Urgent safety considerations for dermatologic surgeons in the COVID-19 pandemic.

Dermatologic surgeons are at increased risk of contracting SARS-COV-2. At time of writing, there is no published standard for the role of pre-operative testing or the use of smoke evacuators, and personal protective equipment (PPE) in dermatologic surgery. Risks and safety measures in otolaryngology, plastic surgery, and ophthalmology are discussed. In Mohs surgery, cases involving nasal or oral mucosa are highest risk for SARS-COV-2 transmission; pre-operative testing and N95 masks should be urgently prioritized for these cases. Other key safety recommendations include strict control of patient droplets and expanded pre-clinic screening. Dermatologic surgeons are encouraged to advocate for appropriate pre-operative tests, smoke evacuators, and PPE. Future directions would include national consensus guidelines with continued refinement of safety protocols.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions.

BACKGROUND: In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality. OBJECTIVE: The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures. MATERIALS AND METHODS: An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures. RESULTS: Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements. CONCLUSION: Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.

Validity of skin cancer malignancy reporting to the Organ Procurement Transplant Network: A cohort study.

BACKGROUND: The Organ Procurement Transplant Network (OPTN) registry collects data on posttransplant malignancies in solid organ transplant recipients. Complete and accurate registry data on skin cancer is critical for research on epidemiology and interventions. OBJECTIVE: The study goal was to determine the validity of Organ Procurement Transplant Network skin cancer data. METHODS: This cohort study compared reporting of posttransplant squamous cell carcinoma (SCC) and malignant melanoma (MM) in OPTN to medical-record review-derived data from the Transplant Skin Cancer Network (TSCN) database. In total, 4934 organ transplant recipients from the TSCN database were linked to patient-level OPTN malignancy data. We calculated sensitivity, specificity, correct classification (CC), positive predictive value (PPV), and negative predictive value (NPV) for SCC and MM reporting in the OPTN database. RESULTS: OPTN reporting for SCC (population prevalence 11%) had sensitivity 41%, specificity 99%, PPV 88%, NPV 93%, and CC 93%. OPTN reporting for MM (population prevalence 1%) had sensitivity 22%, specificity 100%, PPV 73%, NPV 99%, and CC 99%. LIMITATIONS: Only a subset of patients in the TSCN cohort had matched United Network for Organ Sharing cancer registry data for comparison. CONCLUSION: OPTN reporting had poor sensitivity but excellent specificity for SCC and MM. Dermatologists and transplant physicians are encouraged to improve the validity of OPTN skin cancer data through improved communication and reporting.

Complications of hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent painful nodules and abscesses involving intertriginous areas. Repeated episodes of profound inflammation in HS can lead to a number of complications, causing significant morbidity and decreasing quality of life. Complications of HS may affect the skin alone or may have systemic impact. Cutaneous complications of HS include sinus tracts, fistulae, scarring and contractures, squamous cell carcinoma, and lymphedema. Systemic complications of HS include chronic pain, systemic amyloidosis, and possibly anemia. Preventing disease complications by controlling primary disease is a key component of HS management. Clinicians should be prepared to recognize complications early, as prompt management is necessary to minimize negative impacts.

Customized bilaminar resorbable mesh with BMP-2 promotes cranial bone defect healing.

BACKGROUND: For repair of cranial vault (skull) defects, alloplastic (methylmethacrylate or titanium mesh) techniques may result in nonhealing or infectious complications and autogenous (split rib or calvarial) techniques may result in excessive blood loss or donor-site morbidity. Osteogenic factors such as bone morphogenetic protein-2 (BMP-2) provide promising alternatives for repairing bone defects. As a new option for this reconstructive challenge, we investigated by using a bilaminar resorbable construct made from computer-aided design and computer-aided manufacturing computed tomographic scan technology with BMP-2 in hopes of providing initial structural support for the skull, followed by bone healing without permanent foreign body problems. METHODS: Outcomes of consecutive adult patients with long-standing critical-sized cranial vault defects who underwent cranial vault reconstruction between 1999 and 2010 were studied (n = 69). Reconstructive options were titanium mesh, cryopreserved bone, patient-specific implants, autogenous (split calvarial), and a new bilaminar resorbable mesh construct sandwiched with BMP-2. These reconstructive options were compared for operating room time, blood loss, complications, reoperations, and bone healing (3-dimensional computed tomographic scans). RESULTS: Defects in the group were similar, 92 cm (60-176 cm). The autogenous bone group had the longest operating room time (1.1 times longer than the BMP-2 construct group) and the greatest blood loss (1.5 times more than the BMP-2 construct group). Perioperative complications and reoperation rates were lower in autogenous bone (5%) and BMP-2 construct groups (14%) when compared with alloplastic groups (22%-36%). Bone healing was superior with BMP-2 construct and autogenous bone (85%; 90%) versus cryopreserved bone (18%) and minimal healing for alloplastic. CONCLUSIONS: In select cases, a customized bilaminar resorbable construct with BMP-2 resulted in improved bone healing with fewer complications than alloplastic options and without the morbidity and blood loss associated with autogenous bone grafting. This allowed critically sized calvarial defects in adults to be successfully corrected with no residual foreign body.

