CELL CARCINOMA IN YOUNG AGES Tansil Tan Sukmawati/Indonesia Background: Basal cell carcinoma (BCC) is the most common of the malignant skin cancer then others skin cancers. It is localized, very destructive and most are fair-skinned Caucasians – (skin type 1 and type 2). One million people in America are diagnosed with Bcc each year. Patients with more than 40 years tend to get infected more often; however BCC may affect teenagers and now is frequently appearing in fair-skinned people aging from 30-50 years. Once was reported that a 28 years old lady was infected. Cases : Few cases of Basal cell carcinoma were found in young age, two cases appeared in 8 years old child, with skin type 3 and 4 (list) . With a clinical image of papules 2-3 mm, along with shinny appearance, hard in palpation like a pearl, telangiectation towards the central from periphery, uncomfortable feeling in touch, and palisade specific in BCC was found in pathology anatomy examination. Discussion : We found few cases of BCC in very young ages with type skin 3 and 4, with single lesion on face and not related with Nevoid Basal cell carcinoma syndrome, this informed us to search more information and take more care in early diagnosed of BCC lesion, the special characteristic, genetic and environment factors that induce the early de novo BCC lesion. BCC rarely metastases but very destructive in spreading the surroundings and through to the cartilage under the lesion making disconfigure of face which located at 70-85%, near the eyes, mouth and nose. It is very important to diagnose in early lesion to prevent the cosmetic appearance on face.

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CHEMICAL PEELS FOR INDONESIAN SKIN Hanny Suwandhani/Indonesia Chemical peels are a method of resurfacing the skin by inducing a controlled wound to the skin. Chemical peels replace part or all of the epidermis and can improve acne, pigmentation abnormalities, rhytides and photodamage. Chemical peels are divided into 3 categories depending upon the depth of the wound created by the peel. Indonesian skin patients, classified as Fitzpatrick skin type IV and V, would have an increased risk of developing post-inflammatory hyperpigmentation following certain chemical peels. Therefore, it is important to know in selecting patients, priming, choosing chemical peels solutions, peeling technique and post-peel care to minimize it.

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TT –– ZZ Mark M. Tanner, Noerdlingen/Germany FLAPS AND GRAFTS OF ORAL REGION __________ page 41 Mark M. Tanner, Noerdlingen/Germany HOW TO DO EFFICIENT SKIN BIOPSY __________ page 41 Sri Lestari, Henry Tanojo, Yuanita; Padang/Indonesia

SIMPLE EXCISION OF MULTIPLE XANTHELASMA ON BOTH UPPER AND LOWER INNER EYELIDS AND LATERAL LEFT EYE __________ page 42

Sri Lestari, Henry Tanojo, Yuanita; Padang/Indonesia; Lawrence Field, Founder, International Dermatologic Surgery Mentorship Program

TANGENTIAL EXCISIONS OF TWO ADJACENT PIGMENTED NEVI ON RIGHT ALA NASI __________ page 42

Larisa Paramitha Wibawa, Aida SD Suriadiredja, Budiana Tanurahardja, Sjaiful Fahmi Daili, Herman Cipto; Jakarta/Indonesia

BASAL CELL CARCINOMA CLINICAL, HISTOPATHOLOGICAL, AND FAS RECEPTOR EXPRESSION EVALUATION IN DR. CIPTO MANGUNKUSUMO NATIONAL HOSPITAL: A DESCRIPTIVE STUDY __________ page 43

LCC Wijne, K Munte; Rotterdam/The Netherlands

TREATMENT AND RECONSTRUCTION OF MALIGNANT CUTANEOUS TUMORS OF THE SCALP WITH BONE INVOLVEMENT __________ page 44

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Niken Wulandari, Dewi Anggraeni, Adi Satriyo, Tjut Nurul Alam Jacoeb,Herman Cipto, Sondang P. Sirait; Jakarta/Indonesia

SQUAMOUS CELL CARCINOMA IN A PATIENT WITH ERYTHRODERMA AND PREVIOUSLY TREATED WITH NB-UVB PHOTOTHERAPY __________ page 45

