dermatology & plastic surgery institute - cleveland clinic · 2015-08-26 · dermatology &...

Dermatology & Plastic Surgery Institute

2014Outcomes

97973_CCFBCH_15OUT353_ACG.indd 1 6/19/15 11:35 AM

Measuring Outcomes Promotes Quality Improvement


Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its clinical institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with a focus on outcomes data and a review of new technologies and innovations.

The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical and procedural techniques.

In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data. The following reports are available to the public: • Joint Commission Performance Measurement Initiative (qualitycheck.org)

• Centers for Medicare and Medicaid Services (CMS) Hospital Compare (HospitalCompare.hhs.gov), and Physician Compare (medicare.gov/PhysicianCompare)

• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR)

Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic’s culture of continuous improvement and may help referring physicians make informed decisions.

We hope you find these data valuable, and we invite

your feedback. Please send your comments and

questions via email to:

[email protected] or scan here.

To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.


2 Outcomes 20142

Dear Colleague:

Welcome to this 2014 Cleveland Clinic Outcomes book. Every year, we publish Outcomes books for 14 clinical institutes with multiple specialty services. These publications are unique in healthcare. Each one provides an overview of medical or surgical trends, innovations, and clinical data for a particular specialty over the past year. We are pleased to make this information available.

Cleveland Clinic uses data to manage outcomes across the full continuum of care. Our unique organizational structure contributes to our success. Patient services at Cleveland Clinic are delivered through institutes, and each institute is based on a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Institutes define quality benchmarks for their specialty services and report on longitudinal progress.

All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic.org/QPR). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites.

Our practice of releasing annual outcomes books has become increasingly relevant as healthcare transforms from a volume-based to a value-based system. We appreciate your interest and hope you find this information useful and informative.

Sincerely, Delos M. Cosgrove, MD CEO and President


3Dermatology & Plastic Surgery Institute 3

Chairman’s Letter 04

Institute Overview 05

Quality and Outcomes Measures

Melanoma 06

Aesthetic Surgery 13

Breast Surgery 21

Face Transplant 30

Lower Extremity Reconstruction 36

Merkel Cell Carcinoma 40

Alopecia 43

Dermatopathology 46

Dermatologic Surgery and Cutaneous Oncology 50

Infantile Hemangiomas 54

Hospital Consults 58

Teledermatology 60

Institute Patient Experience 62

Innovations 64

Cleveland Clinic — Implementing Value-Based Care 67

Contact Information 68

About Cleveland Clinic 70

Resources 72

what’s inside

Prefer an e-version?

Visit clevelandclinic.org/OutcomesOnline, and

we’ll remove you from the hard copy mailing list

and email you when next year’s books are online.


Chairman LetterChairman LetterChairman’s Letter

Dear Colleagues,

Thank you for your interest in the 2014 outcomes for Cleveland Clinic’s Dermatology & Plastic Surgery Institute. This Outcomes book highlights the institute’s trends and innovations for all referring physicians, alumni, potential patients, and others nationwide.

The highlight of 2014 was in September, when a multidisciplinary team of caregivers led by plastic and reconstructive surgeons successfully performed Cleveland Clinic’s second face transplant. The vascularized composite allograft transplantation of face, orbits, and maxilla took more than 24 hours to complete and is a great example of Cleveland Clinic’s leadership role in creating collaborative teams that produce innovative outcomes.

In addition:

• Ongoing collaboration and coordination between Plastic and Reconstructive Surgery and the Transplant Center have yielded new opportunities to build on the successes of Cleveland Clinic’s Vascularized Composite Allograft Transplant program, with multiple candidates in various stages of review by the team.

• US trials are underway on a new surgical approach that our team has worked on for the treatment of painful cluster and migraine headaches. The procedure involves implantation of a stimulating electrode to modulate the pain, and it has proved effective in European studies.

• The Dermatology Department has leveraged technology through telemedicine in efforts to increase access to patient care.

We welcome your feedback, questions, and ideas for collaboration. Please contact me via email at [email protected] and reference the Dermatology & Plastic Surgery Institute book in your message.

Respectfully,

Frank A. Papay, MD, FACS, FAAP Chairman, Dermatology & Plastic Surgery Institute Professor, Cleveland Clinic Lerner College of Medicine

Outcomes 20144


Institute OverviewInstitute OverviewInstitute Overview

Cleveland Clinic’s Dermatology & Plastic Surgery Institute is one of the largest such practices in the nation, offering patients a wide array of dermatologic, reconstructive, and aesthetic services. The institute and its staff members are regarded as dermatology and plastic surgery leaders through accomplishments in patient care, clinical research, and specialty academy leadership.

The institute includes the Department of Dermatology, with 31 dermatologists who offer subspecialized care for adult and pediatric patients, and the Department of Plastic Surgery, including 17 plastic surgeons with significant expertise in all areas of aesthetic and reconstructive plastic surgery. The Ohio practice consists of care at Cleveland Clinic’s main campus, nine family health centers, and three regional hospitals across Northeast Ohio. In addition to the departments in Ohio, the institute includes three dermatologists and five plastic surgeons who offer care at three Cleveland Clinic locations in southern Florida. Dermatology and Plastic Surgery physicians not only provide focused specialty care clinics, but also participate on numerous care teams combining the collective expertise of multiple Cleveland Clinic specialists, with clinics focused on craniofacial and cleft palate, vascular malformation, wound healing, melanoma, aesthetics, and reconstructive transplant.

Outcomes 2014 –– Northeast Ohio and Florida

Institute Overview Total

Patient Visit Volume Dermatology 122,615 Plastic surgery 47,426 Dermatologic Procedures and Treatments Mohs micrographic surgery 3580 Phototherapy/ultraviolet light treatments 9045 Dermatopathology accessions 24,965Facial Surgeries Facelift/necklift 116 Blepharoplasty (upper & lower) 135 Browlift 21Primary and Secondary Rhinoplasty Primary 59 Secondary 12Breast Surgeries Breast reduction 277 Breast augmentation 180 Mastopexy 164Body Contouring Abdominoplasty 168 Liposuction trunk/extremities 378 Liposuction head/neck 10Breast Reconstruction Reconstruction with TRAM flap 4 Reconstruction with prosthesis 417 Reconstruction with latissimus dorsi flap 26 Oncoplasty 80 DIEP flap 138Endoscopic and Open Carpal Tunnel Surgery Endoscopic 172 Open 364 TRAM = Transverse rectus abdominis myocutaneous DIEP = Deep inferior epigastric perforator

Dermatology & Plastic Surgery Institute 5


6 Outcomes 20146

Melanoma

Sentinel Lymph Node Biopsy Using Indocyanine Green Fluoroscopy

Sentinel lymph node biopsy is the standard of care for intermediate-depth and high-risk thin melanomas. Recently, indocyanine green and near-infrared imaging have been used to aid in sentinel node biopsy. Dermatology & Plastic Surgery Institute researchers conducted a study to compare the technique with standard modalities.1

A retrospective review of 90 consecutive cutaneous melanoma patients who underwent sentinel lymph node biopsy between November 2010 and March 2013 yielded 2 cohorts: group A, including 39 patients who had sentinel lymph node biopsy performed with blue dye and radioisotope; and group B, including 51 patients treated after April 2011 who had sentinel lymph node biopsy performed with radioisotope and indocyanine green SPY Elite™ Imaging System navigation. All patients also underwent lymphoscintigraphy and gamma probe. Median follow-up for the study population was 6.7 months.

The cohorts were assessed for differences in localization rates, sensitivity and specificity of sentinel node identification, recurrence, and length of surgery.

The sentinel lymph node localization rate using the indocyanine green fluorescence method was superior to that using the vital dye method and detected more sentinel lymph nodes (P = 0.02). A trend toward a reduction in operative time was also noted in the indocyanine green cohort.

biopsy


Institute Overview


Recurrences by Cohort and Subsequent Treatmenta (N = 90) November 2010 – March 2013

Group A

39 Patients

Group B

51 Patients

5

CLND

7

CLND

34

Negative SLNB

44

Negative SLNB

2e2c

5 (12.8%)

Positive SLNB

7 (13.7%)

Positive SLNB

1f3d

Radioisotope + Vital Dye

Radioisotope + Indocyanine Green

Sentinel Lymph Node Status

Sentinel Lymph Node Status

Treatmentb

Recurrence

Treatmentb

Recurrence

CLND = complete lymph node dissection, SLNB = sentinel lymph node biopsyaNo patient in group A or B with recurrence would be considered to have had a false-negative sentinel lymph node biopsy, as recurrences were outside of the regional nodal basin. bInterferonc1 with distant metastases, 1 with local recurrenced1 within sampled nodal basin, 2 with distant metastasese2 with local and distant metastasesf1 with distant metastases


8 Outcomes 20148

Melanoma

Sentinel Lymph Node Localization Rate (N = 90) November 2010 – March 2013

Mean and Median Sentinel Node Identification: Vital Dye vs Indocyanine Green November 2010 – March 2013

Group A: Vital Dyes Group B: Indocyanine Green

N Mean (SD) Median (Range) N Mean (SD) Median (Range) P value

Sentinel nodes identified 34 1.71 ± 2.43 1 (0 – 13) 51 1.86 ± 1.18 2 (0 – 6) 0.02

Reference

1. Korn J, Tellez-Diaz A, Bartz-Kurycki M, Gastman B. Indocyanine green SPY elite-assisted sentinel lymph node biopsy in cutaneous melanoma. Plastic Reconstr Surg. 2014 Apr;133(4):914-922.

Sentinel Lymph Node Biopsy Method N %

Lymphoscintigraphy

No localization 3 3.33

Localization 87 96.67

Gamma Probe



Vital Dye (Group A)



Indocyanine Green SPY (Group B)





Noninvasive Analysis of Pigmented Lesions

In 2013, the Department of Dermatology initiated use of MelaFind® to analyze clinically and dermatoscopically ambiguous pigmented lesions.

The MelaFind multispectral optical handpiece emits 10 spectral light bands (430–950 nm) penetrating to a depth of 2 mm below the skin surface. Patterns in the light reflected back to the handpiece are analyzed for the presence of atypia and malignancy (in situ to mature) by algorithms based on a database of more than 10,000 pigmented lesions. Each lesion examined is scored on a low to high disorganization scale.

Patients with a personal or family history of atypical/dysplastic nevi or a personal or family history of malignant melanoma or melanoma in situ are potential candidates for MelaFind analysis. An initial total body skin examination is performed, and dermoscopy is used to evaluate all pigmented nevi. Clinically and dermatoscopically banal lesions are not candidates for MelaFind analysis, and those grossly suspicious for atypia or frank malignancy are biopsied directly.

Between March 2013 and February 2015 a total of 496 ambiguous pigmented lesions in 90 patients were identified by visual inspection and dermoscopy and scanned with MelaFind. Of these, 339 were determined to be low risk, and 157 were high risk and biopsied. Biopsy results yielded 107 normal and 47 atypical nevi, and 3 malignant melanomas.

Without MelaFind analysis, all 496 clinically ambiguous pigmented lesions would have required biopsy. By limiting biopsy to only 157 lesions, unnecessary procedures were reduced by 68%. However, of the 157 high-risk lesions, only 30% were atypical and 2% were malignant melanoma upon biopsy.

Further analysis of the subset of lesions graded as high risk by MelaFind but found to be benign on pathologic analysis is being pursued. Early findings are that the presence of inflammation and/or melanoderma contiguous to the pigmented lesion may yield a false high-risk score. If that can be incorporated into the MelaFind algorithm in the future, then perhaps the specificity of the results can be enhanced, leading to an even lower required biopsy rate for at-risk patients, and also to a higher positive yield on lesions requiring biopsy.


