Dermatology & Plastic Surgery Institute
2012
Outcomes
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 disease-based institutes. Designed for a
physician audience, the Outcomes books contain a summary of many of
our surgical and medical treatments, with data on patient volumes and
outcomes 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 techniques.
In addition to these institute-based books of clinical outcomes, Cleveland
Clinic supports transparent public reporting of healthcare quality data and
participates in the following public reporting initiatives:
• Joint Commission Performance Measurement Initiative (qualitycheck.org)
• Centers for Medicare & Medicaid Services (CMS) Hospital Compare (hospitalcompare.hhs.gov)
• Ohio Department of Health (ohiohospitalcompare.ohio.gov)
• 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:
OutcomesBooksFeedback@ccf.org or scan here.
To view all our Outcomes books, please visit Cleveland Clinic’s Quality and
Patient Safety website at clevelandclinic.org/outcomes.
Dear Colleague:
Welcome to this 2012 Cleveland Clinic Outcomes
book. We distribute Outcomes books for more than
14 specialties. These publications are unique in
healthcare. Each one provides a summary overview
of medical or surgical trends, innovations, and
clinical data for a Cleveland Clinic specialty over
the past year.
Cleveland Clinic uses data to manage outcomes
across the full continuum of care. Clinical services
are delivered through patient-centered institutes,
each based around a single disease or organ
system. Institutes combine medical and surgical
services, along with research and education, under
unified leadership. The individual institute defines
quality benchmarks for its specialty services and
reports 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 reports
has received favorable notice from colleagues,
media, and healthcare observers. We appreciate
your interest and hope you find this information
useful and informative.
Sincerely,
Delos M. Cosgrove, MD
CEO and President
2
Outcomes 2012
what’s inside
Chairman’s Letter
04
Institute Overview
06
Quality and Outcomes Measures
Cutaneous Melanoma 12
Breast Reconstruction
16
Facelift and Chemical Peel
17
Aesthetic Refinements for Graves Ophthalmopathy
19
Patch Testing Effects on Orthopaedic Surgical Practices
20
Hyperhidrosis
22
Psoriasis
26
Acne Vulgaris
32
Sarcoidosis
37
Photodynamic Therapy
40
Skin Cancer in Solid Organ Transplant Recipients
44
Infantile Hemangiomas
46
Institute Patient Experience
51
Surgical Quality Improvement
52
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
54
Innovations60
Selected Publications
62
Staff Listing
68
Contact Information
70
Institute Locations
72
About Cleveland Clinic
74
Resources 76
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.
Dermatology & Plastic Surgery Institute
3
Chairman’sLetter
Letter
Chairman
Dear Colleagues,
I am pleased to present the annual Outcomes book for Cleveland
Clinic’s Dermatology & Plastic Surgery Institute. This review of
2012 captures the institute’s year in data and treatment trends
to share with referring physicians, alumni, potential patients, and
other individuals around the nation interested in dermatology and
plastic surgery. It is an outgrowth of the work of the institute’s
Quality and Compliance Committee, which continues to meet
regularly to guide our quality improvement and efficiency efforts.
This past year was one of continued growth. We added five
full-time physicians and increased access to our services
at locations throughout Northeast Ohio. We expanded our
newest collaborative programs, including the Photodynamic
Therapy Center, Cosmetic and Plastic Surgery Center, Center for
Reconstructive Transplantation, and Multicultural Skin Center.
We launched innovative services, such as a clinic for skin cancer
in organ transplant patients and a multidisciplinary wound care
service, and conducted groundbreaking research, which included
our finding that stimulation of the sphenopalatine ganglion can
stop cluster migraine headaches 70 percent of the time.
4
Outcomes 2012
Institute Overview
In 2012, there also were many exciting achievements in our institute, including:
• Acquiring a MelaFind® skin imaging device (MELA Sciences, Irvington, N.Y.), which categorizes lesions as being
low- or high-risk for dysplasia or melanoma
• Logging three international mission trips totaling 45 vacation days, and more than 400 volunteer hours in Northeast Ohio
• Receiving approval from the Accreditation Council for Graduate Medical Education to increase our number of residents by
one resident per year for the next three years
• Authoring 127 publications
• Increasing our research revenue by 26 percent from 2011
On behalf of my colleagues, I hope this edition of the Dermatology & Plastic Surgery Institute Outcomes book proves a
valuable resource for detailing our services and the high-quality patient outcomes to which our institute is committed.
Respectfully,
Frank A. Papay, MD, FACS, FAAP
Chairman, Dermatology & Plastic Surgery Institute
Dermatology & Plastic Surgery Institute
5
Institute Overview
As one of the largest academic dermatology and plastic
surgery practices in the nation, Cleveland Clinic’s
Dermatology & Plastic Surgery Institute offers patients
a full range of dermatologic, reconstructive, and
aesthetic services.
The institute includes the Department of Dermatology, with
36 dermatologists who offer a full array of 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 Dermatology & Plastic Surgery Institute continues
to benefit from the integration five years ago of its two
subspecialties into a single institute. This model of care
takes advantage of the collective expertise of the institute’s
two component departments, using a collaborative approach
that promotes comprehensive, patient-focused care while
creating broad new research and educational opportunities.
This integration also has allowed continued growth
through the acquisition of new regional markets throughout
Northeast Ohio.
Following two years of unprecedented growth in clinical
staff, the institute continued to add to its ranks in 2012
with five new full-time staff. This resulted in a 6 percent
increase in total patient visits and shorter wait times
for appointments.
6
Outcomes 2012
Dermatology
Cleveland Clinic’s Department of Dermatology provides
expertise in the diagnosis and management of the full
spectrum of dermatologic conditions. It also offers a
wide range of services in cosmetic evaluation and
surgical procedures.
Last year saw an increased volume of Mohs surgery skin
cancer cases. Eight Mohs surgeons performed 3,050
procedures at five sites — making it one of the largest
academic Mohs surgery practices in the nation.
The Photodynamic Therapy Clinic continues to grow and
is conducting NIH-funded research in two projects for
skin cancer and precancers. The volume and demand
for photodynamic therapy has increased in recent years,
prompting the department to purchase photodynamic
therapy units for regional locations.
In 2012, the department also launched a new clinic for
skin cancer in organ transplant patients and acquired a
MelaFind® diagnostic system (MELA Sciences, Irvington,
N.Y.). This device, which will go into clinical use in 2013,
takes images of clinically suspicious pigmented lesions
using 10 wavelengths of light, compares the images to a
bank of 10,000 benign and malignant pigmented lesions,
and categorizes the lesions as being low- or high-risk for
dysplasia or melanoma.
The Department of Dermatology continues to expand
community access to its care with additional clinic hours,
including Saturdays, at community healthcare centers. It
further served the community through multiple free skin
cancer screenings, active participation in National Skin
Cancer Week activities, staff presentations at community
health talks, and provision of medical missionary assistance
in developing nations.
To address the medical, surgical, and cosmetic needs of
populations with greater skin pigmentation (skin types IV
to VI), the Multicultural Skin Center — one of a few such
programs nationally — focuses on improving treatment
outcomes for skin conditions that disproportionately affect
Asian, black, Arab, and Hispanic patients.
Dermatology & Plastic Surgery Institute
7
Institute Overview
Plastic Surgery
Cleveland Clinic’s Department of Plastic Surgery is one
of the largest plastic surgery programs in the country.
The “vertical” organization of its staff, which ensures
that each surgeon has a specific area of clinical focus,
provides patients with deep expertise in virtually all
areas of aesthetic and reconstructive surgery. Surgeons’
close collaboration with their dermatology colleagues
within the broader institute yields synergies in the areas
of aesthetic facial plastic surgery, oculoplastic surgery,
and cosmetic dermatology.
The Center for Reconstructive Transplantation brings
together plastic surgeons and other medical and
surgical specialists from across Cleveland Clinic to care
for patients with deformities resulting from congenital
abnormalities, traumatic injury, or cancer surgery. This
center is dedicated to restoring function and improving
performance for patients who need reconstruction of
difficult facial, head and neck, abdominal, breast,
laryngeal, or hand deformities and dysfunction as well
as providing wound repair.
Specialists in the Cosmetic and Plastic Surgery Center
perform facial cosmetic, breast, and body contouring
procedures at nine regional locations. In facial cosmetic
surgery, the center has a particular focus on minimally
invasive techniques and objectively measures and
publishes its results.
8
In the area of reconstructive breast surgery, the Department
of Plastic Surgery is one of the few U.S. centers that
performs large numbers of deep inferior epigastric perforator
flap procedures along with the spectrum of other immediate
and delayed reconstructive procedure options.
In 2012, the department continued to expand its practices
in the new family health centers and at suburban hospital
locations. For the first time, outpatient plastic surgery
services are available at Twinsburg Family Health and
Surgery Center and Fairview Hospital, and services have
been expanded at family health centers in Strongsville and
Avon. On the inpatient side, services have been added at
Fairview and Hillcrest hospitals.
In addition, patients now have the opportunity to obtain a
cosmetic consult without leaving their homes. Through the
combined efforts of Plastic Surgery and Dermatology, an
eConsult analysis including hospital photography is possible
for patients anywhere in the United States and beyond.
Looking Ahead
Given its successful growth in 2012 in patient
care, management, finance, education, and research,
the Dermatology & Plastic Surgery Institute is
well-prepared to further its regional growth and will
apply current innovations in treating and managing
patients with dermatological and plastic surgery
problems in 2013.
Outcomes 2012
Patient Visit Volume
2008 – 2012
Patient Encounters
150,000
Plastic Surgery
Dermatology
120,000
90,000
60,000
30,000
0
2008
2009
2010
2011
2012
2010
2011
2012
2011
2012
Mohs Micrographic Surgery
2008 – 2012
Procedures
3,500
3,000
2,500
2,000
1,500
1,000
500
0
2008
2009
Phototherapy/Ultraviolet Light Treatments
2008 – 2012
Volume
8,000
6,000
4,000
2,000
0
2008
2009
Dermatology & Plastic Surgery Institute
2010
9
Institute Overview
Facial Cosmetic Surgeries
2008 – 2012
Number
160
Face/Necklift
Browlift
Blepharoplasty
120
80
40
0
2008
2009
2010
2011
2012
Primary and Secondary Rhinoplasty
2008 – 2012
Number
80
Primary
Secondary
60
40
20
0
2008
2009
2010
2011
2012
Cosmetic Breast Surgery
2008 – 2012
Number
400
Breast Reduction
Breast Augmentation
Mastopexy
300
200
100
0
10
2008
2009
2010
2011
2012
Outcomes 2012
Body Contouring
2008 – 2012
Number
400
Abdominoplasty
Liposuction Trunk/Extremities
Liposuction Head/Neck
300
200
100
0
2008
2009
2010
2011
2012
Breast Reconstruction
2008 – 2012
Number
300
Reconstruction TRAM*
Reconstruction w/ Prosthesis
Reconstruction w/ Latissimus Dorsi Flap
Oncoplasty
DIEP**
200
100
0
2008
2009
2010
2011
2012
*Transverse rectus abdominis myocutaneous
**Deep inferior epigastric perforator flap
Endoscopic and Open Carpal Tunnel Surgery
2009 – 2012
Number
200
Endoscopic
Open
150
100
50
0
2009
2010
Dermatology & Plastic Surgery Institute
2011
2012
11
Cutaneous Melanoma
Cleveland Clinic’s large population of malignant melanoma patients can receive evaluation
and treatment in one location from a multidisciplinary melanoma clinic staff comprising
dermatologists, surgeons, oncologists, and radiation oncologists. This approach ensures
the best and most efficient care while enhancing patient convenience. Melanoma survival
outcomes data from Cleveland Clinic’s melanoma registry compare favorably with nationally
published data and, in some instances, show a better survival rate than that documented in
large studies. The availability of melanoma drugs approved in 2011 is expected to result in
even higher survival rates among Dermatology & Plastic Surgery Institute melanoma patients.
Percentage of Patients With No Local Recurrence One Year After Cutaneous Melanoma
Diagnosis and Excision (N = 1,549)
2003 – 2011
Percent
100
75
50
25
0
0
I
II
III
IV
109
89
T Stage
N=
610
538
203
Early-stage melanoma is primarily treated surgically. The incidence of local recurrence
after surgery using approaches standardized at Cleveland Clinic reveals excellent
outcomes. The T stage is based on depth of invasion. In all groups, the primary tumor
was controlled in 95% to 99% of patients after one year.
12
Outcomes 2012
Cutaneous Melanoma Survival, Stages 0, IA, and IB; Patients Diagnosed (N = 690)
2003 – 2007
Percent Survival
Stage
0 OS*
IA OS
IB OS
0 DFS**
IA DFS
IB DFS
100
90
80
70
0
6
12
18
24
30
36
42
48
54
60
Months Since Diagnosis
*OS = overall survival
**DFS = disease-free survival
Survival outcomes for those in the early stages of melanoma show that when nonmelanoma
causes of death (disease-free survival) are excluded, survival was between 98% and 100%. Dermatology & Plastic Surgery Institute
13
Cutaneous Melanoma
Cutaneous Melanoma Survival, Stages IIA, IIB, and IIC; Patients Diagnosed (N = 82)
2003 – 2007
Percent Survival
100
Stage
IIA
IIB
IIC
80
60
40
20
0
0
6
12
18
24
30
36
42
48
54
60
Months Since Diagnosis
The overall survival rate for Cleveland Clinic patients with stage IIA disease is higher than
that reported nationally.1
Cutaneous Melanoma Survival, Stages IIIA, IIIB, IIIC, and IV; Patients Diagnosed (N = 97)
2003 – 2007
Percent Survival
100
Stage
IIIA
IIIB
IIIC
IV
80
60
40
20
0
0
6
12
18
24
30
36
42
48
54
60
Months Since Diagnosis
Cleveland Clinic overall survival outcomes among patients with higher stages of malignant
melanoma at diagnosis are comparable to those reported in national databases.