Sri Lestari, Yuanita; Padang/Indonesia

EXCISION DECORATIVE TATTO ON THE LEFT CHEST __________ page 45

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FLAPS AND GRAFTS OF ORAL REGION Mark M. Tanner, Noerdlingen/Germany Oral region represents one of the most demanding lines of action in reconstructive facial surgery. Personal grade of skills and proper adherence to orofacial particularities are deciding on surgical success. Thus I will present aspects of basic and advanced flap and graft techniques as linear closure, S-plasty, V to Y plasty, M-plasty, island advancement flap, A to T plasty, Burow-plasty, Dieffenbach´s penetrating wedge excision, the Langenbeck „lip shave“ vermillionectomy and Field´s subcutaneously bipedicled island flap. I also will explain on the role of 5-ALA Photodynamic Therapy (PDT) for decreasing the size of excisional defects in non-melanoma skin cancer of the orofacial region (Excisional Margin PDT in NMSC, Euro-PDT Noordwijk 2009). Bilevel Anesthesia and Blunt Dissection are key elements in rapid and safe orofacial surgery. As pain reduction is crucial in surgical procedures around the mouth, I will disperse some additional anesthesia pearls. Polyurethane foam dressings can be temporarily sutured in an excisional defect to bridge the time gap until dermatopathology results will come in before reconstruction. 4.0 half-buried anchoring stitches in combination with a 5.0 running suture optimize final reconstructive or cosmetic closure. Lip-neighboring skin grafts can be cosmetically and functionally disappointing. If incision lines are crossing the vermillion border, step formation has to be prevented by minute adaption. Closure by layers is required in defects penetrating mucosal, muscular and cutaneous structures. In conclusion, a detailed pre-operative cognition of regional anatomy and careful observance of the RSTL will facilitate wound closure and postoperative healing. HOW TO DO EFFICIENT SKIN BIOPSY Mark M. Tanner, Noerdlingen/Germany Successful dermatologic tumor surgery usually has to be preceded by a sound and proper skin biopsy. In this intention a punch-, blade-, razor-, snip-, incisional or excisional biopsy can be adopted according to diameter and morphology of the targeted skin lesion. Special forms are fluorescent biopsy in photodynamic therapy (PDT) or immunostain biopsy. Skin biopsy has to imply altered and intact epithelium for the achievement of clear microscopical findings. It thus will be directed to the bordering portions of the tumor or lesion. A continued and close co-operation with the dermatopathology lab is essential, just as well as an adequate pre- and postexcisional specimen processing. Detailed preparatory assay and observance of RSTL will improve wound closure and postoperative healing. Skin biopsy is preparing both surgeon and patient on the further scheduled procedure. It forms a perfect preliminary practice and is an essential condition for planning and performance of successful Dermatologic Surgery. Conclusively, a sound and proper skin biopsy requires identical mental, hygienic and organizational conditions comparing to the following excision and reconstruction.

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SIMPLE EXCISION OF MULTIPLE XANTHELASMA ON BOTH UPPER AND LOWER INNER EYELIDS AND LATERAL LEFT EYE Sri Lestari, Henry Tanojo, Yuanita; Department of Dermato-Venereology, Dr. M. Djamil Hospital/ Faculty of Medicine, Andalas University, Padang, West Sumatra/Indonesia Background: Xanthelasma appeared as yellow macules, soft papules, or plaques found commonly on the upper eyelids. They do not represent diseases but rather symptoms of different lipoprotein disorders. Xanthelasma can be treated surgically by excision or destructive methods, however, treatment choice was made depending on the availability, physician skills, and patient preferences. Case report: A 39-year-old woman presented with multiple xanthelasma on both upper and lower inner eyelids and lateral left eye. She desired removal because of aesthetic reason. All of the lesions were completely excised by simple excision. The removal order was started from larger lesions on upper eyelids to smaller lesions on lower eyelids and to lesion on the left eye corner. We sterilized the perilesional skin with Bethadine® and alcohol 70%, then injecting total 3 cc Pehacain® (lidocaine 2% and adrenaline 1:80,000) under the lesion and incisional lines using bi-level anesthesia technique (Field L). After ten minutes, we incised the lesions with scalpel no.15, performed a blunt dissection with scissor, then excised the lesions. Excess lipid deposition was removed with scissor. Surrounding skin was blunt undermined and then it was sutured in interupted with 6-0 prolene. We applied topical antibiotic ointment and closed it with bandage. The same procedure was performed on other lesions. Sutures were removed a week later, there was slight erythema of the excised lesions. Conclusion: We did simple excision of multiple xanthelasma using local anesthesia. The lesions were excised with scalpel no.15 then sutured using 6-0 prolene and obtained good result. TANGENTIAL EXCISIONS OF TWO ADJACENT PIGMENTED NEVI ON RIGHT ALA NASI Sri Lestari, Henry Tanojo, Yuanita, Department of Dermato-Venereology, Dr. M. Djamil Hospital/ Faculty of Medicine, Andalas University, Padang, West Sumatra/Indonesia; Lawrence Field, Founder, International Dermatologic Surgery Mentorship Program Background: Pigmented nevus is a common acquired nevomelanocytic nevus which develops after birth, slowly enlarges symmetrically, and stabilizes. Complete removal of nevus is best accomplished by excision. Tangential excision with a razor blade is a different method of removal available producing minimal scar. Case: A 45-year-old woman presented with two adjacent pigmented nevi on her right ala nasi of 6 and 3 mm diameter respectively. She desired removal without significant scar formation. We sterilized the skin with Betadine® and alcohol 70%, then marked perilesional guidelines with sterile marker. We then injected local anasthesia of 0.3 cc Pehacain® (lidocaine 2% and adrenaline 1:80,000) under the lesion without differentially elevating it. The blade was held in convexity parallel to the stabilized ala nasi curvature using the first and third fingers of the right hand, while fingers of left hand stabilized the tissue below the nevus. Both lesions were then tangentially excised with the sterile Gillette® blade and excess tissue additionally amputated with a convex scissor. Sterile gauze with aluminum chloride 40% was pressed on the lesion to achieve hemostasis. One-week follow-up revealed a good result with slight erythema as sign of skin re-epithelialization with a small remnant hyperpigmented locus centrally. Conclusion: Tangential excision is a simple, inexpensive method, requiring no advanced equipments. It represents a rapid technique to remove superficial lesions and maintain the subjacent contour. We performed tangential excisions to remove both nevi at the same setting using Gillette® blade with Pehacain® local anesthesia and obtained good results.