10

The MelaFind device Examples of clinically ambiguous pigmented lesions

400

300

200

100

0

Number of Lesions

Low-risk lesions (N = 339)Normal nevi (N = 107)Atypical nevi (N = 47)Malignant melanoma (N = 3)

Low-Risk LesionsNo Biopsy

High-Risk LesionsBiopsy Results

Outcomes 201410

Melanoma

Clinical Decisions After MelaFind Analysis of Pigmented Lesions in 90 Patients (N = 496) March 2014 – February 2015



National Quality Measures for Cutaneous Malignant Melanoma Staging

In 2009, the American Joint Committee on Cancer defined and described pathologic characteristics that can enhance the accuracy of primary cutaneous melanoma tumor staging.1 The recommendations include adding mitotic rate (stage pT1 and higher) and ulceration characteristics, in addition to tumor thickness, to pathology reports. The institute’s Dermatopathology Section reported the quality measures for all primary malignant melanoma specimens processed at Cleveland Clinic’s main campus in 2014.

Parameter Number Percent

Report lists pT category 120 100

Tumors staged pT1 94 –

pT1 report lists mitotic rate 94 100

Report includes a statement on thickness 120 100

Report includes information on ulceration 120 100

AJCC = American Joint Committee on Cancer, pT = primary tumor

Reference

1. Balch CM, Gershenwald JE, Soong SJ, Thompson JF, Atkins MB, Byrd DR, Buzaid AC, Cochran AJ, Coit DG, Ding S, Eggermont AM, Flaherty KT, Gimotty PA, Kirkwood JM, McMasters KM, Mihm MC Jr, Morton DL, Ross MI, Sober AJ, Sondak VK. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol. 2009 Dec 20;27(36):6199-6206.

Primary Malignant Melanoma Pathology Reports Meeting AJCC Criteria (N = 120) 2014


12 Outcomes 201412

Melanoma

Melanoma Care Path Increases Treatment Quality, Efficiency

In the beginning of 2011, the Dermatology & Plastic Surgery Institute assembled a multidisciplinary group charged with improving the quality and efficiency of melanoma care. The team designed a melanoma treatment algorithm based on the institute’s melanoma outcomes, and a Cleveland Clinic melanoma care path was approved and instituted last year. As a result, since 2010 there has been more than a 50% increase in the number of melanoma patients treated at the main campus.

Total Number of Melanoma Casesa 2010 – 2013

400

300

200

100

0

Number of New Melanoma Patients

2010 2011 2012 2013

aCleveland Clinic main campus cases


13Dermatology & Plastic Surgery Institute

Aesthetic Surgery

Pain Management in Surgical Facial Rejuvenation

The Joint Commission now mandates the adequate assessment, monitoring, and treatment of pain as one of the conditions for hospital accreditation. Furthermore, aggressive efforts to reduce postoperative pain while avoiding adverse sequelae such as nausea and vomiting can improve the patient experience. Multimodal therapy with newer pharmaceuticals, medical devices, and longer-acting local anesthetics offers the potential to reduce pain and enhance patient satisfaction.

Institute surgeons reviewed currently available pain management options with the aim of highlighting multimodal therapy and minimizing opioid use by substituting nonnarcotic treatment whenever possible.

New Modalities of Pain Control in Facial Rejuvenation Surgery

Concept Example

Use new pharmaceutical advancements IV acetaminophen

Use longer-acting local anesthetics Liposomal bupivacaine

Use devices designed to minimize postoperative pain Continuous infusion pain pumps

Use regional anesthesia Facial nerve blocks

Treat nausea prophylactically and aggressively in the Ondansetron, scopolamine patch

postoperative period

Avoid blood-thinning agents Ibuprofen, aspirin, herbals

Traditional methods Head elevation, cold compress (when

appropriate), relaxation techniques


14

pain controlOutcomes 201414

Aesthetic Surgery

Comparison of Pain Pump vs Bupivacaine Block After Endoscopic Brow Lift (N = 28) 2004 – 2012

Pain Pump Bupivacaine Block (N = 14) (N = 14)

Mean recovery room time, minutes 140 143

Pain score upon arrival to recovery 1.3/10 3.6/10

Pain score upon discharge 2.7/10 3.5/10

In an ongoing effort to maximize patient comfort, the institute also assessed the effectiveness of various devices, technologies, and treatment modalities available for pain control after surgical facial rejuvenation. These include local anesthetics, topical creams, intravenous acetaminophen, local anesthetic wound catheter delivery systems, liposomal bupivacaine, postoperative pharmacologic therapeutics, and techniques to eliminate pain with suture removal. This experience combined with a review of the literature has resulted in specific pain management recommendations for various facial rejuvenation surgeries.1

A study comparing regional block to pain pump placement for postoperative pain control in patients undergoing endoscopic brow lift was conducted. Pain scores were similar between the groups upon arrival to the recovery room and upon discharge, supporting the concept of regional anesthesia.



Proposed Methods of Pain Control for Various Facial Rejuvenation Surgeries

Brow Lift Before incision, relative tumescence of the forehead, temple, and scalp with 0.5% lidocaine with epinephrine 1:200,000

Block of supratrochlear, supraorbital, zygomaticofrontal, and zygomaticotemporal nerves with liposomal bupivacaine at the conclusion of the operationa

Head wrap, elevation

Acetaminophen/narcotic tablets

Facelift Before incision, tumescence of the face and neck with 50 cc of 0.5% lidocaine with epinephrine 1:200,000 for hemostasis and postoperative pain control

Injection of surgical incisions and drain sites with 20 cc of 0.25% bupivacaine with epinephrine 1:200,000 at the conclusion of the procedure

Intravenous acetaminophen 30 minutes before conclusion of the operation

Head wrap, elevation

Acetaminophen postoperatively

Blepharoplasty Subdermal infiltration of the lids with 1% lidocaine 1:100,000

Balanced saline and prophylactic steroid ophthalmic drops

Periorbital cold compresses for 48 hours postoperatively

aNote adverse drug interaction when liposomal bupivacaine is used within 20 minutes of lidocaine injection.

Reference

1. Richards BG, Schleicher WF, Zins JE. Putting it all together: recommendations for improving pain management in plastic surgical procedures- surgical facial rejuvenation. Plast Reconstr Surg. 2014 Oct;134(4 Suppl 2):108S-112S.


16 Outcomes 201416

Aesthetic Surgery

Objective Assessment of Apparent Age After Facial Rejuvenation Surgery

Objectifying subjective findings, such as the degree of improvement following surgery for facial aging, is difficult. Dermatology & Plastic Surgery Institute researchers employed an apparent age reduction model to address this task in 2 previous studies. The formula compares preoperative and postoperative apparent age and accounts for the time the patient continues to age during the postoperative period. Pre- and postoperative photographs are randomly mixed to create a single portfolio, and independent reviewers blinded to patient and procedure information are asked to estimate patients’ pre- and postoperative ages, providing an objective measure of improvement.

More recently, the apparent age reduction model was used to determine efficacy of the facelift procedure after massive weight loss in 7 patients treated between March 2002 and April 2014, demonstrating clearly defined improvement and apparent age reduction.

However, the apparent age reduction model is nonvalidated and can be criticized as making subjective findings objective by declaration. Therefore, the institute is embarking on an attempt to validate the apparent age concept with a process to demonstrate evaluator reliability. If successfully validated, apparent age may yield a valuable tool for outcomes research in facial aging and aesthetic surgery.



A 55-year-old female presented with a history of a 100-pound weight loss by diet alone. She had an estimated preoperative apparent age of 69.4 years (top row). She underwent a planned 2-stage procedure with an extended superficial musculoaponeurotic system face lift, anterior lipectomy and platysmaplasty, and upper eyelid blepharoplasty, followed by a direct excision of the nasolabial fold and CO2 laser resurfacing of the scar 8 months later. Her postoperative apparent age was estimated at 60.9 years 16 months after the facelift and 8 months after direct excision (bottom row). Therefore, the apparent age reduction was 8.5 years.

Massive Weight Loss (N = 7) Control (N = 11) Mean (SD) Mean (SD) P Value

Preoperative actual age, years 57.4 (± 5.3) 57.7(± 4.0) 0.12

Postoperative actual age, years 58.7 (± 5.7) 59.5 (± 3.9) 0.12

Preoperative apparent age, years 62.5 (± 7.1) 58.9 (± 5.5) 0.26

Postoperative apparent age, years 57.8 (± 5.8) 55.3 (± 4.6) 0.26

Apparent age reduction, years 6.0 (± 3.0)b 5.40 (± 3.4)b 0.68

Pre- and Postoperative Actual and Apparent Age After Facelift Surgery in Massive Weight Lossa Patients vs Controls March 2002 – April 2014

aMassive weight loss was defined as weight loss greater than 100 pounds.

bThere was similar apparent age reduction between massive weight loss and control patients, indicating that both groups derived a similar age reduction benefit from facelift surgery.


18 Outcomes 201418

Aesthetic Surgery

Blepharoplasty and Phenol-Croton Oil Peel

While blepharoplasty can rejuvenate the eyes and upper cheeks and restore a more youthful and rested appearance, it is less effective in correcting fine lines and hyperpigmentation. Phenol-croton oil peels for fine lines and hyperpigmentation were popularized in the 1960s, and recent research has enabled plastic surgeons to better understand the chemistry behind the ingredients.1-5 In current peel formulas, the phenol and croton oil concentrations have been reduced to minimize adverse effects such as scarring and hypopigmentation associated with the older formulas.

Although there is a great deal of research on phenol-croton oil peels in general, little has been presented with respect to their use on the eyelids. Institute plastic surgeons documented the outcomes of 22 consecutive patients who underwent a combination of blepharoplasty with a periocular phenol-croton oil chemical peel between 2003 and 2013. All patients were female, and the average age was 56 years (range 47–71 years). Four patients (18%) had a second periocular phenol-croton oil peel, and 3 of these underwent a lower lid pinch blepharoplasty at the time of the second peel.

Blepharoplasty combined with an eyelid phenol-croton oil peel demonstrated significant improvement in upper and lower lid laxity, hyperpigmentation, and fine lines and wrinkles.

Complications at the time of first peel were few. There were no reported cases of infection, ectropion, scarring, or dry eye. These results show that judicious use of dilute concentrations of the phenol-croton oil chemical peel can be successfully used in the periocular region with minimal complications.

Fitzpatrick Skin Typea (N = 22) 2003 – 2013

aBased on preoperative photographs

Number of Patients

Type II Type IIIType I

Fitzpatrick Scale

12

10

8

6

4

2

0



A 54-year-old female shown preoperatively (A) and after upper and lower blepharoplasty followed 11 months later with a periocular phenol-croton oil peel (B).

A

B

Of the 22 patients studied, 19 (86%) underwent a total of 52 additional aesthetic procedures at the time of the first eyelid phenol-croton oil chemical peel. The average number of additional procedures was 2.7 per patient.

Aesthetic Procedures Performed at Time of First Chemical Peel (N = 19) 2003 – 2013

Number of Patients

LowerLid

Blepharoplasty

FatInjectionsto Midface

Facelift EndoscopicBrow Lift

BilateralLateral

Canthopexy

OtherUpperLid

Blepharoplasty

Aesthetic Procedure

16

12

8

4

0


20 Outcomes 201420

Complications at Time of First Chemical Peel (N = 22) 2003 – 2013

References

1. Stone PA, Lefer LG. Modified phenol chemical face peels: recognizing the role of application technique. Facial Plast Surg Clin North Am. 2001 Aug;9(3):351-376.

2. Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting the formula. Plast Reconstr Surg. 2000 Jan;105(1):227-239.

3. Hetter GP. An examination of the phenol-croton oil peel: Part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg. 2000 Jan;105(1):240-248.

4. Hetter GP. An examination of the phenol-croton oil peel: Part III. The plastic surgeons’ role. Plast Reconstr Surg. 2000 Feb;105(2):752-763.

