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Skin and Medical Topics – The Skin Center10.25.17

Mohs Surgery

What is Mohs micrographic Surgery (MMS)? Where can I have Mohs Surgery? How long does the surgery take? What kind of physician can perform Mohs Surgery? Where can I find a doctor board certified in Mohs? Is Mohs only for skin cancer? Can I remove my moles using Mohs? Am I a good candidate for Mohs Surgery? What if I have artificial joints or other health issues? What areas are treatable by Mohs Surgery? What are possible complications of Mohs? Is there scarring from surgery? What are alternatives for Mohs Surgery? What about plastic surgery? What about insurance coverage and costs? How do I prepare for my surgery? Can I smoke and drink alcohol before surgery? How is recovery? Can I return to work or school? Is there pain after surgery? What is the chance that my cancer will recur? Can I go out in the sun after surgery? How are skin cancers treated? Why is it called Mohs?

What is Mohs micrographic Surgery (MMS)?Mohs micrographic surgery is a minor surgical procedure and special method of removing skin cancers using local anesthesia (numbing). The majority of cases are performed right in the physicians office. Mohs is a very precise, highly detailed technique whereby small layers of skin are removed and immediately examined under the microscope to make sure the skin cancer is completely removed.

The procedure uses frozen sections of skin which are then stained with special dyes. The dyed frozen pieces of skin are further examined under the microscope and a tumor map is drawn by the Mohs surgeon. The freezing process allows an immediate examination of the entire tumor margin and tissue histology (microscopic examination of cells).

If more cancer cells or roots are seen under the microscope, then another skin layer is removed and again examined. Each time that a skin level is removed, it is called a level. If no more cancer roots are seen, then it is called clear (no more tumor) and no additional levels are needed.

By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with good preservation of normal skin. Once the cancer has been fully removed, the Mohs surgeon looks at the wound to determine the way to get the best wound repair and cosmetic result for you.

Mohs is special because the entire edge and under-surface of each skin cancer layer is carefully examined under the microscope for the presence of very small cancer cells. With regular or traditional surgery only about 1 to 3% of the tumor margins are actually examined thereby increasing the chances that a small tumor root would be missed and left behind. Mohs allows for examination of 100% of the tumor margins thereby reducing the chance that tumor cells will be left behind.

Mohs is usually scheduled only on certain days in the doctors office because of the required equipment, tissue stains (dye), Mohs technologists, and microscopes. Most of these procedures are generally performed with the patient waiting in the office for the tissue to be read or interpreted by the Mohs surgeon.

Where can I have Mohs Surgery?Mohs micrographic surgery is usually performed in an outpatient setting like a doctors office and under local anesthetic (lidocaine). Sometimes the procedure may be performed in an outpatient surgical center with the assistance of an anesthesiologist. Rarely, it is performed in an inpatient hospital setting.

How long does the surgery take?You are generally in the medical office for several hours( average 2-7 hours) on the day of your Mohs procedure. Depending on how large or difficult your skin cancer is, different numbers of levels may be required to achieve clearance. Mohs requires your patience and your doctors careful effort and skill. It is not always possible to predict ahead of time how many hours your specific procedure will take. Most patients leave their days schedule open to allow for adequate time to complete their Mohs.

What kind of physician can perform Mohs Surgery?Most Mohs surgeons are specially trained dermatologists. There are also some plastic surgery, or Ear , Nose and Throat ( ENT) surgeons who are trained and may also perform Mohs.

Where can I find a doctor board certified in Mohs?There is no current Board Certification for Mohs Surgery. There are two nationally recognized and respected national Mohs specialty groups called the American College of Mohs Surgery and the American Society for Mohs Surgery (ASMS).Both of these medical groups have specialty training and certification exams for their members. Members of The American College of Mohs Surgery usually have completed an additional 1 to 2 years of Mohs training. Members of the American Society for Mohs Surgery are also trained and required to actively participate in an annual quality control Mohs slide peer review.

Is Mohs only for skin cancer?Yes, Mohs is a widely used method of surgically removing the most common types of skin cancers including basal cell carcinoma and squamous cell carcinoma. It is currently not used to remove non-cancerous growths.Less frequently, Mohs may also be used for other malignant tumors. In special cases, Mohs may be used to surgically treat malignant melanoma, lentigo maligna, dermatofirosarcoma protuberans, merkel cell tumor, microcystic adnexal carcinoma, malignant trichoepithelioma, angiosarcoma, atypical fibroxanthoma and other cancerous tumors. However, most Mohs surgeons treat primarily basal and squamous cell cancers by this technique.

Can I remove my moles using Mohs?

No, Mohs is usually not for mole removal. It is primarily designed for removing skin cancers. Moles are usually removed by standard or traditional surgery.

Am I a good candidate for Mohs Surgery?You may not be a good candidate for Mohs if you are unable to tolerate local anesthesia, have extreme anxiety, have a surgical phobia, or are in very poor health.Your decision on the best treatment choice may depend on different factors such as the location and type of skin cancer, your past treatments, your overall health, and level of comfort. Your physician can help you sort through the different treatments and assist in your shared decision making process. However, the right decision for you is always yours and your doctors to make.

What if I have artificial joints or other health issues?Your Mohs surgeon needs to know of any other medical conditions that may affect your surgery or wound healing. You would want to make sure to tell your surgeon beforehand if you have any artificial parts (implants) like knees or hips , a pacemaker or defibrillator, or need to take antibiotics before dental procedures because of a heart condition or murmur.Your Mohs surgeon needs to know if you have had a history of Staph or other skin infections in the recent past. You may be asked to wash with a special antibiotic soap or wash like Hibiclens ( Chlorhexidine) the night or morning before surgery to help reduce the number of bacteria on your skin.

Patients need to also advise their surgeon of any drug allergies such as to anesthetics like lidocaine, xylocaine, epinephrine, or novacaine. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, Hepatitis, HIV/ AIDS, or pregnancy.

What areas are treatable by Mohs Surgery?Mohs is used primarily for the treatment of head and neck basal and squamous cell skin cancers. It is particularly useful for skin cancers in difficult areas such as nose, lips, ears, and genitals.

It is also used on hands and feet where there is not a lot of extra tissue for bigger surgical removals. Mohs is very effective for the treatment of recurrent tumors (tumors that were previously removed and have re-grown at the same site). However, depending on the specific patient and tumor type, any area of the body may be treated by Mohs surgery.

What are possible complications of Mohs?As with any surgery or procedure , Mohs is associated with some possible risks and complications. While it is overall a very safe and effective minor surgical treatment, there are some possible uncommon complications. Since a scar usually forms anytime you cut the skin, most patients understand and expect some type of a scar after skin cancer removal.

Possible risks and complications of Mohs include (but are not limited to) bleeding, bruising, wound infection, pain, unsightly scar, keloid ( raised, thick scar), cosmetic disfigurement, skin discoloration, nerve damage, allergic reactions, pain, reaction to local anesthesia, widened or sunken in( depressed) scar, wound opening ( dehiscence) and spitting or retained stitches, cancer recurrence, need for further surgery or treatment including radiation or plastic surgery, and rarely death.

Minor, serious, or life threatening reactions can occur with the use of anesthetics or with medications given before, after or during surgery. Nerves controlling muscle movement, sensation, or other functions may be damaged. This nerve damage may be permanent.Overall, most patients tolerate the minor surgery very well without any complications.

What is reconstruction?Reconstruction is repairing or fixing the wound.

Repairing or closing the wound may involve having your surgeon stitch the wound closed side by side. Sometime an area may heal better by letting the wound heal in by itself naturally without stitches. Additional reconstruction options include using a skin graft, moving a flap of skin, and plastic surgery closure.

Shared decision making is very important in this part and you are involved in how you prefer to repair the wound. Your Mohs surgeon may make some recommendations on how to close your wound.

The main goal with Mohs surgery is to remove the skin cancer first. Once the cancer is cleared out, then your Mohs surgeon will look at how to best fix the area. The goal of Mohs is to clear skin cancer, achieve the smallest scar, and preserve normal tissue.

Is there scarring from Mohs surgery?Yes, all human beings heal by permanent scar formation. In general, when you cut the skin, there will be some type of scar. Some people heal better than others. Some scars are more noticeable depending on the location and skin type.

There are many options for treatment of surgical scars including lasers, scar creams and gels, cortisone injections, and many other choices depending on the scar. You may want to discuss ways to help minimize scarring with your doctor at your stitch removal appointment.

What are alternatives for Mohs Surgery?It is important to understand that there are alternative treatments and options to Mohs. Additional treatment choices include (but are not limited to) local radiation, prescription topical creams, plastic surgery, curettage and desiccation (scrape and burn), regular surgery, chemotherapy creams or injections, cryosurgery ( deep freezing), photodynamic therapy ( uses a type of light and a light activated chemical called a photosensitizer).