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BASAL CELL CARCINOMA CLINICAL, HISTOPATHOLOGICAL, AND FAS RECEPTOR EXPRESSION EVALUATION IN DR. CIPTO MANGUNKUSUMO NATIONAL HOSPITAL: A DESCRIPTIVE STUDY Larisa Paramitha Wibawa*, Aida SD Suriadiredja*, Budiana Tanurahardja**, Sjaiful Fahmi Daili*, Herman Cipto*; Dermatology and Venerology Department* & Pathology Department**, University of Indonesia Medical Faculty/dr. Cipto Mangunkusumo National Hospital, Jakarta/Indonesia Background: Basal cell carcinoma (BCC) is the most common skin cancer in the world. Recent studies demonstrate the pathogenesis of BCC is correlated with Fas, a death receptor in the apoptosis mechanism. The background of this study is to evaluate clinical, histopathological subtypes and Fas receptor expression of BCC patients in dr. Cipto Mangunkusumo National Hospital (RSCM). Methods: Cross sectional descriptive study was performed using retrospective data from medical records, photographs, and histopathological tissues of BCC patients who came to RSCM in a period of January 2006-March 2010. Patients photograph and histopathological section with hematoxillin-eosin were reviewed. Immunohistochemical examination using Fas/CD95 was done on the histopathological tissues. Results: From 37 patients there were 38 lesions. The head and neck region (94,7%) was BCC lessions commonly found. Most tumors (63,2%) have size > 2 cm. Clinical evaluation revealed 76,3% cases were nodular (low risk) and 23,7% (9 lessions) were high risk type (6 superficial and 3 morphea-like type). Hyperpigmentation was found in 97,3% clinically. Histopathologically, there were 34 lessions (89,5%) catagorized as aggressive type, with the mixed type of nodular-micronodular dominating as many as 21 lessions (65,6%). Generally Fas expression was low with median value 4,67 cells (0-317) every 1000 tumor cells. Conclusions: Clinical evaluation only can not replace histopathological evaluation in predicting BCC aggressiveness. Low expression of Fas shows apoptotic failure through this pathway have a role in BCC’s development and related therapy that increases Fas can be given to BCC patients in RSCM.