5. Hetter GP. An examination of the phenol-croton oil peel: Part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000 Mar;105(3):1061-1083.

Aesthetic Surgery

Number of Patients

Prolonged Erythema No ComplicationsHyperpigmentation

Type of Complication

25

20

15

10

5

0

Treatment Strategies for Periocular Phenol-Croton Oil Peels

1. Chemical peel alone for fine periocular rhytids

2. Chemical peel alone for periocular hyperpigmentation

3. Chemical peel after transcutaneous blepharoplasty (at least 3 months)

4. Chemical peel at the time of transconjunctival or pinch blepharoplasty



Breast Surgery

Comparison of Preoperative Quality of Life in Breast Reconstruction, Aesthetic Breast, and Nonbreast Plastic Surgery Patients

The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This definition underscores the importance of weighing quality of life (QOL) when evaluating treatment options. In order to better counsel and educate reconstructive patients, Dermatology & Plastic Surgery Institute surgeons believe it is valuable to distinguish baseline breast-related QOL in reconstructive patients (Group 1) from that seen in women seeking cosmetic breast surgery (Group 2) and in those seeking nonbreast plastic surgical procedures (Group 3).

From June 2012 through November 2013, new patients seeking plastic surgery consultation completed the preoperative BREAST-Q™ — a rigorously evaluated, patient reported outcome instrument1 designed to measure QOL before any treatment is initiated. A total of 411 patients answered the questionnaires: 182 breast reconstruction patients, 70 aesthetic breast patients, and 159 nonbreast plastic surgery patients.

Preoperatively, reconstruction patients had similar satisfaction with breasts and sexual well-being when compared with women being evaluated for nonbreast plastic surgery; however, they had lower psychological well-being and physical well-being of the chest.

Aesthetic breast patients had lower scores in all domains compared with breast reconstruction and nonbreast plastic surgery patients. Other studies of aesthetic breast patients reported similar scores.2,3

Further studies are required to characterize the effect of preoperative QOL on postoperative patient reported outcomes.


22

Breast Surgery

Group 1b Group 2c Group 3d

Score ± SD Score ± SD Score ± SDDomains (N = 182) (N = 70) (N = 159)

Satisfaction with breasts 56.56 ± 25.33† 28.3 ± 22.25*† 63.59 ± 27.02*

Psychosocial well-being 69.56 ± 17.8†‡ 52.4 ± 16.05*† 75.77 ± 22.61*‡

Physical well-being, chest 79.19 ± 15.76†‡ 59.75 ± 20.34*† 84.19 ± 16.97*‡

Physical well-being, abdomen 88.69 ± 13.97†‡ 71.09 ± 22.80†* 79.64 ± 21.22*‡

Sexual well-being 54.46 ± 22.15† 37.65 ± 19.88†* 50.40 ± 23.75*

Mean BREAST-Q Preoperative Questionnaire for Breast Reconstruction Scoresa (N = 411) June 2012 – November 2013

Mean BREAST-Q Preoperative Questionnaire for Breast Reconstruction Scores (N = 411) June 2012 – November 2013

aData sharing the same symbol are significant (P < 0.01).bGroup 1: Breast reconstruction patientscGroup 2: Aesthetic breast patientsdGroup 3: Nonbreast plastic surgery patients

100

75

50

25

0

BREAST-Q Score

SatisfactionWith Breasts

PsychosocialWell-Being

PhysicalWell-Being,

Chest

PhysicalWell-Being,Abdomen

SexualWell-Being

Group 1a (N = 182)Group 2b (N = 70)Group 3c (N = 159)

aGroup 1: Breast reconstruction patientsbGroup 2: Aesthetic breast patientscGroup 3: Nonbreast plastic surgery patients

References

1. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009 Aug;124(2):345-353.

2. Coriddi M, Angelos T, Nadeau M, Bennett M, Taylor A. Analysis of satisfaction and well-being in the short follow-up from breast augmentation using the BREAST-Q, a validated survey instrument. Aesthet Surg J. 2013 Feb;33(2):245-251.

3. Coriddi M, Nadeau M, Taghizadeh M, Taylor A. Analysis of satisfaction and well-being following breast reduction using a validated survey instrument: The BREAST-Q. Plast Reconstr Surg. 2013 Aug;132(2):285-290.

Outcomes 201422



References

1. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009 Aug;124(2):345-353.

2. Coriddi M, Angelos T, Nadeau M, Bennett M, Taylor A. Analysis of satisfaction and well-being in the short follow-up from breast augmentation using the BREAST-Q, a validated survey instrument. Aesthet Surg J. 2013 Feb;33(2):245-251.

3. Coriddi M, Nadeau M, Taghizadeh M, Taylor A. Analysis of satisfaction and well-being following breast reduction using a validated survey instrument: The BREAST-Q. Plast Reconstr Surg. 2013 Aug;132(2):285-290.

Quality of Life After Breast Reconstruction: What Positively Influences Patient Satisfaction?

Implant based breast reconstruction following mastectomy is the most frequent technique used in the United States to restore the breast; however, microsurgical breast reconstruction has been increasingly offered in academic institutions as a preferred method.1 Deciding which modality to use can be stressful for the patient. The institute conducted a study aiming to establish which factors influence postoperative patient reported quality of life. The results will help with perioperative counseling and education.

From 2009–2011, 820 patients who underwent all methods of breast reconstruction after therapeutic or prophylactic mastectomy at Cleveland Clinic completed a postoperative BREAST-Q questionnaire.2 A total of 261 patients answered the questionnaire, which scores patient satisfaction and breast related quality of life on a scale of 0–100 across several domains.

BREAST-Q scores were compared across subgroups according to method of reconstruction, history of radiation treatment, presence of nipple, laterality of reconstruction, and body mass index. Autologous reconstruction was defined as the use of the patient’s own tissue from the lower abdomen or back with or without an implant. The group with nipples included patients with nipple areolar reconstruction or nipple sparing mastectomy.

Autologous reconstruction was associated with higher breast satisfaction compared with the implant group. Radiation therapy was associated with lower postoperative reconstruction satisfaction and lower psychosocial and physical well-being. Overall, factors associated with higher BREAST-Q scores included the use of autologous tissue, bilateral reconstruction, nipple preservation or reconstruction, and a body mass index of 25–29.9 kg/m2.

Overall Median BREAST-Q Satisfaction (N = 261) 2009 – 2011

aSatisfaction with abdomen question was limited to patients undergoing abdominal-based reconstruction.

bSatisfaction with nipple question was limited to patients who had nipple-sparing mastectomy or nipple reconstruction.

100

75

50

25

0

Satisfaction (%)

Breast Outcome PsychosocialWell-Being

SexualWell-Being

PhysicalWell-Being

Appearance,Abdomena

Nippleb


24 Outcomes 201424

Breast Surgery

Comparison of Subgroups By BREAST-Q Scores (N = 261) June 2012 – November 2013

Subgroups Median BREAST-Q Domain Scores (IQR)a Characteristic Differences

Satisfaction Satisfaction Psychosocial Sexual Physical Within Subgroup

With Breasts With Outcomes Well-Being Well-Being Well-Being

Implants only 62.0 (48 – 73) 67.0 (47 – 78) 71.5 (53 – 86) 49.0 (32 – 63) 77.0 (63 – 91) Implant group had lower BMI,

N = 150 higher rate of immediate and

Autologous 69.0 (50 – 85) 67.0 (55 – 86) 76.0 (55 – 92) 54.0 (37 – 67) 77.0 (66 – 85) prophylactic cases, and

N = 111 P ≤ 0.05 less radiation.

Radiation 59.0 (47 – 78) 61.0 (47 – 75) 67.0 (52 – 82) 52.0 (32 – 63) 74.0 (60 – 81)

N = 87

Nonradiation 65.5 (50 – 79) 67.0 (55 – 86) 76.0 (57 – 92) 52.0 (35 – 67) 81.0 (66 – 91)

N = 174 P ≤ 0.05 P ≤ 0.05 P ≤ 0.05

With nipple 65.6 (49 – 81) 67.0 (51 – 86) 76.0 (55 – 92) 52.0 (39 – 67) 77.0 (63 – 91) Group with nipples consisted

N = 166 P ≤ 0.05 of younger patients.

Without nipple 61.0 (47 – 73) 67.0 (47 – 75) 70.0 (55 – 86) 47.0 (32 – 63) 74.0 (63 – 85)

N = 95

Unilateral 59.0 (43 – 75) 61.0 (47 – 75) 73.0 (53 – 86) 49.0 (32 – 67) 77.0 (63 – 91)

N = 127

Bilateral 69.0 (53 – 81) 71.0 (54 – 86) 74.5 (58 – 92) 52.0 (37 – 67) 77.0 (63 – 91)

N = 134 P ≤ 0.05 P ≤ 0.05

BMI < 25 kg/m2 64.0 (49 – 75) 67.0 (47 – 86) 73.0 (55 – 92) 52.0 (34 – 67) 81.0 (66 – 91)

N = 115

BMI 25 – 29.9 kg/m2 69.0 (54 – 81) 67.0 (61 – 86) 79.0 (60 – 92) 54.0 (39 – 67) 77.0 (64 – 85)

N = 84 P ≤ 0.05 P ≤ 0.05

BMI ≥ 30 kg/m2 54.0 (45 – 78) 67.0 (46 – 86) 65.0 (47 - 82) 47.0 (28 – 60) 71.0 (60 – 81)

N = 62

BMI = body mass index, IQR = interquartile range (25th–75th percentile)aBold indicates statistically significant difference in score between subgroups.

References

1. Gurunluoglu R, Gurunluoglu A, Williams SA, Teabockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013 Jan;70(1):103-110.

2. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009 Aug;124(2):345-353.



Subgroups Median BREAST-Q Domain Scores (IQR)a Characteristic Differences

Satisfaction Satisfaction Psychosocial Sexual Physical Within Subgroup

With Breasts With Outcomes Well-Being Well-Being Well-Being

Implants only 62.0 (48 – 73) 67.0 (47 – 78) 71.5 (53 – 86) 49.0 (32 – 63) 77.0 (63 – 91) Implant group had lower BMI,

N = 150 higher rate of immediate and

Autologous 69.0 (50 – 85) 67.0 (55 – 86) 76.0 (55 – 92) 54.0 (37 – 67) 77.0 (66 – 85) prophylactic cases, and

N = 111 P ≤ 0.05 less radiation.

Radiation 59.0 (47 – 78) 61.0 (47 – 75) 67.0 (52 – 82) 52.0 (32 – 63) 74.0 (60 – 81)

N = 87

Nonradiation 65.5 (50 – 79) 67.0 (55 – 86) 76.0 (57 – 92) 52.0 (35 – 67) 81.0 (66 – 91)

N = 174 P ≤ 0.05 P ≤ 0.05 P ≤ 0.05

With nipple 65.6 (49 – 81) 67.0 (51 – 86) 76.0 (55 – 92) 52.0 (39 – 67) 77.0 (63 – 91) Group with nipples consisted

N = 166 P ≤ 0.05 of younger patients.

Without nipple 61.0 (47 – 73) 67.0 (47 – 75) 70.0 (55 – 86) 47.0 (32 – 63) 74.0 (63 – 85)

N = 95

Unilateral 59.0 (43 – 75) 61.0 (47 – 75) 73.0 (53 – 86) 49.0 (32 – 67) 77.0 (63 – 91)

N = 127

Bilateral 69.0 (53 – 81) 71.0 (54 – 86) 74.5 (58 – 92) 52.0 (37 – 67) 77.0 (63 – 91)

N = 134 P ≤ 0.05 P ≤ 0.05

BMI < 25 kg/m2 64.0 (49 – 75) 67.0 (47 – 86) 73.0 (55 – 92) 52.0 (34 – 67) 81.0 (66 – 91)

N = 115

BMI 25 – 29.9 kg/m2 69.0 (54 – 81) 67.0 (61 – 86) 79.0 (60 – 92) 54.0 (39 – 67) 77.0 (64 – 85)

N = 84 P ≤ 0.05 P ≤ 0.05

BMI ≥ 30 kg/m2 54.0 (45 – 78) 67.0 (46 – 86) 65.0 (47 - 82) 47.0 (28 – 60) 71.0 (60 – 81)

N = 62

BMI = body mass index, IQR = interquartile range (25th–75th percentile)aBold indicates statistically significant difference in score between subgroups.

