OBJECTIVE: To conduct a meta-analysis of the literature on surgical methods for the prevention of Frey syndrome and concave facial deformity after parotidectomy. METHODS: A PubMed search through February 2008 identified more than 60 English-language studies involving surgical techniques for prevention of these parameters. Analyzed works included 15 retrospective or prospective controlled studies reporting quantitative data for all included participants for 1 or more of the measured parameters in patients who had undergone parotidectomy. Report quality was assessed by the strength of taxonomy recommendation (SORT) score. Data were directly extracted from reports and dichotomized into positive and negative outcomes. The statistical significance was then calculated. RESULTS: The mean SORT score for all studies was 2.34, and the mean SORT score for all the analyzed studies was 1.88. Meta-analysis for multiple techniques to prevent symptomatic Frey syndrome, positive starch-iodine test results, and contour deformity favored intervention with a cumulative odds ratio (OR) of 3.88 (95% confidence interval [CI], 2.81-5.34); OR, 3.66 (95% CI; 2.32-5.77); and OR, 5.25 (95% CI, 3.57-7.72), respectively. CONCLUSION: Meta-analysis of operative techniques to prevent symptomatic Frey syndrome, positive starch-iodine test results, and facial asymmetry suggests that such methods are likely to reduce the incidence of these complications after parotidectomy.

OBJECTIVES:(1) To define and characterize knowledge of effective hand hygiene and its scientific basis among practicing facial plastic surgeons;(2) to review the existing literature of, basis for, and guidelines on hand washing in clinical practice; and (3) to motivate and facilitate optimum hand hygiene among facial plastic surgeons. METHODS: National Web-based physician survey and literature review. RESULTS: We conducted a national Web-based survey of members of the American Academy of Facial Plastic and Reconstructive Surgery regarding general patient safety practices. A subset of the survey assessed physicians' knowledge of hand hygiene, including supporting rationale and actual practices. One hundred and twenty-two facial plastic surgeons of various demographics replied to the online survey. Of these, 65 (53%) correctly knew which hand washing agents are most effective at killing microorganisms, 88 (74%) knew the preferred hand-washing method for visibly soiled hands, and 51 (42%) correctly identified the indications for hand washing. CONCLUSIONS: Adherence to hand hygiene practices is suboptimal among facial plastic surgeons. There seems to be a lack of knowledge regarding indications, methods, and appropriate agents for hand hygiene. Promotion of Centers for Disease Control and Prevention guidelines is an important step in increasing hand hygiene compliance among facial plastic surgeons.

Use of Food and Drug Administration-approved medications and products for other than the approved indications is common in facial plastic surgery and violates no laws. Addressing practical concerns about such use strengthens the doctor-patient relationship and can minimize the risk of successful allegations of negligence in the event of untoward outcomes. The facial plastic surgeon can find support and assistance with off-label use in two general areas. Abundant scientific literature focuses on off-label use and addresses its practical, scientific, legal, moral, and ethical issues. The Food and Drug Administration also addresses off-label use in its own publications. It offers guidelines for physicians that, if followed, facilitate incorporation of off-label use into practice with minimal risk and maximum potential for therapeutic success.

Christopher B. Skvarka, MD, and Steven S. Greenbaum, MD, have indicated no significant interest with commercial supporters.

Management of hypertrophic scars and keloids has advanced from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that act on a cellular level. There is no universally accepted treatment regimen and no evidence-based literature to guide management. Our objectives are to present a list of available treatment regimens, their proposed mechanisms of action, and supporting evidence and to perform a meta-analysis of clinical trials to identify treatments with a better-than-even likelihood of improvement. We conducted a PubMed search through October 2005, identifying clinical studies of various treatments for hypertrophic scars and keloids. We graded the quality of each study, delineated the results into favorable vs nonfavorable, and calculated the statistical significance of the findings. The meta-analysis of 70 treatment series for various clinical measures showed a 70% chance of improvement with treatment; however, the mean amount of improvement to be expected was around 60%. There was no statistically significant difference between treatments. Most treatments for keloidal and hypertrophic scarring offer minimal likelihood of improvement. The magnitude of likely permanent improvement in any sign or symptom may be clinically meaningful but far short of cure. Novel therapies deserve further investigation but remain without proven benefit to date.

