Modified Method to Increase the Volume and Stability of Bleomycin Foam: An Experimental Study BACKGROUND Bleomycin foam is an effective sclerotherapy method for venous malformations. The preparation method is rather complicated, and the volume and stability of the foam are limited. OBJECTIVE To modify the currently used method for preparing bleomycin foam, to simplify the preparation procedure, and to produce foam with greater volume and increased stability. MATERIALS AND METHODS Experiment 1: 6.0 IU of bleomycin powder was dissolved in different human serum albumin (HSA):saline solution (SS) ratios of 0.5:1.5, 0.75:1.25, 1:1, 1.25:0.75, 1.5:0.5, 1.75:0.25, and 2:0 in volume; then, an air:liquid ratio of 2:1 was used to create foam using the Tessari method. Experiment 2: 6.0 IU of bleomycin was dissolved directly in 2.0 mL of HSA; then, air:liquid ratios of 1:1, 2:1, 3:1, and 4:1 were used to create foam using the Tessari method. The optimum proportions of HSA:SS and air:liquid were screened by comparing the foam half-life (FHL). RESULTS Experiment 1: the optimum proportion of HSA:SS was 2:0, and the FHL was 7.5 minutes. Experiment 2: the optimum proportion of air:liquid was 3:1, and the FHL was 9.0 minutes. CONCLUSION The modified method is simpler and could produce more stable bleomycin foam with greater volume. Address correspondence and reprint requests to: Shao-Hua Liu, MD, PhD, Department of Oral and Maxillofacial Surgery, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan 250012, China, or e-mail: lshabccba@126.com Supported by Development Funding for Novel Clinical Technology, Qilu Hospital of Shandong University (2019-17) and the Key Research & Development Project of Shandong Province (2019GSF108272, 2017GSF218048). The authors have indicated no significant interest with commercial supporters. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Efficacy, Patient-Reported Outcomes, and Safety for Millennial Subjects Treated With OnabotulinumtoxinA for Moderate to Severe Horizontal Forehead Lines BACKGROUND Millennials (aged 18–34 years) represent a growing segment of the facial aesthetic market. OBJECTIVE To evaluate investigator-assessed efficacy, patient-reported outcomes (PROs), and safety for millennials versus subjects aged at least 35 years after onabotulinumtoxinA treatment of forehead lines (FHL) across 2 phase 3 studies. METHODS Eligible subjects with moderate to severe FHL received onabotulinumtoxinA (FHL: 20 U; glabellar lines: 20 U, with/without 24 U in crow's feet line regions) or placebo. All findings were pooled by the age group. RESULTS Millennials composed 15% of subjects (176/1,178). Day 30 responder rates of at least 1-grade Facial Wrinkle Scale improvement in FHL severity for millennials versus subjects aged 35 years and older were 100% versus 97.8% at maximum eyebrow elevation and 78.4% versus 83.5% at rest, respectively. Responder rates were significantly greater with onabotulinumtoxinA than placebo (p ≤ .015) for both groups through Day 180. Similar trends were observed for achieving none/mild severity. Both age groups reported high satisfaction rates and improved psychological impacts with onabotulinumtoxinA treatment. No new safety signals were detected. CONCLUSION OnabotulinumtoxinA treatment was well tolerated, and both age groups experienced significant improvements in FHL severity, high satisfaction, and improved psychological impacts after treatment. Millennials reported numerically greater improvements. Address correspondence and reprint requests to: Melanie D. Palm, MD, MBA, Art of Skin MD, 437 S. Highway 101, Suite 217, Solana Beach, CA 92075, or e-mail: melanie.palm@gmail.com This study was funded by Allergan plc, Dublin, Ireland. Editorial support for this article was provided by Adrienne Drinkwater of Peloton Advantage, Parsippany, New Jersey, and was funded by Allergan plc. M.D. Palm, J. Few, T. Patel, and M. Safa serve as consultants and investigators for Allergan plc. A. Drinkwater was employed by Peloton Advantage, LLC, which received funding from Allergan plc for medical writing and editing on this manuscript. C. Mao and J.K. Garcia are employees of Allergan plc and may own stock/options in the company. The opinions expressed in this article are those of the authors. The authors received no honorarium or fee related to the development of this article. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Commentary on Efficacy, Patient-Reported Outcomes, and Safety for Millennial Subjects Treated With OnabotulinumtoxinA for Moderate to Severe Horizontal Forehead Lines No abstract available

Combination Nasal Sidewall and Alar Defects No abstract available

Finding Chemo for Nemo: Recurrent Eruptive Keratoacanthomas in a Tattoo No abstract available

Evaluating the Impact of Indoor Tanning Legislation in the United States No abstract available