What about insurance coverage and costs?Mohs surgery is generally considered a medical service and is not considered cosmetic. Currently, most insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling surgery and confirm your eligibility and benefits.

Mohs, like any surgical procedure, will result in additional procedure charges above the routine office visit fees. These surgical fees may range from one to two thousand dollars depending on the area, number of Mohs levels, and the type of closure or repair required. The more number of levels required, the higher the cost. Surgical centers and hospitals usually have a much greater costs associated with a facility fee in addition to the surgery fee.

Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally covers 80% of Mohs cancer surgery. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare.

Commercial or non-Medicare insurances currently generally cover a large percentage of your surgery unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or hospital for an approximate estimate of your charges before scheduling the procedure.

What about plastic surgery?You may decide to have regular surgery with a plastic surgeon instead of having Mohs.

Alternatively, you may also choose a hybrid option where your Mohs surgeon removes the tumor and clears it for you and then you have the plastic surgeon fix up the wound and stitch it up for you.

If you prefer to have your plastic surgeon repair the wound, you will want to let your plastic surgeon and dermatologist know ahead of time and plan that into your Mohs schedule.

Heavy alcohol use is not advised at least one week before surgery. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding. Your physician will want to know of any factors that may affect your surgery or wound healing.

How is recovery?Recovery is usually very easy and uneventful. Overall, resting as much as possible the first few days after surgery is generally helpful.

Stitches (sutures) are usually removed at the surgeons office anywhere from 4-14 days from the date of surgery. Your physician will let you know what date to return for stitch removal .

Can I return to work or school?Most patients are able to return to work or school the same day or next day after Mohs. Avoiding heavy lifting, straining, or strenuous exercise for 7-21 days may be required depending on the area of surgery. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure.

Is there pain after surgery?Most patient report no or minimal discomfort after surgery and require no pain medication.

If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take Tylenol (Acetaminophen) or another pain reliever over the counter. Aspirin or Aspirin containing pain relievers may cause increased bleeding. Rarely, prescription pain medications may be required for severe pain.

Your physician will let you know what pain medications are recommended for your specific condition.

How do I take care of my surgical area after Mohs?It is generally required to check with your surgeon for their specific wound care instructions just after surgery.Often, you will be asked to go home and take it east for the rest of the day couch potato day. A few patients like to return to work and resume their work day after surgery.

It may be advisable to avoid heavy lifting and exercise especially the first 24-48 hours after surgery. Your physician will usually give you more detailed instructions depending on the area and size of the surgery.

You will have usually have a bulky pressure dressing on the surgery area for 1 day. You may be asked to keep the area dry until 24 hours. Swimming pools, oceans, and jaccuzis are usually off limits while the stitches are in. These may increase your chance of infection. Many physicians allow you to shower the next day after surgery. Wound care may require cleaning the wound with soap or hydrogen peroxide 2-3 times a day and applying an over the counter antibiotic ointment to the area.

Mild swelling is not uncommon the 1st day or two after surgery and can be lessened by use of an ice bag, ice cubes or chips in a small Ziplock baggie, or frozen peas in their bag. Leaving the dressing in place, ice use every 5-15 minutes every hour for the first 8-24 hours after surgery. Swelling is more common around for surgeries around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after surgery of the head and face area.The surgical area may ooze a little blood or clear liquid especially in the first few hours after surgery; activity may aggravate this. Hot drinks or bending over at the waist can also initiate or worsen bleeding of face wounds. If bleeding occurs, firm pressure applied directly to for ten to fifteen minutes to the site may be helpful. Most bleeding will stop if you apply enough pressure. Your surgeon should be notified of non-stopping bleeding. Rarely, a visit to the hospital emergency room may be necessary for severe bleeding.Your surgeon will need to know if pain is increasing after 1-2 days after your surgery or you are having fever or other concerning symptoms. In such cases, you may need to be seen at the surgeons office. The surgical area may need to be promptly checked for bleeding or infection.

Limiting hot foods, hot drinks, and heavy chewing for 48 hours may help decrease the chances of postoperative bleeding for wounds around the mouth or cheek areas.

Your physician will let you know their recommended wound care.

What about makeup?Most patients are advised to try to avoid applying makeup or powder directly on a fresh wound unless the surface is fully healed. Skin colored tape strips called steristrips are available to minimize and help cover-up a visible wound.It is important to follow your own physicians instructions for wound care.

What is the chance that my cancer will recur?There is a very low chance that your skin cancer will recur after Mohs surgery. Mohs cure rates have been reported as high as 96-99%.It is important to understand that no cancer treatment or surgery has a 100% cure rate. A skin cancer may recur or a new cancer may arise in the same or adjacent area even after Mohs or other surgery. Some skin cancers are more aggressive than others and need additional treatment and closer follow up.Skin cancers frequently need additional follow up and possible further treatment. Although Mohs surgery tends to have the highest cure rate compared to other treatments, Mohs may not be necessarily curative in advanced skin cancer ( rare cases) and may need one or more procedures such as radiation or further surgery to fully treat the lesion.Good follow up appointments with your physician are very important, especially in the first few years after Mohs. Many patients are seen every 4-6 months after their diagnosis of a skin cancer. Self skin examinations monthly are good practice for patients with a history of skin cancer. Any changing or new growth should be promptly checked by your physician. More regular follow up appointments may be needed for those with more aggressive tumors or tumors in high risk areas.Your physician will recommend the proper follow up for your specific condition.

How many levels of Mohs will I need?On average, most patients may only need 1 or 2 levels before clearing the tumor roots. Depending on the skin cancer type and location, a patient may need anywhere from 1 to 10 or more levels of Mohs to clear a tumor.There is no way to predict ahead of time how many levels your cancer will require for cure. The number of Mohs levels needed to completely remove the skin cancer depends on how big your cancer is and where the roots are. Mohs surgeons alway strive to remove your cancer in as few levels as possible.There is also very little way to predict beforehand how large a skin cancer is because often there are invisible portions roots which can be seen only with the help of a microscope. Sometimes, more than one surgical procedure may be required to remove very large or invasive tumors, cancers in small areas or difficult areas, or to obtain the best medical and cosmetic result.

Can I go out in the sun after surgery?

There are no specific strict sun restrictions after Mohs surgery. You may go out in the sun with sunscreen and protective hats and clothing. Overall, the sun is not your friend and should be avoided in excess. Excess sun exposure has been linked to possible skin cancer.Use of sunscreen or other cover up on the scar is very helpful for at least 6 months after surgery to help minimize scarring. It is important to follow your own physicians instructions for wound care and sun protection.

How are skin cancers treated?There are many good and effective ways to treat skin cancers. Options include local radiation (X-ray) treatments, curettage and desiccation C&D ( scrape and burn), cryosurgery ( specialized deep freezing), photodynamic therapy using Levulan and laser and or blue light, regular surgical excision, plastic surgery treatment, interferon injections, laser removal and surgery, Mohs surgery, and several prescription creams including Aldara ( imiquimod) and Efudex ( flurouracil).

Why is it called Mohs?Mohs is named after its inventor Dr. Frederic Mohs who first described the technique in 1941.

Photodynamic Therapy

What is Photodynamic Therapy?Photodynamic Therapy (PDT) is a special medical treatment that uses a photosensitizing drug and a light source to activate the applied drug. The result is an activated oxygen molecule that can destroy specific cells, including pre-cancerous or certain types of cancer cells. The procedure is generally minor and performed in a physicians office or outpatient setting.

PDT essentially has three steps. First, a light sensitizing liquid, cream, or intravenous drug (photosensitizer) is applied or administered. Second, there is an incubation period of minutes to days. Finally, the target tissue is then exposed to a specific wavelength of light which then helps activate the photosensitizing medication.

Steps: 1. Application of photosensitizer drug 2. Incubation period 3. Light activation

Although first discovered around 1913, PDT in the modern sense is a fairly new, evolving science whereby varying incubation times of a light sensitizing drug are used in combination with varying types of available light sources depending on the target tissue. The basic premise of PDT is selective tissue destruction. Although the photosensitizer may be absorbed all over by many cells, atypical or cancerous cells preferentially take up more of the drug and also may retain the drug for longer duration than normal tissues.

At present, the primary limitation of available PDT techniques is the depth of penetration of the light and ability to target cells within at most 1/3 of an inch ( approximately 1cm) of the light source. Therefore tumors or atypical growths must be fairly close to the skin or treatment surface for PDT to work.

What is Photodynamic Therapy used for?PDT is currently used in multiple medical fields including oncology (cancer), dermatology (skin), and cosmetic surgery.