OBJECTIVE: To introduce otolaryngologists to outcomes-linked reimbursement ("pay-for-performance"), identify clinical practice implications, and recommend changes for successful transition from the traditional "pay-for-effort" reimbursement model. STUDY DESIGN: Policy review. RESULTS: Payers are actively linking reimbursement to quality. Since the Institute of Medicine issued its report on medical errors in 1999, there has been much public and private concern over patient safety. In an effort to base health care payment on quality,"pay-for-performance" programs reward or penalize hospitals and physicians for their ability to maintain standards of care established by payers and regulatory groups. More than 100 such programs are operational in the United States today. This reimbursement model relies on detailed documentation in specific patient care areas to facilitate evaluation of outcomes for purposes of determining reimbursement. Because performance criteria for reimbursement have not yet been proposed within otolaryngology-head and neck surgery, otolaryngologists must be involved to ensure the adoption of reasonable goals and development of reasonable systems for documentation. CONCLUSION:"Pay-for-performance" reimbursement is increasingly common in the current era of outcomes-based medicine. It will assume an even greater role over the next 3 years and will directly affect most otolaryngologists.

OBJECTIVES: To determine current practice for use of perioperative antibiotics among facial plastic surgeons, to determine the extent of use of literature support for preferences of facial plastic surgeons, and to compare patterns of use with nationally supported evidence-based guidelines. METHODS: A link to a Web site containing a questionnaire on perioperative antibiotic use was e-mailed to more than 1000 facial plastic surgeons in the United States. Responses were archived in a dedicated database and analyzed to determine patterns of use and methods of documenting that use. Current literature was used to develop evidence-based recommendations for perioperative antibiotic use, emphasizing current nationally supported guidelines. RESULTS: Preferences varied significantly for medication used, dosage and regimen, time of first dose relative to incision time, setting in which medication was administered, and procedures for which perioperative antibiotic was deemed necessary. CONCLUSIONS: Surgical site infection in facial plastic surgery can be reduced by better conformance to currently available evidence-based guidelines. We offer specific recommendations that are supported by the current literature.

BACKGROUND: Cosmetic repair of elongated or lacerated earlobe tracts is a commonly encountered dermatologic procedure. For esthetic purposes, patients may choose to repierce the repaired lobe over the original site. Subsequent piercing within a scarred area potentially increases the risk of recurrent tract elongation secondary to the reduced tensile strength of the scar. OBJECTIVE: To strengthen a damaged earlobe by incorporating a nonabsorbable, dermal polypropylene suture during earlobe METHODS: The technique is described within the text. RESULTS: A deep polypropylene suture placed within a repaired earlobe tract provides a permanent barrier above which repiercing can be performed. CONCLUSION: Permanent reinforcement of the repaired earlobe serves to reduce the possibility of recurrent elongation of the earlobe tract. The technique is relevant when repeat piercing is desired over the original site.

It is difficult to estimate the area affected by an oil spill at sea, the degree of coverage by oil pollutants within the affected area, and the quantity of pollutants involved. Estimates of volumes and flow rates are based on estimated changes in areal extent of the spill. Uncertainties in measurement of area degrade the accuracy of estimating other parameters. To resolve this problem, available stock components have now been assembled into a system that yields repeatable, economical measurement of the areal extent of oil spills at acceptable levels of accuracy. The system comprises overflights with a thermal infrared imaging system, densitometric color enhancement of the infrared images, and automatic digital planimetry of the areas of specified image densities.

