4. Rajan N, Ryan J, Langtry JAA. Squamous cell carcinoma arising

within a facial port-wine stain treated by Mohs micrographic

surgical excision. Dermatol Surg 2006;32:864–6.

5. Del Pozo J, Pazos JM, Fonseca E. Lower lip hypertrophy

secondary to port-wine stain: combinded surgical and

Carbon dioxide laser treatment. Dermatol Surg 2004;

30:211–4.

CAITRIONA B. HACKETT, MRCPI

JAMES A. A. LANGTRY, MBBS, FRCP

Department of Dermatology

Royal Victoria Infirmary Hospital

Newcastle upon Tyne, UK

The Role of Ultrasound in Severity Assessment in Hidradenitis Suppurativa

We have read the recent article of Wortsman and

colleagues, Ultrasound in-depth characterization

and staging of hidradenitis suppurativa1 with great

interest. Dr. Wortsman has made significant

contributions to the use of ultrasound in dermatol-

ogy.2 In her recent article, she and her colleagues

demonstrated that clinically undetectable but

nevertheless substantial changes in dermal and

subdermal tissue, such as subclinical fistulae, can

be identified only using ultrasound.1 This is a

significant discovery because treatment hinges on

relevant and accurate disease assessment.

Hidradenitis suppurativa (HS) is a chronic inflamma-

tory disease of the pilosebaceous unit causing painful,

suppurating, malodorous skin lesions including

inflammatory nodules, abscesses, and sinus tracts.3

The disease is associated with significant morbidity

and represents a major therapeutic challenge to clini-

cians. Therapeutic decisions are based on disease

severity, assessed most commonly using the Hurley

classification. The more time-consuming Sartorius

score might be calculated based on lesion count, but

both classification systems have marked limitations

because they are based on the mere presence of clini-

cally detectable lesions, are heavily influenced by scar

tissue, and therefore have limited sensitivity regarding

the present degree of inflammation.

There is a need for a more-objective method to clas-

sify disease severity to permit reliable stratification

of patients in clinical trails and in everyday practice.

Imaging may provide an appropriate method for

this.4 Based on ultrasound findings in HS, the

authors modified the disease management in 28 of

34 patients (82%), emphasizing the clinical useful-

ness of ultrasound examination.1 Wortsman and

colleagues’ article therefore strongly suggests that

ultrasound provides valuable anatomic information

on the extent of HS lesions and should accompany

clinical examination to permit more-reliable assess-

ment of disease severity in HS.

References

1. Wortsman X, Moreno C, Soto R, Arellano J, et al. Ultrasound

in-depth characterization and staging of hidradenitis suppurativa.

Dermatol Surg 2013;39:1835–42.

2. Wortsman X, Wortsman J. Clinical usefulness of variable-

frequency ultrasound in localized lesions of the skin. J Am Acad

Dermatol 2010;62:247–56.

3. Jemec GB. Clinical practice. Hidradenitis suppurativa. N Engl

J Med 2012;366:158–64.

4. Kelekis NL, Efstathopoulos E, Balanika A, Spyridopoulos TN,

et al. Ultrasound aids in diagnosis and severity assessment of

hidradenitis suppurativa. Br J Dermatol 2010;162:1400–2.

KIAN ZARCHI, MD

GREGOR B. E. JEMEC, MD, DMSC

Department of Dermatology

Roskilde Hospital

Health Science Faculty

University of Copenhagen

Roskilde, Denmark

Advantages of the Half-Circle Suture Needle for Reconstructing Small Cutaneous Surgical Wounds

Dermatologic surgeons use numerous suture types

for closing cutaneous wounds. A thorough under-

standing of suture material properties1,2 and needle

anatomy (Figure 1) is essential for all dermatologic

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surgeons. Anatomic location and defect size, as

well as surgical training, influence a surgeon’s

choice of suture material and suture needle used to

close a wound.

While suture material and suture needle attributes,

such as length, sharpness, and strength, vary

according to manufacturer, the needle shape used

for cutaneous surgery is conventionally 3/8 circle

and reverse cutting.3 The 3/8-circle suture is avail-

able in various lengths (Figure 2), which generally

serves the dermatologic surgeon adequately for a

wide range of wound closures. However, even the

smallest 3/8-circle needle available may feel

unwieldy to adequately maneuver within small

cutaneous defects, especially those created after

Mohs micrographic surgery.

