Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Prospective study to assess the efficacy and safety of a noninvasive electro-muscular stimulation for improvement of muscle strength and muscle toning of the extremities.

OBJECTIVE: We sought to evaluate the safety and efficacy of an electrical muscle stimulation (EMS) device in the improvement of muscle strength and toning of the upper extremities. This device, which is FDA-cleared as a two-channel muscle stimulator, provides up to eight electrodes with waveforms inducing muscle stimulation. Although a prior study demonstrated it is safe and effective for use in the abdomen, this system, which has electrodes specifically designed for the extremities, has not previously been evaluated in the upper extremities. METHODS: Forty-five subjects enrolled in the study to assess improvement in arm (i.e., bicep and tricep muscle) strength, and appearance following a protocol of treatments with this bioelectric muscle activation (BMA) device. All subjects received four 30-min EMS treatment sessions in Arm mode-twice weekly for 2 weeks and at least 48 h apart. Follow up visits were also scheduled 30- and 90-days after treatment. Strength was measured with a dynamometer device at baseline, at the final treatment session, and at the posttreatment 30- and 90-day assessment. Subject satisfaction was assessed gauging overall comfort of the treatment and satisfaction including willingness to recommend to others. The changes in strength between initial treatment and final treatment, as well as 30 and 90-day assessment were evaluated. Clinical photography at these visits was also assessed for each patient. Patients were instructed to not modify their normal exercise routine while participating in this study. RESULTS: All 45 subjects completed the treatment protocol. Most patients showed an improvement in muscle strength from the initial to final treatment (i.e., the fourth treatment). Specifically, the maximum bicep strength increased by a mean of 7.5 lbs (22.83%, p = 0.006), while the average increased by a mean of 8.2 lbs (25.76%, p = 0.001) during this period. Similarly, the maximum tricep strength from initial to final treatment increased by a mean of 10.0 lbs (23.16%, p = 0.000), while the average increased by a mean of 9.6 lbs (27.12%, p = 0.000). Thirty days after the last treatment, the maximum bicep strength increased by a mean of 13.3 lbs (34.13%, p = 0.001) while the average increased by a mean of 13.6 lbs (37.05%, p = 0.000) during this period. Similarly, the maximum tricep strength from initial to 30 days postfinal treatment increased by a mean of 10.9 lbs (24.37%, p = 0.000), while the average increased by a mean of 10.5 lbs (29.37%, p = 0.000). Finally, 90 days after the last treatment, the maximum bicep strength increased by a mean of 19.4 lbs (48.4%, p = 0.000), while the average increased by a mean of 17.4 lbs (46.53%, p = 0.000) during this period. Similarly, the maximum tricep strength from initial to 90 days postfinal treatment increased by a mean of 10.8 lbs (27.12%, p = 0.000), while the average increased by a mean of 10.0 lbs (30.94%, p = 0.001). CONCLUSION: This device was well tolerated and resulted in increased strength measurements in the upper extremities, as assessed by a dynamometer, which were sustained at 30 and 90 days.

Safety and Efficacy of a Novel, Variable-Sequenced, Long-Pulsed, 532-nm and 1,064-nm Laser With Cryogen Spray Cooling for Pigmented and Vascular Lesions.

BACKGROUND: Patients frequently seek treatment for vascular and pigmented lesions. More recently, a novel, variable-sequenced, long-pulsed, 532-nm and 1,064-nm laser with cryogen spray cooling was developed to offer greater flexibility in treatments. OBJECTIVE: A prospective clinical trial evaluated the safety and efficacy of a novel, variable-sequenced, long-pulsed, 532-nm and 1,064-nm laser with cryogen spray cooling (DermaV, Lutronic, South Korea). MATERIALS AND METHODS: Subjects with vascular and/or pigmented lesions were enrolled and underwent laser treatments. RESULTS: Twenty-three subjects were enrolled with vascular lesions (39.1%), pigmented lesions (17.4%), and both (43.5%). Mean age was 53.1 years, and 91.3% were women. Fitzpatrick skin types II-IV were included. All subjects were treated with 532 nm, and 4 were also treated with 1,064 nm. According to 4 blinded physician reviewers, correct before and after photographs were selected in 94.7%, 92.1%, 84.2%, and 76.3% of cases. Overall, 86.8% were responders, meaning that at least 3 of 4 reviewers agreed. For Global Aesthetic Improvement Scale, improvement occurred in 81.6%, 81.6%, 81.6%, and 76.3% of cases. No serious adverse events occurred. Overall, 87.0% of subjects reported being very satisfied or satisfied. CONCLUSION: A novel, variable-sequenced, long-pulsed, 532-nm and 1,064-nm laser with cryogen spray cooling can safely and effectively improve vascular and pigmented lesions.