In oncology, it is FDA approved for non-small cell lung cancer, esophageal cancer, and pre-cancerous changes of Barretts esophagus. Its use is also being further investigated through clinical trials in general oncology for conditions including cancers of the cervix (mouth of uterus), prostate gland, brain, and peritoneal cavity (the abdominal space that contains the stomach, liver, and internal organs).

In dermatology, PDT using Levulan Kerastick (20% delta-aminolevulinic acid HCl) became FDA approved in 2001 for the treatment of pre-skin cancers called actinic keratosis (AK). The initial approval was specifically for normal (non-hyperkeratotic) actinic keratosis of the face and scalp with a specified 14 to 18 hour drug incubation time, and 1,000 seconds (16 minutes and 40 seconds) of activation by a proprietary blue light source.

Since 2001, PDT has also received many other non-FDA approved ( also called off-label ) uses including acne, rosacea, skin cancer, sun damage, cosmetic skin improvement, oily skin, enlarged sebaceous glands, wrinkles, rejuvenation (anti-aging), warts, hidradenitis suppurativa, psoriasis, and many other skin conditions.

What photosensitizer drugs are available?At least 3 currently FDA approved photosensitizers are available including Photofrin (porfimer sodium), Levulan ( 5-aminolevulinic acid or ALA ), Metvix (methyl aminolevulinate (MAOP)) . More drugs are undergoing trials and may become available in the near future. Photofrin is used intravenously ( IV)for internal cancers while Levulan and Metvix are applied topically for skin therapy.

What light sources are available?PDT can essentially use many types of light sources. These include laser, intense pulsed light, light-emitting diodes (LEDs) , blue light, red light, many other visible lights, including natural sunlight. Photosensitizer drugs may become activated by one or several types of applied light depending on the ideal wavelength for the particular drug used and target tissue.

How is the light applied?The light source needs to be directly applied to the target tissue for a specific amount of time. For surface skin treatments, the light is easily directly applied to the area of the skin where the photosensitizer drug has been applied ( such as face, scalp, arms, etc.).For internal cancers, delivering the light to the desired area is more challenging. The light may be delivered through small fiber optic cables into the body cavity or area being treated. Sometimes endoscopes ( a thin lighted elongated tube which is inserted into a body space) are used to deliver the light into the lungs, stomach, or bladder.

How does PDT work?PDT works by direct injury to the target cells and tissues. While all of the exact mechanisms are not fully known yet, the basic pathway seems to involve an activated oxygen molecule that has the ability to injure or destroy nearby or specific cells.Aminolevulinic acid is then incorporated into the bodys natural heme ( blood) biosynthesis pathway and activated to form protoporphyrin IX, a potent photosensitier. Protoporphyrin IX then becomes excited to an activated singlet state. This active singlet state is then directly toxic to cells.Other potential pathways include directly killing abnormal or cancerous cells, damaging the blood vessels and blood supply to the tissue, causing inflammation and irritation, and possibly also activating the persons own immune system to attack the abnormal or cancerous cells.

Does PDT make me permanently more sensitive to light?No, PDT causes a temporary sensitivity to light, including natural sunlight and some indoor lights. The light sensitivity resolves with time depending on both the photosensitizer drug and dosage used.

How long do I have to stay out of the sun and light?Light avoidance is generally required after PDT. The duration depends on the drug and dosage used. Intravenously given Porfimer may make the body including the skin and eyes sensitive to light for about 6 weeks after treatment. Proper protection including long sleeves and sunglasses may be required.Topically applied aminolevulinic acid (Levulan) or methyl aminolevulinate (Metvix) may cause skin sensitivity only on the treatment areas for approximately 24-72 hours. These do not usually cause sensitivity on other body parts other than where the drug was directly applied. Your physician will need to discuss with you the required sun and light avoidance period required after your particular treatment.

How is PDT used to treat the skin?

PDT using Levulan ( 5-aminolevulinic acid or ALA ) and a proprietary Blue light is currently FDA approved for the treatment of skin pre-cancers called actinic keratosis ( rough scaly spots generally on sun exposed skin in more fair skin individuals).PDT is also known as ALA/PDT treatment or Super Blue Light. It has been referred to as a super photo facial when the photosensitizer is used with a machine called intense pulsed light or IPL. These treatments may help remove sun damaged pre-cancerous zones and spots. Sun damage, fine lines, and blotchy pigmentation may also be improved because of the positive effect of PDT. IN some patients, PDT also has been shown to help decrease the appearance of pores and reduce oil glands, effectively treating some subtypes of patients with stubborn acne, rosacea, and help improve the appearance of some small superficial acne scars.Although PDTs use in skin was first investigated in 1990s for actinic keratosis, it was not as popular or widely used because of the required long incubation times (usually 18-24 hours) and limited indications. Since approximately 2001, PDT has become more widespread in use primarily because of advances including shorter incubation times (30-60 minutes) and more applications including acne and cosmetic skin rejuvenation.

What is a photosensitizer drug?Photo sensitizers are chemical compounds that become activated only when exposed to light.

What is Aminolevulinic acid or Levulan?5-aminolevulinic acid also called Levulan or ALA for short is a naturally occurring protein in the body. It is found in small quantities as part of the normal heme ( blood) synthesis pathway. In larger quantities, it is a substance known to increase sensitivity to certain wavelengths of light.

How does PDT work?By preferentially attacking the active or abnormal cells, PDT combines a very high success rate with good preservation of normal skin without significant risks for scarring. Once the areas have healed following PDT, the areas are re- examined to see if additional treatments or possible biopsies are needed.

PDT is special because it is a targeted treatment to preferentially target more rapidly dividing cells and atypical skin growths. With regular or traditional cryosurgery ( freezing with liquid nitrogen) or burning, only the visible pre skin cancers are treated thereby leaving ones that arent as apparent ( sub clinical or hidden) lesions undetected. Photodynamic Therapy allows for field or blanket treatment of an entire area of sun damage thereby reducing the chance that undetected pre skin cancer cells will be left untreated.

Photodynamic Therapy is usually scheduled in the doctors office because of the required photosensitizing prescription / physician applied medication and the special light activation equipments. Currently PDT procedures are generally performed with the patient waiting in the office during the 30 minute to several hours incubation time before the application of the light source.

What is a typical skin PDT session like?You may be given a written procedure consent form to read and sign before your first treatment. The medical staff may take some before photography prior to applying the photosensitizer medication.In the treatment room, you may be sitting or comfortably lying back on a table. This part is generally painless and comfortable. Often a thorough cleansing of the face is done using alcohol and or acetone to degrease the skin. The less oil on the skin, the more readily the skin will absorb the applied topical medication. In some patients microdermabrasion may additionally be performed prior to the application of the medication to further prepare the skin to optimally absorb the photosensitizer.The photosensitizer liquid or cream is applied topically to the whole area being treated (such as the entire face, scalp, back of the hands, back part of the forearms, legs, feet, scalp, chest, or back).The medication is allowed to air dry for a few minutes and then you will wait anywhere from 30-60 minutes for the incubation time. Some areas such as chest, back and particularly forearms and legs require longer incubation times of 2-18 hours for better results. No two people or skin on different areas of the body are exactly alike. PDT requires physician adjustments for specific individualized incubation times and treatment durations.After the proper incubation time, you are brought back into the light source room where the medication is activated with a specific wavelength light source. There may be sensations of warmth, tingling, heat, or burning in some patients. Frequently, you will have a fan to help cool off during the treatment.The treatment area is then washed off and sunscreen applied before leaving the office. Instructions and an appointment for follow up may then be given on how to care for the improved skin.

How much improvement can I expect?No two individuals are the same and results may vary. As with any medical procedure, some conditions can improve dramatically in some patients and not respond in others.

Overall, patients with severe sun damaged skin manifested by actinic keratosis, texture, and tone changes including mottled pigmentation, dull or sallow skin, and skin laxity may see good to excellent improvement with PDT. There have been reports of possible improvement of large pores, non- pitted acne scars, and active acne.

Depending on the area being treated and the recommended incubation time, different numbers of treatment sessions spaced 4-6 weeks apart may be required to achieve the desired improvement and reduction in lesions. It is not always possible to predict ahead of time how many treatments your specific condition may take or how you will respond to PDT.

Photodynamic Therapy requires your patience and your willingness to follow the post procedure instructions, including staying out of the sun for 24-28 hours depending on the area treated and your physicians requirements.

How many treatments will it take to see the best results?To achieve maximum improvement of pre-cancerous (actinic keratosis) sun damage, skin tone and texture, on average a series of 2-3 treatments 2-6 weeks apart may be quite effective. Some patients with milder actinic keratosis are happy with one treatment. More treatments can be done at periodic intervals in the future to maintain the rejuvenated appearance of the skin.

