Blinded vs. unblinded peer review of manuscripts submitted to a dermatology journal: a randomized multi-rater study.

BACKGROUND: Submissions to medical and scientific journals are vetted by peer review, but peer review itself has been poorly studied until recently. One concern has been that manuscript reviews in which the reviewer is unblinded (e.g. knows author identity) may be biased, with an increased likelihood that the evaluation will not be strictly on scientific merits. OBJECTIVES: The purpose of this study was to compare the outcomes of blinded and unblinded reviews of manuscripts submitted to a single dermatology journal via a randomized multi-rater study. MATERIALS AND METHODS: Forty manuscripts submitted to the journal Dermatologic Surgery were assessed by four reviewers, two of whom were randomly selected to be blinded and two unblinded regarding the identities of the manuscripts' authors. The primary outcome measure was the initial score assigned to each manuscript by each reviewer characterized on an ordinal scale of 1-3, with 1 = accept; 2 = revise (i.e. minor or major revisions) and 3 = reject. Subgroup analysis compared the primary outcome measure across manuscripts from U.S. corresponding authors and foreign corresponding authors. The secondary outcome measure was word count of the narrative portion (i.e. comments to editor and comments to authors) of the reviewer forms. RESULTS: There was no significant difference between the scores given to manuscripts by unblinded reviewers and blinded reviewers, both for manuscripts from the U.S. and for foreign submissions. There was also no difference in word count between unblinded and blinded reviews. CONCLUSIONS: It seems, at least in the case of one dermatology journal, that blinding during peer review does not appear to affect the disposition of the manuscript. To the extent that review word count is a proxy for review quality, there appears to be no quality difference associated with blinding.

The benefits of powered liposuction versus traditional liposuction: a paired comparison analysis.

BACKGROUND: There is much debate about the safety of liposuction as well as the efficacy and risk:benefit ratio of newer devices used in this procedure. OBJECTIVE: To determine if there are any benefits in terms of safety and efficacy of power reciprocating cannulas compared to traditional manual liposuction cannulas. METHODS: Patients served as their own controls in a paired comparison analysis of power liposuction cannulas and traditional liposuction cannulas. RESULTS: Power cannulas significantly reduced procedure times, intraoperative pain, and surgeon fatigue, and increased the amount of fat aspirated per minute. Power cannulas also decreased postoperative pain, ecchymoses, and edema, as well as resulting in higher patient satisfaction scores. CONCLUSION: Power liposuction cannulas produce significantly faster recovery times for patients, allow faster procedure times, and reduce surgeon fatigue, resulting in safer and more precise surgery. A lower incidence of touch-up procedures is likely due to these benefits.

The efficacy of powered liposuction.

BACKGROUND: Powered liposuction is a relatively new innovation for more efficient removal of adipose tissue. OBJECTIVE: To evaluate the effectiveness of powered liposuction in removing adipose tissue when compared to traditional liposuction. METHODS: Four powered liposuction devices were evaluated in the power on mode vs. the power off. The fat extracted in each of these modes was measured in a mucous specimen trap. RESULTS: There was increased fat extraction in the powered mode for all instruments. The increased rate of fat extraction varied from 20 to 45% between instruments. the overall increased extraction in powered vs. nonpowered mode was 30%. CONCLUSION: The powered liposuction devices tested significantly increase the efficacy of subcutaneous fat removal during liposuction.

HIV lipodystrophy: review of the syndrome and report of a case treated with liposuction.

BACKGROUND: A syndrome characterized by loss of fat on the face and limbs, localized fatty deposits on the trunk, and metabolic disturbances is becoming increasingly recognized in the human immunodeficiency virus (HIV) patient population. OBJECTIVE: To increase awareness of this syndrome among dermatologists and dermatologic surgeons and to review its various treatment options, including liposuction. METHODS: We present a patient with HIV lipodystrophy syndrome who underwent tumescent liposuction. We also describe our experience with liposuction in the management of this condition and review the treatment options that have been proposed in the literature. RESULTS: In the medical management of HIV lipodystrophy, various agents have been utilized but most have yielded disappointing results. Preliminary evidence on the use of tumescent liposuction in these patients suggests that significant improvement in the cosmetic disfigurement can be achieved. CONCLUSION: This syndrome is common among HIV-infected patients and remains difficult to treat. Although medical therapy may be preferable in most patients, liposuction represents a viable option in selected individuals.

Recruitment and early treatment in a multicenter study of acute spinal cord injury.