14
Outcomes 2012
A deep, nodular, T4 malignant melanoma before successful
treatment (ruler indicates centimeters)
National Quality Measures for Staging of Cutaneous Malignant Melanoma
The seventh edition of the American Joint Committee on Cancer’s Cancer Staging Manual defines and describes the
staging of malignant melanomas of the skin. The institute reported the following quality measures for all primary malignant
melanoma specimens processed by the Dermatopathology Section at Cleveland Clinic’s main campus in 2012:
• 125/130 (96%) of primary cutaneous melanoma pathology reports listed pT category.
• 126/130 (97%) of primary cutaneous malignant melanoma pathology reports included a statement on thickness.
• 125/130 (96%) of primary cutaneous melanoma pathology report cases included information on ulceration.
• 82/83 (99%) of primary cutaneous melanoma pathology reports for pT1 tumor staging listed mitotic rate.
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.
Dermatology & Plastic Surgery Institute
15
Breast Reconstruction
Although current breast reconstruction techniques have
advanced, most procedures still require a multistep
process. An initial breast reconstruction using implants
usually begins with placement of a tissue expander
under the pectoralis muscle following mastectomy.
The tissue expander creates the space for implant
placement during a future reconstructive process.
A single-step breast reconstruction immediately after
mastectomy is now possible, eliminating the need for
initial tissue expansion. Candidates for this technique
are those undergoing skin-sparing or nipple-sparing
mastectomies requiring minimal excision. With maximal
skin preservation, the breast contour and size can be
immediately restored by placing the final implant with a
biologic matrix that supports the lower lateral portions
of the implant.
This single-stage implant breast reconstruction offers
several advantages to Dermatology & Plastic Surgery
Institute patients. In addition to obviating the creation
of an implant pocket with a separate tissue expansion
surgery, this procedure enables better implant
positioning, better control of the mastectomy space
and inframammary fold, and better overall cosmetic
outcomes. Therefore, patients undergo one less surgery,
require fewer postoperative office visits, and can recover
and return to work sooner.
Preoperative
One Year Postoperatively
This 52-year-old patient carries the BRCA gene mutation
for breast cancer and underwent prophylactic bilateral
mastectomy. Both reconstructions were performed using
a single-stage technique with immediate silicone implant
placement and a dermal matrix.
Preoperative
Six Months Postoperatively
A 39-year-old patient had previous bilateral breast
augmentation and mastopexy and was later diagnosed with
cancer in the right breast. The patient opted to undergo
bilateral mastectomies followed by single-stage breast
reconstructions with immediate silicone implant placement
and dermal matrix support.
16
Outcomes 2012
Facelift and Chemical Peel
Although a facelift is an effective means of addressing facial aging, it is generally accepted that the procedure
has little effect on the wrinkles around the mouth. Combining facelift surgery with a chemical peel is effective for
both central tightening and reducing these wrinkles.
Department of Plastic Surgery patients scheduled for facelift surgery are evaluated for the severity of wrinkles
around the mouth, and a chemical peel is offered to appropriate candidates. The regional chemical peel is
performed at the time of surgery, and typical healing time is seven to 10 days. From 2001 through 2012, 47
patients underwent simultaneous facelift and chemical peel procedures. Between 2006 and 2012, photographic
evaluations were done for 20 patients who consented to use of their photographs for research purposes. Results
of the combined technique were reviewed using the following measures:
• Validated patient satisfaction survey: A patient satisfaction survey was mailed to patients. Overall
satisfaction was rated at 6.5 on a 1-to-7 scale, with higher scores indicating greater satisfaction. All
individual survey items received a mean score above 5, indicating “satisfied” or “very satisfied.”
• Apparent age evaluation: A photo book was created with randomly mixed preoperative and postoperative
photographs. The photographs were shown to six independent reviewers who were asked to estimate the
ages of the patients. The apparent age (as estimated by reviewers) was then compared with actual patient age. Mean preoperative apparent age assessment was quite accurate, with no significant difference between
the real age and the apparent age (P = 0.133). However, mean postoperative apparent age estimate was
8.2 years younger than real age (P = 0.0002).
• Wrinkle evaluation: A second photo book was created with randomly mixed preoperative and postoperative close-up photographs. Improvement in wrinkles around the mouth was evaluated by two independent
plastic surgeons using an objective wrinkle classification of 1 to 4, with a higher classification signifying
more severe wrinkles. The mean preoperative wrinkle score of 3.3 was reduced to 2.15 postoperatively.
These findings reveal that combining the facelift with chemical peeling around the mouth is a powerful
technique. Patient satisfaction is high; there is wrinkle improvement and a significant reduction in apparent age.
Dermatology & Plastic Surgery Institute
17
Facelift and Chemical Peel
A 63-year-old patient before (left) and 13 months after (right)
undergoing a facelift combined with chemical peel and lipofilling.
Preoperative (left) and 11 months postoperative (right) views of
a 64-year-old patient who underwent a facelift combined with
chemical peel, endoscopic browlift, and lipofilling.
Comparison of Actual and Apparent Age (N = 20)
2006 – 2012
Age (Years)
65
Actual
Apparent
60
55
50
18
Before Facelift
After Facelift
Outcomes 2012
Aesthetic Refinements for Graves Ophthalmopathy
Graves ophthalmopathy is a chronic, multisystem
autoimmune disorder characterized by increased
volume of intraorbital fat and hypertrophic extraocular
muscles. Clinical findings of proptosis, impaired ocular
motility, diplopia, lid retraction, and impaired visual
acuity are treated with orbital decompression and
fat reduction. Surgeons at the Dermatology & Plastic
Surgery Institute also perform skeletal augmentation to
further improve periorbital aesthetics in severe cases.
Skeletal augmentation was performed on six Graves
ophthalmopathy patients (five females, one male,
12 eyes) from 2010 to 2012. A balanced orbital
decompression was executed to remove the medial
and lateral walls and medial floor. Intraorbital fat was
excised. All patients underwent placement of porous
polyethylene infraorbital rim implants followed by
midface soft tissue elevation, to increase inferior orbital
rim projection and improve globe-cheek relationship.
Outcomes were evaluated for improvement of
proptosis, diplopia, dry eye symptoms, and cosmetic
satisfaction. Postoperative follow-up ranged from
0.5 to 2.5 years (median 1.5 years). The mean
protrusion improvement in Hertel exophthalmometer
measurement was 5.2 mm. Diplopia resolved
completely in two out of six (33%) cases, and
none of the patients experienced worsening
diplopia. Five out of six patients (83%) were able
to discontinue or greatly decrease the use of eye
lubricants postoperatively. All patients reported
cosmetic satisfaction. One patient suffered temporary
paresthesia of the inferior orbital nerve. There were
no infections, hematomas, or ocular complications.
Balanced orbital decompression with infraorbital rim
implants is reliable, effective, and safe, with good
cosmetic results.
Dermatology & Plastic Surgery Institute
A 56-year-old female presented with significant Graves ophthalmopathy
and epiphora. Preoperative and 18-month postoperative Hertel
exophthalmometer measurements were 27 mm (R), 26 mm (L), and
21 mm (R), 21 mm (L), respectively. Preoperative frontal and profile
views are shown at left, and 18-month postoperative frontal and profile
views are shown at right.
19
Patch Testing Effects on Orthopaedic Surgical Practices
More than 1 million lower extremity total joint replacements
are completed annually in the United States, the majority
for complications of osteoarthritis. Most implants are
metal alloys and some contain nickel, which is the leading
cause of metal-associated contact allergies, affecting
approximately 19% of patients evaluated with patch
testing. Although the prevalence of contact allergy to
metals is high, hypersensitivity complications associated
with metal implants have been reported to be less than
0.1%. Potential allergic complications after implantation of
orthopaedic metal devices are cutaneous eruptions, chronic
joint pain, edema, joint loosening, and joint failure.
Dermatology & Plastic Surgery Institute specialists and
others have proposed objective criteria supporting a
causative association between metal release from an
orthopaedic implant, metal allergy, and dermatitis in the
area overlying an implant. However, the clinical decisionmaking process remains difficult.
Patients are frequently referred to the Department of
Dermatology when implant problems develop, to rule out
metal-related hypersensitivity reactions. Dermatologists
commonly rely on patch testing to evaluate these patients.
Institute dermatologists aimed to determine the effect of
patch testing on surgical decision-making and outcomes
in patients evaluated for suspected metal allergy related to
implants in bones or joints. Surgeons’ preoperative choice
of metal implant alloy was compared with patch testing
results and the presence of postsurgical hypersensitivity
complications related to the metal implant at follow-up.
Patients with potential metal hypersensitivity from
implanted devices (N = 72) were divided into two groups
depending on the timing of their patch testing. In the
20
preimplantation group (N = 31), 21 patients had positive
patch test results that influenced the referring surgeon’s
decision-making. In the postimplantation group (N = 41),
the referring surgeons recommended patch testing after
excluding periprosthetic complications such as infection
and mechanical failure. The most common reason for patch
testing in this group was chronic pain at the implant site.
Ten of these patients had at least one relevant positive
patch test for a metal that was a component of their
implant, and in six patients removal of the device was
followed by resolution of the associated symptoms.
These data support a role for patch testing in patients with
putative allergy to metal implants. A decision on whether
to remove an implanted device after positive patch test
results should be made on a case-by-case basis following
discussions with the patient, surgeon, and dermatologist.
Effects of Positive Metal Patch Tests on Orthopaedic Surgeons’
Preoperative Implant Choice and Postimplant Complications
Characteristic
Metal Allergen Avoided Alternative Implant Chosen Implant Alloy Used
Titanium
Zirconium
Complications Postimplantation
Suture Reaction
Nonspecific Joint Pain
Arthrofibrosis
Scar Contracture Dermatitis
Early Joint Loosening Median Postoperative Follow-up, Months (range)
N = 21 (%)
21 (100)
13 (62)
11 (52)
10 (48)
2 (10)
1 (5)
1 (5)
1 (5)
0
0
12 (1.5–71)
Outcomes 2012
Postimplantation Details on Patients With Clinically Relevant Patch Tests Indicating Metal Sensitivity
Implant Type Symptoms/Signs
Relevant
Implant
Outcome
(Material)
Metal
Removal/Revision (Months After
Revision)
Total Follow-up
After First Operation, Months
Fibular Plate Dermatitis, edema Nickel
Device removed
(Stainless Steel)
Dermatitis and edema resolved (54)
62
Nuss Bar Dermatitis
Nickel
Device removed
(Stainless Steel)
Dermatitis
resolved (1)
23
Spinal Fusion Rod (Stainless Steel)
Dermatitis resolved, wound healed (46)
58
Dermatitis, Nickel
Device removed
impaired
wound healing
Total Knee Joint pain, Arthroplasty joint loosening
(Fem/Tib: Co-Cr-Mo) Chromium Revision with oxidized Joint pain, joint
zirconium-niobium
loosening
resolved (14)
Shoulder Arthroplasty Joint pain, Nickel
Revision with
(Metaglene/Screw: joint loosening nickel-free titanium
Ti-6 Al-4V; Hum/Glen: Stainless Steel)
38
Joint pain, joint
36
loosening
resolved (12)
Total Hip Arthroplasty Joint pain, Nickel
Revision with oxidized Joint pain, joint
(Acet: Ti-6 Al-4V; joint loosening
zirconium-niobium
loosening
Fem: Co-Cr-Mo; resolved (1.5)
Insert: Polyethylene)
38
Key: Acet = acetabular component; Al = aluminum; Co = cobalt; Cr = chromium; Fem = femoral component; Glen =
glenosphere; Hum = humeral component; Mo = molybdenum; Ti = titanium; Tib = tibial component; V = vanadium Dermatology & Plastic Surgery Institute
21
Hyperhidrosis
Onabotulinum Toxin A Treatment of Primary
Focal Hyperhidrosis
Primary focal hyperhidrosis (PFH) is defined as focal,
visible, excessive sweating of at least six months’ duration1-3
plus at least two of the following six criteria:
• Bilateral and relatively symmetrical distribution
• Impairment of daily activities
• Frequency of at least one episode per week
Hyperhidrosis Disease Severity Scale Score
My sweating is never noticeable and never interferes with my
daily activities.
1 (mild)
My sweating is tolerable but sometimes interferes with
my daily activities.
2 (moderate)
My sweating is barely tolerable and frequently interferes with
my daily activities.
3 (severe)
My sweating is intolerable and always interferes with my
daily activities.
4 (severe)
• Age of onset < 25
• Positive family history
• Cessation of focal sweating during sleep
PFH affects close to 3% of the U.S. population and occurs
equally in both sexes, though women more commonly
seek treatment. The age of onset can vary anywhere from
childhood to early adolescence, and the condition tends to
progress toward spontaneous regression. A strong family
history of PFH predisposes affected individuals to earlier
onset of symptoms.
The axilla is the most commonly affected site, followed by
the soles, palms, face, and other areas (trunk, genitals,
and lower extremities). Among patients with axillary
hyperhidrosis (HH), 81% also note HH in other areas.
Typically, presentation is symmetrical but may be unilateral.