BACKGROUND The clinical relevance of the anatomic distribution of basal cell carcinoma is not completely understood. Embryonic fusion planes-the regions of mesenchymal migration and fusion of the five primordial facial processes during the 5th to 10th weeks of human development-have been implicated in the pathogenesis of basal cell carcinoma. OBJECTIVE This study sought to examine the predilection of midfacial basal cell carcinoma for cutaneous anatomical sites correlated to embryonic fusion planes. METHODS AND MATERIALS Using archived digital images and a detailed anatomic diagram, cases of basal cell carcinoma were coded according to their specific location and were aggregated into two anatomic domains according to their correlation to embryonic fusion planes. The relative tumor densities were calculated. RESULTS Of the 1,457 cases examined, 859 were located in the midface. Thirty-five percent of the midfacial lesions were located on the domain correlated to embryonic fusion planes, which represented 11.3% of the total surface area of the midface. The relative tumor density of lesions in the fusion plane domain was 3.06 compared to 0.74 for the remaining lesions (p<.001). CONCLUSIONS Although there is no consensus about the importance of anatomic location in the pathogenesis of basal cell carcinoma, these data indicate that, after adjusting for surface area, basal cell carcinoma was more than four times more likely to occur on an embryonic fusion plane than on other regions of the midface. These data support the possibility of an embryologic role for the pathogenesis of basal cell carcinoma.

A study was conducted on a south Texas rangeland area to evaluate aerial color-infrared (CIR) photography and CIR digital imagery combined with unsupervised image analysis techniques to map broom snakeweed [Gutierrezia sarothrae (Pursh.) Britt. and Rusby]. Accuracy assessments performed on computer-classified maps of photographic images from two sites had mean producer's and user's accuracies for broom snakeweed of 98.3 and 88.3%, respectively; whereas, accuracy assessments performed on classified maps from digital images of the same two sites had mean producer's and user's accuracies for broom snakeweed of 98.3 and 92.8%, respectively. These results indicate that CIR photography and CIR digital imagery combined with image analysis techniques can be used successfully to map broom snakeweed infestations on south Texas rangelands.

OBJECTIVE: To demonstrate how to improve the reproducibility and accuracy of digital images of the skin taken with commercially available digital cameras by transforming them to a standard color space, sRGB. METHODS: Our computer algorithm transforms digital images to the standard sRGB color space. It is based on a card with a number of color squares with known colorimetric properties that is included in the image, thereby removing any ambiguity about the color information in the image. Reproducibility and accuracy of the method were assessed by comparing images of color squares with known colorimetric properties taken with different digital cameras at different exposures and zoom settings. RESULTS: Although calibrated images exhibit markedly improved precision and accuracy compared with noncalibrated images, all variability of the imaging process cannot be eliminated. CONCLUSION: With a little care and effort, a calibrated color chart, and computer software, it is possible to greatly improve the quality of clinical imaging in dermatology and possibly other fields of medicine.

Improved detection of forensic evidence by combining narrow band photographic images taken at a range of wavelengths is dependent on the substance of interest having a significantly different spectrum from the underlying substrate. While some natural substances such as blood have distinctive spectral features which are readily distinguished from common colorants, this is not true for visualization agents commonly used in forensic science. We now show that it is possible to select reagents with narrow spectral features that lead to increased visibility using digital cameras and computer image enhancement programs even if their coloration is much less intense to the unaided eye than traditional reagents. The concept is illustrated by visualising latent fingermarks on paper with the zinc complex of Ruhemann's Purple, cyanoacrylate-fumed fingerprints with Eu(tta)(3)(phen), and soil prints with 2,6-bis(benzimidazol-2-yl)-4-[4'-(dimethylamino)phenyl]pyridine [BBIDMAPP]. In each case background correction is performed at one or two wavelengths bracketing the narrow absorption or emission band of these compounds. However, compounds with sharp spectral features would also lead to improved detection using more advanced algorithms such as principal component analysis.

BACKGROUND: The reconstruction of small defects of the alar groove can be a unique challenge owing to the importance of maintaining its concave structure. OBJECTIVE: To present a report of a patient with a small alar groove defect that was repaired using a combination of partial primary closure and second-intention healing. METHODS: A 73-year-old female was referred for the treatment of a basal cell carcinoma of the right nasal ala and underwent Mohs micrographic surgery with clearance of the lesion. The final defect, less than 1 cm, extended to the subcutaneous fat. Two absorbable subcutaneous sutures were placed in the defect, and the wound was then allowed to heal by second intention. RESULTS. This closure yielded a good cosmetic result, with preservation of the alar groove. CONCLUSION: A combination of primary closure and second-intention healing is a time-efficient, low-risk option for nonperforating, small alar groove defects.