Where can I have Photodynamic Therapy?Photodynamic Therapy for skin therapy is usually comfortably performed in an outpatient setting like a doctors office and without any sedation or anesthesia.You may check the for board certified dermatologist members of the American Board of Dermatology in your area or for members of the American Society of Photodynamic Therapy. Additionally, oncologists and other physicians may be trained in this area.While these photosensitizer medications may currently only be available to medical personnel, it may be foreseeable or possible in the distant future where patients could be given a prescription for the topical or oral photosensitizer and a light source for physician directed home use.

How long does a skin PDT procedure take?You are generally in the medical office for several hours( average 1 1/2 hours) on the day of your Photodynamic Therapy. Facial PDT may take 10 minutes to apply the medication, 30-60 minutes to allow proper skin incubation, and 15-20 minutes for light application. Other areas may require longer incubation times and you may leave the office and come back when it is time to have the light.

Many patients prefer to schedule their treatment later in the afternoon so they may go directly home after the treatment. It is not usually advised to have any sun exposure such as from running errands or driving around after the treatment.

What kind of physician can perform Photodynamic Therapy?Most skin PDT is performed only by specially trained dermatologists and their medical staff. Other physicians including oncologists, family physicians, internal medicine doctors, plastic surgeons, or Ear, Nose and Throat ( ENT) surgeons and their medical staff who are trained and may also perform Photodynamic Therapy.While it is generally advisable to undergo this or any medical treatment in an established board-certified physicians office, there are medical spa type environments that may also offer these skin services with or without physician supervision.

Where can I find a doctor board certified in Photodynamic Therapy?There is no current Board Certification, residency, or fellowship training for Photodynamic Therapy. There is a new national organization called the American Society for Photodynamic Therapy (ASPDT). You may check the website for members of this group at There are many other photomedicine interest groups and societies dedicated to this evolving field.

Some dermatologists and oncologists have received special residency or post graduate training for photodynamic therapy. Many other physicians may be trained by companies that manufacturer the photosensitizing material and /or the light source.

Is skin PDT only for pre-cancerous growths?No, Photodynamic Therapy is a widely used method of treating many conditions including pre-cancers (actinic keratosis), some types of superficial skin cancers, acne, rosacea, warts, sebaceous hyperplasia ( enlarged oil glands), fine wrinkles, psoriasis, and other cosmetic indications. It is currently not used to remove malignant melanoma or deeply invasive cancers. It is not used to remove moles or birthmarks.Less frequently, Photodynamic Therapy may also be used off-label for other less common conditions including hidradenitis suppurativa, porokeratosis, disseminated actinic porokeratosis (DSAP), and other investigational conditions.

What are the advantages with Photodynamic Therapy for treating skin pre-cancers?The greatest advantage of PDT is the ability to selectively treat an entire area of skin damage and pre-cancers (blanket or field treatment). PDT generally decreases the likelihood of lighter or darker skin spots ( post-inflammatory hyper or hypo pigmentation) caused by routine freezing with liquid nitrogen. Additionally, PDT frequently may facilitate smoother skin and an overall improved appearance, tone, color, and enhanced skin texture.

In several studies, PDT has been preferred by many patients for ease of use and recovery as compared to alternative treatments including freezing and chemotherapy creams like fluorouracil (Efudex). The PDT side effects may be milder with less down time than with fluorouracil.

For patients with many skin lesions, PDT may be generally more effective than repeated spot treatment with topical liquid nitrogen. Some patients are unable to tolerate the prolonged treatment required with fluorouracil (Efudex) or imiquimod (Aldara) because of the irritation, redness, and possible downtime with these topical creams.PDT has become a very well tolerated, essentially painless, non-invasive (no needles or surgery required) procedure to help reduce sun damage and enhance the overall cosmetic outcome (particularly in sensitive areas of the face and chest).

How many treatments of Photodynamic Therapy will I need?

No two peoples skin is exactly the same and therefore individual results and number of required treatments vary. On average, most patients may benefit from 1 to 3 PDT treatments for an area and annual touch up treatments. While the face tends to respond faster and to fewer treatments, areas like the forearms and legs are much harder ( resistant and tough skin) to treat and may require many more treatments.

There is no way to reliably predict ahead of time exactly how many treatments your condition will require. Photodynamic Therapy physicians always strive to treat your condition in as few treatments as possible without causing a severe burn.

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Skin and Medical Topics – The Skin Center

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Championship Ashe’s splash art is finally here, and it’s really cool – Dot Esports09.07.17

It’s been two weeks since this year’s Championship skin was revealed to be Ashe on the PBE, and since then, we’ve been waiting to see her splash art. After all, the artwork for each Championship skin has been particularly badass.

The wait is finally over, because the art was loaded onto the PBE yesterday, and it’s just as awesome as we were all hoping.

This skin will have stiff competition, though, because between Ashe’s Heartseeker (2014) and Project (2016) skins, players might be checked out on the idea of buying yet another new Ashe skin, especially when Project Ashe is priced a bit high at 1820 RP. That’s essentially a $20 skin.

Still, this skin looks stunning so far on the PBE, and the splash art certainly does it justice. The skin will ship with custom sound effects, ability animations, and a new recall that let’s our favorite Freljordian queen sit atop a badass Worlds-themed throne.

Last year’s Championship Zed set the bar high, and it looks like this year will set it even higher. Remember, when this skin does go live, a portion of the proceeds will be added to the Worlds prize pool, so by buying this skin, you’re directly supporting your favorite Worlds teams.

That, or you’re funding SK Telecom T1 so they can afford Lee “Faker” Sang-hyeok for one more year, because, let’s be honest, they’ll probably win again.

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CESAREO GARASA: Collectibles, comics, a concert oh my! This local con delivers – The Bakersfield Californian09.07.17

This weekends big event will undoubtedly be the Village Fest, aka Bakersfields largest social bacchanal.

However, there is one event happening on Saturday (and Sunday) that offers something totally different for all ages think of it as Village Fests slightly geekier younger cousin: Bakersfield Collector-Con at the Rabobank Convention Center.

That both events are happening on the same day is purely coincidental. Convention founder and promoter Nick Avalos, 39, says the convention’s booking date was out of necessity and opportunity: There was a cancellation.

(This Saturday) was basically the only spot available, Avalos said.

On Saturday, the convention lasts from 10 a.m. to 5 p.m. so collectors can conceivably make the con and still hit Village Fest an hour later (note: The con will be serving booze). But what about those who are too young to attend the latter? Its a feeling anyone under 21 years of age in places like Las Vegas and Reno know all too well: plenty of stuff to do if youre an adult. Kids? Not so much.

Our thing is a family event, so we want to keep the families together, Avalos said. And what better way than having them enjoy a nice day with toys, comic books, (and) a cosplay contest? Then, afterwards, they get to enjoy a live concert.

The concert hes talking about is what, along with the new venue, makes this Collector-Con different from previous years. It was the move to Rabobank Convention Center that afforded Avalos an opportunity to expand the convention in more than just size.

This year we were fortunate enough to turn our convention into a two-day show, Avalos said. The (Rabobank Convention Center) gave us the opportunity to stay there later, so it was either ask the vendors to stay and make their day longer or try to incorporate something else to reach a whole different genre.

So instead of just having a DJ, like years prior, they’ll ratchet up the nostalgia factor to 11 pun intended by playing themes to old cartoons like G.I. Joe and Thundercats then attendees will be treated to an honest-to-goodness rock show after the convention is over.

The concert is family-friendly as well, but fair warning: These band are here to rock. Emily Lazar, the frontwoman and conceptual mastermind behind headliner September Mourning, performs in character as a human/grim reaper hybrid named September (natch). You wont likely find this band on daytime Nickelodeon anytime soon.

September Mourning is amazing, Avalos said. They fit right in with what were doing.

Lazars character isnt the only hybrid here the entire idea of the band is. Lazar, along with famed comic book artist (and Witchblade creator) Marc Silvestri, created the entire project as a multimedia crossover between comic books, music and performance.

Lazar has been a fan of comics since childhood and her choice to partner her music with them wasnt born from a sort of calculated business standpoint. It came from years of reading and enjoying them, stemming from days in her grandparents’ basement in New York, reading Dad’s old comic books.

And while other bands have attempted to cross-pollinate their music with comics and toys sometimes with like-minded theatricality as Lazar Ive yet to see one as ambitious or as immersive as her vision.

The music isnt the soundtrack for the show (KISS), the basis for the comic (My Chemical Romance), or the comic book the basis for the music (Coheed and Cambria). For Lazar, the music and comics work symmetrically with each other an intertwined mythology absorbed over different platforms. Even her characters design on pages and on stages reflects that.

With September, Lazar said, (the) whole thing is that shes a human/reaper hybrid so shes not totally supernatural. Shes human but she has these weird powers. That was a big thing when we were creating it: I wanted to keep the humanity in the hero because I thought that was huge. For me, that was something that I was drawn to as a kid: I wanted to able to relate. And taking that (character) to a totally different level becomes a little bit unreliable. You have to have empathy in a hero.