PFH unduly burdens those affected. Symptoms such as
bacterial or fungal overgrowth, eczematous dermatitis,
and muscle cramps in affected areas may complicate
the condition, which already affects quality of life and
psychosocial well-being.
22
The Hyperhidrosis Disease Severity Scale (HDSS) is
a quick and practical way of measuring interference
with daily activities and may be used for diagnosis
and follow-up. The HDSS may also be used to assess
treatment success. A one- or two-point drop in score
from a baseline severe score (HDSS 3 or 4) or a
one-point reduction from a baseline mild or moderate
score (HDSS 1 or 2) indicates successful treatment.
Treatment failure is defined as no change in the
HDSS score.
Outcomes 2012
Treatment options for PFH include topical antiperspirants,
over-the-counter and prescription-strength preparations
containing aluminum chloride or formaldehyde, oral
glycopyrrolate, and iontophoresis. Surgical options include
tissue excision, liposuction, or curettage of the eccrine
glands, and endoscopic thoracic sympathectomy.
Positive Minor starch-iodine test before onabotulinum toxin A
injections
The Minor starch-iodine test is a colorimetric reaction
that occurs between the iodine/starch combination
and eccrine sweat. It is useful in delineating areas
of PFH involvement and also provides a qualitative
measure for evaluating treatment response.
Onabotulinum toxin A injection is FDA-approved for the
treatment of severe focal axillary HH. No serious adverse
events have been reported, but pain and bleeding at the
injection site are to be expected. A perceived increase
in compensatory sweating from nonaxillary regions after
treatment has been reported.
Onabotulinum toxin A injections may also be used to treat
PFH of the palms, soles, and craniofacial and inguinal
regions. Injection site pain is the biggest challenge when
treating the palms and soles; a combination of topical
anesthesia, ice, and pressure helps to alleviate it. In
addition to pain and bleeding at the injection site, selflimited and reversible muscle weakness resulting from toxin
diffusion to the underlying musculature (e.g., lumbricals,
frontalis) has been reported.
Treatment response can be seen within a week of an
injection session and lasts anywhere from three to 12
months or more before an unacceptable level of sweating
recurs. Onabotulinum toxin A injections for PFH have been
very successful and life-altering for almost all patients, with
the resulting anhidrosis far outweighing the minimal side
effects associated with injections. Negative Minor starch-iodine test one week after treatment with
onabotulinum toxin A
Dermatology & Plastic Surgery Institute
23
Hyperhidrosis
This graph shows the total number of Dermatology & Plastic Surgery Institute patients
treated annually with onabotulinum toxin A for PFH.
Onabotulinum Toxin A for Primary Focal Hyperhidrosis (N = 347)
2006 – 2012
Number of Patients
120
100
80
60
40
20
0
24
2006
2007
2008
2009
2010
2011
2012
Outcomes 2012
The following graph shows the number of onabotulinum toxin A injections administered each year by body
area. The axilla is the most commonly treated site. The number of treatments is more than the number of
patients, reflecting additional injections administered after HH returned. Onabotulinum Toxin A for Primary Focal Hyperhidrosis (N = 594)
2006 – 2012
Number of Treatments
250
Inguinal Region
Craniofacial
Soles
Palms
Axilla
200
150
100
50
0
N=
2006
2007
2008
2009
2010
2011
2012
2
11
33
66
123
165
194
References
1. Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H, Ahn S, Stolman LP. Recognition, diagnosis, and treatment of primary
focal hyperhidrosis. J Am Acad Dermatol. 2004 Aug;51(2):274-286.
2. Solish N, Bertucci V, Dansereau A, Hong HCH, Lynde C, Lupin M, Smith KC, Storwick G. A comprehensive approach to the recognition,
diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee.
Dermatol Surg. 2007 Aug;33(8):908-923.
3. International Hyperhidrosis Society. sweathelp.org. Accessed January 23, 2013. Dermatology & Plastic Surgery Institute
25
Psoriasis
Psoriasis is a chronic skin disorder characterized by erythematous papules and plaques with a silver scale that may affect
children and adolescents but occurs primarily in adults. The exact cause has not been identified, but the disorder may be
due to a combination of immunologic, genetic, and environmental factors.
A 12-year-old female with severe plaque-type psoriasis vulgaris
Between September 2011 and September 2012, 585 psoriasis patients presented to the institute’s Department
of Dermatology; of these, 204 met the outcomes inclusion criteria of being new psoriasis patients with at least one
follow-up. The female-to-male ratio was 1.5-to-1 — higher than the expected 1-to-1 ratio — which may reflect
an increased desire among women to seek treatment for a cosmetically bothersome problem. The mean age at
presentation was 43 years and ranged from 5 months to 89 years. Pediatric patients ages 0 to 18 years accounted for
17% of this new patient population.
Plaque psoriasis was the most common subtype (56%) seen in Cleveland Clinic patients, followed by scalp, guttate,
and inverse psoriasis. This distribution is similar to that reported in the literature.
26
Outcomes 2012
Psoriasis Subtypes (N = 204)
September 2011 – September 2012
Percent
100
75
50
25
0
Plaque
Pustular
Guttate
Inverse
Erythrodermic
Scalp
Nail
Palmoplantar
All newly diagnosed Cleveland Clinic patients were classified by disease severity, as presented in the following table:
Severity
Body Surface Area Involved
Mild
Moderate
Severe
< 3%
3%–10%
> 10%
Source: National Psoriasis Foundation
Dermatology & Plastic Surgery Institute
27
Psoriasis
This graph illustrates the percentage of newly diagnosed
Cleveland Clinic patients who were classified in each
severity category.
Psoriasis Severity (N = 204)
September 2011 – September 2012
Percent
60
Recent studies have found an association between psoriasis
and metabolic syndrome. Statistics have varied, with some
studies showing that up to 40% of psoriasis patients have
metabolic syndrome and, consequently, a higher risk of
developing cardiovascular disease. Similar data specific
to the Northeast Ohio population do not exist; staff aimed
to identify the percentage of psoriasis patients seen at the
institute who suffer from this comorbid condition. Only adult
patients were included in this analysis.
40
20
0
Mild
Moderate
Severe
Up to one-third of psoriasis patients also have psoriatic
arthritis, a condition that causes joint pain and swelling.
Cutaneous signs usually develop first, and only about 15%
of patients develop arthritis before skin symptoms. Among
Cleveland Clinic psoriasis patients, 22% had documented
psoriatic arthritis.
A chart review of 127 psoriasis patients who had
Cleveland Clinic laboratory investigations was conducted to
evaluate patients for metabolic syndrome according to the
International Diabetes Federation definition.1 Patients with
central obesity, defined as a body mass index > 30 kg/m2
or a waist circumference exceeding ethnicity-specific values,
were classified as having metabolic syndrome if two or more
of the following were also present:
• Triglycerides ≥ 150 mg/dL, or taking a specific treatment
for this lipid abnormality
• HDL cholesterol < 40 mg/dL in males or < 50 mg/dL
in females, or taking a specific treatment for this lipid abnormality
• Elevated blood pressure of 130 mm Hg systolic or
≥ 85 mm Hg diastolic, or current treatment of previously
diagnosed hypertension
• Fasting plasma glucose ≥ 100 mg/dL, or previously
diagnosed Type 2 diabetes
A 53-year-old female patient with psoriasis and psoriatic arthritis
28
Outcomes 2012
The analysis demonstrated that 54% of newly diagnosed psoriasis patients also suffered from metabolic syndrome,
which is a higher percentage than documented in most studies. Because psoriasis may serve as a marker for increased
risk of cardiovascular morbidity and mortality, it is important to evaluate patients for this essential comorbidity.
Psoriasis Patients Aged > 18 Years With Metabolic Syndrome (N = 127)
September 2011 – September 2012
Percent
100
75
50
25
0
Metabolic Syndrome
No Metabolic Syndrome
Psoriasis Treatment
Psoriasis is not curable, but available treatments can reduce the bothersome symptoms and appearance of the disease.
Treatment selection depends on disease severity, cost and convenience, and a patient’s response. A combination of
therapies is often recommended. The chart below shows the different psoriasis treatments used by Cleveland Clinic
dermatologists and the percentage of patients receiving each type of treatment.
Psoriasis Patients Aged > 18 Years With Metabolic Syndrome (N = 127)
KEY
September 2011 – September 2012
Topicals: topical corticosteroids, topical vitamin D3
preparations (calcipotriene and calcitriol), coal tar,
anthralin, topical retinoids (tazarotene), salicylic acid,
calcineurin inhibitors
Percent
100
75
Systemic: methotrexate, cyclosporin, acitretin,
mycophenolate mofetil, prednisone, hydroxyurea,
azathioprine
50
25
0
Topical
Only
Systemic*
Biologics
Phototherapy
No Rx
*Patients given a combination of topical and systemic therapy were included in the
systemic therapy group.
Dermatology & Plastic Surgery Institute
Biologics: infliximab (Remicade®), adalimumab
(Humira®), etanercept (Enbrel®), ustekinumab
(Stelara®), alefacept (Amevive®)
Phototherapy: narrowband ultraviolet B light, psoralen
plus ultraviolet A radiation
29
Psoriasis
The graphs below illustrate the percentage improvement associated with each type of
treatment for each level of psoriasis severity. Improvement was based on a composite
of physician and patient global assessment of disease activity and severity.
For mild disease, the use of topical medications is often enough. The success rate for
all treatments used in patients with mild psoriasis is high.
Mild Psoriasis Patients Improved by Treatment Type (N = 103)
September 2011 – September 2012
Percent
100
Improved
No Improvement
75
50
25
0
Topical Only
Systemic*
Phototherapy
*Patients given a combination of topical and systemic therapy were included in the systemic therapy group.
For patients with moderate psoriasis, a combination of topical treatments and
systemic therapy is most often given. Treatment outcomes for this class of patients
are shown on page 31.
30
Outcomes 2012
Moderate Psoriasis Patients Improved by Treatment Type (N = 65)
September 2011 – September 2012
Percent
100
Improved
No Improvement
75
50
25
0
Topical Only
Systemic*
Phototherapy
Biologics
Biologic therapies are usually reserved for patients who fail other systemic therapy or for those with severe disease.
The success rates for these drugs in patients with severe psoriasis are shown below.
Severe Psoriasis Patients Improved by Treatment Type (N = 36)
September 2011 – September 2012
Percent
100
Improved
No Improvement
75
50
25
0
Topical Only
Systemic*
Phototherapy
Biologics
*Patients given a combination of topical and systemic therapy were included in the systemic therapy group.
Reference
1. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome--a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Met. 2006 May;23(5):469-480.
Dermatology & Plastic Surgery Institute
31
Acne Vulgaris
Acne vulgaris is the most common skin condition in the United
States, with approximately 40 million to 50 million Americans
affected. More than 85% of adolescents in North America
report having acne or a history of acne. Acne is a disorder
of the pilosebaceous follicles, characterized by follicular
hyperkeratinization, sebum production, inflammation, and
bacterial overgrowth, specifically with Propionobacterium acnes.
Risk factors for acne include hormonal fluctuations during
adolescence, polycystic ovary syndrome, the use of oil-based
cosmetics, and genetic predisposition. Psychological stress has
been shown to worsen acne. Postadolescent acne predominantly
affects females, in contrast to adolescent acne, which largely
affects males.
Acne Severity (N = 470)
September 2011 – September 2012
15% Severe
41% Moderate
100%
44% Mild
Between September 2011 and September 2012, 1,504 patients
presented to the Dermatology & Plastic Surgery Institute for an
initial acne evaluation. Of those, 470 had at least one follow-up
visit after their initial visit, and demographic data, disease
severity, treatment regimens, and complications reported for
these patients were reviewed in order to determine treatment
outcomes. Among the 470 acne patients, the female-to-male
ratio was 2.5-to-1, and the mean age was 25.2 years with a
range of 8 to 75 years. Postadolescent females ages 25 to 45
years made up 31% of this population.
Although there is no universal classification system for acne,
patients treated at the institute were classified as having mild,
moderate, or severe disease and the presence of comedonal,
papulopustular, or nodulocystic acne. Whether patients had
scarring and/or postinflammatory hyperpigmentation (PIH) was
also specified. Analysis of the data shows that the majority of
patients presented with mild or moderate acne, and the majority
did not suffer from acne complications.
32
Outcomes 2012
Acne Complications (N = 470)
September 2011 – September 2012
Percent
70
60
50
40
30
20
10
0
None
PIH*
Scarring
PIH* +
Scarring
Keloids
*PIH = postinflammatory hyperpigmentation
Patient Race/Ethnicity (N = 470)
Analysis of Complications
PIH can be a significant problem for acne patients,
especially those with darker complexions. In many
cases, patients are more distressed by the dark spots
that take several months or more to resolve than they
are by the more quickly resolving active acne lesions.
The racial differences among patients presenting to
the Dermatology & Plastic Surgery Institute with acne
vulgaris help determine the rate of PIH and other
complications seen in these patient subgroups.
Dermatology & Plastic Surgery Institute
September 2011 – September 2012
1% Asian
2% Hispanic
43% Black
100%
54% Caucasian
33
Acne Vulgaris
Acne Complications in Black Patients (N = 58)
September 2011 – September 2012
Acne complications occurred in 63% of black
patients, with the majority experiencing PIH.
In contrast, 34% of Caucasians developed
acne complications, predominantly scarring.
5% Scarring
5% PIH* + Scarring
5% Keloids
38% None
100%
47% PIH*
*PIH = postinflammatory hyperpigmentation
Treatment Outcomes
The graph below shows the types of acne treatment most frequently used by the institute’s dermatologists.
