Survey of Dermatologic Procedures in Transgender Adults.

BACKGROUND: Dermatologists have the opportunity to provide medically necessary procedures, including laser hair removal, to transgender patients for gender affirmation. Further research is required to better assess the unique dermatologic needs of this population. OBJECTIVE: To examine the prevalence of dermatologic procedures among transgender people in the context of gender-affirming treatment. METHODS: This cross-sectional study examined survey responses from 696 transgender persons enrolled in the Study of Transition, Outcomes, and Gender cohort. Prevalence of self-reported dermatologic procedures was examined and compared across participant subgroups. RESULTS: Electrolysis was the most commonly reported procedure (32.9%). Transfeminine patients were more likely to use dermatologic procedures compared with transmasculine patients. Only 19 participants (2.8%) reported the use of dermal filler injections. CONCLUSION: Differences in utilization of dermatologic procedures were noted in transgender populations. Motivations, barriers, and optimal timing for gender-affirming dermatologic procedures among transgender persons should be examined in future studies.

Safety of Oral Midazolam as a Perioperative Anxiolytic for Outpatient Dermatologic Procedures.

BACKGROUND: Perioperative anxiety can negatively impact patient satisfaction and can complicate outpatient dermatologic procedures. OBJECTIVE: Evaluate adverse events associated with oral midazolam as a perioperative anxiolytic during dermatologic surgery and assess whether an enhanced monitoring approach is associated with an increased detection rate. MATERIALS AND METHODS: Five hundred cases (250 before and after change in monitoring) where patients were administered oral midazolam between July 2015 and May 2017 were retrospectively reviewed. The number of procedures, type of procedures, dose in milligrams, number of doses, major and minor adverse events, and vital signs were recorded. RESULTS: The difference in number of treatment sites, types of procedures, and total dose administered was not significant. There were minor but significant differences in the mean change in blood pressure, heart rate, respiratory rate, and Richmond Agitation and Sedation Scale score before and after the procedure but not oxygen saturation. These vital sign changes were not clinically significant. There were zero major adverse events in both groups. There were 2 patients who became transiently hypoxic. CONCLUSION: Oral midazolam administration was not associated with major adverse events including in the more intensively monitored group. This supports its use as an anxiolytic for outpatient dermatologic procedures.

A review of non-pharmacologic approaches to enhance the patient experience in dermatologic surgery.

Efforts to increase patient comfort by minimizing pain and anxiety have been shown to improve clinical outcomes, reduce pain thresholds, decrease analgesic requirements and complication risk, strengthen the physician-patient relationship, and increase overall patient satisfaction. Patients also have a strong preference for patient-centered communication and educational discussion with physicians. In recent years, the increasing emphasis on patient experience scores as a metric for quality care has had significant implications for physician practice and has reinforced attempts to provide more patient-centered care. Though different pharmacologic agents and techniques have been extensively reviewed in the dermatologic literature, there have been few studies of non-pharmacologic strategies for improving patient-centered care. This evidence-based review describes alternative techniques that have been suggested for use in dermatologic surgery. Mechanoanesthesia, cold therapy, verbal and audiovisual distraction, music, optimal needle insertion methods, hypnosis and guided-imagery, perioperative communication, and educational strategies have been reported to improve the patient experience in dermatologic surgery. These interventions are often cost-effective and easy to implement, avoid medication side effects, and serve as adjunct approaches to enhance patient comfort. This review examines the corresponding evidence for these nonpharmacologic strategies to provide a clinical resource for the dermatologic surgeon seeking to optimize the patient experience.

Traumatic Stress Among Children After Surgical Intervention for Congenital Melanocytic Nevi: A Pilot Study.