Regardless of preclosure preparation, a defect may

remain so tight that lifting and everting the

wound edge to accommodate the 3/8-circle suture

needle could traumatize the skin edge and cause

tissue necrosis. Furthermore, in these instances,

the 3/8 suture needle point may exit prematurely

through the epidermis rather than remain in the

dermis (Figure 3), requiring the surgeon to redo

the maneuver or insert the needle into the dermis

horizontally or at an angle. A horizontally

oriented dermal bite tends to cinch and

strangulate more dermal tissue than a dermal

bite that is vertically (or perpendicularly) oriented

to the surface.

We have found that the less-prominent half-circle

suture needle (Figure 2), which has a smaller chord

length–to–needle length ratio than the 3/8-circle

needle, makes repairing small, cutaneous facial

wounds significantly easier.

Technique

The half-circle suture needle is particularly useful

for approximating the subcutaneous layer of small

(<1 cm) cutaneous wounds on the nose, ear, eyelid,

and lip. It can be used for all closure types.

A narrow-jaw needle holder is used to grasp

the half-circle needle 1–2 mm away from the

Figure 3. Use of a conventional 13mm 3/8-circle needlerisks premature exit through the epidermis of this 6 9 7mmnasal tip wound. The blue arrow points to an impendingneedle tip exit at the site of the blanching epidermis.

Figure 2. Examples of conventional 3/8-circle reverse-cut-ting needles (left column), which are available in variousneedle lengths (denoted by the manufacturer as P-6, P-1,P-2, etc.) and the less-familiar half-circle reverse-cuttingneedle (right column). The shape of the half-circle needle(specifically, a small needle chord length–to–needle lengthratio) confers unique performance in tissue. Figure usedwith permission from Ethicon (Johnson and Johnson).

Figure 1. Needle anatomy. Figure used with permissionfrom Ethicon (Johnson and Johnson).

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needle swage. Dermal sutures are placed using the

standard buried technique, but in contrast to the

3/8-circle needle, the half-circle needle will grasp a

small bite of tissue owing to its smaller chord

length (Figure 4). A running or interrupted

epidermal suture may be used to complete

the reconstruction.

Discussion

In distinction to the 3/8-circle needle, the half-cir-

cle needle has a smaller chord length–to–needle

length ratio (0.64 for the half-circle needle, 0.78

for the 3/8-circle needle). Mathematically, for a

half-circle suture needle with diameter d, the chord

length is d, and the needle length is half pd

(1.571d). Thus, the ratio of chord length to needle

length for a half-circle needle is d/1.571d ffi 0.64.

In contrast, for a 3/8-circle suture needle with

diameter d, the chord length is d sin (67.5)

(0.924d), and the needle length is 3/8 pd (1.178d).

Thus the ratio of chord length to needle length for

a 3/8-circle needle is 0.924d/1.178d ffi 0.78.

As a result of this lower ratio for a half-circle nee-

dle, less turn of the surgeon’s wrist is necessary to

move the needle tip in and out of a smaller area of

dermis. Therefore, a surgeon can readily grasp

dermis in tight wounds, maneuver the half-circle

needle tip out of the dermis and effectively place

subcutaneous sutures. Although this feature may

result in a smaller dermal bite and, therefore, theo-

retically higher incidence of dehiscence than the 3/

8-circle needle, the authors have not observed this

to be the case in several hundred reconstructions in

a range of mobile and nonmobile facial

anatomic locations.

The half-circle suture needles intended for subcuta-

neous use are available directly from Ethicon

(Johnson and Johnson, Somerville, NJ) or Covidien

(North Haven, CT) in a variety of lengths and a

variety of absorbable suture materials. For small

facial wounds, our preference is a half-circle, 8mm,

reverse cutting needle attached to polydioxanone

suture (P-2; PDS II; Ethicon). A 5–0 half-circle nee-

dle is used to repair Mohs defects on the nose, ear,

and eyelid, and the thicker 4–0 half-circle needle is

used to repair small perioral defects. The half-circle

needle may also be used to close punch biopsies in

particularly mobile, aesthetically sensitive areas

(e.g., the cutaneous lip). A variety of larger half-

circle needles are available and are useful for facili-

tating placement of subcutaneous sutures in tight

wounds on thicker skin, such as the scalp and

back.

