Treatments & Procedures
The Division of Dermatologic Surgery at Mount Sinai offers a variety of services including Mohs micrographic surgery, reconstructive surgery and cosmetic procedures. The Chief of the Division, Dr. Hooman Khorasani, is a double-board certified dermatologic surgeon. Dr. Khorasani is joined by Dr. Heidi Waldorf, the Director of Laser & Cosmetic Dermatology and Dr. David Kriegel, the Director of the Mohs/Procedural Dermatology fellowship program. These fellowship-trained surgeons are actively involved in research, education and advancement of this growing field.
Most procedures are performed in outpatient surgical suites including: skin cancer management, Mohs surgery, scar revisions, neurotoxins, fillers, liposuction, fat transfer, blepharoplasty, and the latest laser procedures.
The department's Mohs surgeons, Dr. Khorasani and Dr. Kriegel, perform over 2,000 Mohs cases per year, and have extensive experience in the treatment of melanoma, basal cell carcinoma, squamous cell carcinoma and other rare skin cancers.
Laser Treatment of Leg Veins
Long Pulse Nd: YAG & Diode
Many factors play a role in the development of unsightly leg veins. Most common being incompetent venous valves leading to elevated pressure and pooling of blood inside the veins. Other factors include age, weight, pregnancy, trauma and genetics.
Different medical intervention may be utilized in the treatment of leg veins depending on the vessel diameter, location and skin color. These include sclerotherapy, endovenous thermal ablation and laser treatment. Before proceeding with a treatment patients are often encouraged to obtain a Doppler ultrasound in order to rule out reflux due to incompetent valves.
Laser treatment provides an alternative method to using needles in treating this common complaint by causing heat damage and closure of the targeted veins just beneath the skin surface. For a favorable outcome multiple sessions may be required.
Some of the risks associated with this procedure include:
- Skin discoloration
- Undesired scarring
Recovery and return to daily routine is relatively quick after the laser treatment.
Treatment of Excessive Sweating
Excessive underarm sweating is a common skin complaint that affects individuals and may have a negative impact during social situations and daily activities. miraDry®, a device approved by the FDA, provides a non-invasive lasting solution by delivering energy capable of causing destruction to sweat producing glands. This procedure is done in two sessions three months apart. The procedure is about one hour and is preformed with local anesthesia. Studies have shown that patients treated with miraDry® experienced an average sweat reduction of eighty-two percent. Over ninety percent of patients were pleased with the results.
Tattoo Removal Laser
Q-Switched Nd:YAG & Ruby Laser
Modern advancements of laser technology have made the goal of tattoo removal more practical and with fewer complications. Q-Switched Nd:YAG and Ruby laser are used to remove unwanted tattoos by emitting wavelengths of light that are absorbed by the tattoo pigment in the skin, leading to thermal damage and safe removal of most of the tattoo pigment by the immune system with less pain and scarring compared to older methods. Several factors influence the number of treatment sessions and effectiveness of the laser used to remove a tattoo including the size, color, type, depth of the tattoo pigment and skin texture/color.
A local anesthetic may be used prior to the procedure to alleviate pain, and on average it takes several days to heal after the removal session.
After the procedure the skin may appear red and irritated; therefore, the use of liberal emollients is recommended on the treated area after the session to help with the healing process. Bruising, blistering and skin discoloration may also occur.
Fractionated Co2 Resurfacing
Total FX is a state of the art laser used to treat and improve the appearance of wrinkles, scars, skin tone and pigmentation. It is a fractionated ablative laser that combines Deep FX™ and Active FX™ technology in one treatment with minimal downtime. Fractionated technology enables patients to receive excellent results with minimal downtime by treating only a fraction of the skin, but not sacrificing results.
Active FX technology treats the upper layers of the skin to improve the pigmentation, while the Deep FX treats the deeper layers to stimulate collagen growth and remodeling. This combined approach results in rejuvenated skin by treating pigmentary abnormalities as well as wrinkles and improving skin tone.