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TREATMENT AND RECONSTRUCTION OF MALIGNANT CUTANEOUS TUMORS OF THE SCALP WITH BONE INVOLVEMENT LCC Wijne, K Munte; Erasmus Medical Center, Department of Dermatology and Venereology, Rotterdam/The Netherlands The human scalp is often subject to a lot of ultraviolet radiation especially in people who work outside, with outdoor hobby’s or live in tropical environments without the proper sun-protection. More often than not those patients have more than one tumor at one time with alternate malignant and premalignant lesions. The surroundings are often blurred and difficult to define, and when excised conventionally, they are often not radical and frequently show recurrences yet causing a delay before they are radical removed. Because of the location in the early days one unfortunately chose radiation therapy causing a great deal of recurrences and delay before radical elimination. And then there is often a patient’s delay because outer workers like farmers are not regular visitors of a medical doctor. All of these can cause a widespread tumor growth with a larger chance of perineural invasion, tangential growth in periostium or galea and sometimes destruction of the underlying bone and even metastazing. It can concern a wide diversity of tumors like: basal cell carcinoma, squamous cell carcinoma, melanoma in situ, dermatofibrosarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, atypical fibroxanthoma, and sebaceous carcinoma. In our opinion the best way to treat these tumours is by the use of Mohs micrographic surgery. The defects arising after Mohs surgery are often very extended, and often includes the periostium. If the periostium is excised we accomplish to remove the outer shell of tabula externa by a cutting burr. For closure short after tumor resection there are a few options, if possible you can use large rotation or advancement flaps another one is the use of free vascularised muscle flap covered with a split skin graft, or musclecutaneous flaps. This latter has the advantage of well vascularised thick tissue to cover the defect. Disadvantage is a large and long lasting operation with all possible complications and discomfort. We prefer to wait until enough granulation tissue will derive from the bone (average timeperiod of 6 weeks). Then we are covering the granulation tissue with a split skin graft from the upper leg or scalp. The outcomes are very satisfying, which is less time consuming then a free vascularised flap with adequate tissue covering. Afterwards most people choose for further refining a wig or hairpiece with great cosmetic result. At our department we proceeded 40 Mohs operations of large and variable malignant tumours of the scalp with bone involvement in the period 2008 Till 2010 we did 16 secondary closures. Complications were a partial loss of skin graft in 3 patients. Conclusion we think that secondary healing after which split skin grafting is done is effective and gives a cosmetically sufficient result.

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SQUAMOUS CELL CARCINOMA IN A PATIENT WITH ERYTHRODERMA AND PREVIOUSLY TREATED WITH NB-UVB PHOTOTHERAPY Niken Wulandari, Dewi Anggraeni, Adi Satriyo, Tjut Nurul Alam Jacoeb,Herman Cipto, Sondang P. Sirait; Dermatovenereology Department, Medical Faculty of University of Indonesia, dr Cipto Mangunkusumo Hospital, Jakarta/Indonesia The etiological diagnosis in patient with erythroderma is often a challenge for the clinician because it involves several different diseases, and approximately 20 percent cases with no underlying etiology is identified. We report a case of a male, 53 years old, referred by a dermatologist to undergo phototherapy for his long standing psoriasis. He had episodes of recurrence psoriasis vulgaris, which got severe and developed into erythroderma since a year ago and treated with methotrexate for a year. After 10 times narrowband-ultra violet B (NB-UVB) phototherapy sessions, it was realized that the patient had an ulceratic lesion in the right elbow, which was already present for a long time before without remarkable complaint. Phototherapy procedure was terminated, and biopsy was performed to the ulceratic lesion. The pathologic finding was consistent with squamous cell carcinoma acantholytic type. Regarding this biopsy result, then another biopsy procedure was done to other region of the skin consist of small hyperkeratotic plaque and scaly lesion. Its finding revealed squamous cell carcinoma in situ. Another biopsy was performed to an erythematous scaly plaque to support the diagnosis of psoriasis vulgaris but the result was pseudocarcinomatous hyperplasia epidermis. The patient then underwent skin surgery with wide exicion to the ulceratic lesion in the right elbow. This case suggested the importance of thorough skin examination before undergo phototherapy session. Skin biopsy is a mandatory procedure in erythroderma patients especially those who came without uncertain underlying etiology. EXCISION DECORATIVE TATTO ON THE LEFT CHEST Sri Lestari, Yuanita; Dermato-Venereology Departement of Dr.M.Djamil Hospital/Medical Faculty of Andalas University, Padang/Indonesia  Background: Tattoos decorative have been used in many parts of the world. There are number of different tattoo removal procedure such as surgical excision, liquid nitrogen cryotherapy, dermabrasion, salabrasion, caustics or infrared coagulation. Excional surgery was chosen by the patient because laser was not available in our Department. Elliptical or fusiform excision is one of the most frequently performed. Case report: A decorative tattoo (RH fitures) 11 x 3,6 mm, on the left side of chest was removed.We applied bethadine and alcohol 70 % as antiseptics, then marking the incision lines (ellips design, l:w= 1:3). We delivered anesthesia solution of lidocaine 2% + pehacaine (lidocaine 2% with epinephrine 1 : 80.000) in a total volume of 12 cc (epinephrine 1 : 160.000), infiltrated beneath the tatto and peripherally around the tattoo lesion. All incisional borders were then infiltrated superficially with pehacaine, accomplishing “bilevel anesthesia” (Field). After 20 minutes, we excised the tatto. After blunt undermining, the defect was closed with chromic 5.0 at the dermis and subcutaneous, the skin along the border then being anastomosed with prolene 6.0 interrupted sutures. Conclusion: We have done excision of decorative tattoo on the left side of the chest, using “bilevel anesthesia”. The wound sites were anastomosed using interrupted sutures of 6.0 prolene and obtained a good result.