Assessing the Feasibility of an Alternative Payment Model for Mohs Micrographic Surgery at an Academic Center.

BACKGROUND: Mohs micrographic surgery (MMS) is a cost-effective treatment for nonmelanoma skin cancer that bundles costs for surgical excision, tissue processing, and histopathological interpretation. A comprehensive MMS bundle would include all aspects of an episode of care (EOC), including costs of reconstruction, preoperative, and postoperative care. OBJECTIVE: To assess the feasibility of an alternative payment model for MMS and reconstruction. METHODS: Retrospective chart review and payment analysis for 848 consecutive patients with 1,056 tumors treated with MMS. Average Medicare payment of an EOC was compared with bundles based on specific repair types. RESULTS: The bundle for a flap/graft repair averaged $1,028.08 (confidence interval [CI] 95% $951.37-1,104.79), whereas the bundle for a linear closure (LC) averaged $585.07 (CI 95% $558.75-611.38). The average bundle including all repairs was $730.05 (CI 95% $692.31-767.79), which was statistically significant from both the flap/graft and LC bundles. CONCLUSION: Bundling surgical repairs with MMS based on an average payment does not represent the heterogeneity of the care provided and results in either underpayment or overpayment for a substantial portion of cases. Consequently, EOC payments bundling MMS and surgical repairs would inaccurately reimburse physicians for work completed. Current payment methodology allows for accurate payment for this already cost-effective therapy.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery.

BACKGROUND: Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS). OBJECTIVE: We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS. MATERIALS AND METHODS: A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls. RESULTS: Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure. CONCLUSION: This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

Painful schwannoma of scalp: A case report.

Schwannoma, also known as neurilemmoma, is a benign neoplasm of Schwann cells of the cranial or peripheral nerve sheath. Scalp involvement has been reported in 25% of patients with extracranial head and neck schwannomas, which can be misdiagnosed clinically as epidermal cyst or lipoma. In this article, we report a 32-year-old male presenting with a slow-growing painful subcutaneous mass on the left occipital scalps without any neurological symptoms. Pathological findings confirmed the diagnosis of schwannoma, and surgical removal resulted in the resolution of pain and lack of recurrence.

Upper Lip Anatomy, Mechanics of Local Flaps, and Considerations for Reconstruction.

Reconstruction of defects involving the upper lip can be challenging. The purpose of this review was to analyze the anatomy and function of the upper lip and provide an approach for reconstruction of upper lip defects. The primary role of the upper lip is coverage of dentition and animation, whereas the lower lip is critical for oral competence, speech, and eating. The orbicularis oris (OO) and several other muscles contribute to upper lip function. There are various insertion points for animation muscles, including the upper lip dermis, OO, and modiolus. Special attention should be paid to the philtrum, Cupid's bow, and vermilion border during reconstruction. Advantages and disadvantages of the Abbe, Estlander, and Karapandzic flaps are presented. Knowledge of mechanics, indications, and properties of local flaps while considering unique characteristics of upper lip anatomy and function are crucial for optimal aesthetic and functional outcomes.

Z-plasty for correction of standing cutaneous deformity.

Cutaneous head and neck reconstruction following Mohs micrographic surgery frequently presents the surgical dilemma of dog-ear formation during wound closure. Z-plasty corrects a dog-ear deformity without skin excision by recruiting tissue from the axis of the standing cone and redistributing it along another. We describe dog-ear correction using the Z-plasty technique.

Effect of Platelet-Rich Plasma Injection for Rejuvenation of Photoaged Facial Skin: A Randomized Clinical Trial.