Evidence-Based Clinical Practice Guidelines for Laser-Assisted Drug Delivery.

Importance: Laser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD. Objective: To develop recommendations for the safe and effective use of LADD. Evidence Review: A systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved. Findings: Of the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline's 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections. Conclusions and Relevance: This systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.

Expertise in Head and Neck Cutaneous Reconstructive Surgery.

BACKGROUND: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature. OBJECTIVE: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature. METHODS: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors. RESULTS: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%). CONCLUSION: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

Long-term clinical evaluation of hair clearance in darkly pigmented individuals using a novel diode1060 nm wavelength with multiple treatment handpieces: A prospective analysis with modeling and histological findings.

OBJECTIVE: The purpose of this study was to determine the efficacy and safety of a 1060 nm diode laser system with multiple handpieces for permanent hair reduction. STUDY DESIGN: An open-label, prospective, multi-center study of adult subjects (≥18 years old) of any skin type, having dark brown or black hairs at the areas to be treated and seeking to permanently remove hair underwent six treatment sessions, at 4 to 6 weeks intervals with either a 1060 nm chilled sapphire tip or seven treatment sessions, at 6 weeks interval with a large spot vacuum based handpiece. METHODS: Subjects received treatments on various body areas using chilled sapphire tip or large spot size vacuum-assisted handpiece. Hair counts as well as assessments of hair coarseness and color were performed using photographs taken at baseline, prior to pre-selected treatments and at the follow up visits. At every visit, immediate skin responses and adverse events were evaluated by the investigator and treatment associated pain level experienced was quantified by the subjects. Subjects were asked to assess their improvement and satisfaction at pre-selected treatment sessions and at all the follow up visits. A sub group of subjects that were treated with the large spot size vacuum-assisted handpiece contributed two punch biopsy specimens for histological analysis. RESULTS: A total of 16 subjects age 33 ± 10.9 years were treated with the chilled sapphire tip, and 26 subjects age 36.3 ± 7.67 years were treated with the large spot size vacuum-assisted handpiece. Treatment with chilled sapphire tip yielded a mean of 68%, 82%, and 76% skin type-independent hair reduction in axillae, shin, and arm, respectively, at 6 month follow up visit as compared to baseline. The majority of subjects (≥80%) rated their hair reduction to be either good or very good and were satisfied to highly satisfied with the outcome. Treatment with the large spot size vacuum-assisted handpiece, was most effective in axillae and calves, with a 77.9% and 78.5% hair count reduction, respectively, at the 6 month follow up visit. Subjects reported high satisfaction and improvement throughout the treatments and follow-up periods. Treatments with both handpieces were not associated with intolerable pain levels and common post procedural responses included mild to moderate erythema and/or edema. CONCLUSION: The 1060 nm diode laser system is safe and effective for hair removal and long-term hair reduction in all skin types including darkly pigmented individuals. Lasers Surg. Med. 50:893-901, 2018. © 2018 Wiley Periodicals, Inc.

Long-term Comparison of a Large Spot Vacuum Assisted Handpiece vs the Small Spot Size Traditional Handpiece of the 800 nm Diode Laser.

BACKGROUND The 800 nm long-pulsed diode laser machine is safe and effective for permanent hair reduction. Traditionally, most long-pulsed diode lasers used for hair removal had a relatively small spot size. Recently, a long-pulsed diode laser with a large spot size and vacuum assisted suction handpiece was introduced. The treatment parameters of each type of handpiece differ. Short and long-term clinical efficacy, treatment associated pain, and patient satisfaction are important factors to be considered. OBJECTIVE: This study aims to conduct a direct head to head comparison of both handpieces of the 800nm long-pulsed diode laser by evaluating long term hair reduction, treatment associated pain and patient satisfaction. METHODS: Thirteen subjects were enrolled in this prospective, self-controlled, single-center study of axillary laser hair removal. The study involved 4 treatments using a long pulsed diode laser with a large spot size HS handpiece (single pass), HS handpiece (double pass), and a small spot size ET handpiece according to a randomized choice. The treatment sessions were done at 4-8 week intervals with follow up visits taken at 6 and 12 months after the last treatment session. Hair clearance and thickness analysis were assessed using macro hair count photographs taken at baseline visit, at each treatment session visit and at follow up visits. Other factors including pain, treatment duration, and patients' preference were secondary study endpoints. RESULTS: At 6 months follow up visits after receiving four laser treatments, there was statistically significant hair clearance in the three treatment arms with 66.1 % mean percentage hair reduction with the ET handpiece, 43.6% with the HSS (single pass) and 64.1 % with the HSD (double). However, at one year follow up, the results significantly varied from the 6 months follow up. The mean percentage hair reduction was 57.8% with the ET handpiece treated axillas (n=9), 16.5% with the HSS (single pass) handpiece treated axillas (n=7), and 46.9% with the HSD (double pass) handpiece treated axillas (n=6). Thus, at one year follow up, there was a significant hair reduction that was similar in both the ET and HSD treated axillae (57.8% and 46.9 %), but only minimal hair reduction (16.5%)was observed in the HSS treated axillae. CONCLUSIONS: This is the first study that compared the long-term efficacy of the ET and HS handpieces after four treatment sessions with up to 12 months follow up after the last treatment session. It is also the first study that provided head to head comparison between HS (double pass), HS (single pass), and ET handpiece taking into consideration the end hair reduction result, the time consumed, the pain score experienced, and the overall patient satisfaction. HSD had better hair clearance and patient satisfaction when compared to ET and HSS. The long term follow up results showed that ET was superior to HSS (P less than .05), but was not superior to HSD (P greater than 0.05). However, HSD treated patients had lower pain scores with HSD than with ET. We conclude that ET handpiece is almost as efficacious as HSD handpiece, and the desired end results could be achieved with HDD with better patient satisfaction, less treatment duration and less pain.