How long does this procedure take?
The procedure itself takes about 30 minutes. First, your physician will apply a topical anesthetic that requires 60 minutes to take effect.
What will I feel during and after the procedure?
During the procedure, you will feel warm sensation that continues for several hours after, although this can vary between patients.
How much downtime can I expect?
This can vary between patients, however downtime can range between 7-10 days with most common side effects with redness and minimal crusty. On occasion, redness can persist for up to 2-4 weeks.
When can I expect results?
As your skin heals, you will begin to notice improvement to the fine lines and wrinkles and pigmentation. Most patients experience improvement of the tone and texture of the skin for up to six months.
Fraxel® is non-ablative resurfacing laser therapy that has very few side effects and low downtime, but usually require several treatments to produce optimum results. It can be used for:
- Improving skin tone and texture
- Treatment of unwanted brown spots
- Reducing fine lines and wrinkles around the eyes
- Improved appearance of acne scars and surgical scars
This non-ablative laser targets the skin with microscopic laser columns that penetrate deep into the skin and enhances remodeling of collagen.
Some of the common side effects that follow the procedure include:
- Dry skin
- Peeling/ Flaking
- Bronze skin appearance
There is also a risk of infection, hyperpigmentation and scarring. During the procedure, a topical anesthetic is applied to the face 1-2 hours prior to the procedure to minimize discomfort.
During the first 24 hours after the procedure, patients will feel as though their skin is sunburned and it will appear pink. They can wear makeup to cover up the sunburned appearance. The skin will then bronze over within the 1st week and subsequently exfoliate. Patients are advised to keep the skin moisture. They are also advised to wear a sunscreen of SPF 30 or higher for at least 3 months following treatment.
(Eyelift & Removal of "Bags")
Surgery of the upper and or lower eyelids is a safe and effective outpatient procedure that can be performed under local anesthesia with minimal discomfort. Patients looking to rejuvenate the skin around their eyes often turn to this procedure for a more rested and alert appearance.
The procedure typically involves removing redundant or sagging skin of the eyelids as well excess fatty deposits if puffiness or "bags" have developed with aging.
How is it performed?
Under local anesthesia incision lines are made in a manner that conceals the scar in the natural creases of the eyelids. For the upper eyelids the incision lines are hidden in the natural crease and for the lower eyelid the incision lines are made just below the lash lines. Hiding the incision lines within natural structures of the eyelid is what gives this surgery the reputation as a "scarless" procedure. Through these incisions, fat deposits can be removed or repositioned, muscles tightened and excessive skin removed. For lower eyelids a transconjunctival incision that is placed within the inside of the lower eyelid is an alternative approach to performing the surgery. After the incision lines are created and the surgery is performed the eyelid incisions are closed with removable or absorbable sutures combined with skin adhesives.Sutures will be removed 7 days after the procedure and swelling and bruising can persist for 3 to 10 days after the surgery.
Liposuction, also known as lipoplasty or body contouring, is a cosmetic surgical technique that removes unwanted fat from different sites on the body, including abdomen, thighs, buttocks, hips, knees, arms and neck.
Liposuction is not a replacement for regular exercise and good eating habits, and best candidates for such procedures are individual with relatively normal weight that have a body with disproportionate contours due to localized fat deposits. With power assistant liposuction (PAL) the surgeon is able to remove fat more effectively with minimal trauma and pain for the patient. Skin with diminished elastic tone due to stretch marks, weight loss or aging will not reshape itself to new contours and may require additional surgical techniques to remove excess skin. The procedure is performed with tumescent anesthesia and moderate sedation. Patient recovery is relatively fast and most patients can return to work in a few days.
Dermabrasion is a mechanical refinishing of the skin's top layer with the goal of smoothing the overall texture of the skin. It is also used to smooth out and decrease the thickness of surgical or traumatic scars. Dermabrasion removes the outermost layer of skin by using medical grade sandpaper or by using a rough wire brush, or a burr containing diamond particles, attached to a motorized handle. Following the procedure a person that has undergone dermabrasion will be red and swollen. Aftercare consists of using a moisturizing ointment, which will prevent significant crusting. The skin can be sensitive and slightly pink for a few weeks after the procedure is performed.