References

1. Gurunluoglu R, Gurunluoglu A, Williams SA, Teabockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013 Jan;70(1):103-110.


Aesthetic Outcomes and Quality of Life With Free Flap Breast Reconstruction After Nipple Sparing Mastectomy

Breast cancer treatment has evolved to less aggressive techniques that preserve the breast skin envelope and nipple areolar complex whenever oncologic safety permits. Autologous breast reconstruction often results in more natural and stable results, as well as higher long-term patient satisfaction. Institute surgeons hypothesized that combining free flap breast reconstruction with nipple sparing mastectomy (NSM) would result in optimal aesthetics and breast reconstruction related quality of life (QOL).

Patients who underwent free tissue transfer after NSM between May 2007 and May 2014 were reviewed and patient characteristics, breast cancer history, complications, and reoperations were examined. Postoperative BREAST-Q questionnaires were used to assess patient reported QOL and were scored on a scale of 0–100.1 Pre- and postoperative photographs were evaluated by 2 plastic surgeons, a plastic surgery resident, and a medical student to grade the final aesthetic outcome.

A total of 45 breasts in 29 patients were reconstructed. No cancer recurrence or flap losses were observed. Pre- and postoperative photographs were available for 22 patients, and 12 patients answered the postoperative BREAST-Q questionnaire.

NSM followed by abdominally based, free flap breast reconstruction achieved excellent patient reported QOL and aesthetic outcomes while maintaining oncologic safety. Complication rates were comparable to those seen with other autologous breast reconstruction techniques.


26 Outcomes 201426

Breast Surgery

Mean Breast Appearance Score From Postoperative Photographsa (N = 22) May 2007 – May 2014

Mean BREAST-Q Scores by Domain (N = 12) May 2007 – May 2014

100

75

50

25

0

Score

SatisfactionWith

Breasts

SatisfactionWith

Outcomes

PsychosocialWell-Being

SexualWell-Being

PhysicalWell-Being

PhysicalWell-Being,Abdomen

SatisfactionWith

Nipple

aPostoperative photographs were assessed by 4 different evaluators and graded on a scale of 0–5 for each characteristic.

5

4

3

2

1

0

Aesthetic Outcome

BreastSymmetry

BreastPosition

InframammaryFold

BreastVolume

Breast Shape/Contour

ScarAppearance

Nipple-Areolar

ComplexSymmetry

Nipple-Areolar

ComplexPosition

NippleProjection

AreolarDiameter

AreolarShape

AreolarColor

OverallAppearance



A 46-year-old patient with a body mass index of 30.6 kg/m2 who underwent immediate bilateral reconstruction shown preoperatively (left) and postoperatively (right).

Reference


Pre- and postoperative views of an immediate left breast reconstruction in a 38-year-old patient with a body mass index of 28.3 kg/m2.

Preoperative, postoperative front, and postoperative lateral views of a 49-year-old patient with a body mass index of 25 kg/m2 who underwent immediate microsurgical right breast reconstruction after NSM.


28 Outcomes 2014

Breast Surgery

Outpatient Short-Stay Mastectomy With Immediate Reconstruction

In 2013 Cleveland Clinic began an outpatient mastectomy with expander-implant reconstruction program conducted at an ambulatory surgery center, rather than in a hospital inpatient or outpatient setting. The goal is to provide an enhanced patient experience in an efficient and cost-effective way while maintaining quality. The program is a collaboration of plastic surgery, radiology, pathology, general surgery, anesthesiology, and nursing. The breast health team is actively engaged in pre- and postoperative care at the ambulatory surgery center and subsequently during follow-up visits and support group meetings.

Patients check in at the outpatient facility, undergo dye injection, and are then taken to the ambulatory surgery center for preoperative preparation followed by the procedure. Postoperatively, the patient is taken to phase 2 recovery and, once stable, transferred to an overnight stay room and discharged early the next day.

Thirteen patients participated in 2013, and in 2014 the short-stay program volume increased 62% and included 21 patients. The increase was possibly due to increasing the number of blocked operating room days. The average time from diagnosis to curative surgery was approximately 33 days in 2013 vs only 26.7 days in 2014, with the decrease attributed to increased operating room access and refinements in the breast navigation program.

Additionally, patient throughput times as assessed by the clinical observations of program physicians are shorter compared with hospital-based procedures, even with the absence of resident/fellow participation.

Location Average Length of Time

Check-in to operating room 57 min

Total operating room time (mastectomy + reconstruction) 3 h, 23 min (unilateral)

Phase 2 recovery time 4 h, 23 min (bilateral)

1 h, 31 min

Total time in outpatient facility 23 h, 48 min

Patient Throughput (N = 34) 2013 – 2014

There were 3 delayed (> 3 weeks postoperatively) wound infections, and 1 patient had an expander deflation requiring expander replacement. There were no emergent/urgent hospital transfers and no operating room take backs in the immediate postoperative period.



Complication Rate (N = 34) 2013 – 2014

A postoperative survey showed that 100% of the patients rated their quality of care as 5 (scale of 1–5, 5 being the best possible score) and 100% said they would recommend the program to a family member or friend in the same circumstance. Patients also reported that the ability to communicate with former patients helped them navigate the short-stay patient process and experience.

The breast team is continually evaluating the outcome and patient satisfaction data in order to make any adjustments that may improve the program.

20

15

10

5

0

Percent

2013 (N = 13)2014 (N = 21)

Infection Hematoma SpontaneousDeflation


30 Outcomes 2014

Face Transplant

Osteomyocutaneous Facial Allograft: Skeletal Changes 5 Years After Transplantation

More than 30 face transplantations have been performed worldwide, most including part of the facial skeletal framework. The Dermatology & Plastic Surgery Institute evaluated whether the skeletal component of a facial allograft undergoes changes following transplantation due to the modified circulatory pattern and effects of the immunosuppressive regimen. This is the longest known follow-up reported for a facial allograft with an important bony component.

Pre- and postoperative CT scans of the facial bones were overlapped to assess skeletal changes, which were expressed in both a numeric and color-coded scale. CT angiogram (CTA) of the neck vessels and bone mineral densitometry (BMD) were conducted. Serum calcium, phosphate, vitamin D, alkaline phosphatase, thyroid and parathyroid hormones, thyroid stimulating hormone, follicle stimulating hormone, luteinizing hormone, estradiol, total protein and albumin, serum creatinine, and creatinine clearance were reviewed.

The patient, shown pre- and postoperatively at left, was 51 years old at 5-year follow-up, was clinically asymptomatic, and presented good stability of the Le Fort III skeletal component of the facial allograft. The allograft included more than 535 cm² of facial skin; functional units of full nose with nasal lining and bony skeleton; lower eyelids and upper lip; underlying muscles; bones including orbital floors, zygoma, maxilla with teeth, and hard palate; parotids; nerves; and arteries and veins.



The 5-year follow-up CT images at right showed that skeletal alignment was the same as in the immediate postoperative period and revealed fibrous union of the nasofrontal junction, lateral orbital walls, and left zygomatic arch. The orbital floor plates were in place and maintained the anatomical position of the orbital floors. There was no evidence of displacement or breakage of the titanium plates, and no sign of osteolysis and screw loosening.


Face Transplant

Outcomes 201432


33

transplanttransplanttttttttttttttrrrrrrraaaaaaannnnnnnsssssssppppppppppppplllllllllllllaaaaaaannnnnnnttttttttttttt


Overlapping the immediate postoperative and 5-year postoperative CT scans, shown at left, revealed bone resorption at the level of the Le Fort III osteotomy sites, left infraorbital rim, left maxillary buttress, and anterior maxilla (– 0.28 mm). Patchy areas of bone deposition were detected at the level of the septum and alveolar bones (+ 1.88 mm).

CTA showed segmental absence at the origin of the left external carotid artery, good opacification of the rest of the external carotid arteries and branches likely due to retrograde flow, and attenuated origin of the left lingual artery with good distal opacification. BMD evidenced osteopenia of the spine. The patient had mild hypoalbuminemia (3.4 g/dL) and perimenopausal hormonal levels. All the remaining laboratory values were within normal limits.

Despite the patient having multiple risk factors for bone resorption, facial allograft osteopenia was discovered only at the left infraorbital rim and anterior maxilla. These findings could be explained by the occlusion of the left external carotid system and retrograde revascularization. Bilateral arterial repair is recommended in the event of full-face allotransplantation in order to maximize the normal physiology of the skeletal component of the allograft.


34 Outcomes 2014

Face Transplant

Facial Allotransplantation in a Granulomatosis With Polyangiitis Patient

In September 2014, Cleveland Clinic’s plastic surgery team performed a second near total face transplant. The recipient was a 46-year-old man with extensive craniofacial trauma from a car accident. There were complications during his reconstructive course, including loss of the reconstructed parts and native tissues surrounding the nose, cheek, scalp, and periorbital area, with loss of the right eye. Wound healing issues continued after each surgical intervention, and he was ultimately diagnosed with granulomatosis with polyangiitis (formerly, Wegener’s granulomatosis), requiring immunosuppressive therapy.

This was the first reported case of face transplant in the setting of granulomatosis with polyangiitis, which represents an expanding indication for the surgery. The systemic autoimmune disease can cause necrotizing granulomatous inflammation and vasculitis affecting the face, especially the nasal structures and respiratory passages, and may lead to significant facial disfigurement. Given that these patients are often committed to lifelong immunosuppressive therapy, facial allotransplantation can be considered to restore form and function.

The patient’s wounds stabilized after almost a year of therapy and extensive wound care. However, significant facial disfigurement and a poor quality of life remained. He required painful daily dressing care and had developed breathing and speech difficulties. Facial allotransplantation was considered to correct facial form and function and possibly save the limited eyesight in 1 eye by restoring the eyelids. He was placed on the transplant list in April 2014 after evaluation by the transplant team, which included plastic surgery, transplant medicine, anesthesiology, bioethics, immunology, rheumatology, ophthalmology, and psychiatry.

To prepare for this face transplant, institute plastic surgeons performed a large number of cadaveric studies. The goal was to execute one of the most extensive vascular dissections for facial transplantation done to date to allow a larger area of face and scalp to be transplanted. A donor became available on Sept. 22, 2014, and the patient underwent a 24-hour operation with a team of 9 plastic surgeons. Approximately two-thirds of the donor’s scalp; forehead, eyelids, nose, and cheek tissue; facial nerves; and midfacial skeleton including the upper jaw and teeth were transplanted. The allotransplant effectively replaced about 90% of the patient’s face.

Postoperatively, the patient was admitted to the ICU and managed by multiple services. Immunosuppressive therapy was optimized. No acute rejection was initially detected, but he did exhibit grade III rejection for a short time, which was managed effectively. The patient stabilized and was transferred to rehabilitation within 2 months of surgery. He is currently recovering well at home, and the limited eyesight in the left eye has been preserved.



Left and right views preoperatively, and at 6 months after facial transplantation


36 Outcomes 2014

Lower Extremity Reconstruction

Flap Reconstruction of Soft Tissue Defects Related to Total Knee Arthroplasty

More than 1 million lower extremity total joint replacements are performed annually in the United States, the majority for complications of osteoarthritis. The vast majority of patients undergoing these procedures recover uneventfully. Although rare, complications do occur. Delayed healing and/or infection threatens prosthesis retention, compromises knee function, and may lead to secondary revision procedures. When wound complications occur, coverage of the joint with well vascularized tissue offers the best chance for a successful outcome. Dermatology & Plastic Surgery Institute specialists are experts in the field of wound care and complex soft tissue reconstruction related to orthopaedic joint implants.