Giant cranial osteoma: successful staged excision of the largest reported.

Craniofacial osteomas are benign, slow-growing neoplasms of the craniofacial region that are usually asymptomatic. Uncommonly, giant craniofacial osteomas may be symptomatic and cause serious morbidity including ophthalmologic problems, cerebral compression, pneumocephalus, and seizures. We present a case of a 15-year-old Asian adolescent girl with a giant cranial osteoma (17.5 × 13.2 × 5 cm: significantly larger than previously reported). She also had multiple other synchronous giant osteomas of the face causing facial asymmetry. These osteomas were resected in a multiple-staged approach with a good aesthetic and functional outcome.

Asymmetric class III malocclusion: association with cranial base deformation and occult torticollis.

The etiology of Angle class III malocclusion with facial asymmetry has not been fully elucidated. To investigate the etiology, patients with asymmetric prognathism (n = 30) from a single institution were assessed for previously undiagnosed torticollis and cranial base asymmetry. Presence of torticollis was determined by measuring restricted head movement when turning the head against a wall and cranial base tilt with upward gaze. Cranial base asymmetry was evaluated by preoperative three-dimensional computed tomography scans. Thirty-one percent of patients with prognathism presented with concurrent facial asymmetry. In patients with asymmetric prognathism, cranial base tilt was present on upward gaze in all patients; mean angle between head and wall was 31 degrees greater than that in control patients, and a 22% to 36% difference in the angle was present when comparing one side with the other. Based on these findings, all patients with asymmetric prognathism were found to be affected by torticollis. By computed tomography scan, 85% of these torticollis patients showed slight anteromedial displacement of the glenoid fossa ipsilateral to torticollis, and 73% demonstrated temporal fossa shift of 4 mm or greater. The current study demonstrates a strong association between asymmetric class III malocclusion, torticollis, and cranial base asymmetry. We conclude that undiagnosed torticollis is a likely etiology for otherwise idiopathic cranial base asymmetry and that cranial base asymmetry in turn causes facial asymmetry and malocclusion. This study highlights the importance of evaluating cranial base asymmetry and torticollis in patients with class III malocclusion to allow for earlier treatment and improved outcomes.

Mohs Micrographic Surgery in the Veterans Health Administration.

Veterans with skin cancer have seen improved access to Mohs micrographic surgery over the past 10 years, yet the challenges of travel distance and care coordination remain.

The h-index for associate and full professors of dermatology in the United States: an epidemiologic study of scholastic production.

Promotion in academic dermatology requires evidence of scholastic production. The h-index is a bibliometric measure that combines both volume and impact of scientific contributions. Its calculation better predicts future scientific success than do publication or citation counts. In this epidemiologic survey of associate and full professors of dermatology in residency training programs in the United States, we measured mean and median h-indices among associate and full professors as well as regional differences in h-index. These findings could be used to track individual achievement and as a parameter in considering an individual for professional advancement in dermatology.

Fibrous dysplasia of the zygomaticomaxillary region: outcomes of surgical intervention.

BACKGROUND: Fibrous dysplasia is the most common craniofacial tumor, presenting in both monostotic and polyostotic forms with varying degrees of severity. No consensus exists regarding the surgical management of craniofacial fibrous dysplasia, particularly in the zygomaticomaxillary region. The present study compared long-term outcomes of limited reduction burring versus radical resection of zygomaticomaxillary fibrous dysplasia. METHODS: Patients with craniofacial fibrous dysplasia at the University of California, Los Angeles, Craniofacial Center from 1982 to 2008 were studied based on demographics, treatment, and follow-up data, including examinations, computed tomographic scans, photographs, physician Whitaker scoring, and patient surveys (n=97). Outcomes were compared for zygomaticomaxillary disease treated with radical resection with cranial bone graft reconstruction or limited reduction burring (n=58). RESULTS: Thirty-four percent of patients had monostotic disease, 66 percent had polyostotic disease, 3 percent had McCune-Albright syndrome, and 2.1 percent had malignant degeneration into osteosarcoma. Most patients had surgical treatment (84.5 percent). Of the patients that required optic nerve decompression for vision changes (11.4 percent), most (75 percent) had vision stabilization postoperatively. Differences were recorded in zygomaticomaxillary disease treated with radical resection (63.8 percent) versus reduction burring (36.2 percent) according to age (19.6 versus 14.2 years), complications (13.5 percent versus 4.8 percent), recurrence (66.7 percent versus 24.3 percent), and number of subsequent procedures (2.8 versus 4.0). There were similarities in Whitaker outcome score (1.3±0.3 versus 1.5±0.6) and patient satisfaction (2.7±0.4 versus 2.8±0.3). CONCLUSIONS: Although different approaches have been advocated to treat fibrous dysplasia, the authors' data support a more aggressive management for zygomaticomaxillary disease with radical resection and cranial bone graft reconstruction, especially for more involved disease. CLINICAL QUESTION OF EVIDENCE: Therapeutic, III.