Types of Acne Treatment (N = 470)
September 2011 – September 2012
Percent
60
50
40
30
20
10
0
34
Topical
Only
Systemic
Antibiotics
Hormonal
Treatment
Isotretinoin
Photodynamic
Therapy
Outcomes 2012
Improvement associated with the acne therapies used was based on a composite of physician and patient global assessment
of disease activity and severity. Improvement was most frequent in the photodynamic therapy group (100%), the isotretinoin
group (96%), and the hormonal treatment group (95%).
Acne Treatment Outcomes (N = 470)
September 2011 – September 2012
Percent
100
Improved
No Improvement
75
50
25
0
Topical Only
Systemic
Antibiotics
Hormonal
Treatment
Isotretinoin
Photodynamic
Therapy
PIH* Treatments Used (N = 30)
PIH treatment can be challenging and is usually
prolonged. Both topical retinoids and azelaic acid can
accelerate the resolution of PIH. Topical hydroquinone
is a depigmenting agent that inhibits melanin
production and is considered the gold standard for
treating PIH; it is available in 2% or 4% concentrations
and is applied twice daily. Additionally, patients may
benefit from superficial chemical peels with glycolic
acid or salicylic acid, which can diminish skin
discoloration and help with mild scarring, although care
must be taken to avoid chemical-peel-induced PIH. Half
of the black patients seen at the institute were treated
with hydroquinone, 20% underwent chemical peels,
and 30% received no specific PIH treatment.
Dermatology & Plastic Surgery Institute
September 2011 – September 2012
20% Chemical Peel
30% No Treatment
100%
50% Hydroquinone
*PIH = postinflammatory hyperpigmentation
35
Acne Vulgaris
PIH* Improvement (N = 21)
September 2011 – September 2012
Percent
Improvement was based on a composite of physician
and patient global assessment of disease activity
and severity. The results demonstrated remarkable
improvement with hydroquinone and chemical peels
with concomitant sunscreen application several times
daily. Noticeable improvement in PIH usually required
three to six months of treatment.
100
Improved
No Improvement
75
50
25
0
Hydroquinone
Chemical Peel
*PIH = postinflammatory hyperpigmentation
A 20-year-old male who responded to a five-month course of
isotretinoin 40 mg daily.
36
This PIH patient responded to a combination of salicylic acid (20% to
30%), chemical peels, and 4% hydroquinone cream used twice daily for
three months.
Outcomes 2012
Sarcoidosis
Sarcoidosis is a multisystem granulomatous disease of
unknown etiology. Its development has been associated
with many genetic and environmental factors. The most
frequently affected organs are the lungs (90%), lymph
nodes (90%), eyes (40%), and skin (25%). The most
frequent clinical morphology of cutaneous lesions is
macules and papules, but plaques, nodules, lupus pernio,
subcutaneous infiltrates, and infiltration of pre-existing
scars are also commonly identified.
Dermatology & Plastic Surgery Institute dermatologists
aimed to evaluate treatment outcomes of this skin condition
as it occurs in the Northeast Ohio population. A total of
153 patients with sarcoidosis presented to Cleveland
Clinic’s main campus from Jan. 1, 2006, to Sept. 30,
2012, and of those, 83 met the inclusion criteria for being
newly diagnosed during that time frame with biopsy-proven
cutaneous sarcoidosis.
The female-to-male ratio in the sample was 1.9-to-1,
similar to that seen in other studies. The mean age at
diagnosis was 47 years, with a range of 28 to 69 years.
Sarcoidosis disproportionately affects blacks, and blacks
made up the majority of this Northeast Ohio sample (57%), followed by Caucasians (19%). The chart below illustrates
sarcoidosis frequency by race.
Sarcoidosis Race Distribution (N = 83)
2006 – 2012
1% South Asian
1% Hispanic
19% Caucasian
A 53-year-old female patient with cutaneous and systemic sarcoidosis
present since 28 years of age. Note the sarcoidal papules and plaques
over the entire nose and left cheek (lupus pernio) as well as
involvement of the left eye.
22% Not Recorded
100%
57% Black
Dermatology & Plastic Surgery Institute
37
Sarcoidosis
The cutaneous clinical presentations are summarized in the following chart.
Sarcoidosis Race Distribution (N = 83)
2006 – 2012
1%
2%
10%
11%
Löfgren Syndrome
Erythema Nodosum
Nodular
Macular/Papular
16% Lupus Pernio
100%
60% Plaque
Only 24% of the patients had isolated cutaneous
sarcoidosis, whereas the majority (76%) had
systemic sarcoidosis in addition to their skin
disease. The incidence of extracutaneous disease in
this population was notably higher than the 29%
to 50% reported in most other sarcoidosis studies.
This finding serves to emphasize the importance
of referring all cutaneous sarcoidosis patients
to a specialist for thorough investigation and
appropriate screening.
Treatment and Outcomes
Systemic therapy was the most common treatment approach (65%) used by institute dermatologists, followed by topical
treatment alone (11%). The graph below shows the various treatments used in this population.
Types of Sarcoidosis Treatment (N = 83)
2006 – 2012
Percent
70
60
50
40
30
20
10
0
Topical
Only
Systemic*
Biologics*
IVIG*
Biologic and
Phototherapy
Excision
Treatment No Follow-up
Deferred
*See key on page 39
38
Outcomes 2012
Improvement was based on a composite of physician and patient global assessment of disease activity and
severity. The sarcoidosis treatments used in this patient population were highly successful, as can be seen in
the graph below. Systemic therapies such as intravenous immunoglobulin and biologics were very effective,
as was surgical excision.
Sarcoidosis Treatment Outcomes (N = 83)
2006 – 2012
Number
100
Improved
No Improvement
75
50
25
0
Topical
Only
Systemic
Biologics
IVIG
Biologic and
Phototherapy
Excision
Treatment
Deferred
Key: Topical Only = topical corticosteroids, calcineurin inhibitors; Systemic = prednisone, methotrexate, chloroquine,
hydroxychloroquine, doxycycline, minocycline, leflunomide, dapsone; Biologics = adalimumab (Humira®), infliximab
(Remicade®); IVIG = intravenous immunoglobulin
Dermatology & Plastic Surgery Institute
39
Photodynamic Therapy
Photodynamic therapy (PDT) is a nonsurgical treatment
modality requiring the use of a topical photosensitizer
in combination with visible light in the presence of
oxygen to selectively induce apoptosis in proliferating
tumors. The procedure results in the destruction of
abnormally proliferating cells. The photosensitizing agents
5-aminolevulinic acid and methyl aminolevulinate are used
in PDT for actinic keratoses (AK). PDT is currently FDAapproved only for the treatment of nonhyperkeratotic AK.
However, in most European countries, PDT is approved for
the treatment of superficial squamous cell carcinoma (SCC)
and nodular basal cell carcinoma (BCC). The Department
of Dermatology’s Photodynamic Therapy Center has been
offering PDT for the treatment of AK since 1999.
A 59-year-old-female with nevoid basal cell carcinoma syndrome (Gorlin
syndrome) of the chest, before (left) and after (right) three monthly
sessions of red light PDT.
Another standard of care for AK is topical 5-fluorouracil
(5-FU), a chemotherapy that must be applied twice daily
for many weeks and causes significant erythema and pain
during therapy. To compare efficacy, the Department of
Dermatology reviewed the charts of 100 AK patients treated
with blue light 5-aminolevulinic acid PDT and 100 AK
patients treated with topical 5-FU from January 2006 to
December 2009. The endpoint was the development of a
skin cancer in a three-year follow-up period.
Charts of patients in both groups were also screened for
documented skin cancers occurring in PDT- or 5-FU-treated
areas during the three-year follow-up. Documented skin
cancers were categorized as BCC, SCC, squamous cell
carcinoma in situ (SCCIS), or melanoma. Patients were
excluded if they had had any AK treatment other than
cryotherapy in the year prior to PDT or 5-FU treatment.
A 70-year-old male with numerous facial actinic keratoses before PDT
(left) and one month after (right) receiving one treatment with longincubation red light PDT.
40
The two treatment groups were not different in terms of age
and gender. A comparison of the characteristics of the two
groups is summarized on page 41.
Outcomes 2012
PDT vs. 5-FU Baseline Patient Characteristics
January 2006 – December 2009
PDT Group (N = 100)
5-FU Group (N = 100)
P Value
66
68
0.273
M = 72, F = 28
M = 70, F = 30
0.755
86
79
0.226
History of Melanoma
4
3
0.874
Solid Organ Transplant
2
5
0.772
Age (mean), Years
Gender
History of NMSK*
*NMSK = nonmelanoma skin cancer
The three-year risk of developing a skin cancer in the PDT group vs. the 5-FU group is summarized in the following graph.
Patients Who Developed Cancer vs. Those Who Did Not in PDT (N = 100) vs. 5-FU Group (N = 100)
2006 – 2009
Number of Patients
70
Developed Cancer
No Cancer
60
50
40
30
20
10
0
PDT
5-FU
Group
N=
34
66
Dermatology & Plastic Surgery Institute
53
47
41
Photodynamic Therapy
The relative risk reduction for developing skin cancer in the PDT group vs. the 5-FU group was 0.36. PDT offered a 36%
risk reduction for cutaneous malignancy compared with 5-FU therapy and may be a promising treatment for AK patients at
increased risk of developing skin cancer.
A recent randomized, placebo-controlled study of immunocompetent patients with diffuse AK and a history of
nonmelanoma skin cancer (NMSC) demonstrated both delayed appearance of and fewer new NMSC lesions with PDT
treatment compared with placebo. The rate of new NMSC remained low for six months after PDT and then increased
to eventually parallel the rate seen with placebo. These results indicate that repeated interventions with PDT at regular
intervals could result in adequate AK prevention.1 Among the 200 patients in the Dermatology & Plastic Surgery Institute
cohort, 32 required a second PDT session for AK recurrence and/or skin cancer development. In the 5-FU group, 30
patients needed a second course of treatment. This demonstrates that these high-risk patients with extensive photodamage
require close follow-up and more than one treatment, whether with PDT or topical chemotherapy.
The graph below shows the frequency of different types of skin cancer for each treatment group.
Patients Who Developed Different Types of Skin Cancer in PDT vs. 5-FU Group
2006 – 2009
Number of Patients
30
PDT Group
5-FU Group
20
10
0
N=
42
0
Basal Cell
Squamous
Cell
14
15
27
25
Squamous
Cell In Situ
19
22
Melanoma
0
1
Outcomes 2012
All three types of cancers were less common in patients
treated with PDT vs. 5-FU. The most common cancer in the
PDT group was SCCIS, while BCC was the most common
malignancy in patients treated with 5-FU.
As for development of cutaneous malignancies in areas
outside the treated zone, 35 PDT patients developed a
skin cancer elsewhere on their body during the three-year
follow-up, as did 43 patients in the 5-FU group. This
further indicates that AK patients have an increased risk
of developing these malignancies and should be closely
followed and treated.
Several studies have already illustrated the impressive AK
clearance rate and excellent cosmetic outcomes associated
with PDT, making it an attractive treatment option for areas
with high AK density. Institute dermatologists have further
demonstrated the efficiency of PDT over 5-FU for preventing
skin cancers. Because PDT also has a much milder side
effect profile and higher compliance rate than 5-FU, it has
become a more appealing treatment choice. Taken together,
these variables illustrate that PDT is a promising treatment
option for the prevention of NMSC in high-risk patients with
field mutagenesis.
Reference
1. Alexiades-Armenakas MR, Geronemus RG. Laser-mediated
photodynamic therapy of actinic cheilitis. J Drugs Dermatol.
2004;3:548-551.
Dermatology & Plastic Surgery Institute
43
Skin Cancer in Solid Organ Transplant Recipients
Skin cancer is the most common malignancy among organ transplant recipients and accounts for
substantial morbidity and mortality. These patients tend to develop multiple skin cancers and tend to have
more aggressive skin cancers with higher recurrence rates and increased risk for metastasis than those seen
in the general population. Skin cancer lesions in organ transplant recipients more often grow rapidly to a
large size with invasion of deeper structures and present with a more aggressive histologic growth pattern
as well as increased perineural invasion. Since 1971, it has been recognized that solid organ transplant
recipients are at an increased risk of developing skin cancer as a result of ongoing immunosuppressive
therapy.
Among those with a history of skin cancer prior to transplantation, more than 75% develop additional
skin cancers in the posttransplantation setting, with an average of 17 tumors per patient. The increased
incidence of nonmelanoma skin cancers in organ transplant recipients is alarming, with a 10-fold increase
in basal cell carcinoma and a 65- to 250-fold increase in squamous cell carcinoma compared with the
general population. There is also a 3.4-fold increase in melanoma and an 84-fold increase in Kaposi
sarcoma in the posttransplant population.
According to United Network for Organ Sharing organ procurement and transplantation data, 561,367 solid
organ transplants have been performed in the United States since 1988, with 25,787 performed in 2012
alone. As the number of solid organ transplants and long-term posttransplant survival continue to increase
every year, the burden of cutaneous malignancies in this group is an increasing concern.
In July 2011, Cleveland Clinic established a multidisciplinary Transplant Dermatology Clinic to serve this
high-risk skin cancer population. Patients are offered education and risk assessments with individually
determined follow-up intervals. To date, 640 pretransplant and 217 posttransplant skin evaluations have
been performed. Between July 2011 and February 2013, 80 skin cancers were diagnosed and treated in
pretransplant patients, and 334 skin cancers were diagnosed and treated in posttransplant patients.
