Incidence of Epinephrine Reactions With Local Anesthesia in Mohs Micrographic Surgery BACKGROUND The incidence of reactions to epinephrine-containing local anesthetics in Mohs micrographic surgery (MMS) has not been established. OBJECTIVE To estimate the incidence of epinephrine-induced reactions from local anesthetics in patients who undergo MMS for the removal of cutaneous malignancies. METHODS From 2016 to 2018, 200 MMS patients were recruited from the authors' surgical center. Assessments were obtained throughout the entirety of the Mohs cases during a single visit. RESULTS This study estimated the incidence of epinephrine reactions in patients who undergo MMS to be 2.0% (95% confidence interval: 0.1%–3.9%). No relationship between epinephrine dose and incidence of adverse effects was found. Patient age was a significant risk factor for the development of an epinephrine reaction. CONCLUSION Systemic reactions to epinephrine from local anesthetics are an infrequent adverse event in MMS cases. The data suggest that the absolute dose of local anesthetic with epinephrine does not correlate with the risk of developing an epinephrine reaction. Older age seems to have a protective effect. Address correspondence and reprint requests to: Justin M. McLawhorn, MD, OU Physicians Dermatology, 619 NE 13th Street, Oklahoma City, OK 73104, or justin-mclawhorn@ouhsc.edu The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Assessing the Feasibility of an Alternative Payment Model for Mohs Micrographic Surgery at an Academic Center BACKGROUND Mohs micrographic surgery (MMS) is a cost-effective treatment for nonmelanoma skin cancer that bundles costs for surgical excision, tissue processing, and histopathological interpretation. A comprehensive MMS bundle would include all aspects of an episode of care (EOC), including costs of reconstruction, preoperative, and postoperative care. OBJECTIVE To assess the feasibility of an alternative payment model for MMS and reconstruction. METHODS Retrospective chart review and payment analysis for 848 consecutive patients with 1,056 tumors treated with MMS. Average Medicare payment of an EOC was compared with bundles based on specific repair types. RESULTS The bundle for a flap/graft repair averaged $1,028.08 (confidence interval [CI] 95% $951.37–1,104.79), whereas the bundle for a linear closure (LC) averaged $585.07 (CI 95% $558.75–611.38). The average bundle including all repairs was $730.05 (CI 95% $692.31–767.79), which was statistically significant from both the flap/graft and LC bundles. CONCLUSION Bundling surgical repairs with MMS based on an average payment does not represent the heterogeneity of the care provided and results in either underpayment or overpayment for a substantial portion of cases. Consequently, EOC payments bundling MMS and surgical repairs would inaccurately reimburse physicians for work completed. Current payment methodology allows for accurate payment for this already cost-effective therapy. Address correspondence and reprint requests to: Sogyong Auh, MD, PhD, Premier Dermatology, 2051 Plainfield Road, Crest Hill, IL 60403, or e-mail: sauh@forefrontderm.com The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

ATX-101 (Deoxycholic Acid Injection) Leads to Clinically Meaningful Improvement in Submental Fat: Final Data From CONTOUR BACKGROUND Submental fat (SMF) can negatively affect perceptions of health and attractiveness. The Condition of Submental Fullness and Treatment Outcomes Registry (CONTOUR) was designed to understand SMF treatment in clinical practice. OBJECTIVE To report efficacy, treatment characteristics, and safety associated with real-world use of ATX-101 (deoxycholic acid injection). METHODS CONTOUR enrolled adults considering treatment for SMF reduction. ATX-101–treated patients who completed the end-of-treatment questionnaire were divided into those who ended treatment because they met their treatment goals (n = 197) and those who did not (n = 196). RESULTS Patients who met their goals (a more defined jawline, looking younger, and looking thinner) were more likely to have less SMF at baseline and to receive ≥2 ATX-101 treatments. More patients who met their goals achieved clinically meaningful reduction in SMF and reported increased satisfaction with their appearance (90% vs 57%). Moderate and severe patients' ATX-101 volume was similar for both those who met goals and those who did not, but extreme patients who met their goals required 10 mL more than those patients who did not. CONCLUSION Careful patient selection, adequate volume administration, and an appropriate number of treatments (dependent on baseline SMF severity) contribute to successful outcomes with ATX-101. Address correspondence and reprint requests to: Kathleen Behr, MD, Behr Laser & Skin Care Center, 1125 E Spruce Avenue #207, Fresno, CA, or e-mail: drbehr@435skin.com K. Behr and C.F. Teller are consultants, clinical research investigators, and speakers for Allergan. C.M. Kavali is a consultant and speaker for Allergan. G. Munavalli is a consultant and has a research grant with Allergan. S. Yoelin is a consultant, clinical research investigator, and speaker for Allergan; developed educational materials for Allergan; and received reimbursement for travel on behalf of Allergan. L. Breshears was an employee and stockholder with Evidence Scientific, Inc. at the time the manuscript was written. S. Sangha is an employee and stockholder of Allergan. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Electron Microscopy of Argyria Treated With Picosecond Alexandrite Laser No abstract available

