untitled mization, and, hopefully, a cosmetically and function- ally improved reconstruction. Accepted for Publication: July 14, 2009. Author Affiliation: North Florida Dermatology Associ- ates, Jacksonville, Florida. Correspondence: Dr Kantor, North Florida Dermatol- ogy Associates, 1551 Riverside Ave, Jacksonville, FL 32082 (jonkantor@gmail.com). Financial Disclosure: None reported. 1. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg Oncol. 1989; 15(1):17-19. 2. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol. 2004;50(1):73-76. 3. Kantor J. The set-back buried dermal suture: an alternative to the buried ver- tical mattress for layered wound closure. J Am Acad Dermatol. In press. 4. Dzubow LM. The use of fascial plication to facilitate wound closure follow- ing microscopically controlled surgery. J Dermatol Surg Oncol. 1989;15(10): 1063-1066. 5. Radonich MA, Bisaccia E, Scarborough D. Management of large surgical de- fects of the forehead and scalp by imbrication of deep tissues. Dermatol Surg. 2002;28(6):524-526. Lack of Lower Extremity Hair Not a Predictor for Peripheral Arterial Disease P eripheral arterial disease (PAD) afflicts 8 to 12 mil-lion Americans, but nearly 75% of them areasymptomatic.1 Physicians rely on history and physical examination to determine which patients re- quire further evaluation. Physical findings that have been associated with arterial disease include a unilaterally cool extremity, skin atrophy and lack of hair, and abnormal pedal pulses, among others.2 The disease spectrum ranges from exertional calf pain to chronic limb ischemia ne- cessitating amputation. The suspicion of arterial disease often leads to further examination of the lower extrem- ity vascular supply. Measurement of the ankle-brachial index (ABI) is a noninvasive method for detecting PAD and is about 95% sensitive and specific when the diag- nostic cutoff is 0.9.3 In general, the accepted ABI for the presence of PAD is lower than 0.9, and that for severe disease is lower than 0.7. The present observational case-control study was un- dertaken based on the clinical observation that many men seem to have hairless lower extremities. Our goal was to determine whether this physical sign is a predictor of PAD. Methods. After obtaining institutional review board ap- proval, we enrolled 50 subjects from Hershey Medical Cen- ter in the study. Twenty-five control subjects were re- cruited from various outpatient clinics and had documented normal ABI measurements (�0.9). Twenty-five subjects with PAD were recruited from the vascular clinic and had either an ABI lower than 0.9 or abnormal lower extremity arterial duplex findings. Subjects with ABIs lower than 0.9 due to disease other than PAD were excluded. Subjects with diabetes who had abnormal ABIs were included in the disease group. Due to arterial calcifica- tion, the vessels in subjects with diabetes may be less com- pressible and so might generate falsely elevated indices. Thus, the vascular disease of patients with diabetes is likely worse than the measured value. Lower extremity hairs were counted on all subjects. First, a measurement was taken from the anterior tibial tuber- osity to the proximal portion of the lateral malleolus. The distance was divided by 3, and hairs were counted at a lo- cation one-third of the distance proximal to the lateral mal- leolus. Scissors were used to trim hairs at this location to several millimeters in length. Temporary black hair dye was then applied to the area for approximately 1 minute. Ex- cess dye was removed, and we took 2 pictures of the area using a magnified digital photography technique, which involved pressing the camera lens against the skin to make full contact while the photograph was taken. All photo- graphs were taken with a Nikon D80 camera (Nikon USA Inc, Melville, New York), stored on a memory card, and uploaded to a computer where Photoshop (Adobe Sys- tems Inc, San Jose, California) was used to crop them to standard dimensions of 2572 � 1564 pixels. Hair count analyses were performed, and data were categorized as either leg hair present (1 or more hairs pre- sent in the examined field) or leg hair absent (no hairs present in the examined field). This assessment was per- formed on data from each of the 50 subjects. Statistical analysis was then completed using a �2 analysis. Results. Of the 50 patients recruited for this study, 25 had existing PAD, and 25 were healthy controls (Table). Subjects in the control group had a mean age of 65 years (age range, 50-80 years). Those in the PAD group had a mean age of 75 years (age range, 55-88 years). Sixty- four percent of patients with PAD had absent leg hair, and 40% of patients without PAD had absent leg hair (Table). Using �2 analysis, we found no statistically sig- nificant relationship between disease presence and ab- sence of lower extremity hair (P = .09). Comment. Peripheral arterial disease involves atheroscle- rotic occlusions in the arterial system distal to the aortic bifurcation.4 It is mainly a disorder of advancing age, and one’s risk of PAD is increased by cigarette smoking, dia- betes, hypercholesterolemia, and hypertension.4 Because many patients are asymptomatic, physicians must recog- nize the early signs and take appropriate action. The goal of the present study was to determine whether the ab- sence of lower extremity hair is a useful predictor of PAD. No statistically significant difference was found between the numbers of diseased patients without leg hair (n = 16) and control patients without leg hair (n = 10) (P = .09), sug- Table. Presence of Lower Extremity Hair in Patients With and Without PAD Lower Extremity Hair Patients, No .