The management of patients affected by numerous aggressive skin cancers associated with high rates of
morbidity and mortality presents a challenge to dermatologists. In this patient population, frequent surgical
interventions such as Mohs micrographic surgery, wide local excision, electrodessication and curettage,
and cryosurgery are used as well as systemic and topical chemoprevention and photodynamic therapy. For
patients with metastatic disease, adjuvant chemotherapy, radiation, and reduction of immunosuppression
are also indicated. Pre- and posttransplant skin screening, early detection and management, and a
multidisciplinary care approach are critical to minimize morbidity and mortality in transplant patients.
44
Outcomes 2012
A 63-year-old male kidney transplant patient developed
a poorly differentiated squamous cell carcinoma with
perineural invasion on the right frontal scalp eight months
after transplant. The photograph on the left shows
recurrence of the lesion two months after an initial Mohs
surgery and a large metastatic squamous cell carcinoma
that developed on his vertex scalp. The photograph on the
right shows the bone erosion identified after two stages of
Mohs surgery. This patient subsequently underwent a
craniectomy, craniotomy, and cranioplasty and was also
treated with postoperative radiotherapy to the surgical site.
Pretransplant and Posttransplant Evaluations Performed and
Skin Cancers Diagnosed and Treated
July 2011 – February 2013
Evaluations Performed
Pretransplant
Posttransplant
640
217
Squamous Cell Carcinomas 44
275
Basal Cell Carcinomas 32
54
Melanomas
41
Other Skin Cancers (Merkel Cell Carcinomas)
0
4
80
334
Total Number of Skin Cancers
Perineural invasion is illustrated by this squamous cell
carcinoma tightly wrapped around the nerve bundle.
Dermatology & Plastic Surgery Institute
45
Infantile Hemangiomas
Standardized Clinical Assessment and Management Plan
Since the utility of propranolol for treatment of infantile hemangiomas (IH) was discovered serendipitously in 2008, this
medication has gained increasing acceptance as first-line therapy for this condition. Cleveland Clinic’s Vascular Anomalies
Committee developed a Standardized Clinical Assessment and Management Plan (SCAMP) for administration of propranolol
to infants and children to treat IH (see page 61 in the Innovations section for further discussion of the SCAMP paradigm).
Between October 2009 and November 2012, the institute treated 47 patients with IH in the outpatient setting using the
SCAMP. A pediatric cardiologist evaluated all patients prior to therapy and prescribed the medication. The SCAMP allows
customization of the dosage based on individual responses to treatment. Results were positive, with 100% improvement
and no significant adverse events.
46
Number of Patients
47
Age at Initiation
1–14 months (mean 5.2 months, median 3 months)
Weight at Initiation
2.3–11.1 kg (mean 6.4 kg, median 5.9 kg)
Male/Female
9 (19%)/38 (81%)
Solitary/Multiple IH
41 (87%)/6 (13%)
Success in Shrinking IH
47/47 (100%)
Significant Adverse Events
0/47 (0%)
Outcomes 2012
A solitary nasal IH presenting at age
4 months and after four months of
therapy
A solitary periocular IH presenting
at 3 months of age and after eight
months of therapy
An ulcerated labial IH presenting
at age 2 months and after one
year of treatment
Dermatology & Plastic Surgery Institute
47
Infantile Hemangiomas
A solitary IH on lip presenting at age
5 months and after four months of
treatment
A solitary periocular lesion in a 3-monthold, causing astigmatism, before and after
10 months of therapy
An ulcerated scrotal IH at age 3 months
and after three months of treatment
48
Outcomes 2012
An upper-extremity IH presenting at 2 months of
age and after two months of therapy
A solitary forehead IH presenting in a 2-monthold and after four and nine months of therapy
Dermatology & Plastic Surgery Institute
49
Infantile Hemangiomas
A large segmental IH presenting in a 5-month-old
boy before and after three months of treatment
A facial IH presenting at age 10 months, after
three months of treatment, and after completion
of treatment at age 19 months
50
Outcomes 2012
Selected
Patient Experience
Publications
— Dermatology & Plastic Surgery Institute
Cleveland Clinic is dedicated to delivering excellent clinical outcomes and the
best possible experience for our patients and their families. Patient feedback
is critical in driving priorities and assessing results. Based on this feedback,
Cleveland Clinic’s Office of Patient Experience implements training programs to
improve service and communication as well as educational initiatives to help
patients understand what to expect when they are in our care.
Outpatient Office Survey — Dermatology & Plastic Surgery Institute
2011 – 2012
Percent Best Response*
100
2011 (N = 2,736)
2012 (N = 3,120)
80
60
40
20
0
Appt Access/
Check-In
Clinic Wait Times
and Comfort
Nurse and
Assistant
Physician
Concern for
Needs and Privacy
Overall
Assessment
*Response options: Very Good, Good, Fair, Poor, Very Poor
Each bar represents a composite score based on responses to multiple survey questions.
Source: Press Ganey, a national hospital survey vendor
Dermatology & Plastic Surgery Institute
51
Surgical Quality Improvement
National Surgical Quality Improvement Program
The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) objectively measures and
reports risk-adjusted surgical outcomes based on a defined sampling and abstraction methodology. These outcomes data
reflect Cleveland Clinic’s NSQIP performance benchmarked against more than 350 participating hospitals.
Cleveland Clinic
Overall Multispecialty 30-Day Mortality (N = 4,988)
Cleveland Clinic
Overall Multispecialty 30-Day Morbidity (N = 4,988)
July 2011 – June 2012
July 2011 – June 2012
Percent
5
Percent
12
4
10
8
3
6
2
4
1
0
2
Observed
0
Expected
Observed
Expected
Overall mortality was significantly lower than expected, and overall morbidity was significantly higher than expected.
Plastic Surgery 30-Day Morbidity (N = 129)
July 2011 – June 2012
Percent
8
6
In addition to overall surgical performance,
NSQIP data specific to plastic surgery are
provided. There was no significant difference
between plastic surgery observed and
expected morbidity rates.
4
2
0
52
Observed
Expected
Outcomes 2012
Surgical Care Improvement Program (SCIP) — Appropriateness of Care
This composite metric, based on 10 hospital surgical quality process measures developed by the
Centers for Medicare & Medicaid Services, shows the percentage of patients who received all the
recommended care for which they were eligible.
Cleveland Clinic Surgical Appropriateness of Care
2011 – 2012
Percent
100
92.3
93.0
UHC 90th Percentile, 2012*
80
60
40
20
0
N=
2011
2012
1,501
1,293
* These data are prepared using the University HealthSystem Consortium (UHC)
Clinical Database. uhc.edu
Cleveland Clinic has set a target of UHC’s 90th percentile, and results are
trending positively.
Dermatology & Plastic Surgery Institute
53
Cleveland Clinic —
Improving Quality, Safety, and the Patient Experience
Overview
Cleveland Clinic health system uses a scorecard approach to measure and monitor quality, safety, and patient experience.
Real-time dashboard data are leveraged in each location to drive performance improvement. Although not an exact
match to publicly reported data, more timely internal data create transparency at all organizational levels and support
improved care in all clinical locations. The following measures are examples of health system 2012 quality and safety
focus areas. Throughout this section, “Cleveland Clinic” refers to the academic medical center or “main campus,” and
those results are shown.
Cleveland Clinic Core Measures
Appropriateness of Care
All-Cause 30-Day Readmission Rate
to Any Cleveland Clinic Hospital
2011 – 2012
2011 – 2012
Percent of Patients
100
Percent of Discharges
18
16
14
80
12
60
10
8
40
Cleveland Clinic Performance
Cleveland Clinic Target
20
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
Cleveland Clinic’s goal is for all patients to receive
all the recommended care for their condition. An
aggregated “all or nothing” measurement approach to
monitoring multiple publicly reported process-of-care
measures for heart failure, acute myocardial infarction,
pneumonia, and surgery patients yields results
consistently above 94%.
54
Cleveland Clinic Performance
6
4
2
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
Cleveland Clinic monitors 30-day readmission
rates for any reason to any of its system hospitals.
Unplanned readmissions are actively reviewed for
improvement opportunities. Strategies associated
with communication, education, and follow-up have
been implemented for several high-risk conditions,
including heart failure and pneumonia. These
practices are being expanded and enhanced to
reduce overall avoidable readmissions.
Outcomes 2012
Cleveland Clinic Deaths Among Surgical Patients
With Serious Treatable Complications (PSI 4)
Rate per 1,000 Eligible Patients
Cleveland Clinic Overall In-Hospital Mortality
Observed/Expected Ratio
2011 – 2012
2011 – 2012
O/E Ratio
1.2
Rate per 1,000 Patients
180
1.0
160
140
0.8
120
0.6
100
Cleveland Clinic Performance
UHC* 50th Percentile
(Academic Medical Center)
0.4
80
0.0
Cleveland Clinic Performance
UHC* 50th Percentile
(Academic Medical Center)
60
0.2
40
Q1
Q2
Q3
Q4
2011
Q1
Q2
Q3
Q4
2012
Cleveland Clinic’s observed/expected (O/E) mortality
ratio outperformed the University HealthSystem
Consortium (UHC) academic medical center 50th
percentile throughout 2012 based on the UHC
2012 risk model. Ratios less than 1.0 indicate
mortality performance “better than” expected in
UHC’s risk adjustment model.
20
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
The Agency for Healthcare Research and Quality’s
Patient Safety Indicator 4 (AHRQ PSI 4) reports
deaths among patients with serious treatable
complications. Cleveland Clinic performs in the
top third of UHC’s academic medical centers for
this measure.
*These data are prepared using the University HealthSystem
Consortium (UHC) Clinical Database. uhc.edu
Dermatology & Plastic Surgery Institute
55
Cleveland Clinic —
Improving Quality, Safety, and the Patient Experience
Cleveland Clinic Postoperative Blood Clot Rate (PSI 12)
per 1,000 Eligible Patients
Cleveland Clinic Central Line-Associated Bloodstream
Infection—ICU Rate per 1,000 Line Days
2011 – 2012
2010 – 2012
Rate per 1,000 Patients
20
18
16
14
12
10
8
Cleveland Clinic Performance
6
UHC* 50th Percentile
4
(Academic Medical Center)
2
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Rate per 1,000 Line Days
3.5
2011
2012
Cleveland Clinic continues to improve its
performance with respect to postoperative
blood clots (AHRQ Patient Safety Indicator 12).
Improved screening and prevention strategies
have led to a 45% reduction in these events over
the past two years.
Cleveland Clinic Performance
Cleveland Clinic Target
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2010
2011
2012
Cleveland Clinic has implemented several
strategies to reduce central line-associated
bloodstream infections (CLABSI), including a
central-line bundle of insertion, maintenance,
and removal best practices. In 2012, Cleveland
Clinic initiated focused reviews of every CLABSI
occurrence and is introducing equipment and
technology to support reductions in CLABSI rates
in its high-risk critical care population.
*These data are prepared using the University HealthSystem
Consortium (UHC) Clinical Database. uhc.edu
56
Outcomes 2012
Cleveland Clinic Hospital-Acquired Pressure
Ulcers Prevalence
Cleveland Clinic Falls Rate per 1,000 Patient Days
2011 – 2012
2011 – 2012
Percent
5
Rate per 1,000 Patient Days
4.0
3.5
4
3.0
2.5
3
2.0
2
Cleveland Clinic Performance
NDNQI®* 50th Percentile
(Academic Medical Center)
1
0
Q1
Q2
Q3
Q4
2011
Q1
Q2
Q3
Q4
2012
A pressure ulcer is an injury to the skin that can
be caused by pressure, moisture, or friction. These
sometimes occur when patients have difficulty
changing positions on their own. Cleveland Clinic
caregivers have been trained to provide appropriate
skin care and regular repositioning help while taking
advantage of special devices and mattresses to
reduce pressure for high-risk patients. In addition,
they actively look for hospital-acquired pressure ulcers
and treat them quickly if they occur.
1.5
Cleveland Clinic Performance
NDNQI®* 50th Percentile
(Academic Medical Center)
1.0
0.5
0.0
Q1
Q2
Q3
Q4
2011
Q1
Q2
Q3
Q4
2012
Nationally, falls are a leading cause of hospital
patient injury. Cleveland Clinic fall prevention efforts
include identifying patients who are at risk for
falls, checking on them frequently, assisting them
to the bathroom, and providing nonskid footwear.
Caregivers make sure patients have all necessary
items, including a call light, within easy reach.
*The National Database of Nursing Quality Indicators® (NDNQI®) is owned
by the American Nurses Association. The database collects and evaluates
unit-specific nurse-sensitive data from hospitals domestically and globally,
with > 1900 hospitals participating. The comparison data represented
here are based on a third of all hospitals in the U.S. participating. © 2012,
American Nurses Association, All Rights Reserved. www.nursingquality.org
Dermatology & Plastic Surgery Institute
57
Cleveland Clinic —
Improving Quality, Safety, and the Patient Experience
Patient Experience
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is
a standardized national tool used to measure patients’ perspectives of hospital care. Results
collected for public reporting are available at medicare.gov/hospitalcompare.
Cleveland Clinic HCAHPS Overall Assessment
2011 – 2012
Percent Best Response*
100
84.9
84.0
80
80.0
80.8
60
2011 (N = 10,378)
2012 (N = 11,190)
40
National Average
July 1, 2011 – June 30, 2012
20
0
Recommend Hospital
(% Definitely Yes)*
Hospital Rating
(% 9 or 10)
0–10 Scale
*Response options: Definitely Yes, Probably Yes, Probably No, Definitely No
Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor
58
Outcomes 2012
Cleveland Clinic HCAHPS Domains of Care
2011 – 2012
Percent Best Response*
100
2011 (N = 10,378)
2012 (N = 11,190)
National Average
July 1, 2011 – June 30, 2012
80
60
40
20
0
Discharge
Information
% Yes
Doctor
Nurse
Communication Communication
Pain
Management
Room
New Medications Responsiveness
Clean
Communication
to Needs
% Always
(Options: Always, Usually, Sometimes, Never)
Quiet at
Night
*Except for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions.
Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor
The guiding principle of Cleveland Clinic is “Patients First,” and improving the patient experience is a major strategic
organizational goal. The Office of Patient Experience collaborates with physician and nursing leadership to establish
best practices and implement standardized protocols that ensure delivery of patient-centered care.
Dermatology & Plastic Surgery Institute
59
Innovations
Transoral Posterior Maxillary Craniofacial Surgery to Place a Neurostimulator for
Chronic Cluster Headache Treatment
The pain and autonomic symptoms of chronic cluster headache may result from activation of the trigeminal
parasympathetic reflex, mediated through the sphenopalatine ganglion (SPG). The Dermatology & Plastic
Surgery Institute assisted in the surgical and clinical design of the multicenter Pathway CH-1 study to
evaluate the surgical safety of SPG stimulation for the treatment of acute chronic cluster headache.
A minimally invasive transoral technique was used to implant an experimental miniaturized neurostimulator,
consisting of a stimulating electrode and fixation plate, proximally to the SPG. This technique involves
placing the body of the neurostimulator on the lateral posterior maxilla and using the fixation plate
to anchor the neurostimulator on the superior lateral zygomaticomaxillary buttress. The procedure is
performed using fluoroscopic guidance with general anesthesia and takes 30 to 60 minutes.
Since the study began in June 2012, 43 patients in six European centers have been implanted with the
ATI Neurostimulation SystemTM. In one subject (2%) the procedure was not completed due to anatomical
limitations. Three subjects (7%) were explanted due to early lead migrations or misplacement of the
neurostimulator, and another three patients (7%) underwent a revision procedure due to lack of efficacious
SPG stimulation and nonoptimal electrode locations. Within the first 30 postoperative days, 20 subjects
(47%) reported numbness in the second division of the trigeminal nerve, which resolved within an
average of 90 days from onset in 12 patients (62%). As of June 2013, numbness was unresolved in
eight patients (38%) and had persisted an average of 163 days, with a maximum duration of 356 days.
Reported adverse events include pain (25%), swelling (20%), and paresthesias (19%). The majority of
reported adverse events were classified as mild to moderate, and there have been no infections requiring
explantation. Additionally, 81% of subjects have achieved acute headache pain relief of > 50% and/or a
> 50% reduction in headache frequency with SPG stimulation.
The initial experience using the minimally invasive implantation procedure for the neurostimulator shows
an acceptable safety profile that is comparable with that observed in standard oral maxillofacial surgeries.
Advancements in surgical instruments and gains in surgeon experience have reduced both the number and
severity of adverse events reported.
60
Outcomes 2012
Standardized Clinical Assessment and Management Plan for Propranolol Treatment of
Infantile Hemangiomas
The multidisciplinary Cleveland Clinic Vascular Anomalies Committee developed a Standardized Clinical Assessment
and Management Plan (SCAMP) for administration of propranolol to infants and children for treatment of infantile
hemangiomas. The SCAMP paradigm was developed in other areas of medicine, with the heterogeneous patient
population in mind, as a method for rapid development and evaluation of a clinical management protocol.1 Intrinsic
to this approach is continuous revision of a treatment plan while preserving the ability to carefully measure and
assess outcomes. As far as can be determined, this is the first application of the SCAMP methodology in academic
dermatologic practice.
The high degree of diversity of presentation in infantile hemangiomas, the range of subspecialties involved in the care
of these patients, and the challenge of assessment for cardiac risk were important considerations when the institute
began to use propranolol as a treatment. The importance of systematizing the approach in order to allow an organized
assessment of outcomes and any adverse events led to adoption of the SCAMP paradigm.
The SCAMP was established with the following goals:
• To ensure patient safety with a comprehensive cardiovascular evaluation performed prior to treatment and initiation of treatment under the supervision of an experienced pediatric cardiologist
• To facilitate multidisciplinary involvement in patient care
• To achieve careful documentation of methods and results to facilitate quality improvement
Between October 2009 and November 2012, the institute successfully treated 47 children with infantile
hemangiomas using this SCAMP. (See page 46 of the Outcomes section for a description and photographs of
the results.)
Reference
1. Rathod RH, Farias M, Friedman KG, Graham D, Fulton DR, Newburger JW, Colan S, Jenkins K, Lock JE. A novel approach to gathering and acting on relevant clinical information: SCAMPs. Congenit Heart Dis. 2010 Jul-Aug;5(4):343-353.
Dermatology & Plastic Surgery Institute
61
Selected Publications
Dermatology
Adenuga P, Summers P, Bergfeld W. Hair regrowth in a male patient
with extensive androgenetic alopecia on estrogen therapy. J Am Acad
Dermatol. 2012 Sep;67(3):e121-e123.
Anand S, Ortel BJ, Pereira SP, Hasan T, Maytin EV. Biomodulatory
approaches to photodynamic therapy for solid tumors. Cancer Lett.
2012 Dec 29;326(1):8-16.
Anderson KA, Vidimos AT. Two primary dermatofibrosarcoma
protuberans associated with different pregnancies in a single patient.
Dermatol Surg. 2012 Nov;38(11):1876-1878.
Aouthmany M, Keller E, Piliang M. Dermatopathology diagnosis:
junctional epidermolysis bullosa. Cutis. 2012 Aug;90(2):64, 81-82.
Aouthmany M, Weinstein M, Zirwas MJ, Brodell RT. The natural history
of halo nevi: A retrospective case series. J Am Acad Dermatol. 2012
Oct;67(4):582-586.
Dermatology & Plastic Surgery Institute
staff authored more than
80 publications
in peer-reviewed journals in 2012.
For a complete list of publications, go to
clevelandclinic.org/outcomes.
Atanaskova Mesinkovska N, Tellez A, Molina L, Honari G, Sood A,
Barsoum W, Taylor JS. The effect of patch testing on surgical practices
and outcomes in orthopedic patients with metal implants. Arch
Dermatol. 2012 Jun;148(6):687-693.
Atanaskova Mesinkovska N, Tomecki KJ. Novel systemic antibiotics in
dermatology. Dermatol Ther. 2012 Jan;25(1):1-5.
Becker LC, Bergfeld WF, Belsito DV, Hill RA, Klaassen CD, Liebler D,
Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW, Andersen FA. Safety
assessment of trimoniums as used in cosmetics. Int J Toxicol. 2012
Nov;31(6 Suppl):296S-341S.
Becker LC, Bergfeld WF, Belsito DV, Hill RA, Klaassen CD, Liebler D,
Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW, Andersen FA. Safety
assessment of alkyl benzoates as used in cosmetics. Int J Toxicol.
2012 Nov;31(6 Suppl):342S-372S.
Billings SD, Han AJ. [Iatrogenic vascular tumors in the setting of
breast cancer] [Chinese]. Zhonghua Bing Li Xue Za Zhi. 2012
Oct;41(10):708-711.
Boncher J, Bergfeld WF. Fluoroscopy-induced chronic radiation
dermatitis: a report of two additional cases and a brief review of the
literature. J Cutan Pathol. 2012 Jan;39(1):63-67.
62
Outcomes 2012
Burdick LM, Losher S, Somach SC, Billings SD. Cutaneous
collagenous vasculopathy: a rare cutaneous microangiopathy.
J Cutan Pathol. 2012 Aug;39(8):741-746.
Fernandez-Faith E, Kress D, Piliang M, Sachdeva M, Vidimos A.
Buschke-Ollendorff syndrome and bilateral cutaneous syndactyly.
Pediatr Dermatol. 2012 Sep-Oct;29(5):661-662.
Burnett CL, Bergfeld WF, Belsito DV, Hill RA, Klaassen CD, Liebler D,
Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW, Andersen FA. Final
report of the Cosmetic Ingredient Review Expert Panel on the safety
assessment of cocamidopropyl betaine (CAPB). Int J Toxicol. 2012
Jul-Aug;31(4 Suppl):77S-111S.
Fiume MM, Bergfeld WF, Belsito DV, Hill RA, Klaassen CD, Liebler D,
Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW, Andersen FA. Safety
assessment of stearyl heptanoate and related stearyl alkanoates as
used in cosmetics. Int J Toxicol. 2012 Sep-Oct;31(5 Suppl):141S146S.
Chatterjee S, Tuthill RJ. A 48-year-old woman with an ecchymotic
rash. Cleve Clin J Med. 2012 Feb;79(2):102-105.
Fiume MM, Bergfeld WF, Belsito DV, Hill RA, Klaassen CD, Liebler D,
Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW, Andersen FA. Safety
assessment of propylene glycol, tripropylene glycol, and PPGs as used
in cosmetics. Int J Toxicol. 2012 Sep-Oct;31(5 Suppl):245S-260S.
Cheah AL, Billings SD. The role of molecular testing in the diagnosis
of cutaneous soft tissue tumors. Semin Cutan Med Surg. 2012
Dec;31(4):221-233.
Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA,
Vidimos AT, Zalla MJ, Brewer JD, Begolka WS, Berger TG, Bigby M,
Bolognia JL, Brodland DG, Collins S, Cronin TA, Jr., Dahl MV,
Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW,
McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ.
AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs
micrographic surgery: A report of the American Academy of
Dermatology, American College of Mohs Surgery, American Society for
Dermatologic Surgery Association, and the American Society for Mohs
Surgery. Dermatol Surg. 2012 Oct;38(10):1582-1603.
Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA,
Vidimos AT, Zalla MJ, Brewer JD, Smith Begolka W, Berger TG,
Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA, Jr.,
Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD,
Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG,
Wisco OJ. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria
for Mohs micrographic surgery: A report of the American Academy of
Dermatology, American College of Mohs Surgery, American Society for
Dermatologic Surgery Association, and the American Society for Mohs
Surgery. J Am Acad Dermatol. 2012 Oct;67(4):531-550.
Fernandez AP, Sun Y, Tubbs RR, Goldblum JR, Billings SD. FISH
for MYC amplification and anti-MYC immunohistochemistry: useful
diagnostic tools in the assessment of secondary angiosarcoma
and atypical vascular proliferations. J Cutan Pathol. 2012
Feb;39(2):234-242.
Dermatology & Plastic Surgery Institute
Fiume MM, Heldreth B, Bergfeld WF, Belsito DV, Hill RA,
Klaassen CD, Liebler D, Marks JG, Jr., Shank RC, Slaga TJ,
Snyder PW, Andersen FA. Final report of the Cosmetic Ingredient
Review Expert Panel on the safety assessment of dicarboxylic acids,
salts, and esters [Erratum in: Int J Toxicol. 2012;31(5 Suppl):261S].
Int J Toxicol. 2012 Jul-Aug;31(4 Suppl):5S-76S.
Fiume MM, Heldreth B, Bergfeld WF, Belsito DV, Hill RA,
Klaassen CD, Liebler D, Marks JG, Jr., Shank RC, Slaga TJ,
Snyder PW, Andersen FA. Safety assessment of alkyl PEG ethers
as used in cosmetics. Int J Toxicol. 2012 Sep-Oct;31(5 Suppl):
169S-244S.
Fowler JF, Jr., Maibach HI, Zirwas M, Taylor JS, DeKoven JG,
Sasseville D, Warshaw EM, Belsito DV, Storrs FJ, Zug KA, Pratt MD,
Mathias CGT, DeLeo VA, Fransway AF, Myers F, Marks JG. Effects of
immunomodulatory agents on patch testing: Expert opinion 2012.
Dermatitis. 2012 Nov;23(6):301-303.
Fox MD, Billings SD, Gleason BC, Moore J, Thomas AB,
Shea CR, Victor TA, Cibull TL. Expression of MiTF may be helpful
in differentiating cellular neurothekeoma from plexiform fibrohistiocytic
tumor (histiocytoid predominant) in a partial biopsy specimen.
Am J Dermatopathol. 2012 Apr;34(2):157-160.
Fritchie KJ, Carver P, Sun Y, Batiouchko G, Billings SD, Rubin BP,
Tubbs RR, Goldblum JR. Solitary fibrous tumor: is there a molecular
relationship with cellular angiofibroma, spindle cell lipoma, and
mammary-type myofibroblastoma? Am J Clin Pathol. 2012
Jun;137(6):963-970.
63
Selected Publications
Fritchie KJ, Goldblum JR, Tubbs RR, Sun Y, Carver P, Billings SD,
Rubin BP. The expanded histologic spectrum of myxoid liposarcoma
with an emphasis on newly described patterns: implications for
diagnosis on small biopsy specimens. Am J Clin Pathol. 2012
Feb;137(2):229-239.
Gardner JM, Dandekar M, Thomas D, Goldblum JR, Weiss SW,
Billings SD, Lucas DR, McHugh JB, Patel RM. Cutaneous and
subcutaneous pleomorphic liposarcoma: A clinicopathologic study of
29 cases with evaluation of MDM2 gene amplification in 26.
Am J Surg Pathol. 2012 Jul;36(7):1047-1051.
Goebel C, Diepgen TL, Krasteva M, Schlatter H, Nicolas JF,
Blomeke B, Coenraads PJ, Schnuch A, Taylor JS, Pungier J,
Fautz R, Fuchs A, Schuh W, Gerberick GF, Kimber I. Quantitative
risk assessment for skin sensitisation: Consideration of a simplified
approach for hair dye ingredients. Regul Toxicol Pharmacol. 2012
Dec;64(3):459-465.