Mean Annual Number of Total Knee Arthroplasty Related Flap Reconstructions (N = 147) 1998 – 2014

The mean annual number of soft tissue reconstructions related to total knee arthroplasty performed at Cleveland Clinic increased between 1998 and 2014. The distribution of flap types used for these reconstructions shows that the vast majority were local muscle flaps — in particular, medial gastrocnemius muscle flaps.

Mean Annual Number

02002 – 2005 2006 – 2009 2010 – 2013 20141998 – 2001

Time Period

15

10

5

20



Flap Distribution in Total Knee Arthroplasty Related Soft Tissue Defect Reconstructions (N = 147) 1998 – 2014

Mean Successa Rate of Total Knee Arthroplasty Related Soft Tissue Defect Reconstructions (N = 147) 1998 – 2014

Total Number of Flaps

Local Flaps Free Flaps

140

120

100

80

60

40

20

0

Fasciocutaneous flapsMuscle flaps17

17

6

107

Success Rate

1998 – 2012 2013 – 2014

Time Period

100

80

60

40

20

0

FailureSuccess

a Success was defined as achieving stable coverage of the joint without the need for additional muscle or fasciocutaneous flap use.


38 Outcomes 201438

Lower Extremity Reconstruction

N 103 Flaps;

73 Patients; 74 Knees

Length of Follow-Up (Months)b 64.5 ± 38.8 (range 12 – 202)

Total Number of Flap Related Complications 50/103

Complete flap loss 4/103 (4%)

Partial flap loss 11/103 (11%)

Wound dehiscence 28/103 (27%)

Hematoma 5/103 (5%)

Anastomotic thrombosis (free flap) 2/16 (13%)

Number of Flap Revisionsb 1.1 ± 1.9

aOnly patients with a minimum of 12 months of follow-up were evaluated.

bMean ± SD

Long-Term Outcomes: Flap Related Complication Rates (N = 103a) 1998 – 2014



A 63-year-old patient required reconstruction of a soft tissue defect exposing the knee prosthesis. The defect resulted from multiple revision arthroplasties for periprosthetic joint infection. Intraoperative views of a local muscle flap (medial gastrocnemius) being used to reconstruct the defect are shown.

The patient with a functional joint 12 weeks after a flap transfer and a 1-stage revision arthroplasty.


40 Outcomes 201440

Merkel Cell Carcinoma

A 20-Year Review of Merkel Cell Carcinoma Cases

Merkel cell carcinoma (MCC) is rare, with roughly 1500 cases occurring annually in the United States, making it about 40 times less common than melanoma.1 MCC does not have a distinctive appearance but usually develops on sun-exposed skin as a painless; firm; flesh-colored, red, or blue bump. Patients frequently consult plastic surgeons and dermatologists because lesions grow rapidly or the overlying skin is breaking down.

MCC has a very aggressive clinical course requiring appropriate action. While treatment modalities have been evolving during the past 2 decades, no uniform protocol exists. Treatment may include surgery, radiation, and/or chemotherapy depending on disease stage and lesion size.

The Dermatology & Plastic Surgery Institute reports recurrence rates, years of disease-free survival, and overall survival in 76 consecutive MCC patients diagnosed with biopsy at Cleveland Clinic from 1993 to 2013. The majority of patients had head or neck lesions, 74 required wide-excision surgery with at least a 2-cm margin, and 2 had advanced stage IV disease contraindicating surgery and underwent palliative radiation and chemotherapy.

Of the 74 patients who underwent surgery, 30 had surgery alone, 31 had surgery followed by radiation, 11 had chemotherapy and radiation after surgery, and 2 patients had only chemotherapy after surgery. Thirty-two patients had MCC on their head/neck region, 25 patients had MCC on their extremities, and 17 had lesions on the trunk.



Disease-free survival was greatest for the group having both surgery and chemoradiation, followed by the surgery and radiation therapy group and the surgery alone group. The pattern was similar for overall survival.

Merkel Cell Carcinoma: Mean Disease-Free Survival (N = 74) 1993 – 2013

Merkel Cell Carcinoma: Mean Overall Survival (N = 74) 1993 – 2013

Months

Head and Neck

NA NA

Trunk ExtremityAll Patients

70

60

50

40

30

20

10

0

Surgery aloneSurgery + radiationSurgery + chemoradiationSurgery + chemotherapy

Months

Head and Neck Trunk ExtremityAll Patients

120

100

80

60

40

20

0


NA


42

Merkel Cell Carcinoma: Recurrence Rates (N = 74) 1993 – 2013

Percent

Head and Neck Trunk ExtremityAll Patients

100

80

60

40

20

0


NA NA

The surgery plus chemotherapy group had the highest recurrence rate but included only 2 patients and there were no similar patients in the head/neck and extremity groups. When the surgery plus chemotherapy patients are excluded, the highest recurrence rate occurred in the surgery only group.

While no ideal treatment regimen for MCC exists, these results indicate that treatment with surgery followed by radiation, which is most widely instituted at this time, shows an increase in survival and decrease in locoregional recurrence.

An elderly female with a 1.2-cm Merkel cell carcinoma of the right medial canthus on the nasal dorsum before (A) and after (B) excision with approximately 1.5- to 2-cm margins circumferentially.

A B

Reference

1. Skin Cancer: Merkel Cell Carcinoma. 2013. American Cancer Society. cancer.org/cancer/skincancer-merkelcell/detailedguide/skin-cancer- merkel-cell-carcinoma-key-statistics. Updated December 31, 2013. Accessed April 13, 2015.

Outcomes 201442

Merkel Cell Carcinoma



Alopecia

Clinical Efficacy of Intralesional Kenalog in Alopecia Areata: Using ILK mg/SALT Score as a Predictor of Improvement

Alopecia areata (AA) is an autoimmune disease characterized by episodes of patchy hair loss, most commonly on the scalp. Intralesional Kenalog® (ILK) injections are first line therapy in the treatment of this condition. However, research concerning optimal dosing of ILK for the management of AA is sparse.

Institute researchers investigated the impact of ILK dosing on hair recovery after onset of a new AA lesion using a novel calculation: the ILK/Severity of Alopecia Tool (SALT) score index. A retrospective evaluation of 57 patients from Cleveland Clinic’s alopecia registry produced 15 who met the following inclusion criteria: new episode of AA, no treatment for the new AA lesion prior to baseline photos, availability of baseline and 4-month follow-up photos, and treatment with a known amount of ILK. Thirteen of the patients were female and 2 were male; 9 were white, 5 black, and 1 Hispanic.

Hair loss for each patient was graded at baseline and after 4 months of ILK therapy using the SALT score.1 Patients were divided into 2 groups based on their treatment response: those who experienced > 50% SALT score improvement from baseline to follow-up, and those who did not. The mean ratio of ILK received/initial SALT score (ILK/SALT index) for patients in each group was compared to determine if there was a significant difference between the indexes of patients who experienced significant vs suboptimal improvement.

At 4 months follow-up, patients with a significant improvement in their SALT score (≥ 50%) had a higher ILK/SALT index than patients with suboptimal improvement in SALT score (< 50%). Although the difference did not meet significance, the trend (P < 0.1) suggests that a larger study is warranted to evaluate the relationship between this ratio and treatment outcomes. The ILK/SALT index is a novel calculation that may be a useful tool for guiding alopecia areata treatment.


44 Outcomes 2014 44

Treatment Response (N = 15) February 2012 – August 2013

Total Number of ILK Administration Sessions Per Patient (N = 15) February 2012 – August 2013

Average Number of Days Between ILK Administration Sessions Per Patient (N = 15) February 2012 – August 2013

ILK/SALT Index (N = 15) February 2012 – August 2013

Number of Patients

< 50 Improvement ≥ 50 Improvement

Treatment Response

12

10

8

6

4

2

0

Number of Sessions

< 50 Improvement

P < 0.91

≥ 50 Improvement

Treatment Response

4.384.364.344.324.304.284.264.244.224.204.18

Days

< 50 Improvement

P < 0.34

≥ 50 Improvement

Treatment Response

45

40

35

30

25

20

10

5

0

Ratio

< 50 Improvement

P < 0.1

≥ 50 Improvement

Treatment Response

9876543210

Alopecia



Total Number of ILK Administration Sessions Per Patient (N = 15) February 2012 – August 2013

A 20-year-old female patient in the ≥ 50% improvement group is shown at baseline (left) and at 4-month follow-up (right). Duration of new lesion: 3 months. Initial SALT score: 50%. SALT score at 5-month follow-up: 5.12%. Number of ILK treatment sessions: 4.

A 51-year-old female patient in the ≥ 50% improvement group is shown at baseline (left) and at 4-month follow-up (right). Duration of new lesion: 6 months. Initial SALT score: 25.2%, final SALT score: 2.4%. Number of ILK treatment sessions: 4.

Reference

1. Olsen EA, Hordinsky MK, Price VH, Roberts JL, Shapiro J, Canfield D, Duvic M, King LE Jr, McMichael AJ, Randall VA, Turner ML, Sperling L, Whiting DA, Norris D; National Alopecia Areata Foundation. Alopecia areata investigational assessment guidelines--Part II. National Alopecia Areata Foundation. J Am Acad Dermatol. 2004 Sep;51(3):440-447.


46 Outcomes 201446

Dermatopathology

Dermatopathology Turnaround Times

The institute reports 2014 intralaboratory timeliness, or turnaround times (TAT), of more than 24,500 routine surgical pathology biopsies and external complex consultations from the time of specimen accessioning to report completion. The goal is to meet or exceed the College of American Pathologists recommended benchmark of 2 working days.1 The TAT for the vast majority (75%) of specimens was 1 day, with a total of 93% signed out within 2 days. TATs are variable depending on case complexity as well as other factors such as the presence of a residency training program and the number of hospital beds and surgical pathologists.

Percentage of Dermatopathology Cases Completed Within 2 Days (N = 24,965) 2014

Dermatopathology Turnaround Times (N = 24,965) 2014

a Outside surgical consultations = cases referred by Cleveland Clinic clinicians for review and expert opinion by institute pathologists

b Outside complex consultations = cases referred by other pathologists for expert opinion

c Outside routine biopsies = routine cases referred by clinicians outside Cleveland Clinic

Reference

1. Association of Directors of Anatomic and Surgical Pathology, Nakhleh R, Coffin C, Cooper K. Recommendations for quality assurance and improvement in surgical and autopsy pathology. Hum Pathol. 2006 Aug;37(8):985-988.

Percent

1 Day 2 Days 3 – 4 Days ≥ 5 Days

80

60

40

20

0

Percent

In HouseBiopsies

OutsideSurgical

Consultationsa

OutsideComplex

Consultationsb

OutsideRoutineBiopsiesc

80

60

40

20

0

N = 21,054 339 1405 2167



Dermatopathology Turnaround Times (N = 24,965) 2014

Squamous Cell Carcinoma Arising in Seborrheic Keratoses

Seborrheic keratoses (SK) are common skin neoplasms found more often in older patients. They typically present as brown, keratotic lesions on the trunk and extremities. These lesions are considered benign; however, there are reports that SK can undergo malignant transformation to squamous cell carcinoma (SCC).

From 2003 to 2014, 162 patients were diagnosed with SCC arising in SK (SCC/SK). The findings in this group were compared with those in a control group of 165 randomly selected patients with a diagnosis of SK during the same period. The goal was to identify the demographic characteristics of patients diagnosed with SCC/SK.

SCC/SK was significantly more prevalent in men, in older patients, and among those who had prior skin cancers. Patients with a history of immunosuppression, particularly those who underwent solid organ transplantation, were also at increased risk of developing SCC/SK.

