Virtual Reality to Improve the Experience of the Mohs Patient—A Prospective Interventional Study BACKGROUND Nonmelanoma skin cancer is the most common cancer in the United States with significant quality of life impact. OBJECTIVE To assess the utility of a highly immersive virtual reality (VR) experience in the context of outpatient skin cancer surgery as a means to minimize patient-reported feelings of anxiety or pain. The authors also sought to assess the effects on patient-reported overall satisfaction. MATERIALS AND METHODS Patients completed a pre-VR experience survey after completion of their first Mohs surgery layer, followed by a 10-minute VR experience, and a post-VR experience survey. Differences in the pre-VR survey and post-VR survey were compared using the chi-square test. The anxiety scores were compared using a t-test. RESULTS In all but 2 questions, there was a trend toward improvement of the anxiety-related sensations after completion of the VR experience. There were statistically significant differences for 4 questions: “Are you currently feeling unable to relax” (p = .0013), “are you currently feeling fear of the worst happening” (p < .0001), “are you currently feeling terrified or afraid” (p = .0046), and “are you currently feeling nervous” (p < .0001). CONCLUSION Virtual reality experiences during the Mohs surgical day significantly improved measures of anxiety and patient satisfaction.

Topical Aluminum Chloride and Monsel's Solution Block Toluidine Blue Staining in Mohs Frozen Sections: Mechanism and Solution BACKGROUND A diminished-staining artifact is observed in some Mohs frozen sections that are stained in toluidine blue (T-blue). Such an artifact, not yet described in the literature, may interfere with a Mohs surgeon's accurate reading. The authors hypothesize that topical hemostatic agents, aluminum chloride, and Monsel's solution are the causative factors. OBJECTIVE To evaluate the aforementioned topical hemostatic agents as a potential cause of the nonstaining artifact, to propose the mechanism associated with this phenomenon, and to develop a method to prevent or rectify the problem. MATERIALS AND METHODS Leftover Mohs frozen sections and specimens were treated with aluminum chloride or Monsel's solution and processed with routine Mohs histology. RESULTS Nonstaining artifact is reproduced in aluminum chloride or Monsel's solution–treated ex vivo skin specimens. The authors found that ethylenediaminetetraacetic acid (EDTA), a chelating agent, can reverse the staining blockage. Such a finding suggests that aluminum or ferric cations bind to tissue and subsequently inhibit T-blue from interacting with the tissue. Direct binding of ferric cations to the tissue section is demonstrated with Prussian blue iron staining. CONCLUSION By rinsing Mohs frozen sections in an EDTA solution before T-blue staining, the authors could prevent hemostatic agent–induced nonstaining. Applying an EDTA wash and restaining the slides can correct the same artifact.

Sentinel Lymph Node Biopsy in Patients With Acral Melanoma: Analysis of 201 Cases From the Brazilian National Cancer Institute BACKGROUND Sentinel lymph node biopsy (SLNB) is the most powerful predictor of relapse-free survival (RFS) and overall survival (OS). No studies have evaluated survival of acral melanoma (AM) undergoing SLNB in Brazil. OBJECTIVE The objective of this study was to investigate the factors associated with the survival of patients with AM undergoing SLNB. MATERIALS AND METHODS Patients diagnosed with AM and submitted to SLNB were included in this study. We evaluated the epidemiologic, clinical, and histopathological data. Overall survival and RFS curves were estimated using the Kaplan–Meier method. Multivariable analyses were conducted using the Cox regression model. RESULTS Among the 201 patients, 117 (58.2%) were female. The median age was 64 years old. Median tumor depth was 5.0 mm. Lesions were ulcerated in 134 (66.7%). Five-year OS and RFS rates were 44.6% and 38.6%, respectively. Median follow-up time was 39 months. The factors associated with OS were Breslow thickness, ulceration, and SLNB status, and for RFS, they were Breslow thickness and SLNB status. CONCLUSION This is the largest series of AM submitted to SLNB. The 5-year OS and RFS rates were low (44.6% and 38.6%, respectively), and the main prognostic factors for OS were Breslow thickness, ulceration, and the status of SLNB.