BACKGROUND: Hospitalization and surgery are traumatic experiences that can result after traumatic stress symptoms (PTSS). Surgical interventions for congenital melanocytic nevus (CMN) can be very stressful, but their potential for causing PTSS has not been studied. We aim to determine prospectively whether children undergoing surgery for CMN develop PTSS and what are the specific risk factors for such an event. OBJECTIVE: The authors aim to determine prospectively whether children undergoing surgery for CMN develop PTSS and what the specific risk factors for such an event are. METHODS: Thirty children who were consecutively hospitalized in a pediatric surgery ward for CMN removal during the study period were recruited voluntarily. About 4 months after discharge from the hospital, the children and their parents were assessed for psychological distress. RESULTS: At the assessment 4 months after hospitalization, the children displayed a significant increase in symptoms of distress in comparison with baseline levels. Moreover, 33.3% met full post-traumatic stress disorder (PTSD) diagnostic criteria. The number of invasive procedures, family resources, and parental distress predicted 40% of the variance in PTSS, with parental distress predicting it most significantly. CONCLUSION: The high prevalence of PTSS among children undergoing CMN removal and among their parents emphasizes the importance of actions for prevention and early treatment of psychological distress.

Review of the Evaluation and Treatment of Vasovagal Reactions in Outpatient Procedures.

BACKGROUND: A vasovagal reaction is a commonly encountered event in outpatient procedures. There is a paucity of discussion on vasovagal reactions (VVRs) in the dermatologic surgery literature. However, recent investigations in the physiology, evaluation, and treatment of VVRs have been reported in other specialties. OBJECTIVE: A comprehensive review of the physiology, evaluation, treatment, and prevention of VVRs. MATERIALS AND METHODS: A search as performed using the PubMed/MEDLINE databases. Search terms included "vasovagal," "vasovagal reaction," "syncope," "reflex syncope," "neurocardiogenic syncope," and "fainting." RESULTS: Studies demonstrate greater understanding in the physiology of a vasovagal reaction. Although permanent sequelae are uncommon, it is important to respond in a prompt manner. A variety of treatment and prevention options are presented. CONCLUSION: Vasovagal reactions should be carefully evaluated. Additional studies may provide greater data in understanding and managing vasovagal reactions.

Local anesthesia in pediatric dermatologic surgery: Evaluation of a patient-centered approach.

BACKGROUND/OBJECTIVES: A few studies have documented the effect of local anesthesia for minor dermatologic surgical procedures on children and their parents. Our objective was to evaluate the psychological effect and global satisfaction of a patient-centered approach to dermatologic surgery under local anesthesia. METHODS: Two self-administered questionnaires were used to evaluate the distress and global satisfaction of 388 children who underwent dermatologic surgery under local anesthesia, accompanied by oral and written therapeutic education measures (structured information and a cartoon brochure illustrating the procedure) addressed to children and parents. Distraction techniques were also used during the procedures. RESULTS: Although 54.5% of patients manifested some degree of fear, all other parameters analyzed (pain, surgery-related distress, surgical team-patient and -family relationship, global satisfaction) indicated that the procedures resulted in limited distress and that the large majority of children and parents tolerated them well. CONCLUSION: Specific measures for therapeutic pediatric patient education may be helpful in limiting discomfort, anxiety, and pain perception linked to procedures performed under local anesthesia. Further controlled studies are required to more precisely assess the benefits of specific therapeutic education measures.

An age-based approach to dermatologic surgery: Kids are not just little people.

Surgical dermatologic procedures in children pose unique challenges that differ from those in adults. Child and parental anxiety, along with procedural anxiety in adults, necessitate different approaches. Special considerations are reviewed in the application of topical anesthesia and administration of local anesthesia in children as opposed to adults, and the use and safety of general anesthesia in children is highlighted. In addition, management of postprocedural analgesia differs in children, largely due to concern for safety of opioids in children.

UK-based prospective cohort study to anglicise and validate the FACE-Q Skin Cancer Module in patients with facial skin cancer undergoing surgical reconstruction: the PROMISCR (Patient-Reported Outcome Measure in Skin Cancer Reconstruction) study.