Both issues of the September Mourning comic, A Murder of Reapers and The Hand of Fate, were recently collected into a graphic novel with a cover by Silvestri, and available at major book sellers. Its the companion piece to the bands 2015 EP Volume I and 2016s Volume II.

Their music is a mixture of modern hard rock, djent-style metal, and heavily theatrical goth. The well-produced Volume II (whose first track is appropriately named The Collection) goes from sweeping, operatic passages (Skin and Bones) to almost bouncy metal pop (seriously on Superhuman), to aggressive, melodic despair (20 Below).

They even cover the classic Stand By Me, changing the hopeful repose of the original into a dark invitation. Oh, she goes deep here. Her vocals go from guttural to throat-shredding.

My personal favorites have to be the knockout Eye of the Storm with its unexpectedly killer melodic chorus and the anthemic Children of Fate which acts as both a rallying cry and statement of purpose contextual comic book storyline or not.

Also, the band taught me a very important lesson: If you are auditioning (even if youre not aware of it) for a goth-metal band, dont show up to rehearsal dressed like youre going to play a reggae gig. Yup. That really happened. I saw Lazars talent firsthand. Shes an artistic powerhouse. Dont be surprised if you see her eventually directing movies and giving Rob Zombie a run for his money.

Also performing will be Arizona-based Doll Skin (listed as one of the seven best rising bands under 21 by AP magazine in 2016), Kern County/Los Angeles hybrid (again!) Forget your Friends, and local rising stars (pun also intended) Missing Autumn, Stereo Citizen and Art and the Resistance. There will be no separate tickets on sale for the show, so you’ll have to pay the for the $13 Saturday pass. That’s still a heck of a bargain for the amount of talent on display, though. For $5 more, you can get a two-day pass and geek out frugally.

On both days of the convention, there will be cosplay contests for kids and adults (prizes TBD), and raffles that will benefit the Ronald McDonald House. The con is naturally an anti-bully space and attendees are invited to be themselves and have fun within reason. Just because Superman could fly, doesnt mean you should try it.

Its a sweet revenge to witness a sea change happen over the years where those once derided have become the modern arbiters and creators of pop culture. Take note, kids: That which makes you you, makes you awesome. Or amazing, or spectacular, or even uncanny (puns definitely intended).

Its cool, Lazar said, We liked this stuff back in the day, when it wasnt It was cool, but everybody (treated you) like, Oh, Youre a nerd. You read comic books, I used to get teased.

But that happened to computer geeks too, back in the day, and now theyre owning the world. So its kinda like, the cool kids today were the uncool kids ten-years ago. Thats what its become, which is, I think, awesome. It took them a little bit of time, but the mainstream finally figured it out, but thats how it always is.

Fifth annual Bakersfield Collector-Con, 10 a.m. to 5 p.m. Saturday, 10 a.m. to 4 p.m. Sunday,Rabobank Convention Center, 1001 Truxtun Ave. $13 Saturday, $8 Sunday, $18 two-day pass, free for children 10 and under; VIP (includes early entry) $25 Saturday, $15 Sunday. Note: Live musicfrom 5-10 p.m. Saturday onlywith September Mourning, Doll Skin, Art & The Resistance, Missing Autumn, Forget Your Friends, and Stereo Citizen (those interested in just attending the concert will still have to pay the conventions day pass of $13).

Get ‘Close’ at Maya Cinemas

“Close Encounters of the Third Kind” 40th anniversary, noon, 3:30, 7 and 10:15 p.m. Thursday at Maya Cinemas, 1000 California Ave. $7.50.

Speaking of things fantastic, for those who didnt get to see Steven Spielbergs Close Encounters of the Third Kind in the theater present company included here is our chance.

In honor of the movies 40th anniversary, its been digitally remastered in 4K and re-released in various theaters nationwide where audiences can experience it the way it was meant to be: larger and louder than life on the big really big screen. The MPX screen at the Maya Cinemas is as impressive as IMAX sans 3D. Thursday is the last day audiences can catch it in theaters.

This film a personal favorite shouldnt just be watched, it deserves to be experienced. It is truly one of the rare movies that can accurately be described as magnificent. While the scope is grand, its character development is intimate.

From the mysterious, haunting opening in the Sonoran Desert, to the tender, eerie, colorful, jaw-dropping climax, this was Spielbergs test-run for his masterpiece, E.T. the Extra-Terrestrial, in both emotion and spectacle. Its also, truly, one of cinematographer Vilmos Zsigmonds and visual effects supervisor Douglas Trumbulls finest hours.

Here, Spielberg learned how to subtly ratchet up tension (more-so than on Jaws), how to wring every ounce of emotion out of a score, and how to utilize special effects believably. These were all templates for each of his films after science-fiction or not.

With some of the most iconic imagery we will never see Devils Tower mountain in Wyoming without thinking of this movie and whats probably the most recognizable five-note motif in film history (technically, four notes one of them is an octave), re-watching CE3K makes adults remember what it was like to be a kid discovering wonder for the first time. It’s wistful, majestic, magical, mysterious and scary. It’s truly brilliant at times almost quite literally.

Do your kids a favor: Share this with them. The film is rated PG for some light cursing and some intense moments (the abduction scene in particular), but theyll get it. Theyll really get it.

Also, for better or worse, Spielberg is one of the first filmmakers to re-release his movie in theaters with added material, starting in 1980 with Close Encounters of the Third Kind Special Edition. So those special editions of Star Wars? Thanks to this guy.

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Dita von Teese Stepped Out to Fte Caviar at This Lavish Art Exhibition – InStyle09.07.17

September 7, 2017 @ 10:45 AM

Though Dita von Teese isn’t in the business of painting or sculpting, many would call her burlesque performances and perfectly-coiffed appearance works of art.

Thus, her appearance at a lavish New York City event where beauty and art collided on Wednesday nightLa Prairie’s The Art of Caviar exhibitionwas no surprise. Von Teese’s signature pinup girl waves and red lips were present, as was her retro-inspired style.

For the evening, the performer slipped on a floral jacquard dress from Ulyana Sergeenko. The design was fully equipped with a nipped-in waist and tea length.

To commemorate the 30th anniversary of its Skin Caviar line, La Prairie commissioned a group of contemporary artists to create works inspired by its groundbreaking technology. That blossomed into traveling The Art of Caviar exhibition, which first showed at Art Basel in Basel. The iconic beauty brand then decided to take its show on the roadshowing the pieces to the public in Paris in July.

Among the artists are Paul Coudamy with his pieces Living Cells and Solid Frequencies, Bonjour Lab’s digital work Moving Pixel, a Cinq Fruitsphotography series, and an audiovisual installation by TremensS.

RELATED: Ageism Won’t Keep Burlesque Star Dita Von Teese from the Stage

Art and beauty lovers alike in New York City can see the works in person Thursday, Sept. 7 from 10 a.m. to 8 p.m. at 3 West 57th Street. The exhibition will then travel to Hong Kong at the end of the month and Shanghai in November.

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Art Imitating Life: This New South Park Game Gets Harder If You Choose A Black Character – Blavity09.07.17

How can we forget that famous Scandal moment when Papa Pope told Olivia, “You have to be twice as good as them to get half of what they have?”

Photo: GIPHY

Well, art is again imitating life in the South Park headquarters. A new video game based on the popular animated series incorporates racial life dynamics, Kotakureports.

The game, South Park: The Fractured But Whole, will have its difficulty settings based on the skin color players choose in the game’s character creation screen.

Preview gameplay footage shows that the game’s difficulty slider goes from “Easy,” the white option, to “Very Difficult,” a dark skinned option. In a fun twist on gaming world defaults, if a player wants to play the game on “Normal” mode, they have to play as a person of color.

According to Eurogamer, the skin color of the player’s character will determine how Non-Player Characters (NPCs) react to the character in various situations, and will also affect how much money your character is able to earn for their work.

Dont worry, this doesnt affect combat. Just every other aspect of your whole life, South Parks leading character, Eric Cartman jokes as you select your skin color.

Race isnt the only thing that affects gameplay, either.

Players can also choose if their character is male, female or neither. After choosing your sex, you are asked to chose whether you are cis or trans.

In Eurogamer’s playthrough, its reviewers decided to be a transgender young woman, and found themselves under physical attack by transphobic South Park residents.

If all of this sounds interesting, you’ll be able to play the game yourself soon.

South Park: The Fractured But Whole releases on October 17th.

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Pharrell Has Divulged the Secret to His Perfect Skin – Noisey09.07.17

Right now, you could show me a photograph of Pharrell Williams and I would be quite sure that I was looking at a man in his twenties. Pharrell, however, is actually forty-four years old, and has the smoothest, softest-looking skin in the music industry. People decades younger than him look withered and elderly in comparison.

