Joseph F. Sobanko

Topical anesthetics for dermatologic procedures: a review.

Background Practitioners are increasingly using topical anesthetics to decrease the pain associated with superficial dermatologic, aesthetic, and laser procedures. Numerous lidocaine‐containing products are available, but comprehensive reviews are lacking regarding their relative safety profiles and appropriate dermatologic uses. Materials and Methods A literature review of currently available topical anesthetics, their safety profiles, and dermatologic uses was conducted. Results Factors that should be considered to reduce the risk of side effects associated with the use of topical anesthetics include the amount of product used, body location, size of the surface area, and duration of product application. Many case reports document adverse outcomes associated with the use of compounded products that the Food and Drug Administration has not approved that have inappropriately high anesthetic concentrations and from the use of topical anesthetics on excessively large skin surface areas during laser treatments. Conclusions Lidocaine‐containing products play an integral role in cutaneous anesthesia by providing patient comfort with minimal side effects. Careful attention must be paid to the particular anatomic location, the total surface area covered, and the duration of anesthetic skin contact.

Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: Tissue processing methodology to optimize pathologic staging and margin assessment

BACKGROUND Various methods of tissue processing have been used to treat melanoma with Mohs micrographic surgery (MMS). OBJECTIVE We describe a method of treating melanoma with MMS that combines breadloaf frozen sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation, allowing detection of upstaging and comprehensive pathologic margin assessment before reconstruction. METHODS We conducted a retrospective cohort study evaluating for local recurrence and upstaging in 614 invasive or in situ melanomas in 577 patients treated with this MMS tissue processing methodology using frozen sections with melanoma antigen recognized by T cells 1 (MART-1) immunostaining. Follow-up was available in 597 melanomas in 563 patients. RESULTS Local recurrence was identified in 0.34% (2/597) lesions with a mean follow-up time of 1026 days (2.8 years). Upstaging occurred in 34 of 614 lesions (5.5%), of which 97% (33/34) were detected by the Mohs surgeon before reconstruction. LIMITATIONS Limitations include retrospective study, intermediate follow-up time, and that the recurrence status of 39.6% of patients was self-reported. CONCLUSION Treating melanoma with MMS that combines breadloaf sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation permits identification of upstaging and consideration of sentinel lymph node biopsy before definitive reconstruction and achieves low local recurrence rates compared with conventional excision.

Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial.

BACKGROUND Many patients undergoing Mohs micrographic surgery (MMS) experience anxiety and stress. Although music has been proven to reduce anxiety and promote relaxation in other fields of medicine, scant research investigates the effect of music on anxiety during MMS. OBJECTIVES To determine whether music can reduce anxiety in patients undergoing MMS. METHODS AND MATERIALS An open‐labeled randomized controlled trial was conducted to assess anxiety before and after listening to music. Subjects undergoing MMS were randomly allocated to listen to self‐selected music (n = 50) or to have surgery without music (n = 50). Anxiety was measured using the State‐Trait Anxiety Inventory (STAI) and on a visual analog scale (VAS). RESULTS Subjects in the music group experienced statistically significantly lower STAI and VAS scores than those in the control group. STAI and VAS scores were significantly lower in subjects who underwent MMS for the first time. Anxiety measures did not correlate with sex or type of skin cancer. CONCLUSION Listening to self‐selected music reduces anxiety in patients undergoing MMS, especially those who undergo MMS for the first time. Presenting patients the opportunity to listen to music is a simple strategy to minimize anxiety during MMS.

Management of Acne Scarring, Part I

Acne scarring is the result of a deviation in the orderly pattern of healing and can have profound psychosocial implications for patients. While the most effective means of addressing acne scarring is to prevent its formation through good acne control, there are a number of therapeutic interventions that improve the appearance of acne scars. Many of these procedural modalities have flaws and are limited by operator skill and experience. Laser scar revision, on the other hand, is a precise, well tolerated procedure with clinically demonstrable efficacy and minimal adverse effects that may be used alone or in combination with other scar treatments. The last 20 years has seen a dramatic evolution in laser treatment of acne scars, spanning ablative and nonablative technologies, to the current popularity of fractional laser scar revision. Determining which laser system to use depends upon the type and severity of acne scarring, the amount of recovery a patient can tolerate, and the ultimate goals and expectations of each patient. The importance of proper acne scar classification, laser scar revision techniques, and the evidence that addresses each laser system is reviewed in this article.

Influence of Surgical and Minimally Invasive Facial Cosmetic Procedures on Psychosocial Outcomes A Systematic Review

IMPORTANCE Millions of surgical and minimally invasive cosmetic procedures of the face are performed each year, but objective clinical measures that evaluate surgical procedures, such as complication rates, have limited utility when applied to cosmetic procedures. While there may be subjective improvements in appearance, it is important to determine if these interventions have an impact on patients in other realms such as psychosocial functioning. This is particularly important in light of the Patient Protection and Affordable Care Act and its emphasis on patient-centered outcomes and effectiveness. OBJECTIVES To review the literature investigating the impact of facial cosmetic surgery and minimally invasive procedures on relevant psychological variables to guide clinical practice and set norms for clinical performance. EVIDENCE REVIEW English-language randomized clinical trials and prospective cohort studies that preoperatively and postoperatively assessed psychological variables in at least 10 patients seeking surgical or minimally invasive cosmetic procedures of the face. FINDINGS Only 1 study investigating minimally invasive procedures was identified. Most studies reported modest improvement in psychosocial functioning, which included quality of life, self-esteem, and body image. Unfortunately, the overall quality of evidence is limited owing to an absence of control groups, short follow-up periods, or loss to follow-up. CONCLUSIONS AND RELEVANCE The current literature suggests that a number of psychosocial domains may improve following facial cosmetic surgery, although the quality of this evidence is limited (grade of recommendation 2A). Despite the dramatic rise in nonsurgical cosmetic procedures, there is a paucity of information regarding the impact of chemodenervation and soft-tissue augmentation on psychosocial functioning.