Locations of Squamous Cell Carcinoma in Seborrheic Keratoses vs Seborrheic Keratoses Alone 2003 – 2014

SCC = squamous cell carcinoma, SK = seborrheic keratosis

Percent

Head Neck UpperExtremity

Trunk

Location

LowerExtremity

Genitals

60

40

20

0

SCC/SK (N = 162)SK (N = 165)


48 Outcomes 2014

Dermatopathology

Demographic Characteristics of Squamous Cell Carcinoma Arising in Seborrheic Keratoses 2003 – 2014

Histologic Features of Squamous Cell Carcinoma Arising in Seborrheic Keratoses (N = 162) 2003 – 2014

SCC/SK (N = 162) SK (N = 165) P ValueAge at diagnosis, years ± SD 72.2 ± 12.7 62.3 ± 12.98 < 0.0001Gender, % (N) 0.0054 Male 69.1 (112) 54.5 (90) Female 30.9 (50) 45.5 (75) Prior skin cancers, % (N) < 0.0001 Yes 55.6 (90) 27.9 (46) No 44.4 (72) 72.1 (119) Age at first cancer, years ± SD 69.55 ± 14.03 63.39 ± 29.15 0.005Immunosuppression, % (N) 0.0096 Yes 19.1 (31) 9.1 (15) No 80.9 (131) 90.9 (150) Organ transplant 0.00016 Yes 9.9 (16) 0.6 (1) No 90.1 (146) 99.4 (164) Smoking, % (N) Yes 8 (13) 9.1 (15) No 49.3 (80) 63.6 (105) Former 42.6 (69) 27.3 (45)

% (N)Hyperkeratosis 97.5 (158)Papillomatosis 92.6 (150)Parakeratosis 91.9 (149)Pseudohorn cysts 90.1 (146)Mitotic figures 88.3 (143)Solar elastosis 80.9 (131)Squamous eddies 79.6 (129)Hypogranulosis 79.6 (129)Pigment 59.9 (97)Desmoplasia 53.1 (86)Acantholysis 21.6 (35)Ulceration 17.9 (29)



A 74-year-old man with an erythematous, ulcerated, nodular SCC/SK on the posterior ear

A 79-year-old male with an ulcerated, nodular SCC/SK on the right side of the nose

A 70-year-old man with a large, irregular, pigmented SK and an SCC arising in the circled area of hypopigmentation

A hematoxylin and eosin stain of a well demarcated SCC arising in a hyperkeratotic SK (5 x magnification)


50 Outcomes 201450

Dermatologic Surgery and Cutaneous Oncology

Complications Following Mohs Micrographic Surgery

Complications after cutaneous surgery include bleeding, infection, wound dehiscence, and hematoma formation. The reported acceptable rate of infection for procedures performed in an OR setting for clean wounds is 1%–3%.1 The reported incidence of adverse effects overall (wound dehiscence, infection, bleeding, and hematoma) for outpatient skin surgery, including Mohs surgery, is 0.7%–2.1%.2-5

A retrospective chart review of 756 Mohs micrographic surgery cases from 4 Cleveland Clinic sites between December 2013 and February 2014 was conducted and the prevalence of wound dehiscence, infection, bleeding, and hematoma tabulated. The mean patient age was 69.3 years with a range of 20–101 years. The cohort included 110 immunosuppressed patients.

Variables included office site, surgeon, tumor type, tumor size, recurrence, location, patient age, gender, immune status, medications, prior and prophylactic antibiotics, postoperative antibiotics, anticoagulants, number of Mohs stages, type of closure, and suture type.

Mohs surgery is a very effective and safe outpatient treatment for high-risk skin cancers, and it has a very low prevalence of adverse events. The infection rate for 756 consecutive cases was well below the established benchmark for outpatient surgery, and other adverse events of dehiscence, bleeding, and hematoma were similarly very low and comparable to the low rates reported in the literature.

Tumor Type (N = 756) December 2013 – February 2014

Percent

Basal CellCarcinoma

Squamous CellCarcinoma

Other Primary Recurrent

100

80

60

40

20

0



Tumor Location (N = 756) December 2013 – February 2014

Closure Type (N=756) December 2013 – February 2014

Percent

Face Neck andScalp

UpperExtremity

LowerExtremity

Trunk

100

80

60

40

20

0Genitals

Percent

PrimaryClosure

SecondaryIntention

Flap Full-ThicknessSkin Graft

Referred

100

80

60

40

20

0


52 Outcomes 201452

Dermatologic Surgery and Cutaneous Oncology

Antibiotic Use (N = 756) December 2013 – February 2014

Immunosuppressed Patients (N = 110) December 2013 – February 2014

Percent

PostoperativeAntimicrobial

None Prophylactic Antibiotic Prior Antibiotic

50

40

30

20

10

0

DMARDS = disease modifying antirheumatic drugs

Percent

SolidOrgan

Transplant

Chemo-therapy/DMARDS

Prednisone BoneMarrow

Transplant

HIV ChronicLymphocytic

Leukemia

ChronicMyelogenous

Leukemia

Basal CellNevus

Syndrome

Muir-TorreSyndrome

80

60

40

20

0



Complication Rate (N = 756) December 2013 – February 2014

References

1. Messingham MJ, Aprey CJ. Update on the use of antibiotics in cutaneous surgery. Dermatol Surg. 2005 Aug;31(8 Pt 2):1068-1078.

2. O'Neill JL, Shutty B, Sun Lee Y, Solomon JA, Patel N, Davis SA, Taheri A, Huang KE, Landis ET, Robins DN, Williford PM, Feldman SR, Pearce DJ. Comparing demographic characteristics and adverse even rates at two dermatologic surgery practices. J Cutan Med Surg. 2014 Sep-Oct;18(5):337-340.

3. Cook JL, Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol. 2003 Feb;139(2):143-152.

4. Maragh SL, Brown MD. Prospective evaluation of surgical site infection rate among patients with Mohs micrographic surgery without the use of prophylactic antibiotics. J Am Acad Dermatol. 2008 Aug;59(2):275-278.

5. Rogers HD, Desciak EB, Marcus RP, Wang S, MacKay-Wiggan J, Eliezri YD. Prospective study of wound infections in Mohs micrographic surgery using clean surgical technique in the absence of prophylactic antibiotics. J Am Acad Dermatol. 2010 Nov;63(5):842-851.

Percent

Dehiscence Infection Bleeding Hematoma

8

6

4

2

0

Reported acceptable ratea

aSource: Messingham MJ, Aprey CJ. Update on the use of antibiotics in cutaneous surgery. Dermatol Surg. 2005 Aug;31(8 Pt 2):1068-1078.


54 Outcomes 201454

Infantile Hemangiomas

Propranolol Treatment of Genital Infantile Hemangioma

Infantile hemangiomas (IH) are the most common benign vascular tumors of infancy, occurring in almost 1 of 200 live births. Although they usually manifest in the skin and subcutaneous tissue of the head and neck, trunk, and extremities, 1% of all IH involve the genitalia.1,2 Genital IH are vascular anomalies that often require complex management, and interdisciplinary care has been offered through Cleveland Clinic’s Vascular Anomalies Program since 2009. Propranolol therapy for genital IH has gained acceptance as first-line therapy, and Cleveland Clinic has successfully initiated dose-escalating treatment in 9 children without significant side effects. All patients who continued treatment showed marked improvement in their genital IH.

Genital Infantile Hemangiomas: Patient and Lesion Characteristics April 2010 – July 2014

Age at Age at Appearance TreatmentPatient Gender (months) (months) Location Size (cm) Characteristics

1 F 1 2 Labia, scalp, 2 x 2 Ulcerating, superficial, painful right ear urination

2 M 1 3 Scrotum, back 5 x 2.5 Ulcerating (after discontinuation of propranolol), mixed superficial, deep

3 F 3 3 Left labia 4 x 2 Ulcerating, mixed superficial, deep

4 F 1 1 Perineum including 14 x 11 Ulcerating, superficial buttock, anus, labia

5 F 0 4 Right labia 4 x 3.5 Ulcerating, mixed superficial, deep, diversion of urinary stream

6 M 0 3 Left scrotum, back 5.5 x 4 Ulcerating, mixed superficial, deep

7 F 0 1 Left labia Large Ulcerating, mixed superficial, deep

8 F 0 2 Left labia, perineum, Large Ulcerating, mixed superficial, pubis deep, significant pain, bleeding

9 F 0 3 Right labia, clitoral Large Ulcerating, mixed superficial, deep hood, buttocks



Genital Infantile Hemangioma Outcomes After Propranolol Treatment April 2010 – July 2014

Initial Maximum Treatment Dose Dose DurationPatient (mg/kg/day) (mg/kg/day) (months) Side Effects Other Treatments Posttreatment Findings

1 1 2.5 9, ongoing None None Marked improvement, ulceration resolved 2 1 2.2 2, stopped Transient peripheral Timolol gel started Partial response with prematurely vasoconstriction at after propranolol decreased erythema, baseline, which discontinued subsequent complete was exacerbated response to timolol gel with treatment

3 1 2.3 10, ongoing None None Marked improvement, with plans to ulceration resolved wean at next follow-up

4 1 2 21, completed None Timolol gel used Complete resolution, treatment in conjunction per ulceration resolved plastic surgeon

5 1 2 12, completed None None Complete resolution, treatment ulceration resolved

6 1 2.3 11, completed None None Complete resolution, treatment ulceration resolved

7 1 2.3 4, ongoing None Oral corticosteroids Marked improvement, x 9 days as adjunct ulceration resolved therapy for ulceration

8 0.5 3.5 16, completed None Becaplermin gel used Almost complete resolution treatment unsuccessfully and with minimal residual discontinued nonulcerated lesion prior to propranolol

9 1 2.3 7, ongoing None Timolol gel used Marked improvement, unsuccessfully and ulceration resolved discontinued prior to propranolol


56 Outcomes 201456

Infantile Hemangiomas

This 1-month-old patient presented with multiple IH including an approximately 2 cm2 ulcerated labial lesion causing painful urination (A). Propranolol treatment was initiated at age 2 months with no adverse effects experienced upon dose escalation. Examination at 2 months (B), 5 months (C), and 8 months (D) after beginning propranolol treatment demonstrated dramatic improvement in the appearance of the lesion with complete resolution of ulceration and voiding symptomatology.

A

C

B

D



A

B

Since 2 days of age, this patient had a large, ulcerated left scrotal IH with a deep component (A). Propranolol treatment was initiated at age 3 months with no adverse effects experienced upon dose escalation. Examination at 9 months after treatment initiation demonstrated significant improvement in the appearance of the lesion with complete resolution of ulceration and disappearance of the deep component (B).

References

1. Alter GJ, Trengove-Jones G, Horton CE Jr. Hemangioma of penis and scrotum. Urology. 1993;42(2):205-208.

2. Achauer BM, Chang CJ, Vander Kam VM. Management of hemangioma of infancy: review of 245 patients. Plast Reconstr Surg. 1997;99(5):1301-1308.


Accuracy of Initial Diagnoses

The Department of Dermatology hospital consult service plays an integral role in caring for inpatients with dermatologic problems. New patients seen through the consult service were entered into a database and their age, gender, day of consult, consulting team, reason for consultation, initial and final diagnoses, and whether a culture or biopsy was preformed were recorded.

The majority of dermatology consult requests were for rash (N = 413). Of these, 127 (30.8%) patients underwent biopsies for further diagnostic evaluation, 54 (13%) of which were requested by the dermatology consulting team. Biopsy results were consistent with the dermatology consult team’s initial diagnosis in 91 (71.7%), while the diagnosis was changed in 36 (28.3%). Overall, an accurate initial diagnosis was made in 377 (91.3%) of rash cases.