There are limitations to the 8mm half-circle nee-

dle because of its small size. The tip of the nee-

dle may be difficult to see after it is inserted into

thick, sebaceous skin. It may be necessary to

twist and push the needle further into the dermis

with the needle holder as the forceps in the

opposite hand “searches” for the needle suture

tip. In these instances, the surgeon should avoid

grasping and clamping the delicate needle tip

with a needle holder. Furthermore, we have

found it best to grasp the suture needle 1 or

2 mm from the swage, closer than if the surgeon

was properly holding a 3/8-circle needle.3 Caring

for the needle in this manner will avoid

bending the needle body, which is evident

Figure 4. A 9mm half-circle needle readily enters the deepdermis of the wound oriented vertical, or perpendicular, tothe skin surface. In contrast to the 3/8-circle needle (Fig-ure 3), the half-circle needle featured here re-emerges atthe superficial dermis with a smaller dermal bite, minimalrisk of epidermal puncture, and less turn of the surgeon’swrist.

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should the needle feel stuck as it travels

through the dermis.

Despite its shortcomings, we believe the half-circle

suture needle is particularly useful in specific

circumstances as a means of facilitating surgical

technique and improving aesthetic outcomes.

References

1. Bennett RG. Selection of wound closure materials. J Am Acad

Dermatol 1988;18:619–37.

2. Menaker GM. Wound closure materials in the new millennium.

Curr Probl Dermatol 2001;13:90–4.

3. Bennett RG. Fundamental of cutaneous surgery. Maryland

Heights, MO: Mosby, 1987.

ADAM M. ROTUNDA, MD

Division of Dermatology

Department of Medicine

David Geffen School of Medicine

University of California at Los Angeles

Los Angeles, California;

Department of Dermatology

University of California at Irvine

Irvine, California;

School of Medicine

University of California at Irvine

Irvine, California;

and Private Practice

Newport Beach, California

XUN YANG HU,

College of Human Ecology

Cornell University

Ithaca, New York

MERRICK BRODSKY, BS, BA

School of Medicine

University of California

Irvine, California

Reversible Myopathy and Ophthalmoparesis After Low-Dose Finasteride Administration for Androgenic

Alopecia

Finasteride 1 mg is widely used for androgenic

alopecia with excellent efficacy and safety.1 Most

adverse events related to finasteride are mild

sexual problems such as decreased libido

and ejaculation disorders.1,2

A previously healthy 35-year-old Korean man

was admitted with complaints of sudden-onset,

slowly progressing weakness of the bilateral

proximal-dominant extremities and associated

muscle pain starting 7 days before and diplopia

that had developed 2 days before. On neurologic

examination, Medical Research Council (MRC)

motor grade was decreased to 3 out of 5 for

both shoulders and proximal and distal motor

grade of the lower extremity was 4 out of 5.

The patient had difficulty lifting object, walking,

and standing from squatting because of proximal

joint weakness. On cranial nerve examination,

partial ophthalmoparesis was detected, involving

extraocular muscles of oculomotor, trochlear, and

abducens nerve innervations with mild ptosis

(Figure 1). History taking was unremarkable

except that he had been taking finasteride 1 mg

per day for androgenic alopecia for 4 months

before symptoms developed. Laboratory findings

including brain magnetic resonance imaging for

structural brain lesions and cerebrospinal fluid

examination for demyelinating disorders or

inflammation of the nervous system were all un-

remarkable. Serologic tests revealed that creati-

nine kinase (CK) (798 U/L, normal 51–246 U/L),

myoglobin level (275 ng/mL, normal 17.4–105.7

ng/mL), and CK-MB (8.11 ng/mL, normal

0.1–4.8 ng/mL) levels were high, suggesting

muscular system problems. We performed

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