BACKGROUND: Basal cell carcinoma (BCC) is the most common type of skin cancer. One of the main problems with BCC is the risk of local recurrence of the tumor after treatment. This is mainly due to its irregular outgrowths, which cannot be detected clinically. OBJECTIVE: To better understand the tumor morphology and growth pattern of BCC, we tried to develop a method that provides a precise three-dimensional model of the tumor. METHODS: Because Mohs surgery provides the best overview of the tumor and the tumor margins (both lateral and in depth), the reconstruction was based on slides from Mohs surgery. After digitization and processing of the slides, the tumor was then surrounded by a Mohs surgeon on a computer screen. These selections (lines) were used for a three-dimensional reconstruction of the tumor using MedSurf3D software. RESULTS: This method allows three-dimensional reconstruction of any given BCC. The MedSurf3D software enables visualization of a three-dimensional model of the tissue, which is removed during the surgical procedure. CONCLUSIONS: Three-dimensional reconstruction is a fascinating tool that might improve our understanding of the behavior, growth pattern, and tumor morphology of BCCs. This technique might also be useful in other fields of cutaneous oncology, such as the calculation of the tumor volume of melanomas.

BACKGROUND: ERBIN is a binding partner of Erb-B2, an orphan receptor within the Erb-B family critically involved in the regulation of cell growth and differentiation. Although its function remains unclear, ERBIN is thought to affect the polarity of epithelial cells and cell growth via the Ras signalling pathway. OBJECTIVES: To examine and compare the tissue distribution and the expression levels of ERBIN and Erb-B2 in normal skin and in cutaneous carcinomas. METHODS: Fifteen cases of basal cell carcinoma (BCC), 12 cases of squamous cell carcinoma (SCC) and five cases of keratoacanthoma (KA) were analysed by immunohistochemistry on paraffin-embedded sections using anti-ERBIN and anti-Erb-B2 antibodies. RESULTS: ERBIN and Erb-B2 had a similar distribution in normal human skin. They were primarily localized at the plasma membrane in differentiated keratinocytes and in duct cells from eccrine glands, whereas they were localized diffusely in the cytoplasma of basal keratinocytes. In both SCC and KA the subcellular distribution of ERBIN and Erb-B2 remained unchanged, whereas both proteins were redistributed from the plasma membrane into cytosolic aggregates in BCC. CONCLUSIONS: The subcellular localization of ERBIN in normal human skin is similar to that of Erb-B2 and varies with cell differentiation. Based on our findings and on the biological activities of Erb-B2, it is conceivable that disturbed expression or functioning of ERBIN and Erb-B2 is implicated in the development of the malignant phenotype of BCC.

BACKGROUND: Proliferating trichilemmal tumor is an uncommon tumor of the follicular isthmus of the hair follicle. It usually presents as a solitary nodule on the scalp of older white women. Although these lesions typically behave in a benign fashion, recurrences and metastasis after local excision have been reported. Mohs' micrographic surgery has been effectively used to treat adnexal neoplasms. OBJECTIVE: To report a case of a proliferating trichilemmal tumor in a young black man, which was excised using Mohs' micrographic surgery. METHODS: Case report and review of the literature. RESULTS: Mohs' micrographic surgery demonstrated an irregular extension of the tumor beyond a 1 cm surgical margin. CONCLUSIONS: Proliferating trichilemmal tumors should be considered in the differential diagnosis of cutaneous neoplasms on the scalp in persons of any age (with the possible exception of infants and children), sex, or race. Mohs' micrographic surgery may be considered an optimal treatment option for proliferating trichilemmal tumors because these lesions may have an infiltrative component that may not be clinically apparent.