These data highlight the ability of dermatologists to make an accurate initial diagnosis based solely on the appearance of a rash including morphology and distribution, with incorporation of relevant patient history.

58

Hospital Consults

Outcomes 2014

Patient Age and Gender (N = 691) November 2013 – November 2014

Rash Consult Biopsy Outcomes November 2013 – November 2014

Age Male Female Total Percent

< 18 32 17 49 7.1

≥ 18 311 331 642 92.9

Total 343 348 691 100

Percent 49.6 50.4 100

Rashes

N = 413

No biopsy performed

N = 286

Biopsy

N = 127

Note: 13% of biopsies requested by consulting team

Biopsy changed initial diagnosis

N = 36

Biopsy confirmed initial diagnosis

N = 91



Patient Age and Gender (N = 691) November 2013 – November 2014

Most Frequent Requesting Services (N = 691) November 2013 – November 2014

Reasons for Consults (N = 691) November 2013 – November 2014

Percent of Patients

InternalMedicine

Surgery Hematology/Oncology

Pediatrics Cardiology Cardio-thoracicSurgery

EmergencyDepartment

Other

311 88 66 45 40 31 30 80

50

40

30

20

10

0

N =

Percent of Patients

Rash SkinLesions

Ulcers Blisters Cellulitis Biopsy Other

413 82 74 33 23 20 46

70

60

50

40

30

20

10

0

N =


60 Outcomes 201460

Teledermatology

Percent of Patients

Rash Lesion

80

60

40

20

0

Percent of Patients

DermatologyAppointment

Treated byPrimary Care

Provider

80

60

40

20

0

Teledermatology Triage Outcomes (N = 17) July – December 2014

Reason for Consult (N = 17) July – December 2014

Teledermatology has been shown to be a reliable tool for reducing outpatient wait times and increasing specialty access while decreasing unnecessary office visits.1,2 In July 2014, the Department of Dermatology collaborated with Cleveland Clinic’s Medicine Institute to launch a pilot teledermatology consult program. This internal effort was designed to help triage appropriate patients into earlier dermatology appointments, avoid unneeded referrals, and provide informal consultations.

The feasibility of the program was initially tested by limiting access to a few Department of Internal Medicine staff physicians and was recently expanded to providers at an employee walk-in clinic. Store and forward teledermatology consultations were placed using secure smartphones or tablets designated for this purpose. Patient photos, along with pertinent clinical documentation in the electronic medical record, were reviewed by a dermatology staff member and resident. Triage outcomes were grouped into 2 categories: The treatment plan outlined by the internal medicine provider was reasonable and a dermatology appointment could be deferred, or a dermatology appointment was required for further evaluation and treatment.

The teledermatology consult program decreases unnecessary visits, results in greater access to dermatologists, and saves time, travel, and expense for patients. Given the success of the pilot teledermatology program, plans are being made to expand its availability to all Cleveland Clinic primary care providers and to fully incorporate the process into the electronic health record system during 2015.


61

Teledermatology Triage Outcomes (N = 17) July – December 2014

Reason for Consult (N = 17) July – December 2014

Dermatology & Plastic Surgery Institute

Teledermatology Consult Case Details (N = 17) July – December 2014

CARP = confluent and reticulated papillomatosis, HCV = hepatitis C virus, HIV = human immunodeficiency virus, PCP = primary care provider, SLE = systemic lupus erythematosus aDays until first scheduled dermatology appointment; bIf different from preliminary teledermatology diagnosis

Reason for Consult Teledermatology Diagnosis Triage Outcome Daysa Final Diagnosisb and Treatment

1 Nodule on leg; Tumor Dermatology 5 Sarcoma; amputation of leg transplant history

2 Infected lesion on leg Impetigo Dermatology 6 No show

3 Rash; HIV+ Folliculitis Dermatology 6 No show x 3

4 Rash on legs; HCV+ Lichenoid dermatitis Dermatology 12 Topical corticosteroid

5 Rash; possible bites Arthropod assault Dermatology 30 Topical corticosteroid, antihistamine, exterminator

6 Generalized rash Psoriasiform dermatitis Dermatology 3 Cancellation x 2

7 Rash on trunk Papular eczema flare Dermatology 42 CARP; minocycline and ketoconazole shampoo

8 Generalized rash Morbilliform drug eruption Dermatology 2 Topical and oral corticosteroids

9 Rash on trunk Psoriasiform plaques Dermatology 9 SLE; hydroxychloroquine and mycophenolate mofetil

10 Rash on legs Urticaria PCP -- Antihistamine

11 Rash on arms Contact dermatitis PCP -- Dermatology appointment; failed topical corticosteroid

12 Rash on trunk Irritant dermatitis PCP -- Topical corticosteroid

13 Vesicles on face Herpes simplex vs impetigo PCP - Cephalexin and valacyclovir

14 Rash on arms Contact dermatitis PCP - Topical corticosteroid and antihistamine

15 Rash; possible eczema Eczema PCP - Topical corticosteroid

16 Lesion on leg Ecchymosis PCP - No treatment

17 Lesion on finger Digital myxoid cyst Hand surgeon - Excision of cyst

References

1. Warshaw EM, Hillman YJ, Greer NL, Hagel EM, MacDonald R, Rutks IR, Wilt TJ. Teledermatology for diagnosis and management of skin conditions: a systematic review. J Am Acad Dermatol. 2011 Apr;64(4):759-772.

2. Whited JD, Warshaw EM, Kapur K, Edison KE, Thottapurathu L, Raju S, Cook B, Engasser H, Pullen S, Moritz TE, Datta SK, Marty L, Foman NA, Suwattee P, Ward DS, Reda DJ. Clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial. J Telemed Telecare. 2013 Jun;19(4):197-204.


62 Outcomes 201462

Institute Patient Experience

Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic’s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care.

Outpatient Office Visit Survey — Dermatology & Plastic Surgery

CG-CAHPS Assessmenta 2013 – 2014

aIn 2013, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients’ perspectives of outpatient care.bBased on results submitted to the CG-CAHPS database from 2172 medical practices in 2013.cResponse options: Always, Usually, Sometimes, Never dResponse options: Yes, definitely; Yes, somewhat; NoeResponse options: Yes, No

Source: Press Ganey, a national hospital survey vendor

100

80

0

60

40

20

Percent Best Response

CG-CAHPS 2013 database average(all practices)b

AppointmentAccess

(% Always)c

DoctorCommunication

(% Yes, Definitely)d

Doctor Rating

(% 9 or 10)0 – 10 Scale

Clerical Staff

(% Yes, Definitely)d

Test ResultsCommunication

(% Yes)e

2013 (N = 2663)2014 (N = 5001)



Institute Patient Experience

HCAHPS Overall Assessment 2013 – 2014

Inpatient Survey — Dermatology & Plastic Surgery

The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients’ perspectives of hospital care. Results collected for public reporting are available at medicare.gov/hospitalcompare.

HCAHPS Domains of Carea 2013 – 2014

100

80

0

60

40

20

Best Response (%)

DischargeInformation

% Yes

Doctor Communication

Nurse Communication

PainManagement

RoomClean

New MedicationsCommunication

Responsivenessto Needs

Quiet atNight

% Always(Options: Always, Usually, Sometimes, Never)

2014 (N = 102)National average all patientsb

2013 (N = 122)

aExcept for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions. Source: Press Ganey, a national hospital survey vendorbBased on national survey results of discharged patients, January 2013 – December 2013, from 4067 US hospitals. medicare.gov/hospitalcompare

100

80

0

60

40

20

Best Response (%)

aBased on national survey results of discharged patients, January 2013 – December 2013,from 4067 US hospitals. medicare.gov/hospitalcomparebResponse options: Definitely yes, Probably yes, Probably no, Definitely no

Source: Press Ganey, a national hospital survey vendor

2014 (N = 102)

National averageall patientsa

2013 (N = 122)

Hospital Rating(% 9 or 10)0 – 10 Scale

Recommend Hospital(% Definitely Yes)b


danger zone64 Outcomes 2014

Innovations

Great Auricular Nerve Facelift Danger Zone Identified1

The most commonly injured nerve during facelift surgery is the great auricular nerve (GAN), which supplies sensation to the ear, specifically to the earlobe. A GAN injury can potentially elicit temporary or permanent numbness, painful nodules, and discomfort upon cold exposure. Therefore, it is important to preserve this nerve during surgical dissection in the lower face and neck.

Plastic Surgery Department staff conducted a cadaver study at Cleveland Clinic’s Lerner Research Institute to better identify the location and course of the GAN. Thirteen fresh cadavers (8 male, 5 female) with an average age of 69.3 years were dissected, and the location of the nerve in the vicinity of the earlobe was identified.

A vertical reference line through the middle of the earlobe was created perpendicular to the Frankfurt horizontal line. Paper overlay tracings were then done to record each nerve’s course. The 26 tracings (left and right necks) obtained from the cadavers were overlapped to yield a distribution pattern.

The upper course of the GAN consistently fell within a 30-degree angle posterior to the described reference line. The 30-degree angle accurately identifies the nerve’s course and points to a danger zone in the vicinity of the ear lobule. By marking this danger zone early during facelift surgery, the surgeon is more clearly oriented to the location of the nerve.

Reference

1. Ozturk CN, Ozturk C, Huettner F, Drake RL, Zins JE. A failsafe method to avoid injury to the great auricular nerve. Aesthet Surg J. 2014 Jan 1;34(1):16-21.



Selected Publications

The great auricular nerve (yellow arrow) as seen during facelift surgery

A vertical line (black arrow) through the middle of the earlobe was drawn perpendicular to the Frankfurt horizontal line (blue arrow).

Frankfurt horizontal

Reference line

Paper overlay tracings were obtained after identification of the nerve’s course.

The great auricular nerve consistently fell within a 30-degree angle (blue arrows) in the vicinity of the earlobe. Thus, a danger zone for the nerve was identified (shaded triangle).


Painless Photodynamic Therapy for Actinic Keratoses

Photodynamic therapy (PDT) is an effective treatment alternative to 5-fluorouracil cream for widespread actinic keratoses of the face and scalp, offering good lesion clearance and a short patient downtime. Typically, a topical photosensitizer is applied followed at least 1 hour later by approximately 17 minutes of blue light exposure. However, the prickly pain experienced during PDT illumination can be severe, especially in patients with extensive actinic damage.

The Department of Dermatology has pioneered a painless PDT protocol. Medication is applied and illumination begins immediately, lasting 30–60 minutes. Pain is negligible, yet the resulting erythema and lesion clearance appear to be equivalent to that achieved with traditional PDT regimens. This gentler approach is especially appreciated by our severely sun-damaged patients who cannot tolerate the pain of traditional PDT.

Actinic keratoses on forehead before painless PDT Clearing of actinic keratoses shown 3 months after painless PDT

66 Outcomes 2014

InnovationsInnovations



Selected PublicationsCleveland Clinic — Implementing Value-Based Care

Cleveland Clinic is developing and implementing new models of care that focus on “Patients First” and aim to deliver on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new models of Value-Based Care is a strategic priority for Cleveland Clinic. As care delivery shifts from fee-for-service to a population health and bundled payment delivery system, Cleveland Clinic is focused on concurrently improving patient safety, outcomes, and experience.

What does this new model of care look like?

• The Cleveland Clinic Integrated Care Model (CCICM) is a value-based model of care, designed to improve outcomes while reducing cost. It is designed to deliver value in both population health and specialty care.

• The patient remains at the heart of the CCICM.

• The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in different settings. The care system represents integration of care across the continuum.

• Critical competencies are required to build this new care system. Cleveland Clinic is creating disease- and condition-specific care paths for a variety of procedures and chronic diseases. Another facet is implementing comprehensive care coordination for high-risk patients to prevent unnecessary hospitalizations and emergency department visits. Efforts include managing transitions in care, optimizing access and flow for patients through the CCICM, and developing novel tactics to engage patients and caregivers in this work.