Association Between Perceived Skin Cancer Risk Reduction and Sunscreen Use BACKGROUND Understanding factors that influence people to use sunscreen would allow clinicians to counsel patients in a way that is influential. Perceived efficacy of sunscreen has been associated with sunscreen use, but it is unclear whether the degree of efficacy is important. OBJECTIVE To determine whether larger perceived efficacy of sunscreen (larger skin cancer risk reduction) is associated with increased sunscreen use. MATERIALS AND METHODS A cohort of 131 patients with a history of skin cancer visiting a Mohs micrographic surgery center were surveyed. RESULTS Participants believed sunscreen would reduce their risk of basal cell carcinoma (BCC) by 61.1% (95% confidence interval [CI] = 56.4–65.9), squamous cell carcinoma (SCC) by 59.4% (95% CI = 54.6–64.2), and melanoma by 59.5% (95% CI = 54.8–64.3). Perceived magnitude of risk reduction of BCC, SCC, and melanoma was significant independent predictors of sunscreen use (BCC: odds ratio [OR] 3.5, 95% CI 1.1–11.2, p = .04. Squamous cell carcinoma: OR 2.8, 95% CI 1.0–7.6, p = .05. Melanoma: OR 5.0, 95% CI 1.8–14.2, p = .002). CONCLUSION Larger perceived skin cancer (BCC, SCC, and melanoma) risk reduction was associated with increased sunscreen use. Address correspondence and reprint requests to: Timmie R. Sharma, MD, Department of Dermatology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, or e-mail: Timmie.Sharma@uhhospitals.org The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Cicatricial Ectropion Repair for Dermatologic Surgeons BACKGROUND Cicatricial ectropion occurs when tension of a scar below the eye has sufficient downward pull to evert the lower eyelid. There are many surgical techniques to repair cicatricial ectropion. OBJECTIVE To review the published literature on the repair of cicatricial ectropion, review relevant anatomy, and review surgical considerations for patients with cicatricial ectropion from the perspective of a dermatologic surgeon. MATERIALS AND METHODS A search of PubMed was conducted to identify articles on cicatricial ectropion repair through December 1, 2017. Articles were individually reviewed for applicability to dermatologic surgery. RESULTS Forty-one articles were reviewed. Many articles report significant differences in outcomes when comparing 1 cicatricial ectropion repair technique to another; however, 1 single surgical approach has not been shown to be superior to the rest for most patients. CONCLUSION There is a lack of consensus among the literature about the optimal approach to repairing cicatricial ectropion. The selection of surgical technique will vary depending on several factors including the lateral or medial extent of the ectropion, the degree of scarring and tissue density of potential donor sites for a skin flap, and the severity of lid laxity. Address correspondence and reprint requests to: Jeremy S. Bordeaux, MD, MPH, Department of Dermatology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH 44106, or e-mail: jeremy.bordeaux@uhhospitals.org The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Vascular and Pigmented Lesions of Phacomatosis Pigmentovascularis Treated With a Combination of Long-Pulsed, Q-Switched Laser, and Picosecond Lasers No abstract available

Dermatofibrosarcoma Protuberans of the Scalp: A Challenging Tumor With a Proposed Modification to the Slow Mohs Technique No abstract available

Multimedia Technology Used to Supplement Patient Consent for Mohs Micrographic Surgery BACKGROUND The patient consent process traditionally relies on conversations between the physician and the patient and rarely utilizes supplemental multimedia aids. OBJECTIVE To determine whether the addition of an educational video on Mohs micrographic surgery (MMS) can improve patient satisfaction with the consent process. MATERIALS AND METHODS This prospective observational quality improvement study compared the outcomes of traditional patient consent alone versus standard consent plus an educational video among patients undergoing their first MMS for a primary skin cancer. End points were patient satisfaction and preferences measured by postprocedure questionnaires. RESULTS The addition of a supplemental video to the consent process did not affect overall patient satisfaction, which was very high in both video and control groups. However, specific components of patient satisfaction were improved such as patient perception of the opportunity to ask questions and understand the procedure. CONCLUSION Multimedia aids can be effective tools in the patient consent process. Address correspondence and reprint requests to: Rajiv I. Nijhawan, MD, Department of Dermatology, University of Texas Southwestern Medical Center, 5939 Harry Hines Blvd. Suite 400, Dallas, TX 75390-9191, or e-mail: Rajiv.Nijhawan@UTSouthwestern.edu The development of the educational video was funded by the American Society for Dermatologic Surgery through the Future Leaders Network. The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Cutaneous Ultrasound for Tumor Thickness Measurement in Squamous Cell Carcinoma: The Effect of Neoadjuvant Intralesional Methotrexate in 40 Patients BACKGROUND Intralesional methotrexate (il-MTX) has been used as neoadjuvant therapy for cutaneous squamous cell carcinoma (cSCC) but studies on its effects on tumor thickness are lacking. OBJECTIVE The objective of this study was to evaluate il-MTX response with ultrasound examination. METHODS The authors conducted a prospective study in 40 patients with histologically confirmed cSCC. Neodjuvant il-MTX therapy was administered before surgery. Ultrasound evaluation was performed before the first infiltration and before surgical treatment. RESULTS Response to neoadjuvant treatment was observed in 92.5% of patients, both clinically and sonographically. There was a good correlation between both types of measurements, with r = 0.892 for the minor diameter and r = 0.944 for the major diameter (p < .001). The authors found an ultrasound overestimation compared to the clinical measurements in 92.5% of patients (mean overestimation: 1.08 mm). There was a good correlation between ultrasound and histological measurements in tumor thickness with r = 0.932 (p < .01), with an ultrasound overestimation in 97.5% of cases (mean overestimation: 0.90 mm). CONCLUSION Neoadjuvant il-MTX can reduce not only surface tumor dimensions but also tumor thickness. Ultrasound improves treatment response control with greater accuracy than clinical assessment alone. Address correspondence and reprint requests to: Marta Bergón-Sendín, MD, Department of Dermatology, Hospital General Universitario Gregorio Marañón, c/Dr. Esquerdo 46, 28007 Madrid, Spain, or e-mail: mbergon1@yahoo.es The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.