And while good genes can certainly answer for a lot, there have to be some external factors (it’s well known, for example, that he has his own dermatologist.) Previously, he’s waxed lyrical about the benefits of Glytone Self-Foaming Cleanser, and now, in an interview with Dazed about his new Adidas collection, he’s added another piece to the puzzle of his skincare regime:

I exfoliate like a madman. When you exfoliate and you drink a lot of water, that does good for you. To me, the key is just exfoliating, like a monster. There’s a lot of dead skin. All the time. Like a narcissistic madman.

OK, this is a good start, but I’m going to need more detail. Is Pharrell doing acid exfoliation, or is he using a scrub? What are the specific products he’s using? You can’t just tease people like this Pharrell, we need to know, our glo-ups depend on it. Drop the full product regime, Pharrell, for the love of god.

Elsewhere in the interviewwhich is unfortunately a little short on any news about new musicPharrell discussed politics, and specifically the issue of climate change. The topic is currently weighing heavy on the minds of many following extreme weather in the US, in the forms of Hurricanes Harvey and Irma:

There are just people who make a lot of money on pretending that these are not real issues. I don’t understand how you can live in Alaska and not believe in global warming. Actually, I do understanda lack of empathy is very powerful. It can make you see things that are not there.

It’s an enlightening read if you’re interested in Pharrell’s relationship with fashion; or if, indeed, you are, like me, just after that skincare holy grail.

Follow Noisey on Twitter.

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Entertainment Lancaster Sept. 7-13 Art Calendar – LancasterOnline09.07.17



Monthly pop-up market featuring the original works of artists, hobbyists, artisans, bakers, upcyclers and more. Sponsored by Creatively Lancaster. Kicks off Sat. 10 a.m.-3 p.m. Free. Tellus360, 24 E. King St.



Paintings by local artist Crystal Dull along with works by her two teen daughters, Breonna and Monica. Opening reception, Wed. 6:30-8:30 p.m. Cont. through Oct. Daily 9 a.m.-7 p.m. Free. Harvest View lobby and galleries of Landis Homes, 1001 E. Oregon Road, Lititz, 717-381-3550.


Transcriptformations by Jay Noble. Opens Mon. Cont. through Oct. 19. Mon.-Fri. 8 a.m.-4 p.m. Weekend hours by appt. Free. Breidenstine Hall, Millersville University, 717-872-7249.



Multiartist exhibit. Featured artist: Jenna Johnson. Cont. through Sept. Thurs. 11 a.m.-5 p.m.; Fri. 11 a.m.-7 p.m.; (First Fridays until 9 p.m.) Sat. 10 a.m.-5 p.m. or by appt. Free. 24 W. Walnut St., 610-304-5168.


Works by Christiane David. Mon.-Thurs. and Sat. 10 a.m.-5 p.m.; Fri. 10 a.m.-6 p.m. 112 N. Prince St. 717-293-0809.


Diversification, by David Silvah. Highlight artist: Susan Bailey, with City Mouse/Folk Mouse: A Lancaster Story. Also: Storytellers, an open-call photo exhibit. Cont. through Sept. Tues.-Sat. 10 a.m.-5 p.m.; Sun. 11 a.m.-3 p.m.; Free. 146 N. Prince St., 717-393-8807.


Current Color A Year on the River by Diana Thomas. Cont. through Sept. 30. Tues.-Thurs. 10 a.m.-5 p.m.; Fri.-Sun. 9 a.m.-6 p.m. Free. 41 W. Walnut St., Columbia.


Second Skin, photo exhibit by Ashley Moog. Reception and artist talk, Sept. 21 from 5:30-7 p.m. Exhibit cont. through Oct. 6. Tues. and Thurs. 1-7:30 p.m.; Wed. and Fri. 11 a.m.-7:30 p.m. Free. Winter Visual and Performing Arts Center, 60 W. Cottage Ave., Millersville. 717-872-3304. 717-871-4633.


Forbidden Art, an exhibition of photographs of camp art from the collections of the Auschwitz Memorial. Cont. through Oct. 26. Mon.-Thurs. 10 a.m.-8 p.m.; Sat. 9 a.m.-1 p.m. Free. 550 S. Reading Road, Ephrata, 717-738-9291.


Works of resident pen and ink artist Dale Weibley. Fri. and Sat. 10 a.m.-5 p.m.; and select Fourth Friday events. Free. 653 Locust St., Columbia, 717-669-1890.


Linear Motion, works by C. Mari Pack. Cont. through Sept. 30. Thurs. and Fri. 10 a.m.-5 p.m.; Sat. 10 a.m.-6 p.m. Free. 110 W. King St., Suite 101. 717-381-5032.


Waterworks, a themed membership show, Kauffman Gallery; Solo show by Darby Bolich, Steinmetz Gallery. Cont. through Sept. 7. Thurs.-Sat. 11 a.m.-4 p.m.; Sun. 1-4 p.m. 149 Precision Ave., Strasburg, 717-687-7061.


Woodcut Prints: Fruit of the Tree, by Gene Shaw. Cont. through Sept. 30. Tues.-Fri. 10 a.m.-5 p.m.; Sat. 10 a.m.-3 p.m. and by appt. Free. 34 N. Water St., 717-397-5552.


The Roaring Twenties, a new series of works by Liz Hess. Tues.-Sat. 10 a.m.-5 p.m. Free. 140 N. Prince St., 717-390-7222.


Richard Babusci: What Remains, a collection of oil and acrylic on canvas paintings that depict people disassembling into abstract fragments. Also afterimages, an exhibit of photography by Joseph Greer. Cont. through Sept. Mon.-Fri. 10 a.m.-4 p.m. Evenings and weekends by appt. 21 N. Mulberry St., 717-295-1949.


Plain Meetinghouses by photographer John Herr and Fragmentation by art educator Kay Reist. Cont. through Oct. 29. First Fridays 5-8 p.m. Other hours by appointment. Free. Community Mennonite Church, 328 W. Orange St. 717-392-7567.


Faig Ahmed Azerbaijan carpet art. Cont. through Sept. 22. Mon.-Fri. 8 a.m.-4:30 p.m. (Later on First Fridays.) Free. 204 N. Prince St., 717-396-7833.


Jill Pekelun: Urban Landscapes; Nicole Michaud: Journeys; Passion, to Paint the Remembered Sensation, solo exhibit by Susan Gottlieb. Highlight artists: Rhoda Kahler, Jeff Schaller, Patricia Wertz and Linda Stetina; Emerging artist: Brittany Kurtinecz. Cont. through Sept. 30. Tues., Thurs., Fri. and Sat. 10 a.m.-5 p.m. (First Fridays until 8 p.m.) Free. 138 N. Prince St., 717-299-4400.


Painting on Clay: Toshiko Takaezu and the Abstract Expressionist Movement. Reception, tonight from 5-7; lecture, Sept. 28 at 5 p.m. (Zimmerman Recital Hall). Exhibit cont. through Oct. 15. Wed. 5-8 p.m.; Thurs. and Fri. 1-4:30 p.m.; Sat. and Sun. 11 a.m.-5 p.m. Free. West Church and North White Oak Sts., Lebanon Valley College, Annville, 717-867-6445.


Selective Visions, works by Mimi Shapiro and Paul Engleheart. Cont. through Sept. 29. Mon.-Fri. 8 a.m.-4 p.m. Free. Regitz Gallery in the Ware Center, 42 N. Prince St., 717-871-7600.



Museum houses a collection of American art, with special galleries dedicated to the work of N.C., Andrew and Jamie Wyeth. Rotating exhibitions. Currently: Andrew Wyeth: In Retrospect. Cont. through Sept. 17. Daily 9:30 a.m. to 5 p.m. $15 adults; $10 seniors, $6 students and children 6-12, free children under 6. 1 Hoffmans Mill Road, U.S. Route 1 in Chadds Ford. 610-388-2700.


Home and studio of modernist Charles Demuth (1883-1935). Permanent collection of Demuths art, plus special events and changing exhibitions. Currently: Robert E. Locher: A Modern Classic. Cont. through Nov. 26. Tues.-Sat. 10 a.m.-4 p.m.; Sun. 1-4 p.m. Admission by donation. 120 E. King St., 717-299-9940.


Watch Portraits, a collection of the unique horological work of photographer Atom Moore. Cont. through Dec. Mon.-Sat. 10 a.m.-5 p.m.; Sun. noon-4 p.m. Included with reg. admission of $9 adults, $8 seniors, $5 children 5-16. (Max of $23 per family.) 514 Poplar St., Columbia, 717-684-8261.