INTRODUCTION: Skin cancer is the most common malignancy worldwide, often occurring on the face, where the cosmetic outcome of treatment is paramount. A number of skin cancer-specific patient-reported outcome measures (PROMs) exist, however none adequately consider the difference in type of reconstruction from a patient's point of view. It is the aim of this study to 'anglicise' (to UK English) a recently developed US PROM for facial skin cancer (the FACE-Q Skin Cancer Module) and to validate this UK version of the PROM. The validation will also involve an assessment of the items for relevance to facial reconstruction patients. This will either validate this new measure for the use in clinical care and research of various facial reconstructive options, or provide evidence that a more specific PROM is required. METHODS AND ANALYSIS: This is a prospective validation study of the FACE-Q Skin Cancer Module in a UK facial skin cancer population with a specific focus on the difference between types of reconstruction. The face and content validity of the FACE-Q questionnaire will initially be assessed by a review process involving patients, skin cancer specialists and methodologists. An assessment of whether questions are relevant and any missing questions will be made. Initial validation will then be carried out by recruiting a cohort of 100 study participants with skin cancer of the face pre-operatively. All eligible patients will be invited to complete the questionnaire preoperatively and postoperatively. Psychometric analysis will be performed to test validity, reliability and responsiveness to change. Subgroup analysis will be performed on patients undergoing different forms of reconstruction postexcision of their skin cancer. ETHICS AND DISSEMINATION: This study has been approved by the West Midlands, Edgbaston Research Ethics Committee (Ref 16/WM/0445). All personal data collected will be anonymised and patient-specific data will only be reported in terms of group demographics. Identifiable data collected will include the patient name and date of birth. Other collected personal data will include their diagnosis, treatment performed, method of reconstruction and complications. A unique identifier will be applied to each patient so that pretreatment and post-treatment questionnaire results can be compared. All data acquisition and storage will be in accordance with the Data Protection Act 1998. Following completion of the study, all records will be stored in the Abertawe Bro Morgannwg University (AMBU) Health Board archive facility. Only qualified personnel working on the project will have access to the data.The outputs from this work will be published as widely as possible in peer-review journals and it is our aim to make this open access.

Public perception of dermatologic surgery in Saudi Arabia: an online survey.

BACKGROUND: Dermatologic surgery is a well established subspecialty in dermatology, but observations suggest that the public may not be aware of this field. OBJECTIVE: To explore the public perception of the nature and scope of dermatologic surgery Methods: A cross-sectional online-based survey consisting of two parts was used. The first part recorded demographic data. The second part presented a series of clinical scenarios in common surgical and cosmetic procedures performed by dermatologic surgeons to determine respondents' choice among three specialties: general surgery, plastic surgery, and dermatologic surgery. RESULTS: A total of 1,248 responses were recorded. Seventy-four percent of respondents were female, with 80.29% between the ages of 18 and 34 years. Forty-nine percent considered dermatologic surgeons to be specialized skin surgeons and 71.63% said they would consult dermatologic surgeons for skin tumor excisions. However, plastic surgeons emerged more favorably for cosmetic procedures. For office-based procedures, 80.85% and 87.18% of respondents chose plastic surgeons for fillers and Botox® injections, respectively, compared to 15.79% and 12.02% of respondents who chose dermatologic surgeons. CONCLUSIONS: Although the majority of participants showed no doubt about the surgical skills of dermatologic surgeons, the responses demonstrate that the public is not aware of the full scope and practice of dermatologic surgery, especially as it pertains to cosmetic procedures. Therefore, we must educate the public about the field and branches of dermatologic surgery.

Anxiety levels of patients undergoing common dermatologic procedures versus those seeking general dermatologic care.

Patients undergoing Mohs micrographic surgery frequently experience anxiety as a result of multiple potential factors. There is currently no data regarding how this anxiety compares to other common procedures performed in dermatology offices, such as shave biopsy and excision, relative to a general dermatology visit. Herein, we conducted a survey of 471 dermatology patients at an academic medical center, using a validated tool (Visual Analogue Scale from 1 "no anxiety at all" to 10 "extremely anxious").

Prevalence of Body Dysmorphic Disorder in Plastic Surgery and Dermatology Patients: A Systematic Review with Meta-Analysis.

The aim of the present study was to evaluate the prevalence of body dysmorphic disorder in plastic surgery and dermatology patients, by performing a systematic review of the literature and meta-analysis. The most relevant studies published originally in any language were analyzed. The literature search was performed using the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scielo databases. The final sample comprised 33 publications that were submitted to meta-analysis. The study verified that 15.04% of plastic surgery patients had body dysmorphic disorder (range 2.21-56.67%); patient mean age was 34.54 ± 12.41 years, and most were women (74.38%). Among dermatology patients, 12.65% (range 4.52-35.16%) had body dysmorphic disorder; patient mean age was 27.79 ± 9.03 years, and most were women (76.09%). Both plastic surgeons and dermatologists must adequately assess their patients to identify those with a higher likelihood of body dysmorphic disorder and should arrange multidisciplinary care for such individuals. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical course, treatment modalities, and quality of life in patients with congenital melanocytic nevi - data from the German CMN registry.