Goshe JM, Lewis CD, Meine JG, Schoenfield L, Perry JD. Primary
dermatofibrosarcoma protuberans invading the orbit. Ophthal Plast
Reconstr Surg. 2012 May-Jun;28(3):e65-e67.
Hallahan KM, Sood A, Singh AD. Acute episode of eyelid oedema.
Br J Ophthalmol. 2012 Jun;96(6):909, 913.
Hamann D, Hamann C, Li LF, Xiang H, Hamann K, Maibach H,
Taylor JS, Thyssen JP. The Sino-American belt study: nickel
and cobalt exposure, epidemiology, and clinical considerations.
Dermatitis. 2012 May;23(3):117-123.
Heldreth B, Bergfeld WF, Belsito DV, Hill RA, Klaassen CD, Liebler D,
Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW, Andersen FA. Final
report of the Cosmetic Ingredient Review Expert Panel on the safety
assessment of methyl acetate. Int J Toxicol. 2012 Jul-Aug;31(4
Suppl):112S-136S.
Helm MF, Helm TN, Bergfeld WF. Skin problems in the long-distance
runner 2500 years after the Battle of Marathon. Int J Dermatol.
2012 Mar;51(3):263-270.
Johnson W, Jr., Bergfeld WF, Belsito DV, Hill RA, Klaassen CD,
Liebler D, Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW,
Andersen FA. Safety assessment of 1,2-glycols as used in
cosmetics. Int J Toxicol. 2012 Sep-Oct;31(5 Suppl):147S-168S.
64
Johnson W, Jr., Bergfeld WF, Belsito DV, Hill RA, Klaassen CD,
Liebler D, Marks JG, Jr., Shank RC, Slaga TJ, Snyder PW,
Andersen FA. Safety assessment of isoparaffins as used in cosmetics.
Int J Toxicol. 2012 Nov;31(6 Suppl):269S-295S.
Jou PC, Feldman RJ, Tomecki KJ. UV protection and sunscreens:
What to tell patients. Cleve Clin J Med. 2012 Jun;79(6):427-436.
Jurado SA, Alvin GKG, Selim MA, Pipkin CA, Kress D, Jamora MJJ,
Billings SD. Fibroblastic rheumatism: A report of 4 cases with potential
therapeutic implications. J Am Acad Dermatol. 2012 Jun;66(6):
959-965.
Keller EC, Tomecki KJ, Alraies MC. Distinguishing cellulitis from its
mimics. Cleve Clin J Med. 2012 Aug;79(8):547-552.
Mack JA, Feldman RJ, Itano N, Kimata K, Lauer M, Hascall VC,
Maytin EV. Enhanced inflammation and accelerated wound closure
following tetraphorbol ester application or full-thickness wounding in
mice lacking hyaluronan synthases has1 and has3. J Invest Dermatol.
2012 Jan;132(1):198-207.
Marburger TB, Gardner JM, Prieto VG, Billings SD. Primary cutaneous
rhabdomyosarcoma: a clinicopathologic review of 11 cases. J Cutan
Pathol. 2012 Nov;39(11):987-995.
Maytin EV, Honari G, Khachemoune A, Taylor CR, Ortel B, Pogue BW,
Sznycer-Taub N, Hasan T. The vitamin D analog calcipotriol combined
with aminolevulinate-mediated photodynamic therapy for human
psoriasis: A proof-of-principle study. Isr J Chem. 2012;52(8-9):
767-775.
Patel RM, Billings SD. Cutaneous soft tissue tumors that make you say,
“oh $*&%!”. Adv Anat Pathol. 2012 Sep;19(5):320-330.
Schalock PC, Menne T, Johansen JD, Taylor JS, Maibach HI, Liden C,
Bruze M, Thyssen JP. Hypersensitivity reactions to metallic implants
- diagnostic algorithm and suggested patch test series for clinical use.
Contact Dermatitis. 2012 Jan;66(1):4-19.
Sellheyer K. Reply: Methodology matters as does knowledge of
underlying basic science.... J Cutan Pathol. 2012 Jan;39(1):83-87.
Sellheyer K, Nelson P. The ventral proximal nail fold: stem cell niche of
the nail and equivalent to the follicular bulge - a study on developing
human skin. J Cutan Pathol. 2012 Sep;39(9):835-843.
Outcomes 2012
Wang WL, Evans HL, Meis JM, Liegl-Atzwanger B, Bovee JV,
Goldblum JR, Billings SD, Rubin BP, Lopez-Terrada D, Lazar AJ. FUS
rearrangements are rare in ‘pure’ sclerosing epithelioid fibrosarcoma.
Mod Pathol. 2012 Jun;25(6):846-853.
Warshaw EM, Raju SI, Fowler JF, Jr., Maibach HI, Belsito DV, Zug KA,
Rietschel RL, Taylor JS, Mathias CGT, Fransway AF, DeLeo VA,
Marks JG, Jr., Storrs FJ, Pratt MD, Sasseville D. Positive patch
test reactions in older individuals: Retrospective analysis from the
North American Contact Dermatitis Group, 1994-2008. J Am Acad
Dermatol. 2012 Feb;66(2):229-240.
Warshaw EM, Wang MZ, Mathias CGT, Maibach HI, Belsito DV,
Zug KA, Taylor JS, Zirwas MJ, Fransway AF, DeLeo VA, Marks JG, Jr.,
Pratt MD, Storrs FJ, Rietschel RL, Fowler JF, Jr., Sasseville D.
Occupational contact dermatitis in hairdressers/cosmetologists:
Retrospective analysis of North American Contact Dermatitis Group
data, 1994 to 2010. Dermatitis. 2012 Nov;23(6):258-268.
Weinstein MC, Brodell RT, Bordeaux J, Honda K. The art and science
of surgical margins for the dermatopathologist. Am J Dermatopathol.
2012 Oct;34(7):737-745.
Weyer C, Siegle RJ, Eng GGP. Investigation of hyfrecators and their in
vitro interference with implantable cardiac devices. Dermatol Surg.
2012 Nov;38(11):1843-1848.
Yao Q, Englund KA, Hayden SP, Tomecki KJ. Tumor necrosis factor
receptor associated periodic fever syndrome with photographic
evidence of various skin disease and unusual phenotypes: case report
and literature review. Semin Arthritis Rheum. 2012 Feb;41(4):
611-617.
Yao Q, Piliang M, Nicolacakis K, Arrossi A. Granulomatous
pneumonitis associated with adult-onset Blau-like syndrome.
Am J Respir Crit Care Med. 2012 Sep 1;186(5):465-466.
Yao Q, Zhou L, Tomecki KJ. Coexistent tumor necrosis factor
receptor-associated periodic fever syndrome and Ehlers-Danlos
syndrome. Rheumatol Int. 2012 Jul;32(7):2223-2225.
Dermatology & Plastic Surgery Institute
PUBLICATIONS
PUBLICATIONS
PUBLICATIONS
Sellheyer K, Nelson P, Kutzner H. Fibroepithelioma of Pinkus is a true
basal cell carcinoma developing in association with a newly identified
tumour-specific type of epidermal hyperplasia. Br J Dermatol. 2012
Jan;166(1):88-97.
65
Selected Publications
Plastic Surgery
Afifi AM, Alghoul M, Zor F, Kusuma S, Zins JE. Comparison of
the transpalpebral and endoscopic approaches in resection of the
corrugator supercilii muscle. Aesthet Surg J. 2012 Feb;32(2):
151-156.
Alghoul M, Mendiola A, Seth R, Rubin BP, Zins JE, Calabro A,
Siemionow M, Kusuma S. The effect of hyaluronan hydrogel on
fat graft survival. Aesthet Surg J. 2012 Jul;32(5):622-633.
Bolesta E, Pfannenstiel LW, Demelash A, Lesniewski ML,
Tobin M, Schlanger SE, Nallar SC, Papadimitriou JC, Kalvakolanu DV,
Gastman BR. Inhibition of mcl-1 promotes senescence in cancer
cells: implications for preventing tumor growth and chemotherapy
resistance. Mol Cell Biol. 2012 May;32(10):1879-1892.
Brooks S, Djohan R, Tendulkar R, Nutter B, Lyons J, Dietz J.
Risk factors for complications of radiation therapy on tissue expander
breast reconstructions. Breast J. 2012 Jan-Feb;18(1):28-34.
Chopra K, Gastman BR, Manson PN. Stereolithographic modeling
in reconstructive surgery of the craniofacial skeleton after tumor
resection. Plast Reconstr Surg. 2012 Apr;129(4):743e-745e.
Chopra K, Folstein MK, Slezak S, Silverman R, Singh D, Gastman BR.
The VersaJet for breast-reduction surgery: Operator beware. Eplasty.
2012;12:e11.
Dietz J, Lundgren P, Veeramani A, O’Rourke C, Bernard S,
Djohan R, Larson J, Isakov R, Yetman R. Autologous inferior
dermal sling (autoderm) with concomitant skin-envelope reduction
mastectomy: an excellent surgical choice for women with
macromastia and clinically significant ptosis. Ann Surg Oncol. 2012
Oct;19(10):3282-3288.
Dorafshar AH, Franczyk M, Gottlieb LJ, Wroblewski KE, Lohman RF.
A prospective randomized trial comparing subatmospheric wound
therapy with a sealed gauze dressing and the standard vacuumassisted closure device. Ann Plast Surg. 2012 Jul;69(1):79-84.
Engel SJ, Patel NK, Morrison CM, Rotemberg SC, Fritz J,
Nutter B, Zins JE. Operating room fires: Part II. Optimizing safety.
Plast Reconstr Surg. 2012 Sep;130(3):681-689.
66
Outcomes 2012
Gastman B, Djohan R, Siemionow M. Extending the Cordeiro
maxillofacial defect classification system for use in the era of
vascularized composite transplantation. Plast Reconstr Surg.
2012 Aug;130(2):419-422.
Krokowicz L, Klimczak A, Cwykiel J, Mielniczuk M, Grykien C,
Siemionow M. Pulsed acoustic cellular expression as a protective
therapy against I/R injury in a cremaster muscle flap model.
Microvasc Res. 2012 Mar;83(2):213-222.
Siemionow M, Ozturk C. Donor operation for face transplantation.
J Reconstr Microsurg. 2012 Jan;28(1):35-42.
Van Meeteren J, Lehman JA, Zins J, Brown W, Burgoyne D. New
sterilization technology and the effects on bone pencil. J Craniofac
Surg. 2012 Mar;23(2):582.
Morrison CM, Dobryansky M, Warren RJ, Zins JE. The table tilt:
preventing traction on the brachial plexus during facelift surgery.
Aesthet Surg J. 2012 May;32(4):524.
Voskens CJ, Sewell D, Hertzano R, Desanto J, Rollins S, Lee M,
Taylor R, Wolf J, Suntharalingam M, Gastman B, Papadimitriou JC,
Lu C, Tan M, Morales R, Cullen K, Celis E, Mann D, Strome SE.
Induction of MAGE-A3 and HPV-16 immunity by Trojan vaccines
in patients with head and neck carcinoma. Head Neck. 2012
Dec;34(12):1734-1746.
Nasir S, Porzel A, Pryor L, Zins JE. Biomechanical comparison of
calcium phosphate cements for split cranial bone graft donor sites.
Plast Reconstr Surg. 2012 Oct;130(4):527e-535e.
Yazici I, Cavusoglu T, Karakaya EI, Comert A, Siemionow M.
Microsurgical training model for lymphaticovenous anastomosis in rat.
Microsurgery. 2012 Jul;32(5):420-422.
Nasir S, Roach E. Lingual artery: lifesaver recipient artery for free flap
surgery. J Reconstr Microsurg. 2012 Nov;28(9):633-634.
Zins JE. Commentary on: The percutaneous trampoline platysmaplasty:
Technique and experience with 105 consecutive patients. Aesthet
Surg J. 2012 Jan;32(1):25-26.
Pfannenstiel LW, Demelash A, Gastman BR. Raiding the pharmacy:
genomic screening identifies known chemotherapies as negative
regulators of MCL1. Genome Med. 2012 Jun 27;4(6):53.
Pomahac B, Becker YT, Cendales L, Ildstad ST, Li X, Schneeberger S,
Siemionow M, Thomson AW, Zheng XX, Tullius SG. Vascularized
composite allotransplantation research: the emerging field. Am J
Transplant. 2012 Apr;12(4):1062-1063.
Pomahac B, Papay F, Bueno EM, Bernard S, Diaz-Siso JR,
Siemionow M. Donor facial composite allograft recovery operation:
Cleveland and Boston experiences. Plast Reconstr Surg. 2012
Mar;129(3):461e-467e.
Siemionow M. Impact of reconstructive transplantation on the
future of plastic and reconstructive surgery. Clin Plast Surg. 2012
Oct;39(4):425-434.
Siemionow M, Madajka M, Cwykiel J. Application of cell-based
therapies in facial transplantation. Ann Plast Surg. 2012
Nov;69(5):575-579.
Siemionow M, Ozturk C. Face transplantation: outcomes, concerns,
controversies, and future directions. J Craniofac Surg. 2012
Jan;23(1):254-259.