Importance: There remains little experimental evidence and no randomized clinical trial to date to confirm the benefit of platelet-rich plasma (PRP) for facial rejuvenation. Objective: To investigate whether PRP injection improves the visual appearance, including texture and color, of photodamaged facial skin. Design, Setting, and Participants: In this randomized clinical trial, participants and raters were masked to groupings. The setting was an academic-based, urban outpatient dermatology practice in Chicago, Illinois. Participants were adults aged 18 to 70 years with bilateral cheek rhytids of Glogau class II or greater. The duration of the study was August 21, 2012, to February 16, 2016. Interventions: Each participant received 3 mL intradermal injections of PRP to one cheek and sterile normal saline to the contralateral cheek. Main Outcomes and Measures: Primary outcomes were photoaging scores (with subscores for fine lines, mottled pigmentation, roughness, and sallowness) as rated by 2 masked dermatologists. Secondary outcomes included participant self-assessment scores of improvement on a 5-point scale (worsening, no change, mild improvement, moderate improvement, or significant improvement), participant overall satisfaction scores on a 4-point scale (not satisfied, slightly satisfied, moderately satisfied, or very satisfied), and participant-reported or investigator-observed adverse events. Results: Of 27 enrolled participants, 19 (mean [SD] age, 46.37 [10.88] years; 17 female) were analyzed. Reported adverse events, which were not associated with the study agent, included redness (n = 18), swelling (n = 16), bruising (n = 14), pruritus (n = 1), skin scaling (n = 1), and dryness of skin (n = 1). No participants reported any adverse events at 12 months. Mean (SD) photoaging scores rated by 2 dermatologists showed no significant difference between PRP and normal saline for fine lines (baseline, 1.00 [0.75] vs 1.05 [0.78]; 2 weeks, 0.95 [0.71] vs 0.95 [0.71]; 3 months, 0.95 [0.71] vs 0.95 [0.71]; 6 months, 0.95 [0.71] vs 0.95 [0.71]), mottled pigmentation (baseline, 1.21 [0.53] vs 1.21 [0.54]; 2 weeks, 1.16 [0.60] vs 1.16 [0.60]; 3 months, 1.00 [0.47] vs 1.11 [0.46]; 6 months, 1.16 [0.69] vs 1.16 [0.69]), skin roughness (baseline, 0.47 [0.61] vs 0.47 [0.61]; 2 weeks, 0.47 [0.61] vs 0.47 [0.61]; 3 months, 0.47 [0.61] vs 0.47 [0.61]; 6 months, 0.37 [0.60] vs 0.37 [0.68]), and skin sallowness (baseline, 1.11 [0.88] vs 1.11 [0.88]; 2 weeks, 0.95 [0.85] vs 0.95 [0.85]; 3 months, 0.58 [0.61] vs 0.58 [0.61]; 6 months, 0.37 [0.68] vs 0.37 [0.68]). At 6 months after a single treatment, participants rated the PRP-treated side as significantly more improved compared with normal saline for texture (mean [SD] self-assessment score, 2.00 [1.20] vs 1.21 [0.54]; P = .02) and wrinkles (mean [SD] self-assessment score, 1.74 [0.99] vs 1.21 [0.54]; P = .03). Conclusions and Relevance: Masked participants noted that both fine and coarse texture improved significantly more with a single treatment of PRP than with normal saline. Both participants and raters found PRP to be nominally but not significantly superior to normal saline. Trial Registration: ClinicalTrials.gov Identifier: NCT01372566.

Hepatotoxicity with Vismodegib: An MD Anderson Cancer Center and Research on Adverse Drug Events and Reports Project.

BACKGROUND: On 30 January 2012, the US FDA approved vismodegib (Erivedge®, Genentech, CA, USA) for the management of both metastatic and locally advanced basal cell carcinoma. OBJECTIVE: Our objective was to identify evidence of hepatotoxicity with vismodegib in the FDA Adverse Event Reporting System (FAERS) in treated patients in two National Cancer Institute Comprehensive Cancer Centers. METHODS: FAERS was searched for reports dated 1 January 2009 through 31 December 2015 using terms including hedgehog pathway and vismodegib and hepatic-related terms such as liver, jaundice, and hepatitis, among others. Disproportionality analyses with estimates of proportional reporting ratio and empirical Bayesian geometric mean were conducted. A comprehensive literature review was conducted, and the clinical databases at the University of Texas MD Anderson Cancer Center and Robert H. Lurie Comprehensive Cancer Center of Northwestern University were searched. RESULTS: Two cases of severe liver dysfunction were published (Common Terminology Criteria for Adverse Events [CTCAE] class III), and 94 reports of adverse events (AEs) were detected in FAERS, 35 of which were serious AEs. Safety notifications related to hepatotoxicity have not been issued by the manufacturer or the FDA, although vismodegib is listed in LiverTox and the European Medicines Agency website. CONCLUSION: We identified a detectable safety signal for hepatotoxicity for vismodegib within 4 years of FDA approval. Vismodegib should be used in patients with severe liver disease only after careful consideration, and concomitant hepatotoxic medications should be avoided. Rapid dissemination of such safety concerns is expected to result in fewer serious hepatotoxic AEs and more optimal outcomes for patients with cancer receiving vismodegib.