The Cheek Interpolation Flap for Reconstruction of Auricular Mohs Defects BACKGROUND Surgical reconstruction of auricular defects after Mohs surgery may prove challenging secondary to the complex topography of the ear and few options for local flap repair that do not introduce inordinate risk of anatomic distortion. The matched preauricular skin may be used to overcome these limitations. OBJECTIVE This study aims to examine the utility, technique, and outcomes of preauricular interpolated flaps used for auricular reconstruction. To the authors' knowledge, this study represents the only published series of cheek interpolation flaps for auricular reconstruction. METHODS A retrospective review of interpolated cheek flaps used for auricular reconstruction performed by one surgeon (J.C., 2000–2018) after tumor removal by Mohs micrographic surgery (MMS) at a single institution. RESULTS Twenty cheek interpolation flaps were identified that were used to reconstruct defects after complete removal of skin cancer on the ear. No major complications were observed. CONCLUSION Interpolated flaps are a useful reconstructive technique for auricular defects after MMS. Using the hairless isthmus of the preauricular cheek as the donor site for a 2-stage interpolated flap is a means of repairing the auricle when other options are not ideal. Address correspondence and reprint requests to: Ivy I. Norris, MD, 135 Rutledge Avenue, 11th Floor, MSC 578, Charleston, SC 29425, or e-mail: ivyi.norris@gmail.com This study was funded by the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina. The authors have indicated no significant interest with commercial supporters. This study was approved by the Medical University of South Carolina Institutional Review Board (Pro00068833). © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Postmarket Experience of Polymethylmethacrylate–Collagen Gel Dermal Filler BACKGROUND This report synthesizes 12 years of postmarket surveillance data (PMSD) for polymethylmethacrylate (PMMA)–collagen gel dermal filler. OBJECTIVE To present PMMA–collagen gel PMSD findings on real-world safety. METHODS Postmarket surveillance data were collected from January 2007 to December 2018 and evaluated to determine the overall adverse event (AE) complaint rate, the nature of reported AEs, and whether the complaint included on-label, off-label, both, or unknown areas. RESULTS In the 12 years examined, 754,229 PMMA–collagen gel syringes were distributed worldwide, and 839 product-related complaints (including those classified as unknown) resulted in an overall complaint rate of 0.11%. The 3 most frequent primary complaints in AE reports were lump/bump (309/839, 37%), nodule (152/839, 18%), and swelling (138/839, 16%). Histologically confirmed granuloma accounted for 17/839 complaints (2.0%; overall complaint rate of 0.002%), and histologically unconfirmed granuloma accounted for 66/839 complaints (8%; overall rate of 0.009%). There were 666 complaints representing AEs related to off-label injection in which the periocular area was most frequently represented. CONCLUSION Although a limiting factor across all PMSD is voluntary reporting and resultant underrepresentation of AEs, the PMSD reported here are consistent with safety findings from US clinical studies in more than 1,500 patients with up to 5 years of follow-up. Address correspondence and reprint requests to: Alayne Lehman, RN, MS, Director of Clinical Affairs, Suneva Medical, Inc., S5870 Pacific Center Boulevard, San Diego, CA 92121, or e-mail: alehman@sunevamedical.com This analysis was funded by Suneva Medical, Inc. B. Pilcher and A. Lehman are employees of Suneva Medical, Inc. G. Vachon is a medical writer with Principal Medvantage, LLC and was reimbursed for her editorial support. T.E. Schlesinger and W.E. Roberts have both presented data on behalf of Suneva Medical, Inc. and are paid consultants. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Navigating Barriers to Patient Access and Reimbursement in Mohs Micrographic Surgery BACKGROUND Insurance companies have implemented new policies including excessive prior authorization (PA) requirements, high-deductible plans, and complicated billing structures in an effort to curb rising health care costs. Studies investigating the real-time impact on providers and patients are emerging, but few within the field of dermatology have been published. OBJECTIVE To assess the impact of cost-cutting policies on patients and physicians. METHODS A survey was electronically distributed to members of the American College of Mohs Surgery (ACMS). RESULTS The majority of respondents (78.2%) practiced in a private setting, with no other demographic differences. The majority of respondents (70%) dedicated 1 to 2 employees to obtaining PAs. Fifty percent reported an average time of 30 minutes spent per PA. Fifty-six percent of respondents obtained PA from private insurance before Mohs surgery, whereas only 24.5% obtained PA from Medicare. Forty-nine percent of practitioners provided patients with a financial disclosure prior to Mohs surgery. Moreover, many practitioners reported screening patients for high-deductible policies and request an advanced deposit against the deductible. Sixty percent reported difficulty obtaining payment for service in the absence of an advanced deposit. CONCLUSION The burden of restrictive health care policies will have long-term consequences for the patient–provider interaction and patient outcomes. Address correspondence and reprint requests to: David H. Ciocon, MD, Division of Dermatology, Montefiore Medical Center, 111 East 210 Street, Bronx NY 10467, or e-mail: dhciocon@gmail.com The authors have indicated no significant interest with commercial supporters. A. E. Krausz and J. R. Manning contributed equally to this work. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Dermatologic Surgeons Can Positively Impact the Opioid Epidemic: A Quality Improvement Study of Pain Management in Dermatology Surgery BACKGROUND The opioid epidemic is a national emergency, and it is imperative that all physicians are engaged in reducing exposure. Among dermatologists, dermatologic surgeons prescribe most opioids with the highest rates of prescription occurring in Southern states. OBJECTIVE Implement a quality improvement intervention to decrease opioids prescribed and filled to <10% of surgeries performed and have a 0% increase in the amount of patient complaints regarding postoperative pain. MATERIALS AND METHODS The number of opioids prescribed and filled in a single surgical facility in Georgia was obtained from the state's Prescription Drug Monitoring Program before, 1 month after, and 6 months after implementation of the quality improvement initiative. Telephone encounters regarding postoperative pain was also collected at the same specified periods. RESULTS Proportion of opioids prescribed and filled decreased from 58% to 5% at 1-month postintervention and remained low on 6-month follow-up at 4%. There was no increase in postoperative pain complaints. Rather, a decrease in complaints was noted from 8.6% to 3.1% at 1-month postintervention and sustained on 6-month follow-up at 4.9%. CONCLUSION Our data support the management of postoperative pain with nonopioid medications. Address correspondence and reprint requests to: Kehinde Raji, MD, MPH, Department of Dermatology, Emory University School of Medicine, 1525 Clifton Road, 3rd Floor, Room 338, Atlanta, GA 30322, or e-mail: kraji@emory.edu The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.