J Drugs Dermatol. 2017;16(9):893-898.

ASDS Cosmetic Dermatologic Surgery Fellowship Milestones.

BACKGROUND: The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE: To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS: An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS: Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION: Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

Who are the Pioneers? A Critical Analysis of Innovation and Expertise in Cutaneous Noninvasive and Minimally Invasive Cosmetic and Surgical Procedures.

BACKGROUND: Few studies illustrate the contributions made by various specialties in pioneering commonly performed noninvasive and minimally invasive cosmetic and surgical procedures. OBJECTIVE: To evaluate the contributions made by various specialties in pioneering noninvasive and minimally invasive cosmetic and surgical procedures. MATERIALS AND METHODS: Key words using the Medical Search Headings Database were used to query in the Thomson Reuters Web of Science Database. The 25 most highly cited studies were sorted according to the citation number. The author specialty was identified and assigned scores based on the number of citations. RESULTS: Dermatology was identified as the specialty with the greatest contribution to botulinum toxin treatments for rhytides, injectable fillers, laser treatments, chemical peels, and noninvasive body contouring. Neurology was identified as the leading specialty in botulinum toxin treatments for hyperhidrosis, and vascular surgery was identified as leading specialty in sclerotherapy. Plastic surgery was identified as having made the greatest contribution to hair transplantation, and liposuction. CONCLUSION: Dermatology was identified as the leading specialty for the majority of noninvasive and minimally invasive cosmetic procedures. Other specialties have also contributed important literature to this area.

Multi-Center Pilot Study to Evaluate the Safety Profile of High Energy Fractionated Radiofrequency With Insulated Microneedles to Multiple Levels of the Dermis.

In this multi-center pilot study, the safety pro le of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for safety in the treatment of the aging neck and face. A newly designed insulated microneedle system delivers a signi cant coagulative thermal injury into the dermis while sparing the epidermis from RF injury. Thirty- ve healthy subjects from seven aesthetic practices were evaluated, and data from each were incorporated in this case report. The subjects received a single treatment using settings that delivered the highest RF energies suggested from the new recommended protocols. The depth of thermal delivery was adjusted before each pass and all subjects received a minimum of two to three passes to the treated areas. Before and after photographs along with adverse effects were recorded. This case report demonstrates the ability to deliver significant RF thermal injury to several layers of the dermis with insulated microneedles safely with little injury to the epidermis and minimum downtime.

Treatment of Acne Scars With High Intensity Focused Radio Frequency.

In this multi-site case series, the efficacy of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for treating acne scars. A novel delivery system that uses insulated microneedles to deliver a desired thermal effect to multiple depths of the dermis while sparing the epidermis from RF injury was used. Four (4) healthy subjects from four different practices were evaluated and used in this case report. The subjects were treated between 3 or 4 times depending on the severity of the acne scars presented. The depth of thermal delivery was adjusted before each pass and all subjects received at a minimum, three passes to the treated area. Before and after photographs along with adverse effects were recorded. The theory behind the use of insulated needles with the active RF delivery at the distal tip is to allow for significant thermal injury to several layers of the dermis while avoiding thermal injury to the epidermis. This case report demonstrates significant improvement on acne scars and that all skin types should be safely treatable with minimum downtime realized.

Does class attendance matter? Results from a second-year medical school dermatology cohort study.