Assessment of Provider Utilization Through Skin Biopsy Rates BACKGROUND There have been recent claims of overdiagnosis and unnecessary treatment in dermatology. One potential manifestation of overutilization would be providers who perform numerous biopsies per patient. OBJECTIVE To identify the frequency of skin biopsy rate outliers. MATERIALS AND METHODS Data on biopsy rates at the individual provider level were obtained from Medicare Provider Utilization and Payment Data Public Use Files. The total number of biopsies for each provider was obtained by summing the number of claimed biopsy services for each unique National Provider Identifier. The visit count for each provider was obtained by summing all evaluation and management services claimed. Provider biopsy rates were calculated by dividing the total number of biopsies associated with each National Provider Identifier by the corresponding visit count. RESULTS The mean provider biopsy rate was 0.31 services per visit, or approximately 1 biopsy every 3 visits. Defining outliers as providers who averaged 3 or more biopsies per visit, there were 38 outliers out of 18,260 providers. Physicians had a lower mean biopsy rate than nonphysician clinicians (p = 1.70E–28). CONCLUSION Contrary to claims, the authors' results do not indicate widespread overutilization of skin biopsy services.

WHO Surgical Checklist in Dermatology: Compliance, Barriers, and Attitudes BACKGROUND The World Health Organization (WHO) surgical checklist is associated with reduced morbidity and mortality. Efficacy correlates with compliance. OBJECTIVE This study aims to (1) establish completion rate and (2) identify and address barriers to use. METHODS Records of patients undergoing dermatological surgery were studied. Staff completed attitude and barriers questionnaires. Checklist process was modified, and use was reassessed twice. RESULTS Cycle 1 involved 217 subjects; 72% had excisions. Thirteen percent had surgery to multiple sites. Five percent of checklists were fully completed, with an average of 76% of available points per checklist marked as checked. The lowest single field use included “patient identity” (76%) and “surgical site” (72%). Questionnaire responses from 25 staff showed the checklist to be “important” and “relevant” in dermatology; key barrier to completion was lack of time. Checklist modifications and educational sessions were undertaken; checklist use was reassessed twice more with 103 and 134 patients. Average use increased to 96% and 98%; full completion increased to 71% and 70%; “surgical site” and “identity” completion increased to 100%. CONCLUSION The WHO checklist is relevant and important in dermatology. Introduction must be supported by repeated training sessions. Adequate time and training can significantly improve checklist completion and patient safety.

Collagenase Clostridium Histolyticum for the Treatment of Edematous Fibrosclerotic Panniculopathy (Cellulite): A Randomized Trial BACKGROUND Edematous fibrosclerotic panniculopathy (EFP; cellulite) is associated with thickening and contraction of collagen-rich subdermal septae. Collagenase clostridium histolyticum (CCH) may disrupt collagen-rich septae. OBJECTIVE To evaluate the safety and efficacy of CCH for treatment of EFP. MATERIALS AND METHODS In a randomized, double-blind study, women with moderate or severe EFP of the buttocks or posterolateral thighs (i.e., Clinician Reported Photonumeric Cellulite Severity Scale [CR-PCSS] and Patient Reported Photonumeric Cellulite Severity Scale [PR-PCSS] ratings of 3 to 4, and Hexsel Cellulite Severity Scale score ≤13) received up to 3 treatment sessions (Days 1, 22, and 43) of subcutaneous CCH 0.84 mg or placebo injections. End points included the percentage of 2-level and 1-level composite responders (i.e., had ≥2-level or ≥1-level improvement in CR-PCSS and PR-PCSS) at Day 71. RESULTS Three hundred seventy-five women (mean age, 46.5 years; 86.4% white) were randomly assigned to CCH (n = 189) or placebo (n = 186). At Day 71, the percentages of 2-level and 1-level composite responders were greater with CCH (10.6% and 44.6%, respectively) versus placebo (1.6% and 17.9%; p < .001 for both). The most common adverse events were injection-site related. CONCLUSION CCH significantly improved EFP appearance versus placebo; further evaluation of CCH for EFP (cellulite) is warranted.