• Measuring performance around quality, safety, utilization, cost, appropriateness of care, and patient and caregiver experience is an essential component of this work.

Focus on Value

HomeRetail Venues

Integrated Care Model

Outpatient Clinics

IndependentPhysicianOffices

Skilled NursingFacilities Rehabilitation

Facilities

Community-BasedOrganizations

Post-Acute(other)

AmbulatoryDiagnosis & Treatment

Hospitals

Emergency

Care System

MyChart


Outcomes 201468 Outcomes 2014

Contact Information

General Dermatology Appointments/Referrals

216.444.5725 or 800.223.2273, ext. 45725 Surgical Dermatology Appointments/Referrals

216.444.5724 or 800.223.2273, ext. 45724 Cutaneous Care Center

216.444.2649 or 800.223.2273, ext. 42649 Dermatology Clinical Research

216.445.3157 or 800.223.2273, ext. 53157 Dermatology Financial Counselor

216.445.8662 or 800.223.2273, ext. 58662 Plastic Surgery Appointments/Referrals

216.444.6900 or 800.223.2273, ext. 46900 Plastic Surgery Financial Counselor

216.445.1331 or 800.223.2273, ext. 51331 On the Web at clevelandclinic.org /dermatology and clevelandclinic.org/plastics

Staff Listing

For a complete listing of Cleveland Clinic’s Dermatology & Plastic Surgery Institute staff, please visit clevelandclinic.org/staff.

Publications

Dermatology & Plastic Surgery Institute staff authored 112 publications in 2014.

For a complete list, go to clevelandclinic.org/outcomes.

Locations

For a complete listing of Dermatology & Plastic Surgery Institute locations, please visit clevelandclinic.org/DPSI.


http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/about-cleveland-clinic/quality-patient-safety/treatment-outcomes.aspx?utm_campaign=outcomes-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/dermatology-plastic-surgery/departments-centers/dermatology?utm_campaign=dermatology-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/dermatology-plastic-surgery/departments-centers/dermatology?utm_campaign=dermatology-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/dermatology-plastic-surgery/departments-centers/plastic-surgery?utm_campaign=plastics-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/services/dermatology-plastic-surgery?utm_campaign=dpsi-url&utm_medium=offline&utm_source=redirect

Dermatology & Plastic Surgery Institute 69Dermatology & Plastic Surg

Additional Contact Information General Patient Referral

24/7 hospital transfers or physician consults

800.553.5056 General Information

216.444.2200 Hospital Patient Information

216.444.2000 General Patient Appointments

216.444.2273 or 800.223.2273 Referring Physician Center and Hotline

855.REFER.123 (855.733.3712)

Or email [email protected] or visit clevelandclinic.org/refer123 Request for Medical Records

216.444.2640 or 800.223.2273, ext. 42640 Same-Day Appointments

216.444.CARE (2273)

Global Patient Services/ International Center

Complimentary assistance for international patients and families

001.216.444.8184 or visit clevelandclinic.org/gps Medical Concierge

Complimentary assistance for out-of-state patients and families

800.223.2273, ext. 55580, or email [email protected] Cleveland Clinic Abu Dhabi

clevelandclinicabudhabi.ae Cleveland Clinic Canada

888.507.6885 Cleveland Clinic Florida

866.293.7866 Cleveland Clinic Nevada

702.483.6000 For address corrections or changes, please call

800.890.2467


http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

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https://www.clevelandclinicabudhabi.ae/en/pages/default.aspx

Outcomes 201470

About Cleveland Clinic

Overview

Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 3200 Cleveland Clinic staff physicians and scientists in 130 medical specialties and subspecialties care for more than 5.9 million patients across the system, performing more than 192,000 surgeries and conducting more than 497,000 emergency department visits. Patients come to Cleveland Clinic from all 50 states and more than 147 nations. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 1400-bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 42 buildings on 165 acres. Cleveland Clinic’s CMS case-mix index is the second highest in the nation. Cleveland Clinic encompasses more than 90 northern Ohio outpatient locations, including 18 full-service family health centers, 8 regional hospitals, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida; Cleveland Clinic Nevada, which includes the Lou Ruvo Center for Brain Health in Las Vegas, and urology and nephrology services; Cleveland Clinic Canada; and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu Dhabi is a full-service hospital and outpatient center in the United Arab Emirates (UAE), which began offering services in spring 2015. Cleveland Clinic is the second-largest employer in Ohio, with more than 42,500 employees. It generates $12.6 billion of economic activity a year. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Canada, China, the Dominican Republic, El Salvador, Guatemala, Honduras, Panama, Peru, Saudi Arabia, Turkey, UAE, and the United Kingdom.

The Cleveland Clinic Model

Cleveland Clinic was founded in 1921 by 4 physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education. The Cleveland Clinic health system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 1990s with the development of 18 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and 6 other regional hospitals have joined Cleveland Clinic over the past 2 decades, offering Cleveland Clinic institute services in heart and neurological care, physical rehabilitation, and more. Clinical and support services were reorganized into 27 patient-centered institutes beginning in 2007. Institutes combine medical and surgical specialists for specific diseases or organ systems under unified leadership and in a shared location to provide optimal team care for every patient. Institutes work with the Office of Patient Experience to give every patient the best outcome and experience. A Clinically Integrated Network

Cleveland Clinic is committed to providing value-based care, and it has grown the Cleveland Clinic Quality Alliance into the nation’s second-largest and Northeast Ohio’s largest clinically integrated network. The network comprises more than 5400 physician members, both employed and independent physicians from the community. Led by its physician members, the Quality Alliance strives to improve quality and consistency of care; reduce costs and increase efficiency; and provide access to expertise, data, and experience.



Cleveland Clinic Lerner College of Medicine

Lerner College of Medicine is known for its small class sizes, unique curriculum, and full-tuition scholarships for all students. Each new class accepts 32 students who are preparing to be physician investigators. Cleveland Clinic is building a multidisciplinary Health Education Campus as the new home of the Case Western Reserve University (CWRU) School of Medicine and Cleveland Clinic’s Lerner College of Medicine, as well as the CWRU School of Dental Medicine, the Frances Payne Bolton School of Nursing, and physician assistant and allied health training programs.

Graduate Medical Education

In 2014, nearly 1800 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, which is part of a continuing upward trend.

U.S. News & World Report Ranking

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S. News & World Report. It is ranked No. 1 in urology and has ranked No. 1 in heart care and heart surgery since 1995. In 2014, 4 of its programs were ranked No. 2 in the nation: diabetes and endocrinology, gastroenterology and GI surgery, nephrology, and rheumatology.

For more information about Cleveland Clinic, please visit clevelandclinic.org.

Cleveland Clinic Physician Ratings

At Cleveland Clinic, we believe in transparency. We also believe in the positive influence of the physician-patient relationship on healthcare outcomes. To continue to meet the highest standards of patient satisfaction, we now publish Cleveland Clinic physician ratings, based on nationally recognized Press Ganey patient satisfaction surveys, online at clevelandclinic.org/staff.


http://my.clevelandclinic.org/

http://my.clevelandclinic.org/staff_directory?utm_campaign=staff-url&utm_medium=offline&utm_source=redirect

Outcomes 201472

Resources

Referring Physician Center and Hotline

Call 24/7 for access to medical services or to schedule patient appointments: 855.REFER.123 (855.733.3712), email [email protected], or go to clevelandclinic.org/Refer123. The free Cleveland Clinic Physician Referral App, available for mobile devices, gives you 1-click access. Available at the App Store or Google Play. Remote Consults

Anybody anywhere can get an online second opinion from a Cleveland Clinic specialist through our MyConsult service. For more information, go to clevelandclinic.org/myconsult, email eclevelandclinic.org, or call 800.223.2273, ext. 43223. Request Medical Records

216.444.2640 or 800.223.2273, ext. 42640 Track Your Patients’ Care Online

Cleveland Clinic offers an array of secure online services that allow referring physicians to monitor their patients’ treatment while under Cleveland Clinic care, as well as access test results, medications, and treatment plans. my.clevelandclinic.org/online-services

DrConnect (online access to patients’ treatment progress while under referred care): 877.224.7367; [email protected]

MyPractice Community (affordable electronic medical records system for physicians in private practice): 866.320.4573

eRadiology (teleradiology consultation provided nationwide by board-certified radiologists with specialty training, within 24 hours or stat): 216.986.2915; [email protected]

Medical Records Online

Patients can view portions of their medical record, receive diagnostic images and test results, make appointments, and renew prescriptions through MyChart, a secure online portal. All new Cleveland Clinic patients are automatically registered for MyChart. clevelandclinic.org/mychart Critical Care Transport Worldwide

Cleveland Clinic’s fleet of ground and air transport vehicles is ready to transfer patients at any level of acuity anywhere on earth. Specially trained crews provide Cleveland Clinic care protocols from first contact. To arrange a transfer for STEMI (ST-elevation myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call 877.379.CODE (2633). For all other critical care transfers, call 216.444.8302 or 800.553.5056. CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education operates the largest CME program in the country. Live courses are offered in Cleveland and cities around the nation and the world. The center’s website (ccfcme.org) is an educational resource for healthcare providers and the public. It has a calendar of upcoming courses, online programs on topics in 30 areas, and the award-winning virtual textbook of medicine, The Disease Management Project. Clinical Trials

Cleveland Clinic is running more than 2100 clinical trials at any given time for conditions including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. Cancer Clinical Trials is a mobile app that provides information on the more than 100 active clinical trials available to cancer patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp.


http://my.clevelandclinic.org/professionals/referring.aspx?utm_campaign=refer123-url&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services/myconsult.aspx?utm_campaign=myconsult-redirect&utm_medium=offline&utm_source=redirect

http://my.clevelandclinic.org/online-services

http://my.clevelandclinic.org/online-services/mychart.aspx?utm_campaign=mychart-url&utm_medium=offline&utm_source=redirect

http://www.clevelandclinicmeded.com/

http://my.clevelandclinic.org/services/cancer/clinical-trials-research?utm_campaign=cancertrialapp-url&utm_medium=offline&utm_source=redirect

mailto:eclevelandclinic.org

mailto:[email protected]




Healthcare Executive Education

Cleveland Clinic has programs to teach people from outside the organization how it operates a major medical center. The Executive Visitors’ Program is an intensive 3-day behind-the-scenes view of the Cleveland Clinic organization for the busy executive. The Samson Global Leadership Academy is a 2-week immersion in challenges of leadership, management, and innovation taught by Cleveland Clinic leaders, administrators, and clinicians. Curriculum includes coaching and a personalized 3-year leadership development plan. Learn more at clevelandclinic.org/executiveeducation. Consult QD Physician Blog

A singular blog for physicians and healthcare professionals from Cleveland Clinic. Discover the latest research insights, innovations, treatment trends, and more for all specialties. Join the conversation: consultqd.clevelandclinic.org. Social Media

Cleveland Clinic uses social media to help caregivers everywhere provide better patient care. Millions of people currently like, friend, or link to Cleveland Clinic social media — including leaders in medicine.

Facebook for Medical Professionals facebook.com/CMEclevelandclinic

Follow us on Twitter @cleclinicMD

Connect with us on LinkedIn Clevelandclinic.org/Mdlinkedin


9500 Euclid Avenue, Cleveland, OH 44195 clevelandclinic.org

This project would not have been possible without the commitment and expertise of a team led by

James S. Taylor, MD, Barbara S. Leslie, Nancy F. Toll, Maude L. Campbell, and

Terri Teresczuk, RN, BSN, CPHQ.

Photography by Patricia Shoda, Janine Sot, and Susan Lopez. Graphic design and additional

photography were provided by Cleveland Clinic’s Center for Medical Art and Photography.

© The Cleveland Clinic Foundation 2015

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