Wild, exhibit by photographer Michael Nichols. Cont. through Sept. 17. Tues.-Sun. 10 a.m.-5 p.m. (Wed. and Fri. main building is until 8:45 p.m.) $20 adults, $18 seniors, $14 children 13-18 and students with ID, free for children 12 and under. 2600 Benjamin Franklin Parkway at 26th St., Phila. 215-763-8100.


Museum houses several galleries with rotating exhibits. Currently: Arab Comics: 90 Years of Popular Visual Culture, Cont. through Dec. 8. Rothman Gallery. Tues., Wed. and Fri. 11:30 a.m.-4:30 p.m.; Thurs. 1:30-4:30 p.m.; Sat. and Sun. 12:30-4:30 p.m. Free. Phillips Museum of Art, Steinman College Center, F&M College. 717-291-3879.


Annual Art of the State. Cont. through Sept. 10. Wed.-Sat. 9 a.m.-5 p.m.; Sun. noon-5 p.m. $7 adults, $6 seniors, $5 children 1-11. 300 North St., Harrisburg. 717-787-6778.


Andrew Wyeth: In Retrospect. Cont. through Sept. 17. Treasures on Trial: The Art and Science of Detecting Fakes. Cont. through Jan. 7. Tues.-Sat. 10 a.m.-5 p.m. $20 adults, $18 seniors and students with ID, $5 children 2-11. Guided tour prices begin at $30 for adults, $28 for seniors and $15 for children 8-11. Call for details. 5105 Kennett Pike (Route 52), Winterthur, Del. (For GPS: 5105 Kennett Pike, Wilmington, Del.) 800-448-3883 or 302-888-4600.

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Madonna Turns to This Dermatologist Facial to Help Tighten and Lift – NewBeauty Magazine (blog)09.06.17


A post shared by Madonna (@madonna) on Sep 4, 2017 at 4:39pm PDT

Madonna just turned 59 years old, but the superstar worksvery hard to not look like it. With an ever-evolving look (shes had so manyover the years), one thing has remained a constant, she has always made herskin care a top priority. So much so that she even launched her own skin careline, MDNA (set to be released in the U.S. later this month). When she needs alittle more than at-home treatment, she relies on PFrankMD Skin Salon in NewYork City for a super charged, state-of-the-art facial that employs more thanone skin care technology.

You May Also Like: Madonna’s New Magnetic Mask Is Coming to the U.S. Soon

The OxyLight facial (with a magnetic MDNA mask add-on) isperformed by aesthetician Edyta Jarosz, costs upwards of $600, and consists of theusual facial protocol like cleansing and exfoliating. After the steps found in a traditionalfacial, things start to get next level. Next comes the MDNA magnetic maskadd-on, made from clay sourced directly from Italys Montecatini mountains. The water fromthe clay of Montecatini is said to have healing properties.

Next, the oxygen part comes in, with a big dose of oxygen tohelp infuse serums applied to the skin, it hydrates and helps the skin absorb the productsused. After the pressurized oxygen, the aesthetician then performs a micro-currenttreatment to stimulate facial muscles and tighten skin, followed by an LED light treatment to improve skin tone and texture.

The idea behind the OxyLight treatment is to stimulate cellsto help initiate the production of healthy cells and lift the facial muscles. Sinceits Madonna approved, we can only assume it does exactly what it says it does because wecant imagine the Queen of Pop would have it any other way.

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Un-X-ceptable: 15 Unused Pieces Of X-Men Movie Concept Art – CBR (blog)09.06.17

Marvels merry (and dysfunctional) band of mutants have been a big part of our summer blockbuster lineup since the turn of the century. Since their debut, theyve been through a lot of changes, from costume redesigns. to messy alternate timelines, to Wolverine jumping up the age rating scale. (None of us will ever be the same again after hearing Professor X drop so many F-bombs.) Like any big budget movie series, theX-Menfilms go through lengthy development stages to decide how characters, props and set pieces will look. Sometimes the finished results are impressive even if they deviate from the comics.

RELATED:Suicide Squad: 15 Pieces Of Concept Art (That Would Change Everything)

The futuristicSentinels in Apocalypse, for instance,were about as far from their classic look as possible, but they looked all the more terrifying for it. Sometimes the creatives powers that be manage to translate design elements from page to screen faithfully to great effect. Characters like Mystique and Nightcrawler, who have two of the most distinctive looks in the comics, have remained satisfyingly on point on-screen. But, sometimes seeing what wecouldhave had in the concept art vs. what we actuallygot is a big disappointment. Here is a collection of costumes and character designs from the history of the X-Menmovie series that never made the final cuts.

Its hard to think of a more divisive comic book character redesign for a film than Deadpools in the first solo Wolverine movie. Just to prove the point, the Like bar under the YouTube video that the studio responsible uploaded is almost an even split of Likes and Dislikes. Though Deadpool appeared pretty (unusually) normal-looking in his first appearance, hopes of something comic-accurate were dashed later when a fleshy and muted monstrosity showed up.

Looking through the exhaustive list of 82 alternatives that Studio ADI came up with it looks like we could have gotten something either slightly better or a whole lot worse. But, as the creators note in the videos description: It was our job to satisfy the many creative voices [] Well never satisfy everyone with a design.

How cool is this? Magnetos speedster son wasnt inDays of Future Pastfor very long true to his abilities but his ultra-cool, 70s make-over left a quite an impression on fans both old and new. From looking at concept designer, Henry Fongs artwork for the character not much changed between the conceptual and finished look in the film, right down to Evan Peters shaggy, silvery hair.

Apart from the goggles, the other accessory that caught fans attention was Pietros customized stereobelt, which, as you can see from Henrys wonderfully detailed illustrations, could have looked a lot quirkier. The one we see Quicksilver rocking in the film is a lot slicker with an almost Darth Vader feel to it. The worn, brown leather and stickers in the concept art make it look a lot more home-made.

Though you absolutely cant fault Hugh Jackmans portrayal of Wolverine, its fair to say a lot of liberties were taken when translating the character from page to screen. James Howlett gained several inches in height, learned how to use a comb a bit better, was a lot less stabby, and most notably, wouldnt be caught dead wearing yellow spandex.

Judging from this early concept from concept artist, Tim Flattery you can see that the studio did consider a more faithful version at one time, though. Not only is the character dressed in a costume that very closely resembles his classic one but his hair is much wilder too. More shocking though is the blood dripping from his claws, perhaps indicating a higher age-rating might have been considered as well.

This piece of concept art of the young Jean Grey tells us two big things that nearly happened inApocalypse: one,we nearly got the more colorful costumes carried over from First Class, and two, we nearly got Elle Fanning in the role rather thanGame of ThronesSophie Turner. In fact, for Fox to get as far as commissioning artwork based on Fanning means she must have been very close indeed.

Perhaps the studio thought it couldsave some money on ginger wigs after presumably blowing most of the hair and make-up budget painting Oscar Isaacs blue every day. The art was produced by Allen J. Villanueva in collaboration with long-time X-Mencostume designer, Louise Mingenbach. Allen also produced artwork of Sophie Turner in the same blue and gold suit.

Though the movie versions of the mutant-hunting sentinels didnt bear a huge resemblance to their comic book counterparts (other than a nod to their purple coloring and yellow eyes early on) the futuristic upgrades were satisfyingly terrifying nightmarish monsters to suit a nightmarish possible future. The fact they also looked more like humans than Transformers didnt help either.

This concept art from Maciej Kuciara proves the studio was spoilt for choice with creepy sentinel designs, with some looking blockier than the scaly texture they ended up with. Director Matthew Vaughn said that the scales were not only supposed to resemble Mystique but the robots were originally planned to also borrow from Rogues powers too. Its interesting to think where this aspect could have taken their design.

Yes, according to this piece of atmospheric concept art, Peter Dinklages Bolivar Trask was at one point supposed to make a cameo in the follow-up toDays Of Future Past. In the artwork by illustrator, Bartol Rendulicyou can make out the unmistakable silhouette of Trask disembarking (or possible boarding) a jet with Jennifers Lawrences Mystique aiming a gun at him.

This deleted scene was going to be one of a few set on Strykers base with the mastermind of the sentinel program probably only making a brief appearance. Its not known why the sequence was scrapped but the most likely culprit was probably that the films budget couldnt justify an inconsequential plot detail like this one. Still, it wouldve been a treat for fans to see Dinklage reprise the role.

From other pieces of concept art released after Apocalypsehit theaters, we know that Peter Dinklages Bolivar Trask was, at one point during the development process, going to make a return in Apocalypse.This concept art from Bartol Rendulicfurther cements his involvement, depicting Beast in a pilots helmet labeled asTrasks Plane: Pilots Helmet.

This leaves us with a lot of questions as to what role the antagonist was going to play amongst all the world-ending drama. Did he align himself with Weapon X? Was he a founding member? Or did he work independently to round up the younger mutants? Though it would have been interesting to see the film explore these ideas, they were probably cut so as not to distract from the main plot too much.