Surgical biopsy of suspected interstitial lung disease is superior to radiographic diagnosis.

BACKGROUND: Different modalities are used to diagnose interstitial lung disease. We compared the effectiveness of minimally invasive surgical biopsy versus high-resolution computed tomography for the diagnosis of interstitial lung disease and report the mortality of the procedure. METHODS: We reviewed 194 patients undergoing video-assisted thoracoscopic lung biopsies for the suspicion of interstitial lung disease from January 2003 to February 2012 at Emory University. Demographics and patient characteristics were analyzed in addition to final diagnoses and clinical outcomes. RESULTS: Concordance of radiographic diagnosis with final diagnosis was poor, matching pathologic diagnosis in 15% of cases, and specific diagnoses were included in the radiographic differential in only 34% of cases. A specific diagnosis was made after surgical biopsy in 88% of cases. Overall mortality of surgical biopsy was 6.7% (13/194). Major risk factors for death were preoperative supplemental oxygen, ventilator dependence, and age (p < 0.0001, p < 0.0001, and p = 0.03, respectively). Among patients with ventilator dependence preoperatively, the mortality rate was 100% versus 4.8% in patients not ventilator dependent. All biopsy specimens were concordant 91% of the time, and the first two biopsy specimens were concordant 96% of the time. CONCLUSIONS: Surgical biopsy should remain the gold standard for diagnosis of interstitial lung disease. The mortality is low with proper patient selection. More than two surgical biopsy specimens may not be needed because the concordance rates among pathologic specimens are very high.

Assessment of zonal perfusion using intraoperative angiography during abdominal flap breast reconstruction.

BACKGROUND: There is an ongoing debate about the reliability of various lower abdominal flaps for breast reconstruction. The authors evaluate in vivo perfusion of these flaps to objectively determine which techniques and which skin island zones had better perfusion. METHODS: A prospective study was performed on 77 single-pedicle breast reconstructions [pedicled transverse rectus abdominis muscle (TRAM), n = 22; muscle-sparing free TRAM, n = 37; deep inferior epigastric perforator (DIEP), n = 18]. Perfusion was measured intraoperatively using indocyanine green angiography following flap harvest and before transfer. Flow quantification was performed at 12 standardized data points in each of the four zones of the skin island. Patient risk factors for flap ischemia were assessed, perfusion was quantified, and comparisons were made between the various flaps and between zones. RESULTS: Mean perfusion was significantly higher in the 37 free muscle-sparing flaps (24.9) and the 18 DIEP flaps (21.8) when compared with the 22 pedicled TRAM flaps (19.6) (p < 0.001). Zones I and IV had significantly higher and lower perfusion, respectively (28.4 versus 13.9), when compared with the other zones. There was no significant difference in perfusion between zones II and III (20.6 versus 21.6). Differences in flap flow were significant (p < 0.001) independent of zonal differences. CONCLUSIONS: The authors demonstrated objectively that lower abdominal free flaps based on the inferior epigastric system have better perfusion when compared with pedicled TRAM flaps. There is no appreciable difference in perfusion between zones II and III; however, it is likely related to the perforator location and dominance. Clinical correlation between these absolute perfusion values and flap viability is required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.