Whether it is a surgical or traumatic scar there are several approaches that can be taken to improve the physical appearance of a scar. Many of these approaches are combined over several months to achieve the optimal outcome of an improved cosmetic appearance of a scar. While scar revision can never completely remove a scar a multi faceted approach can lead to significant improvement. Scar revision can involve topical treatments with creams that contain silicone or intralesional injections with corticosteroids to decrease the thickness and itching that certain scars can have. Lasers can also be used to improve the appearance of many scars. The scar redness is often treated with a Pulse Dye laser (V-beam) while the texture of scar can be improved with fractionated Co2 laser (Total Fx).
Occasionally scars may have irregularities that are best treated with Dermabrasion. Dermabrasion removes the outermost layer of skin by using medical grade sandpaper or by using a rough wire brush, or a burr containing diamond particles, attached to a motorized handle.
Finally re-excision and suturing of a scar is sometimes required to either change the direction or place the scar in a natural boundary, which makes the scar's cosmetic appearance less noticeable.
Mohs Micrographic Surgery
Mohs micrographic surgery (MMS) is the most effective treatment for skin cancer today, utilized to treat skin cancers located on cosmetically sensitive areas of the body, particularly the face. Mohs surgery ensures complete cancer removal, while minimizing the amount of healthy tissue lost and maximizing the functional and cosmetic outcome. Compared to other modalities, it is particularly effective in treating patients with high-risk, complex, and recurrent cancers, offering the highest cure rate. Other indications for this procedure include large tumor size, unclear clinical margins, aggressive histologic patterns, and immunosuppression. The procedure provides cure rates approaching 100 percent for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), therefore exceeding the cure rates for traditional surgical excision, radiation therapy, electrodessication and curettage, cryosurgery, photodynamic therapy, and topical chemotherapeutic agents.
In this advanced surgical procedure, the physician uses a microscope to trace the cancer down to its roots. The physician functions as the oncologic surgeon, the pathologist, and the reconstructive surgeon. Given the complex nature of this procedure, it is extremely important to ensure that your surgeon is fellowship trained Mohs surgeon and a member of the American College of Mohs Surgery.
Reconstruction Following Mohs Surgery
At the completion of Mohs surgery the doctor has verified under the microscope that all of the skin cancer has been successfully removed. The chance of the same skin cancer returning at this location is very low (less than 1 percent). Unfortunately, you will be left with a surgical wound and there are several options for healing depending on the location, size, and depth of the defect. In some instances the surgeon will allow the surgical wound to heal on its own, a process known as secondary intension healing. Some areas of the body, such as the ear or scalp, heal extremely well without any need for additional surgery, stitching, or extensive post-operative wound care. For other instances in which the surgical wound is too large or deep to heal on its own, reconstructive surgery may be required. Most skin cancer surgeons have training in complex reconstructive surgery and can perform the procedure immediately or within a few days following the Mohs skin cancer removal; others may request that the reconstruction be performed by another board certified reconstructive surgeon they trust. In either instance, options for reconstruction include:
- Primary closure, in which the skin of the Mohs surgical wound is pulled together and sutured closed with minimal changes to the structures surrounding the wound
- Grafting, in which skin from another area of the body is used to cover up the wound created by the Mohs surgery
- Flap reconstruction, where nearby skin is moved to conceal the wound created after the Mohs technique
In all of these cases, stitching is needed to close the wound and will require follow-up appointments (to assess skin healing and any scar formation) and at-home wound care.
Patients are advised to avid strenuous physical activity, heavy lifting and exercise for 2 weeks following surgery. Most common complications that patients may encounter after the procedure are:
- Bleeding (rare)
- Allergic reactions to adhesives (common)
Depending on the location of the surgery, patients are asked to schedule an appointment for suture removal in 1-2 weeks.