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BACKGROUND Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke. OBJECTIVE The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection. MATERIALS AND METHODS Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course. RESULTS Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3). CONCLUSION The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.

BACKGROUND Dermatologists are at potential risk of acquiring infections from contamination of the mucous membranes by blood and body fluids. However, there are little data on splash safety during procedural dermatology. OBJECTIVE To determine dermatology resident perceptions about splash risk during dermatologic procedures and to quantify the rate of protective equipment use. METHODS An anonymous on-line survey was sent to 108 United States ACGME-approved dermatology residency programs assessing frequency of facial protection during dermatologic procedures, personal history of splash injury, and, if applicable, reasons for not always wearing facial protection. RESULTS A total of 153 dermatology residents responded. Rates of facial protection varied by procedure, with the highest rates during surgery and the lowest during local anesthetic injection. Over 54% of respondents reported suffering facial splash while not wearing facial protection during a procedure. In contrast, 88.9% of respondents correctly answered that there is a small risk of acquiring infection from mucosal splash. Residency program recommendations for facial protection seem to vary by procedure. CONCLUSION The authors' results demonstrate that although facial splash is a common injury, facial protection rates and protective recommendations vary significantly by procedure. These data support the recommendation for enhanced facial protection guidelines during procedural dermatology.

BACKGROUND There are numerous blades available for use in dermatologic procedures. There are different advantages that are inhere.nt to different blades due to their shape and size. One aspect of the blade that is instrumental to its performance, but is not objectively defined, is sharpness. This information could be useful when choosing a blade for a particular procedure. OBJECTIVE This study aims to objectively define the sharpness of blades used in dermatologic surgery. METHODS AND MATERIALS The Sharpness Tester (Cutlery and Allied Trades Research Association, Sheffield, UK) was used to test the force in Newtons a blade requires to cut through a silicone cylinder. New blades were used to determine a standard for the sharpness of new blades. Blades used for surgery were tested to determine the sharpness after use. RESULTS The sharpest blade is the double-edged razor blade (0.395 N) followed by the dermablade (0.46 N), plastic handled #15 (0.541 N), #15c (0.575 N), #10 (0.647 N), and the #15 blade (0.664 N). CONCLUSION The sharpness of a blade is an important factor in its ability to perform a task and should be taken into account when choosing a particular blade for a particular procedure.

Common dermatologic procedures performed on the forehead may injure the supraorbital nerve (SON) leading to adverse outcomes.To describe SON anatomic course and cutaneous depth.Sixteen cadaver specimens were dissected.The supraorbital nerve originated 2.63 ± 0.27 (range, 2.1-3.5) cm from the midline and 0.25 ± 0.16 (range, 0-0.5) cm above the orbital rim. Supraorbital nerve emerged as 1 root dividing into superficial (SON-S) and deep (SON-D) branches. The supraorbital nerve deep branch remained deep to the aponeurosis of the corrugator supercilii and frontalis muscles and coursed laterally toward the scalp. Supraorbital nerve superficial branch emerged nearly perpendicular to the orbital rim and traveled under the corrugator supercilii with an average depth of 0.75 ± 0.16 (range, 0.5-1.1) cm. Supraorbital nerve superficial branches entered the subfrontalis plane at a mean distance of 1.29 ± 0.20 (range, 1.0-1.8) cm above the orbital rim with an average depth of 0.45 ± 0.13 (range, 0.3-0.8) cm. These branches entered the subcutaneous plane by piercing through the frontalis muscle at a mean distance of 2.60 ± 0.32 (range, 1.9-3.2) cm above the orbital rim with an average depth of 0.30 ± 0.10 (range, 0.2-0.6) cm.The supraorbital nerve depth and course are relevant when performing procedures on the forehead. A thorough understanding of the anatomy and depth of SON-S is critical to help minimize nerve damage and optimize patient counseling.

Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized.To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time.The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010.Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively).Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand.

Background Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized. Objective To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them. Methods The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010. Results Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p

Background Although office-based dermatologic procedures are generally considered safe, there is a lack of prospective data on the rate of adverse events (AEs) associated with these procedures. Objective To determine the frequency of AEs after dermatologic surgery and to characterize the most commonly encountered AEs. Methods A web-based interface was designed to track AEs with the input of four dermatologic surgeons. Patient demographic and operative data were collected at the time of the dermatologic surgery procedure. AEs occurring at any time during the data collection period were logged according to an a priori categorization scheme. Results The AE rate was 2.0% in this series of 2,418 subjects undergoing dermatologic surgery from February 1 through December 14, 2010. The most commonly reported AEs were suspicion of infection (64%), postoperative hemorrhage (20%), and wound dehiscence (8%). Suspicion of infection was slightly less frequent in subjects who received prophylactic preoperative antibiotics (0.4%) than in those who did not (1.5%, p = .07). There were no serious AEs and no deaths. Conclusion AEs are uncommon after office-based dermatologic surgery procedures. Preoperative antibiotics may further decrease the infection rate after dermatologic surgery, but the risks and benefits must be weighed given the already low AE rate.