An Observational Study of the Safety and Efficacy of Tissue Stabilized–Guided Subcision BACKGROUND Cellulite is a common female cosmetic concern for which there are few treatment options with long-term effectiveness data. The aim of this multisite prospective registry study was to collect observational data on the real-life clinical use of a tissue stabilized–guided subcision (TS-GS) system for long-term improvement of cellulite appearance. METHODS Fifty-three subjects were enrolled and received a single treatment using the TS-GS system. Physicians treated the subjects according to their standard of care. Global Aesthetic Improvement Scale (GAIS) was completed by the patient and clinician assessing overall aesthetic improvement after 180 days. Treatment parameters, pain scores, quality of life data, and expected treatment effects and adverse events were also recorded throughout the study. RESULTS The patient and physician GAIS scores at Day 180 revealed an overall improvement in 91% and 96% of patients, respectively. Quality of life and self-confidence scores also improved through 180 days. No serious adverse events were reported. Expected treatment effects were similar to those reported in the pivotal trial supporting FDA clearance. CONCLUSION This study demonstrated significant improvement in the appearance of cellulite after a single treatment session in patients with moderate-to-severe cellulite. These results are consistent with the previously published the pivotal study data.

Changes in the Layers of the Temple During Pinch Manipulation: Implications for Thread Lifting BACKGROUND During minimally invasive aesthetic procedures, the skin is often pinched to facilitate filler injection or thread insertion into the desired layer. However, little is known about changes in the facial layers during pinch manipulation. OBJECTIVE To determine which layer of the temple is lifted during pinching and whether the artery and the nerve are affected by pinching. MATERIALS AND METHODS At 11 sites on 3 fresh Korean cadavers, the skin of the temple was pinched gently or deeply, and the skin pulled up was cut at the bottom. The exposed areas were grossly and histologically examined. RESULTS With gentle pinching, the subcutaneous fat and superficial temporal fascia (STF) layer were separated, and the fat was removed with the skin. The superficial temporal artery and temporal branches of the facial nerve were intact. With deep pinching, the STF was separated from the deep temporal fascia and lifted with the skin. CONCLUSION When thread lifting is performed, deep pinching is helpful for anchoring thread to the temporal fascia, whereas gentle pinching helps to insert thread into the safe subcutaneous fat layer, where no significant blood vessels or nerves are present.

Patient Satisfaction and Patients' Family or Significant Other Perceptions After OnabotulinumtoxinA Treatment: A Prospective Cross-Sectional Study BACKGROUND OnabotulinumtoxinA treatment is associated with improved emotional well-being in patients. OBJECTIVE This study aimed to determine satisfaction with onabotulinumtoxinA treatment in patients naive to neurotoxin treatment and patients with previous experience with the procedure and evaluate treatment impact on patients' partners, “significant others,” or close family members. MATERIALS AND METHODS Patients' satisfaction and their family's/significant other's perception to treatment outcome were assessed in a prospective, cross-sectional study using standardized questionnaires. RESULTS OnabotulinumtoxinA treatment was associated with high patient satisfaction ranging from 80% to 100%. Study patients (61 patients) reported that their faces appeared to be more balanced and symmetrical (mean difference, 1.05) and that they looked much better in photographs (mean difference, 1.43), with their significant others also noting the improvement in appearance. Overall, 98% of patients expressed that they would undergo retreatment, and 100% expressed that they would recommend the procedure to others. The main obstacle for treatment repetition was economic constraints (26%). CONCLUSION OnabotulinumtoxinA treatment is one of the most precise and predictable cosmetic treatments available, with high patient satisfaction (97%). A positive outcome of onabotulinumtoxinA treatment, as expressed by patients surveyed using standardized questionnaires, was the appreciation and acceptance by those in close contact with them.