It was exciting for comic book fans to see another Summers brother finally introduced to theX-Mencinematic universe in First Class, though the alternate timeline means that Alex is the older brother on screen, taking Scotts canonical place as one of Xaviers original X-Men. Lucas Tills suit inFirst Classwas designed with training wheels the disk on the chest helping to focus his energy blasts while also nodding to the characters comic book costume.

This dramatic piece of concept art from Alex Mandragjiev shows off a possibly more competent version of the character with a darker edge. The circular chest piece is still just about visible and you can also see more armor details lining the suits exterior. Most notably though, hes got that distinctive, blonde hairdohe often sports in the comics.

Banshees appearance inFirst Classwas all too brief, and after it was revealed that hed become one of the many casualties of Trasks war on mutants during Days of Future Past, his role in the movies seems unlikely to be extended for the foreseeable future. This unused concept art produced byAlex Mandragjievgives us a glimpse at a Banshee who looks badass enough to have made it out alive.

Banshee was played by Caleb Landry Jones, whose natural red hair makes him a dead-ringer for the young Sean Cassidy. The only thing missing was the Irish green on his suit, though from this artwork it looks like that was never really considered at any stage of the films development. It may just be the lighting but this Banshees face also bears an uncanny resemblance to his villainous mutant brother, Black Sean Cassidy.

One of the many things that made Logansuch a successful movie was 11-year-old actress, Daftne Keen. Though she had very little to say throughout most of the film, her actions and ferocious facial expressions spoke louder than words ever could. Obviously, her young age only added to the shock of the ultra-violence but early concept art reveals that an older version of Laura was considered, too.

These variant designs from visual effects specialistAaron Sims depict a classically, moody teenage girl with very heavy goth taste leather, miniskirts, eyeliner and excessive belts. Director James Manigold explained he pushed to lower the characters age to avoid the movie feeling, like aCW show [] I wanted to confront Logan with what he was most frightened of, which was the idea of being [] a real Dad. Not to an unruly teenager, but to a child.

Although Jubilee popped up repeatedly in the background of the original trilogy ofX-Menmovies (youd be forgiven for not remembering her), she didnt make her first proper appearance untilApocalypse. Played by Lana Condor, it was great to see Jubilation Lee in all her 80s, pink and yellow glory. But, at one point, the fun-loving mutant was planned to appear before this inDays of Future Past.

This concept art from artist Phillip Boutte Jr. in collaboration with long-timeX-Mencostume designer, Louise Migenbach, depicts a much grittier-looking version of the character with actress Jamie Chung as the model. In the midst of a sentinel war, it makes sense that Jubilee would shed her colorful wardrobe for something more low-key. The headband provides the only reference to her classic costume from the comics.

Hes the Juggernaut, bitch. After Vinnie Jones, uh,interestingperformance as Cain Marko inX-Men 3: The Last Stand, Professor Xs stepbrother has yet to make a return to the film series. But, concept art released afterDays of FuturePasthit cinemasby Anthony Jonesreveals that the rampaging mutant very nearly bulldozed his way back into the franchise.

The artwork uses Vinnie as a model with the costume design very similar to the one he donned inX3. Key alternations like replacing his domed helmet with a red hood and mask are a good compromise between believability and honoring his comic book roots. Apparently, young Juggernaut would have played the role that Quicksilvers character does in aiding Magnetos prison break.

Even with special effectsbeing at the level they are these days, pulling off Emma Frosts diamond skin must still present a challenge for most. In the comics, the effect varies hugely depending on the artist but usually, her organic diamond form resembles something akin to Colossus with a little more sparkle. From this concept art, it looks like artist Jerad S. Marantz had several cracks at it.

The look of Emmas secondary mutation transformation that January Jones sported in the film was perfectly fine, if not a little obvious. She quite literally looked like a cut diamond. These alternate options are a bit more creative and skin-like, with the diamond spikes making it look more clearly like a defense mechanism rather than just a human engagement ring.

To say that the worlds first look at Oscar Isaacs as Apocalypse wasnt a great success would be an understatement. Supervillains are the backbone of superhero stories, so to feature one whose appearance invites laughable comparisons toPower Rangerscharacters and bad cosplay makes a films marketing an uphill struggle from then on to win back credibility.

Many fans felt the ancient mutants looks didnt improve much when the film was released, which just makes this imposing, variant design from concept artist Jerad S. Marantz even more frustrating to see. The armor is far sleeker than the clunky stuff Oscar had to wear, and more disappointingly it proves that Apocalypses distinctive facial features from the comics could have been pulled off in real life.

Storms hair-volution has been getting tantalizingly close to everyones favorite, 80s punk rock look throughout the film series history; from her long locks inX-MenandX2, to her cropped bob inX3, and her pixie-cut inDays of Future Past.Finally, inApocalypse,Alexandra Shipp rocked the mohawk as a younger version of the character.

The only thing she was missing was the other 90% of the look. It was close but no cigar. Annoyingly, this fantastic concept art from Phillip Boutte Jr. and Louise Migenbach shows just how close we were to seeing Storm decked out in all her biker-chick-from-the-future glory. Though theres no mohawk, the addition of the boy toy belt buckle more than makes up for it.

Which of these unused concept art pieces do you wish had ended up in the films? Let us know in the comments!

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Un-X-ceptable: 15 Unused Pieces Of X-Men Movie Concept Art – CBR (blog)

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The Weirdest And Worst Overwatch Fan Art – Geek09.06.17

1. Widowmaker Farting On Tracer

The Overwatch fandom is very serious about its pairings, and sniper Widowmaker and speedy Tracer have been matched up together since day one. Do their bedroom activities involve facefarting? At least one artist seems to think so.

The world of Overwatch is a horny one, with people bringing all sorts of fetishes to bear on the characters. Some of this sex makes sense, while others… well, I can comfortably say that neither Sombra or any of her cohorts have a “being squashed like a steamroller” fetish.

The full title of this masterpiece is “D.VA Cow’d with 8 boobs have trouble to move!!” exclamation marks included. Why exactly this is something that needed to be added to our already ruined universe is still up for discussion, but the artist’s description on DeviantArt involves a “instant 8 tits disable enable can.”

As with all things, Sonic the Hedgehog is present in Overwatch world as well. This insane CGI image introduces him to a furry version of Tracer who is apparently making him very horny.

Let’s get even hedgehog hornier with this mash-up that melds Sonic and Soldier 76, sucking face with “Mercyetta.” I’m not familiar with every single damn animal in the Sonic universe so I don’t know if that’s a fan character or not.

I can’t read Korean so I don’t know if this text explains why Spongebob’s friend Patrick Star has stolen Widowmaker’s clothes. Just one of those meme mysteries.

Yes, very good likeness. Really gets to the core of the character in so many ways.

I could have filled this entire gallery with images of Tracer having her body warped and stretched in dozens of different ways. For some reason Overwatch’s spunky mascot really seems to draw the attention of a wide variety of pervs.

I have a feeling that this image is on levels of memes that I’m not capable of processing. It’s always high noon somewhere, after all.

All those Doritos and cans of Mountain Dew make it difficult to keep a slim figure, but this D.Va is no longer capable of fitting into her mech suit at all. In fact, it’s starting to look like the suit is inside of her.

There’s a whole subgenre of Overwatch art that takes the normally slender Tracer and buffs up her muscles to steroidal levels, often courtesy of Zarya. Why? I have no idea, do I look like a mind reader?

Of all the romantic pairings in the Overwatch universe, we would have never guessed that McCree / Shrek would be a thing. But America’s favorite ogre has a deep and loving heart.

That looks painful. The relationship between butch Zarya and fey Tracer is a ripe one for fan artists, and when the Brit isn’t getting buff she’s the subject of relentless bullying by the big Russian.

We have to give credit to the artist of this image for coming up with a complex tickle torture device that also looks like it could be a ride at a really perverse amusement park. Symemetra doesn’t seem too put out by the whole ordeal though.

To be honest, I can’t even comprehend the level of mysterious perversion it takes to render a morph of Sombra and an umbrella. Like it’s just totally beyond my comprehension.

Mei’s canonical level of thiccness is hotly debated among Overwatch fan artists, but this one decides to just go whole hog with it and have her pumping Tracer full of some mysterious inflating goop as well.

Or we can go the other way with the same general concept and throw a little vore fetish into the mix as well. Tracer doesn’t look too comfortable in there. Maybe she’s cold.

I’ve seen some big diapers in my time on this Earth, but those are really big diapers.

There needs to be a special word for foot fetish art where the creator really takes a lot of time to determine the different shapes, toe angles and skin tones for each character. Otherwise their fans won’t take them seriously!

Bees? Bees.

The Weirdest And Worst Overwatch Fan Art – Geek

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