BACKGROUND: Congenital melanocytic nevi (CMN) are associated with mental stress as well as medical risks for those affected. The German CMN registry was initiated in 2005. Herein, we present results from an interim analysis focusing on disease course, treatment modalities, and quality of life. PATIENTS AND METHODS: One hundred patients enrolled in the registry between 2005 and 2012 were included in this prospective cohort study, and asked to participate in a follow-up survey. In addition, standardized questionnaires were used to collect data on quality of life (dermatology life quality index, DLQI) and perceived stigmatization (perceived stigmatization questionnaire, PSQ; social comfort questionnaire, SCQ). RESULTS: Eighty-three percent of patients (or their parents) provided answers to the survey questions (mean patient age: 11.2 years, median: 6 years; mean follow-up: 4.4 years). Overall, four individuals were diagnosed with melanoma, including two pediatric cases with CNS melanoma, one adult with cutaneous melanoma, and one case which later turned out to be a proliferative nodule. Four children were diagnosed with neurocutaneous melanocytosis, three of whom exhibited neurological symptoms. Eighty-eight percent (73/83) of patients underwent surgery. Seventy-eight percent reported no or only minor impact of the CMN on quality of life. In general, perceived stigmatization and impairment of social well-being were also low. CONCLUSIONS: Our results provide an overview of the situation of CMN patients in Germany, Austria, and Switzerland. Three percent of patients developed melanoma; 4 % showed CNS involvement.

Surgery combined with photodynamic therapy for the treatment of Hidradenitis Suppurativa: A report of 7 cases.

Hidradenitis Suppurativa (HS) is a chronic inflammatory skin disease in the area of the apocrine sweat glands. The treatment of HS is relatively difficult. Therefore, surgery combined with PDT was applied to treat 7 cases of patients in this study, and treatment efficacy was observed. Simple surgical incisions and drainage were performed for patients with Hurley grade I. Surgical incisions and drainage as well as the removal of necrotic tissues were performed for patients with grades II and III. Immediately after surgery, PDT was performed. Their average Dermatology Life Quality Index (DLQI) was 24.14±4.26 before the surgery and 4.86±2.79 5 months after treatment, respectively. Scale (VSS) scores for evaluating scar formation were low to moderate after surgery and PDT. The experience of treating these 7 patients suggests that surgery combined with PDT might have a more pronounced effect, with the possible advantages of faster healing and less scarring.

Avoiding Psychological Pitfalls in Aesthetic Medical Procedures.