(%) With PAD a (n = 25) Without PAD (n = 25) Present 9 (36) 15 (60) Absent 16 (64) 10 (40) Abbreviation: PAD, peripheral arterial disease. a By �2 analysis, no statistically significant relationship was found between disease presence and absence of lower extremity hair (P = .09). Jonathan Kantor, MD, MSCE (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 12), DEC 2009 WWW.ARCHDERMATOL.COM 1456 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 gesting that a lack of lower extremity hair is not useful as a solitary predictor of disease. Therefore, we believe that it is best to consider this examination finding in the context of a patient’s overall presentation and risk factors for PAD. Our study has several limitations. The sample size was only 50 patients. In addition, no demographic informa- tion (including the presence comorbidities such as dia- betes, hypertension, or smoking) was recorded. Accepted for Publication: June 19, 2009. Author Affiliations: Department of Dermatology, Penn State College of Medicine, Hershey, Pennsylvania (Mr Brueseke and Drs Macrino and Miller); and Depart- ment of Radiology, Western Pennsylvania Hospital, Pitts- burgh (Dr Macrino). Correspondence: Dr Miller, Penn State College of Medi- cine, 500 University Dr, HU 14, Hershey, PA 17033- 0850 (jmiller4@hmc.psu.edu). Author Contributions: All authors had full access to all the data in the study and take responsibility for the in- tegrity of the data and accuracy of the data analysis. Study concept and design: Brueseke, Macrino, and Miller. Ac- quisition of data: Brueseke, Macrino, and Miller. Analy- sis and interpretation of data: Brueseke, Macrino, and Miller. Drafting of the manuscript: Brueseke, Macrino, and Miller. Critical revision of the manuscript for important in- tellectual content: Brueseke and Miller. Administrative, tech- nical, and material support: Brueseke, Macrino, and Miller. Financial Disclosure: None reported. Funding/Support: This study was supported in part by The Pennsylvania State University Department of Der- matology. Role of the Sponsors: The sponsor had no role in the design or conduct of the study or in the collection, analy- sis, or interpretation of the manuscript. 1. American Heart Association. PAD quick facts. http:/www.americanheart.org /presenter.jhtml?identifier=3020248. Accessed March 31, 2007. 2. Sontheimer DL. Peripheral vascular disease: diagnosis and treatment. Am Fam Physician. 2006;73(11):1971-1976. 3. Hummel BW, Hummel BA, Mowbry A, Maixner W, Barnes RW. Reactive hy- peremia vs. treadmill exercise testing in arterial disease. Arch Surg. 1978; 113(1):95-98. 4. Meijer WT, Grobbee DE, Hunink MG, Hofman A, Hoes AW. Determinants of peripheral arterial disease in the elderly: the Rotterdam study. Arch Intern Med. 2000;160(19):2934-2938. COMMENTS AND OPINIONS Association Between Thin Melanomas and Atypical Nevi in Middle-aged and Older Men Possibly Attributable to Heightened Patient Awareness W e read with interest the article “Melanoma inMiddle-aged and Older Men” by Swetter et al.1As the authors noted, men with atypical nevi presented with thinner melanomas than those who lacked atypical nevi. According to the study data, median tumor thickness in men with atypical nevi was 0.6 mm, whereas the median thickness was 1.15 mm in men without atypi- cal nevi (P = .02). The authors suggest that men with atypi- cal nevi may have greater knowledge and awareness of mela- noma risk, resulting in earlier detection of their melanomas. Another explanation, suggested by Liu et al,2 is that pa- tients with atypical or increased numbers of moles have more indolent melanomas and thus present with thinner tumors. Methods. To reconcile these alternate explanations, we analyzed the New York University (NYU) database of patients with melanoma prospectively enrolled from 1972 through 1982, many years prior to our col- leagues’ publication of the melanoma ABCD rule (asymmetry, borders, colors, and diameter �6 mm)3 and during an era of much less public awareness of the importance of early melanoma detection. Each patient in the NYU cohort was assessed for numerous clinical factors, including number of nevi.4 However, these patients were enrolled before the significance of atypi- cal nevi was recognized as a risk factor for melanoma, so counts of atypical nevi were not recorded for any patient in the database. Multiple studies, including Roush and Barnhill5 and Nordlund et al,6 have found that individuals with atypical nevi have a higher num- ber of total nevi. These publications suggest that an analysis of number of nevi and median tumor thick- ness is comparable to the analysis of atypical nevi and tumor thickness performed by Swetter et al.1 Results. The accompanying Table and box plot (Figure) summarize data from all men older than 40 years in our cohort (n = 419) and show that tumor thickness did not vary significantly with the number of moles (P �.99 in the Kruskal-Wallis nonparametric analysis of variance test). These data suggest that mela- nomas arising in patients with increased numbers of nevi are not inherently more indolent than melanomas arising in patients with an average (or less than aver- age) number of nevi. Comment. Although these data contrast with those of Swetter et al,1 taken together these findings suggest that increased public awareness and educational efforts may have led to earlier detection of melanoma. Swetter et al demonstrated that men who were aware of melanoma, understood the importance of skin examinations, and showed an overall interest in their health were more likely to present with thinner tumors. At our own institution, we have noted a substantial decrease in tumor thickness Table. Tumor Thickness by Number of Moles Group Patients, No. Moles, No. Tumor Thickness, Median, mm 1 9 0 1.40 2 328 1-25 1.60 3 85 26-100 1.40 4 36 �100 1.85 Taylor J. Brueseke, BS Sheri Macrino, MD Jeffrey J. Miller, MD (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 12), DEC 2009 WWW.ARCHDERMATOL.COM 1457 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021