STUDY DESIGN: Post hoc secondary analysis of data from 1992 to 1998 in the trial of Sygen in Acute Spinal Cord Injury. OBJECTIVES: Quasi-epidemiologic understanding of injury and treatment patterns and of recruitment in an SCI trial. No drug efficacy results. SUMMARY OF BACKGROUND DATA: The most recent large epidemiologic study was the National SCI Database by Stover and colleagues around 1980. METHODS: Emphasis on descriptive, rather than inferential, statistics: consistent with secondary analysis. RESULTS: The study involved 760 patients at 28 centers in North America. Cervical injuries were more common than thoracic, and complete injuries were more common than incomplete injuries. Recruitment in the complete cervical stratum was 332, but the incomplete thoracic strata had only 31 patients combined. Vital signs at arrival and on randomization show fair stability. Clock times show more injuries on weekends and nights but suggest immediate attention was given. Elapsed times to treatment (especially EMT and Medevac arrival) are short. The rate of direct admission to tertiary centers, traction weight, and time to surgery vary among centers. Inpatient rehabilitation appeared driven by insurance in addition to severity. CONCLUSIONS: The imbalances in favor of cervical and of complete injuries would make it hard for studies to attain results for SCI in general. The vital signs and time patterns suggest local protocol-driven stabilization to prevent secondary physiologic injury early after SCI. Some features of care vary among centers, but the sparseness of prospective data in specific injury and treatment categories suggests that treatment guidelines have limited empirical support and should be made cautiously.

When one liter does not equal 1000 milliliters: implications for the tumescent technique.

BACKGROUND: Tumescent anesthesia has revolutionized the practice of liposuction. Inherent to the tumescent technique is the use of large volumes of dilute solutions of lidocaine with epinephrine instilled into subcutaneous fat deposits. Precise formulation of the tumescent anesthesia is essential to liposuction technique. OBJECTIVES: To determine the actual volumes of fluids contained in intravenous (IV) 1 L bags of saline used for tumescent anesthesia, to calculate volumes supplied in 50 cc stock solutions of 1% lidocaine, and to measure the amount of fluid retained by peristalic pump tubing used for infiltration. METHODS: The amount of saline contained in fifteen 1 L saline bags from three different manufacturers was calculated using graduated cylinder methodology. The volume of tumescent anesthesia retained by peristaltic pump tubing was calculated by expelling the contents of the filler tubing and measuring it. The actual amount of 1% lidocaine contained within fifteen 50 ml "stock" 1% lidocaine bottles from different manufacturers and with different lot numbers was calculated by transferring the contents into graduated cylinders. RESULTS: One liter IV bags of physiologic saline contained an average volume of 1051 ml (range 1033-1069 ml). The 50 ml bottles of 1% lidocaine with epinephrine contain an average of 54 ml of anesthetic (range 52.5-55 ml). Infusion tubing for use with peristaltic pumps may retain 46-146 ml of tumescent anesthesia. CONCLUSION: One liter IV bags of normal saline contain more than 1 L, having an average volume of 1051 ml. Common methods of preparation of 0.05% lidocaine with 1:1,000,000 epinephrine and sodium bicarbonate can increase the total amount of fluid in the tumescent anesthesia to 1112 ml for 0.05% solutions and preparation of a 0.1% solution contains an average volume of 1162 ml. The fluid contained in each bag may be increased over labeling by as much as 11-16%. Final concentrations of lidocaine in tumescent anesthesia may be reduced due to extra fluids. A 0.05% lidocaine solution may have a final lidocaine concentration of 0.045% and a 0.1% lidocaine solution may have an actual concentration of 0.086%. Lidocaine concentrations may be reduced by as much as 10-14%. Extra anesthesia fluid is also contained within stock 50 ml bottles of 1% lidocaine. Dermatologic surgeons should be aware of extra fluid possibly contained within tumescent anesthetic preparation, be aware of the extra anesthesia supplied in standard 1% lidocaine bottles, and possible decreased concentration of lidocaine within the final tumescent anesthesia.

Powered liposuction.