Background Simulation-based training has become popular in many surgical residencies for acquiring procedural skills, but simulator use is rare in dermatologic training. Objective To evaluate the perceived efficacy of obtaining dermatologic procedural skills using simulators. Methods and Materials Opinions of dermatology residents and staff regarding simulator use were assessed using questionnaires completed after a 2-day surgical symposium in which participants were instructed on and practiced with simulators and cadavers. Results Overall, 93.9% strongly agreed that simulators are helpful in acquiring procedural skills. More than three-quarters of participants agreed that simulators are useful in acquiring, refining, assessing, and learning these skills. Many participants further thought that simulator use would be beneficial in learning anatomy and trouble-shooting techniques. An overwhelming majority of those surveyed believed that training on simulators would be helpful in learning various dermatologic procedures; 90.9% of participants thought that training using simulators should be, at least in part, a mandatory component of residency. It was felt that this training should be conducted at the beginning of residency, with additional with sessions held throughout training. Conclusion Simulation offers an excellent model for the acquisition and assessment of dermatologic procedural skills. Cost and availability of instructors remain obstacles. Further studies are required to evaluate the implementation and effectiveness of these models.

Background Periprocedural analgesic therapy is an often overlooked, but critical component of ensuring adequate surgical patient care and overall satisfaction with surgical outcomes. Adequate pain management requires thorough assessment of pain and complete knowledge and understanding of the various therapeutic agents available. Objectives To further the knowledge and understanding of current strategies in pain management. Methods A literature review was conducted through PubMed to define current pain assessment and management strategies. Results and Conclusions Appropriate pain assessment leads to the selection of optimal pharmacologic options for pain control in the acute postoperative setting.

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.A literature review of currently available topical anesthetics, their safety profiles, and dermatologic uses was conducted.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.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.

BACKGROUND. Increases in complications resulting from the nonphysician practice of dermatologic procedures have been reported nationally. This investigation was initiated owing to growing concern regarding the nonphysician practice of medicine in Texas. OBJECTIVE. The objective was to survey dermatologists in Texas to determine the number of patients seeking corrective treatment owing to complications from dermatologic procedures performed by nonphysicians. METHODS. A total of 488 dermatologists in Texas were surveyed and seven patients who experienced complications were interviewed by phone. RESULTS. Nearly 53% of responding physicians noted increased complications resulting from nonphysician practice of medicine. Approximately 33% of responding physicians reported that complications were known to have occurred in the absence of an on-site supervising physician. CONCLUSION. The increase in the number of complications owing to nonphysician practice of medicine in Texas mirrors the increases that have been reported nationally. The serious complications reported underscore the need for improved awareness and regulatory changes by state boards of medicine.

Postinflammatory pigmentary changes are a frequently encountered problem with numerous dermatologic procedures. Limited literature is available that documents this complication with laser hair removal.It is important for all physicians performing laser hair removal to be aware of this potential complication. We present our experience with postinflammatory pigmentary change and discuss some potential etiologic factors.Seven patients who experienced postinflammatory complications after alexandrite laser hair removal are presented. These are all the patients who developed this complication in our office over the past 2.5 years.The patients who we describe in this article all developed a similar pattern of initial hyperpigmented rings, later developing into a thin wafer-like crust followed by hypopigmentation with gradual return to their normal skin color.In general, the alexandrite laser is both safe and effective for hair removal in patients of varying skin types. Complication rates will increase as skin pigment increases and as the power used increases. However, even in light-skinned individuals without recent pretreatment or posttreatment sun exposure, with proper treatment parameters, complications, and side effects can arise. We have found this to be especially true when treating areas other than the face.

background. Low cost, nonsterile examination gloves are used routinely to perform various dermatologic procedures. objective. To evaluate the perforation rate of nonsterile examination gloves in routine dermatologic procedures. methods. Three hundred fifty nonsterile latex examination gloves used to perform shave biopsies were evaluated for perforations using an air inflation/water submersion method. Ninety gloves, which were intentionally perforated with a 30-gauge needle, were used as controls to assess our evaluation method. results. Eight of the 350 gloves were found to have a perforation, which corresponds to a 2.3% perforation rate. Seven of the eight perforations were found in the web space between the second and third finger sleeves, with one being an obvious manufacturing error. All 90 perforations of the control group were correctly identified. conclusion. There appears to be a very low risk of glove perforation when nonsterile examination gloves are used in routine dermatologic procedures.