Laser Treatment for Improvement and Minimization of Facial Scars

Cutaneous injuries that result in scar formation are relatively common, leading patients to seek treatment for cosmetic or functional improvement. Treatments that have the potential to improve or eliminate scarring include radiation therapy, surgical excision, and intralesional injections of corticosteroids, 5-flourouracil, or bleomycin. Unfortunately, these methods are associated with high recurrence rates and untoward sequelae such as skin atrophy, dyspigmentation, and pain. Laser scar revision is a safe procedure with clinically demonstrable efficacy and minimal side effects when used alone or in combination with other scar treatments. The specifics of current laser scar revision techniques are addressed in this overview.

Early postoperative single treatment ablative fractional lasing of Mohs micrographic surgery facial scars: A split-scar, evaluator-blinded study

Despite precise surgical technique, some postoperative facial scars will depress and widen over time, likely due to weakened or inadequately replaced collagen fibers in the underlying dermis. The purpose of this study is to evaluate whether a 10,600 nm ablative carbon dioxide (CO2) fractional laser used early in the post‐surgical setting results in improved postoperative facial scars after a single treatment session.

Special Stains in Mohs Surgery

The excellent cure rates associated with Mohs micrographic surgery depend on accurate interpretation of complete and high-quality microscopic frozen sections. Reliable interpretation of microscopic slides is only possible if the surgeon can distinguish tumor cells from surrounding normal tissue. By highlighting tumor cells with a chromogen that is visible on light microscopy, immunostaining allows the Mohs surgeon to distinguish tumor from normal cells in these challenging scenarios. This article focuses on practical aspects involving the most commonly used immunostains in dermatologic surgery, including MART-1 for melanocytic neoplasms, cytokeratin stains for keratinocytic neoplasms, and CD34 stains for dermatofibrosarcoma protuberans.

Development of a core outcome set for clinical trials in rosacea: study protocol for a systematic review of the literature and identification of a core outcome set using a Delphi survey

BackgroundRosacea is a chronic inflammatory disorder affecting millions of individuals worldwide. Diagnosis is based on signs and symptoms with management and treatment aimed to suppress inflammatory lesions, erythema, and telangiectasia. While many clinical trials of rosacea exist, the lack of consensus in outcome reporting across all trials poses a concern. Proper evaluation and comparison of treatment modalities is challenging. In order to address the inconsistencies present, this project aims to determine a core set of outcomes which should be evaluated in all clinical trials of rosacea.Methods/designThis project will utilize a methodology similar to previous core outcome set research. A long list of outcomes will be extracted over four phases: (1) systematic literature review, (2) patient interviews, (3) other published sources, and (4) stakeholder involvement. Potential outcomes will be examined by the Steering Committee to provide further insight. The Delphi process will then be performed to prioritize and condense the list of outcomes generated. Two homogenous groups of physicians and patients will participate in two consecutive rounds of Delphi surveys. A consensus meeting, composed of physicians, patients, and stakeholders, will be conducted after the Delphi exercise to further select outcomes, taking into account participant scores. By the end of the meeting, members will vote and decide on a final recommended set of core outcomes. For the duration of the study, we will be in collaboration with both the Core Outcome Measures in Effectiveness Trials (COMET) and Cochrane Skin Group - Core Outcome Set Initiative (CSG-COUSIN).DiscussionThis study aims to develop a core outcome set to guide assessment in clinical trials of rosacea. The end-goal is to improve the reliability and consistency of outcome reporting, thereby allowing sufficient evaluation of treatment effectiveness and patient satisfaction.

Assessing Surgical Training and Deliberate Practice Methods in Dermatology Residency: A Survey of Dermatology Program Directors.

BACKGROUND Resident surgical education and technical skills may be enhanced with deliberate practice-based learning. Deliberate practice methods, such as simulation-based training and formal skills-based assessments, allow for trainees to repeatedly practice a defined task with expert supervision and feedback. OBJECTIVE The authors sought to characterize how surgical skills are taught and assessed in dermatology residency, with an emphasis on whether deliberate practice methods are incorporated in the surgical curriculum. MATERIALS AND METHODS A survey was administered to program directors at 117 Accreditation Council for Graduate Medical Education–approved dermatology residency programs during 2013 to 2014. RESULTS A total of 42 responses (36%) were collected. Over half of programs (57%) devote 10 to 30 hours each year to surgical didactics. Sixty-nine percent of programs use simulation models, and 62% of programs use formal assessment-guided feedback in evaluating surgical skills. Residents most commonly assume the role of primary surgeon in excisional surgery (100%) and less commonly in graft and flap reconstruction (52% and 52%, respectively). Twenty-nine percent of residents are the primary surgeons in Mohs micrographic surgery. CONCLUSION Dermatology residency programs are incorporating deliberate practice-based tenets in the surgical curriculum. These results provide a benchmark for programs to assess and improve the quality of dermatologic surgery training.