BACKGROUND: Although Arpad and Giorgio Fischer initially employed blades within cannulas in their early research while inventing liposuction, hollow cannulas have become the standard instrument for this procedure for the last quarter century. Ultrasonic liposuction was developed in the 1990s to facilitate the passage of cannulas through subcutaneous tissue while liquefying fat. However, these instruments had a number of drawbacks including seromas and tissue burns. Powered cannulas were introduced in 1995 by Gross for "liposhaving." This technique was used on the neck with open surgery under direct observation. OBJECTIVE: Based on these principles, a new powered liposuction device has been designed for body liposuction. METHOD: An oscillating blade within a cannula facilitates removal of fat, especially in fibrous areas such as male flanks and breasts. This instrument has proven to be safe in numerous body areas. Powered reciprocating cannulas also have been recently introduced. These simulate the "to and fro" motion of manual liposuction and appear to be safe. CONCLUSION: Powered liposuction may provide the advantages of ultrasonic liposuction with fewer complications.

A history of dermatologic surgery in the United States.

BACKGROUND: Dermatologic surgery has a long and distinguished history in the United States. OBJECTIVE: To examine the specific contributions of American dermatologic surgeons. METHOD: The medical literature on cutaneous reconstructive and cosmetic surgery for the last century and a half was researched. RESULTS: Numerous American dermatologic surgeons have had a major impact on scientific and technological discoveries in cutaneous surgery. Dermatologic surgeons have been significantly involved in cutaneous surgery since the second half of the 19th century. Dermatologic surgeons have contributed many important advances to the fields of chemical peeling, cryosurgery, dermabrasion, electrosurgery, hair transplantation, soft tissue augmentation, tumescent liposuction, laser surgery, phlebology, Mohs chemosurgery, cutaneous reconstruction, wound healing, botulium toxin, blepharoplasty, and rhytidectomy. CONCLUSION: Dermatologic surgeons in the United States have contributed significantly to the history of reconstructive and cosmetic surgery. Dermatologic surgeons have been leaders in advancing this field and are poised to continue in the future.

The efficacy of EMLA versus ELA-Max for pain relief in medium-depth chemical peeling: a clinical and histopathologic evaluation.

BACKGROUND: Medium-depth chemical peels are an effective and popular treatment for actinic damage, fine wrinkles, and pigmentary dyschromias. However, they are also uncomfortable. A previous attempt to study the effectiveness of a topical anesthetic gel in 35% trichloroacetic acid (TCA) peeling found a reduction in discomfort but an increased depth of penetration and delayed healing. OBJECTIVE: To evaluate both the efficacy of two topical anesthetic agents in medium-depth combination peeling as well as the histologic result from chemical peeling combined with topical anesthesia. METHOD: Seventy percent glycolic acid (GA) was applied to the entire face of 10 patients and diluted with water after 2 minutes. This was followed by the sequential application of EMLA cream (lidocaine 2.5% and prilocaine 2.5%), ELA-Max cream (lidocaine 4%), and placebo to selected areas on the face for 30 minutes without occlusion. These agents were then removed and 35% TCA was applied to the entire face. The level of discomfort felt by the patients during the TCA peel was recorded, clinical photographs were taken, and bilateral preauricular biopsies were performed at baseline, 48 hours, and 90 days postoperatively. RESULTS: Clinically there was a statistically significant decrease in pain felt during the 70% GA-35% TCA peel with topical anesthesia when compared to the control. There was no statistically significant difference in efficacy between EMLA and ELA-Max. There was also no difference in either the clinical or the histopathologic appearance between the medium-depth peel combined with topical anesthesia and the medium-depth peel with control. CONCLUSION: Both EMLA and ELA-Max decrease the discomfort felt during medium-depth combination chemical peeling without influencing either the clinical or the histopathologic result.

Ultrasonic-assisted liposuction. Internal and external.

UAL has not provided the promised ideal of "fat dissolution without surgery." In extremely fibrous areas and second procedure liposuction, internal UAL may be a valuable tool once it is further perfected. UAL equipment continues to evolve and as it improves we hope to see a better safety profile, a mechanism for smaller entrance sites, and greater time efficiency in the procedure.

A visit to the office of Drs. Margaret and Robert Weiss.

This is one of an occasional series of articles about visitations to the offices of prominent dermatologic surgeons. There are a number of highly skilled and innovative members of our field from whom we can all learn. Unfortunately, it is impossible for everyone to visit their facilities and observe their work first hand. The purpose of this series is to provide a behind-the-scenes look at the day-to-day workings of the offices of prominent dermatologic surgeons.

New directions in surgical therapy.

Surgical dermatology continues to evolve rapidly. The field is blessed with a number of bright and enthusiastic young surgeons who are willing to spend to necessary time investigating new techniques. The horizon has changed dramatically over the last 5 years and promises to change even more in the years to come.