Dermatology & Plastic Surgery Institute
67
Staff Listing
Institute Chairman
Francis A. Papay, MD
Pamela Ng, MD
Institute Quality
Improvement Officer
James S. Taylor, MD
Amy Polster, MD
Department of Dermatology
Allison T. Vidimos, RPh, MD
Chairman
John Secrist, MD
Anthony Fernandez, MD, PhD
Carol Slover, MD
Melissa Piliang, MD
Apra Sood, MD
Ralph Tuthill, MD
Christine Poblete-Lopez, MD
Vice Chairman
Ursula Stanton-Hicks, MD
Clinical Dermatology Section
Anthony Fernandez, MD, PhD
Section Head
John Anthony, MD
Wilma F. Bergfeld, MD
Beverly K. Lehman Cameron, MD
Melissa Piliang, MD
Berna Remzi, MD
Riddell Scott, MD
James S. Taylor, MD
Kenneth J. Tomecki, MD
Pediatric Dermatology
Section
Laleh Bedocs, DO
Douglas Kress, MD
Joan Tamburro, DO
Dermatopathology Section
Wilma F. Bergfeld, MD
Co-Section Head
Steven Billings, MD
Co-Section Head
Patch Testing Section
Apra Sood, MD
James S. Taylor, MD
Clinical Research Section
Edward V. Maytin, MD, PhD
Cutaneous Care Center
Angela Kyei, MD
Dermatologic Surgery &
Cutaneous Oncology Section
Philip L. Bailin, MD, MBA
Section Head
Molecular Dermatology Section
Edward V. Maytin, MD, PhD
Section Head
Matthew Janik, MD
Jennifer Lucas, MD
Judith Mack, PhD
Rosemary Keskinen, MD
Jon G. Meine, MD
Kishore Rollakanti, BS
Pooja Khera, MD
Missale Mesfin, MD
Sajina Shakya, BS
George Kuffner, MD
Christine Poblete-Lopez, MD
Yan Wang, MD, PhD
Angela Kyei, MD
Allison T. Vidimos, RPh, MD
Irene Lalak, MD
Alexandra Zhang, MD
Antoine Amado De Olazaval, MD
Jacob W. Dijkstra, MD
Kimberly Hollandsworth, MD
Golara Honari, MD
Sanjay Anand, PhD
Edward V. Maytin, MD, PhD
68
Outcomes 2012
Institute Overview
Department of Plastic Surgery
James E. Zins, MD
Chairman
Christi Cavaliere, MD
Section Head, Wound
Healing
Francis A. Papay, MD
Section Head,
Craniomaxillofacial Surgery
Maria Siemionow, MD, PhD
Section Head, Plastic
Surgery Research
Steven Bernard, MD
Risal Djohan, MD
Gaby Doumit, MD
Brian Gastman, MD
Mark Hendrickson, MD
Raymond Isakov, MD
Edward A. Levy, MD
Armand Lucas, MD
Michael Matthew, MD
Andrea A. Moreira, MD
J. Vicente Poblete, MD
Department of General
Anesthesiology
Dermatology and Plastic
Surgery Section
Walter Maurer, MD
Section Head
Charanjit Bahniwal, MD
Raymond Borkowski, MD
Thomas Bralliar, MD
Joseph Foss, MD
Ursula Galway, MD
John George III, MD
Robert Helfand, MD
Maria Inton-Santos, MD
Tatyana Kopyeva, MD
Mauricio Perilla, MD
Antonio Ramirez, MD
Surgical Intensive Care Unit
Marc Popovich, MD
Director
Demetrios Bourdakos, MD
Shahpour Esfandiari, MD
Faith Factora, MD
Samuel Irefin, MD
Ali Jahan, MD
Joti Juneja-Mucci, MD
Piyush Mathur, MD
Douglas Naylor Jr., MD
James Phillips, MD
Nadeem Rahman, MD
Nicholas Russo, MD
Anand Satyapriya, MD
Ellie Wurm, MD
R. Michael Ritchey, MD
Stacy Ritzman, MD
Dawn Schell, MD
Peter Schoenwald, MD
Sara Spagnuolo, MD
Karen Steckner, MD
Some physicians may
practice in multiple
locations. For a detailed
list including staff photos,
please visit clevelandclinic.
org/staff.
Graham Schwarz, MD
Randall Yetman, MD
Dermatology & Plastic Surgery Institute
69
Contact Information
General Patient Referral
24/7 hospital transfers or physician
consults
216.444.8302 or 800.553.5056
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
216.445.8454 or 800.223.2273,
ext. 58454
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
70
Plastic Surgery Financial
Counselor
216.445.1331 or
800.223.2273, ext. 51331
On the Web at
clevelandclinic.org
/dermatology and
clevelandclinic.org/plastics
Additional Contact
Information
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
24/7 hotline to streamline
access to our array of medical
services and schedule patient
appointments
855.REFER.123
(855.733.3712)
Or email refdr@ccf.org or visit
clevelandclinic.org/refer123
Outcomes 2012
Request for Medical Records
Cleveland Clinic Nevada
216.444.2640 or
800.223.2273, ext. 42640
702.483.6000
Same-Day Appointments
For address corrections or
changes, please call
216.444.CARE (2273)
800.890.2467
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 medicalconcierge@
ccf.org
Cleveland Clinic Abu Dhabi
clevelandclinicabudhabi.ae
Cleveland Clinic Canada
888.507.6885
Cleveland Clinic Florida
866.293.7866
Dermatology & Plastic Surgery Institute
71
Institute Locations
Dermatology Locations
Cleveland Clinic Main Campus
9500 Euclid Ave.
Cleveland, OH 44195
General Dermatology
216.444.5725 or 800.223.2273,
ext. 45725
Surgical Dermatology
216.444.5724 or 800.223.2273,
ext. 45724
Independence Family
Health Center
Twinsburg Family Health and
Surgery Center
Crown Centre II
5001 Rockside Road
Independence, OH 44131
8701 Darrow Road
Twinsburg, OH 44087
330.888.4000
216.986.4000
Lorain Family Health and
Surgery Center
5700 Cooper Foster Park Road
Lorain, OH 44053
440.204.7400
Beachwood Family Health and
Surgery Center
Richard E. Jacobs
Health Center
26900 Cedar Road
Beachwood, OH 44122
33100 Cleveland Clinic Blvd.
Avon, OH 44011
216.839.3000
440.695.4000
Chagrin Falls Family
Health Center
Strongsville Family Health and
Surgery Center
551 E. Washington St.
Chagrin Falls, OH 44022
16761 SouthPark Center
Strongsville, OH 44136
440.893.9393
440.878.2500
Willoughby Hills Family
Health Center
2570 SOM Center Road
Willoughby Hills, OH 44094
440.943.2500
Wooster Family
Health Center
721 E. Milltown Road
Wooster, OH 44691
330.287.4500
Elyria Family Health and
Surgery Center
303 Chestnut Commons Drive
Elyria, OH 44035
440.366.9444
72
Outcomes 2012
Plastic Surgery Locations
Cleveland Clinic Main Campus
9500 Euclid Ave.
Cleveland, OH 44195
216.444.6900 or
800.223.2273, ext. 46900
Richard E. Jacobs
Health Center
33100 Cleveland Clinic Blvd.
Avon, OH 44011
440.695.4000
Solon Family Health Center
Beachwood Family Health and
Surgery Center
29800 Bainbridge Road
Solon, OH 44139
26900 Cedar Road
Beachwood, OH 44122
440.519.6800
216.839.3000
Strongsville Family Health and
Surgery Center
Cleveland Clinic Florida
16761 SouthPark Center
Strongsville, OH 44136
2950 Cleveland Clinic Blvd.
Weston, FL 33331
440.878.2500
877.463.2010
Elyria Family Health and
Surgery Center
303 Chestnut Commons Drive
Elyria, OH 44035
Twinsburg Family Health and
Surgery Center
8701 Darrow Road
Twinsburg, OH 44087
330.888.4000
440.366.9444
Lorain Family Health and
Surgery Center
5700 Cooper Foster Park Road
Lorain, OH 44053
Westlake Medical Campus:
Building A
850 Columbia Road
Westlake, OH 44145
440.899.9993
440.204.7400
Dermatology & Plastic Surgery Institute
73
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 3,000 Cleveland
Clinic staff physicians and scientists in 120 medical specialties care for more than 5 million
patients across the system, performing more than 200,000 surgeries and conducting
450,000 Emergency Department visits. Patients come to Cleveland Clinic from all 50 states
and more than 132 nations around the world.
Cleveland Clinic is an integrated healthcare delivery system with local, national, and
international reach. The main campus in midtown Cleveland, Ohio, has a 1,450-bed
hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in
46 buildings on 167 acres. Cleveland Clinic patients represent the highest CMS case-mix
index in the nation. Cleveland Clinic encompasses 75 northern Ohio outpatient locations,
including 16 full-service family health centers, eight community hospitals, an affiliate
hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland
Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, 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 scheduled
to begin offering services in 2014. Cleveland Clinic is the second-largest employer in Ohio
with nearly 44,000 employees. It generates $10.5 billion of economic activity a year.
The Cleveland Clinic Model
Cleveland Clinic was founded in 1921 by four 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 system began to grow in 1987 with the founding of Cleveland Clinic
Florida and expanded in the 1990s with the development of 16 family health centers across
Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and six other community hospitals
joined Cleveland Clinic over the past decade and a half, 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 around specific diseases or body systems
under single 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.
74
Outcomes 2012
Cleveland Clinic Lerner Research Institute
At the Lerner Research Institute, hundreds of principal
investigators, project scientists, research associates,
and postdoctoral fellows are involved in laboratorybased translational and clinical research. Total research
expenditures from external and internal sources exceeded
$265 million in 2012. Research programs include
cardiovascular, oncology, neurology, musculoskeletal,
allergy and immunology, ophthalmology, metabolism, and
infectious diseases.
Cleveland Clinic Lerner College of Medicine
Lerner College of Medicine of Case Western Reserve
University, which celebrated its 10th anniversary in 2012,
is known for its small class size, unique curriculum, and
full-tuition scholarships for all students. The program is
open to 32 students who are preparing to be physician
investigators.
Graduate Medical Education
In 2012, nearly 1,800 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, and
our heart and heart surgery program has been ranked
No. 1 in the nation since 1995. In 2012, Cleveland Clinic’s
urology and nephrology programs were both ranked No. 1
in the nation.
For more information about Cleveland Clinic, please visit
clevelandclinic.org.
Dermatology & Plastic Surgery Institute
75
Resources
Referring Physician Center and Hotline
24/7 hotline to streamline access to our array of
medical services and schedule patient appointments,
call 855.REFER.123 (855.733.3712),
email refdr@ccf.org, or visit clevelandclinic.org/refer123
Remote Consults
Online medical second opinions from Cleveland Clinic’s
MyConsult® are particularly valuable for patients who
wish to avoid the time and expense of travel. Cleveland
Clinic offers online medical second opinions for more
than 1,200 life-threatening and life-altering diagnoses.
For more information, visit clevelandclinic.org/myconsult,
email eclevelandclinic@ccf.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
DrConnect® offers referring physicians secure access
to their patients’ treatment progress while at Cleveland
Clinic. To establish a DrConnect account, visit
clevelandclinic.org/drconnect or email drconnect@ccf.org.
Medical Records Online
Cleveland Clinic continues to expand and improve
electronic medical records (EMRs) to provide faster,
more efficient, and more accurate care by sharing patient
data through a highly secure network. Patients using
MyChart® can renew prescriptions and review test results
and medications from their personal computers. MyChart
provides a link to Microsoft HealthVault, a free online
76
service that helps patients securely gather and
store health information. It connects to Cleveland
Clinic’s social media and Internet site, currently the
most visited hospital website in America. For more
information, visit clevelandclinic.org/mychart.
Critical Care Transport Worldwide
Cleveland Clinic’s critical care transport team and
fleet of mobile ICU vehicles, helicopters, and fixedwing aircraft serve critically ill and highly complex
patients across the globe.
To arrange a transfer for STEMI (ST elevated
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 one of the largest and most successful
CME programs in the country. The center’s
website (ccfcme.org) is an educational resource for
healthcare providers and the public. Available 24/7,
it houses programs that cover topics in 30 areas.
Among other resources, the website contains a
virtual textbook of medicine (Disease Management
Project) and myCME, a system for physicians
to manage their CME portfolios. Live courses,
however, remain the backbone of the center’s CME
operation. Most live courses are held in Cleveland,
but outreach plans are underway.
Outcomes 2012
Clinical Trials
Since its establishment in 1921, Cleveland
Clinic has been an innovator in medical
breakthroughs, with a mission of unlocking
basic science and pursuing clinical research.
Today, Cleveland Clinic is running more
than 2,000 clinical trials of various types.
Our researchers are focusing on an array
of 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. To learn more, go to
clevelandclinic.org/research.
Healthcare Executive Education
Cleveland Clinic’s dynamic executive
education program provides real-world
insights into the highly competitive
business of healthcare. The Executive
Visitors’ Program is an intensive threeday program that provides a behind-thescenes view of our organization for the busy
executive. The Samson Global Leadership
Academy is a two-week immersion into
the challenges of leadership, management,
and innovation. The curriculum includes
coaching and a personalized three-year
leadership development plan. Learn more at
clevelandclinic.org/execed.
Dermatology & Plastic Surgery Institute
77
This project would not have been possible without
the commitment and expertise of a team led by
James Taylor, MD, and Darlene Lyons.
Photography by Patricia Shoda, Janine Sot, and
Rachel Schweizer. Graphic design and additional
photography were provided by Cleveland Clinic’s
Center for Medical Art and Photography.
© The Cleveland Clinic Foundation 2013
9500 Euclid Avenue, Cleveland, OH 44195
clevelandclinic.org
13-OUT-185