BACKGROUND: Little is known about the impacts of class attendance and learning preferences on academic performance in dermatology. OBJECTIVES: This study was designed to examine the effects of medical student class attendance and learning preferences on students' academic performance in an introductory dermatology course. METHODS: A total of 101 second-year medical students enrolled in a required introductory dermatology course were surveyed regarding their learning preferences. Records of class attendance and scores on the final examination were reviewed. RESULTS: The most frequently cited reason for attending classes was social expectation (96%), whereas the least cited was learning well in a classroom-type setting (65%). The top reasons cited by students for not attending classes were availability of lectures online (35%), preference for individual study outside the classroom setting (26%), and the inconvenience of traveling to class (24%). Multivariate analysis found no statistically significant relationship between class attendance and performance on the final examination (estimate -0.074, standard error 0.12; P = 0.54) after adjusting for sex, age, Medical College Admission Test (MCAT) score, having children at home, and reason for attending class. Those who prefer to learn by watching online videos scored significantly higher on the final examination (prefer online videos: 87 ± 5.5; neutral: 86 ± 5.9; do not prefer online videos: 82 ± 2.6 [P = 0.049]). CONCLUSIONS: Class attendance was not associated with improved academic performance in a dermatology course. Those who preferred to learn by watching online videos demonstrated a higher level of performance than those who did not prefer to learn this way.

Medical professional liability claims for Mohs micrographic surgery from 1989 to 2011.

IMPORTANCE: Few studies specifically address lawsuits involving Mohs surgery. OBJECTIVE: To better characterize the types of medical professional liability claims involving Mohs surgery. DESIGN, SETTING, AND PARTICIPANTS: Retrospective legal document review of an online national database. Any legal proceeding involving the search words Mohs and cancer was included. MAIN OUTCOMES AND MEASURES: Number of medical professional liability claims involving Mohs surgery for factors including year of litigation, location, physician specialty, injury sustained, cause of legal action, and verdict. RESULTS: Forty-two cases were identified, which occurred from 1989 to 2011. Of the cases identified, 26 involved non-Mohs surgeons as the primary defendant, mostly due to a delay of or failure in diagnosis (n = 16), cosmetic outcome issues (n = 8), lack of informed consent (n = 7), and a delay of or failure in referral to a Mohs surgeon (n = 6). Common causes for litigation against Mohs surgeons as the primary defendant (n = 16) were lack of proper informed consent (n = 5) and cosmetic outcome issues (n = 4). Only 1 case against a Mohs surgeon was judged for the plaintiff. CONCLUSIONS AND RELEVANCE: The most common lawsuits pertaining to Mohs surgery list non-Mohs surgeons as the primary defendants. Closer coordination between non-Mohs surgeons and Mohs surgeons may help minimize risk to both parties and lead to better patient care. Small sample size is the primary limitation, in part owing to exclusion of out-of-court settlements from the database.

Who do you prefer? A study of public preferences for health care provider type in performing cutaneous surgery and cosmetic procedures in the United States.

BACKGROUND: The public preference for provider type in performing cutaneous surgery and cosmetic procedures is unknown in the United States. METHODS: An internet-based survey was administered to the lay public. Respondents were asked to select the health care provider (dermatologist, plastic surgeon, primary care physician, general surgeon, and nurse practitioner/physician's assistant) they mostly prefer to perform different cutaneous cosmetic and surgical procedures. RESULTS: Three hundred fifty-four respondents undertook the survey. Dermatologists were identified as the most preferable health care provider to evaluate and biopsy worrisome lesions on the face (69.8%), perform skin cancer surgery on the back (73.4%), perform skin cancer surgery on the face (62.7%), and perform laser procedures (56.3%) by most of the respondents. For filler injections, the responders similarly identified plastic surgeons and dermatologists (47.3% vs 44.6%, respectively) as the most preferred health care provider. For botulinum toxin injections, there was a slight preference for plastic surgeons followed by dermatologists (50.6% vs 38.4%). Plastic surgeons were the preferred health care provider for procedures such as liposuction (74.4%) and face-lift surgery (96.1%) by most of the respondents. CONCLUSION: Dermatologists are recognized as the preferred health care providers over plastic surgeons, primary care physicians, general surgeons, and nurse practitioners/physician's assistants to perform a variety of cutaneous cosmetic and surgical procedures including skin cancer surgery, on the face and body, and laser procedures. The general public expressed similar preferences for dermatologists and plastic surgeons regarding filler injections.

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

IMPORTANCE: Excisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery. OBJECTIVE: To systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology. EVIDENCE REVIEW: Survey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations. FINDINGS: In total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions. CONCLUSIONS AND RELEVANCE: When definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.

Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

The new age of noninvasive facial rejuvenation.

The techniques of noninvasive facial rejuvenation are forever being redefined and improved. This article will review historical as well as present approaches to resurfacing, discussing the nonablative tools that can complement resurfacing procedures. Current thoughts on the pre- and postoperative care of resurfacing patients are also considered.