OBJECTIVE: To assess the prevalence of body dysmorphic disorder (BDD) in an aesthetic surgery setting in the region of Southwest China, and to ascertain the differences in terms of body images between patients in the aesthetic setting and general Chinese population. This study tracked patient satisfaction with their body image changes while undergoing aesthetic medical procedures to identify whether the condition of patients who were presenting with BDD symptoms or their psychological symptoms could be improved by enhancing their appearance. Additionally, this study explored whether there was improvement in quality of life (QoL) and self-esteem after aesthetic medical procedures. METHODS: A total of 106 female patients who were undergoing aesthetic medical procedures for the first time (plastic surgery, n = 26; minimally invasive aesthetic treatment, n = 42; and aesthetic dermatological treatment, n = 38) were classified as having body dysmorphic disorder symptoms or not having body dysmorphic disorder symptoms, based on the body dysmorphic disorder examination (BDDE), which was administered preoperatively. These patients were followed up for 1 month after the aesthetic procedures. The multidimensional body self-relations questionnaire-appearance scales (MBSRQ-AS) and rosenberg self-esteem scale (RSE-S) were used to assess patients' preoccupation with appearance and self-esteem pre-procedure and 1 month post-procedure. Additionally, 100 female healthy control participants were recruited as a comparative group into this study and they were also assessed using BDDE, MBSRQ-AS, and RSE-S. RESULTS: A total of 14.2 % of 106 aesthetic patients and 1 % of 100 healthy controls were diagnosed with BDD to varying extents. BDDE scores were 72.83 (SD ± 30.7) and 68.18 (SD ± 31.82), respectively, before and after the procedure for the aesthetic patient group and 43.44 (SD ± 15.65) for the healthy control group (F = 34.28; p < 0.001). There was a significant difference between the groups in subscales of MBSRQ-AS, i.e. appearance evaluation (F = 31.31; p < 0.001), appearance orientation (F = 31.65; p < 0.001), body areas satisfaction (F = 27.40; p < 0.001), and RSE-S scores (F = 20.81; p < 0.001). There was no significant difference, however, in subscales of MBSRQ-AS, i.e. overweight preoccupation (F = 1.685; p = 0.187), self-classified weight (F = 0.908; p = 0.404) between groups. All the subscales of MBSRQ-AS showed significant differences between the aesthetic patients (pre-procedure) and female adult norms from Dr. Cash's result given in Table 4 (p < 0.001). The study also showed that there were no significant differences in the scores of BDDE, MBSRQ-AS, and RSE-S of those fifteen aesthetic patients diagnosed with BDD after aesthetic procedures lasting one month. CONCLUSION: There was a high prevalence rate (14.2 %) of body dysmorphic disorder in aesthetic procedure seekers, and it seemed that those patients suffering from BDD were more likely to be dissatisfied with the results of the aesthetic medical procedures. However, general aesthetic patients showed improvement in most assessments which indicated that aesthetic medical procedures could not only enhance patient appearance, but also patient low self-esteem and QoL. Self-satisfaction could also be promoted. A screening procedure for BDD including suitable screening questionnaires might be considered for routine use in aesthetic clinical settings to minimize dissatisfaction and complaints. LEVEL OF EVIDENCE IV: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Anxiety Among Patients Undergoing Nail Surgery and Skin Punch Biopsy: Effects of Age, Gender, Educational Status, and Previous Experience.

BACKGROUND: Patient anxiety about nail surgery relates mainly to pain associated with needle puncture, anesthetic flow during the procedure, and postoperative care, as well as possible past traumatic experience. OBJECTIVE: The aims of this study were to compare anxiety levels among patients undergoing nail surgery and skin punch biopsy and to assess the effects of demographic characteristics on anxiety. METHODS: Forty-eight consecutive patients who were referred to a dermatological surgery unit for nail surgery intervention (group 1) and 50 age- and sex-matched patients referred to the same unit for skin punch biopsy (group 2) were enrolled in the study. Patients' anxiety levels were measured using Spielberger's State-Trait Anxiety Inventory. RESULTS: There was no significant difference in median anxiety level between group 1 (42.00; interquartile range, 6.50) and group 2 (41.00; interquartile range, 8.25) (P = .517). The demographic factors of patient sex, educational status, and prior surgery showed no significant effects on anxiety levels. CONCLUSION: Nail surgery does not seem to cause significantly greater anxiety than skin punch biopsy.

Plastic surgery after bariatric surgery.

BACKGROUND: Massive weight loss after bariatric surgery often results in excess skin, which can lead to stigma due to appearance and pronounced physical and psychological impairments. This review considers the evidence base for post-bariatric plastic surgery and the treatment options that are available. METHOD: The article is based on a literature search in PubMed with the keywords «bariatric surgery¼ AND «plastic surgery¼, in addition to the authors' experience with a large number of patients. RESULTS: Body contouring surgery after massive weight loss is offered primarily for the treatment of troublesome skin conditions. The surgery can help to improve quality of life and functional status. However, there is little scientific evidence regarding indications for surgery, choice of surgical techniques and risk of complications, and the surgeon's own opinions and clinical experience often play a major role. Many plastic surgeons limit body contouring surgery to those with BMI < 28 kg/m². However, most patients who have undergone bariatric surgery have BMI ≥ 30 kg/m², and requests for body contouring surgery for these individuals are often denied, except when there are compelling medical grounds. INTERPRETATION: Plastic surgery can lead to improved functioning and increased quality of life. The evidence base with respect to indications, treatment methods and outcomes should be strengthened through well-planned prospective studies and a patient registry. There is a particular need for documentation of treatment outcomes in the large group of patients with BMI ≥ 30 kg/m².